2017 Benefit Guide Shallowater by Higginbotham Public Sector

SHALLOWATER ISD

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

Table of Contents Benefit Contact Information How to Enroll Annual Benefit Enrollment 1. Benefit Updates 2. Section 125 Cafeteria Plan Guidelines 3. Annual Enrollment 4. Eligibility Requirements 5. Helpful Definitions 6. Health Savings Account (HSA) vs. Flexible Spending Account (FSA) TRS-ActiveCare and TRS-FirstCare Century Healthcare Medical Supplement MDLIVE Telehealth Cigna Dental Superior Vision Unum Disability APL Cancer Loyal American Accident Voya Critical Illness Cigna Life and AD&D 5Star Family Protection Plan Term Life Insurance with Quality of Life Rider ID Watchdog Identity Theft HSA Bank Health Savings Account (HSA) NBS Flexible Spending Account (FSA) 2

MASA Medical Transport

3 4-5 6-11 6 7 8 9 10

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

11 12-15 16-19 20-21 22-25 26-27 28-31 32-35 36-39 40-43 44-47 48-51 52-53 54-57

58-61 62-63

PG. 6 SUMMARY PAGES

PG. 12 YOUR BENEFITS

Benefit Contact Information SHALLOWATER ISD BENEFITS

DENTAL

FAMILY PROTECTION PLAN

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

Cigna (800) 997-1654 www.cigna.com

5Star Life Insurance Company (866) 863-9753 www.5starlifeinsurance.com

SHALLOWATER ISD BENEFITS OFFICE

VISION

CRITICAL ILLNESS

(806) 832-4531 www.shallowaterisd.net

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

Voya (800) 955-7736 www.voya.com

MEDICAL

DISABILITY

HEALTH SAVINGS ACCOUNT

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

UNUM (800) 583-6908 Claim Status: (800) 858-6843 www.mybenefitshub.com/shallowaterisd

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

MEDICAL

CANCER

FLEXIBLE SPENDING ACCOUNT

FirstCare (800) 884-4901 www.firstcare.com

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

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

MEDICAL SUPPLEMENT

ACCIDENT

IDENTITY THEFT

Century Healthcare (877) 685-2432 www.centuryhealthcare.com

Loyal American (800) 366-8354

ID Watchdog (800) 970-5182 www.idwatchdog.com

TELEHEALTH

LIFE AND AD&D

COBRA

MDLIVE (866) 365-1663 www.consultmdlive.com

Cigna (800) 583-6908 www.cigna.com

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

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

MOBILE ENROLLMENT Enrollment made simple through your smartphone or tablet. Text “FBS SISD” 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 SISD” to 313131 OR SCAN

How to Log In

1 BENEFIT INFO

INTERACTIVE TOOLS

2 3

www.mybenefitshub.com/ shallowaterisd

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: 

NEW! Medical Transportation Solutions will be offered  through MASA. MASA provides medical emergency transportation solutions AND covers your out of pocket medical transport cost when your insurance falls short. MASA does not use a network so you are covered nationwide. MASA rates will be $9.00 per month, per employee only or family coverage.



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. Employees who currently participate must spend current plan year funds by 8/31/17 to avoid forfeitures. You can view account balance using the CHECK FSA link on the Benefit website or use the NBS smart phone app.



Health Savings Accounts by HSABank! Your school district offers employees who are enrolled in a high deductible health care plan the opportunity to contribute to an H.S.A. to pay for eligible medical, dental and vision expenses. Employee only maximum contribution is $3,400 and Family maximum contribution is $6,750 per year. You cannot contribute to both an FSA and HSA at the same time.



Medical Gap Plan by Century HealthCare! GAP plans are designed to cover any out-of-pocket deductible amount and out-of-pocket co-payment or coinsurance amounts the Covered Person actually incurs after the Medical Plan has paid with a maximum benefit of $2500. Only employees and dependents covered under the districts medical plan can enroll in the GAP plan. There are both HSA and non-HSA compatible plans optional. Telehealth by MDLIVE! Plan provides you and your family with around-the-clock access to U.S-based, licensed physicians for telephone consultations. Regardless of your location, it’s easy to connect with a doctor in real-time for treatment or diagnosis of common conditions. Doctors can diagnose conditions, recommend treatment and prescribe medication, if deemed appropriate. MDLIVE is an affordable solution to the challenge of healthcare access. This service is for non-emergency conditions. If you have an emergency, please call 911 or go to your nearest hospital emergency room.

Don’t Forget! 



Enrollment assistance is available by calling Financial Benefit Services at (866) 914-5202 to speak to a representative Monday—Friday between 8am – 5pm CST



Update your profile information: home address, phone numbers, email, beneficiaries



REQUIRED: Provide correct dependent social security numbers 6

SUMMARY PAGES

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

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

CHANGES IN STATUS (CIS):

QUALIFYING EVENTS

Marital Status

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

Change in Number of Tax Dependents

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

Change in Status of Employment Affecting Coverage Eligibility

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

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

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

SUMMARY PAGES

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

Where can I find forms?

to review, change or continue benefit elections each year.

For benefit summaries and claim forms, go to your school

Changes are not permitted during the plan year (outside of

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

annual enrollment) unless a Section 125 qualifying event occurs.

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



Changes, additions or drops may be made only during the

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

website: www.mybenefitshub.com/shallowaterisd. 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.



To find a network provider, go to your school district’s benefit

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.

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 Shallowater 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 Dental Vision Disability Cancer

Dependent Eligibility

Base Life

Legal Spouse, children to age 26 Legal Spouse, children to age 26 Not applicable Legal Spouse, children to age 25. Legal Spouse issued to age 65, coverage terms at age 70. Children to age 23 with student status Not applicable

Group Term Life / AD&D

Legal Spouse, unmarried dependent children to age 26

5Star Family Protection Plan Medical Flexible Spending

Legal Spouse, children & grandchildren to age 23 Legal Spouse, children claimed as tax exemption on IRS tax return

Accident

Continuation after termination or retirement* Cobra Cobra Not Applicable Group Plan, convertible Individual plan, portable Not applicable Portable or convertible, excluding AD&D Individual plan, direct bill Cobra

A dependent age twelve (12) or younger for whom you claim a dependency exemption on your income tax return;

Dependent Flexible Spending

Or dependent [a child over age twelve (12), your parent, your spouse's parent, or any other qualified individual] who is physically or mentally incapable of caring for him/herself, and for whom you can claim a dependency exemption (or could claim an exemption except the person has gross income that exceeds the exemption amount); or

Not applicable

Your spouse who is physically or mentally unable to care for him/herself.

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. 9

Helpful Definitions

SUMMARY PAGES

Actively at Work

In-Network

You are performing your regular occupation for the employer

Doctors, hospitals, optometrists, dentists and other providers

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

who have contracted with the plan as a network provider.

places of business or at some location to which the employer’s business requires you to travel. If you will not be actively at work beginning 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 January 1st through December 31st

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

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

(including diagnostic and/or consultation services).

SUMMARY PAGES

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

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

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

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

Employer Eligibility

A qualified high deductible health plan.

All employers

Contribution Source Account Owner Underlying Insurance Requirement

Employee and/or employer Individual

Employee and/or employer Employer

High deductible health plan

None

Description

Minimum Deductible Maximum Contribution

Permissible Use Of Funds

$1,300 single (2017) $2,600 family (2017) $3,400 single (2017) $6,750 family (2017) Employees may use funds any way they wish. If used for non-qualified medical expenses, subject to current tax rate plus 20% penalty.

N/A Varies per employer Reimbursement for qualified medical expenses (as defined in Sec. 213(d) of IRC).

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

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

Not permitted

Year-to-year rollover of account balance?

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

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

Does the account earn interest?

Yes

Portable?

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

FLIP TO FOR HSA INFORMATION

PG. 54

FLIP TO FOR FSA INFORMATION

PG. 58

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 Smoking cessation counseling– 8 visits per 12 months

• Well-child care – unlimited up to age 12 • Colonoscopy – 1 every 10 years age 50 and over •Healthy diet/obesity counseling– unlimited to

• Well - woman exam & pap smear – annually age 18 and over • Prostate cancer 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. 13 ****Participants can fill 32-day to 90-day supply through mail order.

2017-2018 TRS-FirstCare Plan Highlights Plan Summary 2017 -2018 Medical Plan Year Deductible Out-of-Pocket Maximum (includes medical & drug deductibles, copayments & coinsurance) Annual Maximum

$750 Individual; $2,250 Family $6,000 Individual; $12,000 Family Unlimited

Primary Care Provider (PCP) Office Visit  Includes routine lab/X-ray services, injectables, and supplies  Other services provided in a physician’s office are subject to additional deductible and copayments/coinsurance

$20 copayment

PCP Office Visit-Dependents, through age 19

$0 copayment

Specialist Office Visit  Includes routine lab/X-ray services  Other services provided in a physician’s office are subject to additional deductible and copayments/coinsurance

$60 copayment

Preventive Care Well-woman exam, immunizations, physicals, mammograms, colorectal cancer screening

No copayment

Surgical Procedures Performed in the Physician's Office

25% copayment1

Minor Emergency/Urgency Care Visit

$75 copayment

Emergency Room

$500 copayment1

Ambulance Air/Ground

25% copayment1

Inpatient Services Facility charges, physician services, surgical procedures, pre-admission testing, operating/recovery room, newborn delivery and nursery, ICU/coronary care units, laboratory tests/X-rays, rehabilitation facility, behavioral health (mental health/chemical dependency)

25% copayment1

Outpatient Services Facility charges, physician services, surgical procedures, observation unit

25% copayment1

MRI, CT Scan, PET Scan (Facility/Physician)

$250 copayment1

Diagnostic Tests Sleep study; Stress test; EKG; Ultrasound; Cardiac imaging; Genetic testing; Non-preventive Colonoscopy (Facility/Physician)

