2017 Benefit Guide HEB ISD by Higginbotham Public Sector

HEB ISD

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

Table of Contents Benefit Contact Information How to Enroll Annual Benefit Enrollment 1. New Hires 1. Benefit Updates 2. Section 125 Cafeteria Plan Guidelines 3. Annual Enrollment 4. Eligibility Requirements 5. Helpful Definitions 6. Health Savings Account (HSA) vs. Flexible Spending Account (FSA) Workers Compensation Notice & Requirements TRS Medical Special Insurance Services Medical Gap HSA Bank Health Savings Account (HSA) Cigna Dental Superior Vision The Standard Disability Allstate Cancer UNUM Life and AD&D Sick Leave Bank Legal Ease Legal Services NBS Flexible Spending Account (FSA) Retirement Planning 2

3 4-5 6-14 6-8 9 10 11 12 13

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

14 15 16-24 26-27 28-31 33-39 40-41 42-45 46-49 50-53 54 56-57 58-61 62-65

PG. 6 BENEFIT UPDATES.

PG. 16 YOUR BENEFITS

Benefit Contact Information

Benefit Contact Information HEB ISD BENEFITS

GAP INSURANCE

CANCER

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

Special Insurance Services (800) 767-6811

Allstate Terry Barber (817) 479-0065

TRS-ACTIVECARE MEDICAL

DENTAL

LIFE AND AD&D

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

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

UNUM (800) 858-6843 www.unum.com

TRS HMO MEDICAL

VISION

FLEXIBLE SPENDING ACCOUNT

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

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

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

HEALTH SAVINGS ACCOUNT

DISABILITY

LEGAL SERVICES

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

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

Legal Ease (800) 248-9000 www.legaleaseplan.com/content/heb

403B THE OMNI GROUP

CAREMARK PHARMACY

457 TCG ADMINISTRATORS

(877) 544-6664 www.omni403b.com

800-222-9205 www.caremark.com/trsactivecare

(800) 943-9179 https://tcgservices.com/documents/ #/255/457b

EMPLOYEE ASSISTANCE PROGRAM (EAP)

TELADOC

(800) 854-1446: English (877) 858-2147: Spanish www.lifebalance.net - user ID & password: lifebalance

855-TELADOC www.teladoc.com

HEB ISD â&#x20AC;&#x201C; Benefits Office 817-399-2056 mariaortiz@hebisd.edu

MOBILE ENROLLMENT Enrollment made simple through your smartphone or tablet. Text “FBS HEB” to 313131 and get access to everything you need to complete your benefits enrollment: 

Benefit Information



Online Support



Interactive Tools



And more. PLAY VIDEO

Text “FBS HEB” to 313131 OR SCAN

How to Log In

1 BENEFIT INFO

INTERACTIVE TOOLS

2 3

www.mybenefitshub.com/hebisd

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.

New Hires PLAN YEAR The plan year for all benefits is September 1st through August 31st.

EFFECTIVE DATES FOR INSURANCE Health Insurance can begin your hire date or the 1st of the following month. Please make sure you notify the benefits office if you want your health insurance to begin on your hire date. All other benefits will automatically begin the 1st of the monthly following your 1st day of employment.

NEW HIRES

New hires must enroll in benefits within 30 days of his/her hire date. Failure to complete elections during this timeframe will result in the forfeiture of coverage.

TEACHER RETIREMENT SYSTEM OF TEXAS (TRS)

HEB ISD requires all employees to participate in TRS instead of Social Security. The membership contribution rate is 7.7% of your annual salary. You may contact TRS by calling 1-800-223-8778 or www.trs.state.tx.us to learn more about TRS Retirement.

TRS INSURANCE (TRS INS)

Mandatory active member contribution to TRS-Care (Health Insurance for retirees) is .65% of your annual salary.

PAYCHECKS

Professional and paraprofessional employees receive a paycheck on the 20th of each month. Auxiliary employees receive a paycheck on the 5th and 20th of each month. One-half of your monthly premium will be taken out of each paycheck.

EMPLOYEE ACCESS CENTER From the Employee Benefits website, you can log on to the Employee Access Center to change your address, view your paycheck stubs, see your current salary and benefit information and much more! Your login is your 6 digit unique HEB ID number and your default password is your social security number without the dashes. You may also download the app for your phone by searching for eFinance Plus Employee in your app store. Type in “Hurst” as the employer name and then select “Hurst-Euless-Bedford Independent SD”. Follow the login instructions to view your account.

LONG TERM CARE

TRS offers a Long Term Care plan through Genworth Life Insurance Co. Long Term Care is insurance that will help pay for services provided by Assisted Living Facilities, Nursing Homes, etc. If you are interested in enrolling in the Long Term Care plan or have questions, please call 866-659-1970 or visit www.genworth.com/trsactivemember.

LEAVES & ABSENCES

Click on the link below to review HEB ISD’s Policies DEC (LOCAL) & DEC (REGULATION) - these policies contain the latest information regarding leaves & absences http://pol.tasb.org/Home/Index/1110 Paid Leave Days  Every school year all full time employees in eligible positions will receive: o 5 local sick leave days o 5 state personal leave days o 10 vacation days (only available for 240 & 248 day employees) Availability of Days  Days for the current year are available for use at the beginning of the school year. 

If you start in the middle of a school year, the days are pro-rated based on the actual time employed.



Unused days may carry over from year to year.

State Personal Leave  You may use up to 5 days in a row. 

You may use no more than 5 days per school year.



You must submit a written request to use a personal day at least three workdays in advance.



The supervisor will determine if your request is approved or denied based on the effect your absence would have on the educational program or district operations.



Requests are approved on a first-come, first-served basis.



You may not use a personal leave day on a restricted day (i.e. day before or after a holiday, etc.). Please review the restricted day calendar for the specific dates.



If you worked for another public school district in the state of Texas, your service record will indicate if you are bringing any personal leave days with you.



If you leave the district, your personal leave days will go with you.

Local Sick Leave  Local sick leave day may be used if you or immediate family members are sick. 

Definition of immediate family: o Spouse o Son or daughter, including a biological, adopted, step or foster child, a son- or daughter-in-law o Parent, stepparent, parent-in-law o Sibling, stepsibling, and sibling-in-law o Grandparent and grandchild



Medical certification (doctor’s note) must be provided if: o The employee is absent more than 4 consecutive work days because of personal illness or illness in the immediate family o There is a questionable pattern of absences



If an employee runs out of sick days, the payroll system will automatically use a day from the next leave bank that has available days. (The next bank is typically your personal leave bank.) 7

FMLA (Family & Medical Leave Act)  Provides eligible employees up to 12 work-weeks of unpaid, job-protected leave in a 12month period; and requires group health benefits to be maintained during the leave. Employees are entitled to return to their same or an equivalent job at the end of their FMLA leave. 

