2017 Benefit Guide Victoria ISD by Higginbotham Public Sector

VICTORIA ISD

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

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 Plans HSA Bank Health Savings Account (HSA) Cigna Dental UnitedHealthcare Vision UNUM Long Term Disability APL Cancer UNUM Life and AD&D Texas Life Individual Life UNUM Critical Illness LifeWorks Employee Assistance Program (EAP) Higginbotham Flexible Spending Account (FSA) APL MEDlinkÂ® Medical Supplement MASA Medical Transport 2

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

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

11 12-13 14-17 18-21 22-23 24-27 28-33 34-37 38-39 40-41 42-43 44-51 52-55 56-57

PG. 6 SUMMARY PAGES

PG. 12 YOUR BENEFITS

Benefit Contact Information

Benefit Contact Information VICTORIA ISD BENEFITS

VISION

INDIVIDUAL LIFE

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

UnitedHealthcare (800) 638-3120 www.myuhcvision.com

Texas Life (866) 283-9233 www.texaslife.com

TRS ACTIVECARE MEDICAL

DISABILITY

CRITICAL ILLNESS

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

Policy # 469176 UNUM (800) 583-6908 www.unum.com

UNUM (866) 679-3054 www.unum.com

HEALTH SAVINGS ACCOUNT

CANCER

EMPLOYEE ASSISTANCE PROGRAM

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

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

LifeWorks (888) 739-9020 www.lifeworks.com

DENTAL

LIFE AND AD&D

FLEXIBLE SPENDING ACCOUNT

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

UNUM (800) 583-6908 www.unum.com

Higginbotham (866) 419-3519 www.higginbotham.net

MEDICAL TRANSPORT

MEDICAL SUPPLEMENT—MEDLINK ®

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

Group # 15668 American Public Life (800) 256-8606 www.ampublic.com

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

How to Log In

1 BENEFIT INFO

INTERACTIVE TOOLS

2 3

www.mybenefitshub.com/ victoriaisd

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: 

Employees who elect to waive participation in the TRS ActiveCare coverage are provided an alternate health package that includes a hospital indemnity plan, dental and vision for the employee only at no cost.



If you currently participate in a Healthcare or Dependent Care Flexible Spending Account, you must re-elect a new contribution amount in the summer enrollment to continue to participate.



All NEW Benefit elections will become effective 9/1/17 (elections requiring evidence of insurability, such as life Insurance, may have a later effective date, if approved). After annual enrollment closes, benefit changes can only be made if you experience a qualifying event (and changes must be made within 30 days of event).



IMPORTANT NOTICE: Federal mandate regulations require all dependent information, including social security numbers, even if coverage is declined.



NEW!! MASA Emergency Transport MASA provides medical emergency transportation solutions AND covers your out of pocket medical transport cost when your insurance falls short.

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NEW!! MEDLink Medical Supplement This supplemental coverage helps offset out-ofpocket costs you experience due to deductibles and coinsurance of your employer’s medical plan. The available plan options are based on enrollment in your employer’s medical plans.



NEW!! Increase in dental rates effective 9/1/17



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. You can view account balance using the CHECK FSA link on the Benefit website or use the NBS smart phone app.

Don’t Forget! 

Meet with a benefit counselor during open enrollment to complete your benefit enrollment from 7/17/17-8/18/2018



Enrollment assistance is available by calling Financial Benefit Services at (866) 914-5202 to speak to a representative. Bilingual assistance is available at this number.



Representatives will be on various campuses 7/17/2017-8/18/2018



Verify your profile information: home address, phone numbers, email 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 STATUS (CIS):

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

Marital Status

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

Change in Number of Tax Dependents

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

Change in Status of Employment Affecting Coverage Eligibility

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

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

SUMMARY PAGES

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

Where can I find forms?

to review, change or continue benefit elections each year.

For benefit summaries and claim forms, go to your school

Changes are not permitted during the plan year (outside of

district’s benefit website:

annual enrollment) unless a Section 125 qualifying event occurs.

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



Changes, additions or drops may be made only during the

forms you need under the Benefits and Forms section.

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

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

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

included in the dependent profile. Additionally, you must

victoriaisd. Click on the benefit plan you need information on

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



For benefit summaries and claim forms, go to your school

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

(i.e., Dental) and you can find provider search links under the Quick Links section. When will I receive ID cards? If the insurance carrier provides ID cards, you can expect to 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 Victoria ISD or as both

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

employees and dependents.

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

CARRIER

MAXIMUM AGE

Medical

Aetna

To age 26

Dental

Cigna

To age 26

Vision

UHC

To age 26

Cancer

APL

To age 26

Critical Illness

UNUM

To age 25

Voluntary Life

UNUM

To age 26

EAP

Ceridian

To age 26

Individual Life

TX Life

To age 26 for children To age 18 for grandchildren

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

SUMMARY PAGES

Helpful Definitions Actively at Work

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

$1,000 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 10% 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. 14

FLIP TO FOR FSA INFORMATION

PG. 44

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

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

Preventive Care See below for examples Teladoc® Physician Services

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

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

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

Drug Deductible Short-Term Supply at a Retail Location

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

90-day supply)****

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

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

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

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

$351

$514

$714

+Spouse

$991

$1,264

$1,694

+Children

$671

$834

$1,062

+Family

$1,316

$1,589

$2,004

A specialist is any physician other than family practitioner, internist, OB/GYN or pediatrician. *Illustrates benefits when in-network providers are used. For some plans non-network benefits are also available; there is no coverage for non-network benefits under the ActiveCare Select or ActiveCare Select Whole Health Plan; see Enrollment Guide for more information. Non-contracting providers may bill for amounts exceeding the allowable amount for covered services. Participants will be responsible for this balance bill amount, which maybe considerable. **For ActiveCare 1-HD, certain generic preventive drugs are covered at 100%. Participants do not have to meet the deductible ($2,500 - individual, $5,000 - family) and they pay nothing out of pocket for these drugs. The list of drugs is on the TRS-ActiveCare website. ***If a participant obtains a brand-name drug when a generic equivalent is available, they are responsible for the generic copay plus the cost difference between the brand-name drug and the generic drug. 13 ****Participants can fill 32-day to 90-day supply through mail order.

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 14 Victoria ISD Benefits Website: www.mybenefitshub.com/victoriaisd

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 Victoria ISD website at www.mybenefitshub.com/victoriaisd

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) 15

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. 16

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). 17

CIGNA

Dental

YOUR BENEFITS PACKAGE

PLAY VIDEO

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

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 18 Victoria ISD Benefits Website: www.mybenefitshub.com/victoriaisd

Dental PPO - High Option Monthly PPO Premiums Tier

Rate

EE Only

$22.24

EE + Spouse

$44.02

EE + Child(ren)

$51.46

Family Coverage

$68.41

Receiving regular dental care can not only catch minor problems before they become major and expensive to treat - it may even help improve your overall health. Gum disease is increasingly being linked to complications for pre-term birth, heart disease, stroke, diabetes, osteoporosis and other health issues. Thatâ&#x20AC;&#x2122;s why this dental plan includes Cigna Dental WellnessPlusSM features. When you or your family members receive any preventive care in one plan year, the annual dollar maximum will increase in the following plan year. When you or your family members remain enrolled in the plan and continue to receive preventive care, the annual dollar maximum will increase in the following plan year, until it reaches the level specified below. Please refer to your plan materials for additional information on this plan feature.

Benefits Network Calendar Year Maximum (Class I, II and III expenses) Annual Deductible Individual Family Reimbursement Levels**

Cigna Dental PPO In-Network Total Cigna DPPO Year 1: $1,000 Year 2: $1,100# Year 3: $1,200+ Year 4: $1,300^ $50 per person $150 per family Based on Reduced Contracted Fees

Out-of-Network Year 1: $1,000 Year 2: $1,100# Year 3: $1,200+ Year 4: $1,300^ $50 per person $150 per family

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

Plan Pays

You Pay

Class I - Diagnostic & Preventative Care Oral Evaluations Prophylaxis: routine cleanings X-rays: routine X-rays: non-routine Fluoride Application Sealants: per tooth Space Maintainers non-orthodontic

100%

No Charge

100%

No Charge

Class II - Basic Restorative Restorative: fillings Emergency Care to Relieve Pain Endodontics: minor and major Periodontics: minor and major Oral surgery: minor and major Anesthesia: general and IV sedation

80%*

20%*

80%*

20%*

Class III - Major Restorative Inlays & Onlays Prosthesis Over Implant Crowns: prefabricated stainless steel/resin Crowns: permanent cast and porcelain Bridges and Dentures Repairs: Bridges, Crowns, and Inlays Repairs: Dentures Denture Relines, Rebases, and Adjustments

50%*

Class IV - Orthodontia Coverage for Employee and All Dependents Lifetime Benefits Maximum: $1,500

50% $1,500

50%

50% $1,500

50%

Dental PPO - Low Option Monthly PPO Premiums Tier

Rate

EE Only

$17.04

EE + Spouse

$34.10

EE + Child(ren)

$39.26

Family Coverage

$51.40

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

Benefits Network Calendar Year Maximum (Class I, II and III expenses) Annual Deductible Individual Family Reimbursement Levels**

Cigna Dental PPO In-Network Total Cigna DPPO Year 1: $750 Year 2: $850# Year 3: $950+ Year 4: $1,050^

Out-of-Network

$50 per person $150 per family

Based on Reduced Contracted Fees

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

80th percentile of Reasonable and Customary Allowances Plan Pays You Pay

Plan Pays

You Pay

Class I - Diagnostic & Preventative Care Oral Evaluations Prophylaxis: routine cleanings X-rays: routine X-rays: non-routine Fluoride Application Sealants: per tooth Space Maintainers non-orthodontic

100%

No Charge

100%

No Charge

Class II - Basic Restorative Restorative: fillings Endodontics: minor and major Periodontics: minor and major Oral surgery: minor and major Anesthesia: general and IV sedation Emergency Care to Relieve Pain

60%*

40%*

60%*

40%*

Class III - Major Restorative Inlays and Onlays Prosthesis Over Implant Crowns: prefabricated stainless steel/resin Crowns: permanent cast and porcelain Bridges and Dentures Repairs: Bridges, Crowns, and Inlays Repairs: Dentures Denture Relines, Rebases, and Adjustments

40%*

60%*

40%*

60%*

Not covered

100% of your dentist’s usual fees

Not covered

100% of your dentist’s usual fees

Class IV - Orthodontia

NOTE: Employees who waive the TRS Medical receive employee only low dental at no cost, but must enroll when completing open enrollment walkthrough. 20

