2018 Benefit Guide City of Stephenville by Higginbotham Public Sector

CITY OF STEPHENVILLE

BENEFIT GUIDE EFFECTIVE: 05/01/2018 - 4/30/2019 WWW.MYBENEFITSHUB.COM/ CITYOFSTEPHENVILLE

Table of Contents Benefit Contact Information How to Enroll Annual Benefit Enrollment 2. Section 125 Cafeteria Plan Guidelines 3. Annual Enrollment 4. Eligibility Requirements 5. Helpful Definitions UnitedHealthcare Medical MDLIVE Telehealth APL MEDlinkÂ® Medical Supplement APL Accident Delta Dental UnitedHealthcare Vision APL Short Term Disability UnitedHealthcare Long Term Disability APL Cancer

3 4-5 6-11 6 7 8 9 10-13 14-15 16-19 20-23 24-27 28-29 30-33 34-37 38-41

5Star Family Protection Plan Term Life Insurance

42-45

UnitedHealthcare Life and AD&D NBS Flexible Spending Account (FSA) NBS 457(b) Plan

46-49 50-53 54-55

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

PG. 6 SUMMARY PAGES

PG. 10 YOUR BENEFITS

Benefit Contact Information

Benefit Contact Information CITY OF STEPHENVILLE BENEFITS

DENTAL

FAMILY PROTECTION PLANTERMINAL ILLNESS AND QLL RIDER

Financial Benefit Services (800) 583-6908 http://www.mybenefitshub.com/ cityofstephenville

Group # TX-03962-51243 Delta Dental (800) 521-2651 www.deltadentalins.com

Group # 01925 5Star Life Insurance Company (866) 863-9753 http://5starlifeinsurance.com

MEDICAL

VISION

LIFE AND AD&D

Group # 904974 UnitedHealthcare (888) 299-2070 http://www.myuhc.com

Group # 904974 UnitedHealthcare (800) 638-3120 https://www.myuhcvision.com

Group # 904974 UnitedHealthcare (888) 299-2070 http://www.myuhc.com

TELEHEALTH

SHORT TERM DISABILITY

FLEXIBLE SPENDING ACCOUNT

MDLIVE (888) 365-1663 http://www.consultmdlive.com

Group # 16991 American Public Life (800) 256-8606 http://www.ampublic.com

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

MEDICAL SUPPLEMENT—MEDLINK ®

LONG TERM DISABILITY

457(B) PLAN

Group # 16991 American Public Life (800) 256-8606 http://www.ampublic.com

Group # 904974 UnitedHealthcare (888) 299-2070 http://www.myuhc.com

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

ACCIDENT

CANCER

Group # 16991 American Public Life (800) 256-8606 http://www.ampublic.com

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

How to Log In

1 BENEFIT INFO

INTERACTIVE TOOLS

2 3

www.mybenefitshub.com/ cityofstephenville

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

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): Marital Status

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

A change in number of dependents includes the following: birth, adoption and placement for adoption. Change in Number of Tax You can add existing dependents not previously enrolled whenever a dependent gains eligibility as a Dependents result of a valid change in status event. Change in Status of Employment Affecting Coverage Eligibility

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

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

Changes are not permitted during the plan year (outside of

website:

annual enrollment) unless a Section 125 qualifying event occurs.

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



Changes, additions or drops may be made only during the

can find the forms you need under the Benefits and Forms

annual enrollment period without a qualifying event.

section.

 Employees must review their personal information and verify

How can I find a Network Provider?

that dependents they wish to provide coverage for are

For benefit summaries and claim forms, go to the City of

included in the dependent profile. Additionally, you must

Stephenville benefit website: www.mybenefitshub.com/

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

cityofstephenville. Click on the benefit plan you need information on (i.e., Dental) and you can find provider search links under the Quick Links section.



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.

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

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

insurance company’s phone number and they can call and verify your coverage if you do not have an ID card at that time. If you do not receive your ID card, you can call the carrier’s customer service number to request another card.

timeframe will result in the forfeiture of coverage.

Q&A Who do I contact with Questions? For supplemental benefit questions, you can contact your Benefits/HR department or you can call Financial Benefit Services at 800-583-6908 for assistance.

SUMMARY PAGES

Employee Eligibility Requirements

Dependent Eligibility Requirements

Supplemental Benefits: Eligible employees must work 30 or more

Dependent Eligibility: You can cover eligible dependent

regularly scheduled hours each work week.

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

Eligible employees must be actively at work on the plan effective

maximum age listed below. Dependents cannot be double

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

covered by married spouses within the City of Stephenville or

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

as both employees and dependents.

work concurrent with the plan effective date. For example, if your 2018 benefits become effective on May 1, 2018, you must be actively-at-work on May 1, 2018 to be eligible for your new benefits. PLAN

CARRIER

MAXIMUM AGE

Accident

American Public Life

Through 25

Cancer

American Public Life

Through 25

Dental

Delta Dental

Through 25

Dependent Flex

National Benefit Services

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

Family Protection Plan

5Star Life

Issue through 23; Keep to 100

Healthcare FSA

National Benefit Services

Through 25 or IRS Tax Dependent

Individual Life

Texas Life

Through 24

Medical

UnitedHealthcare

Through 25

Medical Supplement Plan

American Public Life

Through 25

Pharmacy

UnitedHealthcare

Through 25

Telehealth

MDLIVE

Through 25

Vision

UnitedHealthcare

Through 25

If your dependent is disabled, coverage can 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. 8

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 5/1/2018 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 May 1st through April 30th

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

Calendar Year

(including diagnostic and/or consultation services).

January 1st through December 31st

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

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

UNITEDHEALTHCARE

Medical

YOUR BENEFITS PACKAGE

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

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 10 City of Stephenville Benefits Website: www.mybenefitshub.com/cityofstephenville

Medical This is a summary of what the plan does and does not cover. This summary can also help you understand your share of the costs. Itâ&#x20AC;&#x2122;s always best to review your Certificate of Coverage (COC) and check your coverage before getting any health services, when possible.

Medical Plan Options

Product Prescription Drug Plan* Co-payment Your cost for an office visit

Specialist Co-payment Your cost for a specialist office visit

Deductible Your cost before the plan starts to pay

Co-insurance Your cost share after the deductible

Out-of-Pocket Limit Your co-pays, co-insurance and deductibles (including pharmacy) count towards meeting the out-of-pocket limit

PCP** (Primary Care Provider)

Rates Employee Employee + Spouse Employee + Child(ren) Employee + Family

Plan AG-2R

Plan AN-DQ

Plan AX-KS

Choice Insurance

RX Plan LJ

RX Plan 455

RX Plan LJ

$25

None

$10

$50

$100

Designated Network $40 Network $80

Individual - $1,500 Family - $3,000

Individual - $3,000 Family - $6,000

Individual - $2,000 Family - $4,000

20%

Individual - $5,000 Family - $10,000

Individual - $6,500 Family - $13,000

Individual - $7,150 Family - $14,400

$89.39 $963.01 $547.13 $1,417.64

$0 $736.20 $384.62 $1,120.52

$38.07 $836.69 $456.62 $1,252.17

*Refer to the Prescription Drug tables on the next page for more details about each plan. 11

Medical - Prescription Drug Plans Prescription Drug Plan LJ

Prescription Drug Plan 455

(for Medical Plans AG-2R & AX-KS)

(for Medical Plan AN-DQ)

Annual Drug Deductible

Individual Deductible

No Deductible

Individual Deductible

$250 (Deductible does not apply to Tier 1 and Tier 2)

Family Deductible

No Deductible

Family Deductible

$500 (Deductible does not apply to Tier 1 and Tier 2)

Annual Drug Deductible Individual Out-of-Pocket Limit

See Medical Benefit Summary

Family Out-of-Pocket Limit See Medical Benefit Summary Retail Up to 31-day supply

Mail Order* Up to 90-day supply

Network

Tier 1

$20

$50

Tier 2

$35

$87.50

Tier Level

Tier 3

$70

$175

Annual Drug Deductible Individual Out-of-Pocket Limit

See Medical Benefit Summary

Family Out-of-Pocket Limit

See Medical Benefit Summary

Retail Up to 31-day supply

Mail Order* Up to 90-day supply

Network

Tier 1

$12.50

Tier 2

$50

$125

Tier 3

$100

$250

Tier 4

$250

$625

Tier Level

* Only certain Prescription Drug Products are available through mail order; please visit www.myuhc.com or call Customer Care at the telephone number on the back of your ID card for more information.