Leave available for: o Birth of child or placement of a child for adoption or foster care o To care for the employee’s spouse, child, or parent who has a qualifying serious health condition o For the employee’s own qualifying serious health condition that makes the employee unable to perform the employee’s job



Eligibility: o Have worked for HEB ISD for at least 12 months; AND o Have at least 1250 hours of service in the 12 months before taking leave.



If you need to be out for more than 4 consecutive work days due to sickness self or family sickness or want to request FMLA, please contact: Karen Rose, Benefits & Risk Manager, (817) 399-2056, karenrose@hebisd.edu

Order of Use  Employees have the right to designate the order of use for local sick & state personal leave days.  For example, if you are absent due to sickness self, you have the right to have the day pulled from your local sick leave bank or your personal leave bank. As long as the absence is code sickness-using a personal day, the day will NOT be counted as one of your 5 allowed personal leave days during a school year. Bereavement (Funeral Leave)  Use of state leave and/or local sick leave for a death in the immediate family must not exceed ten workdays per occurrence, subject to the approval of the District. The ten workdays do not have to be used consecutively but must be taken within the employee’s duty year of when the family member’s death occurred. 

Use of state leave for the death of a non-immediate family member must not exceed a total of five workdays per school year, subject to the approval of the District. Bereavement documentation may be required.

EMPLOYEE BENEFITS FACEBOOK

We have created a HEB ISD Employee Benefits Facebook account. Please visit http://www.facebook.com/hebbenefits and “Like” our page.

Annual Benefit Enrollment

SUMMARY PAGES

Benefit Updates - What’s New:  New enrollment system!! Welcome to THEbenefitsHUB!

 New FSA Vendor! HEB ISD is switching Flexible Spending

Account (FSA) vendors from TASC to National Benefit You will now conduct your annual enrollment via Services (NBS) effective 9/1/17. Your HealthCare THEbenefitsHUB by visiting Reimbursement and/or Dependent Care www.mybenefitshub.com/hebisd. Your current elections have already been entered into the HUB BUT, please Reimbursement coverages will be administered by NBS. review to ensure accuracy. You will also elect your 9/1/17 benefits via the HUB. If you have any questions,  Increase in Vision rate. please call the FBS Call Center OR, Karen Rose or Maria Ortiz at HEB ISD’s Benefits Department. All employees  Medical Rate Increase - Aetna remains the carrier for are required to login and complete their enrollment. Medical Plans: ActiveCare 1 HD, ActiveCare 2 and Select. The Scott & White HMO Plan is available for all  New Life Carrier! HEB ISD is switching Basic Life w/AD&D, employees working or residing in Dallas, Ellis, Denton, Voluntary Life & Voluntary AD&D carriers from Lincoln Collin, Rockwall and Tarrant counties. All eligible Financial to UNUM effective 9/1/17. This new plan employees, including active, contributing TRS members includes a guarantee issue increase on the Spouse Life of and employees regularly working 10 hours per week $50,000 now and you can elect up to 100% of the MUST either enroll for coverage or decline coverage in employee amount for your spouse. We will roll your THEbenefitsHUB. For TRS medical information, please current election to the new UNUM plans but, please visit: www.trsactivecareaetna.com review your plan for accuracy. Be sure to select your beneficiary!  Increase in Health Savings Account annual maximum to $3,400.  New Dental Carrier! HEB ISD is switching Dental carriers from Lincoln Financial to Cigna effective 9/1/17. We will  Benefit elections will become effective 9/1/2017. roll your current election to the new Cigna dental plan (elections requiring evidence of insurability, such as Life but, please review your plan for accuracy. The High PPO Insurance, may have a later effective date, if approved.) plan will now offer orthodontia benefits for adults. 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).    

Login and complete your supplemental benefit enrollment from 07/17/2017 - 08/22/2017 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—08/22/2017. 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. 9

SUMMARY PAGES

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

CHANGES IN STATUS (CIS):

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

QUALIFYING EVENTS

Marital Status

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

Change in Number of Tax Dependents

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

Change in Status of Employment Affecting Coverage Eligibility

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

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

SUMMARY PAGES

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

Where can I find forms?

to review, change or continue benefit elections each year.

For benefit summaries and claim forms, go to your school

Changes are not permitted during the plan year (outside of

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

annual enrollment) unless a Section 125 qualifying event occurs.

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



Changes, additions or drops may be made only during the

Benefits and Forms section.

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

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

district’s website: www.mybenefitshub.com/hebisd. Click on

included in the dependent profile. Additionally, you must

the benefit plan you need information on (i.e., Dental) and

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.

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

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

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

Q&A Who do I contact with Questions? For supplemental benefit questions, you can contact your Benefits/HR department or you can call Financial Benefit Services at 866-914-5202 for assistance. 11

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 HEB 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

Dental

Cigna

Medical Gap Insurance

Special Insurance Services (SIS)

Vision

Superior Vision

Cancer

Allstate

Medical Flex

NBS

IRS Tax Dependent

Disability

The Standard

N/A

Voluntary Life

UNUM

Legal Services

Legal Ease

19 or to 26 if full time student*

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 Benefit Administrator to request a continuation of coverage. *Please see LegalEase Plan Information document for full definition of covered dependent

SUMMARY PAGES

Helpful Definitions Actively at Work

In-Network

You are performing your regular occupation for the employer

Doctors, hospitals, optometrists, dentists and other providers

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

who have contracted with the plan as a network provider.

places of business or at some location to which the employer’s business requires you to travel. If you will not be actively at work beginning 9/1/2017 please notify your benefits administrator.

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

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

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

Plan Year September 1st through August 31st

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

Calendar Year

(including diagnostic and/or consultation services).

January 1st through December 31st

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

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

SUMMARY PAGES

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

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

Approved by Congress in 2003, HSAs are actual bank accounts in employeeâ&#x20AC;&#x2122;s names that allow employees to save and pay for unreimbursed qualified medical expenses tax-free.

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

Employer Eligibility

A qualified high deductible health plan.

All employers

Contribution Source

Employee

Account Owner

Individual

Employer

Underlying Insurance Requirement

High deductible health plan

None

Description

Minimum Deductible Maximum Contribution Permissible Use Of Funds Cash-Outs of Unused Amounts (if no medical expenses) Year-to-year rollover of account balance? Does the account earn interest?

$1,300 single (2017) $2,600 family (2017) $3,400 single (2017) $6,750 family (2017) If used for non-qualified medical expenses, subject to current tax rate plus 20% penalty. Permitted, but subject to current tax rate plus 20% penalty (penalty waived after age 65). Yes, will roll over to use for subsequent yearâ&#x20AC;&#x2122;s health coverage.

