2017 Benefit Guide Dickinson ISD by Higginbotham Public Sector

DICKINSON ISD

BENEFIT GUIDE EFFECTIVE: 09/01/2017 - 8/31/2018 WWW.MYBENEFITSHUB.COM/ DICKINSONISD

Table of Contents

Benefit Contact Information How to Enroll Annual Benefit Enrollment 1. Whatâ&#x20AC;&#x2122;s New 2. Section 125 Cafeteria Plan Guidelines 3. Annual Enrollment 4. Eligibility Requirements 5. Helpful Definitions TRS-ActiveCare MDLIVE Telehealth Cigna Dental VSP Vision The Standard Disability APL Cancer Sun Life Accident Metlife Critical Illness Sun Life Voluntary Life and AD&D Lifeworks EAP NBS Flexible Spending Account (FSA)

3 4-5 6-10 6 7 8 9 10 11-15 16-17 18-21 22-23 24-27 28-33 34-37 38-41 42-45 46-47 48-51

FLIP TO... PG. 4 HOW TO HOW TO ENROLL ENROLL

PG. 6 SUMMARY PAGES

PG. 12 YOUR BENEFITS

Benefit Contact Information

Benefit Contact Information DICKINSON ISD BENEFITS

VISION

CRITICAL ILLNESS

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

VSP VSP Provider Network: VSP Choice (800) 877-7195 www.vsp.com

MetLife (800) 438-6388 www.metlife.com/mybenefits

DICKINSON ISD BENEFITS OFFICE

DISABILITY

BASIC, VOLUNTARY LIFE AND AD&D

Leigh Manus (281) 229-6050 lmanus@dickinsonisd.org

The Standard (800) 368-1135 www.standard.com

Sun Life (800) 247-6875 www.sunlife.com/us

MEDICAL

EAP

FLEXIBLE SPENDING ACCOUNT

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

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

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

TELEHEALTH

CANCER

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

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

DENTAL

ACCIDENT

Cigna Cigna Dental Choice Plan (800) 244-6224 www.mycigna.com

Sun Life (800) 247-6875 www.sunlife.com/us

MOBILE ENROLLMENT Enrollment made simple through your smartphone or tablet. Text “FBS DICKINSON” to 313131 and get access to

everything you need to

“FBS DICKINSON”

complete your benefits

to 313131

enrollment: 

Benefit Information



Online Support



Interactive Tools



And more. PLAY VIDEO

Text

OR SCAN

How to Log In

1 BENEFIT INFO

INTERACTIVE TOOLS

2 3

www.mybenefitshub.com/dickinsonisd

CLICK LOGIN

ENTER USERNAME & PASSWORD All login credentials have been RESET to the default described below:

Username: 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.

ONLIINE SUPPORT

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.

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

Annual Benefit Enrollment

SUMMARY PAGES

Benefit Updates - What’s New:  Supplemental Benefit elections will become effective

 New Dental Carrier: CIGNA Dental Choice PPO plan offers

10/1/2017 (elections requiring evidence of insurability, such as life Insurance, may have a later effective date, if approved). After annual enrollment closes, benefit changes can only be made if you experience a qualifying event (and changes must be made within 31 days of event). DISD will have a short plan year for 2017-18. Supplemental benefits will be effective 10/1/2017 to 8/31/2018 with the exception of MDLive Telehealth effective 9/1/17.  The Kelsey Select plan is available for ActiveCare Select members in Montgomery, Harris, Fort Bend, Galveston and Brazoria counties. Kelsey is the required network for Galveston Co. and certain zip codes in Brazoria Co. and the enrollment system will show Kelsey Select as the option for AC Select based on the employee's zip code in THEbenefitsHUB. The Kelsey Select plan will be an alternative to Memorial Hermann in Montgomery, Harris and Fort Bend areas. If a member lives in one of these counties and chooses ActiveCare Select they will be placed in the Memorial Hermann plan. To select the Kelsey Select plan they will need to elect this separate plan on enrollment.  Telehealth (eff 9/1/17) provides 24/7/365 access to board-certified doctors via telephone or online video to receive no cost consultations for non-emergency care. One low premium of $10/mo covers all eligible family members whether covered on a medical plan or not.

both in network and out of network benefits with a $1500 plan year maximum per participant and orthodontic coverage for children and adults.  New Cancer Carrier - APL American Public Life offered with no health questions required. New enrollees may be subject to Pre-ex limitations within the first 12 months of coverage. Employees currently enrolled in the Allstate Plan will be rolled into a comparable level of coverage in the new plan. Those covered by the Allstate plan for at least 12 mo. will not be subject to pre-ex limitations.  NEW Carrier - Employee Assistance Program- Lifeworks The Lifeworks Silver plan is an employer paid benefit program offered to help you manage personal and professional life events. This confidential plan includes short-term counseling and referral services for employees and their dependents.  New Flexible Spending Account (FSA) Carrier - National Benefit Services (NBS) If you currently participate in a Healthcare or Dependent Care FSA, you MUST re-elect a new contribution amount every year to continue to participate. New Healthcare FSA cards for the 10/1/17 plan year will arrive by October. The maximum Medical Flex annual contribution will be $2,383 and $4,583 for Dependent (Day Care) flex for the plan year 10/1/178/31/18.

   

Login and complete your supplemental benefit enrollment from 07/17/2017 - 08/18/2017 Enrollment assistance is available by calling Financial Benefit Services at 866-914-5202 to speak to an enrollment representative Monday—Friday, 8 AM—5 PM from 07/17/2017—08/18/2017. Bilingual assistance is available. Update your profile information: home address, phone numbers, email. IMPORTANT!! Due to the Affordable Care Act (ACA) reporting requirements, please add your dependent’s social security numbers in the online enrollment system. If you have questions, please contact your Benefits Administrator. 6

SUMMARY PAGES

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

CHANGES IN STATUS (CIS):

Changes in benefit elections can occur only if you experience a qualifying event. You must present proof of a qualifying event to your Benefit Office within 31 days of your qualifying event and meet with your Benefit/HR Office to complete and sign the necessary paperwork in order to make a benefit election change. Benefit changes must be consistent with the qualifying event.

QUALIFYING EVENTS

Marital Status

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

Change in Number of Tax Dependents

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

Change in Status of Employment Affecting Coverage Eligibility

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

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

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:

annual enrollment) unless a Section 125 qualifying event occurs.

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



Changes, additions or drops may be made only during the

the forms you need under the Benefits and Forms section.

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

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

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

included in the dependent profile. Additionally, you must

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

notify your employer of any discrepancy in personal and/or benefit information.



For benefit summaries and claim forms, go to your school

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

Dental) and you can find provider search links under the Quick Links section. When will I receive ID cards? If the insurance carrier provides ID cards, you can expect to receive those 1-2 weeks after your effective date. For most dental and vision plans, you can login to the carrier website and print a temporary ID card or simply give your provider the insurance company’s phone number and they can call and

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

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

Q&A Who do I contact with Questions? For supplemental benefit questions, you can contact your Benefits Coordinator or you can call Financial Benefit Services at 866-914-5202 for assistance. 8

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 Dickinson ISD or as both

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

employees and dependents.

work concurrent with the plan effective date. For example, if your 2017 benefits become effective on September 1, 2017, you must be actively-at-work on September 1, 2017 to be eligible for your new benefits. PLAN

CARRIER

MAXIMUM AGE

Medical

Aetna

To 26

Dental

Cigna

To 26

Vision

VSP

To 26

Cancer

American Public Life

To 26

Medical Flex

NBS

IRS Tax Dependent

Disability

The Standard

N/A

Voluntary Life

Sun Life

Unmarried to 26

Telehealth

MDLIVE

To 26

Accident

Sun Life

Unmarried to 26

Critical Illness

MetLife

To 26

Employee Assistance Program (EAP)

Lifeworks

To 26

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

SUMMARY PAGES

Helpful Definitions Actively at Work You are performing your regular occupation for the employer on a full-time basis, either at one of the employer’s usual

In-Network

places of business or at some location to which the employer’s

Doctors, hospitals, optometrists, dentists and other providers

business requires you to travel. If you will not be actively at

who have contracted with the plan as a network provider.

work beginning 10/1/2017 please notify your benefits coordinator.

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

Annual Enrollment

for covered expenses.

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

Plan Year Medical, EAP, and MDLive - September 1, 2017 thru August 31,

Annual Deductible

2018.

The amount you pay each plan year before the plan begins to pay covered expenses. TRS Active Care medical deductible resets 09/01/2017 and the Dental deductible resets 10/01/2017.

Calendar Year January 1st through December 31st

Supplemental Plan Year October 1st 2017 through August 31, 2018 one time short plan year.

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

Co-insurance

taken prescriptions drugs or is under a health care provider’s

After any applicable deductible, your share of the cost of a

orders to take drugs, or received medical care or services

covered health care service, calculated as a percentage (for

(including diagnostic and/or consultation services).