25% copayment1

Home Health Care Limited to 60 visits per plan year

25% copayment1

Hospice Care

25% copayment1

Skilled Nursing Facility Limited to 30 days per plan year

25% copayment1

Accidental Dental Care

25% copayment1

Prosthetics

25% copayment1

Orthotics

25% copayment1

Spinal Manipulation Limited to 10 visits per year

25% copayment1

Durable Medical Equipment

25% copayment1

All Other Covered Services

25% copayment1

Prescription Drug Plan Year Deductible

$100 Individual: $300 Family

Annual Maximum

Unlimited

Participating Retail Pharmacy  Select Generic/ACA (Tier 1) deductible waived  Preferred Generic (Tier 2) deductible waived  Preferred Brand/Non-Preferred Generic (Tier 3)  Non-Preferred Brand/Non-Preferred Generic (Tier 4)  Specialty/Injectables (Tier 5)

Standard Drugs/30-day supply $0 per prescription $15 per prescription $40 per prescription2 $100 per prescription2 20% per prescription2

Participating Mail Order Pharmacy  Select Generic/ACA (Tier 1) deductible waived  Preferred Generic (Tier 2) deductible waived  Preferred Brand/Non-Preferred Generic (Tier 3)  Non-Preferred Brand/Non-Preferred Generic (Tier 4)  Specialty/Injectables (Tier 5)

Maintenance Drugs/90-day supply $0 per prescription $45 per prescription $120 per prescription2 $300 per prescription2 20% per prescription2

Subject to medical deductible

Subject to prescription drug deductible

Gross Monthly Cost for Coverage Effective September 1, 2017 - August 31, 2018 Coverage Category Employee only Employee and spouse Employee and child(ren) Employee and family

Total Cost - Active* $514.82 $1,287.60 $816.07 $1,298.52

*District and state fund are provided each month to active contributing TRS members to use toward the cost of TRS-ActiveCare coverage. State funding is subject to appropriation by the Texas Legislature. Please contact your Benefits Administrator to determine your net monthly cost for your coverage.

CENTURY HEALTHCARE YOUR BENEFITS PACKAGE

Medical Supplement

PLAY VIDEO

About this Benefit Medical supplement is designed to help supplement your Employer's major medical plan. This plan provides supplemental coverage to help offset outof-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 16 Shallowater ISD Benefits Website: www.mybenefitshub.com/shallowaterisd

Medical Supplement The Gap Plans provide coverage for medically necessary eligible out-of-pocket expenses related to the insured’s major medical plan’s co-insurance and deductibles up to the maximum benefit selected, provided such expenses are the result of treatment for a covered injury or sickness.

Inpatient Hospital Benefit The benefit option offers a $2,500 In-Hospital benefit per covered person per calendar year. Note: This coverage may not cover 100% of out-of-pocket expenses. BENEFITS INCLUDE:  Coverage for out-of-pocket expenses due to an inpatient hospital confinement  Coverage for inpatient hospital charges for eligible out-ofpocket expenses resulting from the treatment of an accidental injury or sickness  Emergency room treatment and ambulance for a covered injury or sickness when it results in hospital confinement within 24 hours  Durable medical equipment (DME) when provided while confined in a hospital

Outpatient Hospital Benefit The Outpatient Hospital benefit limit is 50% of the In-hospital benefit amount selected and three times the individual outpatient benefit for dependent coverage. BENEFITS INCLUDE:  Emergency room treatment and ambulance as long as the person is NOT hospitalized within 24 hours of being transported to the hospital and ER treatment  Outpatient surgery in an outpatient surgical facility, emergency facility or physician’s office  Diagnostic testing, x-rays, labs, MRI’s, and CT scans  Outpatient radiation therapy or chemotherapy  Physical therapy or chiropractic care  Durable medical equipment (DME) if dispensed at the doctor’s office The Outpatient Benefit does not cover a physician’s office visit charge. Please note that in order for a service to be covered under the Gap Plan, it needs to be covered under the major medical plan.

Traditional Plan Example of Gap Plan Payout Vs. No Gap Plan How It Works INPATIENT HOSPITAL CLAIM EXAMPLE

WITHOUT GAP PLAN

Inpatient Hospital Bill Benefit Paid Patient Responsibility

$5,000 N/A $5,000

WITH DEDUCTIBLE RELIEF GAP PLAN $5,000 $2,500 $2,500

HSA Compatible Plan Deductible - In order for your gap plan to be compatible with a Health Savings Account (HSA), it has a deductible amount of $1,300 that must be satisfied before any benefits are payable. When dependent coverage is elected, benefits are payable only after the entire family deductible has been satisfied by one or more insured persons. Example of Gap Plan Payout Vs. No Gap Plan How It Works INPATIENT HOSPITAL CLAIM EXAMPLE

WITHOUT GAP PLAN

Inpatient Hospital Bill Deductible-Paid by Insured Benefit Paid Patient Balance

$5,000 N/A N/A $5,000

WITH DEDUCTIBLE RELIEF GAP PLAN $5,000 $1,300 $2,500 $1,200

Medical Supplement Traditional Plan AGE BASED MONTHLY COST BY COVERAGE AMOUNT Benefit Amount $2,500 IP / $1,250 OP Under Age 40: Insured Only Insured & Spouse Insured & Child(ren) Insured & Family Ages 40—49: Insured Only Insured & Spouse Insured & Child(ren) Insured & Family Age 50 & Above: Insured Only Insured & Spouse Insured & Child(ren) Insured & Family

$29.64 $54.50 $73.24 $97.42 $38.22 $70.23 $83.38 $112.97 $82.50 $151.59 $144.57 $211.88

HSA Compatible Plan AGE BASED MONTHLY COST BY COVERAGE AMOUNT Benefit Amount $2,500 IP / $1,250 OP Under Age 40: Insured Only Insured & Spouse Insured & Child(ren) Insured & Family Ages 40—49: Insured Only Insured & Spouse Insured & Child(ren) Insured & Family Age 50 & Above: Insured Only Insured & Spouse Insured & Child(ren) Insured & Family

$18.21 $32.78 $40.25 $54.82 $25.25 $45.46 $46.47 $66.67 $40.77 $73.39 $66.05 $98.67

Medical Supplement Plan Exclusions Benefits will not be paid for losses caused by or resulting from any one or more of the following:                 

Declared or undeclared war or any act thereof Suicide or intentionally self-inflicted injury or any attempt, while sane or insane (while sane, in Colorado and Missouri) Any hospital confinement or other treatment for injury or sickness while an insured person is in the service of the armed forces of any country Confinement in a hospital or other treatment facility operated by an agency of the United States government or one of its agencies, unless the insured person is legally required to pay for the services Confinement or other treatment for injury or sickness which is not medically necessary Confinement or other treatment for dental or vision care not related to an accidental injury Confinement or other treatment for mental or nervous disorders Confinement or other treatment for alcoholism, drug addiction or complications thereof Any hospital confinement or other covered treatment for injury or sickness for which compensation is payable under any Worker's Compensation Law, any Occupational Disease Law, or similar legislation Any hospital confinement or other covered treatment for injury or sickness that is payable under any insurance that does not require deductible and/or coinsurance payments by the insured person Any hospital confinement or other covered treatment for injury or sickness for which benefits are not payable under the insured person's major medical plan Any hospital confinement or other covered treatment for injury or sickness if, on the insured person’s effective date of coverage, the insured person was not covered by a major medical plan An insured person engaging in any act or occupation which is a violation of the law of the jurisdiction where the loss or cause occurred. A violation of the law includes both misdemeanor and felony violations Prescription drugs Durable medical equipment, unless dispensed in a hospital, an outpatient surgical or emergency facility, a diagnostic testing facility, or a similar facility that is licensed to provide outpatient treatment Well newborn care, whether inpatient or outpatient Wellness or preventive care

This plan is underwritten by Companion Life Insurance Company arranged through Special Insurance Services, Inc.

MDLIVE YOUR BENEFITS PACKAGE

Telehealth

PLAY VIDEO

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

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 20 Shallowater ISD Benefits Website: www.mybenefitshub.com/shallowaterisd

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

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

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

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

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

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

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

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

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

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

Scan with your smartphone to get the app.

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

Disclaimers: MDLIVE does not replace the primary care physician. MDLIVE operates subject to state regulation and may not be available in certain states. MDLIVE does not guarantee that a prescription will be written. MDLIVE does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for 21 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

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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 22 Shallowater ISD Benefits Website: www.mybenefitshub.com/shallowaterisd

Dental PPO - High Option Benefits Network Calendar Year Maximum (Class I, II, III and IX expenses) Annual Deductible Individual Family Reimbursement Levels**

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

Cigna Dental PPO In-Network Out-of-Network Total Cigna DPPO $1,000

$1,000

$50 per person $150 per family

Based on Reduced Contracted Fees

90th percentile of Reasonable and Customary Allowances Plan Pays You Pay

Plan Pays

You Pay

100%

No Charge

100%

No Charge

80%*

20%*

80%*

20%*

50%*

50% $1,000 Dependent children to age 19

50%

50% $1,000 Dependent children to age 19

50%

Subject to plan deductible Subject to plan annual maximum

Monthly PPO Premiums Tier

Rate

EE Only

$35.45

EE + Spouse

$70.89

EE + Child(ren)

$72.31

Family Coverage

$107.76

Subject to plan deductible Subject to plan annual maximum

Missing Tooth Limitation – The amount payable is 50% of the amount otherwise payable until insured for 24 months; thereafter, considered a Class III expense. Pretreatment review is available on a voluntary basis when extensive dental work in excess of $200 is proposed. * Subject to annual deductible Dental Oral Health Integration Program (OHIP) - All dental customers = Clinical research shows an association between oral health and overall health. The Cigna Dental Oral Health Integration Program (OHIP)® is designed to provide enhanced dental coverage for customers with certain eligible medical conditions. Eligible conditions for the program include cardiovascular disease, cerebrovascular disease (stroke), diabetes, maternity, chronic kidney disease, organ transplants, and head and neck cancer radiation. The program provides:  100% coverage for certain dental procedures  guidance on behavioral issues related to oral health  discounts on prescription and non-prescription dental products For more information and to see the complete list of eligible conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24. **For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Contracted Fee Schedule. For services provided by an out-of-network dentist, Cigna Dental will reimburse according to Reasonable and Customary Allowances but the dentist may balance bill up 23to their usual fees.