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

Procedure

Exclusions and Limitations

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

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

Alternate Benefit

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

Services performed primarily for cosmetic reasons Replacement of a lost or stolen appliance Replacement of a bridge or denture within five years following the date of its original installation Replacement of a bridge or denture which can be made useable according to accepted dental standards Procedures, appliances or restorations, other than full dentures, whose main purpose is to change vertical dimension, diagnose or treat conditions of TMJ, stabilize periodontally involved teeth, or restore occlusion Veneers of porcelain or acrylic materials on crowns or pontics on or replacing the upper and lower first, second and third molars Bite registrations; precision or semi-precision attachments; splinting A surgical implant of any type Instruction for plaque control, oral hygiene and diet Dental services that do not meet common dental standards Services that are deemed to be medical services Services and supplies received from a hospital Charges which the person is not legally required to pay Charges made by a hospital which performs services for the U.S. Government if the charges are directly related to a condition connected to a military service Experimental or investigational procedures and treatments Any injury resulting from, or in the course of, any employment for wage or profit Any sickness covered under any workers’ compensation or similar law Charges in excess of the reasonable and customary allowances To the extent that payment is unlawful where the person resides when the expenses are incurred; Procedures performed by a Dentist who is a member of the covered person’s family (covered person’s family is limited to a spouse, siblings, parents, children, grandparents, and the spouse’s siblings and parents); For charges which would not have been made if the person had no insurance; For charges for unnecessary care, treatment or surgery; To the extent that you or any of your Dependents is in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid; To the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply with a “no fault” insurance law or an uninsured motorist insurance law. Cigna HealthCare will take into account any adjustment option chosen under such part by you or any one of your Dependents. In addition, these benefits will be reduced so that the total payment will not be more than 100% of the charge made for the Dental Service if benefits are provided for that service under this plan and any medical expense plan or prepaid treatment program sponsored or made 21 available by your Employer.

UNITED HEALTHCARE YOUR BENEFITS PACKAGE

Vision

PLAY VIDEO

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

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 22 Victoria ISD Benefits Website: www.mybenefitshub.com/victoriaisd

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

$6.29 $12.56 $11.92 $18.72

Co-Pays for In-Network Services Exam Materials

$10 $20

Benefit Frequency Comprehensive Exam Spectacle Lenses Frames Contact Lenses in Lieu of Eye Glasses

Once every 12 months Once every 12 months Once every 12 months Once every 12 months

Frame Benefit Private Practice Provider Retail Chain Provider

$130.00 retail frame allowance $130.00 retail frame allowance

Out-of-Network Reimbursements Up To: (copays do not apply) Exams Frames Single Vision Lenses Bifocal Lenses Trifocal Lenses Lenticular Lenses Elective Contacts in Lieu of Eye Glasses3 Necessary Contacts in Lieu of Eye Glasses2

 

Lens Options

Contact Lens Benefit

Laser Vision Benefit



UnitedHealthcare Vision has partnered with the Laser Vision Network of America (LVNA) to provide our members with access to discounted laser vision correction providers. Members receive 15% off usual and customary pricing, 5% off promotional pricing at over 500 network provider locations and even greater discounts through set pricing at LasikPlus locations. For more information, call 1-888-563-4497 or visit us at www.uhclasik.com. for Covered Contact Lens Selection does not apply at Costco, Walmart or Sam’s Club locations. The allowance for non-selection contact lenses will be applied toward the fitting/ evaluation fee and purchase of all contacts. 2Necessary contact lenses are determined at the provider’s discretion for one or more of the following conditions: Following post cataract surgery without intraocular lens implant; to correct extreme vision problems that cannot be corrected with spectacle lenses; with certain conditions such as keratoconus, anisometropia, irregular corneal/astigmatism, aphakia, facial deformity or corneal deformity. If your provider considers your contacts necessary, you should ask your provider to contact UnitedHealthcare Vision confirming reimbursement that UnitedHealthcare Vision will make before you purchase such contacts. 3The out-of-network reimbursement applies to materials only. The fitting/evaluation is not included.

$150.00 $210.00

Important to Remember

Standard scratch-resistant coating, Glass coating -- covered in full. Other optional lens upgrades may be offered at a discount. (Discount varies by provider.) Covered-in-full elective contact lenses1 The fitting/evaluation fees, contact lenses, and up to two follow-up visits are covered in full (after copay). If you choose disposable contacts, up to 6 boxes are included when obtained from a network provider. All other elective contact lenses A $150.00 allowance is applied toward the fitting/evaluation fees and purchase of contact lenses outside the covered selection (materials copay does not apply). Toric, gas permeable and bifocal contact lenses are examples of contact lenses that are outside of our covered contacts. Necessary contact lenses2 Covered in full after applicable copay.

$40.00 $45.00 $40.00 $60.00 $80.00 $80.00

1Coverage



Benefit frequency based on last date of service. Your $150.00 contact lens allowance is applied to the fitting/evaluation fees as well as the purchase of contact lenses. For example, if the fitting/evaluation fee is $30, you will have $120.00 toward the purchase of contact lenses. The allowance may be separated at some retail chain locations between the examining physician and the optical store. You can log on to our website to print off your personalized ID card. An ID card is not required for service, but is available as a convenience to you should you wish to have an ID card to take to your appointment. Out-of-Network Reimbursement, when applicable: Receipts for services and materials purchased on different dates must be submitted together at the same time to receive reimbursement. Receipts must be submitted within 12 months of date of service to the following address: UnitedHealthcare Vision Attn. Claims Department P.O. Box 30978 Salt Lake City, UT 84130 FAX: 248.733.6060. At a participating network provider you will receive a 20% discount on an additional pair of eyeglasses or contact lenses. This program is available after your vision benefits have been exhausted. Please note that this discount shall not be considered insurance, and that UnitedHealthcare Vision shall neither pay nor reimburse the provider or member for any funds owed or spent. Not all providers may offer this discount. Please contact your provider to see if they participate. Discounts on contact lenses may vary by provider. Additional materials do not have to be purchased at the time of initial material purchase. Additional materials can be purchased at a discount any time after the insured benefit has been used. NOTE: Employees who waive the TRS Medical receive employee only low dental at no cost, but must enroll when completing open enrollment walkthrough. 23

UNUM YOUR BENEFITS PACKAGE

Disability

PLAY VIDEO

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

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

34.6 months is the duration of the average disability claim.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 24 Victoria ISD Benefits Website: www.mybenefitshub.com/victoriaisd

Long Term Disability 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. New Hires: Coverage is available to you without answering any medical questions or providing evidence of insurability. You may apply for coverage within 60 days after your eligibility date. If you do not apply within 60 days after your eligibility date, you can apply only during an annual enrollment period. Benefits are subject to the pre-existing condition exclusion referenced later in this document. Please see your Plan Administrator for your eligibility date.

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

Elimination Period The Elimination Period is the length of time of continuous disability, due to sickness or injury, which must be satisfied before you are eligible to receive benefits. 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. 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: SS ADEA: Your duration of benefits is based on the following table: Age at Disability Less than age 62 Age 62 Age 63 Age 64 Age 65 Age 66 Age 67 Age 68 Age 69 or older

Maximum Duration of Benefits To Social Security Normal Retirement Age 60 months 48 months 42 months 36 months 30 months 24 months 18 months 12 months

Year of Birth 1937 or before 1938 1939 1940 1941 1942 1943-1954 1955 1956 1957 1958 1959 1960 and after

Social Security Normal Retirement Age 65 years 65 years 2 months 65 years 4 months 65 years 6 months 65 years 8 months 65 years 10 months 66 years 66 years 2 months 66 years 4 months 66 years 6 months 66 years 8 months 66 years 10 months 67 years

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.

Long Term Disability VICTORIA ISD Costs below are based on a Monthly payroll deduction (Employer billing mode is based on 12 Payments per year)

Product: Educator Select Income Protection Plan

Annual Earnings 3600 5400 7200 9000 10800 12600 14400 16200 18000 19800 21600 23400 25200 27000 28800 30600 32400 34200 36000 37800 39600 41400 43200 45000 46800 48600 50400 52200 54000 55800 57600 59400 61200 63000 64800 66600 68400 70200 72000 73800 75600 77400 79200 81000 82800 84600 86400 88200 90000 91800 93600

Injury (Days) Sickness (Days) Maximum Monthly Monthly Earnings Benefit 300 200 450 300 600 400 750 500 900 600 1050 700 1200 800 1350 900 1500 1000 1650 1100 1800 1200 1950 1300 2100 1400 2250 1500 2400 1600 2550 1700 2700 1800 2850 1900 3000 2000 3150 2100 3300 2200 3450 2300 3600 2400 3750 2500 3900 2600 4050 2700 4200 2800 4350 2900 4500 3000 4650 3100 4800 3200 4950 3300 5100 3400 5250 3500 5400 3600 5550 3700 5700 3800 5850 3900 6000 4000 6150 4100 6300 4200 6450 4300 6600 4400 6750 4500 6900 4600 7050 4700 7200 4800 7350 4900 7500 5000 7650 5100 7800 5200

0* 7*

14* 14*

5.44 8.16 10.88 13.60 16.32 19.04 21.76 24.48 27.20 29.92 32.64 35.36 38.08 40.80 43.52 46.24 48.96 51.68 54.40 57.12 59.84 62.56 65.28 68.00 70.72 73.44 76.16 78.88 81.60 84.32 87.04 89.76 92.48 95.20 97.92 100.64 103.36 106.08 108.80 111.52 114.24 116.96 119.68 122.40 125.12 127.84 130.56 133.28 136.00 138.72 141.44

4.34 6.51 8.68 10.85 13.02 15.19 17.36 19.53 21.70 23.87 26.04 28.21 30.38 32.55 34.72 36.89 39.06 41.23 43.40 45.57 47.74 49.91 52.08 54.25 56.42 58.59 60.76 62.93 65.10 67.27 69.44 71.61 73.78 75.95 78.12 80.29 82.46 84.63 86.80 88.97 91.14 93.31 95.48 97.65 99.82 101.99 104.16 106.33 108.50 110.67 112.84

Plan A SS ADEA Duration of Benefits Elimination Period (Days) 30* 60 30* 60

3.58 5.37 7.16 8.95 10.74 12.53 14.32 16.11 17.90 19.69 21.48 23.27 25.06 26.85 28.64 30.43 32.22 34.01 35.80 37.59 39.38 41.17 42.96 44.75 46.54 48.33 50.12 51.91 53.70 55.49 57.28 59.07 60.86 62.65 64.44 66.23 68.02 69.81 71.60 73.39 75.18 76.97 78.76 80.55 82.34 84.13 85.92 87.71 89.50 91.29 93.08