Medical

MDLIVE YOUR BENEFITS PACKAGE

Telehealth

PLAY VIDEO

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

75%

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 14 City of Stephenville Benefits Website: www.mybenefitshub.com/cityofstephenville

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

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

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

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

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

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

How much does it cost? $0 Covers you, your spouse, and children up to age 26, with unlimited phone consultations.

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

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

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

Scan with your smartphone to get the app.

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

Disclaimers: MDLIVE does not replace the primary care physician. MDLIVE operates subject to state regulation and may not be available in certain states. MDLIVE does not guarantee that a prescription will be written. MDLIVE does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for 15 abuse. MDLIVE physicians reserve the right to deny care for potential misuse of services. For complete terms of use visit www.mdlive.com/terms-of-use/ 010113

AMERICAN PUBLIC LIFE YOUR BENEFITS PACKAGE

MEDlinkÂŽ

PLAY VIDEO

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

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 16 City of Stephenville Benefits Website: www.mybenefitshub.com/cityofstephenville

MEDlink® IV Enhanced

Limited Benefit Group Medical Expense Supplemental Insurance City of Stephenville

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.

ENHANCED PLAN SUMMARY OF BENEFITS*

Base Policy

Option 1

Maximum In-Hospital Benefits

$2,500 per Covered Person per Calendar Year

In-Hospital Ambulance Benefit

Up to $350 per trip for ground transportation or up to $1,000 per trip for air transportation where a Covered Person is Confined as an Inpatient. Limited to one trip per day.

In-Hospital Deductible

$0 per Covered Person per Calendar Year

Outpatient Benefit Rider Maximum Outpatient Benefits

$1,000 per Covered Person per Calendar Year for Covered Outpatient Services

Outpatient Ambulance Benefit

Up to $350 per trip for ground transportation or up to $1,000 per trip for air transportation where a Covered Person resides less than 18 hours. Limited to one trip per day.

Outpatient Deductible

$0 per Covered Person per Calendar Year

Covered Outpatient Services Hospital Emergency Room

Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.

Urgent Care Facility

Maximum of three Urgent Care visits per Covered Person per Calendar Year. Maximum of six Urgent Care visits per Calendar Year for all Covered Persons combined. Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.

Outpatient Surgery

Outpatient Surgery in Hospital Outpatient Facility or Freestanding Outpatient Surgery Center. Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.

Diagnostic Testing

Diagnostic Testing in a Hospital Outpatient Facility or MRI Facility. Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.

Outpatient Treatment for a Serious Mental Illness in a Hospital Outpatient Facility

Maximum of 60 days of treatment per Covered Person per Calendar Year. Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.

Benefit Rider Physician Outpatient Treatment Benefit Rider

$25 per visit; Maximum of four visits per Covered Person per Calendar Year and eight visits per Calendar Year for all Covered Persons combined for treatment in a: Hospital Outpatient Facility s s Freestanding Emergency Care Clinic s Urgent Care Facility/Clinic s Physician Office

Total Monthly Premiums by Plan* Ages 18-54 Ages 55+

Employee

Employee & Spouse

Employee & Child

Employee & Family

$39.02

$90.17

$69.86

$120.92

$56.50

$130.38

$99.58

$173.37

*Total premium includes the Plan selected and any applicable rider premium. Premiums are subject to increase with notice. The premium and amount of benefits vary dependent upon the Plan selected at time of application.

17 APSB-22354(TX) MGM/FBS City of Stephenville

MEDlink® IV Enhanced

Limited Benefit Group Medical Expense Supplemental Insurance

Important Policy Provisions Eligibility

You are eligible to be covered under this Policy/Certificate if you are Actively At Work, qualify for coverage as defined in the Master Application, are covered under your Employer’s Medical Plan and are under age 70 (if you work for an employer employing less than 20 employees). Your Eligible Dependents, as defined in the Policy/Certificate, are eligible for coverage if they are covered under the Employer’s Medical Plan. You must apply for insurance during the Initial Enrollment period or on the date the person first becomes eligible for coverage. If you do not apply during the Initial Enrollment period or on the date you become eligible for coverage, you may be subject to additional underwriting by APL. Evidence of coverage under your Employer’s Medical Plan is required.

When Coverage Begins

Coverage will begin on the requested Certificate Effective Date or the Certificate Effective Date assigned by us, upon approval of your application, if our underwriting rules are met, the premium has been paid and all persons to be insured are covered under your Employer’s Medical Plan and you are Actively At Work on the Certificate Effective Date. If you are not Actively At Work on the Certificate Effective Date due to disability, Injury, Sickness, temporary layoff, leave of absence or Family and Medical Leave of Absence, coverage begins on the date you return to Actively At Work.

Limitations & Exclusions No benefits will be payable for expenses incurred during any period the Covered Person does not have coverage under your Employer’s Medical Plan, except as provided in the Absence of the Insured’s Employer’s Medical Plan provision, described in the Policy. A hospital is not an institution, or part thereof, used as: a place for rehabilitation, a place for rest or for the aged, a nursing or convalescent home, a long term nursing unit or geriatrics ward, or an extended care facility for the care of convalescent, rehabilitative or ambulatory patients.

Pre-Existing Condition Limitation

No benefits are payable during the Pre-Existing Condition Exclusion Period following the Covered Person’s Effective Date for any loss resulting from a Pre-Existing Condition. The Pre-Existing Condition Limitation will apply only if the Covered Person is subject to a Pre-Existing Condition Limitation under the Employer’s Medical Plan. Therefore, any Pre-Existing Condition Limitation applied to the Major Medical plan would, in effect, limit coverage under this plan.

Exclusions

No benefits are payable for any loss resulting from or caused, whether directly or indirectly, by: s war or any act of war, whether declared or undeclared, or active service in the armed forces; (This exclusion includes Accident sustained or Sickness contracted while in the service of any military, naval or air force of any country engaged in war. If coverage is suspended for any Covered Person during a period of military service, APL will refund the pro-rata portion of any premium paid for any such Covered Person upon receipt of your written request) s an intentionally self-inflicted Injury or Sickness; s suicide or attempted suicide, while sane or insane; s rest care or rehabilitative care and treatment; s outpatient routine newborn care; s voluntary abortion except, with respect to you or your covered Eligible Dependent spouse: s where you or your Dependent spouse’s life would be endangered if the fetus were carried to term; or s where medical complications have arisen from abortion; s pregnancy of an Eligible Dependent child;

s participating in a riot, insurrection, rebellion, civil commotion, civil disobedience or unlawful assembly; (This does not include a loss which occurs while acting in a lawful manner within the scope of authority.) s committing, or attempting to commit, an illegal act that is defined as a felony; (Felony is as defined by the law of the jurisdiction in which the act takes place.) s participation in a contest of speed in power driven vehicles, parachuting or hang gliding; s air travel, except: s as a fare-paying passenger on a commercial airline on a regularly scheduled route; or s as a passenger for transportation only and not as a pilot or crew member; s being intoxicated or under the influence of any narcotic unless administered by a Physician or taken according to the Physician’s instructions; (Intoxication means that which is determined and defined by the laws and jurisdiction of the geographical area in which the event that caused the loss occurred.) s alcoholism or drug addiction; s sex changes; s experimental treatment, drugs or surgery; s Accident or Sickness arising out of, and in the course of, any occupation for compensation, wage or profit; (This does not apply to those sole proprietors or partners not covered by Workers’ Compensation.) s dental or vision services, including treatment, surgery, extractions or x-rays, unless: s resulting from an Accident occurring while the Covered Person’s coverage is in force and if performed within 12 months of the date of such Accident; or s due to congenital disease or anomaly of a covered newborn child. s routine examinations, such as health exams, periodic check-ups or routine physicals, except when part of Inpatient routine newborn care; s elective cosmetic surgery; s drugs (prescription and non-prescription for use outside of a covered facility as defined in this Policy/Certificate or any attached rider); s sterilization and reversal of sterilization; s an expense that does not meet the definition of Covered Charges; s an expense or service that exceeds any of the Maximum Benefits, as shown in the Schedule of Benefits; or s any expense for which benefits are not payable under your Other Medical Plan.