Dental PPO - Low Option Benefits Network Calendar Year Maximum (Class I, II, III and IX expenses) Annual Deductible Individual Family Reimbursement Levels**

Cigna Dental PPO In-Network Out-of-Network Cigna DPPO Advantage $1,000

$1,000

$50 per person $150 per family

Based on Reduced Contracted Fees

Based on Maximum Allowable Charge (In-network fee level)

Plan Pays

You Pay

Plan Pays

You Pay

100%

No Charge

100%

No Charge

100%*

0%*

100%*

0%*

60%*

40%*

60%*

40%*

50% $1,000 Dependent children to age 19

50%

50% $1,000 Dependent children to age 19

50%

Subject to plan deductible Subject to plan annual maximum

Monthly PPO Premiums Tier

Rate

EE Only

$35.45

EE + Spouse

$70.89

EE + Child(ren)

$72.31

Family Coverage

$107.76

Subject to plan deductible Subject to plan annual maximum

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

Dental PPO - High and Low Options Procedure

Exclusions and Limitations

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

50% coverage on Class III and IV for 24 months Two per Calendar year Two per Calendar year 1 per Plan year for people under 19 Bitewings: 2 per Calendar year Full mouth: 1 every 36 consecutive months., Panorex: 1 every 36 consecutive months Payable only when in conjunction with Ortho workup Various limitations depending on the service Various limitations depending on the service Replacement every 5 years Replacement every 5 years Replacement every 5 years Covered if more than 6 months after installation Covered if more than 6 months after installation Reviewed if more than once Reviewed if more than once Limited to posterior tooth. One treatment per tooth every three years up to age 14 Limited to non-Orthodontic treatment 1 per 60 consecutive months if unserviceable and cannot be repaired. Benefits are based on the amount payable for nonprecious metals. No porcelain or white/tooth colored material on molar crowns or bridges When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses

Alternate Benefit

Benefit Exclusions                         

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

This benefit summary highlights some of the benefits available under the proposed plan. A complete description regarding the terms of coverage, exclusions and limitations, including legislated benefits, will be provided in your insurance certificate or plan description. Benefits are insured and/or administered by Connecticut General Life Insurance Company. "Cigna HealthCare" refers to various operating subsidiaries of Cigna Corporation. Products and services are provided by these subsidiaries and not by Cigna Corporation. These subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. DPPO insurance coverage is set forth on the following policy form numbers: AR: HP-POL77; CA: HP-POL57; CO: HP-POL78; CT: HP-POL58; DE: HP-POL79; FL: HP-POL60; ID: HPPOL82; IL: HP-POL62; KS: HP-POL84; LA: HPPOL86: MA: HP-POL 63; MI: HP-POL88; MO: HP- POL65; MS: HP-POL90; NC: HP-POL96; NE: HP-POL92; NH: HP-POL94; NM: HP-POL95; NV: HP-POL93; NY: HP-POL67; OH: HP-POL98; OK: HP-POL99; OR: HP-POL68; PA: HP-POL100; RI: HP-POL101; SC: HP-POL102; SD: HP-POL103; TN: HP-POL69; TX: HP-POL70; UT: HP-POL104; VA: HP-POL72; VT: HP-POL71; WA: POL-07/08; WI: HP-POL107; WV: HP-POL106; and WY: HP-POL108. “Cigna,” the “Tree of Life” logo and “Cigna Dental Care” are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company (CGLIC), Cigna Health and Life Insurance Company (CHLIC), Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. and its subsidiaries. Cigna Dental PPO plans are underwritten or administered by CGLIC or CHLIC, with network management services provided by Cigna Dental Health, Inc. and certain of its subsidiaries. In Arizona and Louisiana, the insured Dental PPO plan offered by CGLIC is known as the “CG Dental PPO”. In Texas, the insured dental product offered by CGLIC and CHLIC is referred to as the Cigna Dental Choice Plan, and this plan utilizes the national Cigna Dental PPO network. Cigna Dental Care (DHMO) plans are underwritten or administered by Cigna Dental Health Plan of Arizona, Inc., Cigna Dental Health of California, Inc., Cigna Dental Health of Colorado, Inc., Cigna Dental Health of Delaware, Inc., Cigna Dental Health of Florida, Inc., a Prepaid Limited Health Services Organization licensed under Chapter 636, Florida Statutes, Cigna Dental Health of Kansas, Inc. (Kansas and Nebraska), Cigna Dental Health of Kentucky, Inc. (Kentucky and Illinois), Cigna Dental Health of Maryland, Inc., Cigna Dental Health of Missouri, Inc., Cigna Dental Health of New Jersey, Inc., Cigna Dental Health of North Carolina, Inc., Cigna Dental Health of Ohio, Inc., Cigna Dental Health of Pennsylvania, Inc., Cigna Dental Health of Texas, Inc., and Cigna Dental Health of Virginia, Inc. In other states, Cigna Dental Care plans are underwritten by CGLIC, CHLIC, or Cigna HealthCare of Connecticut, Inc. and administered by Cigna Dental Health, Inc. BSD58551 © 2015 Cigna

SUPERIOR VISION YOUR BENEFITS PACKAGE

Vision

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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 26 Shallowater ISD Benefits Website: www.mybenefitshub.com/shallowaterisd

Vision Benefits Exam Frames Contact Lenses1

In-Network

Out-of-Network

Covered in full $125 retail allowance $150 retail allowance

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

Covered in full

Up to $150 retail

Medically Necessary Contact Lenses

EE only EE + Spouse EE + Child(ren) EE + Family

$7.38 $12.60 $13.33 $19.99

Co-Pays

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

Monthly Premiums

Covered in full Covered in full Covered in full See description2 Covered in full

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

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

Exam Materials

$10 $25

Services/Frequency Exam Frame Lenses Contact Lenses

12 months 24 months 12 months 12 months

(Based on date of service)

Contact lenses and related professional services (fitting, evaluation and followup) are covered in lieu of eyeglass lenses and frames benefit. 2 Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay.

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

SuperiorVision.com Customer Service 800.507.3800

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

UNUM

YOUR BENEFITS PACKAGE

Long Term Disability

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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 28 Shallowater ISD Benefits Website: www.mybenefitshub.com/shallowaterisd

Long Term Disability Policy # 125360 Please read carefully the following description of your Unum Educator Select Income Protection Plan insurance.

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

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

Benefit Amount You may purchase a monthly benefit in $100 units, starting at a minimum of $200, up to 66 2/3% of your monthly earnings rounded to the nearest $100, but not to exceed a monthly maximum benefit of $7,500. Please see your Plan Administrator for the definition of monthly earnings. The total benefit payable to you on a monthly basis (including all benefits provided under this plan) will not exceed 100% of your monthly earnings unless the excess amount is payable as a Cost of Living Adjustment. However, if you are participating in Unumâ&#x20AC;&#x2122;s Rehabilitation and Return to Work Assistance program, the total benefit payable to you on a monthly basis (including all benefits provided under this plan) will not exceed 110% of your monthly earnings (unless the excess amount is payable as a Cost of Living Adjustment).

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

Inpatient means that you are confined to a hospital room due to your sickness or injury for 23 or more consecutive hours. (Applies to Elimination Periods of 30 days or less.)

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

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

Next Steps How to Apply/Effective Date of Coverage Current Employees: To apply for coverage, complete your enrollment form by the enrollment deadline. Your effective date of coverage is September 1. New Hires: To apply for coverage, complete your enrollment form within 60 days of your eligibility date. Please see your Plan Administrator for your effective date. If you do not enroll during the initial enrollment period, you may apply only during an annual enrollment.

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

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

You may choose an Elimination Period (injury/sickness) of 0/7, 14/14, 30/30, 60/60, 90/90 or 180/180 days. If, because of your disability, you are hospital confined as an inpatient, benefits begin on the first day of inpatient confinement. 29

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

Product: Educator Select Income Protection Plan

ADEAII Duration of Benefits Elimination Period (Days)

Injury (Days) Sickness (Days) Maximum Annual Monthly Monthly Earnings Earnings Benefit 3600 300 200 5400 450 300 7200 600 400 9000 750 500 10800 900 600 12600 1050 700 14400 1200 800 16200 1350 900 18000 1500 1000 19800 1650 1100 21600 1800 1200 23400 1950 1300 25200 2100 1400 27000 2250 1500 28800 2400 1600 30600 2550 1700 32400 2700 1800 34200 2850 1900 36000 3000 2000 37800 3150 2100 39600 3300 2200 41400 3450 2300 43200 3600 2400 45000 3750 2500 46800 3900 2600 48600 4050 2700 50400 4200 2800 52200 4350 2900 54000 4500 3000 55800 4650 3100 57600 4800 3200 59400 4950 3300 61200 5100 3400 63000 5250 3500 64800 5400 3600 66600 5550 3700 68400 5700 3800 70200 5850 3900 72000 6000 4000 73800 6150 4100 75600 6300 4200 7740030 6450 4300