2.46 3.69 4.92 6.15 7.38 8.61 9.84 11.07 12.30 13.53 14.76 15.99 17.22 18.45 19.68 20.91 22.14 23.37 24.60 25.83 27.06 28.29 29.52 30.75 31.98 33.21 34.44 35.67 36.90 38.13 39.36 40.59 41.82 43.05 44.28 45.51 46.74 47.97 49.20 50.43 51.66 52.89 54.12 55.35 56.58 57.81 59.04 60.27 61.50 62.73 63.96

90 90

180 180

2.12 3.18 4.24 5.30 6.36 7.42 8.48 9.54 10.60 11.66 12.72 13.78 14.84 15.90 16.96 18.02 19.08 20.14 21.20 22.26 23.32 24.38 25.44 26.50 27.56 28.62 29.68 30.74 31.80 32.86 33.92 34.98 36.04 37.10 38.16 39.22 40.28 41.34 42.40 43.46 44.52 45.58 46.64 47.70 48.76 49.82 50.88 51.94 53.00 54.06 55.12

1.64 2.46 3.28 4.10 4.92 5.74 6.56 7.38 8.20 9.02 9.84 10.66 11.48 12.30 13.12 13.94 14.76 15.58 16.40 17.22 18.04 18.86 19.68 20.50 21.32 22.14 22.96 23.78 24.60 25.42 26.24 27.06 27.88 28.70 29.52 30.34 31.16 31.98 32.80 33.62 34.44 35.26 36.08 36.90 37.72 38.54 39.36 40.18 41.00 41.82 42.64

Long Term Disability VICTORIA ISD

Annual Earnings

Monthly Earnings

95400 97200 99000 100800 102600 104400 106200 108000 109800 111600 113400 115200 117000 118800 120600 122400 124200 126000 127800 129600 131400 133200 135000 136800 138600 140400 142200 144000

7950 8100 8250 8400 8550 8700 8850 9000 9150 9300 9450 9600 9750 9900 10050 10200 10350 10500 10650 10800 10950 11100 11250 11400 11550 11700 11850 12000

Monthly Benefit 5300 5400 5500 5600 5700 5800 5900 6000 6100 6200 6300 6400 6500 6600 6700 6800 6900 7000 7100 7200 7300 7400 7500 7600 7700 7800 7900 8000

144.16 146.88 149.60 152.32 155.04 157.76 160.48 163.20 165.92 168.64 171.36 174.08 176.80 179.52 182.24 184.96 187.68 190.40 193.12 195.84 198.56 201.28 204.00 206.72 209.44 212.16 214.88 217.60

115.01 117.18 119.35 121.52 123.69 125.86 128.03 130.20 132.37 134.54 136.71 138.88 141.05 143.22 145.39 147.56 149.73 151.90 154.07 156.24 158.41 160.58 162.75 164.92 167.09 169.26 171.43 173.60

94.87 96.66 98.45 100.24 102.03 103.82 105.61 107.40 109.19 110.98 112.77 114.56 116.35 118.14 119.93 121.72 123.51 125.30 127.09 128.88 130.67 132.46 134.25 136.04 137.83 139.62 141.41 143.20

65.19 66.42 67.65 68.88 70.11 71.34 72.57 73.80 75.03 76.26 77.49 78.72 79.95 81.18 82.41 83.64 84.87 86.10 87.33 88.56 89.79 91.02 92.25 93.48 94.71 95.94 97.17 98.40

56.18 57.24 58.30 59.36 60.42 61.48 62.54 63.60 64.66 65.72 66.78 67.84 68.90 69.96 71.02 72.08 73.14 74.20 75.26 76.32 77.38 78.44 79.50 80.56 81.62 82.68 83.74 84.80

43.46 44.28 45.10 45.92 46.74 47.56 48.38 49.20 50.02 50.84 51.66 52.48 53.30 54.12 54.94 55.76 56.58 57.40 58.22 59.04 59.86 60.68 61.50 62.32 63.14 63.96 64.78 65.60

APL

Cancer

YOUR BENEFITS PACKAGE

PLAY VIDEO

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

Breast Cancer is the most commonly diagnosed cancer in women.

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

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

GC12 Limited Benefit Group Cancer Indemnity Insurance Victoria 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.

Benefits

Summary of Benefits Option 1 Base Plan

Cancer Screening Benefits

Option 2 Base Plan

Level 1

Diagnostic Testing - 1 test per Calendar Year

$50 per test

Follow-Up Diagnostic Testing - 1 test per Calendar Year

$100 per test

Medical Imaging – 1 per Calendar Year

$500 per test

Cancer Treatment Benefits

Level 1

Level 4

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

$10,000

$20,000

$50 per treatment

Level 1

Hormone Therapy - Maximum of 12 treatments per Calendar Year Surgical Benefits Surgical Anesthesia

$30 Unit Dollar Amount Maximum $30 Unit Dollar Amount Maximum $3,000 per operation $3,000 per operation 25% of amount paid for covered surgery

25% of amount paid for covered surgery

$6,000

$600

Prosthesis Surgical Implantation – 1 device per site, per lifetime Non-Surgical (not hair piece) – 1 device per site, per lifetime

$1,000 $100

Patient Care Benefits

Level 1

$100 $200 $100 $200

Outpatient Facility - Per day surgery is performed

$200

Attending Physician - Per day of Hospital Confinement

$30

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

$100 $100

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

$100 per day

Donor

$100 per day

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

$100 per day

Hospice Care Up to maximum of 365 days per lifetime

$100 per day

$100 $100

Level 1

Cancer Treatment Center Evaluation or Consultation - 1 per lifetime

N/A

Evaluation or Consultation Travel and Lodging - 1 per lifetime

N/A

$300 per Diagnosis of Cancer $300 per Diagnosis of Cancer

Bone Marrow Transplant - Maximum per lifetime Stem Cell Transplant - Maximum per lifetime

Hospital Confinement Per day of Hospital Confinement (1-30 days) Per day for Eligible Dependent children Per day of Hospital Confinement (31+ days) Per day for Eligible Dependent children

US Government, Charity Hospital or HMO Per day of Hospital Confinement (1-30 days) Per day of Hospital Confinement (31+ days)

Miscellaneous Benefits

Second and Third Surgical Opinion Second Surgical Opinion Third Surgical Opinion APSB-22338(TX) MGM/FBS Victoria ISD

GC12 Limited Benefit Group Cancer Indemnity Insurance Miscellaneous Benefits Continued Drugs and Medicine Inpatient Outpatient - Maximum $150 per month

Level 1

$150 per Confinement $50 per Prescription

$150

Actual coach fare or $.40 per mile

$.40 per mile

$50 per day

Actual coach fare or $.40 per mile

Travel by car Maximum of 12 trips per Calendar year for all modes of transportation combined

$.40 per mile

Family Lodging - up to a maximum of 100 days per Calendar Year

$50 per day

$300 per day

Hair Piece (Wig) - 1 per lifetime Transportation Travel by bus, plane or train Travel by car Maximum of 12 trips per Calendar year for all modes of transportation combined Lodging - up to a maximum of 100 days per Calendar Year Family Transportation Travel by bus, plane or train

Blood, Plasma and Platelets Experimental Treatment Ambulance Ground Air Maximum of 2 trips per Hospital Confinement for all modes of transportation combined

Paid in the same manner and under the same maximums as any other benefit $200 per trip

$200 per trip

$2,000 per trip

$150 per day

N/A

$25 per visit $1,000

Waive Premium

Internal Cancer First Occurrence Benefit Rider

Level 1

Level 2

Lump Sum Benefit Maximum 1 per Covered Person per lifetime

$2,500

$5,000

Inpatient Special Nursing Services - Per day of Hospital Confinement Outpatient Special Nursing Services Up to same number of Hospital Confinement days Medical Equipment - Maximum of 1 benefit per Calendar Year Physical, Occupational, Speech, Audio Therapy & Psychotherapy Maximum per Calendar Year Waiver of Premium

Benefit Riders

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

$3,750

$7,500

Heart Attack/Stroke First Occurrence Benefit Rider

Level 1

Lump Sum Benefit - Maximum 1 per Covered Person per lifetime

$2,500

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

$3,750

Intensive Care Unit

$600 per day

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

$300 per day

Hospital Intensive Care Unit Rider

APSB-22338(TX) MGM/FBS Victoria ISD

GC12 Limited Benefit Group Cancer Indemnity Insurance OPTION 1 TOTAL MONTHLY PREMIMS BY PLAN**

Issue Ages

Individual

Individual & Spouse

1 Parent Family

2 Parent Family

18+

$20.64

$43.80

$26.70

$49.80

OPTION 2 TOTAL MONTHLY PREMIUMS BY PLAN**

Issue Ages

Individual

Individual & Spouse

1 Parent Family

2 Parent Family

$26.90

$56.62

$34.14

$63.86

18+

*The premium and amount of benefits vary dependent upon Plan selected at time of application. **Total premium includes the Plan selected and any applicable rider premium.

Plan Benefit Highlights Cancer Screening Benefits Diagnostic Testing

Pays the indemnity amount for one test per Calendar Year when a Covered Person receives a screening test that is generally medically recognized to detect internal cancer. The test must be performed after the 30-day period following the Covered Person’s effective date for this benefit to be paid. This benefit is payable without a diagnosis of Cancer. This benefit ONLY pays for a screening test and does not include any test payable under the Medical Imaging benefit.

This benefit is payable for reconstructive breast surgery performed on a non-diseased breast to establish symmetry with a diseased breast when the reconstructive surgery of the diseased breast is performed while covered under this policy. Reconstructive surgery to the non-diseased breast must occur within 24 months of the reconstructive surgery of the diseased breast.

Anesthesia

Pays 25% of the paid Surgical benefit amount for services of an anesthesiologist as a result of a covered surgery. Services of an anesthesiologist for Bone Marrow or Stem Cell Transplants are covered under the Bone Marrow or Stem Cell Transplant benefits. Services of an anesthesiologist for Skin Cancer or surgical prosthesis implantation are not covered under this benefit.

Follow-Up Diagnostic Testing

Bone Marrow/Stem Cell Transplant

Pays the indemnity amount for one follow-up invasive screening test per Calendar Year when a Covered Person receives abnormal results from a covered screening test. For tests involving an incision or surgery, this benefit will only be paid for a test that results in a negative diagnosis of Cancer. Diagnostic surgeries that result in a positive diagnosis of Cancer will be paid under the Surgical benefit.