N/A $2,400 medical reimbursement $5,000 dependent care Reimbursement for qualified medical expenses (as defined in Sec. 213(d) of IRC). Not permitted No.

Yes

Portable?

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

Are claims substantiated?

Only upon audit

Yes receipts may be required.

Can I access the entire amount No, money is available as it is contributed at the start of the plan year? to the account.

FLIP TO FOR HSA INFORMATION 14

PG. 27

Yes

FLIP TO FOR FSA INFORMATION

PG. 55

Workers Compensation Employee Notice of Alliance Requirements IMPORTANT CONTACT INFORMATION

To locate a provider, go to www.pswca.org. To contact your adjuster at the TASB Risk Management Fund, visit www.tasbrmf.org or call (800) 482-7276.

INFORMATION , INSTRUCTIONS, RIGHTS, AND OBLIGATIONS If you are injured at work, tell your supervisor or employer immediately. The information in this notice will help you to seek medical treatment for your injury. Your employer will also help with any questions about how to get treatment. You may also contact your adjuster at the TASB Risk Management Fund (the Fund) for any questions about treatment for a work related injury. The Fund is your employer’s workers’ compensation coverage provider and they are working with your employer to ensure you receive timely and appropriate health care. The goal is to return you to work as soon as it is safe to do so.

HOW DO I CHOOSE A TREATING DOCTOR? If you are hurt at work and you live in the Alliance service area, you are required to choose a treating doctor from the provider list. This is required for you to receive coverage of healthcare costs for your work related injury. A provider listing is available through the Alliance website at www.pswca.org and a link to that site is contained on the Fund’s website at www.tasbrmf.org. It identifies providers who are taking new patients. HOW DO I CHANGE TREATING DOCTORS?

Within the first 60 days of beginning treatment, if you become dissatisfied with your first choice of a treating doctor, you can select an alternate treating doctor from the list of Alliance treating doctors in your service area. The Fund will not deny a choice of an alternate treating doctor. However, before you can change treating doctors a second time, you must obtain permission from your adjuster.

WHO PAYS FOR THE HEALTHCARE?

Alliance providers have agreed to seek payment from the Fund for your health care. They should not request payment from you. If you obtain health care from a doctor who is not in the Alliance without prior approval from your adjuster, you may have to pay for the cost of that care and your income benefits may be disputed. You may treat with medical providers that are not contracted with the Alliance only if one of the following situations occurs: - Emergencies: You should go to the nearest hospital or emergency care facility. - You do not live within an Alliance service area. - Your treating doctor refers you to a provider or facility outside of the Alliance. Your adjuster must approve this referral.

WHAT TO DO WHEN YOU ARE INJURED ON THE JOB

If you are injured while on the job, tell your employer as soon as possible. A list of Alliance treating doctors in your service area may be available from your employer. A complete list of Alliance treating doctors is also available online at www.pswca.org. Or, you may contact us directly at the following address and/or toll-free telephone number: TASB Risk Management Fund P.O. Box 2010 Austin, TX 78768 (800) 482-7276

IN CASE OF AN EMERGENCY…

If you are hurt at work and it is a life threatening emergency, you should go to the nearest emergency room. If you are injured at work after normal business hours or while working outside your service area, you should go to the nearest care facility. After you receive emergency care, you may need ongoing care. You will need to select a treating doctor from the Alliance provider list. This list is available online at www.pswca.org. If you do not have internet access call (800) 4827276 or contact your employer for a list. The doctor you choose will oversee the care you receive for your work related injury. Except for emergency care you must obtain all health care and specialist referrals through your treating doctor.

NON -EMERGENCY CARE … Report your injury to your employer as soon as you can. Select a treating doctor from the Alliance provider list. This list is available online at www.pswca.org. If you do not have internet access, call (800) 482-7276 or contact your employer for a list. 15

Health Insurance ActiveCare 1-HD, 2 & Select â&#x20AC;&#x201C; Aetna 800-222-9205

HMO â&#x20AC;&#x201C; Scott & White 800-321-7947

www.trsactivecareaetna.com

In-Network Benefits

www.trs.swhp.org

ActiveCare 1-HD

ActiveCare 2

ActiveCare Select+

Scott & White HMO#

(Participant Pays)

No out-of-network benefits

$1,200 individual $3,600 family

$1,000 individual $3,000 family

$7,150 individual $14,300 family

$6,550 individual $13,100 family

Deductible must be met before benefits are paid

Medical Benefits

$2,500 Employee Only $5,000 Family

Deductible Maximum Out-of-Pocket

(Includes medical & prescription

deductibles, coinsurance & copays)

$1,000 individual $3,000 family

$6,550 Employee Only $7,150 individual $13,100 Family $14,300 family

Coinsurance

20%

20% (after deductible)

$30 copay - Primary $50 copay - Specialist

$30 copay - Primary $60 copay - Specialist

$20 copay^ - Primary $50 copay - Specialist

Preventive Care

Plan pays 100%

Diagnostic Lab

20% (after deductible)

Quest Facility-Plan pays 100%; Other Facility-20%*

20%*

High-tech Radiology

20% (after deductible)

$100 copay & 20%*

20%*

Outpatient Surgery

20% (after deductible)

$150 copay & 20%*

Emergency Room

20% (after deductible)

$200 copay & 20%*

$150 copay & 20%*

Inpatient Hospitalization

20% (after deductible)

$150 copay/day & 20%*

Teladoc

$40 consultation fee

Plan pays 100%

Not covered

Subject to medical deductible

$0 Generic $200 Brand

Participant pays (after deductible)

Office Visit Copay

Prescription Drugs Drug Deductible

$200: 31 day supply $450: 32-90 day supply

$489.00 $1,469.00 $837.00 $1,779.00

$20 $40

%Extended-Day @ Mail Order or Retail-Plus

$126.00 $766.00 $446.00 $1,091.00

$45 $105 $180

%Short-Term Maintenance @ Retail Facility

Monthly Premiums Employee Only Employee & Spouse Employee & Child(ren) Employee & Family

$35 $60 $90

@ Retail Facility

20% (after deductible)

$20 $40 $65

%Short-Term

Specialty Drugs

%Extended-Day @ Mail Order or Retail-Plus

20% (after deductible) 20% (after deductible) 20% (after deductible)

%Short-Term Maintenance @ Retail Facility

Tier 1 - Generic Tier 2 - Preferred Brand Tier 3 - Non-Preferred Brand

@ Retail Facility

(Participants deductible does not have to be met)