0* 7*

14* 14*

30* 30*

60 60

90 90

180 180

7.28 10.92 14.56 18.20 21.84 25.48 29.12 32.76 36.40 40.04 43.68 47.32 50.96 54.60 58.24 61.88 65.52 69.16 72.80 76.44 80.08 83.72 87.36 91.00 94.64 98.28 101.92 105.56 109.20 112.84 116.48 120.12 123.76 127.40 131.04 134.68 138.32 141.96 145.60 149.24 152.88 156.52

6.16 9.24 12.32 15.40 18.48 21.56 24.64 27.72 30.80 33.88 36.96 40.04 43.12 46.20 49.28 52.36 55.44 58.52 61.60 64.68 67.76 70.84 73.92 77.00 80.08 83.16 86.24 89.32 92.40 95.48 98.56 101.64 104.72 107.80 110.88 113.96 117.04 120.12 123.20 126.28 129.36 132.44

5.34 8.01 10.68 13.35 16.02 18.69 21.36 24.03 26.70 29.37 32.04 34.71 37.38 40.05 42.72 45.39 48.06 50.73 53.40 56.07 58.74 61.41 64.08 66.75 69.42 72.09 74.76 77.43 80.10 82.77 85.44 88.11 90.78 93.45 96.12 98.79 101.46 104.13 106.80 109.47 112.14 114.81

4.36 6.54 8.72 10.90 13.08 15.26 17.44 19.62 21.80 23.98 26.16 28.34 30.52 32.70 34.88 37.06 39.24 41.42 43.60 45.78 47.96 50.14 52.32 54.50 56.68 58.86 61.04 63.22 65.40 67.58 69.76 71.94 74.12 76.30 78.48 80.66 82.84 85.02 87.20 89.38 91.56 93.74

2.50 3.75 5.00 6.25 7.50 8.75 10.00 11.25 12.50 13.75 15.00 16.25 17.50 18.75 20.00 21.25 22.50 23.75 25.00 26.25 27.50 28.75 30.00 31.25 32.50 33.75 35.00 36.25 37.50 38.75 40.00 41.25 42.50 43.75 45.00 46.25 47.50 48.75 50.00 51.25 52.50 53.75

1.78 2.67 3.56 4.45 5.34 6.23 7.12 8.01 8.90 9.79 10.68 11.57 12.46 13.35 14.24 15.13 16.02 16.91 17.80 18.69 19.58 20.47 21.36 22.25 23.14 24.03 24.92 25.81 26.70 27.59 28.48 29.37 30.26 31.15 32.04 32.93 33.82 34.71 35.60 36.49 37.38 38.27

Long Term Disability SHALLOWATER INDEPENDENT SCHOOL DISTRICT Costs below are based on a Monthly payroll deduction (Employer billing mode is based on 12 Payments per year) Plan A Product: Educator Select Income Protection Plan Injury (Days) Sickness (Days) Maximum Annual Monthly Monthly Earnings Earnings Benefit 79200 6600 4400 81000 6750 4500 82800 6900 4600 84600 7050 4700 86400 7200 4800 88200 7350 4900 90000 7500 5000 91800 7650 5100 93600 7800 5200 95400 7950 5300 97200 8100 5400 99000 8250 5500 100800 8400 5600 102600 8550 5700 104400 8700 5800 106200 8850 5900 108000 9000 6000 109800 9150 6100 111600 9300 6200 113400 9450 6300 115200 9600 6400 117000 9750 6500 118800 9900 6600 120600 10050 6700 122400 10200 6800 124200 10350 6900 126000 10500 7000 127800 10650 7100 129600 10800 7200 131400 10950 7300 133200 11100 7400 135000 11250 7500

ADEAII Duration of Benefits Elimination Period (Days) 0* 7*

14* 14*

30* 30*

60 60

90 90

180 180

160.16 163.80 167.44 171.08 174.72 178.36 182.00 185.64 189.28 192.92 196.56 200.20 203.84 207.48 211.12 214.76 218.40 222.04 225.68 229.32 232.96 236.60 240.24 243.88 247.52 251.16 254.80 258.44 262.08 265.72 269.36 273.00

135.52 138.60 141.68 144.76 147.84 150.92 154.00 157.08 160.16 163.24 166.32 169.40 172.48 175.56 178.64 181.72 184.80 187.88 190.96 194.04 197.12 200.20 203.28 206.36 209.44 212.52 215.60 218.68 221.76 224.84 227.92 231.00

117.48 120.15 122.82 125.49 128.16 130.83 133.50 136.17 138.84 141.51 144.18 146.85 149.52 152.19 154.86 157.53 160.20 162.87 165.54 168.21 170.88 173.55 176.22 178.89 181.56 184.23 186.90 189.57 192.24 194.91 197.58 200.25

95.92 98.10 100.28 102.46 104.64 106.82 109.00 111.18 113.36 115.54 117.72 119.90 122.08 124.26 126.44 128.62 130.80 132.98 135.16 137.34 139.52 141.70 143.88 146.06 148.24 150.42 152.60 154.78 156.96 159.14 161.32 163.50

55.00 56.25 57.50 58.75 60.00 61.25 62.50 63.75 65.00 66.25 67.50 68.75 70.00 71.25 72.50 73.75 75.00 76.25 77.50 78.75 80.00 81.25 82.50 83.75 85.00 86.25 87.50 88.75 90.00 91.25 92.50 93.75

39.16 40.05 40.94 41.83 42.72 43.61 44.50 45.39 46.28 47.17 48.06 48.95 49.84 50.73 51.62 52.51 53.40 54.29 55.18 56.07 56.96 57.85 58.74 59.63 60.52 61.41 62.30 63.19 64.08 64.97 65.86 66.75

* If, because of your disability, you are hospital confined as an inpatient, benefits begin on the first day of inpatient confinement. Find your Annual/Monthly Earnings above to determine your Maximum Monthly Benefit. If your Annual/Monthly Earnings are not shown, use the next lower Annual/Monthly Earnings and corresponding Maximum Monthly Benefit. Or, you may refer to the Plan Highlights to calculate your Maximum Monthly Benefit based on your earnings.

AMERICAN PUBLIC LIFE

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 32 Shallowater ISD Benefits Website: www.mybenefitshub.com/shallowaterisd

GC3 Limited Benefit Group Cancer Indemnity Insurance Shallowater ISD

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

SUMMARY OF BENEFITS* Benefits

Level 1 Plan

Level 2 Plan

Radiation Therapy/Chemotherapy/ Immunotherapy Benefit

$1,000 per calendar month of treatment

$1,500 per calendar month of treatment

Hormone Therapy Benefit

$50 per treatment, up to 12 per calendar year

Surgical Schedule Benefit

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

$4,800 max per operation; $45 per surgical unit

Anesthesia Benefit

25% of the amount paid for covered surgery

Hospital Confinement Benefit

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

$300 per day 1-90 days; $300 per day, 91+ days in lieu of other benefits

US Government/Charity Hospital/HMO

$200 per day in lieu of most other benefits

$300 per day in lieu of most other benefits

Outpatient Hospital or Ambulatory Surgical Center Benefit

$400 per day of surgery

$600 per day of surgery

Drugs & Medicine Benefit - Inpatient

$150 per confinement

Drugs & Medicine Benefit - Outpatient

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

$50 per prescription, up to $150 per cal month

Transportation & Outpatient Lodging Benefit

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

Family Member Transportation & Lodging Benefit

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

Blood, Plasma & Platelets Benefit

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

$250 per day, up to $12,500 per calendar year

Bone Marrow/Stem Cell Transplant

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

Autologous - $1,500 per calendar year Non-Autologous - $4,500 per calendar year

Experimental Treatment Benefit

Pays as any non-experimental benefit

Attending Physician Benefit

$40 per day of confinement

$50 per day of confinement

Surgical Prosthesis Benefit

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

$3,000 per device (includes surgical fee); max 1 device per site, 2 lifetime max

Hair Prosthesis Benefit

$50 per hair prosthetic, 2 lifetime max

Dread Disease Benefit

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

$300 per day, 1-90 days of hospital confinement

Hospice Care Benefit

$75 per day, $13,500 lifetime max

$100 per day, $18,000 lifetime max

Inpatient Special Nursing Services

$150 per day of confinement

Ambulance Ground Benefit

$200 per ground trip

Ambulance Air Benefit

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

Extended Care Benefit

$200 per day

$300 per day

Home Health Care Benefit

$200 per day

$300 per day

Second & Third Surgical Opinions

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

Waiver of Premium

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

Physical/Speech Therapy Benefit

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

Riders Diagnostic Testing Benefit Rider

$50; 1 person, per calendar year

Critical Illness Rider: Heart Attack/Stroke

$2,500 lump sum benefit

$600 up to a max of 30 days per confinement; $100 ambulance benefit; per ICU admission

Optional Benefit Rider Intensive Care Unit Rider

*Premium and amount of benefits provided vary dependent upon the level selected at time of application.

