2016 Benefit Guide - Raymondville ISD by Higginbotham Public Sector

RAYMONDVILLE ISD

BENEFIT GUIDE EFFECTIVE: Medical 09/01/2016 - 8/31/2017 Voluntary 10/01/2016 - 8/31/2017 www.mybenefitshub.com/raymondvilleisd

Table of Contents Benefit Contact Information How to Enroll Annual Benefit Enrollment 1. Annual Enrollment 2. Eligibility Requirements 3. Helpful Definitions 4. Section 125 Cafeteria Plan Guidelines TRS-ActiveCare HSA Bank Health Savings Account (HSA) APL MEDlinkÂ® MDLIVE Telehealth APL Hospital Indemnity Cigna Dental Superior Vision The Hartford Disability APL Cancer APL Accident Cigna Life and AD&D 5Star Individual Life w/ Critical Illness ID Watchdog Identity Theft NBS Flexible Spending Account (FSA) MASA Medical Transport

3 4-5 6-9 6 7 8 9 10-11 12-15 16-19 20-21 22-25 26-29 30-31 32-35 36-39 40-43 44-47 48-51 52-53 54-57 58-59

FLIP TO... PG. 4 HOW TO ENROLL

PG. 8 HELPFUL DEFINITIONS

PG. 10 YOUR BENEFITS PACKAGE

Benefit Contact Information

Benefit Contact Information BENEFIT ADMINISTRATORS

HOSPITAL INDEMNITY

LIFE AND AD&D

Financial Benefit Services (469) 385-4685 www.mybenefitshub.com/ raymondvilleisd

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

Cigna (469) 385-4685 www.cigna.com

RAYMONDVILLE ISD BENEFITS

DENTAL

INDIVIDUAL LIFE W/ CRITICAL ILLNESS

(956) 689-8175 www.raymondvilleisd.org

Cigna (800) 244-6224 www.cigna.com

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

MEDICAL

VISION

ID THEFT

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

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

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

HSA

DISABILITY

FLEXIBLE SPENDING ACCOUNT

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

The Hartford (800) 523-2233 www.thehartford.com

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

MEDICAL SUPPLEMENT—MEDLINK ®

CANCER

MEDICAL TRANSPORT

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

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

TELEHEALTH

ACCIDENT

MDLIVE (888) 365-1663 www.consultmdlive.com

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

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

TEXT

need to complete your enrollment.

“rvilleisd” TO

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

313131

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

TRY ME

SCAN:

On Your Computer Access the Raymondville ISD

Our online benefit enrollment

benefits website from your

platform provides a simple and

computer, tablet or smartphone!

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

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

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

Where can I find forms?

to review, change or continue benefit elections each year.

For benefit summaries and claim forms, go to your school

Changes are not permitted during the plan year (outside of

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

annual enrollment) unless a Section 125 qualifying event occurs.

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



Changes, additions or drops may be made only during the

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

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

included in the dependent profile. Additionally, you must

raymondvilleisd. Click on the benefit plan you need

notify your employer of any discrepancy in personal and/or

information on (i.e., Dental) and you can find provider search

benefit information.



For benefit summaries and claim forms, go to your school

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

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

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

verify your coverage if you do not have an ID card at that time. If you do not receive your ID card, you can call the carrier’s customer service number to request another card. If the insurance carrier provides ID cards, but there are no changes to the plan, you typically will not receive a new ID card each year.

Q&A Who do I contact with Questions? For supplemental benefit questions, you can contact your Benefits/HR department or you can call Financial Benefit Services

at 866-914-5202 for assistance.

SUMMARY PAGES

Employee Eligibility Requirements

Dependent Eligibility Requirements

Supplemental Benefits: Eligible employees must work 20 or more

Dependent Eligibility: You can cover eligible dependent

regularly scheduled hours each work week.

children under a benefit that offers dependent coverage, provided you participate in the same benefit, through the

Eligible employees must be actively at work on the plan effective

maximum age listed below. Dependents cannot be double

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

covered by married spouses within Raymondville ISD or as

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

both employees and dependents.

work concurrent with the plan effective date. For example, if your 2016 benefits become effective on October 1, 2016, you must be actively-at-work on October 1, 2016 to be eligible for your new benefits.

PLAN

CARRIER

MAXIMUM AGE

Medical

Aetna

Dental

Cigna

Vision

Superior Vision

Cancer

American Public Life

Accident

American Public Life

ID Theft

ID Watchdog

Voluntary Life

Cigna

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

Helpful Definitions

SUMMARY PAGES

Actively at Work

In-Network

You are performing your regular occupation for the employer

Doctors, hospitals, optometrists, dentists and other providers

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

who have contracted with the plan as a network provider.

places of business or at some location to which the employer’s business requires you to travel. If you will not be actively at work beginning 10/1/2016 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 Medical: September 1st through August 31st Voluntary: October 1st through September 30th

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

Calendar Year

orders to take drugs, or received medical care or services

January 1st through December 31st.

(including diagnostic and/or consultation services).

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.

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 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.

CHANGES IN STATUS (CIS):

QUALIFYING EVENTS

Marital Status

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

Change in Number of Tax Dependents

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

Change in Status of Employment Affecting Coverage Eligibility

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

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

Gain or loss of Medicare/Medicaid coverage may trigger a permitted election change.

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

ActiveCare 1-HD

ActiveCare Select or ActiveCare Select Whole Health

ActiveCare 2

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

$2,500 employee only $5,000 family

$1,200 individual $3,600 family

$1,000 individual $3,000 family

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

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

$6,850 individual $13,700 family

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

80% 20%

Office Visit Copay Participant pays

20% after deductible

$30 copay for primary $60 copay for specialist

$30 copay for primary $50 copay for specialist

Diagnostic Lab Participant pays

20% after deductible

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

Preventive Care See next page for a list of services

Plan pays 100%

Teladoc® Physician Services

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

Plan pays 100%

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

20% after deductible

$100 copay plus 20% after deductible

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

20% after deductible

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

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

Emergency Room (true emergency use) Participant pays

20% after deductible

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

Outpatient Surgery Participant pays

20% after deductible

$150 copay per visit plus 20% after deductible

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

$5,000 copay plus 20% after deductible

Not covered

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

Prescription Drugs Drug deductible (per plan year)

Subject to plan year deductible

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

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

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

$20 $40** $65**

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

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

$35 $60** $90**

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

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

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

Specialty Drugs Participant pays

20% after deductible

20% coinsurance per fill

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

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

TRS-ActiveCare Plans—Preventive Care

Network Benefits When Using In-Network Providers

(Provider must bill services as “preventive care”)

ActiveCare 1-HD Preventive Care Services

ActiveCare Select or ActiveCare Select Whole Health

ActiveCare 2 Network

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

Plan pays 100% (deductible waived)

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/facts-and-features/fact-sheets/ preventive-services-covered-under-aca/#CoveredPreventive ServicesforAdults For purposes of this benefit, the current recommendations of the USPSTF regarding breast cancer screening and mammography and prevention will be considered the most current (other than those issued in or around November 2009). The preventive care services described above may change as USPSTF, CDC and HRSA guidelines are modified. (Examples of covered services included are: Routine annual physicals (one per year); immunizations; well-child care; breastfeeding support, services and supplies; cancer screening mammograms; bone density test; screening for prostate cancer and colorectal cancer (including routine colonoscopies); smoking cessation counseling services and healthy diet counseling; and obesity screening/counseling. Examples of covered services for women with reproductive capacity are: Female sterilization procedures and specified FDA-approved contraception methods with a written prescription by a health care practitioner, including cervical caps, diaphragms, implantable contraceptives, intra-uterine devices, injectables, transdermal contraceptives and vaginal contraceptive devices. Prescription contraceptives for women are covered under the pharmacy benefits administered by Caremark. To determine if a specific contraceptive drug or device is included in this benefit, contact Customer Service at 1-800222-9205. The list may change as FDA guidelines are modified.

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

HSA BANK

HSA (Health Savings Account)

YOUR BENEFITS PACKAGE

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

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

Money withdrawn for medical spending never falls under taxable income.

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

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

What is an HSA? 

 

A tax-advantaged savings account that you use to pay for eligible medical expenses as well as deductible, coinsurance, 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.

Using Funds



Not enrolled in Medicare (if an accountholder enrolls in Medicare mid-year, catch-up contributions should be prorated) Authorized Signers who are 55 or older must have their own HSA in order to make the catch-up contribution Monthly Fee: Your account will be charged a monthly fee of $1.75, waived with an average daily balance at or above $3,000.

Examples of Qualified Medical Expenses      

Surgery Braces Contact lenses Dentures Eyeglasses Vaccines

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

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

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).

AMERICAN PUBLIC LIFE YOUR BENEFITS PACKAGE

MEDlinkÂŽ

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.

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

SUMMARY OF BENEFITS Base Policy

Option 1

Option 2

In-Hospital Benefit - Maximum In-Hospital Benefit

$1,500 per confinement

$2,500 per confinement

Outpatient Benefit

up to $200 per treatment

$25 per treatment; $125 max per family per Calendar Year

Physician Outpatient Treatment Benefit

Option 1 Total Monthly Premiums by Plan* Issue Ages 17-54

Issue Ages 55-59

Issue Ages 60-69

Employee Only

$21.50

$32.00

$49.00

Employee + Spouse

$39.50

$59.00

$88.00

Employee + Child(ren)

$36.50

$47.00

$64.00

Family Coverage

$54.50

$74.00

$103.00

Issue Ages 17-54

Issue Ages 55-59

Issue Ages 60-69

Employee Only

$28.00

$44.50

$68.50

Employee + Spouse

$51.50

$81.50

$122.50

Employee + Child(ren)

$45.50

$62.00

$86.00

Family Coverage

$69.00

$99.00

$140.00

Option 2 Total Monthly Premiums by Plan* Hospital Emergency Room

Plans available to employees age 70 and over if You work for an employer employing 20 or more employees on a typical workday in the preceding Calendar Year. *Total premium includes the Plan selected and any applicable rider premium. Premiums are subject to increase with notice.

APSB-22330(TX)-0116 MGM/FBS Raymondville ISD 17

MEDlink® Limited Benefit Medical Expense Supplemental Insurance Limitations Eligibility This policy will be issued to those persons who meet American Public Life Insurance Company’s insurability requirements. Evidence of insurability acceptable to us may be required. If our underwriting rules are met, you are on active service, you are covered under your Employer’s Medical Plan and premium has been paid, your insurance will take effect on the requested Effective Date or the Effective Date assigned by us upon approval of your written application, whichever is later. Covered Charges mean those charges that are incurred by a Covered Person because of an Accident or Sickness; are for necessary treatment, services and medical supplies and recommended by a Physician; are not more than any dollar limit set forth in the Schedule; are incurred while insured under the Policy, subject to any Extension of Benefits; and are not excluded under the Policy. A Hospital is not any institution 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.