%Short-Term

Certain Generic Preventive Drugs are Covered 100%

$35 $60 50%

$45 $105

$150 (excludes generic) Maintenance Retail Quantity Quantity (up to 90-day

(up to 30day supply)

supply) @ BSW Pharmacies & mail order

$10 30% 50%

20%

Non-Formulary: $50 or 50% Specialty: 20%

$289.00 $1,039.00 $609.00 $1,364.00

$336.04 $1,038.08 $663.42 $1175.98

* After the deductible has been met +

Visit www.trsactivecareaetna.com to search for providers in 1-HD & 2. For the Select Plan choose the Baylor Scott & White Quality Alliance (DFW Area) option. # Visit www.trs.swhp.org to search for providers in the Baylor Scott & White HMO plan ^ First visit copay for illness waived % Prescription Definitions: Short Term: up to 31-day supply; Extended-Day or Retail-Plus: 60 to 90 day supply: Maintenance: drugs commonly used (daily) to treat conditions (i.e. blood pressure, heart disease, asthma, diabetes, etc.) that are considered chronic or long-term

Visit www.trsactivecareaetna.com to download the Enrollment Guide

Maximum Annual Costs 2017-2018 Hurst Euless Bedford ISD For Illustration Purposes Only

Employee Only

1 - HD

Select

HMO

Deductible (Medical)

$2,500

$1,000

$1,200

$1,000

$200

$150

Maximum Out of Pocket (co-ins & copays)

$4,050

$5,950

$5,750

$5,400

Subtotal Medical & Prescription Costs

$6,550

$7,150

$6,550

Annual Premium

$1,512

$5,868

$3,468

$4,032

Total Premium, Medical & Prescription Expenses

$8,062

$13,018

$10,618

$10,582

Employee & Spouse

1 - HD

Select

HMO

Deductible (Medical)

$5,000

$2,000

$2,400

$2,000

$400

$300

Maximum Out of Pocket (co-ins & copays)

$8,100

$11,900

$11,500

$10,800

Subtotal Medical & Prescription Costs

$13,100

$14,300

$13,100

$9,192

$17,628

$12,468

$12,457

$22,292

$31,928

$26,768

$25,557

1 - HD

Select

HMO

$5,000

$3,000

$3,600

$3,000

$600

$450

Maximum Out of Pocket (co-ins & copays)

$8,100

$10,700

$10,100

$9,650

Subtotal Medical & Prescription Costs

$13,100

$14,300

$13,100

$5,352

$10,044

$7,308

$7,961

$18,452

$24,344

$21,608

$21,061

1 - HD

Select

HMO

$5,000

$3,000

$3,600

$3,000

$800

$600

Maximum Out of Pocket (co-ins & copays)

$8,100

$10,500

$9,900

$9,500

Subtotal Medical & Prescription Costs

$13,100

$14,300

$13,100

Annual Premium

$13,092

$21,348

$16,368

$14,112

Total Premium, Medical & Prescription Expenses

$26,192

$35,648

$30,668

$27,212

Deductible (Prescription)

Annual Premium

Total Premium, Medical & Prescription Expenses

Employee & Child(ren) Assumes 2 Children Deductible (Medical) Deductible (Prescription)

Annual Premium

Total Premium, Medical & Prescription Expenses

Employee & Family Assumes 4 family members Deductible (Medical) Deductible (Prescription)

Split Premiums/Pooling Funds Comparison TRS ActiveCare  Married couples working for different participating entities OR  Married couples both working for HEB ISD  Family coverage and all want the same plan; One employee will decline coverage and the other employee will elect Family coverage  May “pool” their funds  Requires an Application to Split Premium form to be completed by both employees and both employers

Employee & Family ActiveCare 1 -HD $126.00 $446.00 $572.00

ActiveCare 2 $489.00 $837.00 $1,326.00

ActiveCare Select $289.00 $609.00 $898.00

Scott & White HMO $336.04 $663.42 $999.46

Each employee pays

ActiveCare 1-HD $1,316.00 -$225.00 -$225.00 $866.00 ÷2 $433.00

ActiveCare 2 $2,004.00 -$225.00 -$225.00 $1,554.00 ÷2 $777.00

ActiveCare Select $1,589.00 -$225.00 -$225.00 $1,139.00 ÷2 $569.50

Scott & White HMO $1,400.98 -$225.00 -$225.00 $950.98 ÷2 $475.49

Monthly Savings or (additional cost) Annual Savings or (additional cost)

($294.00) ($3,528.00)

($228.00) ($2,736.00)

($241.00) ($2,892.00)

$48.48 $581.76

Standard Funding Employee Only Premium Employee & Child(ren) Premium Total Premium due

Pooling Funds Employee & Family Total Premium HEB Contribution for Employee A HEB Contribution for Employee B Total Premium due

How to Search for Health Care Providers in

TRS ActiveCare 1-HD, 2, or Select

To locate an in network provider for a medical plan go to: www.trsactivecareaetna.com Click on:

In the search bar, you may search by name, specialty, procedure or condition. Choose your health plan:

ActiveCare Select â&#x20AC;&#x201C; Make sure you choose Baylor Scott & White Quality Alliance (DFW Region) NOT ActiveCare Select

ActiveCare 1-HD

ActiveCare 2 19

How to Search for Health Care Providers in

Scott & White HMO

To locate an in network provider for a medical plan go to: www.trs.swhp.org

Click on Provider Information:

Click on Browse providers online:

Choose the TRS â&#x20AC;&#x201C; Active Care Participants Network then you may search by doctor, facility or specialty:

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. 22 can fill 32-day to 90-day supply through mail order. ****Participants

2017-2018 Scott & White Health Plan Highlights Summary of Benefits for TRS-ActiveCare Fully Covered Health Care Services Preventive Services

No Charge

Standard Lab and X-ray

No Charge

Disease Management and Complex Case Management

No Charge

Well Child Care Annual Exams

No Charge

Immunizations (age appropriate)

No Charge

Plan Provisions Annual Deductible

$1,000 Individual/ $3,000 Family

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

Lifetime Paid Benefit Maximum

$6,550 Individual/ $13,100 Family (includes combined Medical and Rx copays, deductibles and coinsurance)

None

Outpatient Services $20 co-pay

Primary Care1

(First Primary Care Visit for Illness $0 Copay2)

Specialty Care

$50 co-pay

Other Outpatient Services

20% after deductible3

Diagnostic/Radiology Procedures

20% after deductible

Eye Exam (one annually) Allergy Serum & Injections Outpatient Surgery

No Charge 20% after deductible $150 co-pay and 20% of charges after deductible

Maternity Care Prenatal Care

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

Inpatient Delivery

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

$150 per day4 and 20% of charges after deductible

Diagnostic & Therapeutic Services Physical and Speech Therapy 5

Manipulative Therapy

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

Equipment and Supplies Preferred Diabetic Supplies and Equipment Non-Preferred Diabetic Supplies and Equipment Durable Medical Equipment/ Prosthetics