Pays an indemnity amount once per lifetime when a bone marrow or stem cell transplant is performed on a Covered Person as treatment for a diagnosed Cancer. This benefit is payable in or out of the Hospital and is payable in lieu of the Surgical and Anesthesia benefits. If a bone marrow and a stem cell transplant are performed on the same day, only the Bone Marrow Transplant benefit will be payable.

Medical Imaging

Prosthesis

Pays the indemnity amount, up to the maximum number of tests per Calendar Year, when a Covered Person has been diagnosed with Cancer and receives a MRI, CT scan, CAT scan or PET scan. These tests must be at the request of a Physician.

Cancer Treatment Benefits

Radiation Therapy, Chemotherapy or Immunotherapy

Pays actual charges, up to the maximum benefit per 12-month period, when a Covered Person receives treatment and incurs a charge for covered Radiation Therapy, Chemotherapy or Immunotherapy. The 12-month period begins on the first day the Covered Person receives covered Radiation Therapy, Chemotherapy or Immunotherapy. Chemotherapy or Immunotherapy coverage will be limited to drugs only. This benefit does not cover other procedures related to Radiation Therapy, Chemotherapy, Immunotherapy, anti-nausea drugs or any drugs or medicines covered under the Drugs and Medicine benefit or Hormone Therapy benefit.

Hormone Therapy

Pays an indemnity amount, up to 12 treatments per calendar year, when hormone therapy treatment is prescribed by a Physician for a Covered Person. This benefit covers drugs and medicine only. This benefit does not cover associated administrative processes or any drugs or medicines covered under the Drugs and Medicine benefit or Radiation Therapy, Chemotherapy or Immunotherapy benefit.

Surgical Benefits Surgical

Pays an indemnity amount when a surgical operation is performed on a Covered Person for a covered diagnosed Cancer, Skin Cancer or for reconstructive surgery due to Cancer. The indemnity amount is payable up to the maximum per operation amount chosen and will be calculated by multiplying the surgical unit value assigned to the procedure, as shown in the most current Physician’s Relative Value Table, by the Unit Dollar Amount. This benefit will be paid for surgery performed in or out of the Hospital. Two or more surgical procedures performed through the same incision will be considered one operation and benefits will be limited to the most expensive procedure. Diagnostic surgeries that result in a negative diagnosis of Cancer are not covered under this benefit. Bone Marrow or Stem Cell Transplant surgeries are paid under the Bone Marrow or Stem Cell Transplant benefits. Surgeries required to implant a permanent prosthetic device are covered under the Prosthesis benefit.

APSB-22338(TX) MGM/FBS Victoria ISD

Pays an indemnity amount once per lifetime for a non-surgical or a surgically implanted prosthetic device prescribed by a Physician as a direct result of surgery for Cancer. The Cancer must have manifested after the 30 days following the Effective Date. This benefit does not cover prosthetic related supplies. Artificial limbs will be paid under the surgical implantation portion of this benefit. Temporary prosthetic devices used as tissue expanders are covered under the Surgical benefit. Benefits for hair prosthesis will only be covered under the Hair Piece benefit.

Patient Care Benefits Hospital Confinement

Pays an indemnity amount when a Covered Person is confined to a Hospital for the treatment of a covered Cancer or the treatment of a condition or disease directly caused by Cancer or the treatment of Cancer. Outpatient treatment or a stay of less than 18 hours in an observation unit or an Emergency Room is not covered. A Hospital is not an institution, or part thereof, used as: a hospice unit, including any bed designated as a hospice or a swing bed; a convalescent home; a rest or nursing facility; a rehabilitative facility; an extended-care facility; or a facility primarily affording custodial, educational care, or care of treatment for persons suffering from mental diseases or disorders, or care for the aged, or drug or alcohol addiction.

Outpatient Facility

Pays an indemnity amount when a facility fee is charged for a surgical procedure performed on an outpatient basis in a Hospital or at an Ambulatory Surgical Center on a Covered Person for a diagnosed Cancer. Surgical procedures for Skin Cancer performed on an outpatient basis in a Hospital or Ambulatory Surgical Center are not covered under this benefit.

Attending Physician

Pays an indemnity amount for one Physician’s visit per day of Hospital confinement when a Covered Person requires the services of a Physician, other than a surgeon, while confined in a Hospital for the treatment of Cancer.

Extended Care Facility

Pays the indemnity amount when a Covered Person is confined to an Extended Care Facility due to Cancer. Confinement must be at the direction of a Physician and begin within 14 days after a Hospital Confinement. This benefit is payable for the same number of days benefits were paid for the Covered Person’s preceding Hospital Confinement. 31

See your Policy/Certificate for more information regarding the benefits listed above.

GC12 Limited Benefit Group Cancer Indemnity Insurance Home Health Care

Pays the indemnity amount when a Covered Person requires Home Health Care in lieu of Hospital Confinement due to Cancer. Home Health Care must be prescribed by a Physician and provided by a Nurse or by a home health Nurse’s aide under the supervision of a registered Nurse. Confinement must begin within 14 days after a covered Hospital Confinement and is payable up to the same number of days benefits were paid for the Covered Person’s preceding Hospital Confinement. The caregiver may not be a member of the Insured’s Immediate Family. This benefit does not include physical, speech or audio therapy, or psychotherapy as these therapies are covered under the Physical, Occupational, Speech or Audio Therapy or Psychotherapy benefit. If the Covered Person qualifies for coverage under the Hospice Care benefit, the Hospice Care benefit will be paid in lieu of this benefit.

Hospice Care

Pays the indemnity amount, up to the maximum number of days per lifetime, when a Covered Person is diagnosed by a Physician as terminally ill and requires Hospice Care due to Cancer. Care must be directed by a licensed hospice organization in the patient’s home or on an outpatient or short-term Inpatient basis in a hospice facility. The Covered Person is considered terminally ill if expected to live six months or less.

US Government, Charity Hospital or H.M.O.

Pays an indemnity amount if an itemized list of services is not available because a Covered Person is confined in a charity Hospital or U.S. Government owned Hospital or covered under a Health Maintenance Organization (H.M.O.) or a Diagnostic Related Group (D.R.G.) where no charges are made to the Covered Person. If this option is elected and the Covered Person is confined as an Inpatient in a Hospital as a result of Cancer or Dread Disease, benefits for each full day of confinement will be paid. If outpatient services are provided, we will pay the benefit for each day that outpatient surgery is performed or outpatient therapy is received for Cancer covered by the Policy. This benefit will be paid in lieu of most benefits under the Policy/Certificate.

Pays the indemnity amount for lodging, up to the maximum number of days, when treatment is received on an outpatient basis. The Covered Person’s lodging must be in a single room in a motel, hotel or other accommodation acceptable to us and will be paid only while the Covered Person is receiving the specialized treatment as an outpatient.

Family Transportation & Lodging

Pays the actual coach fare for transportation by bus, plane or train, or the per mile amount for transportation by car for one adult family member to be near a Covered Person who is receiving covered Radiation Therapy, Chemotherapy, Immunotherapy, Bone Marrow Transplant, Stem Cell Transplant or surgery due to Cancer in a Hospital that is at least 50 miles away from the Covered Person’s residence, using the most direct route. Travel must be by scheduled bus, plane or train, or by car and be within the United States or its Territories. If the family member travels by bus, plane or train, the Insured will have the option to receive the coach fare benefit or the per mile benefit. If the Insured is unable to provide proof of coach fare, the per mile benefit will be paid. Travel by car will be paid at the stated rate per mile for up to 1,000 miles round trip. Benefits will be provided for only one mode of transportation per round trip, up to the maximum number of trips per Calendar year. If the Covered Person receives treatment while Hospital Confined, benefits for travel and/or lodging will be paid once per Hospital Confinement. If treatment for the Covered Person is received on an outpatient basis, we will pay the indemnity amount for lodging, subject to the maximum number of days, for the family member’s lodging in a single room in a motel, hotel or other accommodation acceptable to us. If treatment is received on an outpatient basis, benefits for travel and/or lodging will be paid only on those days the Covered Person received outpatient treatment. If the family member and the Covered Person who is receiving treatment travel in the same car or lodge in the same room, benefits for travel and lodging will only be paid under the Transportation and Lodging benefit.

Miscellaneous Benefits

Blood, Plasma & Platelets

Pays the indemnity amount once per lifetime when a Covered Person obtains a treatment opinion at a National Cancer Institute designated Comprehensive Cancer Treatment Center. If the center is located more than 50 miles from the Covered Person’s place of residence, we will also pay a transportation and lodging indemnity amount in lieu of the Transportation and Lodging benefit and Family Member Transportation and Lodging benefit.

Ambulance

Cancer Treatment Cancer Evaluation or Consultation

Second & Third Surgical Opinion

Pays the indemnity amount for a second surgical opinion when the attending Physician recommends surgery for a Covered Person as treatment of a diagnosed Cancer. The second surgical opinion must be obtained from the consulting Physician prior to surgery. If the second surgical opinion does not agree with the first surgical opinion and a third surgical opinion is required, we will pay an indemnity amount for a third surgical opinion. Each surgical opinion is payable once per diagnosis of Cancer. Surgical opinions for reconstructive, Skin Cancer or prosthesis surgeries are not covered under this benefit.

Drugs & Medicine

Pays the indemnity amount when anti-nausea and pain medication are prescribed by a Physician and administered to a Covered Person who is also receiving Radiation Therapy, Chemotherapy, Immunotherapy, a covered surgery, Bone Marrow Transplant or Stem Cell Transplant. This benefit does not cover associated administrative processes. This benefit does not include drugs or medicines covered under the Radiation Therapy, Chemotherapy or Immunotherapy benefit or the Hormone Therapy benefit.

Transportation & Lodging

Pays the actual coach fare for transportation for a Covered Person by bus, plane or train or the per mile amount for transportation by car, to receive covered Radiation Therapy, Chemotherapy, Immunotherapy, Bone Marrow Transplant, Stem Cell Transplant or surgery in a Hospital that is at least 50 miles away from the Covered Person’s residence, using the most direct route. The Hospital must be prescribed by a Physician and be the nearest Hospital which offers the specialized treatment. If the Covered Person travels by bus, plane or train, the Insured will have the option to receive the coach fare benefit or the per mile benefit. If the Insured is unable to provide proof of coach fare, the per mile benefit will be paid. Travel must be by scheduled bus, plane or train, or by car and be within the United States or its Territories. Travel by car will be paid at the stated rate per mile for up to 1,000 miles round trip. Benefits will be provided for only one mode of transportation per round trip, up to the maximum number of trips per Calendar year. If the Covered Person receives treatment while Hospital Confined, benefits for 32be paid once per Hospital Confinement. transportation will 32 APSB-22338(TX) MGM/FBS Victoria ISD

Pays the indemnity amount for blood, plasma and platelets. This benefit does not include coverage for any laboratory processes or colony stimulating factors. Benefits for Blood, Plasma and Platelets are ONLY provided under this benefit. Pays the indemnity amount, up to two trips per confinement, for either licensed air or ground ambulance transportation of a Covered Person to a Hospital or from one medical facility to another where the Covered Person is admitted as an Inpatient and Hospital confined for at least 18 consecutive hours for the treatment of Cancer. If both air and ground ambulance is required on the same day, we will only pay the highest benefit amount.