In-Hospital Benefit Benefits payable are limited to any out-of-pocket deductible amount; any out-of-pocket co-payment or coinsurance amounts the Covered Person actually incurs after the Employer’s Medical Plan has paid; any out-of-pocket amount the Covered Person actually incurs for surgery performed by a Physician after the Employer’s Medical Plan has paid; and the Maximum In-Hospital Benefit shown in the Policy Schedule. The Covered Person must be an Inpatient and covered by your Employer’s Medical Plan when the Covered Charges are incurred.

Outpatient Benefits Treatment is for the same or related conditions, unless separated by a period of 90 consecutive days. After 90 consecutive days, a new Outpatient Benefit will be payable. The Covered Person must be covered by your Employer’s Medical Plan when the Covered Charges are incurred.

Physician Outpatient Treatment Benefit Benefit maximum of $125 per family per Calendar Year. The Covered Person must be covered by your Employer’s Medical Plan when the Covered Charges are incurred. The Covered Person must not be an Inpatient when the Covered Charges are incurred.

Premiums The premium rates may be changed by Us. If the rates are changed, We will give You at least 31 days advance written notice. If a change in benefits increases Our liability, premium rates may be changed on the date Our liability is increased. This plan may be continued in accordance with the Consolidated Omnibus Reconciliation Act of 1986.

APSB-22330(TX)-0116 MGM/FBS Raymondville ISD 18

Exclusions We will pay no benefits for any 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 your Employer’s Medical Plan provision or which result from: (a) suicide or any attempt, thereof, while sane or insane; (b) any intentionally self-inflicted injury or Sickness; (c) rest care or rehabilitative care and treatment; (d) outpatient routine newborn care; (e) voluntary abortion except, with respect to You or Your covered Dependent spouse: (1) where Your or Your Dependent spouse’s life would be endangered if the fetus were carried to term; or (2) where medical complications have arisen from abortion; (f) pregnancy of a Dependent child; (g) participation in a riot, 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; (h) commission of a felony; (i) participation in a contest of speed in power driven vehicles, parachuting, or hang gliding; (j) air travel, except: (1) as a fare-paying passenger on a commercial airline on a regularly scheduled route; or (2) as a passenger for transportation only and not as a pilot or crew member; (k) intoxication; (Whether or not a person is intoxicated is determined and defined by the laws and jurisdiction of the geographical area in which the loss occurred.) (l) alcoholism or drug use, unless such drugs were taken on the advice of a Physician and taken as prescribed; (m) sex changes; (n) experimental treatment, drugs, or surgery; (o) an act of war, whether declared or undeclared, or while performing police duty as a member of any military or naval organization; (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. We will refund the pro rata unearned premium for any such period the Covered Person is not covered.) (p) 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.) (q) mental illness or functional or organic nervous disorders, regardless of the cause; (r) dental or vision services, including treatment, surgery, extractions, or x-rays, unless: (1) 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 (2) 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; (t) any expense for which benefits are not payable under the Covered Person’s Employer’s Medical Plan; or (u) air or ground ambulance.

MEDlink® Limited Benefit Medical Expense Supplemental Insurance Termination of Coverage Your Insurance coverage will end on the earliest of these dates: the date You no longer qualify as an Insured; the end of the last period for which premium has been paid; the date the Policy is discontinued; the date You retire; if You work for an employer employing less than 20 employees on a typical work day in the preceding Calendar Year, the date You attain age 70; the date You cease to be on Active Service; the date Your coverage under Another Medical Plan ends; or the date You cease employment with the employer through whom You originally became insured under the Policy. Insurance coverage on a Dependent will end on the earliest of these dates: the date Your coverage terminates; the end of the last period for which premium has been paid; the date the Dependent no longer meets the definition of Dependent; the date the Dependent’s coverage under Another Medical Plan ends; or the date the Policy is modified so as to exclude Dependent coverage. We may end the coverage of any Covered Person who submits a fraudulent claim. We may end the coverage of a Subscribing Unit if fewer persons are insured than the Policyholder’s application requires.

2305 Lakeland Drive | Flowood, MS 39232 ampublic.com | 800.256.8606 Underwritten by American Public Life Insurance Company. This is a brief description of the coverage. For complete benefits, limitations, exclusions and other provisions, please refer to the policy 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 Medical Expense Supplemental Insurance | (10/14) | Raymondville ISD

APSB-22330(TX)-0116 MGM/FBS Raymondville ISD 19

MDLIVE YOUR BENEFITS PACKAGE

Telehealth

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

DID YOU KNOW?

75%

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

Telehealth When should I use MDLIVE?

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

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

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

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

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

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

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

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

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

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

Scan with your smartphone to get the app.

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

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

AMERICAN PUBLIC LIFE YOUR BENEFITS PACKAGE

Hospital Indemnity

About this Benefit Hospital Confinement Indemnity Insurance pays a daily benefit if you have a covered stay in a hospital*, critical care unit and rehabilitation facility. The benefit amount is determined based on the type of facility and the number of days you stay. Hospital Confinement Indemnity Insurance is a limited benefit policy. It is not health insurance and does not satisfy the requirement of minimum essential coverage under the Affordable Care Act.

DID YOU KNOW? The median hospital costs per stay have steadily grown to over $10,000.

$8,800

9,600

10,400

2003

2008

2012

HI-4005 Limited Benefit Group Hospital Indemnity Insurance Raymondville 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.

Benefit Description

Available Options

Daily Hospital Confinement Benefit

$100 per day

Optional Benefit Riders Intensive Care/Coronary Care Unit Rider

$100 per day;

Annual First Occurrence Hospital Rider

$200 per calendar year

Surgical and Anesthesia Benefits Rider Surgical Benefits

$1,000 Scheduled Benefit

Anesthesia Benefit Amount

25% of the Surgical Benefit Amount

Outpatient Sickness Rider

$25 per visit

Emergency Accident Rider

$100 per day per Accident

Premiums by Plan* Employee

Employee & Spouse

Employee & Child

Family

$25.69

$48.90

$38.20

$61.39

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

Policy Benefit Highlights Daily Hospital Confinement Benefit

Pays a daily indemnity benefit for each day the Insured Person is confined at the direction of or under the supervision of a Physician for at least 24 hours as an Inpatient to a Hospital for a covered Injury or covered Sickness for each Period of Confinement. The maximum benefit period for this benefit is 180 days for any one Period of Confinement. An Accident or Injury is a sudden, unexpected and unintended injury which is caused directly by an Accident; is independent of any Sickness or disease; over which the Insured Person has no control; and takes place while the Insured Person’s coverage is in force. Inpatient means confinement in a Hospital for at least 24 continuous hours in duration. Sickness means an illness or disease which first manifests itself after coverage becomes effective for the Insured Person.

Intensive Care/Coronary Care Unit Rider

Pays an indemnity benefit if You or Your covered Dependent is confined in a Hospital’s Intensive Care or Coronary Care Unit due to a covered Injury or Sickness. We will pay the indemnity benefit for each day of such confinement, but not to exceed 20 days during any one Period of Confinement. Each Period of Confinement must be separated by at least 30 days. This benefit will be paid in addition to the Hospital Confinement Benefit in the Policy/Certificate.

Annual First Occurrence Hospital Rider

Pays an indemnity benefit for You or Your covered Dependent’s First Occurrence Hospital Confinement. The Hospital Confinement must be due to a covered Injury or Sickness; begin while this rider is in force for the person confined; and be at the direction of and under the supervision of a Physician.

Surgical and Anesthesia Benefits Rider Surgical Benefits

Pays a Surgical Benefit when surgery is performed by a Physician on You or Your covered Dependent due to a covered Injury or Sickness. We will pay the Surgical Benefit for the surgical operation equal to the percentage set opposite the procedure listed in the Schedule of Operations, multiplied by the Insured or covered Dependent person’s Surgical Schedule Benefit, as shown in the Certificate Schedule of Benefits. The surgery can be performed in a Hospital (on an inpatient or outpatient basis), in an Ambulatory Surgical Center, or in a Physician’s office.

Anesthesia Benefits

Pays 25% of the Surgical Benefit Amount paid when You or Your covered Dependent has a covered surgical procedure performed, there is a separate charge for anesthesia and the anesthesia is administered by a Physician in connection with the covered surgical procedure.

Outpatient Sickness Rider

Pays an indemnity benefit when You or Your covered Dependent receives treatment by a Physician for a covered Sickness in the Physician’s Office; Clinic; Urgent Care Facility; or Emergency Room.

Emergency Accident Rider

Pays a indemnity benefit per day per Accident if You or Your covered Dependent sustains an Injury which requires Emergency Care by a Physician. Emergency Care means medical treatment for an Injury demanding immediate attention. The treatment must be: rendered in an emergency room of a Hospital, in a Physician's office; clinic or urgent care facility and, received within 30 days of the Injury.

First Occurrence Hospital Confinement means the first time You or Your covered Dependent is confined as an inpatient to a Hospital in a Calendar Year for a period of confinement for which benefits are payable under the policy/certificate to which this rider is attached. Refer to Limitation and Exclusions section for benefit rider day(s), visit and testing limits.

APSB-22337(TX)-MGM/FBS Raymondville ISD

HI-4005 Limited Benefit Group Hospital Indemnity Insurance Limitations and Exclusions Eligibility

This policy/certificate will be issued to those persons who meet American Public Life Insurance Company’s insurability requirements. Evidence of insurability acceptable to Us may be required. If You are working either under contract to or as an employee of the Policyholder, or are a member in or employed by the association, if the Policy is issued to an association, You are eligible for insurance provided You qualify for coverage as defined in the Master Application and are Actively at Work on Your effective date of coverage. Actively At Work means the person is performing the normal duties of his/her principal occupation, at his/her usual place of business, on a full time basis (at least 18 hours per week). A person is deemed to be Actively at Work on each day of regular paid vacation during which he/she is not totally disabled, provided he/she was Actively at Work on the last preceding working day.