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. 10

TRS ACTIVECARE AETNA STATE PLANS GROUP # 866325 | DICKINSON INDEPENDENT SCHOOL DISTRICT 2017‐2018

ActiveCare 1-HD (District Pays $112.50 Per Check)

Cost to Employee (Per Paycheck)

Employee Only

$63.00

Employee and Child(ren)

$223.00

Employee and Spouse

$383.00

Employee and Family

$545.50

Family (Both Employees Employed at DISD)

$433.00

Split Premium—Family (Spouse works at another TRS ActiveCare district)

$216.50

ActiveCare Select Plan (District Pays $112.50 Per Check)

Cost to Employee (Per Paycheck)

Employee Only

$144.50

Employee and Child(ren)

$304.50

Employee and Spouse

$519.50

Employee and Family

$682.00

Family (Both Employees Employed at DISD)

$569.50

Split Premium—Family (Spouse works at another TRS ActiveCare district)

$284.75

ActiveCare 2 (District Pays $112.50 Per Check)

Cost to Employee (Per Paycheck)

Employee Only

$244.50

Employee and Child(ren)

$418.50

Employee and Spouse

$734.50

Employee and Family

$889.50

Family (Both Employees Employed at DISD)

$777.00

Split Premium—Family (Spouse works at another TRS ActiveCare district)

$388.50

AETNA YOUR BENEFITS PACKAGE

Medical

About this Benefit Major medical insurance is a type of health care coverage that provides benefits for a broad range of medical expenses that may be incurred either on an in-patient or out-patient basis. More than 70% of adults across the United States are already being diagnosed with a chronic disease.

www.mybenefitshub.com/texarkanaisd 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 12 Dickinson ISD Benefits Website: www.mybenefitshub.com/dickinsonisd

2017 – 2018 TRS-ActiveCare Plan Highlights Effective September 1, 2017 through August 31, 2018 | In-Network Level of Benefits*

Deductible (per plan year) In-Network Out-of-Network Out-of-Pocket Maximum (per plan year; medical and prescription drug deductibles, copays, and coinsurance count toward the out-of-pocket maximum) In-Network Out-of-Network Coinsurance In-Network Participant pays (after deductible) Out-of-Network Participant pays (after deductible) Office Visit Copay Participant pays Diagnostic Lab Participant pays

Preventive Care See below for examples Teladoc® Physician Services

High-Tech Radiology (CT scan, MRI, nuclear medicine) Participant pays Inpatient Hospital (preauthorization required) (facility charges) Participant pays Emergency Room (true emergency use) Participant pays Outpatient Surgery Participant pays Bariatric Surgery Physician charges (only covered if performed at an IOQ facility) Participant pays Annual Vision Examination (one per plan year; performed by an ophthalmologist or optometrist using calibrated instruments) Participant pays Annual Hearing Examination Participant pays Preventive Care Routine physicals – annually age 12 and over Mammograms – 1 every year age 35 and over Smokingcessationcounseling– 8 visits per 12 months

• Well-child care – unlimited up to age 12 • Colonoscopy – 1 every 10 years age 50 and over •Healthydiet/obesitycounseling– unlimited to

• Well woman exam & pap smear – annually age 18 and over • Prostatecancer screening–1 per year age 50 and over • Breastfeeding support – 6 lactation counseling visits

Drug Deductible Short-Term Supply at a Retail Location

Extended-Day Supply at Mail Order or Retail-Plus Pharmacy Location (60- to

90-day supply)****

Specialty Medications Short-Term Supply of a Maintenance Medication at Retail Location (up to a 31-day supply)

What is a maintenance medication? Maintenance drugs are prescriptions commonly used to treat conditions that are considered chronic or long-term. These conditions usually require regular, daily use of medicines. Examples of maintenance drugs are those used to treat high blood pressure, heart disease, asthma and diabetes.

When does the convenience fee apply? For example, if you are covered under TRS-ActiveCare Select, the first time you fill a 31-day supply of a generic maintenance drug at a retail pharmacy you will pay $20, then you will pay $35 each month that you fill a 31-day supply of that generic maintenance drug at a retail pharmacy. A 90-day supply of that same generic maintenance medication would cost $45, and you would save $225 over the year by filling a 90-day supply.

Premium Information for ALEX You will need to enter the applicable amount â&#x20AC;&#x201C; YOUR ANNUAL COST â&#x20AC;&#x201C; from the table below into ALEX when prompted. To determine this cost, ask your Benefits Administrator for your monthly cost (this is the amount you will owe each month after your employer contributes to your coverage). Then multiply your monthly cost by 12 to get YOUR ANNUAL COST (use this amount for ALEX) Individual

$351

$514

$714

+Spouse

$991

$1,264

$1,694

+Children

$671

$834

$1,062

+Family

$1,316

$1,589

$2,004

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. **For ActiveCare 1-HD, certain generic preventive drugs are covered at 100%. Participants do not have to meet the deductible ($2,500 - individual, $5,000 - family) and they pay nothing out of pocket for these drugs. The list of drugs is on the TRS-ActiveCare website. ***If a participant obtains a brand-name drug when a generic equivalent is available, they are responsible for the generic copay plus the cost difference between the brand-name drug and the generic drug. ****Participants can fill 32-day to 90-day supply through mail order.

D ::"::::��,�:..

Memorial Hermann and

Fort Bend counties

eIS ey Ca

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Kelsey Select- all of Gal veston and zip codes 77511, 77512, 77578, 77581, 77583, 77584 and 77588 of Brazoria county.

Kelsey Select High Performance Network The Kelsey Select plan is availa ble to members in Montgomery, Harris, Fort Bend, Galveston and Brazoria counties. The Kelsey Select plan will be an alternative to Memorial Hermann in Montgomery, Harris and Fort Bend areas. If a member lives in one of these counties and chooses ActiveCare Select they will be placed in the Me morial Hermann plan. To select the Kelsey Select plan they will need to elect this separate plan on enrollment. Members living in Galveston or certain zip codes in Brazoria County (77511, 77512, 77578, 77581, 77583, 77584 and 77588) will not be able to enroll in the standard Select plan but will have Kelsey Select as an option. For members in this area currently in an ActiveCare Select plan, they will be moved to the Kelsey Select plan on 9/1/17 if no new election is made. MESA and Third Party Administrator portals are being enhanced to support these enrollment rules. In addition, Aetna and TRS are developing additional communications for members that may be impacted by the addition of the Kelsey Select High Performance Network. 15

MDLIVE YOUR BENEFITS PACKAGE

Telehealth

PLAY VIDEO

About this Benefit Telehealth provides 24/7/365 access to boardcertified doctors via telephone consultations who 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.

75%

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

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 16 Dickinson ISD Benefits Website: www.mybenefitshub.com/dickinsonisd

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

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

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

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

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

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

How much does it cost? $10 per month One cost covers entire family 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 17 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

PLAY VIDEO

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.

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

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 18 Dickinson ISD Benefits Website: www.mybenefitshub.com/dickinsonisd

Dental PPO Cigna Dental Choice Plan Network Options

Reimbursement Levels Policy Year Benefits Maximum Applies to:

In-Network: Total Cigna DPPO Network

Out-of-Network: See Non-Network Reimbursement

Based on Contracted Fees

Maximum Reimbursable Charge

$1,500

$50 $150

Tier

Monthly Rates

Dental PPO Employee Only

$36.24

Employee + Spouse

$83.74

Employee + Child(ren)

$89.54

Employee + Family

$106.56

Class I, II, III, & IX expenses

Policy Year Deductible Individual Family

Benefit Highlights Class I: Diagnostic & Preventive Oral Evaluations Prophylaxis: routine cleanings X-rays: routine X-rays: non-routine Fluoride Application Sealants: per tooth Space Maintainers: non-orthodontic Emergency Care to Relieve Pain

Class II: Basic Restorative Restorative: fillings Endodontics: minor and major Periodontics: minor and major Oral Surgery: minor and major Anesthesia: general and IV sedation Repairs: Bridges, Crowns and Inlays Repairs: Dentures Denture Relines, Rebases and Adjustments

Class III: Major Restorative Inlays and Onlays Prosthesis Over Implant Crowns: prefabricated stainless steel / resin Crowns: permanent cast and porcelain Bridges and Dentures

Class IV: Orthodontia Coverage for Employee and All Dependents

Plan Pays

You Pay

Plan Pays

You Pay

100% No Deductible

No Charge

100% No Deductible

No Charge

80% 20% 80% After Deductible After Deductible After Deductible

20% After Deductible

50% 50% 50% After Deductible After Deductible After Deductible

50% After Deductible

50% No Deductible

50% 50% 50% No Deductible No Deductible No Deductible

Lifetime Benefits Maximum: $1,500

Class IX: Implants

50% 50% 50% After Deductible After Deductible After Deductible

50% After Deductible

This material is for informational purposes only and is designed to highlight some of the benefits available under this plan. Consult the plan documents to determine specific terms of coverage relating to your plan. Terms include covered procedures, applicable waiting periods, exclusions and limitations.