Physical, Occupational, Speech, Audio Therapy or Psychotherapy

Pays the indemnity amount, up to the maximum per Calendar Year, when a Covered Person is advised by a Physician to seek physical, occupational, speech, audio therapy or psychotherapy as a result of Cancer or the treatment of Cancer. These therapies must be performed by a caregiver licensed in physical, occupational, speech, audio therapy or psychotherapy. If two or more therapies occur on the same day, only one benefit will be paid.

Waiver of Premium

When the Certificate is in force and the Insured becomes Disabled, we will waive all premiums due including premiums for any riders attached to the Certificate. Disability must be due to Cancer and occur while receiving treatment for such Cancer for which benefits are payable under the Policy. The Insured must remain Disabled for 60 continuous days before this benefit will begin. The Waiver of Premium will begin on the next premium due date following the 60 consecutive days of Disability. This benefit will continue for as long as the Insured remains Disabled until the earliest of either the date the Insured is no longer Disabled or the date coverage ends according to the Termination provisions in the Certificate. Proof of Disability must be provided for each new period of Disability before a new Waiver of Premium benefit is payable. Other Benefits include: s Donor s Dread Disease s Experimental Treatment s Hair Piece s Inpatient Special Nursing Services s Medical Equipment s Outpatient Special Nursing Services

GC12 Limited Benefit Group Cancer Indemnity Insurance Important Policy Provisions Eligibility

You and your Eligible Dependents are eligible to be insured under the Certificate if you and your Eligible Dependents meet APL’s underwriting rules and you are Actively at Work and qualify for coverage as defined in the Master Application.

Limitations & Exclusions

No benefits will be paid for any of the following: s care or treatment received outside the territorial limits of the United States s treatment by any program engaged in research that does not meet the definition of Experimental Treatment s losses or medical expenses incurred prior to the Covered Person’s Effective Date regardless of when Cancer was diagnosed

Only Loss for Cancer or Dread Disease

The 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. The Policy/Certificate also covers other conditions or diseases directly caused by Cancer or the treatment of Cancer. The Policy/Certificate does not cover any other disease, sickness or incapacity which existed prior to the diagnosis of Cancer, even though after contracting Cancer it may have been complicated, aggravated or affected by Cancer or the treatment of Cancer except for conditions specifically provided in the Dread Disease benefit.

Pre-Existing Condition Exclusion

No benefits are payable for any loss incurred during the Pre-Existing Condition Exclusion Period following the Covered Person’s Effective Date as the result of a PreExisting Condition. Pre-Existing Conditions specifically named or described as excluded in any part of the Policy/Certificate are never covered. If any change to coverage after the Certificate Effective Date results in an increase or addition to coverage, the Time Limit on Certain Defenses and Pre-Existing Condition Limitation for such increase will be based on the effective date of such increase.

Waiting Period

The Policy/Certificate contains a Waiting Period during which no benefits will be paid. If any Covered Person has a Specified Disease diagnosed before the end of the Waiting Period immediately following the Covered Person’s Effective Date, coverage for that person will apply only to loss that is incurred after one year from the Covered Person’s Effective Date. If any Covered Person is diagnosed as having a Specified Disease during the Waiting Period immediately following the Covered Person’s Effective Date, the Insured may elect to void the Certificate from the beginning and receive a full refund of premium.

Termination of Coverage

Insurance coverage for a Covered Person under the Certificate and any attached riders for a Covered Person will end as follows: s the date the Policy terminates s the date the Certificate terminates s the end of the grace period if the premium remains unpaid s the end of the Certificate Month in which the Policyholder requests to terminate the coverage for an Eligible Dependent s the date a Covered Person no longer qualifies as an Insured or Eligible Dependent s the date of the Covered Person’s death

Optionally Renewable

The policy is optionally renewable. The Policyholder has the right to terminate the policy on any premium due date after the first Anniversary following the Policy Effective Date. APL must give at least 60 days written notice prior to cancellation.

Portability (Voluntary Plans Only)

When the Insured no longer meets the definition of Insured, he or she will have the option to continue this coverage, including any attached riders. No Evidence of Insurability will be required. Portability must meet all of the following conditions: s the Certificate has been continuously in force for the last 12 months s APL receives a request and payment of the first premium for the portability coverage no later than 30 days after the date the Insured no longer qualifies as an eligible Insured. All future premiums due will be billed directly to the Insured. The Insured is responsible for payment of all premiums for the portability coverage s the Policy, under which this Certificate was issued, continues to be in force on the date the Insured ceases to qualify for coverage The benefits, terms and conditions of the portability coverage will be the same as those elected under the Certificate immediately prior to the date the Insured exercised portability. Portability coverage may include any Eligible Dependents who were covered under the Certificate at the time the Insured ceased to qualify as an eligible Insured. No new Eligible Dependents may be added to the portability coverage except as provided in the Newborn and Adopted Children provision. No increases in coverage will be allowed while the Insured is exercising his or her rights under this rider. If the Policy is no longer in force, then portability coverage is not available.

If the Policy/Certificate replaced Specified Disease Cancer coverage from another company that terminated within 30 days of the Certificate Effective Date, the Waiting Period will be waived for those Covered Persons that were covered under the prior coverage. However, the Pre-Existing Condition Limitation will still apply.

Termination of Certificate

Insurance coverage under the Certificate and any attached riders will end on the earliest of any of the following dates: s the date the Policy terminates s the end of the grace period if the premium remains unpaid s the date insurance has ceased on all persons covered under this Certificate s the end of the Certificate Month in which the Policyholder requests to terminate this coverage s the date you no longer qualify as an Insured s the date of your death

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. | This product contains Limitations & Exclusions | Policy Form GC12APL Limited Benefit Group Cancer Indemnity Insurance Series | Texas | (04/13) | Victoria ISD 33

APSB-22338(TX) MGM/FBS Victoria ISD

UNUM YOUR BENEFITS PACKAGE

Life and AD&D

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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 34 Victoria ISD Benefits Website: www.mybenefitshub.com/victoriaisd

Term Life Insurance and AD&D Eligibility

Other losses may be covered as well. Please see your Plan Administrator.

All employees working at least 20 hours each week in active employment in the U.S. with the employer, and their eligible spouses and children to age 26. *Note: Disabled children over the maximum child age may be eligible for benefits, please see your plan administer for more details.

Coverage amount(s) will reduce according to the following schedule: Age: Insurance Amount Reduces to: 70 65% of original amount 75 50% of original amount

Coverage Amounts

Coverage may not be increased after a reduction.

Your Term Life coverage options are: Employee: Up to 5 times salary in increments of $10,000. Not to exceed $500,000. Spouse: Up to 100% of employee amount in increments of $5,000. Not to exceed $500,000. Benefits will be paid to the employee. Child: Up to 100% of employee coverage amount in increments of $2,000. Not to exceed $10,000. The maximum death benefit for a child between the ages of live birth and 6 months is $1,000. Benefits will be paid to the employee. In order to purchase Life coverage for your spouse and/or child, you must purchase Life coverage for yourself. Your AD&D coverage options are: Employee: Up to 5 times salary in increments of $10,000. Not to exceed $500,000. You may purchase AD&D coverage for yourself regardless of whether you purchase Life coverage. Spouse: Up to 100% of employee amount in increments of $5,000. Not to exceed $500,000. Benefits will be paid to the employee. Child: Up to 100% of employee amount in increments of $2,000. Not to exceed $10,000. The maximum death benefit for a child between the ages of live birth and 6 months is $1,000. Benefits will be paid to the employee. In order to purchase AD&D coverage for your spouse and/or child, you must purchase AD&D coverage for yourself. AD&D Benefit Schedule: The full benefit amount is paid for loss of:  Life  Both hands or both feet or sight of both eyes  One hand and one foot  One hand and the sight of one eye  One foot and the sight of one eye  Speech and hearing

Guarantee Issue Current Employees: If you and your eligible dependents enroll on or before 09/01/2017, you may apply for any amount of Life insurance coverage up to $200,000 for yourself and any amount of coverage up to $50,000 for your spouse. Any Life insurance coverage over the Guarantee Issue amount(s) will be subject to evidence of insurability. If you and your eligible dependents do not enroll on or before 09/01/2017, you can apply for coverage only during an annual enrollment period and will be required to furnish evidence of insurability for the entire amount of Life insurance coverage. AD&D coverage does not require evidence of insurability. If you and your eligible dependents enroll on or before 09/01/2017 and later wish to increase your Life insurance coverage, you may increase your coverage with evidence of insurability at anytime during the year. However, you may wait until the next annual enrollment and only coverage over one benefit unit increase will be subject to evidence of insurability. Employees hired on or after 09/01/2017: If you and your eligible dependents enroll within 31 days of your eligibility date, you may apply for any amount of Life insurance coverage up to $200,000 for yourself and any amount of coverage up to $50,000 for your spouse. Any Life insurance coverage over the Guarantee Issue amount(s) will be subject to evidence of insurability. If you and your eligible dependents do not enroll within 31 days of your eligibility date, you can apply for coverage only during an annual enrollment period and will be required to furnish evidence of insurability for the entire amount of coverage. AD&D coverage does not require evidence of insurability. If you and your eligible dependents enroll within 31 days of your eligibility date, and later, wish to increase your coverage, you may increase your Life insurance coverage, with evidence of insurability, at anytime during the year. However, you may wait until the next annual enrollment and only coverage over one benefit unit increase will be subject to evidence of insurability. Please see your Plan Administrator for your eligibility date. 35

Term Life Insurance and AD&D Term Life Coverage Rates

Portability/Conversion

Rates shown are your Monthly deduction:

If you retire, reduce your hours or leave your employer, you can take this coverage with you according to the terms outlined in the contract. However, if you have a medical condition which has a material effect on life expectancy, you will be ineligible to port your coverage. You may also have the option to convert your Term life coverage to an individual life insurance policy.