Base Policy and Riders

No benefits are payable for the first twelve (12) months as a result of a Pre-Existing Condition. A Pre-Existing Condition is a disease or physical condition for which the Insured Person had treatment; incurred expense; took medication; or received a diagnosis or advice from a Physician; during the twelve (12) month period of time immediately prior to the Effective Date of coverage. The term “Pre-Existing Condition” will also include conditions that are related to such disease or physical condition. Pre-Existing Conditions specifically named or described as permanently excluded in any part of this contract are never covered. Pre-Existing Conditions specifically named or described as excluded for a limited time will be covered after the excluded period expires. All benefits payable only up to the maximum benefit listed on the Policy/Certificate Schedule in the policy. Period of Confinement means continuous confinement in a Hospital. Periods of Confinement for the same or a related cause, which are separated by less than 90 days, will be considered the same Period of Confinement. Each Period of Confinement must begin while coverage is in force for the Insured Person confined.

Daily Hospital Confinement Benefit

Benefits payable will not exceed the Maximum Total Benefit of 180 Days for any one Period of Confinement, unless such confinement is due to a Mental or Emotional Disorder. If confinement is due to a Mental or Emotional Disorder, benefits payable will not exceed the Maximum Total Benefit of 30 days for any one Period of Confinement. The Hospital Confinement must begin while this policy/certificate is in force for the Insured Person. The Daily Benefit is shown in the Policy Schedule. A Hospital is not an institution 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.

Intensive Care/Coronary Care Unit Rider

A step-down unit is not considered an Intensive Care Unit.

Annual First Occurrence Hospital Rider

The Benefit for this rider is payable one time each Calendar year for You and each of Your covered Dependents. The first day of confinement must be in the Calendar Year for which the benefit amount is payable.

Surgical and Anesthesia Benefits Rider Surgical Benefits

If an operation is not listed in the Schedule of Operations, We will pay an amount comparable to that which would be payable for the operation listed in the Schedule of Operations, which is most nearly similar in severity and complexity. If two or more surgical procedures are performed at the same time, through the same or different incisions, only one benefit, the largest, will be payable.

Outpatient Sickness Rider

The total Maximum Visits per Calendar Year, for You and for each of Your covered Dependents, is as shown in the Policy/Certificate Schedule of Benefits: 5 per Adult, 5 for all covered Dependent children, and 10 per family (for all covered persons combined).

Emergency Accident Rider

The maximum days per Calendar Year payable for the Emergency Accident Benefit is 2 days per covered person, with the exception of Dependent children, which is limited to a total of 2 days for all covered Dependent children combined.

Renewability

This policy/certificate is conditionally renewable. This means that We have the right to terminate your policy/certificate on any premium due date after the first Policyholder’s Anniversary Date. We must give the Policyholder at least 60 days written notice prior to cancellation. We cannot cancel Your coverage because of change in Your age or health. We can, however, change Your premiums if We change premiums for all similar Certificates issued to the Policyholder. We must give the Policyholder at least 60 days written notice before We change Your premiums. We do not cover hospital confinements or other losses in the Policy or Riders attached thereto: (a) due to hernia, adenoids, tonsils, varicose veins, appendix, disorder of the reproduction organs or elective sterilization within six months after the Insured Person's Effective Date unless due to an emergency; (b) for an Injury or Sickness covered under Workers Compensation, an Employers Liability Law, benefits provided by the Federal Employee Liability Act or similar law; (c) for an Injury or Sickness due to war or act of war, whether declared or undeclared; (d) for Dental Treatment unless due to Injury; (e) for injuries that are intentionally self-inflicted; (f) for an Injury or Sickness incurred while committing or attempting to commit a felony; (g) for an Injury or Sickness incurred while engaging in an illegal occupation; (h) for cosmetic care, except when the Hospital confinement is due to medically necessary reconstructive plastic surgery. Medically necessary reconstructive plastic surgery is defined as: 1. surgery to restore a normal bodily function. 2. surgery to improve functional impairment by anatomic alteration made necessary as a result of a congenital birth defect. 3. breast reconstruction following mastectomy. (i) which are primary for rest care, convalescent care or for rehabilitation; (j) due to being intoxicated. (Intoxication means that which is determined and defined by the laws and jurisdiction of the geographical area in which the loss or cause of loss was incurred); (k) for Injury sustained or Sickness, which manifests itself while on full-time duty in the armed forces. Upon notice, We will refund the proportion of unearned premium paid while in such forces; (l) for treatment of alcoholism or drug addiction;

All Riders are subject to all the Provisions, Conditions, Limitations and Exclusions of the Policy to which it is attached, which are not in conflict with those of the Rider.

24APSB-22337(TX)-MGM/FBS

Raymondville ISD

HI-4005 Limited Benefit Group Hospital Indemnity Insurance Limitations and Exclusions continued (m) which are rendered outside the United States, its possessions, or Canada, except for emergency care for acute onset of Sickness or accidental Injury sustained while traveling for business or pleasure; (n) for which payment is not legally required, except for: 1. Medicaid; 2. treatment of non-service connected disabilities in Veteran Administration hospitals; and, 3. inpatient care rendered to armed services retirees and dependents in military medical facilities of the United States Government; nor, (o) Pre-Existing Conditions, unless the Insured Person has satisfied the Pre-Existing Condition Exclusion Period shown in the Schedule.

Termination of Dependent(s)

Insurance coverage on Your Dependent will end on the earliest of these dates: the date the coverage under the Certificate terminates; the date the Dependent no longer meets the definition of Eligible Dependent, as defined in the Policy/Certificate; the date the Policy is modified so as to exclude Dependent coverage; or the date We receive Your written request for termination. We may end the coverage of any Insured Person who submits a fraudulent claim.

Termination of Coverage Termination of Certificate

Your Insurance coverage will end on the earliest of these dates: the date You no longer qualify as an Insured; the last day of the period for which a premium has been paid, subject to the Grace Period; the date the Policy terminates; the date You retire; the date You cease to be on Actively at Work, as defined in the Policy/Certificate; the date You cease employment, or terminate Your contract with the employer through whom You originally became insured under the Policy; or the date We receive Your written request for termination.

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 and other provisions, please refer to the policy/certificate. This coverage does not replace Workersâ&#x20AC;&#x2122; 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 HI-4005 series | Texas | Limited Benefit Hospital Indemnity Insurance | (3/15) | Raymondville ISD

APSB-22337(TX)-MGM/FBS Raymondville ISD

CIGNA

Dental

YOUR BENEFITS PACKAGE

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

DID YOU KNOW?

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

Dental PPO - High Plan Monthly PPO Premiums Tier

Rate

EE Only

$28.76

EE + Spouse

$55.44

EE + Child(ren)

$60.84

Family Coverage

$85.12

Receiving regular dental care can not only catch minor problems before they become major and expensive to treat - it may even help improve your overall health. Gum disease is increasingly being linked to complications for pre-term birth, heart disease, stroke, diabetes, osteoporosis and other health issues. That’s why this dental plan includes Cigna Dental WellnessPlusSM features. When you or your family members receive any preventive care in one plan year, the annual dollar maximum will increase in the following plan year. When you or your family members remain enrolled in the plan and continue to receive preventive care, the annual dollar maximum will increase in the following plan year, until it reaches the level specified below. Please refer to your plan materials for additional information on this plan feature.

Benefits Network Calendar Year Maximum (Class I, II, III and IX expenses)

Cigna Dental Choice In-Network Total Cigna DPPO

Out-of-Network

Year 1: $1,500 Year 2: $1,600# Year 3: $1,700+ Year 4 and Beyond: $1,800^

$50 per person $150 per family

Based on Reduced Contracted Fees

90th percentile of Reasonable and Customary Allowances

Plan Pays

You Pay

Plan Pays

You Pay

100%

No Charge

100%

No Charge

80%*

20%*

80%*

20%*

50%*

Annual Deductible Individual Family Reimbursement Levels** Class I - Preventive & Diagnostic Care Oral Exams Routine Cleanings Bitewing X-rays Full Mouth X-rays Panoramic X-ray Emergency Care to Relieve Pain Fluoride Application Sealants Space Maintainers Class II - Basic Restorative Care Fillings Root Canal Therapy/Endodontics Periodontal Scaling and Root Planning Surgical Extractions of Impacted Teeth Brush Biopsies Oral Surgery – All except simple extractions Anesthetics Oral Surgery – Simple extractions Class III - Major Restorative Care Crowns Denture Repairs Denture Relines, Rebases and Adjustments Repairs to Bridges, Crowns and Inlays Dentures Bridges Inlays/Onlays Prosthesis Over Implant Class IV - Orthodontia Lifetime Maximum Class IX - Implants Deductible Annual Maximum

50% $1,500 Dependent children to age 19 50% Subject to plan deductible Subject to plan annual maximum

50%

50% $1,500 Dependent children to age 19 50% Subject to plan deductible Subject to plan annual maximum

50%

Dental PPO - Low Plan Monthly PPO Premiums Tier

Rate

EE Only

$20.78

EE + Spouse

$41.04

EE + Child(ren)

$45.18

Family Coverage

$63.43

Benefits Network Calendar Year Maximum (Class I, II, III and IX expenses)

Cigna Dental Choice In-Network Total Cigna DPPO

Out-of-Network

Year 1: $750 Year 2: $850# Year 3: $950+ Year 4 and Beyond: $1,050^

$50 per person $150 per family

Based on Reduced Contracted Fees

90th percentile of Reasonable and Customary Allowances

Plan Pays

You Pay

Plan Pays

You Pay

100%

No Charge

100%

No Charge

60%*

40%*

60%*

40%*

60%*

40%*

60%*

Not covered

100% of your dentist’s usual fees

Not covered

100% of your dentist’s usual fees

60%

40% Subject to plan deductible Subject to plan annual maximum

60%

Class II - Basic Restorative Care Fillings Root Canal Therapy/Endodontics Periodontal Scaling and Root Planning Surgical Extractions of Impacted Teeth Brush Biopsies Oral Surgery – All except simple extractions Anesthetics Oral Surgery – Simple extractions Class III - Major Restorative Care Crowns Denture Repairs Denture Relines, Rebases and Adjustments Repairs to Bridges, Crowns and Inlays Dentures Bridges Inlays/Onlays Prosthesis Over Implant Class IV - Orthodontia Class IX - Implants Deductible Annual Maximum 28