APSB-22356(TX) MGM/FBS Shallowater ISD

GC3 Limited Benefit Group Cancer Indemnity Insurance Monthly Premium**

Level 1

Level 1 + ICU Rider

Level 2

Level 2 + ICU Rider

Individual

$20.00

$23.00

$27.10

$30.10

One-Parent Family

$27.50

$31.70

$37.10

$41.30

Two-Parent Family

$35.00

$41.30

$47.20

$53.50

** Total Premium includes the policy and riders of the option selected.

Eligibility

Diagnostic Testing Benefit Rider

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

Critical Illness Rider

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

Base Policy

All diagnosis of cancer must be positively diagnosed by a legally licensed doctor of medicine certified by the American Board of Pathology or American Board of Osteopathic Pathology. This policy/certificate pays only for loss resulting from definitive cancer treatment including direct extension, metastatic spread or recurrence. Proof must be submitted to support each claim. This policy/certificate also covers other conditions or diseases directly caused by cancer or the treatment of cancer. No benefits are payable for any covered person for any loss incurred during the first year of this policy/certificate as a result of a Pre-Existing Condition. A PreExisting Condition is a specified disease for which, within 12 months prior to the covered person’s effective date of coverage, medical advice, consultation or treatment, including prescribed medications, was recommended by or received from a member of the medical profession, or for which symptoms manifested in such a manner as would cause an ordinarily prudent person to seek diagnosis, medical advice or treatment. Pre-Existing Conditions specifically named or described as excluded in any part of this contract are never covered. This policy/certificate contains a 30-day waiting period during which no benefits will be paid under this policy/certificate. If any covered person has a specified disease diagnosed before the end of the 30-day period immediately following the covered person’s effective date, coverage for that person will apply only to loss that is incurred after one year from the effective date of such person’s coverage. If any covered person is diagnosed as having a specified disease during the 30-day period immediately following the effective date, you may elect to void the policy/certificate from the beginning and receive a full refund of premium. All benefits payable only up to the maximum amount listed in the schedule of benefits in the policy/certificate. A Hospital is not an institution, 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; a skilled nursing facility; or a facility primarily affording custodial, educational care, or care or treatment for persons suffering from mental diseases or disorders, or care for the aged, or drug or alcohol addiction. 34

APSB-22356(TX) MGM/FBS Shallowater ISD

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

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

Hospital Intensive Care Unit Rider

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

GC3 Limited Benefit Group Cancer Indemnity Insurance Conditionally Renewable

This policy/certificate is conditionally renewable. This means that We have the right to terminate your policy/certificate on any premium due date after the first Policyholder’s Anniversary Date. We must give the Policyholder at least 60 days written notice prior to cancellation. We cannot cancel Your coverage because of a change in Your age or health. We can change Your premiums if We change premiums for all similar Certificates issued to the Policyholder. We must give the Policyholder at least 60 days written notice before We change Your premiums.

Continuation Rider Continuation

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

Termination of Coverage

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

Termination of Rider Coverage

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

Conversion

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

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

Underwritten by American Public Life Insurance Company. This is a brief description of the coverage. For complete benefits, limitations, exclusions and other provisions, please refer to the policy and riders. This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. | This policy is considered an employee welfare benefit plan established and/or maintained by an association or employer intended to be covered by ERISA, and will be administered and enforced under ERISA. Group policies issued to governmental entities and municipalities may be exempt from ERISA guidelines. | Policy Form GC-3 Series | Texas | Limited Benefit Group Cancer Indemnity Insurance Policy | (11/14) | Shallowater ISD

APSB-22356(TX) MGM/FBS Shallowater ISD

LOYAL AMERICAN YOUR BENEFITS PACKAGE

Accident

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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 36 Shallowater ISD Benefits Website: www.mybenefitshub.com/shallowaterisd

Accident Summary of Benefits

Plan A Pays

Plan B Pays

Ambulance Ground Ambulance Benefit: Loyal American will pay this benefit if you require transportation by a licensed professional ambulance company to or from a hospital or $150 $75 between medical facilities within 90 days for injuries sustained after a covered accident. Payable once per accident. Air Ambulance Benefit: Loyal American will pay this benefit if you require transportation by a license professional air ambulance company to or from a hospital or between medical $600 $300 facilities within 48 hours for injuries sustained after a covered accident. Payable once per accident. Indemnity Benefits Emergency Room Treatment Benefit: Loyal American will pay this benefit if you received Insured/Spouse: Insured/Spouse: hospital emergency room treatment within 72 hours of injuries sustained in a covered $150 $75 accident and for which charges are submitted. Child: $75 Child: $40 Accident Follow-Up Treatment Benefit: Loyal American will pay this benefit for three additional treatments of injuries sustained in a covered accident over and above emergency $50 $25 treatment administered during the first 72 hours following the accident. Treatment must per visit per visit begin within 30 days of the covered accident and must be within the 6 month period following the covered accident. Specific Sum Injuries Benefit: The specific indemnity amount as listed in the policyâ&#x20AC;&#x2122;s Benefit Schedule will be paid according to the type of injury received in a covered accident. Loyal American will pay for dislocations (separated joint), burns, tendon (torn, ruptured, severed, ligaments, or rotator cuff), torn knee cartilage, eye injuries, lacerations, and fractures (broken bones). Blood, Plasma, Platelets Benefit: Loyal American will pay this benefit if you require transfusion, administration, cross matching, typing and processing of blood, plasma or $100 $50 platelets when administered within 90 days for injuries sustained in a covered accident. Payable once per accident. Hospital Benefits Initial Accident Hospitalization Benefit: Loyal American will pay this benefit if hospital confinement is required within six (6) months for injuries sustained in a covered accident. $500 $250 Payable once per accident. Hospital Confinement Benefit: Loyal American will pay this benefit for a maximum of 180 $200 $100 days per confinement.* if you require confinement in a hospital or in a hospital intensive per day per day care unitâ&#x20AC;&#x201C; sub acute within six (6) months for injuries sustained in a covered accident. Intensive Care Hospital Intensive Care Unit Confinement Benefit: Loyal American will pay this benefit for a maximum of 15 days per confinement* if you are confined in a hospital intensive care unit $400 $200 within 30 days because of injuries received in a covered accident. per day per day *Confinements separated by less than 90 days will be considered as the same period of confinement. Physical Therapy Physical Therapy Benefit: Loyal American will pay this benefit, not to exceed five treatments per accident, for services prescribed by a doctor and rendered by a licensed $50 per $25 per physical therapist. Physical therapy must be for injuries sustained in a covered accident and treatment treatment must start within 60 days after the accident. Treatment must be completed within 6 months after the accident. 1 prosthetic 1 prosthetic Prostheses Benefit: Loyal American will pay this benefit if a doctor prescribes the use of a prosthetic device due to the loss of a hand, foot or sight of an eye in a covered accident. The device/artificial device/artificial limb: $100 limb: $50 prosthetic must be received within 1 year of the covered accident. This benefit is payable once per accident and is not payable for hearing aids, dental aids, false teeth or for cosmetic More than 1: More than 1: prosthesis (e.g. hair wigs). We will not pay for joint replacement (e.g. artificial hip or knee). $500 $250 Appliance Benefit: Loyal American will pay this benefit if a doctor advises you to use a medical appliance as an aid to personal locomotion within 90 days as a result of injuries $50 $25 sustained in a covered accident. Benefits are payable for crutches, wheelchairs, braces, etc. 37 Benefits are payable for crutches and wheelchairs once per accident.

Accident Summary of Benefits

Plan A Pays

Plan B Pays

$100 per day

$50 per day

$300

$150

Family Lodging & Transportation Family Lodging Benefit: Loyal American will pay this benefit for a maximum of 30 days per accident, during the time you are confined in a hospital, for one motel/hotel room for a family member to accompany you if injuries sustained in a covered accident require hospital confinement, and if the hospital and motel/ hotel are more than 100 miles from your residence. Transportation Benefit: Loyal American will pay this benefit for a maximum of three trips per calendar year if you require special treatment and confinement in a hospital located more than 100 miles from your residence or site of the accident for injuries sustained in a covered accident. Accidental Death Accidental Death* Benefit: This policy will pay the following benefit for death if it is the result of injuries sustained in a covered accident. Death must occur within 90 days of a covered accident. Common-Carrier: You must be a fare paying passenger on a common-carrier. Common-carrier vehicles are limited to commercial airplanes, trains, buses, Insured: $100,000 Insured: $50,000 trolleys, subways, ferries and boats that operate on a regular scheduled basis Spouse: $50,000 Spouse: $25,000 between predetermined points or cities. Taxies and privately chartered vehicles Child: $15,000 Child: 7,500 are not included. Other Accidents: Other Accidents are those not classified as common-carrier Insured: $25,000 Insured: $12,500 and are not specifically excluded in the limitations and exclusions section of the Spouse: $10,000 Spouse: $5,000 policy. Child: $5,000 Child: $2,500 Dismemberment Accidental Dismemberment* Benefit This policy will pay a percentage of the Accidental Death-Other Accidents Benefit for the selected plan. *Death or dismemberment must occur within 90 days of the accident. Only the highest single benefit will be paid for accidental dismemberment. Both arms and both legs 100% 100% Two arms or legs

50%

Sight of two eyes, hands, or feet

50%

Sight of one eye, hand, foot, arm, or leg

20%

One or more fingers and/or one or more toes

Accident This is a limited benefit policy. This policy does not pay for losses resulting from sickness. RENEWABILITY CONDITIONS: The policy is guaranteed renewable. Premium rates may be changed on a class basis. A class may be defined by age, sex, occupation, premium payment method, issue state, elimination period, benefit period, etc. WHAT IS NOT COVERED BY THIS POLICY. We will not pay benefits for any injury as a result of you(r):  Operating, learning to operate, serving as a crew member of or jumping or falling from any aircraft. Aircraft includes those which are not motor-driven.  Engaging in hang gliding, bungee jumping, parachuting, sailgliding, parakiting, or hot-air ballooning.  Participating or attempting to participate in an illegal activity.  Riding in or driving any motor-driven vehicle in a race, stunt show, or speed test.  Intentionally causing a self-inflicted injury.  Having any sickness or declining process caused by a sickness, including physical or mental infirmity. We also will not pay benefits to diagnose or treat the sickness. Sickness means any disease or disorder that is not caused by an injury.  Practicing for or participating in any semi-professional or professional competitive athletic contest for which any type of compensation or remuneration is received.  Committing or trying to commit suicide, whether sane or insane.  Being in an accident which occurs more than 40 miles outside the territorial limits of the United States, Canada, Puerto Rico, and Virgin Islands.  Involvement in any period of armed conflict, even if it is not declared. This brochure contains a summary of the Accident Insurance Policy form L-6020. Coverage as described in the brochure is provided only through the issuance of a policy. The policy should be consulted for full terms and conditions of coverage.