Age Band

Employee per $1,000

Spouse per $1,000

Child per $1,000 $0.20

24 and under 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64

$0.031

$0.041 $0.060 $0.094 $0.141 $0.216 $0.316 $0.440 $0.549

65-69

$0.791

70-74

$1.495

75+

$4.622

Accelerated Benefit NOTE: The premium paid for child coverage is based on the cost of coverage for one child, regardless of how many children you have.

NOTE: Your rate will increase as you age and move to the next age band.

AD&D Coverage Rates AD&D Cost Per:

Monthly Rate

$1,000 $1,000 $1,000

$0.02 $0.02 $0.02

Employee Spouse Child

If you become terminally ill and are not expected to live beyond a certain time period as stated in your certificate booklet, you may request up to 50% of your life insurance amount up to $750,000, without fees or present value adjustments. A doctor must certify your condition in order to qualify for this benefit. Upon your death, the remaining benefit will be paid to your designated beneficiary(ies). This feature also applies to your covered dependents.

Waiver of Premium If you become disabled (as defined by your plan) and are no longer able to work, your premium payments will be waived during the period of disability.

Retained Asset Account Benefits of $10,000 or more are paid through the Unum Retained Asset Account. This interest bearing account will be established in the beneficiary's name. He or she can then write a check for the full amount or for $250 or more, as needed.

Additional AD&D Benefits

Your rate is based on your insurance age, which is your age immediately prior to and including the anniversary/effective date.

Education Benefit: If you or your insured spouse die within 365 days of an accident, an additional benefit is paid to your dependent child(ren). Your child(ren) must be a full-time student beyond grade 12. (Not available in Illinois or New York.) Seat Belt/Air Bag Benefit: If you or your insured dependent(s) die in a car accident and are wearing a properly fastened seat belt and/or are in a seat with an air bag, an amount will be paid in addition to the AD&D benefit.

Additional Benefits Life Planning Financial & Legal Resources

Limitations/Exclusions/Termination of Coverage Suicide Exclusion

Insurance Age

This personalized financial counseling service provides expert, objective financial counseling to survivors and terminally ill employees at no cost to you. This service is also extended to you upon the death or terminal illness of your covered spouse. The financial consultants are master level consultants. They will help develop strategies needed to protect resources, preserve current lifestyles, and build future security. At no time will the consultants offer or sell 36 any product or service.

Life benefits will not be paid for deaths caused by suicide in the first twenty-four months after your effective date of coverage. No increased or additional benefits will be payable for deaths caused by suicide occurring within 24 months after the day such increased or additional insurance is effective.

Term Life Insurance and AD&D AD&D Benefit Exclusions AD&D benefits will not be paid for losses caused by, contributed to by, or resulting from:  Disease of the body or diagnostic, medical or surgical treatment or mental disorder as set forth in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders;  Suicide, self-destruction while sane, intentionally selfinflicted injury while sane, or self-inflicted injury while insane;  War, declared or undeclared, or any act of war;  Active participation in a riot;  Attempt to commit or commission of a crime;  The voluntary use of any prescription or nonprescription drug, poison, fume, or other chemical substance unless used according to the prescription or direction of your or your dependent’s doctor. This exclusion does not apply to you or your dependent if the chemical substance is ethanol;  Intoxication. (“Intoxicated” means that the individual’s blood alcohol level equals or exceeds the legal limit for operating a motor vehicle in the state or jurisdiction where the accident occurred.)

Termination of Coverage Your coverage and your dependents’ coverage under the Summary of Benefits ends on the earliest of:  The date the policy or plan is cancelled;  The date you no longer are in an eligible group;  The date your eligible group is no longer covered;  The last day of the period for which you made any required contributions;  The last day you are in active employment unless continued due to a covered layoff or leave of absence or due to an injury or sickness, as described in the certificate of coverage;  For dependent’s coverage, the date of your death. In addition, coverage for any one dependent will end on the earliest of:  The date your coverage under a plan ends;  The date your dependent ceases to be an eligible dependent;  For a spouse, the date of divorce or annulment. Unum will provide coverage for a payable claim which occurs while you and your dependents are covered under the policy or plan.

Next Steps How to Apply Current employees: To apply for coverage, complete your enrollment by the enrollment deadline

For employees hired on or after 09/01/2017: To apply for coverage, complete your enrollment form within 31 days of your eligibility date. All employees: If you apply for coverage after your effective date, or if you choose coverage over the guarantee issue amount, you will need to complete a medical questionnaire which you can get from your Plan Administrator. You may also be required to take certain medical tests at Unum’s expense.

Effective Date of Coverage Your coverage will become effective on 09/01/2017. For employees who become eligible after this date, please see your Plan Administrator for your effective date.

Delayed Effective Date of Coverage Employee: Insurance coverage will be delayed if you are not in active employment because of an injury, sickness, temporary layoff, or leave of absence on the date that insurance would otherwise become effective. Dependent: Insurance coverage will be delayed if that dependent is totally disabled on the date that insurance would otherwise be effective. Exception: infants are insured from live birth. “Totally disabled” means that, as a result of an injury, a sickness or a disorder, your dependent is confined in a hospital or similar institution; is unable to perform two or more activities of daily living (ADLs) because of a physical or mental incapacity resulting from an injury or a sickness; is cognitively impaired; or has a life threatening condition.

Changes to Coverage Each year you and your spouse will be given the opportunity to change your Life coverage and AD&D coverage. You and your spouse may purchase additional Life coverage up to one benefit unit increase without evidence of insurability if you are already enrolled in the plan. Elected Life coverage over the one benefit unit increase will be medically underwritten and will require evidence of insurability and approval by Unum’s Medical Underwriters. The suicide exclusion will apply to any increase in coverage. AD&D coverage does not require evidence of insurability for increase amounts.

Questions If you should have any questions about your coverage or how to enroll, please contact your Plan Administrator.

TEXAS LIFE

Individual Life

YOUR BENEFITS PACKAGE

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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 38 Victoria ISD Benefits Website: www.mybenefitshub.com/victoriaisd

Individual Life Life Insurance Highlights Voluntary permanent life insurance can be an ideal complement to the group term and optional term your employer might provide. Designed to be in force when you die, this voluntary universal life product is yours to keep, even when you change jobs or retire, as long as you pay the necessary premium. Group and voluntary term, on the other hand, typically are not portable if you change jobs and, even if you can keep them after you retire, usually costs more and declines in death benefit.

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

The policy, PureLife-plus, is underwritten by Texas Life Insurance Company, and it has these outstanding features: 

High Death Benefit. With one of the highest death benefit available at the worksite,1 PureLife-plus gives your loved ones peace of mind, knowing there will be significant life insurance in force should you die prematurely.



Minimal Cash Value. Designed to provide high death benefit, PureLife-plus does not compete with the cash accumulation in your employer-sponsored retirement plans.



Long Guarantees. Enjoy the assurance of a policy that has a guaranteed death benefit to age 121 and level premium that guarantees coverage for a significant period of time (after the guaranteed period, premiums may go down, stay the same, or go up).



Refund of Premium. Unique in the marketplace, PureLifeplus offers you a refund of 10 years’ premium, should you surrender the policy if the premium you pay when you buy the policy ever increases. (Conditions apply.)



Accelerated Death Benefit Rider. Should you be diagnosed as terminally ill with the expectation of death within 12 months (24 months in Illinois), you will have the option to receive 92% (84% in Illinois) of the death benefit, minus a $150 ($100 in Florida) administrative fee. This valuable living benefit gives you peace of mind knowing that, should you need it, you can take the large majority of your death benefit while still alive. (Conditions apply.)

You may apply for this permanent, portable coverage, not only for yourself, but also for your spouse, minor children and grandchildren. Like most life insurance policies, Texas Life policies contain certain exclusions, limitations, exceptions, reductions of benefits, waiting periods and terms for keeping them in force. Please contact a Texas Life representative for costs and complete details. 1

Voluntary and Universal Whole Life Products, Eastbridge Consulting Group, October 2008 39

UNUM

Critical Illness

YOUR BENEFITS PACKAGE

PLAY VIDEO

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 Victoria ISD Benefits Website: www.mybenefitshub.com/victoriaisd

Critical Illness How can critical illness insurance help? Critical illness insurance can pay a lump sum benefit at the diagnosis of a critical illness. You can choose the level of coverage from $10,000 to $30,000 - and you can use the money any way you see fit.

Covered Conditions       

Heart attack Major organ failure Occupational HIV Benign brain tumor Blindness End-stage renal (kidney) failure Coronary artery bypass surgery; pays 25% of lump sum benefit

Covered Conditions With Time Limitations

  

Stroke—Evidence of persistent neurological deficits confirmed by a neurologist at least 30 days after the event Coma—Coma resulting from severe traumatic brain injury lasting for a period of 14 or more consecutive days Permanent paralysis—Complete and permanent loss of the use of two or more limbs for continuous 90 days as a result of a covered accident

Available Family Coverage Who can have it? Benefit Employees who are actively $10,000 to $30,000 in $5,000 at work increments Dependent children Eligible children are covered newborn until their 26th for the same conditions as birthday, regardless of employee and the following marital or student status specific childhood conditions: All eligible children are cerebral palsy, cleft lip or palate, cystic fibrosis, Down automatically covered syndrome and spina bifida. at 25% of the employee Diagnosis must occur after the benefit amount (no child’s coverage effective date. additional cost) Spouse ages 17 through From $5,000 to $15,000 in $5,000 increments 64 with purchase of employee coverage

Reduction of Benefits The benefit amount for the employee and spouse reduces by 50% on the first policy anniversary date after the insured

individual’s 70th birthday. Premiums will not be reduced. For coverage purchased after age 70, benefit amounts will not be reduced.

Benefit Overview Critical illness insurance is designed to help employees offset the financial effects of a catastrophic illness with a lump sum benefit if an insured is diagnosed with a covered critical illness. The Critical Illness benefit is based on the amount of coverage in effect on the date of diagnosis of a critical illness or the date treatment is received according to the terms and provisions of the policy. Coverage Amounts

Guarantee Issue Pre-Existing Condition Benefit Waiting Period Portability Wellness Benefit Recurrence Benefit

Premium Rate Information

Employee - $10,000 to $30,000 in increments of $5,000 Spouse - $5,000 to $15,000 in increments of $5,000 Child - 25% of Employee Coverage Amount Employee - $30,000 Spouse - $15,000 12/12 exclusion 30 days Included $50 per insured per calendar year Included - 50% of the coverage amount for an additional payout for a subsequent occurrence of benign brain tumor, coma, heart attack or stroke. Paid by the Employee Wellness benefit premium is in addition to the base premium.