40% Subject to plan deductible Subject to plan annual maximum

Dental PPO - High and Low Plans Procedure

Exclusions and Limitations

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

50% coverage on Class III and IV for 12 months Two per Calendar year Two per Calendar year 2 per Calendar year for people under 19 Bitewings: 2 per Calendar year Full mouth: 1 every 36 consecutive months, Panorex: 1 every 36 consecutive months Payable only when in conjunction with Ortho workup Various limitations depending on the service Various limitations depending on the service Replacement every 5 years Replacement every 5 years Replacement every 5 years Covered if more than 6 months after installation Covered if more than 6 months after installation Reviewed if more than once Reviewed if more than once Limited to posterior tooth. One treatment per tooth every three years up to age 14 Limited to non-Orthodontic treatment 1 per 60 consecutive months if unserviceable and cannot be repaired. Benefits are based on the amount payable for nonprecious metals. No porcelain or white/tooth colored material on molar crowns or bridges When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses

Alternate Benefit

Benefit Exclusions     

                   

Services performed primarily for cosmetic reasons Replacement of a lost or stolen appliance Replacement of a bridge or denture within five years following the date of its original installation Replacement of a bridge or denture which can be made useable according to accepted dental standards Procedures, appliances or restorations, other than full dentures, whose main purpose is to change vertical dimension, diagnose or treat conditions of TMJ, stabilize periodontally involved teeth, or restore occlusion Veneers of porcelain or acrylic materials on crowns or pontics on or replacing the upper and lower first, second and third molars Bite registrations; precision or semi-precision attachments; splinting A surgical implant of any type Instruction for plaque control, oral hygiene and diet Dental services that do not meet common dental standards Services that are deemed to be medical services Services and supplies received from a hospital Charges which the person is not legally required to pay Charges made by a hospital which performs services for the U.S. Government if the charges are directly related to a condition connected to a military service Experimental or investigational procedures and treatments Any injury resulting from, or in the course of, any employment for wage or profit Any sickness covered under any workers’ compensation or similar law Charges in excess of the reasonable and customary allowances To the extent that payment is unlawful where the person resides when the expenses are incurred; Procedures performed by a Dentist who is a member of the covered person’s family (covered person’s family is limited to a spouse, siblings, parents, children, grandparents, and the spouse’s siblings and parents); For charges which would not have been made if the person had no insurance; For charges for unnecessary care, treatment or surgery; To the extent that you or any of your Dependents is in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid; To the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply with a “no-fault” insurance law or an uninsured motorist insurance law. Cigna HealthCare will take into account any adjustment option chosen under such part by you or any one of your Dependents. In addition, these benefits will be reduced so that the total payment will not be more than 100% of the charge made for the Dental Service if benefits are provided for that service under this plan and any medical expense plan or prepaid treatment program sponsored or made available by your Employer.

Missing Tooth Limitation – The amount payable is 50% of the amount otherwise payable until insured for 12 months; thereafter, considered a Class III expense. Pretreatment review is available on a voluntary basis when extensive dental work in excess of $200 is proposed. * Subject to annual deductible Dental Oral Health Integration Program (OHIP) - All dental customers = Clinical research shows an association between oral health and overall health. The Cigna Dental Oral Health Integration Program (OHIP)® is designed to provide enhanced dental coverage for customers with certain eligible medical conditions. Eligible conditions for the program include cardiovascular disease, cerebrovascular disease (stroke), diabetes, maternity, chronic kidney disease, organ transplants, and head and neck cancer radiation. The program provides:  100% coverage for certain dental procedures  guidance on behavioral issues related to oral health  discounts on prescription and non-prescription dental products For more information and to see the complete list of eligible conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24. **For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Contracted Fee Schedule. For services provided by an out-of-network dentist, Cigna Dental will reimburse according to the Contracted Fee Schedule but the dentist may balance bill up to their usual fees. # Increase contingent upon receiving Preventive Services in Plan Year 1 + Increase contingent upon receiving Preventive Services in Plan Years 1 and 2 ^ Increase contingent upon receiving Preventive Services in Plan Years 1, 2 and 3

SUPERIOR VISION YOUR BENEFITS PACKAGE

Vision

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

DID YOU KNOW?

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

Vision Benefits Exam Frames Contact Lenses1

In-Network

Out-of-Network

Covered in full $125 retail allowance $150 retail allowance

Up to $35 retail Up to $70 retail Up to $80 retail

Covered in full

Up to $150 retail

Medically Necessary Contact Lenses

$200 allowance2

Lasik Vision Correction

Lenses (standard) per pair Single Vision Bifocal Trifocal Progressive Lenticular

Covered in full Covered in full Covered in full See description3 Covered in full

Up to $25 retail Up to $40 retail Up to $45 retail Up to $45 retail Up to $80 retail

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

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

$7.47 $12.77 $13.49 $20.29

Co-Pays Exam Materials

$10 $25

Services/Frequency Exam Frame Lenses Contact Lenses

12 months 12 months 12 months 12 months

(Based on date of service)

Contact lenses and related professional services (fitting, evaluation and followup) are covered in lieu of eyeglass lenses and frames benefit. 2 Lasik Vision Correction is in lieu of eyewear benefit, subject to routine regulatory filings and certain exclusions and limitations 3 Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay

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

SuperiorVision.com Customer Service 800.507.3800

The Plan discount features are not insurance. All allowances are retail; the member is responsible for paying the provider directly for all non-covered items and/or any amount over the allowances, minus available discounts. These are not covered by the plan. Discounts are subject to change without notice. Disclaimer: All final determinations of benefits, administrative duties, and definitions are governed by the Certificate of Insurance for your vision plan. Please check with your Human Resources department if you have any questions 31

THE HARTFORD YOUR BENEFITS PACKAGE

Disability

About this Benefit Disability insurance protects one of your most valuable assets, your paycheck. This insurance will replace a portion of your income in the event that you become physically unable to work due to sickness or injury for an extended period of time.

DID YOU KNOW?

Just over 1 in 4 of today's 20 year -olds will become disabled before they retire.

34.6 months is the duration of the average disability claim.

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

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Mental Illness, Alcoholism and Substance Abuse 

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

Benefit Reductions Your benefit payments may be reduced by other income you receive or are eligible to receive due to your disability, such as:  Social Security Disability Insurance (please see www.mybenefitshub.com/raymondvilleisd for exceptions)  Workers' Compensation  Other employer-based Insurance coverage you may have  Unemployment benefits  Settlements or judgments for income loss  Retirement benefits that your employer fully or partially pays for (such as a pension plan.)

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Exclusions You cannot receive Disability benefit payments for disabilities that are caused or contributed to by:  War or act of war (declared or not)  Military service for any country engaged in war or other armed conflict  The commission of, or attempt to commit a felony  An intentionally self-inflicted injury  Any case where your being engaged in an illegal

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

What other benefits are included in my disability coverage? 



Your benefit payments will not be reduced by certain kinds of other income, such as:  Retirement benefits if you were already receiving them before you became disabled  Retirement benefits that are funded by your after-tax contributions  Your personal savings, investment, IRAs or Keoghs  Profit-sharing  Most personal disability policies  Social Security increases Coverage goes into effect subject to the terms and conditions of the policy. You must satisfy the definition of Actively at Work with your employer on the day your coverage takes effect.

occupation was a contributing cause to your disability You must be under the regular care of a physician to receive benefits

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

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

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

PREMIUM OPTIONâ&#x20AC;&#x201D;MONTHLY PREMIUM COST Annual Earnings $3,600 $5,400 $7,200 $9,000 $10,800 $12,600 $14,400 $16,200 $18,000 $19,800 $21,600 $23,400 $25,200 $27,000 $28,800 $30,600 $32,400 $34,200 $36,000 $37,800 $39,600 $41,400 $43,200 $45,000 $46,800 $48,600 $50,400 $52,200 $54,000 $55,800 $57,600 $59,400

Monthly Earnings $300 $450 $600 $750 $900 $1,050 $1,200 $1,350 $1,500 $1,650 $1,800 $1,950 $2,100 $2,250 $2,400 $2,550 $2,700 $2,850 $3,000 $3,150 $3,300 $3,450 $3,600 $3,750 $3,900 $4,050 $4,200 $4,350 $4,500 $4,650 $4,800 $4,950

Monthly Benefit $200 $300 $400 $500 $600 $700 $800 $900 $1,000 $1,100 $1,200 $1,300 $1,400 $1,500 $1,600 $1,700 $1,800 $1,900 $2,000 $2,100 $2,200 $2,300 $2,400 $2,500 $2,600 $2,700 $2,800 $2,900 $3,000 $3,100 $3,200 $3,300

(based on 12 payments per year) Accident/Sickness Elimination Period in Days 0/7 14 / 14 30 / 30 60 / 60 90 / 90 $6.34 $5.66 $5.04 $3.40 $2.54 $9.51 $8.49 $7.56 $5.10 $3.81 $12.68 $11.32 $10.08 $6.80 $5.08 $15.85 $14.15 $12.60 $8.50 $6.35 $19.02 $16.98 $15.12 $10.20 $7.62 $22.19 $19.81 $17.64 $11.90 $8.89 $25.36 $22.64 $20.16 $13.60 $10.16 $28.53 $25.47 $22.68 $15.30 $11.43 $31.70 $28.30 $25.20 $17.00 $12.70 $34.87 $31.13 $27.72 $18.70 $13.97 $38.04 $33.96 $30.24 $20.40 $15.24 $41.21 $36.79 $32.76 $22.10 $16.51 $44.38 $39.62 $35.28 $23.80 $17.78 $47.55 $42.45 $37.80 $25.50 $19.05 $50.72 $45.28 $40.32 $27.20 $20.32 $53.89 $48.11 $42.84 $28.90 $21.59 $57.06 $50.94 $45.36 $30.60 $22.86 $60.23 $53.77 $47.88 $32.30 $24.13 $63.40 $56.60 $50.40 $34.00 $25.40 $66.57 $59.43 $52.92 $35.70 $26.67 $69.74 $62.26 $55.44 $37.40 $27.94 $72.91 $65.09 $57.96 $39.10 $29.21 $76.08 $67.92 $60.48 $40.80 $30.48 $79.25 $70.75 $63.00 $42.50 $31.75 $82.42 $73.58 $65.52 $44.20 $33.02 $85.59 $76.41 $68.04 $45.90 $34.29 $88.76 $79.24 $70.56 $47.60 $35.56 $91.93 $82.07 $73.08 $49.30 $36.83 $95.10 $84.90 $75.60 $51.00 $38.10 $98.27 $87.73 $78.12 $52.70 $39.37 $101.44 $90.56 $80.64 $54.40 $40.64 $104.61 $93.39 $83.16 $56.10 $41.91

180 / 180 $1.94 $2.91 $3.88 $4.85 $5.82 $6.79 $7.76 $8.73 $9.70 $10.67 $11.64 $12.61 $13.58 $14.55 $15.52 $16.49 $17.46 $18.43 $19.40 $20.37 $21.34 $22.31 $23.28 $24.25 $25.22 $26.19 $27.16 $28.13 $29.10 $30.07 $31.04 $32.01