Premium Changes

The premium rates may be changed by APL at the first anniversary date of this Policy or any premium due date thereafter. No such increase in rates will be made unless 60 days prior notice is given to the Policyholder. Premiums will not increase during the initial 12 months of coverage.

Optionally Renewable

This Policy is renewable at the option of APL. The Policyholder or APL may terminate this Policy on any premium due date after the first anniversary following the Policy Effective Date, subject to 60 days written notice.

Termination of Certificate

Your insurance coverage under this Certificate and any attached riders will end on the earliest of these dates: s the date the Policy terminates; s the end of the grace period if the premium remains unpaid; s the date you no longer qualify as an Insured; s the date you attain age 70 (if you work for an employer employing less than 20 employees); s the date your coverage under your Employer’s Medical Plan ends; or s the date of your death.

MEDlink® IV Enhanced

Limited Benefit Group Medical Expense Supplemental Insurance Termination of Coverage

Your insurance coverage under this 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 Certificate Month in which APL receives a written request from you to terminate the Covered Person’s coverage; s the date a Covered Person no longer qualifies as an Insured or Eligible Dependent; or s the date of the Covered Person’s death. APL may end the coverage of any Covered Person who submits a fraudulent claim.

Cobra Continuation of Coverage

This plan may be continued in accordance with the Consolidated Omnibus Reconciliation Act of 1986.

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 certificate/policy and riders. This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. | This policy is considered an employee welfare benefit plan established and/or maintained by an association or employer intended to be covered by ERISA, and will be administered and enforced under ERISA. Group policies issued to governmental entities and municipalities may be exempt from ERISA guidelines. | Policy Form MEDlink® Series | Texas | Limited Benefit Group Medical Expense Supplemental Insurance | 19 (10/14) | City of Stephenville

APSB-22354(TX) MGM/FBS City of Stephenville

AMERICAN PUBLIC LIFE YOUR BENEFITS

Accident

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About this Benefit

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

of disabling injuries suffered by American workers are not work American workers 36% ofreport they always or usually live paycheck to paycheck.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details 20 on covered expenses, limitations and exclusions are included in the summary plan description located on the City of Stephenville Benefits Website: www.mybenefitshub.com/cityofstephenville

A-3 Supplemental Limited Benefit Accident Expense Insurance City of Stephenville

AMERICAN PUBLIC LIFE YOUR BENEFITS

Accident

Summary of Benefits* Benefit Description

Level 2 - 2 Unit

Accidental Death - per unit

$10,000

Medical Expense Accidental Injury Benefit - per unit

actual charges up to $1,000

Daily Hospital Confinement Benefit

$150 per day

Air and Ground Ambulance Benefit Accidental Dismemberment Benefit Single finger or toe Multiple fingers or toes Single hand, arm, foot or leg Multiple hands, arms, feet or legs

actual charges up to $2,500 $1,000 $1,000 $5,000 $10,000

Accidental Loss of Sight Benefit - per unit Loss of Sight in one eye Loss of Sight in both eyes

$5,000 $10,000

Optional Benefit Riders Gunshot Wound Benefit Rider

once per 24 hours $1,000 benefit

(Primary Insured Only/Public Safety Personnel Only)

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

DID YOU KNOW?

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

American workers 36% ofreport they always or

Level 2 - 2 Unit

Individual

Individual & Spouse

1 Parent Family

2 Parent Family

$17.10

$29.80

$34.90

$47.60

Optional Benefit Riders Gunshot Wound Benefit Rider Monthly Premium

Benefit per 24 Hour Period

$1.00

$1,000

usually live paycheck to paycheck.

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

*The premium and amount of benefits vary dependent upon the Plan selected at time of application. Premiums are subject to increase with notice. 21

APSB-22329(TX)-MGM/FBS City of Stephenville

A-3 Supplemental Limited Benefit Accident Expense Insurance Eligibility

Gunshot Wound Benefit Rider Only

This policy will be issued to only those persons who meet American Public Life Insurance Company’s insurability requirements. Persons not meeting APL’s insurability requirements will be excluded from coverage by an endorsement attached to the policy.

This Rider does not pay benefits for: any non-fatal Gunshot Wound received in a non - occupational related shooting; or, non - fatal Gunshot Wounds received while on active duty in the armed services (the company will return any premium paid past the time of entry into the armed forces when notice is received).

Base Policy and Optional Benefits No benefits are payable for a pre-existing condition. Pre-existing condition means an Injury that pertains solely to an Accidental Bodily Injury which resulted from an accident sustained before the Effective Date of coverage. Pre-Existing Conditions specifically named or described as permanently excluded in any part of this contract are never covered.

This Rider does not pay benefits for self-inflected Gunshot Wound.

A Hospital is not an institution which is primarily a place for alcoholics or drug addicts; the aged; a nursing, rest or convalescent nursing home; a mental institution or sanitarium; a facility contracted for or operated by the United States Government for treatment of members or ex-members of the armed forces (unless You are legally required to pay for services rendered in the absence of insurance); or, a long-term nursing unit or geriatrics ward.

Gunshot Wound Benefit Rider is only available through payroll deduction.

Medical Expense Accidental Injury Benefit

Benefits otherwise provided by this Policy will not be payable for services or expenses or any such Loss resulting from or in connection with:

Expenses must commence within 60 days of the covered accident. The maximum benefit amount payable for any one accident for the Insured Person shall not exceed the Medical Expense Benefit.

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

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

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

This Rider is subject to all the Provisions, Conditions, Limitations and Exclusions of the Policy to which it is attached, which are not in conflict with those of the Rider.

The Gunshot Wound Benefit Rider is guaranteed renewable to age 65 or age 70, if actively at work. While this Rider is in effect, premiums are due according to the terms of the Policy. We reserve the right to change premium rates by class.

Exclusions

(1) (2) (3) (4) (5) (6)

(7) (8)

Accidental Dismemberment Benefit The total amount payable for all Losses resulting from the same accident will not exceed the Maximum Dismemberment Benefit of $5,000 cumulative per unit, per Accident. Loss must be within 90 days of the accident causing such Injury.

(9) (10)

sickness, illness or bodily infirmity; suicide, attempted suicide or intentional self-inflicted Injury, whether sane or insane; dental care or treatment unless due to accidental Injury to natural teeth; war or any act of war (whether declared or undeclared) or participating in a riot or felony; alcoholism or drug addiction; travel or flight in or descent from any aircraft or device which can fly above the earth’s surface in any capacity other than as a fare paying passenger on a regularly scheduled airline; Injury originating prior to the effective date of the Policy; Injury occurring while intoxicated (Intoxication means that which is determined and defined by the laws and jurisdiction of the geographical area in which the loss or cause of loss is incurred.); Voluntary inhalation of gas or fumes or taking of poison or asphyxiation; Voluntary ingestion or injection of any drug, narcotic or sedative, unless administered on the advice and taken in such doses as prescribed by a Physician;

A-3 Supplemental Limited Benefit Accident Expense Insurance (11)

(12) (13) (14)

(15)

(16)

Injury sustained or sickness which first manifests itself while on full-time duty in the armed forces; (Upon notice, We will refund the proportion of unearned premium while in such forces.) Injury incurred while engaging in an illegal occupation; Injury incurred while attempting to commit a felony or an assault; Injury to a covered person while practicing for or being a part of organized or competitive rodeo, sky diving, hang gliding, parachuting or scuba diving; driving in any race or speed test or while testing an automobile or any vehicle on any racetrack or speedway; hernia, carpal tunnel syndrome or any complication therefrom;

If You are entitled to benefits under this Policy as a result of sprained or lame back, or any intervertebral disk conditions, such benefits shall be payable for a maximum period of time, not exceeding in the aggregate three (3) months for any Injury.