Dental PPO - Limitations and Exclusions Benefit Plan Provisions: In-Network Reimbursement Non-Network Reimbursement Cross Accumulation Policy Year Benefits Maximum Policy Year Deductible Late Entrant Limitation Provision Pretreatment Review Alternate Benefit Provision Oral Health Integration Program (OHIP)

Timely Filing

For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Fee Schedule or Discount Schedule. For services provided by a non-network dentist, Cigna Dental will reimburse according to the Maximum Reimbursable Charge. The MRC is calculated at the 90th percentile of all provider charges in the geographic area. The dentist may balance bill up to their usual fees. All deductibles, plan maximums, and service specific maximums cross accumulate between in and out of network. Benefit frequency limitations are based on the date of service and cross accumulate between in and out of network. The plan will only pay for covered charges up to the yearly Benefits Maximum, when applicable. Benefit-specific Maximums may also apply. This is the amount you must pay before the plan begins to pay for covered charges, when applicable. Benefit-specific deductibles may also apply. Payment will be reduced by 50% for Class III and IV services for 12 months for eligible members that are allowed to enroll in this plan outside of the designated open enrollment period. This provision does not apply to new hires. Pretreatment review is available on a voluntary basis when dental work in excess of $200 is proposed. 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. Cigna Dental Oral Health Integration Program offers enhanced dental coverage for customers with the following medical conditions: diabetes, heart disease, stroke, maternity, head and neck cancer radiation, organ transplants and chronic kidney disease. Thereâ&#x20AC;&#x2122;s no additional charge for the program, those who qualify get reimbursed 100% of coinsurance for certain related dental procedures. Eligible customers can also receive guidance on behavioral issues related to oral health and discounts on prescription and non-prescription dental products. Reimbursements under this program are not subject to the plan deductible, but will be applied to and are subject to the plan annual maximum. Discounts on certain prescription and non-prescription dental products are available through Cigna Home Delivery Pharmacy only, and you are required to pay the entire discounted charge. For more information including how to enroll in this program and a complete list of program terms and eligible medical conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24. Out of network claims submitted to Cigna after 365 days from date of service will be denied.

Benefit Limitations: Missing Tooth Limitation

For teeth missing prior to coverage with Cigna, the amount payable is 50% of the amount otherwise payable until covered for 12 months; thereafter, considered a Class III expense. Oral Evaluations 2 per policy year X-rays (routine) Bitewings: 2 per policy year X-rays (non-routine) Complete series of radiographic images and panoramic radiographic images: Limited to a combined total of 1 per 36 months Diagnostic Casts Payable only in conjunction with orthodontic workup Cleanings 2 per policy year, including periodontal maintenance procedures following active therapy Fluoride Application 1 per policy year for children under age 26 Sealants (per tooth) Limited to posterior tooth. 1 treatment per tooth every 36 months for children under age 17 Space Maintainers Limited to non-orthodontic treatment for children under age 19 Replacement every 60 months if unserviceable and cannot be repaired. Benefits are based on the amount payable for Inlays, Crowns, Bridges, Dentures and non-precious metals. No porcelain or white/tooth-colored material on molar Partials crowns or bridges. Denture and Bridge Repairs Reviewed if more than once Denture Adjustments, Rebases and Relines Covered if more than 6 months after installation 1 every 60 months if unserviceable and cannot be repaired. Benefits are based on the amount payable for non-precious Prosthesis Over Implant metals. No porcelain or white/tooth colored material on molar crowns or bridges.

Benefit Exclusions: Covered Expenses will not include, and no payment will be made for the following: Procedures and services not listed under Benefit Highlights; Diagnostic: cone beam imaging; Preventive Services: instruction for plaque control, oral hygiene and diet; Restorative: Veneers of porcelain or acrylic materials on crowns or pontics on or replacing the upper and lower first, second and/or third molars; Periodontic: bite registrations; splinting; Prosthodontic: precision or semi-precision attachments; Procedures, appliances or restorations, except full dentures, whose main purpose is to: change vertical dimension; diagnose or treat conditions or dysfunction of the temporomandibular joint (TMJ); stabilize periodontally involved teeth; or restore occlusion; Athletic mouth guards; Replacement of a lost or stolen appliance; Services performed primarily for cosmetic reasons; Personalization; Services that are deemed to be medical in nature; Services and supplies received from a hospital; Drugs: prescription drugs Charges in excess of the Maximum Reimbursable Charge. Contracted providers are not obligated to provide discounts on non-covered services and may charge their usual fees.

This document provides a summary only. It is not a contract. If there are any differences between this summary and the official plan documents, the terms of 20 the official plan documents will prevail.

VSP YOUR BENEFITS PACKAGE

Vision

PLAY VIDEO

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.

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

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 22 Dickinson ISD Benefits Website: www.mybenefitshub.com/dickinsonisd

Vision Benefit WellVision Exam

Description Your Coverage with a VSP Provider

Copay

Frequency

$10

Every plan year*

$25

See frame and lenses

 Focuses on your eyes and overall wellness

Prescription Glasses    

$150 allowance for a wide selection of frames $170 allowance for featured frame brands 20% savings on the amount over your allowance $80 Costco® frame allowance

Included in Prescription Glasses

 Single vision, lined bifocal, and lined trifocal lenses  Polycarbonate lenses for dependent children

Included in Prescription Glasses

Lens Enhancements

   

Standard progressive lenses Premium progressive lenses Custom progressive lenses Average savings of 20-25% on other lens enhancements

$55 $95 - $105 $150 - $175

Contacts (instead of glasses)

 $150 allowance for contacts; copay does not apply  15% savings on a contact lens exam (fitting and evaluation)

Every 12 months

$20

As needed

Frame

Lenses

 Services related to diabetic eye disease, glaucoma and agerelated macular degeneration (AMD). Retinal screening for Diabetic Eyecare Plus eligible members with diabetes. Limitations and Program coordination with medical coverage may apply. Ask your VSP doctor for details.

Extra Savings

Your Monthly Contribution

Every 12 months

Glasses and Sunglasses  Extra $20 to spend on featured frame brands. Go to www.vsp.com/specialoffers for details.  20% savings on additional glasses and sunglasses, including lens enhancements, from any VSP provider within 12 months of your last WellVision Exam. Retinal Screening  No more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam Laser Vision Correction  Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities

$9.90 Member only

$20.96 Member + family

Your Coverage with Out-of-Network Providers Visit www.vsp.com for details, if you plan to see a provider other than a VSP network provider. Exam .................................................up to $45

Lined Bifocal Lenses ........................................... up to $50

Progressive Lenses ........................... up to $50

Frame ................................................................. up to $70

Lined Trifocal Lenses .........................up to $65

Contacts ...............................................................up to $105

Single Vision Lenses ..........................up to $30 Coverage with a participating retail chain may be different. Once your benefit is effective, visit vsp.com for details. Coverage information is subject to change. In the event of a conflict between this information and your organization’s contract with VSP, the terms of the contract will prevail. Based on applicable laws, benefits may vary by location. 800-877-7195 23 www.vsp.com

THE STANDARD YOUR BENEFITS PACKAGE

Disability

PLAY VIDEO

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.

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.

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 24 Dickinson ISD Benefits Website: www.mybenefitshub.com/dickinsonisd

Educator Options Voluntary Long Term Disability Voluntary Long Term Disability Insurance

Own Occupation Period

Standard Insurance Company has developed this document to provide you with information about the optional insurance coverage you may select through Dickinson ISD. Written in non-technical language, this is not intended as a complete description of the coverage. If you have additional questions, please refer to the group Voluntary Long Term Disability Insurance for Educators and Administrators brochure included in your packet or check with your human resources representative.

For the plan’s definition of disability, as described in your brochure, the own occupation period is the first 24 months for which LTD benefits are paid.

Eligibility

The maximum period for which benefits are payable is shown in the tables below. If you become disabled before age 62, LTD benefits may continue during disability until you reach age 65. If you become disabled at age 62 or older, the benefit duration is determined by your age when disability begins:

To become insured, you must be:  A regular employee of Dickinson Independent School District, excluding temporary or seasonal employees, full-time members of the armed forced, leased employees or independent contractors  Actively at work at least 20 hours each week  A citizen or resident of the Unites States or Canada

Any Occupation Period The any occupation period begins at the end of the own occupation period and continues until the end of the maximum benefit period.

Maximum Benefit Period

Employee Coverage Effective Date Please contact your benefit administrator for more information regarding the following requirements that must be satisfied for your insurance to become effective. You must satisfy:  Eligibility requirements  An eligibility waiting period of the first day of the month that follows or coincides with the date you become an eligible employee  An evidence of insurability requirement, if applicable  An active work requirement. This means that if you are not actively at work on the day before the scheduled effective date of insurance, your insurance will not become effective until the day after you complete one full day of active work as an eligible employee.

Benefit Amount You may select a monthly benefit amount in $100 increments from $200 to $8,000; based on the tables and guidelines presented in the Rates section of these Coverage Highlights. The monthly benefit amount must not exceed 66 2/3 percent of your monthly earnings. Plan Maximum Monthly Benefit: 66 2/3 percent of predisability earnings Plan Minimum Monthly Benefit: 25 percent of your LTD benefit before reduction by deductible income.

Benefit Waiting Period The benefit waiting period is the period of time that you must be continuously disabled before benefits become payable. Benefits are not payable during the benefit waiting period. The benefit waiting period options associated with your plan include: Accidental Injury

Other Disabilities

0 days

7 days

14 days

30 days

60 days

90 days

180 days

Preexisting Condition Exclusion A general description of the Pre-existing Condition Exclusion is included in the Group Voluntary Long Term Disability insurance for Educators and Administrators brochure. If you have questions, please check with your benefit administrator. Pre-existing Condition Period: The 90-days period just before your insurance become effective Exclusions Period: 12 months.

Age

Maximum Benefit Period

62 63 64 65 66 67 68 69+

3 years 6 months 3 years 2 years 6 months 2 years 1 year 9 months 1 year 6 months 1 year 3 months 1 year

Final Day Hospital Benefit With this benefit, if an insured employee is admitted as a hospital inpatient for at least four hours (and charged room and board) during the Benefit Waiting Period, the Benefit Waiting Period will be satisfied. Benefits become payable on the date of hospitalization; the maximum benefit period also begins on that date. This feature is included only on LTD plans with Benefit Waiting Periods of 30 days or less.