Disability PREMIUM OPTIONâ&#x20AC;&#x201D;MONTHLY PREMIUM COST Annual Earnings $61,200 $63,000 $64,800 $66,600 $68,400 $70,200 $72,000 $73,800 $75,600 $77,400 $79,200 $81,000 $82,800 $84,600 $86,400 $88,200 $90,000 $91,800 $93,600 $95,400 $97,200 $99,000 $100,800 $102,600 $104,400 $106,200 $108,000 $109,800 $111,600 $113,400 $115,200 $117,000 $118,800 $120,600 $122,400 $124,200 $126,000 $127,800 $129,600 $131,400 $133,200 $135,000

Monthly Earnings $5,100 $5,250 $5,400 $5,550 $5,700 $5,850 $6,000 $6,150 $6,300 $6,450 $6,600 $6,750 $6,900 $7,050 $7,200 $7,350 $7,500 $7,650 $7,800 $7,950 $8,100 $8,250 $8,400 $8,550 $8,700 $8,850 $9,000 $9,150 $9,300 $9,450 $9,600 $9,750 $9,900 $10,050 $10,200 $10,350 $10,500 $10,650 $10,800 $10,950 $11,100 $11,250

Monthly Benefit $3,400 $3,500 $3,600 $3,700 $3,800 $3,900 $4,000 $4,100 $4,200 $4,300 $4,400 $4,500 $4,600 $4,700 $4,800 $4,900 $5,000 $5,100 $5,200 $5,300 $5,400 $5,500 $5,600 $5,700 $5,800 $5,900 $6,000 $6,100 $6,200 $6,300 $6,400 $6,500 $6,600 $6,700 $6,800 $6,900 $7,000 $7,100 $7,200 $7,300 $7,400 $7,500

(based on 12 payments per year) Accident/Sickness Elimination Period in Days 0/7 14 / 14 30 / 30 60 / 60 90 / 90 $107.78 $96.22 $85.68 $57.80 $43.18 $110.95 $99.05 $88.20 $59.50 $44.45 $114.12 $101.88 $90.72 $61.20 $45.72 $117.29 $104.71 $93.24 $62.90 $46.99 $120.46 $107.54 $95.76 $64.60 $48.26 $123.63 $110.37 $98.28 $66.30 $49.53 $126.80 $113.20 $100.80 $68.00 $50.80 $129.97 $116.03 $103.32 $69.70 $52.07 $133.14 $118.86 $105.84 $71.40 $53.34 $136.31 $121.69 $108.36 $73.10 $54.61 $139.48 $124.52 $110.88 $74.80 $55.88 $142.65 $127.35 $113.40 $76.50 $57.15 $145.82 $130.18 $115.92 $78.20 $58.42 $148.99 $133.01 $118.44 $79.90 $59.69 $152.16 $135.84 $120.96 $81.60 $60.96 $155.33 $138.67 $123.48 $83.30 $62.23 $158.50 $141.50 $126.00 $85.00 $63.50 $161.67 $144.33 $128.52 $86.70 $64.77 $164.84 $147.16 $131.04 $88.40 $66.04 $168.01 $149.99 $133.56 $90.10 $67.31 $171.18 $152.82 $136.08 $91.80 $68.58 $174.35 $155.65 $138.60 $93.50 $69.85 $177.52 $158.48 $141.12 $95.20 $71.12 $180.69 $161.31 $143.64 $96.90 $72.39 $183.86 $164.14 $146.16 $98.60 $73.66 $187.03 $166.97 $148.68 $100.30 $74.93 $190.20 $169.80 $151.20 $102.00 $76.20 $193.37 $172.63 $153.72 $103.70 $77.47 $196.54 $175.46 $156.24 $105.40 $78.74 $199.71 $178.29 $158.76 $107.10 $80.01 $202.88 $181.12 $161.28 $108.80 $81.28 $206.05 $183.95 $163.80 $110.50 $82.55 $209.22 $186.78 $166.32 $112.20 $83.82 $212.39 $189.61 $168.84 $113.90 $85.09 $215.56 $192.44 $171.36 $115.60 $86.36 $218.73 $195.27 $173.88 $117.30 $87.63 $221.90 $198.10 $176.40 $119.00 $88.90 $225.07 $200.93 $178.92 $120.70 $90.17 $228.24 $203.76 $181.44 $122.40 $91.44 $231.41 $206.59 $183.96 $124.10 $92.71 $234.58 $209.42 $186.48 $125.80 $93.98 $237.75 $212.25 $189.00 $127.50 $95.25

180 / 180 $32.98 $33.95 $34.92 $35.89 $36.86 $37.83 $38.80 $39.77 $40.74 $41.71 $42.68 $43.65 $44.62 $45.59 $46.56 $47.53 $48.50 $49.47 $50.44 $51.41 $52.38 $53.35 $54.32 $55.29 $56.26 $57.23 $58.20 $59.17 $60.14 $61.11 $62.08 $63.05 $64.02 $64.99 $65.96 $66.93 $67.90 $68.87 $69.84 $70.81 $71.78 $72.75

AMERICAN PUBLIC LIFE

Cancer

YOUR BENEFITS PACKAGE

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

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

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

GC3 Limited Benefit Group Cancer Indemnity Insurance Raymondville ISD

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

Summary of Benefits Benefits

Level 1 Plan

Level 2 Plan

Radiation Therapy/Chemotherapy/ Immunotherapy Benefit

$500 per calendar month of treatment

$1,000 per calendar month of treatment

Hormone Therapy Benefit

$50 per treatment, up to 12 per calendar year

Surgical Schedule Benefit

$1,600 max per operation; $15 per surgical unit

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

Anesthesia Benefit

25% of the amount paid for covered surgery

Hospital Confinement Benefit

$100 per day 1-90 days; $100 per day, 91+ days in lieu of other benefits

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

US Government/Charity Hospital/HMO

$100 per day in lieu of most other benefits

$200 per day in lieu of most other benefits

Outpatient Hospital or Ambulatory Surgical Center Benefit

$200 per day of surgery

$400 per day of surgery

Drugs & Medicine Benefit - Inpatient

$150 per confinement

Drugs & Medicine Benefit - Outpatient

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

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

Transportation & Outpatient Lodging Benefit

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

Family Member Transportation & Lodging Benefit

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

Blood, Plasma & Platelets Benefit

$150 per day, up to $7,500 per calendar year

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

Bone Marrow/Stem Cell Transplant

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

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

Experimental Treatment Benefit

Pays as any non-experimental benefit

Attending Physician Benefit

$30 per day of confinement

$40 per day of confinement

Surgical Prosthesis Benefit

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

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

Hair Prosthesis Benefit

$50 per hair prosthetic, 2 lifetime max

Dread Disease Benefit

$100 per day, 1-90 days of hospital confinement

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

Hospice Care Benefit

$50 per day, $9,000 lifetime max

$75 per day, $13,500 lifetime max

Inpatient Special Nursing Services

$150 per day of confinement

Ambulance Ground Benefit

$200 per ground trip

Ambulance Air Benefit

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

Extended Care Benefit

$100 per day

$200 per day

Home Health Care Benefit

$100 per day

$200 per day

Second & Third Surgical Opinions

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

Waiver of Premium

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

Physical/Speech Therapy Benefit

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

Diagnostic Testing Benefit Rider

$50; 1 person, per calendar year

Critical Illness Rider: Heart Attack/Stroke

$2,500 lump sum benefit

Up to $600 max of 30 days per ICU confinement; $100 ambulance per ICU admission

Riders

Optional Benefit Rider Intensive Care Unit Rider

APSB-22356(TX) MGM/FBS Raymondville ISD-0316

GC3 Limited Benefit Group Cancer Indemnity Insurance Total Monthly Premium**

Level 1

Level 1 + ICU Rider

Level 2

Level 2 + ICU Rider

Individual

$12.50

$15.50

$20.00

$23.00

One-Parent Family

$17.30

$21.50

$27.50

$31.70

Two-Parent Family

$22.10

$28.40

$35.00

$41.30

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

Eligibility

Diagnostic Testing Benefit Rider

If You are working either under contract to or as a Full-Time Employee for the Policyholder, or You are a member in or employed by the association, You are eligible for insurance provided You qualify for coverage as defined in the Master Application. You must apply for insurance within thirty (30) days of the Policy Effective Date or the date that You become eligible for coverage. If You do not apply within thirty (30) days of the Policy Effective Date or the date You become eligible for coverage, You may be subject to additional underwriting by Us.

Critical Illness Rider

This policy/certificate will be issued only to those persons who meet American Public Life Insurance Company’s insurability requirements. The policy/certificate and the Internal Cancer coverage under the Critical Illness Rider will not be issued to anyone who has been diagnosed or treated for Cancer in the previous ten years. The Heart Attack or Stroke coverage under the Critical Illness Rider will not be issued to anyone who has been diagnosed or treated for any heart or stroke related conditions. The Hospital Intensive Care Unit Rider will not cover heart conditions for a period of two years following the Effective Date of coverage for anyone who has been diagnosed or treated for any heart related condition prior to the 30th day following the Covered Person’s Effective Date of coverage.

Base Policy

All diagnosis of cancer must be positively diagnosed by a legally licensed doctor of medicine certified by the American Board of Pathology or American Board of Osteopathic Pathology. This policy/certificate pays only for loss resulting from definitive cancer treatment including direct extension, metastatic spread or recurrence. Proof must be submitted to support each claim. This policy/certificate also covers other conditions or diseases directly caused by cancer or the treatment of cancer. No benefits are payable for any covered person for any loss incurred during the first year of this policy/certificate as a result of a Pre-Existing Condition. A PreExisting Condition is a specified disease for which, within 12 months prior to the covered person’s effective date of coverage, medical advice, consultation or treatment, including prescribed medications, was recommended by or received from a member of the medical profession, or for which symptoms manifested in such a manner as would cause an ordinarily prudent person to seek diagnosis, medical advice or treatment. Pre-Existing Conditions specifically named or described as excluded in any part of this contract are never covered. This policy/certificate contains a 30-day waiting period during which no benefits will be paid under this policy/certificate. If any covered person has a specified disease diagnosed before the end of the 30-day period immediately following the covered person’s effective date, coverage for that person will apply only to loss that is incurred after one year from the effective date of such person’s coverage. If any covered person is diagnosed as having a specified disease during the 30-day period immediately following the effective date, you may elect to void the policy/certificate from the beginning and receive a full refund of premium. All benefits payable only up to the maximum amount listed in the schedule of benefits in the policy/certificate. A Hospital is not an institution which is primarily a place for alcoholics or drug addicts; the aged; a nursing, rest or convalescent nursing home; a mental institution or sanitarium; a facility contracted for or operated by the United States Government for treatment of members or ex-members of the armed forces (unless You are legally required to pay for services rendered in the absence of insurance); or, a long-term nursing unit or geriatrics ward.