$5/$10 copay; no deductible 30% after Rx deductible 20% after deductible 23

2017-2018 Scott & White Health Plan Highlights Summary of Benefits for TRS-ActiveCare Home Health Services Home Health Care Visit

$50 co-pay

Worldwide Emergency Care Nurse Advice Line

1-877-505-7947

Online Services

No Charge â&#x20AC;&#x201D; go to http://trs.swhp.org

After Hours Primary Care Clinics

$20 co-pay

Ambulance and Helicopter

$40 copay and 20% of charges after deductible

Emergency Room6

$150 copay and 20% of charges after deductible

Urgent Care Facility

$55 copay

Prescription Drugs Annual Benefit Maximum

Unlimited

Rx Deductible

$150

Does not apply to preferred generic drugs

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

Maintenance Quantity

Retail Quantity (Up to a 30-day supply)

(Up to a 90-day supply) Only at BSW Pharmacies, including Mail Order

$5 copay

$10 copay

Preferred Brand7

30% after Rx deductible

Non-preferred

50% after Rx deductible

Non-formulary

Greater of $50 or 50% after Rx deductible

Not available

Preferred Generic7

trs.swhp.org

Online Refills

1-800-707-3477 or 1-855-388-3090

Mail Order

Specialty Medications (up to a 30-day supply) The SWHP MOMS Program provides you with specialized nurses who are notified of the delivery of your baby. These licensed professionals will contact you after you return home and help you with everything from the general well-being of both you and your baby, to breast/bottle feeding, to information on how to add your baby to your health plan. 24

20% after Rx deductible 1

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

SPECIAL INSURANCE SERVICES

YOUR BENEFITS PACKAGE

Medical Gap Insurance

PLAY VIDEO

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

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 26 HEB ISD Benefits Website: www.mybenefitshub.com/hebisd

Medical Gap Insurance Basic Plan Benefits offered to employees of HEB ISD

Hospital Confinement Benefit* - This benefit is designed to offset the cost you incur as an in-patient in the hospital when your primary comprehensive major medical policy applies such expenses to your deductible or coinsurance maximum, up to the $1,500 plan year maximum per insured person.

Out-Patient Benefit* - This benefit offsets the cost you incur for out-patient treatment when your primary major medical policy applies such expenses to your deductible or coinsurance maximum, up to the $1,500 benefit limit, and up to a maximum of three out -patient occurrences per family per calendar year. An “occurrence” is the treatment, or the series of treatments, for a specific injury or illness within a plan year. Expenses related to physician office visits are not included in this benefit. Covered expenses include:   

Surgery in an Out-Patient Facility or a Physician’s Office Emergency Room visits Diagnostic testing, MRI’s, CT scans, Lab & X-ray at a diagnostic or hospital out-patient facility or at a Physician’s office if the cost is not included in the global office visit fee and is not part of wellness/preventive care  Physical therapy  Chiropractic care *For expenses to be eligible under this plan they must be medically necessary for the treatment of an injury or illness. Expenses not covered by your group major medical plan are not covered.

How to File a Claim When you enroll in the Benefit Connection plan, you will receive an ID card, along with specific instructions on how to file a claim. This form outlines the procedures you should follow to obtain a claim form, what you need to file a claim, and where you should send your claim. Simply stated, you will need to submit a completed claim form, itemized bills (NOT balance due statements), and EOB’s that correspond to the itemized bills. Claims may be filed at any time, but must be filed no longer than 12 months from the date of service in order to be eligible for coverage.

Under Age 40

Ages 40 - 49

Ages 50 & Above

Monthly

Employee Only

$25.98

$34.21

$71.85

Employee & Spouse

$47.76

$62.85

$132.02

Employee & Child(ren)

$62.45

$67.22

$123.81

Employee & Family

$83.64

$95.11

$182.41

This information sheet highlights the important features of the product. The policy has limitations and exclusions. The exact provisions governing the insurance are contained in the master policy issued to each group on form number GAPP-4200, policy series G4200. Your carrier representative can supply you with costs and complete details of coverage.

HSA BANK

HSA (Health Savings Account)

YOUR BENEFITS PACKAGE

PLAY VIDEO

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

The interest earned in an HSA is tax free.

Money withdrawn for medical spending never falls under taxable income.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 28 HEB ISD Benefits Website: www.mybenefitshub.com/hebisd

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

What is an HSA? 

 

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

prorated) Authorized Signers who are 55 or older must have their own HSA in order to make the catch-up contribution

Examples of Qualified Medical Expenses      

Surgery Braces Contact lenses Dentures Eyeglasses Vaccines

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

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

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

2017 Annual HSA Contribution Limits Individual: $3,400 Family: $6,750 Catch-Up Contributions: Accountholders who meet the qualifications noted below are eligible to make an HSA catch-up contribution of an additional $1,000.  Health Savings accountholder  Age 55 or older (regardless of when in the year an accountholder turns 55)  Not enrolled in Medicare (if an accountholder enrolls in Medicare mid-year, catch-up contributions should be

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

How an HSA works: 



 

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

Are you eligible for an HSA? If you participate in TRS ActiveCare 1HD you are eligible to open an HSA.  You cannot be covered by any other non-HSA-compatible health plan, including Medicare Parts A and B.  You cannot be covered by TriCare.  You cannot have accessed your VA medical benefits in the past 90 days (to contribute to an HSA).  You cannot be claimed as a dependent on another person’s tax return (unless it’s your spouse).  You must be covered by the qualified HDHP on the first day of the month.  You cannot be enrolled in the GAP plan.  You cannot be enrolled in the Healthcare Reimbursement (Flexible Spending Plan)  You can be enrolled in the Dependent Care Reimbursement Plan When you open an account, HSA Bank will request certain information to verify your identity and to process your application.

What are the annual IRS contribution limits? Contributions made by all parties to an HSA cannot exceed the annual HSA limit set by the Internal Revenue Service (IRS). Anyone can contribute to your HSA, but only the

accountholder and employer can receive tax deductions on those contributions. Combined annual contributions for the accountholder, employer, and third parties (i.e., parent, spouse, or anyone else) must not exceed these limits2.