Without Cancer Monthly Rates per $1,000 Issue Age Non-Tobacco Tobacco Under 25 $0.29 $0.29 25-29 $0.31 $0.31 30-34 $0.46 $0.46 35-39 $0.63 $0.63 40-44 $0.93 $0.93 45-49 $1.25 $1.25 50-54 $1.64 $1.64 55-59 $2.14 $2.14 60-64 $2.78 $2.78 65-69 $3.20 $3.20 70+ $5.99 $5.99 Wellness Benefit - Additional Monthly Cost per $50 Employee and Children $1.60 Spouse $1.60 41

LIFEWORKS

EAP (Employee Assistance Program)

YOUR BENEFITS PACKAGE

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

38%

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 42 Victoria ISD Benefits Website: www.mybenefitshub.com/victoriaisd

Employee Assistance Program (EAP) LifeWorksâ&#x20AC;&#x201D;fast, confidential help with family, work, money, health and life, whenever you need it. Life brings new ups and downs every day. From finding child or elder care or managing your personal finances, to getting help with a relationship or taking care of your health, LifeWorks offers fast, free, confidential help, 24/7. Call anytime to speak with a caring, professional consultant or visit LifeWorks.com to find help and resources with almost any issue, including:

Life

Family

Money

Work

Health

Stress and overload

Parenting

Budgeting

Time management

Exercise

Addiction and

Finding child care

Debt management

Career development

Healthy eating

recovery

Adoption

Credit and collections

Getting along at work

Managing stress

Relationships

Discipline and safety

Saving and investing

Communication

Sleep

Depression

Teenagers

Basic tax planning

Job stress and burnout

Quitting tobacco

Grief and loss

Single parenting

Buying a car

Relocation

Heart health

Divorce and

Blended families

Home buying and

Networking

Navigating the health

separation

Education

renting

Retirement planning

care system

Finding time for you

Planning for college

Saving for college

Managing people

Living with a disability

Moving

Financial aid

Bankruptcy

Handling change at work

Aging well

Home improvement

Caring for older

Estate planning

Legal issues

relatives Caregiver resources

Call LifeWorks at 888-456-1324 anytime. En espaĂąol: 888-732-9020, TTY: 800-999-3004.

You can also visit www.lifeworks.com (username: visd; password: lifeworks)

HIGGINBOTHAM

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 44 Victoria ISD Benefits Website: www.mybenefitshub.com/victoriaisd

FSA (Flexible Spending Account) What is a Flexible Spending Account? A Flexible Spending Account is a benefit provided by your employer that lets you set aside a certain amount of your paycheck into an account before paying income taxes. Then, during the year, you can use the funds in the account to pay for qualified expenses with untaxed dollars.

Why should I participate in the plan?

If I set aside part of my pay, won’t I make less money? NO. For every dollar you set aside to pay qualified expenses, you save FICA and federal income tax withholding. Your net take-home pay will increase by the tax you save. Plus, when you pay a qualified expense or receive a cash reimbursement, it’s TAX FREE.

Your biggest benefit is savings on payroll withholding taxes. You will save $25 to $40 on every $100 you budget to pay for qualified expenses.

Can I change my contribution during the year?

What expenses qualify for payment?

YES, but only in certain situations. For the Health FSA and Dependent Care FSA, you can change your election if you have a change in status or a change in your employment or the employment of your spouse or a dependent.

Most qualified expenses are for goods or services that you’ll buy anyway. They include health care costs such as co-pays, doctors’ fees, over-the-counter items and prescriptions, dental and eye care expenses and daycare expenses for dependents so you can work.

How do I know how much is available for me to spend and how do I file a claim? Your balance and claim forms are available 24/7 online at www.myRSC.com and all other details are always available online or by calling the Flex Hotline at 866-419-3519. Filing claims is easy. Just complete a claim form and attach a copy of the bill. Then, send it to us. Within a short time (usually less than 72 hours), you’ll receive your TAX-FREE reimbursement.

Must money be deposited in my account before I pay expenses or file a claim? NO. The entire annual amount you elect for the Health Care Spending Account (Health FSA) is available on the first day. However, only amounts contributed to date are available for the Dependent Care Spending Account (Dependent Care FSA).

What if I don’t use all the money in my account? Generally, contributions that are not used during the plan year are forfeited back to your employer, but changes to IRS may allow extra time to spend your money or to carryover up to $500. Check with your employer to learn your options.

What happens to my accounts if I terminate employment? You may request reimbursement for qualified expenses incurred prior to your termination date.

AS OF JANUARY 1, 2011: All over-the-counter items require a one-time physician’s prescription per plan year.

I already have health insurance. Why should I participate in the Health FSA? The Health FSA is used to pay for expenses not covered by insurance. These include co-pays, over-the-counter medications, glasses, contacts, orthodontics and prescription drugs, just to name a few.

I don’t use my employer’s health insurance. Can I still save? YES. You can still set aside money (before taxes are taken out) to budget and pay for qualified expenses. Remember, a qualified expense paid from this plan cannot be eligible for reimbursement from another plan. 45

FSA (Flexible Spending Account) How Flexible Spending Accounts Work When you pay for these expenses with pre-tax dollars, you pay no social security or federal income tax on your contributions. Your taxable income and your taxes are reduced. Here’s how it works:

Let’s say you earn $25,000 per year. And you are paid semi-monthly, so each paycheck is for gross compensation of $1,041.67. You have insurance premiums and other expenses eligible for payment through the Health FSA of $62.50 per pay period. Here is a comparison of what your paycheck looks like both with and without the Flexible Spending Account.

As you can see, when you pay for your expenses with pre-tax dollars, your net income is increased!

Gross Earnings Plan Contributions Taxable Earnings Less Taxes FICA Federal

Without FSA

With FSA

$1,041.67 -0$1,041.67

$1,041.67 $62.50 $979.17

$79.69 $105.42

$74.91 $93.41

$856.56 $62.50

$810.85

$794.06

$810.85

$33.58 Monthly

$402.96 Annually

Eligible Expenses

****GAIN****

When you incur a medical, dental or vision expense, you will be reimbursed the “full” amount of the expense at that time, up to your yearly contribution election. EXAMPLE: You are going to contribute $500 for the plan year ($41.67 per month). On January 15, you visit your eye doctor and receive your exam and contact lenses for a total charge of $200.

Fax that receipt to Higginbotham and receive your full $200 back within 24-72 hours, even though you do not have the $200 in your account at that time.

You are entitled to the entire $500 from day one of your plan year.

Orthodontia Expenses If you are currently paying on an orthodontia contract for yourself, your spouse or your children, you can put that payment aside in your Health FSA and use the mySourceCard to make the payment each month to your orthodontist. All we need is a copy of your current contract and the first payment receipt made with the mySourceCard. Your monthly orthodontic payments will be substantiated automatically for the current plan year.

Your account balance and claim forms are available 24/7 online at www.myRSC.com All other general details are always available online or by calling the Flex Hotline at 866-419–3519

FSA (Flexible Spending Account) Health Care Expenses That Qualify for Reimbursement NOTE: Only health care expenses NOT reimbursed by insurance can be claimed on a Flexible Spending Account plan.              

Acupuncture (excluding remedies and treatments prescribed by acupuncturist) Alcoholism treatment Ambulance Artificial limbs/teeth Chiropractors Christian Science Practitioner’s fees Contact lenses and solutions Co-payments (doctor, dental, vision, pharmacy) Costs of physical or mental illness confinement Crutches Deductibles Dental fees (cosmetic procedures not eligible) Dentures Diagnostic fees

                

Drug and medical supplies (syringes, needles, etc.) Endodontist fees Eye examination fees Eyeglasses prescribed by your doctor Eye surgery (cataracts, LASIK, etc.) Hearing devices and batteries Home health care Hospital bills Insulin Laboratory fees Laser eye surgery Obstetrics and fertility Office visits Oral surgery Orthodontic fees Orthopedic devices Osteopath fees

Health Care Expenses That Require a Physician’s Letter Listing a Medical Condition Making the Item Necessary           

Bedpans Ring Cushions Boost/Pediasure Foot spa Massagers Massages Reconstructive surgery in connection with birth defect, disease or accident Special school for disabled child Therapeutic support gloves Weight loss program fees and over-the-counter drugs pertaining to a specific disease Wigs for hair loss caused by disease

FSAStore for Eligible Products The thousands of products that are available at FSAStore are all FSA/HSA eligible or FSA/HSA eligible with a prescription and can be purchased with your FSA/HSA debit card or any major credit card. FSAStore offers free shipping on orders of at least $50, and its prices on brand products are very competitive. When you take into account that you are using pre-tax dollars, you generally save up to 40%.

              

Oxygen Periodontist fees Physician fees (cosmetic procedures not eligible) Podiatrist fees Prescribed medicines Psychiatric care Psychologist and psychiatrist fees Radiology Routine physicals and other nondiagnostic services or treatments Smoking cessation over-the-counter drugs Smoking cessation programs Surgical fees Wheelchair Vitamins with doctor’s letter X-rays and MRI

Health Care Expenses That Do Not Qualify for Reimbursement         

Cosmetic surgery, procedures and/or medications Dental bleaching and electronic toothbrushes Hair restoration (procedures, drugs or medications) Health club or gym memberships for general health Marriage and family counseling Weight loss program food supplements Weight loss programs for general health or appearance Mail order prescriptions from another country Premiums you or your spouse pay for insurance coverage (payroll-deducted premiums sponsored by your employer are eligible under the Premium Only Plan)

Reimbursements are as simple as 1, 2, 3!

  

Complete a claim form Provide required documentation Submit by email or mail

For additional information on Over-the-Counter items that do or do not qualify for reimbursement please visit the benefit site, www.mybenefitshub.com/victoriaisd for detailed information.

FSA (Flexible Spending Account) Health Care Spending Account Worksheet Accurate budgeting of out-of-pocket medical expenses not reimbursed or covered by insurance is necessary to gain maximum benefit from the Health Care Spending Account. Only expenses that you know you or your family will incur during the plan year can be included in the program. You should consider your cost of deductibles and coinsurance features of any medical and dental insurance policies as well as those costs not covered by insurance. INCLUDE EXPENSES FOR ALL MEMBERS OF YOUR IMMEDIATE FAMILY!!

