2017 Benefit Guide - Burkburnett ISD by Higginbotham Public Sector

BURKBURNETT ISD

BENEFIT GUIDE EFFECTIVE: 01/01/2017 - 12/31/2017 www.mybenefitshub.com/burkburnettisd

Table of Contents Benefit Contact Information How to Enroll Annual Benefit Enrollment 1. Benefit Updates 2. Section 125 Cafeteria Plan Guidelines 3. Annual Enrollment 4. Eligibility Requirements 5. Helpful Definitions 6. HSA vs. FSA Comparison TRS-ActiveCare APL MEDlink® NBS Health Savings Account (HSA) MDLIVE Telehealth Cigna Dental Superior Vision Unum Disability Loyal American Cancer APL Accident Allstate Heart & Stroke The Hartford Life and AD&D Combined Insurance Term Life with LTC NBS Flexible Spending Account (FSA) MASA Medical Transport Zebit Financial Wellness 2

3 4-5 6-11 6 7 8 9 10 11 12-13 14-17 18-19 20-21 22-25 26-27 28-31 32-35 36-39 40-43 44-49 50-53 54-57 58-59 60-61

FLIP TO... PG. 4 HOW TO ENROLL

PG. 6 BENEFIT UPDATE— WHAT’S NEW

PG. 12 YOUR BENEFITS PACKAGE

Benefit Contact Information

Benefit Contact Information BURKBURNETT ISD BENEFITS

DENTAL

LIFE AND AD&D

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

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

The Hartford (800) 583-6908 www.thehartford.com Will Prep/Estate Guidance: Code WILLHLF www.estateguidance.com/wills Travel Assistance/ID Theft: (800) 243-6108

BURKBURNETT ISD BENEFITS OFFICE

VISION

TERM LIFE W/ LONG TERM CARE

(940) 569-3326 ext. 2010 www.burkburnettisd.org

Superior Vision Network: Superior Select Southwest (800) 507-3800 www.superiorvision.com

Combined Insurance (877) 352-3303 www.combinedinsurance.com

TRS ACTIVECARE MEDICAL

DISABILITY

FLEXIBLE SPENDING ACCOUNT/403(B)

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

Unum (800) 583-6908 Claim Status: (800) 858-6843 EAP: (800) 854-1446 Travel Assistance: (800) 872-1414 www.unum.com

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

MEDLINK®

CANCER

MEDICAL TRANSPORT

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

Loyal American (800) 366-8354

MASA U.S. (800) 423-3226 International (800) 643-9023 www.masamts.com

HEALTH SAVINGS ACCOUNT

ACCIDENT

FINANCIAL WELLNESS

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

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

Zebit (855) 449-3248 www.zebit.com/hi/burkburnett

TELEHEALTH

HEART & STROKE

COBRA

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

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

Dental, Vision, MEDlink®, Med Flex National Benefit Services (800) 274-0503 www.nbsbenefits.com 3

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

TEXT

need to complete your enrollment.

“bbisd”

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 Burkburnett ISD benefits

Our online benefit enrollment

website from your computer, tablet

platform provides a simple and

or smartphone!

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

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

Username:

Sample Username

lincola1234 Sample Password

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

lincoln1234

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

If you have trouble

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

logging in, click on the

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

“Login Help Video”

your Social Security Number.

for assistance.

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

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

Annual Benefit Enrollment

SUMMARY PAGES

Benefit Updates - What’s New:  New! MASA provides medical emergency transportation

and covers transport cost when your insurance falls short. MASA does not use a network so you and your family are covered nationwide for $9 per month.  Change: There is a slight premium increase on the

MDLIVE telehealth insurance from $7 to $8 per month. MDLIVE gives you & your family telephone consultations with a licensed physician for treatment, as appropriate, for minor illnesses.  New! Zebit offers free financial education and interest

free financing for a closed marketplace of competitively priced products. Members pay back loan over 6 months. First payment due at purchase. Not enrolled in the hub, eligible employees can register for free at www.zebit.com/hi/burkburnett (you must be employed by BISD over 1 year & earn $10K+ for the interest free credit).  MEDlink® with APL: MEDlink® provides supplemental

coverage to help offset deductibles and coinsurance of hospitalization. You must be enrolled in BISD’s medical insurance to be eligible for MEDlink®. If enrolled in a MEDlink® plan you are not eligible for an HSA.

    

 FSA with National Benefit Services: Eligible Flex

expenses must be incurred within the plan year, contributions are use-it or lose-it. You MUST re-elect a new contribution amount every year to continue to participate. Current Healthcare FSA participants, KEEP your FSA debit card, new funds will be available mid January. New participants receive flex cards in late January.  Health Savings Accounts with NBS: HSA accounts are

available to employees enrolled in a high-deductible health plan. Funds roll over and accumulate year to year and accounts are not prefunded. There is a monthly $2 service fee. You are not eligible for an HSA if you have MEDlink® or have access to FSA funds.  Term Life Insurance by The Hartford: Group Term Life

and AD&D are inexpensive ways to purchase life insurance. Coverage is typically available to You, Your Spouse and Dependent Children. New and Existing participants who increase life coverage will be contacted by The Hartford in December with a link for a required online health statement.

Login and complete your benefit enrollment from 10/24/2016 - 11/22/2016 (5PM) Enrollers will be on site from10/25/2016 - 10/27/2016 Enrollment assistance is available by calling Financial Benefit Services at (800) 583-6908 to speak to a representative Monday—Friday between 8am – 5pm CST Update your profile information: home address, phone numbers, email, beneficiaries REQUIRED: Provide correct dependent social security numbers

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

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.

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.

burkburnettisd



Changes, additions or drops may be made only during the

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

annual enrollment period without a qualifying event.

Dental) and you can find the forms you need under the Benefits and Forms section.

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

For benefit summaries and claim forms, go to your school

notify your employer of any discrepancy in personal and/or

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

benefit information.



How can I find a Network Provider?

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.

burkburnettisd Click on the benefit plan you need information on (i.e., Dental) and you can find provider search links under the Quick Links section. When will I receive ID cards? If the insurance carrier provides ID cards, you can expect to

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.

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

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 800-583-6908 for assistance.

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.

SUMMARY PAGES

Employee Eligibility Requirements

Dependent Eligibility Requirements

Supplemental Benefits: Eligible employees must work 20 or more

Dependent Eligibility: You can cover eligible dependent

regularly scheduled hours each work week.

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

Eligible employees must be actively at work on the plan effective

maximum age listed below. Dependents cannot be double

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

covered by married spouses within the Burkburnett 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 2017 benefits become effective on January 1, 2017, you must be actively-at-work on January 1, 2017 to be eligible for your new benefits.

PLAN

CARRIER

MAXIMUM AGE

CONTINUATION

Medical

Aetna

To 26

COBRA (Wellsystems)

MEDlink®

APL

To 26

COBRA (NBS)

Health Savings Account

NBS

Tax Dependent

Contact NBS

Telehealth

MDLIVE

Unmarried to 26

Individual Plan

Dental

Cigna

To 26

COBRA (NBS)

Vision

Superior Vision

To 26

COBRA (NBS)

Cancer

Loyal American

Unmarried to 25

Portable*

Accident

APL

To 26

Portable*

Heart & Stroke

Allstate

Unmarried to 26

Portable*

Voluntary Term Life

The Hartford

Unmarried to 26

Port/Convert*

Term Life w/ LTC

Combined Insurance

Issuable to 18

Direct Pay*

Medical Flex

NBS

To 26

COBRA (NBS)

Dependent Flex

NBS

12 or younger or qualified individual unable to care for themselves & claimed as a dependent on your taxes

N/A

If your dependent is disabled, coverage may be able to continue past the maximum age under certain plans. If you have a disabled dependent who is reaching an ineligible age, you must provide a physician’s statement confirming your dependent’s disability. Contact your HR/Benefit Administrator to request a continuation of coverage. *Contact carrier within 30 days of termination to be eligible for continuation.

SUMMARY PAGES

Helpful Definitions Actively at Work

In-Network

You are performing your regular occupation for the employer

Doctors, hospitals, optometrists, dentists and other providers

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

who have contracted with the plan as a network provider.

places of business or at some location to which the employer’s business requires you to travel. If you will not be actively at work beginning 01/01/2017 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 Supplemental Plans: January 1st through December 31st Medical Plans: September 1st through August 31st

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

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

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

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

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

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

Employer Eligibility

A qualified high deductible health plan.

All employers

Contribution Source Account Owner Underlying Insurance Requirement

Employee and/or employer Individual

Employee and/or employer Employer

High deductible health plan

None

Description

Minimum Deductible

Maximum Contribution

$1,300 single (2017) $2,600 family (2017) $3,400 single (2017) $6,750 family (2017)

N/A

Varies per employer

Permissible Use Of Funds

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

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

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

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

Not permitted

Year-to-year rollover of account balance?

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

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

Does the account earn interest?

Yes

Portable?

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

Funding

You will only have access to HSA funds that have been contributed up to that point. HSAs are not front loaded.

You will have access to the entire annual contribution amount on the effective date of your FSA. FSA balance is front loaded to provide access to the entire annual contribution.

FLIP TO… PG. 18

FLIP TO… PG. 54

FOR HSA INFORMATION

FOR FSA INFORMATION 11

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.

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.

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 Burkburnett ISD Benefits Website: www.mybenefitshub.com/burkburnettisd

MEDlink® Limited Benefit Medical Expense Supplemental Insurance Burkburnett ISD

AMERICAN PUBLIC LIFE YOUR BENEFITS

MEDlink®

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

Issue Ages

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

Employee Only

$28.00

$44.50

$68.50

Employee + Spouse

$51.50

$81.50

$122.50

Option 2 Total Monthly Premiums by Plan*

Employee + Child(ren)

$45.50

$62.00

$86.00

Family Coverage

$69.00

$99.00

$140.00

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

About this Benefit MEDlink® 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.

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 West Texas EBC Benefits Website: www.mybenefitshub.com/wtxebc

Eligibility

In-Hospital Benefit

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.

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.

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 incurred in a covered facility as defined in the Policy or any attached rider; 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. Covered charges also include Inpatient routine newborn care and are subject to above.

Outpatient Benefits

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.

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.

APSB-22330(TX)-0116 MGM/FBS Burkburnett ISD

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

MEDlink® Limited Benefit Medical Expense Supplemental Insurance 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.