When Benefits End LTD benefits end automatically on the earliest of:  The date you are no longer disabled  The date your maximum benefit period ends  The date you die  The date benefits become payable under any other LTD plan under which you become insured through employment during a period of temporary recovery  The date you fail to provide proof of continued disability and entitlement to benefits

Rates Employees can select a monthly LTD benefit ranging from a minimum of $200 to a maximum amount based on how much they earn. Follow these steps, referencing the attached charts, to find the monthly cost for your desired level of monthly LTD benefit and benefit waiting period: 1. Find the maximum LTD benefit by locating the amount of your earnings in either the Annual Earnings or Monthly Earnings column. The LTD benefit amount shown associated with these earnings is the maximum amount you can receive. If your earnings fall between two amounts, you must select the lower amount. 2. Select the desired monthly LTD benefit between the minimum of $200 and the determined maximum amount, making sure not exceed the maximum for your earnings. 3. In the same row, select the desired benefit waiting period to see the monthly cost for that selection. If you have questions regarding how to determine your monthly LTD benefit, the benefit waiting period, or the premium payment of your desired benefit, please contact your human resources representative. 25

Educator Options Voluntary Long Term Disability Group Insurance Certificate If you become insured, you will receive a group insurance certificate containing a detailed description of the insurance coverage. The information presented above is controlled by the group policy and does not modify it in any way. The controlling provisions are in the group policy issued by Standard Insurance Company.

Options 1 â&#x20AC;&#x201C;6: Maximum benefit to age 65 for both accident and sickness Accident / Sickness Benefit Waiting Period Cost Per Month Monthly Disability 0-7 14 - 14 30 - 30 60 - 60 90 - 90 180 - 180 Benefit 200 7.76 6.84 5.80 3.76 3.24 2.38

Annual Earnings

Monthly Earnings

3,600

300

5,400

450

300

11.64

10.26

8.70

5.64

4.86

3.57

7,200

600

400

15.52

13.68

11.60

7.52

6.48

4.76

9,000

750

500

19.40

17.10

14.50

9.40

8.10

5.95

10,800

900

600

23.28

20.52

17.40

11.28

9.72

7.14

12,600

1,050

700

27.16

23.94

20.30

13.16

11.34

8.33

14,400

1,200

800

31.04

27.36

23.20

15.04

12.96

9.52

16,200

1,350

900

34.92

30.78

26.10

16.92

14.58

10.71

18,000

1,500

1,000

38.80

34.20

29.00

18.80

16.20

11.90

19,800

1,650

1,100

42.68

37.62

31.90

20.68

17.82

13.09

21,600

1,800

1,200

46.56

41.04

34.80

22.56

19.44

14.28

23,400

1,950

1,300

50.44

44.46

37.70

24.44

21.06

15.47

25,200

2,100

1,400

54.32

47.88

40.60

26.32

22.68

16.66

27,000

2,250

1,500

58.20

51.30

43.50

28.20

24.30

17.85

28,800

2,400

1,600

62.08

54.72

46.40

30.08

25.92

19.04

30,600

2,550

1,700

65.96

58.14

49.30

31.96

27.54

20.23

32,400

2,700

1,800

69.84

61.56

52.20

33.84

29.16

21.42

34,200

2,850

1,900

73.72

64.98

55.10

35.72

30.78

22.61

36,000

3,000

2,000

77.60

68.40

58.00

37.60

32.40

23.80

37,800

3,150

2,100

81.48

71.82

60.90

39.48

34.02

24.99

39,600

3,300

2,200

85.36

75.24

63.80

41.36

35.64

26.18

41,400

3,450

2,300

89.24

78.66

66.70

43.24

37.26

27.37

43,200

3,600

2,400

93.12

82.08

69.60

45.12

38.88

28.56

45,000

3,750

2,500

97.00

85.50

72.50

47.00

40.50

29.75

46,800

3,900

2,600

100.88

88.92

75.40

48.88

42.12

30.94

48,600

4,050

2,700

104.76

92.34

78.30

50.76

43.74

32.13

50,400

4,200

2,800

108.64

95.76

81.20

52.64

45.36

33.32

52,200

4,350

2,900

112.52

99.18

84.10

54.52

46.98

34.51

54,000

4,500

3,000

116.40

102.60

87.00

56.40

48.60

35.70

55,800

4,650

3,100

120.28

106.02

89.90

58.28

50.22

36.89

57,600

4,800

3,200

124.16

109.44

92.80

60.16

51.84

38.08

59,400

4,950

3,300

128.04

112.86

95.70

62.04

53.46

39.27

61,200

5,100

3,400

131.92

116.28

98.60

63.92

55.08

40.46

63,000

5,250

3,500

135.80

119.70

101.50

65.80

56.70

41.65

64,800

5,400

3,600

139.68

123.12

104.40

67.68

58.32

42.84

26 66,600

5,550

3,700

143.56

126.54

107.30

69.56

59.94

44.03

Educator Options Voluntary Long Term Disability Options 1 â&#x20AC;&#x201C;6: Maximum benefit to age 65 for both accident and sickness (cntd.) Accident / Sickness Benefit Waiting Period Cost Per Month Annual Earnings 68,400 70,200 72,000 73,800 75,600 77,400 79,200 81,000 82,800 84,600 86,400 88,200 90,000 91,800 93,600 95,400 97,200 99,000 100,800 102,600 104,400 106,200 108,000 109,800 111,600 113,400 115,200 117,000 118,800 120,600 122,400 124,200 126,000 127,800 129,600 131,400 133,200 135,000 136,800 138,600 140,400 142,200 144,000

Monthly Earnings 5,700 5,850 6,000 6,150 6,300 6,450 6,600 6,750 6,900 7,050 7,200 7,350 7,500 7,650 7,800 7,950 8,100 8,250 8,400 8,550 8,700 8,850 9,000 9,150 9,300 9,450 9,600 9,750 9,900 10,050 10,200 10,350 10,500 10,650 10,800 10,950 11,100 11,250 11,400 11,550 11,700 11,850 12,000

Monthly Benefit 3,800 3,900 4,000 4,100 4,200 4,300 4,400 4,500 4,600 4,700 4,800 4,900 5,000 5,100 5,200 5,300 5,400 5,500 5,600 5,700 5,800 5,900 6,000 6,100 6,200 6,300 6,400 6,500 6,600 6,700 6,800 6,900 7,000 7,100 7,200 7,300 7,400 7,500 7,600 7,700 7,800 7,900 8,000

0-7

14 - 14

30 - 30

60 - 60

90 - 90

180 - 180

147.44 151.32 155.20 159.08 162.96 166.84 170.72 174.60 178.48 182.36 186.24 190.12 194.00 197.88 201.76 205.64 209.52 213.40 217.28 221.16 225.04 228.92 232.80 236.68 240.56 244.44 248.32 252.20 256.08 259.96 263.84 267.72 271.60 275.48 279.36 283.24 287.12 291.00 294.88 298.76 302.64 306.52 310.40

129.96 133.38 136.80 140.22 143.64 147.06 150.48 153.90 157.32 160.74 164.16 167.58 171.00 174.42 177.84 181.26 184.68 188.10 191.52 194.94 198.36 201.78 205.20 208.62 212.04 215.46 218.88 222.30 225.72 229.14 232.56 235.98 239.40 242.82 246.24 249.66 253.08 256.50 259.92 263.34 266.76 270.18 273.60

110.20 113.10 116.00 118.90 121.80 124.70 127.60 130.50 133.40 136.30 139.20 142.10 145.00 147.90 150.80 153.70 156.60 159.50 162.40 165.30 168.20 171.10 174.00 176.90 179.80 182.70 185.60 188.50 191.40 194.30 197.20 200.10 203.00 205.90 208.80 211.70 214.60 217.50 220.40 223.30 226.20 229.10 232.00

71.44 73.32 75.20 77.08 78.96 80.84 82.72 84.60 86.48 88.36 90.24 92.12 94.00 95.88 97.76 99.64 101.52 103.40 105.28 107.16 109.04 110.92 112.80 114.68 116.56 118.44 120.32 122.20 124.08 125.96 127.84 129.72 131.60 133.48 135.36 137,24 139.12 141.00 142.88 144.76 146.64 148.52 150.40

61.56 63.18 64.80 66.42 68.04 69.66 71.28 72.90 74.52 76.14 77.76 79.38 81.00 82.62 84.24 85.86 87.48 89.10 90.72 92.34 93.96 95.58 97.20 98.82 100.44 102.06 103.68 105.30 106.92 108.54 110.16 111.78 113.40 115.02 116.64 118.26 119.88 121.50 123.12 124.74 126.36 127.98 129.60

45.22 46.41 47.60 48.79 49.98 51.17 52.36 53.55 54.74 55.93 57.12 58.31 59.50 60.69 61.88 63.07 64.26 65.45 66.64 67.83 69.02 70.21 71.40 72.59 73.78 74.97 76.16 77.35 78.54 79.73 80.92 82.11 83.30 84.49 85.68 86.87 88.06 89.25 90.44 91.63 92.82 94.01 27 95.20

APL

Cancer

YOUR BENEFITS PACKAGE

PLAY VIDEO

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.

Breast Cancer is the most commonly diagnosed cancer in women.