APSB-22356(TX) 38

MGM/FBS Raymondville ISD-0316

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

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

Hospital Intensive Care Unit Rider

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

GC3 Limited Benefit Group Cancer Indemnity Insurance Conditionally Renewable

Continuation Rider Continuation

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

Termination of Coverage

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

Termination of Rider Coverage

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

Conversion

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

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

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

APSB-22356(TX) MGM/FBS Raymondville ISD-0316

AMERICAN PUBLIC LIFE YOUR BENEFITS PACKAGE

Accident

About this Benefit Accident insurance is designed to supplement your medical insurance coverage by covering indirect costs that can arise with a serious, or a not-so-serious, injury. Accident coverage is low cost protection available to you and your family without evidence of insurability.

DID YOU KNOW?

2/3 of disabling injuries suffered by American workers are not work related. American workers 36% ofreport they always or

usually live paycheck to paycheck.

A3 Supplemental Limited Benefit Accident Expense Insurance Raymondville ISD

AMERICAN PUBLIC LIFE YOUR BENEFITS

Accident

Summary of Benefits* Benefit Description Accidental Death - per unit Medical Expense Accidental Injury Benefit - per unit Daily Hospital Confinement Benefit Air and Ground Ambulance Benefit

DID YOU KNOW?

2/3 of disabling injuries suffered by American workers are not work American workers 36% ofreport they always or

Level 2 - 2 Units

Level 3 - 3 Units

Level 4 - 4 Units

$5,000

$10,000

$15,000

$20,000

actual charges up to actual charges up to actual charges up to actual charges up to $500 $1,000 $1,500 $2,000 $75 per day

$150 per day

$225 per day

$300 per day

actual charges up to actual charges up to actual charges up to actual charges up to $1,250 $2,500 $3,750 $5,000

Accidental Dismemberment Benefit Single finger or toe Multiple fingers or toes Single hand, arm, foot or leg Multiple hands, arms, feet or legs

$500 $500 $2,500 $5,000

$1,000 $1,000 $5,000 $10,000

$1,500 $1,500 $7,500 $15,000

$2,000 $2,000 $10,000 $20,000

Accidental Loss of Sight Benefit - per unit Loss of Sight in one eye Loss of Sight in both eyes

$2,500 $5,000

$5,000 $10,000

$7,500 $15,000

$10,000 $20,000

Individual

Individual & Spouse

1 Parent Family

2 Parent Family

$10.80 $17.10 $21.50 $24.50

$19.40

$21.20 $34.90 $45.20 $52.00

$29.80 $47.60 $62.60 $72.40

Level 1 - 1 Unit

Level 1 - 1 Unit Level 2 - 2 Units Level 3 - 3 Units Level 4 - 4 Units

$29.80 $38.90 $44.90

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

usually live paycheck to paycheck.

(03/16)

APSB-22329(TX)-MGM/FBS Raymondville ISD

A3 Supplemental Limited Benefit Accident Expense Insurance Limitations and Exclusions Eligibility This policy will be issued to only those persons who meet American Public Life Insurance Company’s insurability requirements. Persons not meeting APL’s insurability requirements will be excluded from coverage by an endorsement attached to the policy.

Base Policy and Optional Benefits

Exclusions Benefits otherwise provided by this Policy will not be payable for services or expenses or any such Loss resulting from or in connection with: (1) (2) (3)

No benefits are payable for a pre-existing condition. Preexisting condition means an Injury that pertains solely to an Accidental Bodily Injury which resulted from an accident sustained before the Effective Date of coverage. Pre-Existing Conditions specifically named or described as permanently excluded in any part of this contract are never covered.

(4)

A Hospital is not an institution which is primarily a place for alcoholics or drug addicts; the aged; a nursing, rest or convalescent nursing home; a mental institution or sanitarium; a facility contracted for or operated by the United States Government for treatment of members or ex-members of the armed forces (unless You are legally required to pay for services rendered in the absence of insurance); or, a long-term nursing unit or geriatrics ward.

(7)

(5) (6)

(8)

(9) (10)

Medical Expense Accidental Injury Benefit Expenses must commence within 60 days of the covered accident. The maximum benefit amount payable for any one accident for the Insured Person shall not exceed the Medical Expense Benefit.

Air and Ground Ambulance Benefit Emergency transportation must occur within 21 calendar days of the accident causing such Injury.

Daily Hospital Confinement Benefit

(11)

(12) (13) (14)

The maximum benefit period for this benefit is 30 days per covered accident.

(15)

Accidental Death

(16)

Accidental Death must result within 90 days of the covered accident causing the injury.

sickness, illness or bodily infirmity; suicide, attempted suicide or intentional self-inflicted Injury, whether sane or insane; dental care or treatment unless due to accidental Injury to natural teeth; war or any act of war (whether declared or undeclared) or participating in a riot or felony; alcoholism or drug addiction; travel or flight in or descent from any aircraft or device which can fly above the earth’s surface in any capacity other than as a fare paying passenger on a regularly scheduled airline; Injury originating prior to the effective date of the Policy; Injury occurring while intoxicated (Intoxication means that which is determined and defined by the laws and jurisdiction of the geographical area in which the loss or cause of loss is incurred.); Voluntary inhalation of gas or fumes or taking of poison or asphyxiation; Voluntary ingestion or injection of any drug, narcotic or sedative, unless administered on the advice and taken in such doses as prescribed by a Physician; Injury sustained or sickness which first manifests itself while on full-time duty in the armed forces; (Upon notice, We will refund the proportion of unearned premium while in such forces.) Injury incurred while engaging in an illegal occupation; Injury incurred while attempting to commit a felony or an assault; Injury to a covered person while practicing for or being a part of organized or competitive rodeo, sky diving, hang gliding, parachuting or scuba diving; driving in any race or speed test or while testing an automobile or any vehicle on any racetrack or speedway; hernia, carpal tunnel syndrome or any complication therefrom;

A3 Supplemental Limited Benefit Accident Expense Insurance If You are entitled to benefits under this Policy as a result of sprained or lame back, or any intervertebral disk conditions, such benefits shall be payable for a maximum period of time, not exceeding in the aggregate three (3) months for any Injury.

Guaranteed Renewable You have the right to renew this Policy until the first premium due date on or after Your 69th birthday, if you pay the correct premium when due or within the Grace Period. When an Insured’s coverage terminates at age 70, coverage for other Insured Persons, if any, shall continue under this Policy. We have the right to change premium rates by class.

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

Accidental Dismemberment Benefit The total amount payable for all Losses resulting from the same accident will not exceed the Maximum Dismemberment Benefit of $5,000 cumulative per unit, per Accident. Loss must be within 90 days of the accident causing such Injury.

APSB-22329(TX)-MGM/FBS Raymondville ISD

Underwritten by American Life Insurance Company. This is a brief description of the coverage. For actual benefits, limitations, exclusions and other provisions, please refer to the policy and riders. This coverage does not replace Workers’ Compensation Insurance. | This product is inappropriate for people who are eligible for Medicaid coverage. | Policy Form A3 Series | Texas | Supplemental Limited Benefit Accident Expense Insurance Policy | (10/14) | Raymondville ISD

APSB-22329(TX)-MGM/FBS Raymondville ISD

Base Policy and Optional Benefits

Exclusions Benefits otherwise provided by this Policy will not be payable for services or expenses or any such Loss resulting from or in connection with: (1) (2) (3)

(4)

(7)

(5) (6)

(8)

(9) (10)

Air and Ground Ambulance Benefit Emergency transportation must occur within 21 calendar days of the accident causing such Injury.

Daily Hospital Confinement Benefit

(11)

(12) (13) (14)

The maximum benefit period for this benefit is 30 days per covered accident.

(15)

Accidental Death

(16)

Accidental Death must result within 90 days of the covered accident causing the injury.

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

APSB-22329(TX)-MGM/FBS Raymondville ISD

CIGNA YOUR BENEFITS PACKAGE

Life and AD&D

About this Benefit Group term life is the most inexpensive way to purchase life insurance. You have the freedom to select an amount of life insurance coverage you need to help protect the well-being of your family. Accidental Death & Dismemberment is life insurance coverage that pays a death benefit to the beneficiary, should death occur due to a covered accident. Dismemberment benefits are paid to you, according to the benefit level you select, if accidentally dismembered.

DID YOU KNOW? Motor vehicle crashes are the

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

Life and AD&D Basic and Voluntary Term Life Eligibility Active, full-time Employees of the Employer regularly working a minimum of 30 hours per week . Eligibility Waiting Period You are eligible for benefits on the first of the month following the date of hire.

Basic Term Life (paid by your employer) Employee  Benefit Amount and Maximum – $10,000  Benefit Reduction Schedule – Benefits will reduce to 35% at age 65, 50% at age 70

Voluntary Term Life (paid by you) Employee  Benefit Amount – Units of $10,000  Guaranteed Coverage Amount – $200,000  Maximum – The lesser of 7 times salary or $500,000  Benefit Reduction Schedule – Benefits will reduce to 35% at age 65, 50% at age 70 Spouse (up to age 70) — Spouse is eligible provided that you apply for and are approved for coverage for yourself.  Benefit Amount – Units of $5,000  Guaranteed Coverage Amount – $50,000  Maximum – The lesser of $250,000 or 50% of the Employee’s Voluntary Life Insurance Amount. Dependent Children — Under age 19 (or under age 26 if they are full-time students) , as long as you apply for and are approved for coverage for yourself. Premium includes all eligible children.  Maximum Per Child – $10,000  Benefit Amount from birth to 6 months – $500

Basic and Voluntary AD&D Eligibility Active, full-time Employees of the Employer regularly working a minimum of 30 hours per week. Eligibility Waiting Period You are eligible for benefits on the first of the month following the date of hire.