2017 Annual HSA Contribution Limits Individual = $3,400 Family = $6,750

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

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

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

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

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

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

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

1 Investment accounts are not FDIC insured, may lose value and are not a deposit or other obligation of, or guarantee by the bank. Investment losses which are replaced are subject to the annual contribution limits of the HSA. 2 HSA funds contributed in excess of these limits are subject to penalty and tax unless the excess and earnings are withdrawn prior to the due date, including any extensions for filing Federal Tax returns. Accountholders should consult with a qualified tax advisor in connection with excess contribution removal. The Internal Revenue Service requires HSA Bank to report withdrawals that are considered refunds of excess contributions. In order for the withdrawal to be accurately reported, accountholders may not withdraw the excess directly. Instead, an excess contribution refund must be requested from HSA Bank and an Excess Contribution Removal Form completed. 3 Federal Tax savings are available no matter where you live and HSAs are taxable in AL, CA, and NJ. HSA Bank does not provide tax advice. Consult your tax professional for tax‐related questions. 4 This list is not comprehensive. It is provided to you with the understanding that HSA Bank is not engaged in rendering tax advice. The information provided is not intended to be used to avoid Federal tax penalties. For more detailed information, please refer to IRS Publication 502 titled, “Medical and Dental Expenses”. Publications can be ordered directly from the IRS by calling 1-800-TAXFORM. If tax advice is required, you should seek the services of a professional. 5 Insurance premiums only qualify as an IRS-qualified medical expense: while continuing coverage under COBRA; for qualified long-term care coverage; coverage while receiving unemployment compensation; for any healthcare coverage for those over age 65 including Medicare (except Medicare supplemental coverage). 31

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 32 HEB ISD Benefits Website: www.mybenefitshub.com/hebisd

Dental Plans Cigna

800-224-6224

www.cigna.com

The district offers a choice of three different dental plans. A summary of the respective plans follows. PPO High

PPO Low

DHMO

Plan Pays 100%

Fixed Co-Pays

Plan Pays 80%

Plan Pays 70%

Deductible Applies

Fixed Co-Pays

Plan Pays 50%

Deductible Applies

Plan Pays 50%

Not Covered

Fixed Co-Pays

Ortho. Lifetime Maximum

$1,000

Not Covered

N/A

Deductible (Per Plan Year)

$50 Person $150 Family

$25 Person $75 Family

None

$1,000

$750

$1,125

$875

Class I – Diagnostic & Preventative (cleanings, exams, x-rays, sealants, etc.)

Class II – Basic Restorative (fillings, extractions, oral surgery, etc.)

Class III – Major Restorative (crowns, bridges, dentures, etc.)

Orthodontics (Children & Adults)

Fixed Co-Pays

Progressive Maximum Benefit Year 1 Year 2 (Contingent upon receiving preventive services in Year 1)

Year 3 (Contingent upon receiving preventive

N/A $1,250

$1,000

$1,375

$1,125

Primary Care Dentist Required

Yes

Out of Network Benefits

Yes

Out of Network Reimbursement

Maximum Reimbursable Charge

Maximum Allowable Charge

None

Premiums

Monthly

SemiMonthly

Monthly

SemiMonthly

Monthly

SemiMonthly

Employee Only

$37.52

$18.76

$24.50

$12.25

$13.21

$6.61

Employee + 1

$74.54

$37.27

$50.47

$25.24

$25.10

$12.55

Employee + Family

$113.06

$56.53

$68.11

$34.06

$39.63

$19.82

services in Years 1 & 2)

Year 4 (Contingent upon receiving preventive services in Years 2 & 3)

Dental PPO - High Option Benefits

Network

Reimbursement Levels

Cigna Dental Choice

Monthly PPO Premiums

In-Network

Out-of-Network

Total Cigna DPPO

See Non-Network Reimbursement

Based on Contracted Fees

Maximum Reimbursable Charge

Progressive Maximum Benefit Progressive Benefit Year 2: Increase contingent upon receiving Preventive Services in Plan Year 1. Progressive Benefit Year 3: Increase contingent upon receiving Preventive Services in Plan Years 1 and 2. Progressive Benefit Year 4: Increase contingent upon receiving Preventive Services in Plan Years 2 and 3

Policy Year Benefits Maximum Applies to: Class I, II & III expenses Policy Year Deductible Individual Family

Year 1: $1,000 Year 2: $1,125 Year 3: $1,250 Year 4: $1,375

$50 $150

Plan Pays

You Pay

Plan Pays

You Pay

100% No Deductible

No Charge

100% No Deductible

No Charge

80% After Deductible

20% After Deductible

80% After Deductible

20% After Deductible

50% After deductible

Class I - Diagnostic & Preventative 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 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 Crowns: prefabricated stainless steel/resin

Class III - Major Restorative Inlays and Onlays Crowns: permanent cast and porcelain Bridges and Dentures Endodontics: minor and major

Class IV - Orthodontia Coverage for Employee and All Dependents Lifetime Benefits Maximum: $1,000

50% No Deductible

50% 50% No Deductible No Deductible

50% No Deductible

Tier

Rate

EE Only

$37.52

EE + 1 Dep

$74.54

EE + 2 or more Deps

$113.06

Dental PPO - Low Option Benefits

Network

Reimbursement Levels

Cigna Dental Choice

Monthly PPO Premiums

In-Network

Out-of-Network

Total Cigna DPPO

See Non-Network Reimbursement

Based on Contracted Fees

Tier

Rate

EE Only

$24.50

EE + 1 Dep

$50.47

EE + 2 or more Deps

$68.11

Maximum Allowable Charge

Policy Year Benefits Maximum Applies to: Class I, II & III expenses

Year 1: $750 Year 2: $875 Year 3: $1,000 Year 4: $1,125

$25 $75

Policy Year Deductible Individual Family

Plan Pays

You Pay

Plan Pays

You Pay

100% No Deductible

No Charge

100% No Deductible

No Charge

70% After Deductible

30% After Deductible

70% After Deductible

30% After Deductible

50% After deductible

Class II - Basic Restorative Restorative: fillings Periodontics: minor and major Endodontics: 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 Crowns: prefabricated stainless steel/resin

Class III - Major Restorative Inlays and Onlays Crowns: permanent cast and porcelain Bridges and Dentures

Dental PPO - High & Low Options Benefit Plan Provisions:

Benefit Plan Provisions:

In-Network Reimbursement

For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Fee Schedule or Discount Schedule.

Non-Network Reimbursement

For services provided by a non-network dentist, Cigna Dental will reimburse according to the Maximum Allowable 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-network 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.