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.

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 your Employer’s 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 your Employer’s 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

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) | West Texas EBC

APSB-22330(TX)-0116 MGM/FBS Burkburnett ISD

MEDlinkÂŽ Limited Benefit Medical Expense Supplemental Insurance

NBS

HSA (Health Savings Account)

YOUR BENEFITS PACKAGE

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

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

Money withdrawn for medical spending never falls under taxable income.

HSA (Health Savings Account) You can use your Health Savings Account (HSA) to pay for a wide range of IRS-qualified medical expenses for yourself, your spouse or tax dependents. An IRS-qualified medical expense is defined as an expense that pays for healthcare services, equipment, or medications. Funds used to pay for IRS-qualified medical expenses are always tax-free.

What is an HSA? 

 



A tax-advantaged savings account that you use to pay for eligible medical expenses as well as deductible, co-insurance, prescriptions, vision and dental care. Allows you to save while reducing your taxable income. Unused funds that will roll over year to year. There’s no “use it or lose it” penalty. Potential to build more savings through investing. If you maintain a minimum balance of $1,000, your additional funds may be invested in mutual funds yielding tax‐free earnings. A way to accumulate additional retirement savings. After age 65, funds can be withdrawn for any purpose without penalty.

Using Funds Pre-paid Debit Card: You may use the card to pay merchants or service providers that accept Master Card credit cards, so there is no need to pay cash up front and wait for reimbursements.

2017 Annual HSA Contribution Limits Individual: $3,400 Family: $6,750 Catch-Up Contributions: Account holders over the age of 55 who have not yet enrolled in Medicare are eligible to make an additional $1,000 “catch‐up” contribution to their HSA.

Participant Account Web Access www.nbsbenefits.com A Health Savings Account (HSA) works with a high deductible health plan (HDHP) and lets you set aside a portion of your paycheck ‐ before taxes– into an account to help you pay for medical expenses before you reach your deductible or that you aren’t covered by your plan. It can also help you pay for future medical expenses.

A Health Savings Account (HSA): 



Grows with you. If you maintain a balance of $1,000, your additional funds may be invested in mutual funds yielding tax‐free earnings. An additional investment fee of $2.50/month is charged on balances less than $3,000. Helps you plan for the future. Until you turn 65, withdrawals used for eligible expenses are tax free. After you turn 65, or if you become disabled, your HSA account becomes similar to a regular IRA. Withdrawals you use for non-eligible expenses will be taxed at your regular income tax rate but won’t incur additional penalties.

For a list of sample expenses, please refer to the Burkburnett ISD benefit website at www.mybenefitshub.com/ burkburnettisd

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

Will my HSA Funds be up fronted to me? Like a savings account, you can only withdrawal what you’ve contributed to the account. Funds are not up fronted. Are there any monthly fees? There is an Administrative Fee of $2.00/month on all balances. There is an additional Investment Fee of $2.50/month for accounts invested in mutual funds if balance is under $3,000.

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? $8.00 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

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?

Cigna's Oral Health Integration Program provides extra cleanings if you are pregnant or have certain medical conditions. Register in advance by completing the OHIP form.

Dental PPO - Low Plan Benefits

Total Cigna Dental Choice In-Network Out-of-Network Total Cigna Choice

Network Calendar Year Maximum (Class I, II, and III expenses) 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 Fluoride Application Sealants Class II - Basic Restorative Care Fillings Emergency Care to Relieve Pain Root Canal Therapy/Endodontics Osseous Surgery Periodontal Scaling and Root Planing Space Maintainers (Limited to nonOrthodontic treatment) Surgical Extractions of Impacted Teeth Brush Biopsies Oral Surgery - All except simple extractions Oral Surgery - Simple Extractions Class III - Major Restorative Care Crowns Anesthetics Denture Repairs Denture Relines, Rebases and Adjustments Repairs to Bridges, Crowns and Inlays Dentures Bridges Inlays/Onlays Prosthesis Over Implant Class IV - Orthodontia

$1,000

$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%*

Not covered

100% of your dentist’s usual fees

Not covered

100% of your dentist’s usual fees

50%*

50%* Subject to plan deductible Subject to plan annual maximum

50%*

50%* Subject to plan deductible Subject to plan annual maximum

Class IX - Implants Deductible Annual Maximum

Monthly PPO Premiums Tier

$1,000

Rate

EE Only

$31.12

EE + Spouse

$61.04

EE + Child(ren)

$77.76

Family

$122.44

Missing Tooth Limitation – The amount payable is 50% of the amount otherwise payable until insured for 24 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 nonprescription 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 Reasonable and Customary Allowances but the dentist may balance bill up to their usual fees.

Dental PPO - High Plan Benefits

Total Cigna Dental Choice In-Network Out-of-Network Total Cigna Choice

Network Calendar Year Maximum (Class I, II, and III expenses) 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 Fluoride Application Sealants Class II - Basic Restorative Care Fillings Emergency Care to Relieve Pain Root Canal Therapy/Endodontics Periodontal Scaling and Root Planing Space Maintainers(Limited to nonOrthodontic treatment) Surgical Extractions of Impacted Teeth Brush Biopsies Oral Surgery - All except simple extractions Oral Surgery - Simple Extractions Class III - Major Restorative Care Crowns Anesthetics 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

Monthly PPO Premiums Tier

Rate

EE Only

$33.06

EE + Spouse

$64.86

EE + Child(ren)

$82.64

Family

$129.78

$1,000

$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%*

50%* $1,000 Dependent children to age 19 50%* Subject to plan deductible Subject to plan annual maximum

50%*

50%* $1,000 Dependent children to age 19 50%* Subject to plan deductible Subject to plan annual maximum

50%*

Missing Tooth Limitation â&#x20AC;&#x201C; The amount payable is 50% of the amount otherwise payable until insured for 24 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)ÂŽ 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 nonprescription 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 Reasonable and Customary Allowances but the dentist may balance bill up to their usual fees.

Dental PPO - Low and High Plan Procedure

Exclusions and Limitations

Late Entrants Limit Exams Prophylaxis (Cleanings) Fluoride Histopathologic Exams 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 24 months Two per Calendar year Two per Calendar year 1 per Calendar year for people under 19 Various limits per Calendar year depending on specific test 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      

                  

Charges in excess of the reasonable and customary allowances 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 To the extent that payment is unlawful where the person resides when the expenses are incurred; Procedures performed by a Dentist who is a member of the covered person’s family (covered person’s family is limited to a spouse, siblings, parents, children, grandparents, and the spouse’s siblings and parents); For charges which would not have been made if the person had no insurance; For charges for unnecessary care, treatment or surgery; To the extent that you or any of your Dependents is in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid; To the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply with a “no-fault” insurance law or an uninsured motorist insurance law. Cigna HealthCare will take into account any adjustment option chosen under such part by you or any one of your Dependents. In addition, these benefits will be reduced so that the total payment will not be more than 100% of the charge made for the Dental Service if benefits are provided for that service under this plan and any medical expense plan or prepaid treatment program sponsored or made available by your Employer.

This benefit summary highlights some of the benefits available under the proposed plan. A complete description regarding the terms of coverage, exclusions and limitations, including legislated benefits, will be provided in your insurance certificate or plan description. Benefits are insured and/or administered by Connecticut General Life Insurance Company. "Cigna HealthCare" refers to various operating subsidiaries of Cigna Corporation. Products and services are provided by these subsidiaries and not by Cigna Corporation. These subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. DPPO insurance coverage is set forth on the following policy form numbers: AR: HP-POL77; CA: HP-POL57; CO: HP-POL78; CT: HP-POL58; DE: HP-POL79; FL: HP-POL60; ID: HPPOL82; IL: HP-POL62; KS: HP-POL84; LA: HPPOL86: MA: HP-POL 63; MI: HP-POL88; MO: HP- POL65; MS: HP-POL90; NC: HP-POL96; NE: HP-POL92; NH: HP-POL94; NM: HP-POL95; NV: HP-POL93; NY: HP-POL67; OH: HP-POL98; OK: HP-POL99; OR: HP-POL68; PA: HP-POL100; RI: HP-POL101; SC: HP-POL102; SD: HP-POL103; TN: HP-POL69; TX: HP-POL70; UT: HP-POL104; VA: HP-POL72; VT: HP-POL71; WA: POL-07/08; WI: HP-POL107; WV: HP-POL106; and WY: HP-POL108. “Cigna,” the “Tree of Life” logo and “Cigna Dental Care” are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company (CGLIC), Cigna Health and Life Insurance Company (CHLIC), Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. and its subsidiaries. Cigna Dental PPO plans are underwritten or administered by CGLIC or CHLIC, with network management services provided by Cigna Dental Health, Inc. and certain of its subsidiaries. In Arizona and Louisiana, the insured Dental PPO plan offered by CGLIC is known as the “CG Dental PPO”. In Texas, the insured dental product offered by CGLIC and CHLIC is referred to as the Cigna Dental Choice Plan, and this plan utilizes the national Cigna Dental PPO network. Cigna Dental Care (DHMO) plans are underwritten or administered by Cigna Dental Health Plan of Arizona, Inc., Cigna Dental Health of California, Inc., Cigna Dental Health of Colorado, Inc., Cigna Dental Health of Delaware, Inc., Cigna Dental Health of Florida, Inc., a Prepaid Limited Health Services Organization licensed under Chapter 636, Florida Statutes, Cigna Dental Health of Kansas, Inc. (Kansas and Nebraska), Cigna Dental Health of Kentucky, Inc. (Kentucky and Illinois), Cigna Dental Health of Maryland, Inc., Cigna Dental Health of Missouri, Inc., Cigna Dental Health of New Jersey, Inc., Cigna Dental Health of North Carolina, Inc., Cigna Dental Health of Ohio, Inc., Cigna Dental Health of Pennsylvania, Inc., Cigna Dental Health of Texas, Inc., and Cigna Dental Health of Virginia, Inc. In other states, Cigna Dental Care plans are underwritten by CGLIC, CHLIC, or Cigna HealthCare of Connecticut, Inc. and administered by Cigna Dental Health, Inc. BSD46380 © 2015 Cigna

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 Superior Select Southwest Network Benefits

In-Network

Out-of-Network

Covered in full

Up to $35 retail

$150 retail allowance $175 retail allowance

Up to $70 retail Up to $80 retail

Covered in full

Up to $150 retail

Exam Frames Contact Lenses1 Medically Necessary Contact Lenses Lasik Vision Correction

$200 allowance2

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

Monthly Premiums EE Only EE + 1 Dependent EE + Family

$8.28 $14.12 $20.74

Co-Pays Exam Materials

$10 $25

Services/Frequency 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-ofnetwork visits are deducted from reimbursements. 1

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.