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

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 28 Dickinson ISD Benefits Website: www.mybenefitshub.com/dickinsonisd

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

SUMMARY OF BENEFITS

Plan 1

Cancer Treatment Policy Benefits

Level 1

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

$10,000

$50 per treatment

Hormone Therapy - Maximum of 12 treatments per calendar year Experimental Treatment Surgical Rider Benefits Surgical Anesthesia Bone Marrow Transplant - Maximum per lifetime Stem Cell Transplant - Maximum per lifetime Prosthesis - Surgical Implantation/Non-Surgical (not Hair Piece) 1 device per site, per lifetime

Plan 2

paid in same manner and under the same maximums as any other benefit Level 3 Level 3 $45 unit dollar amount Max $4,500 per operation

$45 unit dollar amount Max $4,500 per operation

25% of amount paid for covered surgery $9,000

$9,000

$900

$2,000 / $200

Patient Care Rider Benefits

Level 4

Hospital Confinement Per day of Hospital Confinement (1-30 days) Per day for Eligible Dependent Children (1-30 days) Per day of Hospital Confinement (31+ days) Per day for Eligible Dependent Children (31+ days) Outpatient Facility - Per day surgery is performed

$300 $600 $600 $1,200 $600

Attending Physician - Per day of Hospital Confinement

$50

Dread Disease - Per day of Hospital Confinement (1-30 days / 31+ days)

$300 / $600

Extended Care Facility - Up to the same number of Hospital Confinement Days

$300 per day

Donor

$300 per day

Home Health Care - Up to the same number of Hospital Confinement Days

$300 per day

Hospice Care - Up to maximum of 365 days per lifetime

$300 per day

US Government, Charity Hospital or HMO Per day of Hospital Confinement (1-30 days / 31+ days) Miscellaneous Care Rider Benefits

$300/ $600 Level 2

$300 / $600 Lev el 2

Cancer Treatment Center Evaluation or Consultation - 1 per lifetime

$750

Evaluation or Consultation Travel and Lodging - 1 per lifetime

$350

Second / Third Surgical Opinion - per diagnosis of cancer Drugs and Medicine - Inpatient / Outpatient (maximum $150 per month) Hair Piece (Wig) - 1 per lifetime Transportation - Maximum 12 trips per calendar year for all modes of transportation combined Travel by bus, plane or train Travel by car Lodging - up to a maximum of 100 days per calendar year Family Transportation - Maximum 12 trips per calendar year for all modes of transportation combined Travel by bus, plane or train Travel by car Family Lodging - up to a maximum of 100 days per calendar year

$300 / $300

$150 per confinement $50 per prescription $150

actual coach fare or $0.75 per mile $0.75 per mile $100 per day actual coach fare or $0.75 per mile $0.75 per mile $100 per day

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

GC14 Limited Benefit Group Cancer Indemnity Insurance Level 2

Level 2

$300 per day

$200 / $2,000 per trip $150 per day

$150 per day

$150

$25 per visit / $1,000

Waive Premium

Miscellaneous Care Rider Benefits Con’t. Blood, Plasma and Platelets Ambulance - Ground/Air - Maximum of 2 trips per Hospital Confinement for all modes of transportation combined Inpatient Special Nursing Services - per day of Hospital Confinement Outpatient Special Nursing Services - Up to same number of Hospital Confinement days Medical Equipment - Maximum of 1 benefit per calendar year Physical, Occupational, Speech, Audio Therapy & Psychotherapy / Maximum per calendar year Waiver of Premium Internal Cancer First Occurrence Rider Benefits

Level 2

Lump Sum Benefit - Maximum 1 per Covered Person per lifetime

Not Available

$5,000

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

Not Available

$7,500

Intensive Care Unit

Not Available

$600 per day

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

Not Available

$300 per day

Hospital Intensive Care Unit Rider Benefits

TOTAL MONTHLY PREMIUMS BY PLAN** Issue Ages 18 +

Individual

Individual & Spouse

1 Parent Family

2 Parent Family

Plan 1

Plan 2

Plan 1

Plan 2

Plan 1

Plan 2

Plan 1

Plan 2

$21.46

$29.06

$45.48

$61.86

$26.86

$37.50

$50.82

$70.24

**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.

Benefits are only payable following a diagnosis of cancer for a loss incurred for the treatment of cancer while covered under the policy. A charge must be incurred for benefits to be payable. When coverage terminates for loss incurred after the coverage termination date, our obligation to pay benefits also terminates for a specified disease that manifested itself while the person was covered under the policy. All benefits are subject to the benefit maximums.

Pre-Existing Condition Exclusion

Cancer Treatment Benefits

No benefits are payable for any loss incurred during the pre-existing condition exclusion period, following the covered person’s effective date as the result of a pre-existing condition. Pre-existing conditions specifically named or described as excluded in any part of the policy are never covered. If any change to coverage after the certificate effective date results in an increase or addition to coverage, the time limit on certain defenses and pre-existing condition exclusion for such increase will be based on the effective date of such increase.

Eligibility

Waiting Period

You and your eligible dependents are eligible to be insured under this certificate if you and your eligible dependents meet our underwriting rules and you are actively at work with the policyholder and qualify for coverage as defined in the master application.

Limitations and Exclusions

No benefits will be paid for any of the following: treatment by any program engaged in research that does not meet the definition of experimental treatment; or losses or medical expenses incurred prior to the covered person’s effective date regardless of when specified disease was diagnosed.

Only Loss for Cancer

The policy pays only for loss resulting from definitive cancer treatment including direct extension, metastatic spread or recurrence. Proof must be submitted to support each claim. The policy also covers other conditions or diseases directly caused by cancer or the treatment of cancer. The policy does not cover any other disease, sickness or incapacity which existed prior to the diagnosis of cancer, even though after contracting cancer it may have been complicated, aggravated or affected by cancer or the treatment of cancer. 30

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

The policy and any attached riders contain a waiting period during which no benefits will be paid. If any covered person has a specified disease diagnosed before the end of the waiting period immediately following the covered person’s effective date, coverage for that person will apply only to loss that is incurred after one year from the covered person’s effective date. If any covered person is diagnosed as having a specified disease during the waiting period immediately following the covered person’s effective date, you may elect to void the certificate from the beginning and receive a full refund of premium. If the policy replaced group specified disease cancer coverage from any company that terminated within 30 days of the certificate effective date, the waiting period will be waived for those covered persons that were covered under the prior coverage. However, the pre-existing condition exclusion provision will still apply.

GC14 Limited Benefit Group Cancer Indemnity Insurance Termination of Certificate

Insurance coverage under the certificate and any attached riders will end on the earliest of these dates: the date the policy terminates; the end of the grace period if the premium remains unpaid; the date insurance has ceased on all persons covered under this certificate; the end of the certificate month in which the policyholder requests to terminate this coverage; the date you no longer qualify as an insured; or the date of your death.

Termination of Coverage

Insurance coverage for a covered person under the certificate and any attached riders for a covered person will end as follows: the date the policy terminates; the date the certificate terminates; the end of the grace period if the premium remains unpaid; the end of the certificate month in which the policyholder requests to terminate the coverage for an eligible dependent; the date a covered person no longer qualifies as an insured or eligible dependent; or the date of the covered person’s death. We may end the coverage of any Covered Person who submits a fraudulent claim.

Surgical Benefits Limitations and Exclusions

No benefits will be paid for any of the following: treatment by any program engaged in research that does not meet the definition of experimental treatment; losses or medical expenses incurred prior to the covered person’s effective date of this rider regardless of when a specified disease was diagnosed; or loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as a result of a pre-existing condition. For the purpose of benefits under this rider, the waiting period will begin on the covered person’s effective date of this rider.

Patient Care Benefits A hospital is not an institution, or part thereof, used as: a hospice unit, including any bed designated as a hospice or a swing bed; a convalescent home; a rest or nursing facility; a rehabilitative facility; an extended-care facility; or a facility primarily affording custodial, educational care, or care of treatment for persons suffering from mental diseases or disorders, or care for the aged, or drug or alcohol addiction.

Limitations and Exclusions

Only Loss for Cancer or Dread Disease

Pays only for loss resulting from definitive cancer treatment including direct extension, metastatic spread or recurrence. Proof must be submitted to support each claim. This rider also covers other conditions or diseases directly caused by cancer or the treatment of cancer. This rider does not cover any other disease, sickness or incapacity which existed prior to the diagnosis of cancer, even though after contracting cancer it may have been complicated, aggravated or affected by cancer or the treatment of cancer except for conditions specifically provided in the dread disease benefit.

Miscellaneous Benefits Waiver of Premium

When the certificate is in force and you become disabled, we will waive all premiums due including premiums for any riders attached to the certificate. Disability must be due to cancer and occur while receiving treatment for such cancer. You must remain disabled for 60 continuous days before this benefit will begin. The waiver of premium will begin on the next premium due date following the 60 consecutive days of disability. This benefit will continue for as long as you remain disabled until the earliest of either of the following: the date you are no longer disabled; the date coverage ends according to the termination provisions in the certificate; or the date coverage ends according to the termination provisions in this rider. Proof of disability must be provided for each new period of disability before a new waiver of premium benefit is payable.

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

Limitations and Exclusions

Termination of Surgical, Patient Care & Miscellaneous Benefit Rider(s) The above listed rider(s) will terminate and coverage will end for all covered persons on the earliest of: the end of the grace period if the premium for the rider remains unpaid; the date the policy or certificate to which the rider is attached terminates; the end of the certificate month in which APL receives a request from the policyholder to terminate the rider; or the date of your death. Coverage on an eligible dependent terminates under the rider when such person ceases to meet the definition of eligible dependent.