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 Benefit Limitations: Missing Tooth Limitation Oral Evaluations X-rays (routine) X-rays (non-routine) Diagnostic Casts Cleanings Fluoride Application Sealants (per tooth) Space Maintainers Inlays, Crowns, Bridges, Dentures and Partials

Denture and Bridge Repairs Denture Adjustments, Rebases and Relines Prosthesis Over Implant

When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna 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 â&#x20AC;&#x201C; 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 nonprescription 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. 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. 2 per policy year Bitewings: 2 per policy year Complete series of radiographic images and panoramic radiographic images: Limited to a combined total of 1 per 36 consecutive months Payable only in conjunction with orthodontic workup 2 per policy year, including periodontal maintenance procedures following active therapy 1 per policy year for children under age 19 Limited to posterior tooth. 1 treatment per tooth every 36 months for children under age 14 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 non-precious metals. No porcelain or white/tooth-colored material on molar crowns or bridges. Reviewed if more than once 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 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; Implants: implants or implant related services; Orthodontia: Orthodontic treatment. 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 in36 excess of the Maximum Reimbursable Charge. Contracted providers are not obligated to provide discounts on non-covered services and may charge their usual fees.

Dental - DHMO 



This Patient Charge Schedule applies only when covered dental services are performed by your Network Dentist, unless otherwise authorized by Cigna Dental as described in your plan documents. Not all Network Dentists perform all listed services and it is suggested to check with your Network Dentist in advance of receiving services. This Patient Charge Schedule applies to Specialty Care when an appropriate referral is made to a Network Specialty Periodontist or Oral Surgeon. You must verify with the Network Specialty Dentist that your treatment plan has been authorized for payment by Cigna Dental. Prior authorization is not required for specialty referrals for Pediatric, Orthodontic and Endodontic services. You may select a Network Pediatric Dentist for your child under the age of 7 by calling Customer Service at 1.800.Cigna24 to get a list of Network Pediatric Dentists in your area. Coverage for treatment by a Pediatric Dentist ends on your child’s 7th birthday; however, exceptions for medical reasons may be considered on an individual basis. Your Network General Dentist will provide care upon your child’s 7th birthday.

DHMO Premiums Tier

Rate

EE Only

$13.21

EE + 1 Dep

$25.10

EE + 2 or more Deps

$39.63



Procedures listed on the Patient Charge Schedule are subject to the plan limitations and exclusions described in your plan book/certificate of coverage and/or group contract.



All patient charges must correspond to the Patient Charge Schedule in effect on the date the procedure is initiated.



The American Dental Association may periodically change CDT Codes or definitions. Different codes may be used to describe these covered procedures.



The administration of IV sedation, general anesthesia, and/or nitrous oxide is not covered except as specifically listed on this Patient Charge Schedule. The application of local anesthetic is covered as part of your dental treatment.



Cigna Dental considers infection control and/or sterilization to be incidental to and part of the charges for services provided and not separately chargeable.



This Patient Charge Schedule is subject to annual change in accordance with the terms of the group agreement.

After your enrollment is effective: Call the dental office identified in your Welcome Kit. If you wish to change dental offices, a transfer can be arranged at no charge by calling Cigna Dental at the toll free number listed on your ID card or plan materials. Multiple ways to locate a *DHMO Network General Dentist:  Online provider directory at www.Cigna.com  Online provider directory on www.myCigna.com  Call the number located on your ID card to: - Use the Dental Office Locator via Speech Recognition - Speak to a Customer Service Representative For full Patient Charge Schedule, go to www.mybenefitshub.com/hebisd Code

Procedure Description

Member Pays

Office visit fee (per patient, per office visit in addition to any other applicable patient charges) Office visit fee

$ 5.00

Diagnostic/preventive – Oral evaluations are limited to a combined total of 4 of the following evaluations during a 12 consecutive month period: Periodic oral evaluations (D0120), comprehensive oral evaluations (D0150), comprehensive periodontal evaluations (D0180), and oral evaluations for patients under 3 years of age (D0145).

Code

Procedure Description

Member Pays

Diagnostic/preventive (cont.) D0145

Oral evaluation for a patient under 3 years of age and counseling with primary caregiver

$0.00

D0150

Comprehensive oral evaluation – New or established patient

$0.00

D0210

X-rays intraoral – Complete series of radiographic images (limit 1 every 3 years)

$0.00

D9310

Consultation (diagnostic service provided by dentist or physician other than requesting dentist or physician)

$10.00

D0240

X-rays intraoral – Occlusal radiographic image

$0.00

D9430

Office visit for observation – No other services performed

$5.00

D0270

X-rays (bitewing) – Single radiographic image

$0.00

D0120

Periodic oral evaluation – Established patient

$0.00

D0330

X-rays (panoramic radiographic image) – (limit 1 every 3 years)

$0.00

D0140

Limited oral evaluation – Problem focused

$0.00

D0431

Oral cancer screening using a special light source

$50.00 37

Dental - DHMO Code

Procedure Description

Member Pays

Diagnostic/preventive (cont.)

D1110

D1120

Prophylaxis (cleaning) – Adult (limit 2 per calendar year) Additional Prophylaxis (Cleaning) – In Addition to the 2 Prophylaxes (Cleanings) Allowed per Calendar Year Prophylaxis (cleaning) – Child (limit 2 per calendar year) Additional Prophylaxis (Cleaning) – In Addition to the 2 Prophylaxes (Cleanings) Allowed per Calendar Year

Code

Procedure Description

Member Pays

Periodontics (cont.) $0.00

D4341

Periodontal scaling and root planing – 4 or more teeth per quadrant (limit 4 quadrants per consecutive 12 months)

$40.00

D4342

Periodontal scaling and root planing – 1 to 3 teeth per quadrant (limit 4 quadrants per consecutive 12 months)

$30.00

D4910

Periodontal maintenance (limit 2 per calendar year) (only covered after active periodontal therapy)

$30.00

Additional periodontal maintenance procedures (beyond 2 per calendar year)

$55.00

Periodontal charting for planning treatment of periodontal disease

$0.00

Periodontal hygiene instruction

$0.00

$45.00

$0.00 $35.00

D1206

Topical application of fluoride varnish (limit 2 per calendar year). There is a combined limit of a total of 2 D1206s and/or D1208s per calendar year.

$0.00

D1351

Sealant – Per tooth

$10.00

Restorative (fillings, including polishing)

Prosthetics (removable tooth replacement – dentures) includes up to 4 adjustments within first 6 months after insertion – Replacement limit 1 every 5 years. Characterization is considered an upgrade with maximum additional charge to the member of $200.00 per denture.