PLAN A MONTHLY INDIVIDUAL

$12.70

SINGLE PARENT

$20.40

INSURED & SPOUSE

$19.50

FAMILY

$27.20

VOYA

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 40 Shallowater ISD Benefits Website: www.mybenefitshub.com/shallowaterisd

Critical Illness What is Cri cal Illness Insurance? Cri cal Illness Insurance pays a lump‐sum benefit if you are diagnosed a er your eﬀec ve date of coverage with a covered illness or condi on listed below. Please review cer ficates of coverage for any limita ons that may apply. Cri cal Illness Insurance is a limited benefit policy. It is not health insurance and does not sa sfy the requirement of minimum essen al coverage under the Aﬀordable Care Act. Features of Cri cal Illness Insurance include:  Guaranteed Issue: No medical ques ons or tests required for coverage.  Flexible: You can use the benefit money for any purpose you like.  Payroll deduc ons: Premiums are paid through convenient payroll deduc ons.  Portable: Should you leave your current employer or re re, you can take your coverage with you.

For what cri cal illnesses and condi ons are benefits available? Cri cal Illness Insurance provides a benefit for the following illnesses and condi ons. Covered illnesses/condi ons are broken out into groups called “modules”. Benefits are paid at 100% of the Maximum Cri cal Illness Benefit amount unless otherwise stated. For a complete descrip on of your benefits, along with applicable provisions, condi ons on benefit determina on, exclusions and limita ons, see your cer ficate of insurance and any riders. Base Module  Heart a ack  Stroke  Coronary artery bypass (25%)  Coma  Major organ failure  Permanent paralysis  End stage renal (kidney) failure

How can Cri cal Illness Insurance help? Below are a few examples of how your Cri cal Illness Insurance benefit could be used (coverage amounts may vary):  Medical expenses, such as deduc bles and copays  Child care  Home healthcare costs  Mortgage payment/rent and home maintenance

Who is eligible for Cri cal Illness Insurance? 

 

week. Your spouse*— under age 70. Coverage is available only if employee coverage is elected. Your child(ren)— to age 26. Coverage is available only if employee coverage is elected.

*The use of “spouse” in this document means a person insured as a spouse as described in the cer ficate of insurance or rider.

What Maximum Cri cal Illness Benefit am I eligible for? 

For you You have the opportunity to purchase a Maximum Cri cal Illness Benefit of $5,000 ‐ $30,000 in $5,000 increments.



For your spouse You also have the opportunity to purchase a Maximum Cri cal Illness Benefit of $5,000 ‐ $15,000 in $5,000 increments for your spouse.



For your children You also have the opportunity to purchase a Maximum Cri cal Illness Benefit of $1,000, $2,500, $5,000 or $10,000 for each covered child.

How many mes can I receive the Maximum Cri cal Illness Benefit? Usually you are only able to receive the Maximum Cri cal Illness Benefit for one covered illness or disease within each module. Your plan includes the Restora on Benefit, which provides a one‐ me restora on of 100% of the maximum benefit amount in order to pay an addi onal benefit if you experience a second covered illness for a diﬀerent condi on. Your plan also includes the Recurrence Benefit, which allows you to receive a benefit for the same condi on a second me. It’s important to note that in order for the second covered illness or the second occurrence of the illness to be covered, it must occur a er 6 consecu ve months without the occurrence of any covered cri cal illness named in your cer ficate, including the illness from the first benefit payment. If a par al benefit is paid out, it will not reduce the available maximum benefit amount for the illnesses or diseases in that same module. If you have reached the benefit limit by receiving the maximum benefit in each module, you may choose to end your coverage; however, if you have coverage for your spouse and/or child(ren), you must con nue your coverage in order to keep their coverage ac ve. Please see the cer ficate of coverage for details.

You—all ac ve employees working at least 15 hours per 41

Critical Illness What optional benefits are available?



You may choose to include the optional benefits below with your critical illness coverage. For a list of standard exclusions and limitations, please refer to the end of this document. For a complete description of your available benefits, along with applicable provisions, exclusions and limitations, see your certificate of insurance and any riders.



Spouse Critical Illness Insurance: If you have coverage for yourself, you may enroll your spouse, as long as your spouse is under age 70 and is not covered under the Policy as an employee.  Your spouse will receive coverage for the same covered conditions as you.  Your spouse will be able to receive a benefit the same number of times as you, as outlined above.  Guaranteed issue: No medical questions or tests required for coverage.



*The use of “spouse” in this form means a person insured as a spouse as described in the certificate of insurance or benefit. Please contact your employer for more information. Children’s Critical Illness Insurance: As long as you have critical illness coverage on yourself, your natural child(ren), stepchild (ren), adopted child(ren) or child(ren) for whom you are a legal guardian are eligible to be covered under your employer’s plan, up to the age of 26.  Your children are covered for the same covered conditions as you are with the exception of carcinoma in situ and coronary artery bypass; however, actual benefit amounts may vary.  Your child(ren) will be able to receive a benefit the same number of times as you, as outlined above.  One premium amount covers all of your eligible children.  Guaranteed issue: No medical questions or tests required for coverage.  If both you and your spouse are covered under the policy as an employee, then only one, but not both, may cover the same child(ren) under this benefit. If the parent who is covering the child(ren) stops being insured as an employee then the other parent may apply for children’s coverage.

Exclusions and Limitations Benefits are not payable for any critical illness caused in whole or directly by any of the following*:  Participation or attempt to participate in a felony or illegal activity.



Suicide, attempted suicide or any intentionally selfinflicted injury, while sane or insane. War or any act of war, whether declared or undeclared, other than acts of terrorism. Loss that occurs while on full-time active duty as a member of the armed forces of any nation. We will refund, upon written notice of such service, any premium which has been accepted for any period not covered as a result of this exclusion. Alcoholism, drug abuse, or misuse of alcohol or taking of drugs, other than under the direction of a doctor.

Benefits reduce 50% for the employee and/or covered spouse on the policy anniversary following the 70th birthday, however, premiums do not reduce as a result of this benefit change. *See the certificate of insurance and any riders for a complete list of available benefits, along with applicable provisions, exclusions and limitations.

Who do I contact with questions? For more information, please call the Voya Employee Benefits Customer Service Team at (800) 955-7736.

Critical Illness How much does Critical Illness Insurance cost? See the chart below for the premium amounts.

EMPLOYEE COVERAGE MONTHLY RATES: UNI-TOBACCO Issue Age

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

Under 30

$1.90

$3.80

$5.70

$7.60

$9.50

$11.40

30-39

$2.40

$4.80

$7.20

$9.60

$12.00

$14.40

40-49

$4.65

$9.30

$13.95

$18.60

$23.25

$27.90

50-59

$8.55

$17.10

$25.65

$34.20

$42.75

$51.30

60-64

$12.60

$25.20

$37.80

$50.40

$63.00

$75.60

65-69

$17.15

$34.30

$51.45

$68.60

$85.75

$102.90

70+

$25.95

$51.90

$77.85

$103.80

$129.75

$155.70

SPOUSE COVERAGE MONTHLY RATES: UNI-TOBACCO

CHILD(REN) COVERAGE MONTHLY RATES

Issue Age

$5,000

$10,000

$15,000

Coverage Amount

Rate

Under 30

$2.40

$4.80

$7.20

$1,000

$0.13

30-39

$3.45

$6.90

$10.35

$2,500

$0.33

40-49

$6.75

$13.50

$20.25

$5,000

$0.65

50-59

$12.15

$24.30

$36.45

$10,000

$1.30

60-64

$15.80

$31.60

$47.40

65-69

$16.10

$32.20

$48.30

70+

$29.10

$58.20

$87.30

CIGNA 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 44 Shallowater ISD Benefits Website: www.mybenefitshub.com/shallowaterisd

Life and AD&D Basic and Voluntary Term Life

Voluntary AD&D (paid by you)

Eligibility Active, full-time Employees of the Employer regularly working a minimum of 20 hours per week .

Employee  Benefit Amount – Units of $10,000  Maximum – $250,000  Benefit Reduction Schedule – Benefits will reduce to 65% at age 70, 45% at age 75, 30% at age 80, and 20% at age 85.

Eligibility Waiting Period No Waiting Period.

Basic Term Life (paid by your employer) Employee  Benefit Amount and Maximum – $30,000  Benefit Reduction Schedule – Benefits will reduce to 65% at age 70, 45% at age 75, 30% at age 80, and 20% at age 85.

Voluntary Term Life (paid by you) Employee  Benefit Amount – Units of $10,000  Guaranteed Coverage Amount – Lesser of 7 times annual compensation or $150,000  Maximum – Lesser of 7 times annual compensation or $250,000  Benefit Reduction Schedule – Benefits will reduce to 65% at age 70, 45% at age 75, 30% at age 80, and 20% at age 85. Your Spouse* — Spouse is eligible provided that you apply for and are approved for coverage for yourself.  Benefit Amount – Units of $5,000  Guaranteed Coverage Amount – $75,000  Maximum – The lesser of $100,000 or 50% of the Employee’s Voluntary Life Insurance Amount. Your Unmarried, Dependent Children — Under age 19 (or under age 26 if they are full-time students) , as long as you apply for and are approved for coverage for yourself. Premium includes all eligible children.  Maximum Per Child – $10,000  Benefit Amount from birth to 6 months – $500  Benefit Amount from 6 months to 26 – $10,000 No one may be covered more than once under this plan.

Basic and Voluntary AD&D Eligibility Active, full-time Employees of the Employer regularly working a minimum of 20 hours per week . Eligibility Waiting Period No Waiting Period.

Basic AD&D (paid by your employer) Employee  Benefit Amount and Maximum – $30,000  Benefit Reduction Schedule – Benefits will reduce to 65% at age 70, 45% at age 75, 30% at age 80, and 20% at age 85.