Basic AD&D (paid by your employer) Employee  Benefit Amount and Maximum – $10,000  Benefit Reduction Schedule – Benefits will reduce to 35% at age 65, 50% at age 70

Voluntary AD&D (paid by you) Employee  Benefit Amount – Units of $10,000  Maximum – $500,000



Benefit Reduction Schedule – Benefits will reduce to 35% at age 65, 50% at age 70

Spouse (up to age 70) — Spouse is eligible provided that you apply for and are approved for coverage for yourself.  Benefit Amount – 50% of the employee’s sum if no children are insured. 40% of the employee’s sum if children are insured.  Maximum – $250,000 Dependent Children — Under age 19 (or under age 26 if they are full-time students) , as long as you apply for and are approved for coverage for yourself.  Benefit Amount – 10% of the employee’s sum if spouse is insured. 15% of the employee’s sum if spouse is not insured.  Maximum – $10,000 No one may be covered more than once under this plan. *For purposes of this brochure, wherever the term Spouse appears it shall also include Domestic Partner or Civil Union Partner. Your domestic partner is eligible for insurance if he or she meets specific criteria stated in the Group Policy. Additional information is available from your Benefit Services Representative.

Guaranteed Coverage for Voluntary Term Life Insurance Guaranteed Coverage Amount is the amount of coverage you can elect without answering any medical questions or taking a health exam. Guaranteed Coverage is only available during Initial Enrollment and other times as approved. If you apply for coverage that is above the Guaranteed Coverage Amount, or if you are applying for coverage after 31 days after you become eligible, you must fill out a Medical Evidence of Insurability form. All dependent child benefits are guaranteed issue.

How Much Your Voluntary Life Coverage Will Cost per Month* Age

Employee Cost Per $1,000

Spouse Cost Per $1,000

$0.06 $0.08 $0.09 $0.12 $0.18 $0.29 $0.45 $0.71 $1.27 $2.06 $3.21

$0.06 $0.08 $0.09 $0.12 $0.18 $0.29 $0.45 $0.71 $1.27 N/A N/A

<29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+ Child Rate per $1,000

$0.20

*Costs are subject to change 45

Life and AD&D How Much Your Voluntary AD&D Coverage Will Cost per Month*

have insured your spouse or children, their premium is also waived.

The cost of the voluntary insurance is paid by you. Indicate your desired election on your enrollment form.

Rehabilitation During a Period of Disability If the insurance company determines that you are a suitable candidate for rehabilitation, the insurance company may require you to participate in an assessment and rehabilitation plan, not to exceed 18 months. A rehabilitation plan may consist of educational, vocational or physical rehabilitation or may include modified work or work on a part-time basis. If you refuse such assistance without good cause (a medical reason preventing participation, in whole or in part, in the rehabilitation plan), insurance under this plan will end.

Cost Per $1,000 Employee

$0.03

Family

$0.06

Other Voluntary Life Coverage Features Accelerated Death Benefitâ&#x20AC;&#x201D;Terminal Illness If you or your spouse is diagnosed by two unaffiliated physicians as terminally ill with a life expectancy of 12 months or less, the benefit for terminal illness provides for up to 75% of the Basic Term Life Insurance coverage amount in-force or $257,000, whichever is less of the Voluntary Term Life Insurance coverage amount in-force, to be paid to the insured. This benefit is payable only once in the insured's lifetime, and will reduce the life insurance death benefit. Continuation for Disability for Employees Age 60 or over If your active service ends due to disability, at age 60 or over, your coverage will continue while you are disabled. Benefits will remain in force until the earliest of: the date you are no longer disabled, the date the policy terminates, the date you are Disabled for 12 consecutive months, or the day after the last period for which premiums are paid. You are considered disabled if, because of injury or sickness, you are unable to perform all the material duties of your Regular Occupation, or you are receiving disability benefits under your Employerâ&#x20AC;&#x2122;s plan. Extended Death Benefit The extended death benefit ensures that if you become disabled prior to age 60, and die before it is determined if you qualify for Waiver of Premium, we will pay the life insurance benefit if you remain disabled during that period. If you qualify for this benefit and have insured your spouse or children, their coverage is also extended. No additional premium payment is required for the extended coverage. Waiver of Premium If you are totally disabled prior to age 65 and can't work for at least 9 months, you won't need to pay premiums for your coverage while you are disabled, provided the insurance company approves you for this benefit. You are considered totally disabled when you are completely unable to engage in any occupation for wage or profit because of injury or sickness. This benefit will remain in force until age 65, subject to proof of continuing disability each year. If you qualify and

When Your Coverage Begins and Ends Coverage becomes effective on the later of the programâ&#x20AC;&#x2122;s effective date, the date you become eligible, the date we receive your completed enrollment form, or the date you authorize any necessary payroll deductions. Your coverage will not begin unless you are actively at work on the effective date. Dependent coverage will not begin for any dependent who on the effective date is hospital or home confined; receiving chemotherapy or radiation treatment; or disabled and under the care of a physician. Coverage will continue while you and your dependents remain eligible, the group policy is in force, and required premiums are paid. Conversion If group life coverage ends (except due to nonpayment of premium), your employment is terminated, membership in an eligible class is terminated, or insurance coverage is reduced based on attained age, you can convert to an individual non-term policy. To convert, you must apply for the conversion policy and pay the first premium payment within 31 days after your group coverage ends. Dependents may convert their coverage as well. Premiums may change at this time, and terms of coverage will be subject to change. Portability If your employment is terminated and you are under age 70, you can continue your [employee-paid] life insurance on a direct-bill basis. Coverage may also be continued for your spouse/children. Premiums will increase at this time. Coverage can be continued to age 70, unless the insurance company terminates portability for all insured persons. Refer to your certificate for details. Exclusions Life insurance will not be paid if you commit suicide, while sane or insane, within the first two years of coverage.

Life and AD&D A Valuable Combination of Benefits To help survivors of severe accidents adjust to new living circumstances, we will pay benefits according to the chart below. Only one benefit (the largest) will be paid for losses from the same accident. If, within 365 days of a covered accident, bodily injuries result in:  Loss of life  Total paralysis of upper and lower limbs, or  Loss of any combination of two: hands, feet or eyesight, or

 Loss of speech and hearing in both ears  Total paralysis of both lower or upper limbs  Total paralysis of upper and lower limbs on      

one side of the body, or Loss of hand, foot or sight in one eye, or Loss of speech or loss of hearing in both ears, or Severance and Reattachment of one hand or foot Total paralysis of one upper or lower limb, or Loss of all four fingers of the same hand, or Loss of thumb and index finger of the same hand Loss of all toes of the same foot

We will pay this % of the benefit amount: 100% 100% 75%

50%

25% 20%

Additional Benefits of Personal Accident Insurance For Wearing a Seatbelt & Protection by an Airbag Basic Accident Only Additional 10% benefit but not more than $1,000 if the covered person dies in an automobile accident while wearing a seatbelt. We will increase the benefit by an additional 5% but not more than $500 if the insured person was also positioned in a seat protected by a properly-functioning and properly deployed Supplemental Restraint System (Airbag). For Wearing a Seatbelt & Protection by an Airbag Voluntary Accident Only Additional 10% benefit but not more than $25,000 if the covered person dies in an automobile accident while wearing a seatbelt. We will increase the benefit by an additional 5% but not more than $10,000 if the insured person was also positioned in a seat protected by a properly-functioning and properly deployed Supplemental Restraint System (Airbag). For Comas 1% of full benefit amount, for up to 11 months, if you, your spouse, or your children are in a coma for 30 days or more as a result of a covered accident. If the covered person is still in a coma after 11 months, or dies, the full benefit amount will be paid.

For Training for Your Spouse If you die from a covered accident, your spouse will receive educational reimbursement if he or she enrolls, in an accredited school to gain skills needed for employment. We will pay the

actual cost of the education or training program to 3% of your benefit amount, not exceeding $3,000. What is Not Covered Self-inflicted injuries or suicide while sane or insane; commission or attempt to commit a felony or an assault; any act of war, declared or undeclared; any active participation in a riot, insurrection or terrorist act; bungee jumping; parachuting; skydiving; parasailing; hang-gliding; sickness, disease, physical or mental impairment, or surgical or medical treatment thereof, or bacterial or viral infection; voluntarily using any drug, narcotic, poison, gas or fumes except one prescribed by a licensed physician and taken as prescribed; while operating any type of vehicle while under the influence of alcohol or any drug, narcotic or other intoxicant including any prescribed drug for which the covered person has been provided a written warning against operating a vehicle while taking it; while the covered person is engaged in the activities of active duty service in the military, navy or air force of any country or international organization (this does not include Reserve or National Guard training, unless it extends beyond 31 days); traveling in an aircraft that is owned, leased or controlled by the sponsoring organization or any of its subsidiaries or affiliates; air travel, except as a passenger on a regularly scheduled commercial airline or in an aircraft being used by the Air Mobility Command or its foreign equivalent; being flown by the covered person or in which the covered person is a member of the crew. When Your Coverage Begins and Ends Coverage becomes effective on the later of the program’s effective date, the date you become eligible, the date we receive your completed enrollment form, or the date you authorize any necessary payroll deductions. Your coverage will not begin unless you are actively at work on the effective date. Dependent coverage will not begin for any dependent who on the effective date is hospital or home confined; receiving chemotherapy or radiation treatment; or disabled and under the care of a physician. Coverage will continue while you and your dependents remain eligible, the group policy is in force, and required premiums are paid. Conversion If, before you reach age 70, this group coverage is reduced or ends for any reason except nonpayment of premium or age, you can convert to an individual policy. No medical certification is needed. To continue coverage, you must apply for the conversion policy and pay the first premium in effect for your age and occupation within 31 days after your group coverage ends. Family members may convert their coverage as long as they have not reached the maximum age limitation. Converted policies are subject to certain benefits and limits as outlined in your certificate, should you become insured under the plan.

5STAR

Individual Life

YOUR BENEFITS PACKAGE

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

DID YOU KNOW? Experts recommend at least

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

Individual Life with Critical Illness The Family Protection Plan Term life insurance with Critical Illness coverage to age 100 This insurance is a voluntary benefit that is being provided through your employer to complement your overall benefit package. Most people are not prepared for the financial devastation that frequently accompanies death or the survival of a critical illness. The Family Protection Plan was developed to provide term life insurance protection and an instant emergency fund if an unexpected critical illness occurs, to age 100*. 