Guaranteed Renewable You have the right to renew this Policy until the first premium due date on or after Your 69th birthday, if you pay the correct premium when due or within the Grace Period. When an Insured’s coverage terminates at age 70, coverage for other Insured Persons, if any, shall continue under this Policy. We have the right to change premium rates by class.

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

Underwritten by American Life Insurance Company. This is a brief description of the coverage. For complete benefits, limitations, exclusions and other provisions, please refer to the certificate/policy and riders. This coverage does not replace Workers’ Compensation Insurance. | This product is inappropriate for people who are eligible for Medicaid coverage. | Policy Form A3 Series | Texas | Supplemental Limited Benefit Accident Expense Insurance Policy | (10/14) | City of Stephenville

APSB-22329(TX)-MGM/FBS City of Stephenville

A-3 Supplemental Limited Benefit Accident Expense Insurance Eligibility

Gunshot Wound Benefit Rider Only

This Rider does not pay benefits for self-inflected Gunshot Wound.

Gunshot Wound Benefit Rider is only available through payroll deduction.

Medical Expense Accidental Injury Benefit

Benefits otherwise provided by this Policy will not be payable for services or expenses or any such Loss resulting from or in connection with:

Expenses must commence within 60 days of the covered accident. The maximum benefit amount payable for any one accident for the Insured Person shall not exceed the Medical Expense Benefit.

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

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

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

This Rider is subject to all the Provisions, Conditions, Limitations and Exclusions of the Policy to which it is attached, which are not in conflict with those of the Rider.

Exclusions

(1) (2) (3) (4) (5) (6)

(7) (8)

(9) (10)

A-3 Supplemental Limited Benefit Accident Expense Insurance (11)

(12) (13) (14)

(15)

(16)

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

APSB-22329(TX)-MGM/FBS City of Stephenville

DELTA DENTAL

Dental

YOUR BENEFITS PACKAGE

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

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

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

Dental PPO Monthly Rates

After Employer Contribution

EE Only EE + Spouse EE + Child(ren) EE, Sp + Children

$0 $30.60 $39.52 $72.92

Eligibility

Primary enrollee, spouse and eligible dependent children to age 26.

Deductibles

$50 per person / $150 per family each calendar year.

Maximums

$1,000 per person each calendar year.

Waiting Period(s)

Basic Benefits—0 Months Major Benefits—0 Months Orthodontics—0 Months Other Services: 0 months

Benefits and Covered Services* Diagnostic & Preventive Services (D & P) Exams, cleanings, x-rays, sealants Enhanced pregnancy benefit

Basic Services Fillings, denture repair and sealants

Endodontics Root canals

Oral Surgery Periodontics Gum treatment

PPO Dentists1,2

Non-Delta Dental Dentists 1,2,3

100%

Your deductible does not apply to D&P. D&P does not count towards your maximum 80%

80%

50%

Major Services Crowns, inlays, onlays and cast restorations

Prosthodontics Bridges, dentures, implants

Orthodontic Maximums

50%

For dependent children Lifetime maximum per person 1. 2. 3.

$1,000

Delta Dental Premier® dentists are considered out-of-network dentists. Reimbursement is based on the PPO contracted fee for PPO dentists, Premier contracted fee for Premier desists, program allowance for non -Delta Dental dentists Non-Delta Dental dentists may balance bill the difference between the contracted rate and their usual fee for services.

Delta Dental Insurance Company 1130 Sanctuary Parkway, Suite 600 Alpharetta, GA 30009

Customer Service 800-521-2651

Claims Address P.O. Box 1809 Alpharetta, GA 30023-1809

www.deltadentalins.com 25

Dental PPO However, 3D x-rays are not a covered benefit. (8) Application of Sealants as a Benefit is limited to dependents up to age 16 Dental Services described in this section are covered when such through the completion of the procedure or the date eligibility terminates, services are: whichever occurs first. Treatment with Sealants as a covered service is limited to application to 1st and 2nd permanent molars. 1. Necessary; Applications to deciduous teeth or teeth with caries are not covered services. 2. Provided by or under the direction of a Dentist or other Sealants will be replaced only after 2 years have appropriate provider as specifically described; elapsed following any prior provision of such materials. 3. The least costly, clinically accepted treatment, and (9) Specialist Consultations, screenings of patients, and assessments of patients 4. Not excluded as described in the Section entitled. General are limited to once per lifetime per Provider and count toward the oral exam Exclusions. frequency. (10) Delta Dental will not cover replacement of an amalgam or resin-based composite restorations (fillings) or prefabricated crowns within 24 months of treatment if the service is provided by the same (1) Services that are more expensive than the form of treatment customarily Provider/Provider office. Replacement restorations within 24 months are provided under accepted dental practice standards are called “Optional included in the fee for the original restoration. Services”. Optional Services also include the use of specialized techniques (11) Protective restorations (sedative fillings) are allowed once per tooth per instead of standard procedures. lifetime when definitive treatment is not performed on the same date of service. Examples of Optional Services: a) a composite restoration instead of an (12) Prefabricated crowns are allowed on baby (deciduous) teeth and amalgam restoration on posterior teeth; b) a crown where a filling would permanent teeth up to age 16. restore the tooth; c) an inlay/onlay instead of an amalgam restoration; d) (13) Therapeutic pulpotomy is limited to once per lifetime for baby (deciduous) porcelain, resin or similar materials for crowns placed on a maxillary second or teeth only and is considered palliative treatment for permanent teeth. third molar, or on any mandibular molar (an allowance will be made for a (14) Root canal therapy and pulpal therapy (resorbable filling) are limited to porcelain fused to high noble metal crown); or e) an overdenture instead of once in a lifetime. Retreatment of root canal therapy by the same Provider/ denture. Provider office within 24 months is considered part of the original procedure. If an Enrollee receives Optional Services, an alternate Benefit will be allowed, (15) Apexification is only benefited on permanent teeth with incomplete root which means Delta Dental will base Benefits on the lower cost of the customary canal development or for the repair of a perforation. Apexification visits have a service or standard practice instead of on the higher cost of the Optional lifetime limit per tooth of one (1) initial visit, four (4) interim visits and one (1) Service. The Enrollee will be responsible for the difference between the final visit to age 19. higher cost of the Optional Service and the lower cost of the customary service (16) Retreatment of apical surgery by the same Provider/Provider office within or standard procedure. 24 months is considered part of the original procedure. (2) Exam and cleaning limitations a) Delta Dental will pay for oral examinations (17) Palliative treatment is covered per visit, not per tooth, and the fee includes (except after-hours exams and exams for observation) and cleanings (including all treatment provided other than required x-rays or select Diagnostic periodontal cleanings in the presence of inflamed gums or any combination procedures. thereof) no more than twice in a Calendar Year. b) A full mouth debridement is (18) Periodontal limitations: a) Benefits for periodontal scaling and root planing allowed once in a lifetime and counts toward the cleaning frequency in the year in the same quadrant are limited to once in every 24-month period. See note on provided. c) Note that periodontal cleanings, Procedure Codes that include additional Benefits during pregnancy. b) Periodontal surgery in the same periodontal cleanings and full mouth debridement are covered as a Basic quadrant is limited to once in every 36-month period and includes any surgical Benefit, and routine cleanings are covered as a Diagnostic and re-entry or scaling and root planing. c) Periodontal services, including bone Preventive Benefit. See note on additional Benefits during pregnancy. d) Caries replacement grafts, guided tissue regeneration, graft procedures and biological risk assessments are allowed once in 36 months for Enrollees age three (3) to materials to aid in soft and osseous tissue regeneration are only covered for the 19. treatment of natural teeth and are not covered when submitted in conjunction (3) X-ray limitations: a) Delta Dental will limit the total reimbursable amount to with extractions, periradicular surgery, ridge augmentation or implants. d) the Provider’s Accepted Fee for a complete intraoral series when the fees for Periodontal surgery is subject to a 30 day wait following periodontal scaling and any combination of intraoral x-rays in a single treatment series meet or exceed root planning in the same quadrant. e) Cleanings (regular and periodontal) and the Accepted Fee for a complete intraoral series. b) When a panoramic film is full mouth debridement are subject to a 30 day wait following periodontal submitted with supplemental film(s), Delta Dental will limit the total scaling and root planing if performed by the same Provider office. reimbursable amount to the Provider’s Accepted Fee for a complete intraoral (19) Oral Surgery services are covered once in a lifetime except removal of cysts series. c) If a panoramic film is taken in conjunction with an intraoral complete and lesions and incision and drainage procedures, which are covered once in the series, Delta Dental considers the panoramic film to be included in the complete same day. series. d) A complete intraoral series and panoramic film are each limited to (20) The following Oral Surgery procedure is limited to age 19 or orthodontic once every 60 months. e) Bitewing x-rays are limited to two (2) times in a limiting age: transseptal fiberotomy/supra crestal fiberotomy, by report. Calendar Year when provided to Enrollees under age 18 and one (1) time each (21) The following Oral Surgery procedures are limited to age 19 (or orthodontic Calendar Year for Enrollees age 18 and over. Bitewings of any type are limiting age) provided Orthodontic Services are covered: surgical access of an disallowed within 12 months of a full mouth series unless warranted by special unerupted tooth, placement of device to facilitate eruption of impacted tooth, circumstances. (4) Topical application of fluoride solutions is limited to Enrollees and surgical repositioning of teeth. to age 19 and no more than twice in a Calendar Year. (22) Crowns and Inlays/Onlays are limited to Enrollees age 12 and older and are (5) Space maintainer limitations: a) Space maintainers are limited to the initial covered not more often than once in any 60 month period except when Delta appliance and are a Benefit for an Enrollee to age 14. b) Recementation of space Dental determines the existing Crown or Inlay/Onlay is not satisfactory and maintainer is limited to once per lifetime. c) The removal of a fixed space cannot be made satisfactory because the tooth involved has experienced maintainer is considered to be included in the fee for the space maintainer; extensive loss or changes to tooth structure or supporting tissues. however, an exception is made if the removal is performed by a different (23) Core buildup, including any pins, are covered not more than once in any 60 Provider/Provider’s office. month period. (6) Pulp vitality tests are allowed once per day when definitive treatment is not (24) Post and core services are covered not more than once in any 60 month performed. period. (7) Cephalometric x-rays, oral/facial photographic images and diagnostic casts (25) Crown repairs are covered not more than twice in any 60 month period. are covered once per lifetime only when Orthodontic Services are covered. If (26) Denture Repairs are covered not more than once in any six (6) month Orthodontic Services are covered, see Limitations as age limits may apply.