Internal Cancer First Occurrence Benefits Pays a lump sum benefit amount when a covered person receives a first diagnosis of internal cancer and the date of diagnosis occurs after the waiting period. Only one benefit per covered person, per lifetime is payable under this benefit and the lump sum benefit amount will reduce by 50% at age 70.

Limitations and Exclusions

We will not pay benefits for a diagnosis of internal cancer received outside the territorial limits of the United States or a metastasis to a new site of any cancer diagnosed prior to the covered person’s effective date, as this is not considered a first diagnosis of an internal cancer.

Pre-Existing Condition Exclusion

No benefits are payable for any loss incurred during the pre-existing condition exclusion period following the covered person’s effective date of this rider as the result of a pre-existing condition.

Waiting Period

This rider contains a 30-day waiting period during which no benefits will be paid. If any internal cancer is diagnosed before the end of the waiting period immediately following the covered person’s effective date of this rider, coverage will apply only to loss that is incurred after one year from the covered person’s effective date of this rider.

Termination

This rider will terminate and coverage will end for all covered persons on the earliest of any of the following: the end of the grace period if the premium for this rider remains unpaid; the date the policy or certificate to which this rider is attached terminates; the end of the certificate month in which we receive a request from the policyholder to terminate this rider; the date of covered person’s death or the date the lump sum benefit amount for internal cancer has been paid for all covered persons under this rider. Coverage on an eligible dependent terminates under this rider when such person ceases to meet the definition of eligible dependent.

Hospital Intensive Care Unit Benefits Pays a daily benefit amount, up to the maximum number of days for any combination of confinement, for each day charges are incurred for room and board in an intensive care unit (ICU) or step-down unit due to an accident or sickness. Benefits will be paid beginning on the first day a covered person is confined in an ICU or step-down unit due to an accident or sickness that begins after the effective date of this rider. This benefit will reduce by 50% at age 70.

Limitations and Exclusions

For a newborn child born within the 10-month period following the effective date, no benefits under this rider will be provided for confinements that begin within the first 30 days following the birth of such child. No benefits under this rider will be provided during the first two years following the effective date for confinements caused by any heart condition when any heart condition was diagnosed or treated prior to the end of the 30-day period following the covered person’s effective date. The heart condition causing the confinement need not be the same condition diagnosed or treated prior to the effective date. 31

GC14 Limited Benefit Group Cancer Indemnity Insurance We will not pay benefits for any loss caused by or resulting from any of the following: intentionally self-inflicted bodily injury, suicide or attempted suicide, whether sane or insane; alcoholism or drug addiction; any act of war, declared or undeclared, or any act related to war, or active service in the armed forces, or military service for any country at war [(if coverage is suspended for any covered person during a period of military service, we will refund the pro-rata portion of any premium paid for any such covered person upon receipt of the policyholder’s written request)]; participation in any activity or event while intoxicated or under the influence of any narcotic unless administered by a physician or taken according to the physician’s instructions; participation in, or attempting to participate in, a felony, riot or insurrection (a felony is defined by the law of the jurisdiction in which the activity takes place).

Termination

This rider will terminate and coverage will end for all covered persons on the earliest of any of the following: the end of the grace period if the premium for this rider remains unpaid; the date the policy or certificate to which this rider is attached terminates; the end of the certificate month in which we receive a request from the policyholder to terminate this rider or the date of the covered person’s death. Coverage on an eligible dependent terminates under this rider when such person ceases to meet the definition of eligible dependent.

Optionally Renewable This policy/riders are optionally renewable. The policyholder or we have the right to terminate the policy/riders on any premium due date after the first anniversary following the policy/riders effective date. We must give at least 60 days written notice to the policyholder prior to cancellation.

Portability (Voluntary Plans Only) When you no longer meet the definition of Insured, you will have the option to continue this coverage, including any attached riders. No Evidence of Insurability will be required. Portability must meet all of the following conditions: the certificate has been continuously in force for the last 12 months; we receive a request and payment of the first premium for the portability coverage no later than 30 days after the date you no longer qualify as an eligible insured; and the policy, under which this certificate was issued, continues to be in force on the date you cease to qualify for coverage. All future premiums due will be billed directly to you. You are responsible for payment of all premiums for the portability coverage. The benefits, terms and condition of the portability coverage will be the same as those elected under the certificate immediately prior to the date you exercised portability. Portability coverage may include any eligible dependents who were covered under the certificate at the time you ceased to qualify as an eligible insured. No new eligible dependents may be added to the portability coverage except as provided in the New Born and Adopted Children provision. No increases in coverage will be allowed while you are exercising your rights under this rider. The premium for the portability coverage will be based on the premium tables used for such coverage at the time of the portability request. Coverage under this rider will terminate in accordance with the provisions of the Termination of Coverage in the certificate. If the policy is no longer in force, then portability coverage is not available.

2305 Lakeland Drive | Flowood, MS 39232 ampublic.com | 800.256.8606 Underwritten by American Public Life Insurance Company. This is a brief description of the coverage. For detailed benefits, limitations, exclusions and other provisions, please refer to the policy/certificate/riders. This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. | This policy is considered an employee welfare benefit plan established and/or maintained by an association or employer intended to be covered by ERISA, and will be administered and enforced under ERISA. Group policies issued to governmental entities and municipalities may be exempt from ERISA guidelines. | Policy Form GC14 Series | TX | Limited Benefit Group Cancer Indemnity Insurance | (10/14) | MGM/FBS | Dickinson ISD 32

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

GC14 Limited Benefit Group Cancer Indemnity Insurance Dickinson ISD

SUN LIFE YOUR BENEFITS PACKAGE

Accident

PLAY VIDEO

About this Benefit

2/3

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

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

usually live paycheck to paycheck.

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 34 Dickinson ISD Benefits Website: www.mybenefitshub.com/dickinsonisd

Accident Stay on stable financial ground, even when an accident has you off your feet. Receive a payment if you experience any of the following injuries, care, or losses due to a covered accident. Benefits for injuries are payable once for each covered accident, and benefits for hospital stays and related care are payable up to a specific number of days or visits for each covered accident.

Injuries Covered benefits

The plan pays Low

Dislocations1 Hip

$2,000

Knee, ankle, bones of the foot

$1,000

Elbow or wrist

$500

Shoulder

$500

Collarbone or bones of the hand

$500

Finger(s) or toe(s)

$100

Lower jaw

$500

Fractures1 Hip or thigh

$2,000

Skull—depressed

$3,000

Skull—simple; vertebral processes; or bones of face or nose

$500

Leg

$1,200

Vertebrae

$1,200

Pelvis

$1,200

Upper jaw or upper arm

$600

Lower jaw, knee cap, ankle, foot, collarbone, shoulder, forearm, hand, or wrist

$500

Rib, finger, toe, coccyx

$200

Multiple ribs

$500

Additional injuries Eye injury

$200

Gunshot wound

$250

Paralysis—monoplegia, uniplegia

$500

Paralysis—diplegia

$1,000

Paralysis—hemiplegia

$1,000

Accident Paralysis—paraplegia

$1,000

Paralysis—quadriplegia

$5,000

Coma

n/a

Concussion Concussion Lifetime Maximum Benefit

$100 $1,500

Lacerations 2" to 6" with sutures

$200

Greater than 6" with sutures

$400

Burns Greater than 36% of body, 2nd degree

$500

9 to 18 square inches, 3rd degree

$1,000

Over 18, up to 35 square inches, 3rd degree

$3,000

Over 35 square inches, 3rd degree

$10,000

Skin graft

50% of the applicable Burn Benefit

1. Benefits displayed reflect amounts payable for open reductions. Benefits payable for closed reductions are 50% of open reduction amount.

Care Covered benefits

The plan pays Low

Medical services Diagnostic exam (one time per each Covered Accident): CT, CAT, EKG, EEG, or MRI

$100

X-ray

$20

Physician’s follow-up treatment office visit (per visit, up to two times per Covered Accident)

$50

Physical therapy, occupational therapy (per visit, up to six visits per Covered Accident)

$20

Medical devices

$50

Epidural pain management (up to two injections per Covered Accident)

$25

Hospital Hospital admission

$500

Hospital confinement (per day up to 365 days per Covered Accident)

$100

Intensive Care Unit admission

$750

Intensive Care Unit confinement (per day up to 15 days)

$150

Ambulance (Ground)

$100

Ambulance (Air)

$500

Emergency Room admission or Urgent Care facility

$100

Accident Family lodging (per day, maximum lodging night stays: 30 days per Covered Accident)

$100

Transportation (100 or more miles up to three times per Covered Accident)

$150

Rehabilitation Unit (per day up to 30 days per Covered Accident)

$100

Blood, plasma, or platelet transfusion

$100

Surgery Open surgery (not otherwise listed)

$1,000

Exploratory surgery or debridement

$100

Laparoscopic surgery or hernia repair

$100

Prosthesis (one)

n/a

Prosthesis (two)

n/a

Tendon/ligament/rotator cuff tear

$500

Torn knee cartilage

$500

Ruptured/herniated disc

$500

Emergency dental Emergency dental extraction

n/a

Emergency dental crown

n/a

Loss Covered benefits

The plan pays Low

Life and Dismemberment Losses2 Accidental Death

$20,000

Accidental Death Common Carrier3

$40,000

Catastrophic Loss4 Accidental dismemberment: one hand, one foot, one leg, one arm, loss of sight of one eye or loss of one eye, or loss of hearing of one ear or loss of one ear

$25,000 $4,000

Two or more fingers or toes One finger or one toe

$1,000

2. 3.