 



  

Term Insurance to Age 100. Offers a guaranteed level premium to age 100 and a guaranteed level death benefit for the first 10 years. After 10 years the death benefit is projected to remain level to age 100 and we do not anticipate a reduction in the future. The coverage amount cannot be individually decreased on a particular insured due to a change in age, health, or employment status. Critical Illness Benefit pays the insured 30% of the policy coverage amount in a lump sum upon the occurrence of heart attack, life threatening cancer, stroke, cardiac bypass or heart transplant surgery or a terminal condition. Portability. You and your family continue coverage with no loss of benefits or increase in cost should you terminate employment after the first premium is paid. Family Protection. Individual policies can be purchased on the employee, spouse, children and grandchildren. Children and Grandchildren Plan. Policies can also be purchased for children and grandchildren ages newborn through 23 for $4.33/month for a $10,000 policy or $8.67/ month for a $20,000 policy. Convenience. Premiums are taken care of simply and easily through payroll deductions. Easy Application Process. This insurance does not require a medical exam or blood profile. Eligibility for coverage is based on a few simple health questions on the application. Emergency Burial Benefit. Within 24 hours after receiving notice of an insured's death, an emergency death benefit of the lesser of 50% of the coverage amount, or $15,000 will be mailed to the insured's beneficiary, unless the death is within the two-year contestability period and/or under investigation.

The Family Protection Plan Covered Critical Illnesses Covered critical illnesses include:  Heart Attack  Life-Threatening Cancer  Stroke  Cardiac Bypass Surgery  Heart Transplant Surgery This benefit is also paid for terminal conditions

DID YOU KNOW? Those with no life insurance think it’s 3 times more expensive than it actually is.

The Benefits of Critical Illness Coverage More people are suffering from a critical illness than ever before. Chances are you have seen first hand the financial hardship that either a relative, close friend, or co-worker has had to endure during the recovery process of a critical illness. Most employee benefits plans are designed to cover specific expenses. But, The Family Protection Plan pays a one-time lump sum of 30% (25% in Michigan) of the policy benefit in cash directly to the owner-in addition to any other insurance plan the insured may have! There are no restrictions on how this benefit is used. *Age 95 in Maryland and Utah. Not available in all states.

Individual Life with Critical Illness These rates are for employees who elect this coverage 10-1-11 or later.

MONTHLY PREMIUMS & INITIAL COVERAGE AMOUNTS Critical Age on Coverage Illness Amount App. Date $10,000 Benefit $3,000

Coverage Critical Illness Amount Benefit $25,000 $7,500

Critical Coverage Critical Coverage Critical Coverage Critical Coverage Critical Illness Coverage Illness Amount Illness Amount Illness Amount Illness Amount Benefit Amount Benefit Benefit $125,000 Benefit $150,000 Benefit $50,000 $15,000 $75,000 $22,500 $100,000 $30,000 $37,500 $45,000

18-25

$8.25

$14.13

$23.92

$33.71

$43.50

$53.29

$63.08

$8.28

$14.19

$24.04

$33.90

$43.75

$53.60

$63.46

$8.33

$14.33

$24.33

$34.33

$44.33

$54.33

$64.33

$8.43

$14.56

$24.79

$35.02

$45.25

$55.48

$65.71

$8.54

$14.85

$25.38

$35.90

$46.42

$56.94

$67.46

$8.68

$15.21

$26.08

$36.96

$47.83

$58.71

$69.58

$8.83

$15.56

$26.79

$38.02

$49.25

$60.48

$71.71

$8.97

$15.92

$27.50

$39.08

$50.67

$62.25

$73.83

$9.13

$16.31

$28.29

$40.27

$52.25

$64.23

$76.21

$9.32

$16.79

$29.25

$41.71

$54.17

$66.63

$79.08

$9.55

$17.38

$30.42

$43.46

$56.50

$69.54

$82.58

$9.87

$18.17

$32.00

$45.83

$59.67

$73.50

$87.33

$10.27

$19.17

$34.00

$48.83

$63.67

$78.50

$93.33

$10.75

$20.38

$36.42

$52.46

$68.50

$84.54

$100.58

$11.32

$21.79

$39.25

$56.71

$74.17

$91.63

$109.08

$11.93

$23.33

$42.33

$61.33

$80.33

$99.33

$118.33

$12.55

$24.88

$45.42

$65.96

$86.50

$107.04

$127.58

$13.18

$26.44

$48.54

$70.65

$92.75

$114.85

$136.96

$13.82

$28.04

$51.75

$75.46

$99.17

$122.88

$146.58

$14.48

$29.71

$55.08

$80.46

$105.83

$131.21

$156.58

$15.19

$31.48

$58.63

$85.77

$112.92

$140.06

$167.21

$15.96

$33.40

$62.46

$91.52

$120.58

$149.65

$178.71

$16.79

$35.48

$66.63

$97.77

$128.92

$160.06

$191.21

$17.68

$37.69

$71.04

$104.40

$137.75

$171.10

$204.46

$18.59

$39.98

$75.63

$111.27

$146.92

$182.56

$218.21

$19.53

$42.33

$80.33

$118.33

$156.33

$194.33

$232.33

$20.50

$44.75

$85.17

$125.58

$166.00

$206.42

$246.83

$21.50

$47.25

$90.17

$133.08

$176.00

$218.92

$261.83

$22.56

$49.90

$95.46

$141.02

$186.58

$232.15

$277.71

$23.70

$52.75

$101.17

$149.58

$198.00

$246.42

$294.83

$24.96

$55.90

$107.46

$159.02

$210.58

$262.15

$313.71

Individual Life with Critical Illness These rates are for employees who elect this coverage 10-1-11 or later.

MONTHLY PREMIUMS & INITIAL COVERAGE AMOUNTS Critical Age on Coverage Illness Amount App. Date $10,000 Benefit $3,000

Coverage Critical Illness Amount Benefit $25,000 $7,500

$26.36

$59.40

$114.46

$169.52

$224.58

$279.65

$334.71

$27.90

$63.25

$122.17

$181.08

$240.00

$298.92

$357.83

$29.57

$67.42

$130.50

$193.58

$256.67

$319.75

$382.83

$31.34

$71.85

$139.38

$206.90

$274.42

$341.94

$409.46

$33.20

$76.50

$148.67

$220.83

$293.00

$365.17

$437.33

$35.10

$81.25

$158.17

$235.08

$312.00

$388.92

$465.83

$37.04

$86.10

$167.88

$249.65

$331.42

$413.19

$494.96

$39.04

$91.10

$177.88

$264.65

$351.42

$438.19

$524.96

$41.13

$96.31

$188.29

$280.27

$372.25

$464.23

$556.21

$43.40

$102.00

$199.67

$297.33

$395.00

$492.67

$590.33

$46.01

$108.52

$212.71

$316.90

$421.08

$525.27

$629.46

$49.16

$116.40

$228.46

$340.52

$452.58

$564.65

$676.71

$53.10

$126.25

$248.17

$370.08

$492.00

$613.92

$735.83

$58.04

$138.60

$272.88

$407.15

$541.42

$675.69

$809.96

$64.23

$154.08

$303.83

$453.58

$603.33

$753.08

$902.83

Available only on children and grandchildren of employee: $4.98 monthly Age on application date: Full-term newborn to 23 years Coverage amount—$10,000 Critical Illness benefits—$3,000 $9.97 monthly Age on application date: Full-term newborn to 23 years Coverage amount—$20,000 Critical Illness benefits—$6,000

ID WATCHDOG

Identity Theft

YOUR BENEFITS PACKAGE

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

DID YOU KNOW?

An identity is stolen every 2 seconds, and takes over

300 hours

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

Identity Theft Identity theft can strike anyone, at any time. More than 11 million Americans were victimized by identity theft in 2011, including more than 500,000 children.

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

Repairing the damage caused by identity theft is frustrating and time consuming. The average victim spends 330 hours repairing the damage from identity theftâ&#x20AC;&#x201D;the equivalent of working a full-time job for more than 2 months.

ID Watchdog Monthly Rates Plus

Platinum

Individual Plan

$7.95

$11.95

Family Plan

$14.95

$22.95

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

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

Whoâ&#x20AC;&#x2122;s Evaluating your Credit Report? Potential Creditors, Potential Employers, Insurance Companies, Current Creditors, Government Agencies

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.

FSA (Flexible Spending Account) NBS Flexcard

When Will I Receive My Flex Card?

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

NBS Prepaid MasterCard® Debit Card

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

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

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

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

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

FSA Annual Contribution Max:

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

$2,550

Dependent Care Annual Max: $5,000

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

Detailed claim history and processing status Health Care and Dependent Care account balances Claim forms, Direct Deposit form, worksheets, etc. Online claim FAQs 55

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

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

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

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

        

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

Dependent Care Expense Account Example Expenses:    

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

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

What Happens If I Don’t Use All of My Funds by The End of the Plan Year (September 30th)? Eligible expenses must be incurred within the plan year +75 day grace period. Contributions are use-it-or- lose-it. Remember to retain all your receipts (including receipts for card swipes). Please contact your benefits admin to determine if your district has the grace period or the $500 Roll-Over option. If your district does not have the roll-over, your plan contributions are use-it-or-lose-it.

How Do I File A Claim? In most situations, you will be able to swipe your card however, in the event you lose your card or are waiting to receive one, you can visit www.thebenfitshub.com/ raymondvilleisd and complete the “Claim Form” to send to NBS or use the web or phone app to file online.

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

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

Get Your Money 1. 2. 3. 4.

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

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

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

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

MASA YOUR BENEFITS PACKAGE

Medical Transport

About this Benefit Medical Transport covers emergency transportation to and from appropriate medical facilities by covering the out-of-pocket costs that are not covered by insurance. It includes emergency transportation via ground ambulance, air ambulance and helicopter.

DID YOU KNOW?

A ground ambulance can cost up to

$2,400

and a helicopter transportation fee can cost

over $30,000

Medical Transport MASA provides medical emergency transportation solutions and covers your out of pocket medical transport cost when your insurance falls short. MASA does not use a network, which means you are covered anywhere.

THE TRUTH... Americans today suffer from a false sense of security that their medical coverage will pay for all costs associated with emergency or critical care transport. The reality is that a majority of Americans are only partially covered for these high costs. Most healthcare policies will only pay based off of the “Usual and Customary Charges” while Medicare pays based off a set fee schedule, both leaving you with the remainder of the bill. You face the possibility that your medical coverage will deny the claim leaving you responsible for the ENTIRE bill. We provide medical emergency transportation solutions AND cover your out of pocket medical transport cost when your insurance falls short.

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

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

What is Covered?  

Emergency Helicopter Transport Emergency Ground Ambulance Transport

How Much Does It Cost? MASA Emergent rates are $9 a month, per employee only/ family coverage.

Emergent Card Example:

“All I had to do was send the bill which was never paid by Medicare and TriCare for Life --- and the rest is history. When MASA received that bill, it was paid and all amounts owed satisfied.” --- MASA Member, 2015

NOTES