Delta Dental Exclusions and Limitations

General Limitations

Dental PPO period except for fixed Denture Repairs which are covered not more than twice in any 60 month period. (27) Prosthodontic appliances, implants and/or implant supported prosthetics that were provided under any Delta Dental program will be replaced only after 60 months have passed, except when Delta Dental determines that there is such extensive loss of remaining teeth or change in supporting tissue that the existing fixed bridge or denture cannot be made satisfactory. Fixed prosthodontic appliances are limited to Enrollees age 16 and older. Replacement of a prosthodontic appliance and/or implant supported prosthesis not provided under a Delta Dental program will be made if Delta Dental determines it is unsatisfactory and cannot be made satisfactory. Diagnostic and treatment facilitating aids for implants are considered a part of, and included in, the fees for the definitive treatment. Delta Dental’s payment for implant removal is limited to one (1) for each implant during the Enrollee’s lifetime whether provided under Delta Dental or any other dental care plan. (28) When a posterior fixed bridge and a removable partial denture are placed in the same arch in the same treatment episode, only the partial denture will be a Benefit. (29) Recementation of Crowns, Inlays/Onlays or bridges is included in the fee for the Crown, Inlay/Onlay or bridge when performed by the same Provider/ Provider office within six (6) months of the initial placement. After six (6) months, payment will be limited to one (1) recementation in a lifetime by the same Provider/Provider office. (30) Delta Dental limits payment for dentures to a standard partial or complete denture (Enrollee Coinsurances apply). A standard denture means a removable appliance to replace missing natural, permanent teeth that is made from acceptable materials by conventional means and includes routine post delivery care including any adjustments and relines for the first six (6) months after placement. a) Denture rebase is limited to one (1) per arch in a 24-month period and includes any relining and adjustments for six (6) months following placement. b) Dentures, removable partial dentures and relines include adjustments for six (6) months following installation. After the initial six (6) months of an adjustment or reline, adjustments are limited to two (2) per arch in a Calendar Year and relining is limited to one (1) per arch in a six (6) month period. c) Tissue conditioning is limited to two (2) per arch in a 12-month period. However, tissue conditioning is not allowed as a separate Benefit when performed on the same day as a denture, reline or rebase service. d) Recementation of fixed partial dentures is limited to once in a lifetime. (31) Limitations on Orthodontic Services: a) The maximum amount payable for each Enrollee. b) Benefits for Orthodontic Services will be provided in monthly payments based on the Enrollee’s continuing eligibility. c) Benefits are not paid to repair or replace any orthodontic appliance received under this plan. d) Benefits are not paid for orthodontic retreatment procedures. e) Benefits for Orthodontic Services are limited to dependent child Enrollees under age 26.

partial denture to replace extracted anterior permanent teeth during the healing period for children 16 years of age or under). Provisional and/or temporary restorations are not separately payable procedures and are included in the fee for completed service. (5) services for congenital (hereditary) or developmental (following birth) malformations, including but not limited to cleft palate, upper and lower jaw malformations, enamel hypoplasia (lack of development), fluorosis (a type of discoloration of the teeth) and anodontia (congenitally missing teeth), except those services provided to newborn children for medically diagnosed congenital defects or birth abnormalities. (6) treatment to stabilize teeth, treatment to restore tooth structure lost from wear, erosion, or abrasion or treatment to rebuild or maintain chewing surfaces due to teeth out of alignment or occlusion. Examples include but are not limited to: equilibration, periodontal splinting, complete occlusal adjustments or Night Guards/Occlusal guards and abfraction. (7) any Single Procedure provided prior to the date the Enrollee became eligible for services under this plan. (8) prescribed drugs, medication, pain killers, antimicrobial agents, or experimental/investigational procedures. (9) charges for anesthesia, other than General Anesthesia and IV Sedation administered by a Provider in connection with covered Oral Surgery or selected Endodontic and Periodontal surgical procedures. Local anesthesia and regional/or trigeminal bloc anesthesia are not separately payable procedures. (10) extraoral grafts (grafting of tissues from outside the mouth to oral tissues). (11) laboratory processed crowns for Enrollees under age 12. (12) fixed bridges and removable partials for Enrollees under age 16. (13) interim implants and endodontic endosseous implant. (14) indirectly fabricated resin-based Inlays/Onlays. (15) charges by any hospital or other surgical or treatment facility and any additional fees charged by the Provider for treatment in any such facility. (16) treatment by someone other than a Provider or a person who by law may work under a Provider’s direct supervision. (17) charges incurred for oral hygiene instruction, a plaque control program, preventive control programs including home care times, dietary instruction, xray duplications, cancer screening, tobacco counseling or broken appointments. (18) dental practice administrative services including, but not limited to, preparation of claims, any nontreatment phase of dentistry such as provision of an antiseptic environment, sterilization of equipment or infection control, or any ancillary materials used during the routine course of providing treatment such as cotton swabs, gauze, bibs, masks or relaxation techniques such as music. (19) procedures having a questionable prognosis based on a dental Delta Dental does not pay Benefits for: consultant’s professional review of the submitted documentation. (1) treatment of injuries or illness covered by workers’ compensation or (20) any tax imposed (or incurred) by a government, state or other entity, in employers’ liability laws; services received without cost from any federal, state connection with any fees charged for Benefits provided under the Contract, or local agency, except for services covered by the will be the responsibility of the Enrollee and not a Medical Assistance Act of 1967, as amended (Article 695j, Vernon’s Texas Civil covered Benefit. Statutes). Delta Dental will reimburse the Texas Department of Human (21) Deductibles, amounts over plan maximums and/or any service not Services for the cost of services paid by the covered under the dental plan. Department under said Act to the extent such costs are for services which are (22) services covered under the dental plan but exceed Benefit limitations or Benefits under this Contract. If the Texas Department of Human Services is are not in accordance with paying benefits pursuant to Chapters 31 and 32 of the Human Services Code processing policies in effect at the time the claim is processed. (financial and medical assistance programs administered pursuant to the (23) services for Orthodontic treatment (treatment of malocclusion of teeth Human Services code) and a parent who is covered by the group policy has and/or jaws) except as provided under the Orthodontic Services section, if possession or access to a applicable. child pursuant to a court order, or is entitled to access or possession of a child (24) services for any disturbance of the Temporomandibular (jaw) Joints (TMJ) and is required by the court to pay child support, then all benefits paid on or associated musculature, nerves and other tissues) except as provided under behalf of the child or children must be paid to the the TMJ Benefit section, if applicable. Texas Department of Human Services. (25) missed and/or cancelled appointments. (2) cosmetic surgery or procedures for purely cosmetic reasons. (3) maxillofacial prosthetics. (4) provisional and/or temporary restorations (except an interim removable