Exam Frame Lenses Contact Lenses

12 months 12 months 12 months 12 months

(Based on date of service) 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

SuperiorVision.com Customer Service 800.507.3800

Glasses available online at www.ditto.com Contacts available online at www.ContactsDirect.com/ superiorvision

UNUM 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 Policy # 217339

Pre-Existing Condition Exclusion

Please read carefully the following description of your Unum Educator Select Income Protection Plan insurance.

Benefits will not be paid for disabilities caused by, contributed to by, or resulting from a pre-existing condition. You have a pre-existing condition if you received medical treatment, consultation, care or services including diagnostic measures, or took prescribed drugs or medicines in the 3 months just prior to your effective date of coverage; and the disability begins in the first 12 months after your effective date of coverage.

Eligibility You are eligible for disability coverage if you are an active employee in the United States working a minimum of 20 hours per week. The date you are eligible for coverage is the later of: the plan effective date; or the day after you complete the waiting period.

Guarantee Issue Current Employees: Coverage is available to you without answering any medical questions or providing evidence of insurability. You may enroll on or before the enrollment deadline. After the initial enrollment period, you can apply only during an annual enrollment period. Newly Hires: Coverage is available to you without answering any medical questions or providing evidence of insurability. You may apply for coverage within 60 days after your eligibility date. If you do not apply within 60 days after your eligibility date, you can apply only during an annual enrollment period. Benefits are subject to the pre-existing condition exclusion referenced later in this document.

Benefit Duration Your duration of benefits is based on your age when the disability occurs. Plan: ADEA II: Your duration of benefits is based on the following table: Age at Disability Less than age 60 Age 60 through 64 Age 65 through 69 Age 70 and over

Maximum Duration of Benefits To age 65, but not less than 5 years 5 years To age 70, but not less than 1 year 1 year

Delayed Effective Date of Coverage If you are absent from work due to injury, sickness, temporary layoff or leave of absence, your coverage will not take effect until you return to active employment. Please contact your Plan Administrator after you return to active employment for when your coverage will begin.

Please see your Plan Administrator for your eligibility date.

Benefit Amount You may purchase a monthly benefit in $100 units, starting at a minimum of $200, up to 66 2/3% of your monthly earnings rounded to the nearest $100, but not to exceed a monthly maximum benefit of $8,000. Please see your Plan Administrator for the definition of monthly earnings. The total benefit payable to you on a monthly basis (including all benefits provided under this plan) will not exceed 100% of your monthly earnings unless the excess amount is payable as a Cost of Living Adjustment. However, if you are participating in Unumâ&#x20AC;&#x2122;s Rehabilitation and Return to Work Assistance program, the total benefit payable to you on a monthly basis (including all benefits provided under this plan) will not exceed 110% of your monthly earnings (unless the excess amount is payable as a Cost of Living Adjustment).

Elimination Period The Elimination Period is the length of time of continuous disability, due to sickness or injury, which must be satisfied before you are eligible to receive benefits.

Waiver of Premium After you have received disability payments under the plan for 90 consecutive days, from that point forward you will not be required to pay premiums as long as you are receiving benefits.

Questions If you should have any questions about your coverage or how to enroll, please contact your Plan Administrator. This plan highlight is a summary provided to help you understand your insurance coverage from Unum. Some provisions may vary or not be available in all states. Please refer to your certificate booklet for your complete plan description. If the terms of this plan highlight summary or your certificate differ from your policy, the policy will govern. For complete details of coverage, please refer to policy form number C.FP-1, et al. Underwritten by: Unum Life Insurance Company of America 2211 Congress Street, Portland, Maine 04122, www.unum.com ÂŠ2007 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.

You may choose an Elimination Period (injury/sickness) of 14/14, 30/30, 60/60, 90/90 or 180/180 days. If, because of your disability, you are hospital confined as an inpatient, benefits begin on the first day of inpatient confinement. Inpatient means that you are confined to a hospital room due to your sickness or injury for 23 or more consecutive hours. (Applies to Elimination Periods of 30 days or less.) 29

Disability BURKBURNETT INDEPENDENT SCHOOL DISTRICT Costs below are based on a Monthly payroll deduction (Employer billing mode is based on 12 Payments per year) Plan A

Product: Educator Select Income Protection Plan

ADEAII Duration of Benefits Elimination Period (Days)

Injury (Days) Sickness (Days)

Annual Earnings

Monthly Earnings

3600 5400 7200 9000 10800 12600 14400 16200 18000 19800 21600 23400 25200 27000 28800 30600 32400 34200 36000 37800 39600 41400 43200 45000 46800 48600 50400 52200 54000 55800 57600 59400 61200 63000 64800 66600 68400 70200 72000 73800 75600 77400

300 450 600 750 900 1050 1200 1350 1500 1650 1800 1950 2100 2250 2400 2550 2700 2850 3000 3150 3300 3450 3600 3750 3900 4050 4200 4350 4500 4650 4800 4950 5100 5250 5400 5550 5700 5850 6000 6150 6300 6450

Maximum Monthly Benefit 200 300 400 500 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 2000 2100 2200 2300 2400 2500 2600 2700 2800 2900 3000 3100 3200 3300 3400 3500 3600 3700 3800 3900 4000 4100 4200 4300

14* 14*

30* 30*

60 60

90 90

180 180

5.68 8.52 11.36 14.20 17.04 19.88 22.72 25.56 28.40 31.24 34.08 36.92 39.76 42.60 45.44 48.28 51.12 53.96 56.80 59.64 62.48 65.32 68.16 71.00 73.84 76.68 79.52 82.36 85.20 88.04 90.88 93.72 96.56 99.40 102.24 105.08 107.92 110.76 113.60 116.44 119.28 122.12

4.88 7.32 9.76 12.20 14.64 17.08 19.52 21.96 24.40 26.84 29.28 31.72 34.16 36.60 39.04 41.48 43.92 46.36 48.80 51.24 53.68 56.12 58.56 61.00 63.44 65.88 68.32 70.76 73.20 75.64 78.08 80.52 82.96 85.40 87.84 90.28 92.72 95.16 97.60 100.04 102.48 104.92

3.92 5.88 7.84 9.80 11.76 13.72 15.68 17.64 19.60 21.56 23.52 25.48 27.44 29.40 31.36 33.32 35.28 37.24 39.20 41.16 43.12 45.08 47.04 49.00 50.96 52.92 54.88 56.84 58.80 60.76 62.72 64.68 66.64 68.60 70.56 72.52 74.48 76.44 78.40 80.36 82.32 84.28

2.22 3.33 4.44 5.55 6.66 7.77 8.88 9.99 11.10 12.21 13.32 14.43 15.54 16.65 17.76 18.87 19.98 21.09 22.20 23.31 24.42 25.53 26.64 27.75 28.86 29.97 31.08 32.19 33.30 34.41 35.52 36.63 37.74 38.85 39.96 41.07 42.18 43.29 44.40 45.51 46.62 47.73

1.56 2.34 3.12 3.90 4.68 5.46 6.24 7.02 7.80 8.58 9.36 10.14 10.92 11.70 12.48 13.26 14.04 14.82 15.60 16.38 17.16 17.94 18.72 19.50 20.28 21.06 21.84 22.62 23.40 24.18 24.96 25.74 26.52 27.30 28.08 28.86 29.64 30.42 31.20 31.98 32.76 33.54

Disability BURKBURNETT INDEPENDENT SCHOOL DISTRICT Costs below are based on a Monthly payroll deduction (Employer billing mode is based on 12 Payments per year) Plan A

Product: Educator Select Income Protection Plan

ADEAII Duration of Benefits Elimination Period (Days)