$500

Payable for life/death and dismemberment losses that are due to a Covered Accident or Accidental Injury as defined by the policy. Benefits displayed are payable for the employee only. Life and dismemberment benefits for the spouse are 100% of the benefit amount listed. Life and dismemberment benefits for dependent children are 50% of the benefit amount listed. Accidental Death Common Carrier pays an additional benefit if accidental death occurs while traveling as a fare-paying passenger on a public conveyance. Both arms or both hands, both legs or both feet, one hand and one foot or one arm and one leg, irrecoverable loss of hearing of both ears, irrecoverable loss of sight of both eyes, or irrecoverable loss of speech or ability to speak.

Rate Sheet Coverage and monthly rate for Accident Insurance. Accident coverage is contributory, meaning that you are responsible for paying for all or a portion of the cost through payroll deduction.

Low Employee Only Employee & Spouse Employee & Children Employee & Family

$8.46 $13.31 $13.85 $22.02

Injuries and other related benefits due to a covered accident must be diagnosed or treated within a defined period of time from the date of your accident. This could be as few as three days for certain benefits. Please refer to your policy for details. Accident insurance is a limited benefit policy. It provides accident coverage only and does not provide basic hospital, basic medical, or major medical insurance. This coverage does not constitute comprehensive health insurance (often referred to as â&#x20AC;&#x153;major medical coverageâ&#x20AC;?) and does not satisfy the requirement for

Minimum Essential Coverage under the Affordable Care Act. Failing to maintain Minimum Essential Coverage may result in a tax penalty. The certificate and its riders have exclusions and limitations that may affect any benefits payable. Benefits payable are subject to all terms and conditions of the certificate. The policy, certificate, and any rider, if applicable, may not be available in all states. 37

METLIFE

Critical Illness

YOUR BENEFITS PACKAGE

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

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

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 38 Dickinson ISD Benefits Website: www.mybenefitshub.com/dickinsonisd

Critical Illness COVERAGE OPTIONS Critical Illness Insurance Eligible Individual Employee

Initial Benefit $10,000 or $20,000

Spouse/Domestic Partner1

100% of the employee’s Initial Benefit

Two Children are Eligible2

100% of the employee’s Initial Benefit

Requirements Coverage is guaranteed provided you are actively at work.3 Coverage is guaranteed provided the employee is actively at work and the spouse/domestic partner is not subject to a medical restriction as set forth on the enrollment form and in the Certificate.3 Coverage is guaranteed provided the employee is actively at work and the dependent is not subject to a medical restriction as set forth on the enrollment form and in the Certificate.3

BENEFIT PAYMENT Your Initial Benefit provides a lump-sum payment upon the first diagnosis of a Covered Condition. Your plan pays a Recurrence Benefit4 equal to the Initial Benefit for the following Covered Conditions: Heart Attack, Stroke, Coronary Artery Bypass Graft, Full Benefit Cancer and Partial Benefit Cancer. A Recurrence Benefit is only available if an Initial Benefit has been paid for the Covered Condition. There is a Benefit Suspension Period between Recurrences. Initial Benefits and Recurrence Benefits will be paid until the Total Benefit Amount has been reached. The maximum amount that you can receive through your Critical Illness Insurance plan is called the Total Benefit and is 3 times the amount of your Initial Benefit. This means that you can receive multiple Initial Benefit and Recurrence Benefit payments until you reach the maximum of 300% or $30,000 or $60,000. Please refer to the table below for the percentage benefit amount for each Covered Condition. Covered Conditions Full Benefit Cancer

Partial Benefit Cancer

Initial Benefit

Recurrence Benefit

100% of Initial Benefit

25% of Initial Benefit

Heart Attack

100% of Initial Benefit

Stroke6

100% of Initial Benefit

Coronary Artery Bypass Graft7

100% of Initial Benefit

Kidney Failure

100% of Initial Benefit

Not applicable

Alzheimer’s Disease8

100% of Initial Benefit

Not applicable

Major Organ Transplant Benefit

100% of Initial Benefit

Not applicable

22 Listed Conditions

25% of Initial Benefit

Not applicable

22 Listed Conditions MetLife Critical Illness Insurance will pay 25% of the Initial Benefit Amount for each of the 22 Listed Conditions until the Total Benefit Amount is reached. A Covered Person may only receive one payment for each Listed Condition in his/her lifetime. The Listed Conditions are Addison’s disease (adrenal hypofunction); amyotrophic lateral sclerosis (Lou Gehrig’s disease); cerebrospinal meningitis (bacterial); cerebral palsy; cystic fibrosis; diphtheria; encephalitis; Huntington’s disease (Huntington’s chorea); Legionnaire’s disease; malaria; multiple sclerosis (definitive diagnosis); muscular dystrophy; myasthenia gravis; necrotizing fasciitis; osteomyelitis; poliomyelitis; rabies; sickle cell anemia (excluding sickle cell trait); systemic lupus erythematosus (SLE); systemic sclerosis (scleroderma); tetanus; and tuberculosis.

Critical Illness Example of Initial & Recurrence Benefit Payments The example below illustrates an employee who elected an Initial Benefit of $10,000 and has a Total Benefit of 3 times the Initial Benefit Amount or $30,000. Illness – Covered Condition Heart Attack – first diagnosis Heart Attack – second diagnosis, two years later Kidney Failure – first diagnosis, three years later

Payment

Total Benefit Remaining

Initial Benefit payment of $10,000 or 100% Recurrence Benefit payment of $10,000 or 100% Initial Benefit payment of $10,000 or 100%

$20,000 $10,000 $0

SUPPLEMENTAL BENEFITS MetLife provides coverage for the Supplemental Benefits listed below. This coverage would be in addition to the Total Benefit Amount payable for the previously mentioned Covered Conditions. Health Screening Benefit9 After your coverage has been in effect for thirty days, MetLife will provide an annual benefit of $50 or $100* per calendar year for taking one of the eligible screening/prevention measures. MetLife will pay only one health screening benefit per covered person per calendar year. For a complete list of eligible screening/prevention measures, please refer to the Disclosure Statement/Outline of Coverage. *The Health Screening Benefit amount depends upon the Initial Benefit Amount selected. Employees would receive a $50 benefit with the $10,000 initial benefit amount or a $100 benefit with the $20,000 Initial Benefit Amount.

INSURANCE RATES MetLife offers competitive group rates and convenient payroll deduction so you don’t have to worry about writing a check or missing a payment! Your employee rates are outlined below. Monthly Premium $10,000 of Coverage

Monthly Premium $20,000 of Coverage

Issue Age

Employee Only

Employee + Spouse

Employee + Children

Employee +Spouse/ Children

Issue Age

Employee Only

Employee + Spouse

Employee + Children

Employee +Spouse/ Children

<25

$7.80

$16.60

$11.50

$20.30

<25

$15.60

$33.20

$23.00

$40.60

25-29

$8.60

$19.10

$12.30

$22.80

25-29

$17.20

$38.20

$24.60

$45.60

30-34

$11.00

$24.80

$14.70

$28.50

30-34

$22.00

$49.60

$29.40

$57.00

35-39

$14.20

$32.40

$17.90

$36.10

35-39

$28.40

$64.80

$35.80

$72.20

40-44

$18.90

$43.50

$22.60

$47.20

40-44

$37.80

$87.00

$45.20

$94.40

45-49

$25.00

$57.40

$28.70

$61.10

45-49

$50.00

$114.80

$57.40

$122.20

50-54

$31.70

$73.20

$35.40

$76.90

50-54

$63.40

$146.40

$70.80

$153.80

55-59

$40.40

$91.40

$44.10

$95.10

55-59

$80.80

$182.80

$88.20

$190.20

60-64

$48.10

$107.20

$51.80

$110.90

60-64

$96.20

$214.40

$103.60

$221.80

65-69

$56.30

$125.60

$60.00

$129.30

65-69

$112.60

$251.20

$120.00

$258.60

70+

$70.40

$156.90

$74.10

$160.60

70+

$140.80

$313.80

$148.20

$321.20

Critical Illness QUESTIONS & ANSWERS Who is eligible to enroll? Regular active full-time employees who are actively at work along with their spouse/domestic partner and dependent children can enroll for MetLife Critical Illness Insurance coverage.3 How do I pay for coverage? Coverage is paid through convenient payroll deduction. Will my rates increase? Your premium is based on your Issue Age, meaning your initial rate is based on your age at the time your coverage becomes effective and your rates will not increase due to age 10. What is the coverage effective date? The coverage effective date is 10/01/2015. If I Leave the Company, Can I Keep My Coverage11? Under certain circumstances, you can take your coverage with you if you leave. You must make a request in writing within a specified period after you leave your employer. You must also continue to pay premiums to keep the coverage in force. Who do I call for assistance? Contact a MetLife Customer Service Representative at 1 800 GET-MET8 (1-800-438-6388), Monday through Friday from 8:00 a.m. to 11:00 p.m. EST.