General Exclusions

UNITEDHEALTHCARE YOUR BENEFITS PACKAGE

Vision

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

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

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

Vision Monthly Premiums EE Only EE + Spouse EE + Family

$7.27 $12.36 $18.19

Co-Pays for In-Network Services Exam Materials

$10 $25

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

Once every 12 months Once every 12 months Once every 24 months Once every 12 months

Frame Benefit Private Practice Provider $130.00 retail frame allowance Retail Chain Provider $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. 1Coverage

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—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



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.

AMERICAN PUBLIC LIFE

Short Term Disability

YOUR BENEFITS

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About this Benefit Disability insurance protects one of your most valuable assets, your ability to earn a living. This insurance will replace a portion of your income in the event that you become physically unable to work. Short term disability coverage provides benefits when you are unable to work for a short period of time due to a covered sickness or injury.

60% of Americans do not have a â&#x20AC;&#x153;rainy dayâ&#x20AC;? fund to cover three months of unanticipated financial

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 30 on covered expenses, limitations and exclusions are included in the summary plan description located on the City of Stephenville Benefits Website: www.mybenefitshub.com/cityofstephenville

GDIS11APL Group Short-Term Disability Income Insurance City of Stephenville

SUMMARY OF BENEFITS FOR CITY OF STEPHENVILLE Plan: Standard Industry Non-Takeover: No consideration will be given to prior group disability income coverage in determining the effect of Pre-Existing Conditions on benefits payable. Eligibility: All active, permanent employees or members and employees of members on Active Employment working 20 hours or more per week who have satisfied the employer’s waiting period for Eligibility, which shall be no less than 90 days from date of hire. Evidence of insurability acceptable by APL may be required. Age at Entry: Premiums are based on age at entry and do not increase solely with attained age. Pre-Existing Condition Limitation: No Disability Benefit is payable if Disability is caused by or resulting from a Pre-Existing Condition and begins before you have been continuously covered under the policy for 12 months. This provision will not apply if you have gone treatment free, incurred no expense, taken no medication and received no diagnosis or advice from a Physician for 12 consecutive months after the Effective Date of coverage for such condition(s). This limitation will not apply to a Disability resulting from a Pre-Existing Condition that begins after you have been continuously covered under the policy for 12 months. Any increase in benefits will be subject to this Pre-Existing Condition Limitation. A new Pre-Existing Condition period must be satisfied with respect to any increase applied for and approved by APL.

GROUP SHORT-TERM DISABILITY PREMIUMS* Monthly Premium per $100 of Covered Monthly Benefit Option I

Elimination Period: 14 Days injury 14 Days sickness

Benefit Period: 180 Days

Ages 18-39

Ages 40-49

Ages 50-59

Ages 60+

$2.16

$2.34

$2.70

$3.40

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

Policy Benefits

Disability Payments are payable when you are Disabled due to a covered Injury or Sickness while coverage is in force. Disability Payments will be provided for each period you remain Disabled due to a covered Disability and under the Regular and Appropriate Care of a Physician, which continues beyond the Elimination Period. Disability Payments will be provided for only one Disability when more than one Disability exists at the same time or a Disability results from two or more causes. Disability will be considered to have begun on the date you were seen and treated by a Physician following continuous cessation of work.

Survivor Benefit

Upon notification of your death, we will pay your eligible survivor(s) a lump sum benefit equal to two times your Disability Payment, for which you were eligible for during the calendar month preceding death, if on the date of your death your Disability continued for 90 or more consecutive days and you were receiving or were entitled to receive Disability Payments under the Policy. If you have no eligible survivor(s), no payment will be made.

Accelerated Survivor Benefit

You may elect to receive the Survivor Benefit prior to your death if you have a Terminal Illness and you are receiving Disability Payments. You may elect the Accelerated Survivor Benefit only once during your lifetime. If you elect to receive the Accelerated Survivor Benefit prior to death, no Survivor Benefit will be paid upon your death.

Accidental Death Benefit

The Accidental Death Benefit of $10,000 will be paid if you die as the direct result of an Injury and death occurs within 90 days after the date of the Injury. If you die and the Accidental Death Benefit applies, such benefit will be increased 1% for each full month that your Certificate was continuously in force just prior to death. The total increase shall not be more than 60%.

Waiver of Premium Benefit (not available for 90 Day Plan)

If you become Disabled due to a covered Injury or Sickness and are eligible to receive a Disability Payment, your insurance will be continued without payment of premium. Waiver of Premium will begin the first of the month following your satisfaction of the Elimination Period or 90 days of continuous Disability, whichever is later, provided premium has been paid from the beginning of Disability to the date Waiver of Premium begins. Waiver of Premium will continue until the a) end of your Disability, b) end of the Maximum Benefit Period, c) date you are no longer eligible to receive a Disability Payment, d) date the Policy terminates or e) date your employment with the Policyholder or subscribing Employer unit ends, whichever first occurs. We will require proof on an annual basis that you remain Disabled during said period.

Mental Illness Limited Benefit

If you become Disabled due to Mental Illness, Disability Payments will be paid up to the following: 90 Day Plan - 3 Months; 180 Day Plan - 3 Months; 1 Year Plan - 6 Months; 2 Year Plan - 1 Year provided you are under the Regular and Appropriate Care of a Physician, and receive medical treatment from either: a registered specialist in psychiatry; a Physician administering treatment on the advice of a registered specialist in psychiatry who certifies that such treatment is medically necessary; or a Physician, if in Our opinion, a specialist in psychiatry is not required to certify that such treatment is medically necessary.

Alcohol and Drug Addiction Limited Benefit

If you are Disabled due to alcoholism or drug addiction, a limited benefit of up to 15 days for each Disability will be paid. In no event will benefits be paid beyond the Maximum Disability Period shown in the Policy Schedule of Benefits. If drug addiction is sustained at the hands of, or while under the Regular and Appropriate Care of a Physician in the course of treatment for Injury or Sickness, it will be covered the same as any other illness.

APSB-22336(TX)- City of Stephenville

GDIS11APL Group Short-Term Disability Income Insurance Special Conditions Limited Benefit (2 Year Plan Only)

If you are disabled due to a Special Condition and you are under the Regular and Appropriate Care of a Physician, Disability Payments will be provided for one year, not to exceed the Maximum Disability Period. Special Conditions means Chronic Fatigue Syndrome; Fibromyalgia; Environmental allergic illness; Self-Reported Symptoms; any disease, disorder, accident or injury of the neck or back not resulting in hemiplegia, paraplegia or quadriplegia. See your Policy for more specific information.

Disabled and Not Working Benefit

Your Disability Payment will be the lesser of the Disability Benefit described in the Policy Schedule of Benefits or 60% of your Monthly Compensation less any Deductible Sources of Income you receive or are entitled to receive.