Injury (Days) Sickness (Days) Annual Earnings

Monthly Earnings

79200 81000 82800 84600 86400 88200 90000 91800 93600

6600 6750 6900 7050 7200 7350 7500 7650 7800

Maximum Monthly Benefit 4400 4500 4600 4700 4800 4900 5000 5100 5200

14* 14*

30* 30*

60 60

90 90

180 180

124.96 127.80 130.64 133.48 136.32 139.16 142.00 144.84 147.68

107.36 109.80 112.24 114.68 117.12 119.56 122.00 124.44 126.88

86.24 88.20 90.16 92.12 94.08 96.04 98.00 99.96 101.92

48.84 49.95 51.06 52.17 53.28 54.39 55.50 56.61 57.72

34.32 35.10 35.88 36.66 37.44 38.22 39.00 39.78 40.56

LOYAL AMERICAN

Cancer

YOUR BENEFITS PACKAGE

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

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

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

Cancer Additional Benefit Amounts

Plan A Plan B Plan C Maximum Maximum Maximum

$50 Per $100 Per $100 Per Calendar Calendar Calendar Year Year Year Basic Benefit– We will pay the expense incurred, but not to exceed the maximum benefit amount shown on the Certificate Schedule, once per calendar year per Insured Person for screening tests performed to determine whether Cancer exists in an Insured Person. Covered annual Cancer screening tests include but are not limited to: mammogram, pap smear, breast ultrasound, ThinPrep, biopsy, chest x‐ray, thermography, colonoscopy, flexible sigmoidoscopy, hemocult stool specimen, PSA (blood test for prostate cancer) CEA (blood tests for colon cancer), CA125 (blood test for ovarian cancer) CA15‐3 (blood test for breast cancer) serum protein electrophesis (blood test for myeloma) $100 Per $200 Per $200 Per Additional Benefit Calendar Calendar Calendar Year Year Year We will pay the expense incurred, but not to exceed two times the maximum benefit amount per calendar year as shown on the Certificate Schedule, for one additional invasive diagnostic procedure for an Insured Person. This additional benefit is payable regardless of the results of the additional diagnostic procedure. However, the amount payable will be reduced dollar for any dollar payable under the Positive Diagnosis Benefit contained in the base Certificate First Occurrence Benefit Rider (Form LG‐6043) If the Insured Person received a positive diagnosis of internal Cancer, We will pay the $2,000 Once $5,000 Once $5,000 Once First Occurrence benefit amount shown on the Certificate Schedule Per Lifetime Per Lifetime Per Lifetime If the Insured Person receiving the positive diagnosis of Internal Cancer is a child under the age of 21, we will pay one and one‐half times the First Occurrence benefit $3,000 Once $7,500 Once $7,500 Once amount shown on the Certificate Schedule Per Lifetime Per Lifetime Per Lifetime $10,000 Per $15,000 Per $20,000 Per Annual Radiation, Chemotherapy, Immunotherapy, and Experimental Treatment Calendar Calendar Calendar Benefit Rider (Form LG‐6045) Year Year Year We will pay the expense incurred, but not to exceed the maximum benefit amount shown on the Certificate Schedule, per calendar year per Insured Person for Radiation Treatment, Chemotherapy, Hormonal Therapy, Immunotherapy or Experimental Treatment. The Radiation Treatment, Chemotherapy, Hormonal Therapy, Immunotherapy or Experimental Treatment must be for the treatment of an Insured Person’s Cancer. The benefit amount shown on the Certificate Schedule is the maximum calendar year benefit available per Insured Person regardless of the number or types of Cancer treatments received in the same year. Surgical Benefit Rider (Form LG 6048) Surgical Expense ‐ We will pay the Surgical Expense benefit for a surgical procedure for the treatment of an Insured Person’s Cancer (except Skin Cancer) according to the $1,000 $2,500 $2,500 Surgical Schedule shown in this rider. However, in no event will the amount payable Procedure Procedure Procedure exceed the maximum Surgical Expense benefit shown on the Certificate Schedule, nor Maximum Maximum Maximum will it exceed the expense incurred Anesthesia Expense ‐ We will pay the anesthesia expense incurred, not to exceed $250 $625 $625 25% of the covered Surgical Expense benefit for the operation performed. This Procedure Procedure Procedure includes the services of an anesthesiologist or of an anesthetist under supervision of a Maximum Maximum Maximum physician for the purpose of administering anesthesia Breast Reconstruction ‐ with transverse rectus adominis myocutaneous flap (TRAM), single pedicle, including closure of donor site, with microvascular anastomosis $900 $2,250 $2,250 (supercharging) is one of the surgical procedures listed in the Surgical Schedule. If Procedure Procedure Procedure this procedure is performed on an Insured Person as the result of a mastectomy for Maximum Maximum Maximum which We paid a Surgical Expense benefit for the treatment of Breast Cancer, We will pay the expense incurred not to exceed $900 per $1,000 of the Surgical Benefit Issued Skin Cancer Surgery Expense ‐ We will pay the expense incurred, not to exceed the procedure amount listed in this rider ($125 to $750 depending on the procedure) Per Per Per when a surgical operation is preformed on an Insured Person for treatment of a Procedure Procedure Procedure diagnosed Skin Cancer. This benefit is payable in lieu of any benefits for Surgical Expense and Anesthesia Expense which are not applicable to Skin Cancer. Annual Cancer Screening Benefit Rider (Form LG‐6041)

Cancer Additional Benefit Amounts Continued Daily Hospital Confinement Benefit Rider (form LG‐6042) Confinements of 30 Days or Less ‐ We will pay the Daily Hospital Confinement benefit amount shown on the Certificate Schedule for each of the first 30 days in each period of hospital confinement during which an Insured Person is confined to a hospital, including a government or charity hospital, for the treatment of Cancer. Confinement of 31 Days or More ‐ If an Insured Person is continuously confined to a hospital, including a government or charity hospital, for longer than 30 consecutive days for the treatment of Cancer, We will pay two times the Daily Hospital Confinement benefit amount shown on the Certificate Schedule. This benefit payment will begin on the 31st continuous day of such confinement and continue for each day of confinement until the Insured Person is discharged from the Hospital. Benefits for an Insured Dependent under Age 21 - The amount payable under this benefit will be double the Daily Hospital Confinement benefit shown in the Certificate Schedule if the Insured Person so confined is a dependent Child under the age of 21.

Plan A Plan B Plan C Maximum Maximum Maximum

$150 Per Day

$250 Per Day

$300 Per Day

$500 Per Day

$300/$600 Per Day

$250/$500 Per Day

Additional Benefit Amounts Continued SPECIFIED DISEASE BENEFIT RIDER (FORM LG 60‐52) If an Insured Person is first diagnosed with one or more covered Specified Diseases and is hospitalized for the definitive treatment of any covered Specified Disease, We will pay benefits according to the provisions of this rider. COVERS THESE 38 SPECIFIED DISEASES Addison’s Disease Lupus Erythematosus Rocky Mountain Spotted Fever Amyotrophic Lateral Sclerosis Malaria Sickle Cell Anemia Botulism Meningitis Tay‐Sachs Disease Bovine Spongiform Encephalopathy Multiple Sclerosis Tetanus Budd‐Chiari Syndrome Muscular Dystrophy Toxic Epidermal Necrolysis Cystic Fibrosis Myasthenia Gravis Tuberculosis Diptheria Neimann‐Pick Disease Tularemia Encephalitis Osteomyelitis Typhoid Fever Epilepsy Poliomyelitis Undulant Fever Hansen’s Disease Q Fever West Nile Virus Histoplasmosis Rabies Whipple’s Disease Legionnaire’s Disease Reye’s Syndrome Whooping Cough Lyme Disease Rheumatic Fever BENEFITS If an Insured Person is first diagnosed with one or more covered Specified Diseases and is hospitalized for the definitive treatment of any covered Specified Disease, We will pay benefits according to the provisions of this rider. An applicant may select 1, 2, or 3, units of coverage. Initial Hospitalization Benefit We will pay a benefit of $1,500 per unit of coverage selected when an Insured Person is confined to a hospital (for 12 or more hours, not applicable in SD) as a result of receiving treatment for a Specified Disease. This benefit is payable only once per period of confinement and once per calendar year for each Insured Person. Hospital Confinement Benefit We will pay a benefit of $300 per unit of coverage selected when an Insured Person is hospitalized during any continuous period of 30 days or less for the treatment of a covered Specified Disease. Benefits will double per day beginning with the 31st day of continual confinement. If the hospital confinement follows a previously covered confinement, it will be deemed a continuation of the first confinement unless it is the result of an entirely different Specified Disease, or unless the confinements are separated by 30 days or more. This page is an Insert to be used ONLY with Brochure Form LG-6040. If you do not have this Brochure, ask that your agent provide one for you. All exclusions, limitations, definitions and terms of renewability of the Group Limited Benefit Cancer Certificate (form LG-6040) apply to these riders. THESE ARE LIMITED RIDERS.

Cancer Optional Benefits You May Select for Additional Premium Hospital Intensive Care Unit Benefit Rider (Form LG‐6047)* Intensive Care Unit Benefit - We will pay the daily Hospital ICU Benefit shown on the Certificate Schedule for an Insured Person’s confinement in an ICU for sickness or Injury.

$500 Per Day

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

$1,000 Per Day

Step Down Unit Benefit - We will pay one‐half the daily Hospital ICU Benefit amount shown on the Certificate $250 Schedule for an Insured Person’s confinement in a Step Down Unit for sickness or injury. Per Day *Additional Limitations and Exclusions for the Hospital ICU Care Unit Benefit Rider - If the rider is issued and coverage is in force, it will provide benefits if an Insured Person goes into a hospital Intensive Care Unit (including a Cardiac Intensive Care Unit or Neonatal Intensive Care Unit). Benefits start the first day of confinement in an ICU for sickness or injury. Any combination of benefits payable under this rider is limited to a maximum of 45 days per each period of confinement. ALL BENEFITS CONTAINED IN THIS HOSPITAL ICU BENEFIT RIDER REDUCE BY ONE‐HALF AT AGE 75 Benefits are not payable for any ICU or Step Down Unit confinement that results from intentional self‐inflicted injury; or the Insured Person’s being intoxicated or under the influence of alcohol, drugs or any narcotics, unless administered on and according to the advice of a medical practitioner.

MONTHLY RATES

EMPLOYEE

SINGLE PARENT

BASE PLAN A

$19.88

$24.48

EMPLOYEE AND SPOUSE $33.56

BASE PLAN B

$31.62

$37.94

$52.52

BASE PLAN C

$35.46

$42.40

$58.82

MONTHLY RATES

EMPLOYEE

SINGLE PARENT

BASE PLAN A WITH ICU

$22.20

$27.68

EMPLOYEE AND SPOUSE $37.96

BASE PLAN B WITH ICU

$33.96

$41.12

$56.92

BASE PLAN C WITH ICU

$37.78

$45.60

$63.22

PRE-EXISTING CONDITIONS LIMITATION. Relative to any Insured Person, We will not pay benefits for expenses resulting from Pre-existing Conditions during the 12 months after coverage becomes effective for such Insured Person. “Pre-existing Condition” means Cancer, or a listed Specified Disease if that optional rider is issued, which was diagnosed by a Physician or for which medical consultation, advice or treatment was recommended by or received from or sought from a Physician within 1 year prior to the effective date of coverage for each Insured Person.

FAMILY

$33.56

FAMILY $37.96

EXCLUSIONS AND LIMITATIONS. No benefits will be paid under the Certificate or any attached riders for: 1. any loss due to any disease or illness other than Cancer, or a listed covered Specified Disease; 2. care and treatment received outside the territorial limits of the United States; 3. treatment by any program engaged in research that does not meet the criteria for Experimental Treatment as defined; 4. treatment that has not been approved by a Physician as being medically necessary; or 5. losses or medical expenses incurred prior to the Certificate Effective Date of an Insured Person’s coverage regardless of the Date of Positive Diagnosis.

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.

Accident AMERICAN PUBLIC LIFE YOUR BENEFITS

Accident

Summary of Benefits* Benefit Description Accidental Death - per unit Medical Expense Accidental Injury Benefit - per unit

Level 1 - 1 Unit

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

Daily Hospital Confinement Benefit

$75 per day

Air and Ground Ambulance Benefit

$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

$200 upon admission

Benefit Rider Hospital Admission Benefit

DID YOU KNOW?

2/3

of disabling injuries suffered by American workers are not work related.