Your Spouse* — Spouse is eligible provided that you apply for and are approved for coverage for yourself.  Maximum – $250,000 Your Unmarried, Dependent Children — Under age 19 (or under age 26 if they are full-time students) , as long as you apply for and are approved for coverage for yourself. Premium includes all eligible children.  Maximum – $10,000 No one may be covered more than once under this plan.

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

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

Employee (and Spouse) Cost Per $1,000

<20 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+ Child Rate per $1,000

$0.06 $0.06 $0.06 $0.07 $0.09 $0.13 $0.21 $0.36 $0.56 $0.86 $1.56 $2.80 $4.60 $0.10

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

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

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

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

Cost Per $1,000 Employee

$0.02

Family

$0.04

Other Voluntary Life Coverage Features Accelerated Death Benefit Terminal Illness If you or your spouse is diagnosed by two unaffiliated physicians as terminally ill with a life expectancy of 12 months or less, the benefit for terminal illness provides for up to 50% of the Basic Term Life Insurance coverage amount in-force and up to 50% of the Voluntary Term Life Insurance coverage amount in-force to be paid to the insured. This benefit is payable only once in the insured's lifetime, and will reduce the life insurance death benefit. Continuation for Disability for Employees Age 60 or over If your active service ends due to disability, at age 60 or over, your coverage will continue while you are disabled. Benefits will remain in force until the earliest of: the date you are no longer disabled, the date the policy terminates, the date you are Disabled for 12 consecutive months, or the day after the last period for which premiums are paid. You are considered disabled if, because of injury or sickness, you are unable to perform all the material duties of your Regular Occupation, or you are receiving disability benefits under your Employerâ&#x20AC;&#x2122;s plan. Extended Death Benefit The extended death benefit ensures that if you become disabled prior to age 60, and die before it is determined if you qualify for Waiver of Premium, we will pay the life insurance benefit if you remain disabled during that period. If you qualify for this benefit and have insured your spouse or children, their coverage is also extended. No additional premium payment is required for the extended coverage. Waiver of Premium If you are totally disabled prior to age 60 and can't work for at least 9 months, you won't need to pay premiums for your coverage while you are disabled, provided the insurance company approves you for this benefit. You are considered totally disabled when you are completely unable to engage in any occupation for wage or profit because of injury or sickness. This benefit will remain in force until age 65, subject to proof of continuing disability each year. If you qualify and 46

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

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

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

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

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

50%

25% 20%

Additional Benefits of Personal Accident Insurance For Wearing a Seatbelt & Protection by an Airbag Basic Accident Only Additional 10% benefit but not more than $3,000 if the covered person dies in an automobile accident while wearing a seatbelt. We will increase the benefit by an additional 5% but not more than $1,500 if the insured person was also positioned in a seat protected by a properly-functioning and properly deployed Supplemental Restraint System (Airbag). For Wearing a Seatbelt & Protection by an Airbag Voluntary Accident Only Additional 10% benefit but not more than $3,000 if the covered person dies in an automobile accident while wearing a seatbelt. We will increase the benefit by an additional 3% but not more than $1,500 if the insured person was also positioned in a seat protected by a properly-functioning and properly deployed Supplemental Restraint System (Airbag). For Comas 1% of full benefit amount, for up to 11 months, if you, your spouse, or your children are in a coma for 30 days or more as a result of a covered accident. If the covered person is still in a coma after 11 months, or dies, the full benefit amount will be paid. For Exposure & Disappearance Benefits are payable if you or an insured family member suffer a covered loss due to unavoidable exposure to the elements as a result of a covered accident.

If your or an insured family member's body is not found within one year of the disappearance, wrecking or sinking of the conveyance in which you or an insured family member were riding, on a trip otherwise covered, it will be presumed that you sustained loss of life as a result of a covered accident. What is Not Covered Self-inflicted injuries or suicide while sane or insane; commission or attempt to commit a felony or an assault; any act of war, declared or undeclared; any active participation in a riot, insurrection or terrorist act; bungee jumping; parachuting; skydiving; parasailing; hanggliding; sickness, disease, physical or mental impairment, or surgical or medical treatment thereof, or bacterial or viral infection; voluntarily using any drug, narcotic, poison, gas or fumes except one prescribed by a licensed physician and taken as prescribed; while operating any type of vehicle while under the influence of alcohol or any drug, narcotic or other intoxicant including any prescribed drug for which the covered person has been provided a written warning against operating a vehicle while taking it; while the covered person is engaged in the activities of active duty service in the military, navy or air force of any country or international organization (this does not include Reserve or National Guard training, unless it extends beyond 31 days); traveling in an aircraft that is owned, leased or controlled by the sponsoring organization or any of its subsidiaries or affiliates; air travel, except as a passenger on a regularly scheduled commercial airline or in an aircraft being used by the Air Mobility Command or its foreign equivalent; being flown by the covered person or in which the covered person is a member of the crew. When Your Coverage Begins and Ends Coverage becomes effective on the later of the program’s effective date, the date you become eligible, the date we receive your completed enrollment form, or the date you authorize any necessary payroll deductions. Your coverage will not begin unless you are actively at work on the effective date. Dependent coverage will not begin for any dependent who on the effective date is hospital or home confined; receiving chemotherapy or radiation treatment; or disabled and under the care of a physician. Coverage will continue while you and your dependents remain eligible, the group policy is in force, and required premiums are paid. Conversion If, before you reach age 70, this group coverage is reduced or ends for any reason except nonpayment of premium or age, you can convert to an individual policy. No medical certification is needed. To continue coverage, you must apply for the conversion policy and pay the first premium in effect for your age and occupation within 31 days after your group coverage ends. Family members may convert their coverage as long as they have not reached the maximum age limitation. Converted policies are subject to certain benefits and limits as outlined in your certificate, should you become insured under the plan. 47

5STAR LIFE

Individual Life

YOUR BENEFITS PACKAGE

PLAY VIDEO

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

Experts recommend at least

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

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 Shallowater ISD Benefits Website: www.mybenefitshub.com/shallowaterisd

Term Life with Terminal Illness and Quality of Life Rider The Family Protection Plan: Individual Life Insurance with Terminal Illness Coverage to Age 100 With the Family Protection Plan (FPP), you can provide financial stability for your loved ones should something happen to you. You have peace of mind that you are covered up to age 100.* No matter what the future brings, you and your family will be protected. If faced with a chronic medical condition that required continuous care, would you be able to protect yourself? Traditionally, expenses associated with treatment and care necessitated by a chronic injury or illness have accounted for 86% of all health care spending and can place strain on your assets when you need them most. To provide protection during this time of need, 5Star Life Insurance Company (5Star Life) is pleased to offer the Quality of Life Rider, which is included with your FPP life insurance coverage. This rider accelerates a portion of the death benefit on a monthly basis—4% each month as scheduled by your employer at the group level, and payable directly to you on a tax favored basis. You can receive up to 75% of the current face amount of the life benefit, following a diagnosis of either a chronic illness or cognitive impairment that requires substantial assistance. Benefits are paid for the following:  Permanent inability to perform at least two of the six Activities of Daily Living (ADLs) without substantial assistance, or  A permanent severe cognitive impairment, such as dementia, Alzheimer’s disease and other forms of senility requiring substantial supervision. Example

Weekly Premium

Death Benefit

Accelerated Benefit

Your age at issue: 35

$10.00

$89,655

4% $3,586.20 a month

Affordability—With several options to choose from, select the coverage that best meets the needs of your family. Terminal Illness—This plan pays the insured 30% (25% in Connecticut and Michigan) of the policy coverage amount in a lump sum upon the occurrence of a terminal condition that will result in a limited life span of less than 12 months. Portability—You and your family continue coverage with no loss of benefits or increase in cost should you terminate employment after the first premium is paid. If this happens, we can simply bill you directly. Coverage can never be cancelled by the insurance company or your employer unless you stop paying premiums. Family Protection—Individual policies can be purchased on the employee, their spouse, children and grandchildren. Children & Grandchildren Plan—Policies can be purchased for children and grandchildren ages 15 days to age 23. Convenience—Premiums are taken care of simply and easily through payroll deductions. Protection You Can Count On—Within 24 hours after receiving notice of an insured’s death, an emergency death benefit of the lesser of 50% of the coverage amount, or $10,000, will be mailed to the insured’s beneficiary, unless the death is within the two-year contestability period and/or under investigation. This product also contains no war or terrorism exclusions.

For example, in case of chronic illness, you would receive $3,586 each month up to $67,241.25. The remainder death benefit of $22,413.75 would be made payable to your beneficiary.

* Life insurance product underwritten by 5Star Life Insurance Company (a Baton Rouge, Louisiana company). Product may not be available in all states or territories. Request FPP insurance from Dell Perot, Post Office Box 83043, Lincoln, Nebraska 68501, (866) 863-9753.