Footnotes: 1 Coverage for Domestic Partners, civil union partners and reciprocal beneficiaries varies by state. Please contact MetLife for more information. 2 Dependent Child coverage varies by state. Please contact MetLife for more information. 3 Coverage is guaranteed provided (a) the employee is actively at work and (b) dependents are not subject to medical restrictions as set forth on the enrollment form and in the Certificate. Some states require the insured to have medical coverage. Additional restrictions apply to dependents serving in the armed forces or living overseas. 4 We will not pay a Recurrence Benefit for a Covered Condition that Recurs during a Benefit Suspension Period. We will not pay a Recurrence Benefit for either a Full Benefit Cancer or a Partial Benefit Cancer unless the Covered Person has not had symptoms of or been treated for the Full Benefit Cancer or Partial Benefit Cancer for which we paid an Initial Benefit during the Benefit Suspension Period. In some states, we will not pay a Recurrence Benefit for a Covered Condition that Recurs less than 180 days after another Occurrence of a Covered Condition for which we paid an Initial Benefit. 5 Please review the Disclosure Statement or Outline of Coverage/Disclosure Document for specific information about cancer benefits. Not all types of cancer are covered. Some cancers are covered at less than the Initial Benefit Amount. 6 In certain states, the covered condition is Severe Stroke. 7 In NJ sitused cases, the Covered Condition is Coronary Artery Disease. 8 Please review the Outline of Coverage for specific information about Alzheimerâ&#x20AC;&#x2122;s Disease. 9 In most states there is a 30 day waiting period for the Health Screening Benefit. There is no waiting period for MD sitused cases. There is a separate mammogram benefit for MT residents and for cases sitused in CA and MT. 10 The plan is guaranteed renewable, and may not be canceled due to an increase in your age or a change in your health. Premium rates can only be raised as the result of a rate change made on a class-wide basis. Benefit reduces by 25% at age 65 and 50% at age 70. Coverage is guaranteed renewable provided: (1) premiums are paid as required under the Certificate; and (2) in a situation where the Group Policy ends, it is not replaced by a substantially similar critical illness policy as described in the Certificate. 11 See your certificate for details.

SUN LIFE YOUR BENEFITS PACKAGE

Life and AD&D

PLAY VIDEO

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.

Motor vehicle crashes are the

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

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 42 Dickinson ISD Benefits Website: www.mybenefitshub.com/dickinsonisd

Life and AD&D intoxicated.  Intoxicated means the minimum blood alcohol level required to be considered operating an automobile under the influence of alcohol in the jurisdiction where the accident occurred.  For the purposes of this exclusion, “Motorized Vehicle” includes, but is not limited to, automobiles, motorcycles, boats, and snowmobiles.

Coverage Amounts For you $10,000 with no medical questions asked.1 (District Paid at no cost to the employee) Benefits are reduced to 65% at age 65, to 45% at age 70, to 30% at age 75 and to 20% at age 80. Coverage is discontinued at termination of employment or retirement.

*Subject to state law variations. 1.

The policy includes an equal amount of AD&D insurance, which provides a benefit if you suffer a covered accidental injury or die from a covered accident.

More about Sun Life’s Life and AD&D insurance 

  

Take comfort in knowing that Life and AD&D insurance can provide the people you love with financial support when you can’t be there—and they need it most. 3. Apply to take your coverage with you if you retire or change employers.2 Get medical, dental, or legal assistance if an emergency occurs when you or a family member are traveling 100 or more miles from home, with Emergency Travel Assistance.³ Access 24-hour surveillance of up to 10 credit or debit cards and get help from anti-fraud experts if your personal data is compromised, with Identity Theft Protection.³

How Life and AD&D insurance can help 

    

Life and AD&D insurance may provide additional financial support by: covering household expenses, relieving debt (e.g., mortgage or student loans) you might leave behind, allowing your family members to hire someone if they need help when you are gone, leaving an inheritance for your loved ones or even for an organization you are passionate about, and assisting your family with the cost of your funeral or medical bills.

Limitations and exclusions No AD&D benefit will be paid for a loss which is due to or results from:*  suicide while sane or insane  intentionally self-inflicted injuries  bodily or mental infirmity or disease of any kind, or infection     



unless due to an accidental cut or wound committing or attempting to commit an assault, felony, or other criminal act active participation in a war (declared or undeclared) or active duty in any armed service during a time of war active participation in a riot, rebellion, or insurrection injury sustained from any aviation activities, other than riding as a fare-paying passenger the employee’s voluntary use of any controlled substance as defined in Title II of the Comprehensive Drug Abuse Prevention and Control Act of 1970, as now or hereafter amended, unless administered on the advice of a Physician the employee’s operation of any motorized vehicle while

If the amount you apply for exceeds the Guaranteed Issue amount or if you decline coverage during your initial eligibility period and want to elect coverage or increase coverage at a later date, you are required to complete and submit an Evidence of Insurability application, which must be approved by Sun Life prior to coverage taking effect. Subject to policy terms, conversion is available when coverage terminates or reduces or when an employee retires, and portability is available when employment terminates. Coverage is subject to state variations. If portability is not available in your state, continuation may be available. Refer to your Certificate for specific conditions. Value-added services are offered only on specific lines of coverage and carry a separate charge, which is added to the cost of the insurance. The cost is included in the total amount billed. Emergency Travel Assistance is provided by Assist America®. Identity Theft Protection is provided by SecurAssist®, an Assist America program. Sun Life is not responsible or liable for care, services, or advice given by any provider or vendor of the Services. Sun Life reserves the right to discontinue any of the Services at any time.

Optional Life and Accidental Death and Dismemberment (AD&D) Available Coverage Amounts 

Choose the benefit amounts that best meet your needs and your

For you You can elect $10,000 to $500,000—in $10,000 increments— not to exceed 5 times your basic annual earnings with no medical questions asked up to $100,000.1

For your spouse

Benefits are reduced to Coverage terminates 65% at age 65, to 45% at when your spouse turns age 70, to 30% at age 75 70 years old. and to 20% at age 80. Coverage is discontinued at termination of employment or retirement.



For your child(ren)

If you elect coverage for If you elect coverage yourself, you can sign up for yourself, you can for $5,000 to $250,000— choose a $5,000 or in $5,000 increments— $10,000 benefit with no medical questions amount. asked up to $50,000.1 (Not to exceed 50% of your elected amount.) A full benefit is payable for a dependent child who is 6 months to 26 years old. A reduced benefit is payable for a child from 14 days to 6 months.

budget: The cost for Sun Life’s Life and AD&D insurance depends on the benefit amount you choose and your age. 43

Life and AD&D Limitations and exclusions If the employee's cause of death is suicide:*  No amount of Life or Dependent Life insurance is payable if the suicide occurs within 24 months after the employee's insurance is effective.  No increased or additional amount of Life insurance is payable if the suicide occurs within 24 months after the increased or additional amount of Life insurance is effective.  No amount of Life insurance in excess of the Guaranteed Issue amount is payable if the suicide occurs within 24 months after the amount in excess of the Guaranteed Issue amount is effective. This coverage does not constitute comprehensive health insurance (often referred to as “major medical coverage”) and does not satisfy the requirement for Minimum Essential Coverage under the Affordable Care Act.

Life and AD&D

LIFEWORKS

EAP (Employee Assistance Program)

YOUR BENEFITS PACKAGE

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

38%

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

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 46 Dickinson ISD Benefits Website: www.mybenefitshub.com/dickinsonisd

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

Description

Emotions and Stress

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

Parenting

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

Midlife and Retirement

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

Addictive Behaviors

Drug and alcohol abuse, eating disorders, gambling

Education

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

Caring of older adults

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

Disability

Special needs programs, advocacy and specific disabilities information

Everyday Issues

Community resources and consumer information

Financial Issues

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

Legal Issues

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

Work

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

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

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Telephone: (888) 456-1324   

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

Mobile 

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

In-Person 



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

Employees and their families will have access to face-to-face assessments and short- term, solution-focused counseling with EAP clinicians. 47

NBS

FSA (Flexible Spending Account)

YOUR BENEFITS PACKAGE

PLAY VIDEO

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.

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 48 Dickinson ISD Benefits Website: www.mybenefitshub.com/dickinsonisd

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

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

Online claims FAQs

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

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

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 by October. NBS debit cards are good for 3 years.

FSA Annual Contribution Max:

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

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

$2,600 - Due to short plan year, max contribution for 2017-18 is $2,383.

Dependent Care Annual Max: $5,000 - Due to short plan year, max contribution is $4,583.

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. 49

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

How does a Flexible Spending Account Benefit Me? A Cafeteria plan enables you to save money on group insurance, health-related expenses, and dependent-care expenses. You may save as much as 35 percent on the cost of each benefit option! Eligible expenses must be incurred within the plan year and contributions are use-it-or- lose-it unless used within the 30 day Grace Period. Remember to retain all your receipts.

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

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

        

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

Dependent Care Expense Account Example Expenses:    

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

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

What Happens If I Don’t Use All of My Funds by The End of the Plan Year (August 31st)? Eligible expenses must be incurred within the plan year +30 day grace period. Contributions are use-it-or- lose-it unless used within the 30 day Grace Period. Remember to retain all your receipts (including receipts for card swipes).

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

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

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

Get Your Money 1. 2. 3. 4.

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

NBS Flexcard—FSA Pre-paid Benefit Card Dickinson ISD does sponsor the use of the NBS Flexcard. 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 (888) 353-9125. For immediate access to your account information at any time, log on to our website www.NBSbenefits.com. Information includes:    

Detailed claim history and processing status Health Care and Dependent Care account balances Claim forms, worksheets, etc. Online Claim Submission

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