American workers 36% ofreport they always or

Individual

Individual & Spouse

1 Parent Family

2 Parent Family

Level 1 - 1 Unit

$11.70

$20.70

$22.70

$31.70

Level 2 - 2 Units

$18.00

$31.10

$36.40

$49.50

Level 3 - 3 Units

$22.40

$40.20

$46.70

$64.50

Level 4 - 4 Units

$25.40

$46.20

$53.50

$74.30

*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.

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

Accident - Continued...

Accident - Continued... 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 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. 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.

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.

Hospital Admission Benefit The maximum benefit is 4 units.

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) (5) (6)

(7) (8)

(9) (10)

(11)

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

Daily Hospital Confinement Benefit The maximum benefit period for this benefit is 30 days per covered accident.

(14)

Accidental Death

(15)

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

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.

(12) (13)

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

(16)

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;

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.

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) | Burkburnett ISD

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

Accident - Continued...

Hospital Admission Benefit The maximum benefit is 4 units.

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) (5) (6)

(7) (8)

(9) (10)

(11)

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

Daily Hospital Confinement Benefit

(12) (13)

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

(14)

Accidental Death

(15)

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

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

(16)

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

ALLSTATE

Heart & Stroke

YOUR BENEFITS PACKAGE

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

DID YOU KNOW?

61,800,000 Americans have one or more types of cardiovascular disease according to current estimates.

Heart & Stroke EXPLANATION OF BENEFITS

1/2 UNIT

1 UNIT

$50

$100

$200

$400

$250

$500

$100

$200

$100

$200

Second Surgical Opinion Amount shown for a second opinion obtained after a positive diagnosis that results in the physician recommending surgery for a covered illness.

Ambulance Amount shown for transfer by ambulance to a hospital or emergency room for the treatment of a covered condition.

Non-Air Ambulance Air Ambulance Cardiac Catheterization Amount shown for a cardiac catheterization procedure.

Blood, Plasma and Platelets Amount shown for the administration of blood, plasma or platelets during a covered hospital confinement, subject to a maximum of 1 payment per continuous hospital confinement.

Non-Local Transportation Amount shown for a covered hospital confinement which is obtained more than 100 miles from the covered person’s home because the prescribed treatment cannot be obtained locally. This is subject to a maximum of 1 payment per continuous hospital confinement

Surgery and Anesthesia 1. Surgery. Amount shown in the surgical schedule for a surgery performed in a hospital or ambulatory surgical center. For a surgical procedure not listed in the surgical schedule, we pay $17 per unit of coverage ($8.50 per half unit) multiplied by the 1964 California Relative Value Schedule (C.R.V.S.) unit value for the procedure, subject to maximum of amount shown. If no 1964 C.R.V.S. unit value exists for the procedure, then the payment amount will be based upon relative difficulty and payment amounts for other procedures, up to maximum amount shown. Two or more surgical or invasive procedures done at the same time and through a common incision or entry point are considered one operation and benefit is paid for the one with the largest total benefit.

$2,500 maximum

$5,000 maximum

2. Anesthesia. Additional percentage shown of the amount paid for surgery benefit described in “ 1 ” above for anesthesia received during the surgery.

25%

3. Ambulatory Surgical Center. Amount shown when surgery benefit described in “ 1 ” above is paid for a surgery performed at an ambulatory surgical center. These benefits do not pay for surgeries covered by other benefits in the policy.

$125

$250

$25 each day

$50 each day

$100

$200

Family Member Lodging and Transportation 1. Lodging. Amount shown per day when the Non-Local Transportation benefit is paid and a family member stays in a motel, hotel, or any other accommodation acceptable to us, in order to be near the covered person, subject to a maximum of 60 days per continuous hospital confinement. 2. Transportation. Amount shown when the Non-Local Transportation benefit is paid and a family member travels more than 100 miles from their home to be near the covered person for a portion of their continuous hospital confinement. This is subject to a maximum of 1 payment per continuous hospital confinement.

Heart & Stroke EXPLANATION OF BENEFITS Hospital Confinement Amount shown per day for each day a covered person is admitted and confined as an inpatient in a hospital due to a Heart Attack, Heart Disease or Stroke.

1/2 UNIT

1 UNIT

$100 each day

$200 each day

$12.50 each day

$25 each day

$12.50 each day

$25 each day

$50 each day

$100 each day

$25 each day

$50 each day

$100

$200

$50

$100

$75

$150

$375

$750

$500

$1,000

$1,250

$2,500

$1,250

$2,500

$50,000

$100,000

Physicianâ&#x20AC;&#x2122;s Attendance Amount shown per day for the services of a physician during a covered hospital confinement. Payable only for the number of days the hospital confinement benefit is payable.

Inpatient Drugs and Medicine Amount shown per day for drugs or medicine required during a covered hospital confinement. Payable only for the number of days the hospital confinement benefit is payable.

Private Duty Nursing Amount shown per day for private nursing care and attendance by a nurse during a covered hospital confinement, subject to a maximum of 60 days per continuous hospital confinement. Must be required and authorized by attending physician.

Physiotherapy Amount shown per day for physiotherapy performed by a licensed physical therapist during a covered hospital confinement, subject to a maximum of 60 days per continuous hospital confinement.

Oxygen Amount shown for the use of oxygen equipment during a covered hospital confinement, subject to a maximum of 1 payment per continuous hospital confinement.

Cardiograms Amount shown for an electrocardiogram, echocardiogram, phonocardiogram or vector cardiogram required during a covered hospital confinement, subject to a maximum of 1 payment per continuous hospital confinement.

Cerebral or Carotid Angiogram Amount shown for a cerebral or carotid angiogram required during a covered hospital confinement, subject to a maximum of 1 payment per continuous hospital confinement.

Coronary Angioplasty Amount shown for a coronary angioplasty procedure, regardless of the number of blood vessels repaired during the procedure.

Pacemaker Insertion Amount shown for the initial insertion of a permanent pacemaker.

Thromboendarterectomy Amount shown for a thromboendarterectomy operation.

Coronary Artery Bypass Graft Operation Amount shown for a coronary artery bypass graft operation, regardless of the number of grafts performed during the operation.

Heart Transplant Amount shown for the implantation of a natural human heart. This benefit is only payable once per covered person. 42

Heart & Stroke HeartCare Plus Premiums for Texas Plan A - HeartCare Plus Policy (HSP2) INDIVIDUAL Monthly 1/2 unit

FAMILY (if covered) Monthly 1/2 unit

INDIVIDUAL Monthly 1 unit

FAMILY (if covered) Monthly 1 unit

$8.98

$17.32

$17.96

$34.64 Issue Ages 18-64.

HeartCare Plus and HeartCare Direct Insurance Might Be Right For You If:    

There are cardiovascular diseases in your family's history You don't have much money set aside for an unexpected cardiovascular illness You want to help keep your family financially secure You want coverage you can take with you if you leave your job

Optional Riders for HeartCare Plus and HeartCare Direct Optional riders which can be added to your base policy are: an optional intensive care benefit which pays benefits for an intensive care confinement due to any covered accident or disease, and a cancer initial diagnosis benefit which pays a onetime benefit when a covered person is positively diagnosed with cancer (other than skin cancer). Exclusions and Limitations apply.

What You Get

Pre-Existing Condition Limitation

HeartCare Plus Policy and HeartCare Direct  Pays you benefits that can be used for non-medical expenses that health insurance might not cover  Benefits are paid as you go and cover the costs of specific treatments and expenses (up to the maximum allowed) as they happen  Supplemental coverage it works in addition to other insurance you may have such as medical and disability income  Guaranteed renewable for life, subject to change in premiums by class  Coverage for yourself or your entire family

A pre-existing condition is the existence of: symptoms which would cause an ordinarily prudent person to seek diagnosis, care or treatment within a 1 year period preceding the effective date of coverage of the insured person or a condition for which medical advice or treatment was recommended by or received from a physician within a 1 year period preceding the effective date of the coverage of the insured person. If a covered person has a pre-existing condition as defined, we do not pay benefits for such conditions under this policy or any riders attached to this policy during the 12 month period beginning on the date that person became a covered person. If the loss is not due to a pre-existing condition, then the pre-existing condition limitation does not apply. All losses are subject to the Incontestability provision. Exclusions and limitations to the policy also apply to the riders. This brochure highlights some features of the policy, but is not the insurance contract. Only the actual policy provisions control. The policy itself sets forth, in detail, the rights and obligations of both the insured and the insurance company.

HeartCare Plus Policy Only  Pays in addition to your Workers' Compensation  Premiums can be made using pre-tax dollars under Section 125  Plan is portable. lt's a benefit that you can keep if you change jobs or retire by paying premiums directly to Allstate Workplace Division.

THE HARTFORD 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.

Voluntary Life Benefit Highlights What is Voluntary Life Insurance?

Voluntary Life Insurance is coverage that you pay for. Voluntary Life Insurance pays your beneficiary (please see below) a benefit if you die while you are covered. This highlight sheet is an overview of your Voluntary Life Insurance. Once a group policy is issued to your employer, a certificate of insurance will be available to explain your coverage in detail.

Am I eligible?

You are eligible if you are an active full time employee who works at least 20 hours per week on a regularly scheduled basis.

When can I enroll?

You can enroll during your scheduled enrollment period, within 31 days of the date you have a change in family status, or within 31 days of the completion of your eligibility waiting period as stated in your group policy.

When is it effective?

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

How much Voluntary Life Insurance can I purchase?

You can purchase Voluntary Life Insurance in increments of $10,000. The maximum amount you can purchase cannot be more than the lesser of 5 times your annual Salary or $500,000. Annual Salary is as defined in The Hartford’s contract with your employer.

I already have Voluntary Life Insurance coverage; do I have to do anything?

If you take no action, your coverage and coverage for your eligible dependents will automatically continue with The Hartford subject to the terms of the contract.

Am I guaranteed coverage?

If you enroll during your annual enrollment period or are newly eligible and elect an amount that exceeds the guaranteed issue amount of $150,000, you will need to provide evidence of insurability that is satisfactory to The Hartford before the excess can become effective. If you enroll after your annual or initial enrollment period, evidence of insurability will be required for all coverage amounts.

What is a beneficiary?

Your beneficiary is the person (or persons) or legal entity (entities) who receives a benefit payment if you die while you are covered by the policy. You must select your beneficiary when you complete your enrollment application; your selection is legally binding.