Disabled and Working Benefit

American Public Life will provide a Disability Payment if you are Disabled and your monthly Disability Earnings, if any, are less than 20% of your Monthly Compensation due to the same Injury or Sickness. If you are Disabled and your Disability Earnings are greater than 20% of your Monthly Compensation due to the same Injury or Sickness, we will figure your payment as follows: your Disability Payment will not be reduced as long as the Disability Earnings plus the gross Disability Benefit does not exceed 100% of your Monthly Compensation. If the Disability Earnings plus the gross Disability Benefit exceeds 100% of your Monthly Compensation, the Disability Payment will be reduced by the amount exceeding your Monthly Compensation. We will stop payments and your claim will end, if at any time you are no longer Disabled or if your Disability Earnings exceed 80% of your Monthly Compensation. The Elimination Period cannot be satisfied with days you are Disabled and working.

Successive Disabilities

Disabilities which result from the same or related causes for which benefits are payable will be considered one period of Disability unless the Disabilities are separated by your return to Active Employment or any other gainful occupation for at least three consecutive months. A Disability due to a different or unrelated cause will be considered a new period of Disability.

Important Policy Provisions When Coverage Begins

Coverage or changes in coverage including increases will begin on the later of the requested Effective Date or the date we approve the written application, if you apply in writing on or before said Effective Date, meet our underwriting rules, are on Active Employment and have paid all applicable premiums due. If you are not on Active Employment due to an Injury or Sickness when your coverage would otherwise take effect, coverage will take effect on the first of the month following the date you return to Active Employment for at least five consecutive workdays. Any change in coverage will apply only to a Disability that begins after the Effective Date of such change, subject to all the provisions of the Policy. Increases or changes in coverage will be subject to an additional Pre-Existing Condition Limitation.

Minimum Disability Benefit

The Disability Payment payable will be no less than 10% or $100 of your Monthly Disability Benefit, whichever is greater.

Leave of Absence

Your coverage may be continued for up to one year during a Leave of Absence approved in writing by your employer.

Exclusions

The Policy does not cover any loss, fatal or non-fatal, which results from any of the following:  Intentionally self-inflicted Injury while sane or insane  An act of war, declared or undeclared  Injury sustained or Sickness contracted while in the service of the armed forces of any country  Committing a felony  Penal incarceration. We will not pay benefits for Disability or any other loss during any period for which you are incarcerated in a penal or correctional institution for a period of 30 consecutive days or longer  Injury or Sickness arising out of and in the course of any occupation for wage or profit, or for which you are entitled to Workers’ Compensation.* *The term “entitled to Workers’ Compensation” shall also include Workers’ Compensation claim settlements that occur via compromise and release. Further, no benefits will be paid under this Policy for any period during which you are entitled to Workers’ Compensation benefits.

Termination of Insurance

Your insurance coverage will end on the earliest of these dates:  the date you do not meet the Eligibility requirements as defined in the Eligibility section of this brochure;  the date you retire;  the date you cease to be on Active Employment, except as provided for under the Leave of Absence provision;  the end of the last period for which premium has been paid;  the date the Policy is discontinued; or  the date your employment terminates. If your coverage ends as a result of your termination of Active Employment, such termination is caused by an Injury or Sickness for which Disability Benefits would be payable, and Disability is established prior to the termination of Active Employment, then Disability Benefits will be paid as if such termination had not occurred. Termination of the Policy will have no effect on Disability Payments that began before such termination. American Public Life may end your coverage if you make a fraudulent claim.

Deductible Sources of Income

Deductible Sources of Income will include all of the following:  Other group disability income  Governmental or other retirement system, whether due to disability, normal retirement or voluntary election of retirement benefits  United States Social Security Act or similar plan or act, including any amounts due your dependent(s) on account of your Disability  State Disability  Unemployment compensation  Sick leave or other salary or wage continuance plans provided by the Employer which extend beyond 30 calendar days from the date of Disability.

2305 Lakeland Drive | Flowood, MS 39232 ampublic.com | 800.256.8606 Underwritten by American Life Insurance Company. This brochure highlights important features of the policy. For complete details, please refer to your certificate/policy. Policy provisions and benefits may vary depending on the location of your employer or, where required by law, your state of residence. 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. | Policy Form GDIS11APL Series | Texas | Group Short-Term Disability Income Insurance Policy | (03/15) | MGM/FBS | City of Stephenville 32

APSB-22336(TX)- City of Stephenville

GDIS11APL Group Short-Term Disability Income

UNITEDHEALTHCARE YOUR BENEFITS PACKAGE

Long Term Disability

PLAY VIDEO

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

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

34.6 months is the duration of the average disability claim.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 34 City of Stephenville Benefits Website: www.mybenefitshub.com/cityofstephenville

Long Term Disability Am I eligible? You are eligible if you are an active, full-time employee who works at least 30 hours per week on a regularly scheduled basis. You must choose to elect either the 40% plan or the 60% plan.

How much coverage would I have? 40% Plan—You may purchase coverage that pays you a benefit of 40% of your monthly Earnings to a maximum monthly benefit of $5,000 per month.

What is Long Term Disability Insurance?

60% Plan—You may purchase coverage that pays you a benefit of 60% of your monthly Earnings to a maximum monthly benefit of $5,000 per month.

Long Term Disability Insurance pays you a portion of your Earnings if you cannot work because of a disabling illness or injury. This highlight sheet is an overview of your Long Term Disability Insurance. Once a group policy is issued to your employer, a certificate of coverage will be available to explain your benefits in detail.

These plans include a minimum benefit of the greater of: 10% of the benefit based on Monthly Income Loss before the deduction of Other Income Benefits or $100 per month. Earnings are defined in the UnitedHealthcare contract with your employer.

Why do I need Long Term Disability Insurance? Voluntary Long Term Disability Insurance protects the financial security for you and your family. The ability to earn an income is something to be cherished and protected – disabilities happen, and they happen more frequently than most think. Can you afford to be disabled? Did You Know: 3 in 10 workers will be disabled for more than 90 days before the age of 65. Many American families live paycheck to paycheck, and the majority could not afford to go one month or one week, let alone 2 or 3 years, without the support of regular income. http://www.disabilitycanhappen.org

What is disability? Disability is defined in the UnitedHealthcare contract with your employer. The Covered Person is Disabled or has a Disability when We determine that: 1. You are not Actively at Work and are unable to perform some or all of the Material and Substantial Duties of your Regular Occupation due to your Sickness or Injury; and 2. You have a 20% or more loss in Indexed Pre-Disability Monthly Earnings due solely to the same Sickness or Injury; and 3. You are under the Regular Care of a Physician. Disability must begin while the Covered Person is insured under the Policy. After 24 months of payments, the Covered Person is Disabled when We determine that due to the same Sickness or Injury, you are unable to perform some or all of the material and substantial duties of any Gainful Occupation for which you are reasonably fitted by education, training or experience and you continue to suffer a 40% or more loss in Indexed Pre-Disability Monthly Earnings due solely to the Sickness or Injury.

How long do I have to wait before I can receive payment? (Elimination Period) You must be disabled for at least 90 days before you can receive a Long Term Disability Insurance benefit payment.

Are there other limitations to enrollment? The guaranteed issue amount is the amount of Insurance that you may elect without providing evidence of insurability. If you enroll during this enrollment period, your coverage is provided to you on a guaranteed basis - no medical information is required. If you enroll after this enrollment period, evidence of insurability will be required for all coverage amounts. You must be Actively at Work with your employer on the day your coverage takes effect. This coverage, like most group benefit Insurance, requires that a certain percentage of eligible employees participate. If that group participation minimum is not met, the insurance coverage that you have elected may not be in effect.

How long will my disability payments continue? For as long as you remain disabled, or until you reach your Social Security Normal Retirement Age (as stated in the 1983 revision of the United States Social Security Act.), whichever is sooner. If your disability occurs at age 60 or above, your payments may be reduced.

Long Term Disability Can the duration or amount of my benefit be reduced? Yes. Your benefit duration may be reduced once you reach certain ages specified in the in chart below. Maximum Benefit Period: Reducing Benefit Duration reflecting Social Security Normal Retirement Age Age at Disability Greater of SSNRA * or Less than age 60 Age 60 Age 61 Age 62 Age 63 Age 64 Age 65 Age 66 Age 67 Age 68 69 and over

Maximum Benefit Period To age 65 60 Months 48 Months 42 Months 36 Months 30 Months 24 Months 21 Months 18 Months 15 Months 12 Months

*SSNRA means the Social Security Normal Retirement Age as figured by the 1983 amendment or any later amendment to the Social Security Act. In addition, as described below within the Important Details, your monthly Long Term Disability benefit may be reduced by other income you receive.