Term Life with Terminal Illness and Quality of Life Rider

Age on App. Date 18-25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 50

$10,000 $7.56 $7.58 $7.65 $7.74 $7.88 $8.07 $8.27 $8.49 $8.73 $9.00 $9.30 $9.64 $10.02 $10.41 $10.84 $11.31 $11.83 $12.41 $13.00 $13.63 $14.28 $14.97 $15.69 $16.43 $17.22 $18.08 $19.04 $20.16 $21.40 $22.79 $24.27 $25.93 $27.66 $29.42 $31.23 $33.12 $35.08 $37.13 $39.31 $41.68 $44.33

MONTHLY RATES WITH QUALITY OF LIFE RIDER DEFINED BENEFIT Employee Coverage Amounts Spouse Coverage Amounts $25,000 $50,000 $75,000 $100,000 $10,000 $20,000 $30,000 $12.40 $20.46 $28.52 $36.58 $7.56 $10.78 $14.01 $12.46 $20.58 $28.71 $36.83 $7.58 $10.83 $14.08 $12.63 $20.92 $29.21 $37.50 $7.65 $10.97 $14.28 $12.85 $21.38 $29.90 $38.42 $7.74 $11.15 $14.56 $13.21 $22.08 $30.96 $39.83 $7.88 $11.43 $14.98 $13.67 $23.00 $32.33 $41.67 $8.07 $11.80 $15.53 $14.17 $24.00 $33.83 $43.67 $8.27 $12.20 $16.13 $14.73 $25.13 $35.52 $45.92 $8.49 $12.65 $16.81 $15.31 $26.29 $37.27 $48.25 $8.73 $13.12 $17.51 $16.00 $27.67 $39.33 $51.00 $9.00 $13.67 $18.33 $16.75 $29.17 $41.58 $54.00 $9.30 $14.27 $19.23 $17.60 $30.88 $44.15 $57.42 $9.64 $14.95 $20.26 $18.54 $32.75 $46.96 $61.17 $10.02 $15.70 $21.38 $19.52 $34.71 $49.90 $65.08 $10.41 $16.48 $22.56 $20.60 $36.88 $53.15 $69.42 $10.84 $17.35 $23.86 $21.77 $39.21 $56.65 $74.08 $11.31 $18.28 $25.26 $23.08 $41.83 $60.58 $79.33 $11.83 $19.33 $26.83 $24.52 $44.71 $64.90 $85.08 $12.41 $20.48 $28.56 $26.00 $47.67 $69.33 $91.00 $13.00 $21.67 $30.33 $27.56 $50.79 $74.02 $97.25 $13.63 $22.92 $32.21 $29.19 $54.04 $78.90 $103.75 $14.28 $24.22 $34.16 $30.92 $57.50 $84.08 $110.67 $14.97 $25.60 $36.23 $32.73 $61.13 $89.52 $117.92 $15.69 $27.05 $38.41 $34.56 $64.79 $95.02 $125.25 $16.43 $28.52 $40.61 $36.54 $68.75 $100.96 $133.17 $17.22 $30.10 $42.98 $38.69 $73.04 $107.40 $141.75 $18.08 $31.82 $45.56 $41.10 $77.88 $114.65 $151.42 $19.04 $33.75 $48.46 $43.90 $83.46 $123.02 $162.58 $20.16 $35.98 $51.81 $47.00 $89.67 $132.33 $175.00 $21.40 $38.47 $55.53 $50.48 $96.63 $142.77 $188.92 $22.79 $41.25 $59.71 $54.17 $104.00 $153.83 $203.67 $24.27 $44.20 $64.13 $58.33 $112.33 $166.33 $220.33 $25.93 $47.53 $69.13 $62.65 $120.96 $179.27 $237.58 $27.66 $50.98 $74.31 $67.04 $129.75 $192.46 $255.17 $29.42 $54.50 $79.58 $71.56 $138.79 $206.02 $273.25 $31.23 $58.12 $85.01 $76.29 $148.25 $220.21 $292.17 $33.12 $61.90 $90.68 $81.19 $158.04 $234.90 $311.75 $35.08 $65.82 $96.56 $86.31 $168.29 $250.27 $332.25 $37.13 $69.92 $102.71 $91.77 $179.21 $266.65 $354.08 $39.31 $74.28 $109.26 $97.71 $191.08 $284.46 $377.83 $41.68 $79.03 $116.38 $104.33 $204.33 $304.33 $404.33 $44.33 $84.33 $124.33

Term Life with Terminal Illness and Quality of Life Rider

Age on App. Date 66* 67* 68* 69* 70*

$10,000 $44.93 $48.25 $52.03 $56.33 $61.17

MONTHLY RATES WITH QUALITY OF LIFE RIDER DEFINED BENEFIT Employee Coverage Amounts Spouse Coverage Amounts $25,000 $50,000 $75,000 $100,000 $10,000 $20,000 $30,000 $105.81 $207.29 $308.77 $410.25 $44.93 $85.52 $126.11 $114.13 $223.92 $333.71 $443.50 $48.25 $92.17 $136.08 $123.58 $242.83 $362.08 $481.33 $52.03 $99.73 $147.43 $134.31 $264.29 $394.27 $524.25 $56.33 $108.32 $160.31 $146.42 $288.50 $430.58 $572.67 $61.17 $118.00 $174.83

*Qualify of Life not available ages 66-70. Quality of Life benefits not available for children. Child life coverage available only on children and grandchildren of employee (age on application date: full term new born to 23 years). $4.98 monthly for $10,000 coverage and $9.97 monthly for $20,000 coverage.

ID WATCHDOG

Identity Theft

YOUR BENEFITS PACKAGE

PLAY VIDEO

About this Benefit Identity theft protection monitors and alerts you to identity threats. Resolution services are included should your identity ever be compromised while you are covered. An identity is stolen every 2 seconds, and takes over

300 hours

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

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 52 Shallowater ISD Benefits Website: www.mybenefitshub.com/shallowaterisd

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

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

Repairing the damage caused by identity theft is frustrating and time consuming.

ID Watchdog Monthly Rates Individual Plan

$7.95

Family Plan

$14.95

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

The average victim spends 330 hours repairing the damage from identity theftâ&#x20AC;&#x201D;the equivalent of working a full-time job for more than 2 months.

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

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

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 54 Shallowater ISD Benefits Website: www.mybenefitshub.com/shallowaterisd

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 participate in the FSA plan if you participate in HSA. 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.

Authorized Signers who are 55 or older must have their own HSA in order to make the catch-up contribution Monthly Fee: Your account will be charged a monthly fee of $1.75, waived with an average daily balance at or above $3,000.

Examples of Qualified Medical Expenses      

Surgery Braces Contact lenses Dentures Eyeglasses Vaccines

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

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 prorated) 55

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

How an HSA works: 



 

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

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

What are the annual IRS contribution limits? Contributions made by all parties to an HSA cannot exceed the annual HSA limit set by the Internal Revenue Service (IRS). Anyone can contribute to your HSA, but only the accountholder and employer can receive tax deductions on those contributions. Combined annual contributions for the accountholder, employer, and third parties (i.e., parent, spouse, or anyone else) must not exceed these limits2. 56

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 catchup contribution. According to IRS guidelines, each year you have until the tax filing deadline to contribute to your HSA (typically April 15 of the following year). Online contributions must be submitted by 2:00 p.m., Central Time, the business day before the tax filing deadline. Wire contributions must be received by noon, Central Time, on the tax filing deadline, and contribution forms with checks must be received by the tax filing deadline.

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

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

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

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

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

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

1 Investment accounts are not FDIC insured, may lose value and are not a deposit or other obligation of, or guarantee by the bank. Investment losses which are replaced are subject to the annual contribution limits of the HSA. 2 HSA funds contributed in excess of these limits are subject to penalty and tax unless the excess and earnings are withdrawn prior to the due date, including any extensions for filing Federal Tax returns. Accountholders should consult with a qualified tax advisor in connection with excess contribution removal. The Internal Revenue Service requires HSA Bank to report withdrawals that are considered refunds of excess contributions. In order for the withdrawal to be accurately reported, accountholders may not withdraw the excess directly. Instead, an excess contribution refund must be requested from HSA Bank and an Excess Contribution Removal Form completed. 3 Federal Tax savings are available no matter where you live and HSAs are taxable in AL, CA, and NJ. HSA Bank does not provide tax advice. Consult your tax professional for tax‐related questions. 4 This list is not comprehensive. It is provided to you with the understanding that HSA Bank is not engaged in rendering tax advice. The information provided is not intended to be used to avoid Federal tax penalties. For more detailed information, please refer to IRS Publication 502 titled, “Medical and Dental Expenses”. Publications can be ordered directly from the IRS by calling 1-800-TAXFORM. If tax advice is required, you should seek the services of a professional. 5 Insurance premiums only qualify as an IRS-qualified medical expense: while continuing coverage under COBRA; for qualified long-term care coverage; coverage while receiving unemployment compensation; for any healthcare coverage for those over age 65 including Medicare (except Medicare supplemental coverage). 57

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.

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

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 58 Shallowater ISD Benefits Website: www.mybenefitshub.com/shallowaterisd

FSA (Flexible Spending Account) NBS Flexcard

When Will I Receive My Flex Card?

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

NBS Prepaid MasterCard® Debit Card

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

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

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

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

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

FSA Annual Contribution Max:

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

$2,600

Dependent Care Annual Max: $5,000

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

Detailed claim history and processing status Health Care and Dependent Care account balances Claim forms, Direct Deposit form, worksheets, etc. Online claims FAQs 59

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

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

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

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

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

Dependent Care Expense Account Example Expenses:    

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

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

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 +75 day grace period. Contributions are use-it-or- lose-it. Remember to retain all your receipts (including receipts for card swipes). Please contact your benefits admin to determine if your district has the grace period or the $500 Roll-Over option. If your district does not have the roll-over, your plan contributions are use-it-or-lose-it.

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

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

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

Get Your Money 1. 2. 3. 4.

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

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

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

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

MASA YOUR BENEFITS PACKAGE

Medical Transport

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

A ground ambulance can cost up to

$2,400

and a helicopter transportation fee can cost

over $30,000

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 62 Shallowater ISD Benefits Website: www.mybenefitshub.com/shallowaterisd

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

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

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

NO health questions NO age limits NO claim forms NO deductibles NO provider network limitations NO dollar limits on emergency transport costs Children covered to age 26

What is Covered?  

Emergency Helicopter Transport Emergency Ground Ambulance Transport

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

We provide medical emergency transportation solutions AND cover your out of pocket medical transport cost when your insurance falls short. “All I had to do was send the bill which was never paid by Medicare and TriCare for Life --- and the rest is history. When MASA received that bill, it was paid and all amounts owed satisfied.” --- MASA Member, 2015