Are there other limitations to enrollment?

If you do not enroll within 31 days of your first day of eligibility, you will be considered a “late entrant.” Typically, late entrants must show evidence of insurability and may be responsible for the cost of physical exams or other associated costs if they are required. This coverage, like most group benefit insurance, requires that a certain percentage of eligible employees participate. If that group participation minimum is not met, the Insurance coverage that you have elected may not be in effect. If you elect Voluntary Life Insurance for yourself, you may choose to purchase Spouse Voluntary Life Insurance in increments of $5,000, to a maximum of $125,000. Coverage cannot exceed 50% of the amount of your Employee voluntary/supplemental life insurance coverage. You may not elect coverage for your spouse if they are in active full-time military service or is already covered as an employee under this policy.

Spouse Voluntary Life Insurance

If your spouse is confined in a hospital or elsewhere because of disability on the date his or her insurance would normally have become effective, coverage (or an increase in coverage) will be deferred until that dependent is no longer confined and has performed all the normal activities of a healthy person of the same age for at least 15 consecutive days. If you enroll during your annual enrollment period or are newly eligible and elect an amount that exceeds the guaranteed issue amount of $50,000, your spouse will need to provide evidence of insurability that is satisfactory to The Hartford before the excess can become effective. If you enroll after your annual or initial enrollment period, evidence of insurability will be required for all coverage amounts.

Voluntary Life Benefit Highlights

Child(ren) Voluntary Life Insurance

If you elect Voluntary Life Insurance for yourself, you may choose to purchase Child(ren) Voluntary Life Insurance coverage in increments of $10,000 for each child – no medical information is required.  If your dependent child(ren) is confined in a hospital or elsewhere because of disability on the date his or her insurance would normally have become effective, coverage (or an increase in coverage) will be deferred until that dependent is no longer confined and has performed all the normal activities of a healthy person of the same age for at least 15 consecutive days.  Your child(ren) must be at least 15 days but not yet age 26 to be covered.  Child(ren) age 26 or older may be covered if they were disabled prior to attaining age 26.

Does my coverage reduce as I get older?

By 35% at age 65 and by 50% at age 70. All coverage cancels at retirement.

Can I keep my Life Coverage if I leave my employer?

Yes, subject to the contract, you have the option of:  Converting your group life coverage to your own individual policy (policies).  If you leave your employer, Portability is an option that allows you to continue your life insurance coverage. To be eligible, you must terminate your employment prior to Social Security Normal Retirement Age. This option allows you to continue all or a portion of your Life Insurance coverage under a separate Portability term policy. Portability is subject to a minimum of $5,000 and a maximum of $250,000 and does include coverage for your Spouse and Child(ren). To elect Portability, you must apply and pay the premium within 31 days of the termination of your Life Insurance. Evidence of Insurability will not be required. Dependent Spouse Portability is subject to a maximum of $50,000. Dependent Child Portability is subject to a maximum of $10,000.

What is the Living Benefits Option?

If you are diagnosed as terminally ill with a 12 month life expectancy, you may be eligible to receive payment of a portion of your Life Insurance. The remaining amount of your Life Insurance would be paid to your beneficiary when you die.

Do I still pay my Life Insurance premiums if I become disabled?

If you become totally disabled before age 60 and your disability lasts for at least 9 months, your Life Insurance premium may be waived. The premium for your dependent’s coverage will also be waived if you are disabled and approved for waiver of premium. Coverage for your dependents will end if the policy terminates.

Important Details

As is standard with most term life Insurance, this Insurance coverage includes limitations and exclusions:  The amount of your coverage may be reduced when you reach certain ages.  Death by suicide (two years). Other exclusions may apply depending upon your coverage. Once a group policy is issued to your employer, a certificate of Insurance will be available to explain your coverage in detail.

This benefit highlights sheet is an overview of the insurance being offered and is provided for illustrative purposes only and is not a contract. It in no way changes or affects the policy as actually issued. Only the insurance policy issued to the policyholder (your employer) can fully describe all of the provisions, terms, conditions, limitations and exclusions of your insurance coverage. In the event of any difference between the benefit highlights sheet and the insurance policy, the terms of the insurance policy apply.

Voluntary AD&D Benefit Highlights

What is Voluntary Accidental Death and Dismemberment Insurance?

What does Voluntary AD&D Insurance cover?

Voluntary Accidental Death and Dismemberment Insurance pays your beneficiary (please see below) a death benefit if you die due to a covered accident while you are insured. It also pays you a benefit for certain accidental losses. Once a group policy is issued to your employer, a certificate of insurance will be available to explain your coverage in detail.  Death benefits are paid in addition to any life insurance benefits.  Voluntary Accidental Death and Dismemberment insurance pays benefits for accidental loss of limbs, thumb and index finger, speech, hearing, and sight.  Voluntary Accidental Death and Dismemberment Insurance covers losses that occur away from work or at work. Benefits are paid regardless of any worker’s compensation benefits you collect. This highlight sheet is an overview of your Voluntary Accidental Death and Dismemberment Insurance. You may receive benefits due to certain losses or death from an accident. The covered losses or death can occur up to 365 days after that accident. The policy pays for:  100% of the amount of coverage you purchase in the event of accidental loss of life, or speech and hearing in both ears.  One-half (50%) for accidental loss of one hand or foot, sight of one eye, or speech or hearing in both ears.  One-quarter (25%) for accidental loss of thumb and index finger of the same hand.

Additionally, your employer may have elected optional/supplemental benefits as part of your AD&D coverage. Refer to the certificate of insurance for further information. Your total benefit for all losses due to the same accident will not be more than 100% of the amount of coverage you purchase.

What optional benefits has my employer selected as part of my Voluntary AD&D Insurance?

    

Am I eligible?

You are eligible if you are an active full time employee who works at least 20 hours per week on a regularly scheduled basis.

When can I enroll?

When is it effective?

Coverage goes into effect subject to the terms and conditions of the policy. You must be actively at work with your employer on the day your coverage takes effect.

Child Education Benefit Day Care Benefit Paralysis Benefit Seat Belt & Air Bag Spouse Education Benefit

You can purchase Voluntary Accidental Death and Dismemberment Insurance in increments of $10,000.

How much Voluntary AD&D Insurance can I purchase?

The maximum amount you can purchase cannot be more than 10 times your annual salary or $500,000. Salary is as defined in The Hartford’s contract with your employer.

Voluntary AD&D Benefit Highlights Does my coverage reduce as I get older?

No.

Do I have to provide medical information to receive coverage?

No medical information is required. You are guaranteed the amount of coverage that you select, subject to maximum amounts defined in your policy.

What is a beneficiary?

Are there other limitations to enrollment?

This coverage, like most group benefit insurance, requires that a certain percentage of eligible employees participate. If that group participation minimum is not met, the insurance coverage that you have elected may not be in effect.

Voluntary Accidental Death and Dismemberment Insurance for your Dependents

You may also choose Voluntary Accidental Death and Dismemberment Insurance for your spouse and/or dependent child(ren). You may choose voluntary Accidental Death and Dismemberment Insurance for your spouse in the following amounts:  50% of the amount you select for yourself if you do not have any child(ren) whom you cover under this Voluntary Accidental Death and Dismemberment Insurance policy.  40% if you have child(ren) whom you cover under this Voluntary Accidental Death and Dismemberment Insurance policy. You may not elect coverage for your spouse if your spouse is already covered as an employee under this policy. You may choose guaranteed voluntary Accidental Death and Dismemberment Insurance for each child at least 15 days but under age 26 in the following amounts:  15% of the amount you select for yourself if you do not have a spouse whom you cover under this Voluntary Accidental Death and Dismemberment Insurance policy  10% if you have a spouse whom you cover under this Voluntary Accidental Death and Dismemberment Insurance policy

Important Details

As is standard with most insurance, this Voluntary Accidental Death and Dismemberment Insurance includes limitations and exclusions. Voluntary Accidental Death and Dismemberment Insurance does not cover losses caused by or contributed by:  sickness; disease; or any treatment for either;  any infection, except certain ones caused by an accidental cut or wound;  intentionally self-inflicted injury, suicide or suicide attempt;  war or act of war, whether declared or not;  injury sustained while in the armed forces of any country or international authority;  taking prescription or illegal drugs unless prescribed for or administered by a licensed physician;  injury sustained while committing or attempting to commit a felony;  the injured person’s intoxication. Other exclusions may apply depending upon the terms of your policy and other requirements. Once a group policy is issued to your employer, a certificate of insurance will be available to explain your coverage in detail.

This benefit highlights sheet is an overview of the general purposes of the Voluntary Accidental Death and Dismemberment Insurance being offered and is provided for illustrative purposes only and is not a contract. It in no way changes or affects the policy as actually issued. Only the insurance policy issued to the policyholder (your employer) can fully describe all of the provisions, terms, conditions, limitations and exclusions of your insurance coverage. In the event of any difference between the benefit highlights sheet and the policy, the terms of the insurance policy apply.