PLANNED MEDICAL EXPENSES Known Annual Medical Expenses (those expenses not covered by insurance that your entire family will incur during the plan year for the following services): Deductibles — Coinsurance Prescriptions and Doctor Visits (CO-PAYS) Over-the-Counter Medications (with RX) Massage Therapy (Dr.’s RX Needed) Lasik Eye Surgery Medical Supplies and Equipment Therapist, Psychologist, Chiropractor

Hearing Aids and Supplies Laboratory and X-ray Expenses

PLANNED DENTAL CARE (Your portion of these expenses) Deductibles Fillings and Crowns Extractions, Dentures and Bridgework Oral Surgery Orthodontic Expenses

PLANNED VISION CARE Examination Glasses/RX Sunglasses Contact Lenses, Solution and Materials

TOTAL

Total Expenses / # of pay periods =

This is only a worksheet and is just for your use. Visit our website at www.myRSC.com for more information.

FSA (Flexible Spending Account) Reasons to Take Advantage of the Tax Savings Now Taking advantage of the Health FSA and Dependent Care FSA doesn’t change what you do at tax time. You actually get a “tax refund” on every paycheck after electing the benefits because you pay no tax on the money you set aside each pay period. You decide how much money to put into the plan and where and when to spend the money in your account. This is a great way to budget. A regular amount is deducted from your paycheck, but the entire annual election is always available for you to spend on eligible expenses from day one of the plan year. Starting January 1, 2015, Health Care Reform limits the annual election for Health FSAs to $2,600. Once you have enrolled in the plan, everything you need can be found at the website www.myRSC.com. You can even enter your claim online. Then you just print the claim form and submit it along with your detailed receipts. It only takes a few moments to go to the website and familiarize yourself with the reimbursement plan. Turning in a reimbursement claim is quick and easy. Don’t worry about it making your social security benefits smaller because social security benefits are based on your lifetime earnings history. Your social security benefits may be slightly reduced by participating in the plan. However, tax advisors will tell you that the tax savings you earn today will far outweigh any reduction in social security benefits. The Flexible Spending Accounts are not just for people who need prescription drugs and have children — everyone has medical expenses, not just families. And with the new IRS Revenue ruling, anyone who buys over-thecounter (OTC) drugs may be reimbursed through the plan. The plan is not just for prescription drugs. Things like cough syrup, pain relievers, allergy medicine, etc. are included with an OTC prescription. It is OK if both you and your spouse enroll in a similar plan at work. There is no IRS limit on the amount of medical expenses that can be reimbursed per household. Each employer sets the annual limits for the Health FSA plan.

Don’t worry that you cannot afford to have any more money taken out of your paycheck… Did you know you can get money out of the plan before you put it in? By joining the plan, you can have the plan pay your health care expenses in full at the time of service, even before you make your contribution. Do you take a deduction for medical expenses on a Form 1040? If so, you can only do so after you spend in excess of 7.5%-10% of your adjusted gross income for them. The first dollar you pay for unreimbursed medical expenses is not deductible on your Form 1040. But through the Health FSA, the very first dollar you spend will earn you 25%-40% in tax savings.

Dependent Care Spending Account        

 

You and your spouse must be employed in order to participate, or one of you can be a full-time student actively looking for work, or disabled. Kindergarten is not reimbursable, unless it can be determined that the educational part is incidental and cannot be separated from the cost of care. Overnight camps are not eligible — only day camps can be considered. Household service is eligible if part of the service is for the care of a qualifying person. Before and after school care is eligible. Your care provider cannot be your dependent. The debit card cannot be used for dependent child care. The maximum flex deduction per family per year is $5,000 when filing jointly or head of household; and $2,500 when married filing separately. HOWEVER, the IRS maximum limit for income tax purposes is $6,000 and $3,000 — whatever amount you do not deduct from your Flexible Spending Account, you can deduct the difference (up to $3,000 or $6,000) on your income tax return. Any care for your children whom you claim as tax dependents under the age of 13 is eligible. A person may qualify for only part of the year if he/she turns 13 mid-year. Care for spouse or dependents of any age who spend at least eight hours a day in your home, who are mentally or physically incapable of self-care is eligible.

FSA (Flexible Spending Account) Answers to Common Questions

Mobile myRSC

Q: I take a dependent care credit on Form 1040. Will the Dependent Care Spending Account save more? A: The more you earn, the more you’ll save. In addition, you’ll also save social security tax (FICA) with a Dependent Care Spending Account. So, don’t wait until April 15 to take the credit. Now, you can save taxes on every paycheck.

Benefits at Your Fingertips You can access your employee account information on your smartphone with the Mobile myRSC app for iPhone and Android.

Which is best for you? Visit www.myRSC.com and use the easy calculator under the Employees tab to determine your savings. Q: Are there any negatives I should know about? A: Because you will not pay social security tax on the amount of gross pay you set aside to pay for qualified expenses, your social security benefits at retirement may be slightly reduced. However, most tax advisors recommend taking advantage of current taxsavings opportunities like the Health FSA and Dependent Care FSA. Also, if disability insurance is paid on a pre-tax basis, any future benefits you receive will be taxable.

Quick Tips on Submitting Your Claims to Avoid Denial

Locating and Loading the Mobile myRSC App Simply search for “myRSC” on the App StoreSM for Apple products or on the Google Play™ Store for Android products, and then load as you would any other app.

What You Can Do with Mobile myRSC    

View Accounts: Detailed account and balance information. Card Activity: Account information. SnapClaim: File a claim and upload receipt photos directly from your smartphone. Manage Subscriptions: Set up e-mail notifications to keep you up-to-date on all account and health debit card activity.

How to Use Mobile myRSC

We need to know the date of service in order to pay the claim when you submit a dental or doctor bill. Please DO NOT submit “balance forward” or “previous balance” statements. On your doctor visit co-pays, we need the actual statement from the doctor if the charge is anything other than a co-pay amount. They will print a statement for you. We need date of service, service rendered, patient’s name, insurance payments, etc. If the statement is pink or yellow, please make a dark copy before faxing. The pink and yellow copies are not legible when faxed. An OTC RX Checklist is located at the back of this booklet. Please have your physician complete this form and return it to us, and any over-the-counter items you submit will be reimbursable back to you. When submitting a statement for a coinsurance, deductible or hospital expense, please make sure the Explanation of Benefits (EOB) states very clearly the date of service, patient name and procedure. The best document to submit is the EOB from your health insurance provider, as all these details will be included once insurance has been processed. For any forms, worksheets, or informational flyers referenced in this document, please visit: www.mybenefitshub.com/victoriaisd

Thank You for Your Help in the Above Submitting a complete claim request helps us pay all eligible claims in full and will also eliminate the letters coming back to you requesting more information regarding the reimbursement! 50

Logging In Use the same username and password you use to log in to the full myRSC website. After logging in, you will be on the home page, which will list your options. Getting Help Click the Help button at the bottom right of all pages to access contact information for your administrator, who will be able to provide assistance. Going Home Press the Home button on the bottom left corner of any page to return to the home page and start over.

FSA (Flexible Spending Account) mySourceCard™ The debit card is a quick and easy way to pay for qualified expenses from your Flexible Spending Account. You have no out-of-pocket expense — the money is taken directly out of your account. Plus, you don’t have to wait on reimbursement. Go to www.myRSC.com and request your mySourceCard debit card. Employee  24/7 access to plan documents, letters and notices, forms, account balances, contributions, investments and other plan information or cafeteria plans, health reimbursement arrangements and transit plans  Change personal information/census data online  Access to contact information or the administrator  Access to 125 tax calculators

Debit Card Procedure   

 



Use your debit card at the time of service (doctor’s office, hospital, pharmacy, etc.). The debit card cannot be used for child care. Make sure you get a statement for the service rendered.  Hospital: Statement from the doctor with the procedure code and diagnosis code, date of service, name of patient and name and address of the provider.  Dental/Vision: Statement with the procedure code, date of service, name of patient and name and address of the provider. Fax in the statement the next time you come to work: 817-882-9267 or toll-free 866-419-3516. You can either fax the documents after you have received your services OR you can wait until you receive an e-mail from the plan requesting that you send in the statements. You will NOT get an e-mail for all of your swipes — the copays for your doctor visits and prescription co-pays will automatically substantiate. However, any time you swipe the card for any amount other than a copay amount, you will need to submit the itemized statement or an Explanation of Benefits. Very Important: If you do not fax the documentation within 60 days from the date you receive the e-mail, your debit card will be suspended until proper substantiation is received.

Debit Card FAQs Q: Can I use my debit card to pay for over-the-counter drugs? A: No. You must provide a physician-signed over-the-counter prescription, and you must submit a paper claim for these items and then be reimbursed.

Q: The following items are auto substantiated: A: (1) Certain transactions involving dollar amounts that are consistent with predetermined co-pay under the plan. (2) Certain recurring previously approved expenses. (3) Certain charges that are substantiated at the time of the sale or if the vendors that participate are in the inventory information system (IIAS). Q: Purchases at pharmacies and medical providers that do not subscribe to the IIAS are treated as conditionally approved and paid at the time of service; statements must be faxed after the purchase to substantiate the purchase was for a qualified expense, i.e.: A: (1) A dentist office could charge you $200 for teeth bleaching. The $200 would be approved at the time of sale, but the member must submit the statement with the required information. Since teeth bleaching is not a covered expense, the claim would be denied, and the member would pay the plan $200. (2) A physician could charge $150 for a consult for cosmetic surgery. The $150 would be approved at the time of purchase, but cosmetic surgery is not a covered item and the claim is not eligible for reimbursement under IRS guidelines. The claim would be denied, and the member would owe the plan $150. (3) A member pays $125 for a qualified medical expense. He/ she uses the debit card, sends in the form with the required information, and it is marked as eligible in the system.

Renewing Your Debit Card    

Your debit card will work for three years initially. Check the expiration date on front of the card. If your company has the “grace extension” added to the end of the plan year and you have a “balance” from the old year, that balance will “transfer” to the new debit card. To receive a replacement card, you will be charged a $2.00 fee. If your card is “suspended” as of the last day of your plan year, your new card will not work until the old plan year expenses are paid back.

New Plan Year Debit Card Use with an Old Plan Year Balance The main thing to keep in mind is that if your company has the “grace extension” or "rollover provision" on the prior plan year, the balance in your “prior” plan year will be loaded to your debit card — the system will automatically do a “look back” at the old plan year and apply these expenses to that plan year first.

APL YOUR BENEFITS PACKAGE

MEDlinkÂŽ IV

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 52 Victoria ISD Benefits Website: www.mybenefitshub.com/victoriaisd

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 56 Victoria ISD Benefits Website: www.mybenefitshub.com/victoriaisd

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

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.

Emergent Card Example:

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

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