D2140

Amalgam – 1 surface, primary or permanent

$0.00

D2330

Resin-based composite – 1 surface, anterior

$0.00

D5110

Full upper denture

$150.00

D2390

Resin-based composite crown, anterior

$35.00

D5120

Full lower denture

$150.00

Crown and bridge – All charges for crown and bridge (fixed partial denture) are per unit (each replacement or supporting tooth equals 1 unit) – Replacement limit 1 every 5 years. The charges below include the cost of base metal. Noble metal and high noble metal (precious) or titanium metal, if used, will be charged to the Member at an additional maximum amount of $150.00 per tooth. If a cast post and core is made of high noble metal, an additional fee up to $100.00 per tooth may be charged for the upgraded post and core. Porcelain, if used on molar teeth, will be charged to the Member at an additional maximum amount of $75.00 per tooth. Porcelain/Ceramic

D5211

Upper partial denture – Resin base (including clasps, rests and teeth)

$150.00

D5212

Lower partial denture – Resin base (including clasps, rests and teeth)

$150.00

D7111

Extraction of coronal remnants – Deciduous tooth

$5.00

D2740

Crown – Porcelain/ceramic substrate

$225.00

D7140

$5.00

D2792

Crown – Full cast noble metal

$185.00

Extraction, erupted tooth or exposed root – Elevation and/or forceps removal

D2722

Crown – Resin with noble metal

$185.00

D7220

Removal of impacted tooth – Soft tissue

$50.00

D2950

Core buildup – Including any pins

$50.00

D7240

Removal of impacted tooth – Completely bony

$90.00

Endodontics (root canal treatment, excluding final restorations) D3310

Anterior root canal – Permanent tooth (excluding final restoration)

$80.00

D3330

Molar root canal – Permanent tooth (excluding final restoration)

$250.00

Periodontics (treatment of supporting tissues [gum and bone] of the teeth) periodontal regenerative procedures are limited to 1 regenerative procedure per site (or per tooth, if applicable), when covered on the patient charge schedule. The relevant procedure codes are D4263, D4264, D4266 and D4267. Localized delivery of antimicrobial agents is limited to 8 teeth (or 8 sites, if applicable) per 12 consecutive months, when covered on the patient charge schedule. D4211

Gingivectomy or gingivoplasty – 1 to 3 teeth per quadrant

$80.00

D4240

Gingival flap (including root planing) – 4 or more teeth per quadrant

$150.00

Oral surgery (includes routine postoperative treatment) Surgical removal of impacted tooth – Not covered for ages below 15 unless pathology (disease) exists.

Orthodontics (tooth movement) Orthodontic treatment (maximum benefit of 24 months of interceptive and/or comprehensive treatment. Atypical cases or cases beyond 24 months require an additional payment by the patient.) D8670

Periodic orthodontic treatment visit – As part of contract Children – Up to 19th birthday: 24-month treatment fee Charge per month for 24 months

$1,340.00 $56.00

Adults: 24-month treatment fee Charge per month for 24 months

$1,940.00 $81.00

SUPERIOR 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 40 HEB ISD Benefits Website: www.mybenefitshub.com/hebisd

Vision Benefits

Monthly Premiums

In-Network

Out-of-Network

Exam (Opthalmologist)

Covered in full

Up to $42 retail

Exam (Optometrist)

Covered in full

Up to $37 retail

$130 retail allowance

Up to $68 retail

Covered in full

Not covered

Exam

$10

$50 retail allowance

Not covered

Materialsâ&#x201A; Contact Lens Fitting (standard & specialty)

$25

Frames Contact Lens Fitting (standard) Contact Lens Fitting (specialty2)

Lenses (standard) per pair Single Vision

Covered in full

Up to $32 retail

Bifocal

Covered in full

Up to $46 retail

Trifocal

Covered in full

Up to $61 retail

See description3

Up to $61 retail

Progressive lens upgrade Contact Lenses 4

EE Only

$7.18

EE + 1 dependent

$13.94

EE + family

$20.47

Co-Pays

Services/Frequency Exam

12 months

Frame

24 months

Contact Lens Fitting

12 Months

Lenses

12 months

Contact Lenses

12 months

$150 retail allowance Up to $100 retail

Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements 1 Materials co-pay applies to lenses and frames only, not contact lenses 2 The specialty contact lens fitting is for new contact lens wearers and/or a member who wears toric, gas permeable, or multifocal lenses. 3 Covered to providerâ&#x20AC;&#x2122;s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay 4 Contact lenses are in lieu of eyeglass lenses and frames benefit

Discount Features

Discounts on Non-Covered Exam and Materials

Look for providers in the Provider Directory who accept discounts, as some do not; please verify their services and discounts (range from 10%-30%) prior to service as they vary. Discounts on Covered Materials Frames: 20% off amount over allowance Lens options: 20% off retail Progressives: 20% off amount over retail lined trifocal lens, including lens options The following options have out-of-pocket maximums5 on standard (not premium, brand, or progressive) lenses. Maximum Member Out-of-Pocket Single Vision

Bifocal & Trifocal

Scratch coat

$13

Ultraviolet coat

$15

Tints, solid or gradients

$25

Anti-reflective coat

$50

Polycarbonate

$40

20% off retail

High index 1.6

$55

20% off retail

Photochromics

$80

20% off retail

Exams, frames, and prescription lenses: Lens options, contacts, other prescription materials: Disposable contact lenses:

20% off retail 10% off retail

Refractive Surgery Superior Vision has a nationwide network of refractive surgeons and leading LASIK networks who offer members a discount. These discounts range from 15%-50%, and are the best possible discounts available to Superior Vision. The Plan discount features are not insurance. All allowances are retail; the member is responsible for paying the provider directly for all non-covered items and/or any amount over the allowances, minus available discounts. These are not covered by the plan. Discounts are subject to change without notice. Disclaimer: All final determinations of benefits, administrative duties, and definitions are governed by the Certificate of Insurance for your vision plan. Please check with your Human Resources department if you have any questions.

Discounts and maximums may vary by lens type. Please check with your provider.

THE STANDARD YOUR BENEFITS PACKAGE

Long Term 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 42 HEB ISD Benefits Website: www.mybenefitshub.com/hebisd

Long Term Disability Voluntary Long Term Disability Insurance

Preexisting Condition Exclusion

Standard Insurance Company has developed this document to provide you with information about the optional insurance coverage you may select through HEB 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.

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.

Employer Plan Effective Date The group policy effective date was September 1, 2011.

Eligibility To become insured, you must be: A regular employee of Hurst-Euless-Bedford 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



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.

Preexisting Condition Waiver For the first 45 days of disability, The Standard will pay full benefits even if you have a preexisting condition. After 45 days, The Standard will continue benefits only if the preexisting condition exclusion does not apply.

Own Occupation Period For the plan’s definition of disability, as described in your brochure, the own occupation period is the first 12 months for which LTD benefits are paid.

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 Maximum benefit to age 65 for any covered disability. 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:

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. Benefits are payable for non-occupational disabilities only. Occupational disabilities are not covered. Plan Maximum Monthly Benefit: 66 2/3 percent of predisability earnings Plan Minimum Monthly Benefit: 10 percent of your LTD benefit before reduction by deductible income.

Option

Accidental Other Injury Disabilities



 Maximum Benefit Period

0 days

7 days