Voluntary Life and AD&D Employee Life Rates Age Band 0-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

$70,000

$80,000

$100,000

$0.40 $0.40 $0.40 $0.60 $1.00 $1.50 $2.60 $4.00 $5.30 $8.60 $15.00 $27.20

$0.80 $0.80 $0.80 $1.20 $2.00 $3.00 $5.20 $8.00 $10.60 $17.20 $30.00 $54.40

$1.20 $1.20 $1.20 $1.80 $3.00 $4.50 $7.80 $12.00 $15.90 $25.80 $45.00 $81.60

$1.60 $1.60 $1.60 $2.40 $4.00 $6.00 $10.40 $16.00 $21.20 $34.40 $60.00 $108.80

$2.00 $2.00 $2.00 $3.00 $5.00 $7.50 $13.00 $20.00 $26.50 $43.00 $75.00 $136.00

$2.40 $2.40 $2.40 $3.60 $6.00 $9.00 $15.60 $24.00 $31.80 $51.60 $90.00 $163.20

$2.80 $2.80 $2.80 $4.20 $7.00 $10.50 $18.20 $28.00 $37.10 $60.20 $105.00 $190.40

$3.20 $3.20 $3.20 $4.80 $8.00 $12.00 $20.80 $32.00 $42.40 $68.80 $120.00 $217.60

$4.00 $4.00 $4.00 $6.00 $10.00 $15.00 $26.00 $40.00 $53.00 $86.00 $150.00 $272.00

Any amount over $150,000 will be medically underwritten. You must complete an Evidence of Insurability Form

Spouse Life Rates Age Band 0-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

$35,000

$40,000

$50,000

$0.20 $0.20 $0.20 $0.30 $0.50 $0.75 $1.30 $2.00 $2.65 $4.30 $7.50 $13.60

$0.40 $0.40 $0.40 $0.60 $1.00 $1.50 $2.60 $4.00 $5.30 $8.60 $15.00 $27.20

$0.60 $0.60 $0.60 $0.90 $1.50 $2.25 $3.90 $6.00 $7.95 $12.90 $22.50 $40.80

$0.80 $0.80 $0.80 $1.20 $2.00 $3.00 $5.20 $8.00 $10.60 $17.20 $30.00 $54.40

$1.00 $1.00 $1.00 $1.50 $2.50 $3.75 $6.50 $10.00 $13.25 $21.50 $37.50 $68.00

$1.20 $1.20 $1.20 $1.80 $3.00 $4.50 $7.80 $12.00 $15.90 $25.80 $45.00 $81.60

$1.40 $1.40 $1.40 $2.10 $3.50 $5.25 $9.10 $14.00 $18.55 $30.10 $52.50 $95.20

$1.60 $1.60 $1.60 $2.40 $4.00 $6.00 $10.40 $16.00 $21.20 $34.40 $60.00 $108.80

$2.00 $2.00 $2.00 $3.00 $5.00 $7.50 $13.00 $20.00 $26.50 $43.00 $75.00 $136.00

NOTE: Rates for Spouse based on Spouseâ&#x20AC;&#x2122;s Age Any amount over $50,000 will be medically underwritten. You must complete an Evidence of Insurability Form.

Child Life Rates Child(ren)

$10,000 $1.00

Stand Alone AD&D Employee Family

$10,000 $0.40 $0.60

$20,000 $0.80 $1.20

$30,000 $1.20 $1.80

$40,000 $1.60 $2.40

$50,000 $2.00 $3.00

$60,000 $2.40 $3.60

$70,000 $2.80 $4.20

$80,000 $3.20 $4.80

$100,000 $4.00 $6.00

NOTE: FINAL RATES MAY VARY SLIGHTLY DUE TO ROUNDING. THESE GRIDS ARE PRICES OF FREQUENTLY SELECTED AMOUNTS. YOU MAY CHOOSE ANY INCREMENT OF $10,000 UP TO $500,000 (NOT TO EXCEED 5 TIMES YOUR ANNUAL SALARY). FOR SPOUSE ANY INCREMENT OF $5,000 UP TO $125,000 (NOT TO EXCEED 50% OF EMPLOYEE LIFE AMOUNT). FOR AD&D ANY INCREMENT OF $10,000 UP TO $500,000 (NOT TO EXCEED 10 TIMES YOUR ANNUAL SALARY). TO PURCHASE AN AMOUNT OTHER THAN THOSE LEVELS INDICATED ABOVE, SIMPLY ADD LEVELS TOGETHER. 49

COMBINED INSURANCE

Term Life w/ LTC

YOUR BENEFITS PACKAGE

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. Long Term Care insurance is designed to help create a safety net if you are no longer able to care for yourself. If you suffer from an eligible prolonged illness, disability or cognitive disorder, long term care insurance will provide financial support.

DID YOU KNOW? Experts recommend at least

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

Term Life with Long Term Care Having a plan of protection for you and your family is very important. The new benefits being offered allow you to be in control of that plan so when events happen you can be protected on a guarantee basis.

Plan Features

LifeTime Benefit Term



 

Permanent Term Insurance that lasts a Lifetime! Finally, a Life Insurance & Long Term Care benefit for “Pre” and “Post” Retirement needs.

An Example of How LifeTime Benefit Term with LTC Works 

A 35-year old non-smoker can purchase $75,000 of coverage including the Accelerated Death Benefit for Long Term Care and Terminal Illness with Extension of Long Term Care Benefits for $10.92 weekly. At Age 65, the employee would have guaranteed paid-up insurance of $19,820. At Age 85, the full face amount of $75,000 would be paid-up based on current interest rates. Long Term Care benefit of $3,000 (4% of $75,000) per month would be available for up to 75 months.

  

$75,000

    

Life Insurance Premiums Guaranteed for Life Long Term Care coverage worth 3x your death benefit amount. That’s up to 75 Months of care for Nursing Home, Assisted Living and Home Care! Paid-Up Life & LTC Insurance starting after the tenth year Death Benefit is Fully Paid-Up prior to Age 100 Plan is Portable with no increase in premium Spouse and Children coverage available Accelerated Death Benefit for Terminal Illness Included Guaranteed protection for Today and Tomorrow

This plan requires a paper application and underwriting, please see an FBS Enroller for assistance.

Face Amount at Issue

$225,000 (75 mo.)

Age

$75,000 ITC Benefit Amount (25 mo.)

$19,820 Paid-up Guaranteed!

$75,000

Paid-up at Current Rate

Term Life with Long Term Care Non-Tobacco Rates Riders Issue Age 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70

TI, LTC75

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

$70,000

$80,000

$90,000

$100,000

N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A 6.75 7.18 7.65 8.14 8.60 9.08 9.58 10.11 10.66 11.51 12.41 13.36 14.36 15.42 16.71 18.07 19.51 21.04 22.65 25.17 27.84 30.67 33.68 36.88

N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A 6.66 6.93 7.23 7.60 8.00 8.40 8.84 9.29 9.77 10.28 10.81 11.36 11.93 12.70 13.51 14.37 15.29 16.28 17.20 18.15 19.16 20.22 21.33 23.01 24.81 26.71 28.71 30.84 33.42 36.14 39.02 42.07 45.29 50.34 55.67 61.33 67.35 73.77

6.75 6.75 6.88 7.00 7.11 7.26 7.39 7.65 7.93 8.20 8.50 8.80 9.18 9.58 9.99 10.39 10.84 11.40 11.99 12.60 13.26 13.93 14.65 15.42 16.21 17.04 17.89 19.04 20.26 21.55 22.94 24.41 25.80 27.23 28.74 30.33 31.99 34.52 37.22 40.06 43.07 46.26 50.13 54.21 58.53 63.11 67.94 75.51 83.51 91.99 101.03 110.65

9.00 9.00 9.17 9.34 9.49 9.69 9.85 10.20 10.57 10.94 11.34 11.74 12.25 12.77 13.32 13.86 14.45 15.20 15.99 16.80 17.68 18.57 19.54 20.56 21.61 22.71 23.85 25.39 27.01 28.73 30.58 32.55 34.39 36.30 38.31 40.44 42.65 46.03 49.62 53.41 57.42 61.68 66.84 72.28 78.04 84.14 90.58 100.68 111.34 122.65 134.70 147.53

11.25 11.25 11.46 11.67 11.86 12.11 12.31 12.75 13.21 13.67 14.17 14.67 15.31 15.96 16.64 17.32 18.06 18.99 19.99 21.00 22.09 23.21 24.42 25.70 27.01 28.39 29.81 31.73 33.76 35.91 38.23 40.69 42.99 45.38 47.89 50.55 53.31 57.53 62.03 66.77 71.78 77.10 83.55 90.35 97.54 105.18 113.23 125.85 139.18 153.32 168.37 184.41

13.50 13.50 13.75 14.00 14.23 14.53 14.78 15.30 15.85 16.40 17.00 17.60 18.37 19.16 19.97 20.79 21.68 22.79 23.98 25.20 26.51 27.85 29.31 30.84 32.42 34.07 35.78 38.08 40.51 43.09 45.87 48.83 51.59 54.46 57.47 60.66 63.97 69.04 74.43 80.12 86.13 92.52 100.26 108.42 117.05 126.21 135.87 151.02 167.01 183.98 202.05 221.29

15.75 15.75 16.04 16.34 16.60 16.95 17.24 17.85 18.49 19.14 19.84 20.54 21.43 22.35 23.30 24.25 25.29 26.59 27.98 29.40 30.93 32.49 34.19 35.98 37.82 39.75 41.74 44.43 47.26 50.27 53.52 56.96 60.19 63.53 67.05 70.77 74.64 80.55 86.83 93.47 100.49 107.94 116.97 126.49 136.56 147.25 158.52 176.19 194.85 214.64 235.72 258.18

18.00 18.00 18.34 18.67 18.97 19.37 19.70 20.40 21.13 21.87 22.67 23.47 24.49 25.54 26.63 27.71 28.90 30.39 31.97 33.59 35.35 37.13 39.07 41.11 43.22 45.43 47.70 50.77 54.01 57.45 61.16 65.10 68.79 72.61 76.63 80.88 85.30 92.05 99.24 106.82 114.84 123.36 133.68 144.56 156.07 168.28 181.16 201.35 222.68 245.31 269.40 295.06

20.25 20.25 20.63 21.00 21.34 21.79 22.16 22.95 23.78 24.60 25.50 26.40 27.55 28.73 29.96 31.18 32.51 34.19 35.97 37.79 39.77 41.78 43.96 46.25 48.62 51.11 53.66 57.12 60.77 64.63 68.80 73.24 77.38 81.68 86.20 90.99 95.96 103.56 111.64 120.18 129.20 138.78 150.39 162.63 175.58 189.32 203.81 226.52 250.51 275.97 303.07 331.94

22.50 22.50 22.92 23.33 23.71 24.21 24.63 25.50 26.42 27.33 28.33 29.33 30.61 31.93 33.28 34.64 36.13 37.98 39.97 41.99 44.18 46.42 48.84 51.39 54.03 56.78 59.63 63.47 67.52 71.82 76.45 81.37 85.98 90.76 95.78 101.10 106.62 115.06 124.05 133.53 143.56 154.20 167.10 180.70 195.09 210.35 226.45 251.69 278.35 306.63 336.75 368.82

For a full list of non-tobacco and tobacco rates, please refer to the Burkburnett ISD benefit website at www.mybenefitshub.com/burkburnettisd

Term Life with Long Term Care Tobacco Rates Riders Issue Age 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70

TI, LTC75

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

$70,000

$80,000

$90,000

$100,000

N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A 6.82 7.22 7.64 8.09 8.62 9.17 9.76 10.39 11.06 11.75 12.49 13.26 14.06 14.91 16.04 17.23 18.48 19.81 21.20 22.92 24.73 26.63 28.62 30.73 34.07 37.61 41.36 45.33 49.55

N/A N/A N/A N/A N/A N/A N/A 6.69 6.94 7.19 7.44 7.71 8.05 8.41 8.77 9.15 9.54 10.01 10.50 11.01 11.57 12.13 12.85 13.63 14.43 15.28 16.17 17.23 18.35 19.52 20.78 22.11 23.50 24.97 26.51 28.12 29.82 32.08 34.46 36.96 39.62 42.40 45.84 49.45 53.25 57.25 61.45 68.14 75.21 82.71 90.65 99.11

8.58 8.58 8.79 9.00 9.23 9.46 9.69 10.04 10.41 10.78 11.16 11.56 12.07 12.61 13.16 13.73 14.31 15.01 15.75 16.52 17.35 18.19 19.28 20.44 21.65 22.92 24.25 25.84 27.52 29.28 31.17 33.16 35.25 37.46 39.77 42.17 44.73 48.12 51.69 55.45 59.44 63.60 68.76 74.18 79.87 85.87 92.17 102.22 112.82 124.06 135.98 148.66

11.44 11.44 11.72 12.00 12.30 12.62 12.92 13.39 13.89 14.37 14.89 15.42 16.10 16.81 17.54 18.31 19.09 20.01 21.00 22.02 23.13 24.25 25.70 27.26 28.86 30.56 32.33 34.45 36.69 39.04 41.56 44.22 47.00 49.94 53.03 56.23 59.63 64.15 68.92 73.93 79.25 84.80 91.68 98.90 106.49 114.49 122.90 136.29 150.43 165.42 181.31 198.21

14.29 14.29 14.65 15.00 15.38 15.77 16.15 16.73 17.36 17.96 18.61 19.27 20.12 21.01 21.93 22.88 23.86 25.01 26.25 27.53 28.91 30.31 32.13 34.07 36.08 38.21 40.42 43.07 45.86 48.80 51.95 55.27 58.75 62.43 66.28 70.29 74.54 80.19 86.15 92.41 99.06 106.00 114.59 123.63 133.12 143.11 153.62 170.36 188.03 206.77 226.63 247.76

17.15 17.15 17.58 18.00 18.45 18.93 19.38 20.08 20.83 21.55 22.33 23.13 24.15 25.22 26.31 27.46 28.63 30.01 31.50 33.03 34.69 36.38 38.56 40.89 43.29 45.85 48.50 51.68 55.04 58.57 62.35 66.32 70.50 74.91 79.54 84.34 89.45 96.23 103.38 110.89 118.87 127.20 137.51 148.35 159.74 171.73 184.35 204.43 225.64 248.12 271.96 297.32

20.01 20.01 20.51 21.00 21.53 22.08 22.61 23.42 24.30 25.14 26.05 26.98 28.17 29.42 30.70 32.03 33.40 35.01 36.75 38.54 40.47 42.44 44.98 47.70 50.51 53.49 56.58 60.29 64.21 68.33 72.74 77.38 82.26 87.39 92.80 98.40 104.36 112.27 120.61 129.37 138.68 148.40 160.43 173.08 186.36 200.35 215.07 238.50 263.24 289.48 317.28 346.87

22.87 22.87 23.43 24.00 24.60 25.23 25.83 26.77 27.77 28.73 29.77 30.83 32.19 33.62 35.08 36.61 38.17 40.01 41.99 44.04 46.25 48.50 51.41 54.51 57.72 61.13 64.67 68.91 73.38 78.09 83.13 88.43 94.01 99.88 106.05 112.46 119.26 128.30 137.84 147.85 158.49 169.60 183.35 197.80 212.99 228.97 245.79 272.57 300.85 330.83 362.61 396.42

25.73 25.73 26.36 27.00 27.68 28.39 29.06 30.11 31.24 32.33 33.49 34.69 36.22 37.82 39.47 41.18 42.94 45.02 47.24 49.55 52.04 54.56 57.83 61.33 64.93 68.77 72.75 77.52 82.55 87.85 93.52 99.49 105.76 112.36 119.31 126.51 134.17 144.34 155.07 166.33 178.30 190.79 206.27 222.53 239.61 257.59 276.52 306.64 338.46 372.18 407.93 445.97

28.58 28.58 29.29 30.00 30.75 31.54 32.29 33.46 34.71 35.92 37.21 38.54 40.24 42.03 43.85 45.76 47.71 50.02 52.49 55.05 57.82 60.63 64.26 68.14 72.15 76.41 80.83 86.13 91.72 97.61 103.91 110.54 117.51 124.85 132.56 140.57 149.08 160.38 172.30 184.81 198.11 211.99 229.18 247.25 266.23 286.22 307.24 340.71 376.06 413.54 453.26 495.52

Optional Child Face Amount $5,000 $10,000 $15,000 $20,000 $25,000

Deduction Premium(*) $1.05 $2.09 $3.14 $4.18 $5.23

For a full list of non-tobacco and tobacco rates, please refer to the Burkburnett ISD benefit website at www.mybenefitshub.com/burkburnettisd *Deduction premium shown covers all eligible dependent children (to 25)regardless of number of children. 53

NBS

FSA (Flexible Spending Account)

YOUR BENEFITS PACKAGE

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

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

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

FSA (Flexible Spending Account) NBS Flexcard

When Will I Receive My Flex Card?

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

NBS Prepaid MasterCard® Debit Card

New Members can expect Flex Cards to be delivered to the address listed in THEbenefitsHUB near the end of January Don’t forget, Flex Cards Are Good For 3 Years!

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

NBS Contact Information:

8523 South Redwood Road West Jordan, UT 84088 Phone (800) 274‐0503 Current plan participants: Fax (800) 478‐1528 KEEP YOUR CARDS! NBS debit cards are good for 3 years. You can Email: service@nbsbenefits.com expect your existing card to be funded by mid-January. If you need a replacement card please contact NBS directly at (800) 274-0503.

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

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

FSA Annual Contribution Max: $2,550

Dependent Care Annual Max: $5,000

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

    

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

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

How does a Flexible Spending Account Benefit Me? Eligible expenses must be incurred within the plan year. Only the Health FSA has a 75 day grace period. Contributions are use-it-orlose-it. Remember to retain all your receipts (including receipts for card swipes).

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

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

        

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

Dependent Care Expense Account Example Expenses:    

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

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

What Happens If I Don’t Use All of My Funds by The End of the Plan Year (December 31st)? Eligible expenses must be incurred within the plan year. Only the Health FSA has a 75 day grace period. Contributions are use-it-or-lose-it. Remember to retain all your receipts (including receipts for card swipes).

How Do I File A Claim? In most situations, you will be able to swipe your card for a medical claim. However, in the event you lose your card or are waiting to receive one, you can visit www.mybenefitshub.com/burkburnettisd and complete the “Claim Form” to send medical or daycare claims to NBS or use the web or phone app to file online. Remember you cannot use your debit card for dependent daycare claims.

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 health 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. If you choose to enroll in the HSA you are not eligible to enroll in the FSA.

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. MASA provides 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

ZEBIT YOUR BENEFITS PACKAGE

Financial Wellness

About this Benefit Zebit is a free employee financial wellness benefit that provides financial resources and access to no-cost credit options to relieve the number one cause of stress—financial stress. Zebit helps you plan, manage, and respond to life events.

Tips for Saving Money

     

Save your loose change. Keep track of your spending. Never purchase expensive items on impulse. Create a budget. Aim for short-term savings goals Save money by buying items online, in bulk.

Financial Wellness Welcome to Zebit, Burkburnett ISD! Shop thousands of products and eCertificates. From school supplies to furnishing the home, we’ve got it all. Zebit Market has over 30,000 products at competitive retail prices. Pay back loan over 6 months. First payment due at purchase. Even if you’re not eligible for Zebitline credit yet, you can still use the Instant Budget app and wellness education modules.

How Zebit Works   

JOIN: Verify your employment. No credit check. SHOP: Visit the Zebit Market and shop with your credit. The first payment is due at checkout. Your order ships within a few days. PAY OVER TIME: Use your debit or credit card to make payments interest free over 6 months.

Instant Budget App 

 

GET YOUR BUDGET. Answer 4 simple questions—your zip code, income, household composition and size—and receive an instant budget comparison of people just like you. COMPARE YOUR BUDGET. Enter your actual expenses to see how you compare. How do you match up? SET SAVINGS GOALS. We identify where you can cut back and give advice to reach your saving goal.

Zebitline Eligibility    

You must be employed by Burkburnett ISD for at least one year You must be at least 18 years old You must make at least $10,000 annually You are enrolled in direct deposit

How to Register for Zebit STEP 1 Have your Employee ID & Date of Hire/Employment available. Please refer to your Consolidated Enrollment Form for your Employee Payroll ID# and Date of Hire/ Employment. If you are not sure of your Employee ID or Date of Hire/ Employment, please contact your HR Department at 915-926-4066. STEP 2 Go to www.zebit.com/hi/burkburnett Find out how Zebit works and click on “Register Now”. STEP 3 Enter in your email address We’ll send you an email that you need to open and click on. STEP 4 Select the first checkbox that says “I work at an employer… that offers Zebit as a voluntary benefit”

Available for download on the App Store, Google Play, and Amazon.

Type in “Burkburnett ISD” and select it from the list.

Wellness Education

STEP 5 Enter in your Employee ID & Date of Hire/Employment. It will be a 2 to 6-digit number

Zebit Financial Wellness Education contains 20 interactive modules to help you learn the basics and improve your financial life. Education topics include:  Home Ownership  Savings  Investments  Payday Loans  Auto Loans  Prepaid Cards  Mobile Payments  Checking Accounts  Credit Cards  Credit Scores & Reports

         

Insurance Taxes Education Financing 529 Plans Identity Protection Retirement Emergency Savings Overdraft Mortgages Social Security

STEP 6 Enter in a few other pieces of information. Then submit your registration STEP 7 Zebit sends you an email. The email confirms the status of your application. STEP 8 Upon approval, create a password. Then you can log in and shop the Zebit Market!

Contact (855) 449-3248 help@zebit.com

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