Cost by Age Band Age

40% Plan Monthly Rate

60% Plan Monthly Rate

<25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+

$0.090 $0.100 $0.150 $0.220 $0.310 $0.480 $0.630 $0.750 $0.710 $0.710

$0.140 $0.170 $0.250 $0.380 $0.550 $0.800 $1.050 $1.270 $1.130 $1.130

Use the formula below to calculate the cost of coverage: For the 40% Plan To calculate monthly benefits: Annual Earnings รท 12 = monthly earnings x .40 = monthly benefit To calculate monthly cost: monthly earnings x rate รท 100 = monthly cost For the 60% Plan To calculate monthly benefits: Annual Earnings รท 12 = monthly earnings x .60 = monthly benefit To calculate monthly cost: monthly earnings x rate รท 100 = monthly cost 36

Long Term Disability Important Details

Pre-Existing Condition Exclusion

This Benefit Highlights Sheet is an overview of the Long Term Disability Insurance being offered and is provided for illustrative purposes only and is not a contract. It in no way changes or affects the policy as actually issued. Only the insurance policy issued to the policyholder (your employer) can fully describe all of the provisions, terms, conditions, limitations and exclusions of your insurance coverage. In the event of any difference between the Benefit Highlights Sheet and the insurance policy, the terms of the insurance policy apply. Once a group policy is issued to your employer, a certificate of coverage will be available to explain your benefits in detail.

We will not cover any Disability that begins during the first 12 months after the Covered Person’s Effective Date of insurance that is caused or contributed to by a Pre-Existing Condition.

Exclusions You cannot receive Long Term Disability Insurance benefit payments for disabilities that are caused or contributed to by:  War or act of war (declared or not)  The commission of, or attempt to commit a felony  An intentionally self-inflicted injury  Any case where your being engaged in an illegal occupation was a contributing cause to your disability You must be under the regular care of a physician to receive benefits.

Mental Illness, Alcoholism, or Substance Abuse 



You can receive benefit payments for Long Term Disabilities resulting from mental illness, alcoholism and substance abuse for a total of 24 months for all disability periods during your lifetime. Any period of time that you are confined in a hospital or other facility licensed to provide medical care for mental illness, alcoholism and substance abuse does not count toward the 24 months lifetime limit.

Pre-Existing Condition means: any Sickness or Injury including Mental Illness, Substance Abuse for which the Covered Person, within 3 months prior to his Effective Date of insurance:  was diagnosed by or received Treatment from a legally qualified Physician; or  had symptoms for which an ordinarily prudent person would have sought Treatment. Your benefit payments will be reduced by other income you receive or are eligible to receive due to your disability, such as:  Social Security Disability Insurance (please see next section for exceptions)  Workers' Compensation  Other employer-based Insurance coverage you may have  Unemployment benefits  Settlements or judgments for income loss  Retirement benefits that your employer fully or partially pays for (such as a pension plan)  Loss of time or lost wages from a no-fault motor vehicle insurance plan.  Benefits from Employer’s sick leave of salary continuation plan. Your benefit payments will not be reduced by certain kinds of other income, such as:  Retirement benefits if you were already receiving them before you became disabled  Retirement benefits that are funded by your after-tax contributions  Your personal savings, investments, IRAs or Keoghs  Profit-sharing  Most personal disability policies  Social Security increases

UnitedHealthcare Life and Disability products are provided by UnitedHealthcare Insurance Company; Unimerica Insurance Company; and in California by Unimerica Life Insurance Company; and in New York by Unimerica Life Insurance Company of New York. Texas Coverage is provided on Form LASD-POL-TX (05/03), Form UHCLD-POL 2/2008-TX, or UICLD-POL-TX 4/5. UnitedHealthcare Insurance Company is located in Hartford, CT; Unimerica Insurance Company and Unimerica Life Insurance Company in Milwaukee, WI; Unimerica Life Insurance Company of NY in New York, NY. 37

AMERICAN PUBLIC LIFE

Cancer

YOUR BENEFITS

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 38 on covered expenses, limitations and exclusions are included in the summary plan description located on the City of Stephenville Benefits Website: www.mybenefitshub.com/cityofstephenville

GC13 Limited Benefit Group Cancer Indemnity Insurance City of Stephenville

SUMMARY OF BENEFITS Benefits

Option 1

Option 2

Radiation Therapy/Chemotherapy/Immunotherapy Benefit Maximum per 12-month period

$15,000

$20,000

$50 per treatment

Hormone Therapy - Maximum of 12 treatments per Calendar Year Experimental Treatment Benefit

Paid in the same manner and under the same maximums as any other benefit

Waiver of Premium

Waive Premium

Lump Sum Benefit Maximum 1 per Covered Person per lifetime

$5,000

$10,000

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

$7,500

$15,000

Lump Sum Benefit Maximum 1 per Covered Person per lifetime

$5,000

$10,000

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

$7,500

$15,000

Option 1

Option 2

Individual

$13.66

$23.00

Individual & Spouse

$29.48

$49.94

1 Parent Family

$15.70

$26.50

2 Parent Family

$31.52

$53.48

Internal Cancer First Occurrence Benefit

Heart Attack/Stroke First Occurrence Benefit

Monthly Premium*

*The premium and amount of benefits vary dependent upon the option selected at time of application. All benefits are per covered person, per calendar year unless otherwise stated.

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 care or treatment received outside the territorial limits of the United States, treatment by any program engaged in research that does not meet the definition of Experimental Treatment or losses or medical expenses incurred prior to the Covered Person’s Effective Date regardless of when Cancer was diagnosed.

Only Loss for Cancer

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.

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 Pre-Existing 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. 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 PreExisting 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: the date the Policy terminates; the end of the grace period if the premium remains unpaid; the date insurance has ceased on all persons covered under this Certificate; the end of the Certificate Month in which the Policyholder requests to terminate this coverage; the date you no longer qualify as an Insured; or the date of your death.

Termination of Coverage

Insurance coverage for a Covered Person under the Certificate and any attached riders for a Covered Person will end as follows: the date the Policy terminates; the date the Certificate terminates; the end of the grace period if the premium remains unpaid; the end of the Certificate Month in which the Policyholder requests to terminate the coverage for an Eligible Dependent; the date a Covered Person no longer qualifies as an Insured or 39

APSB-22331(TX) MGM/FBS City of Stephenville

GC13 Limited Benefit Group Cancer Indemnity Insurance 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: the Certificate has been continuously in force for the last 12 months; 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; 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.

Heart Attack/Stroke First Occurrence Benefit Rider

Pays a lump sum amount when a Covered Person receives a first diagnosis of Heart Attack/Stroke and the Date of Diagnosis occurs after the Waiting Period. The Heart Attack/Stroke lump sum benefit amount will reduce by 50% at age 70.

Exclusions & Limitations

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

Termination

This rider will terminate and coverage will end for all Covered Persons on the earliest of any of the following: the end of the grace period if the premium for this rider remains unpaid; the date the Policy or Certificate to which this rider is attached terminates; the end of the Certificate Month in which we receive a request from the Policyholder to terminate this rider; the date of your death; or the date the lump sum benefit amount for Heart Attack or Stroke has been paid for all Covered Persons under this rider. Coverage on an Eligible Dependent terminates under this rider when such person ceases to meet the definition of Eligible Dependent.

Internal Cancer First Occurrence Benefit Rider

Pays a lump sum benefit amount when a Covered Person receives a first diagnosis of a covered Internal Cancer and the Date of Diagnosis occurs after the Waiting Period. The Internal Cancer lump sum benefit amount will reduce by 50% at age 70.

Exclusions & Limitations

We will not pay benefits for a diagnosis of Internal Cancer received outside the territorial limits of the United States or a metastasis to a new site of any Cancer diagnosed prior to the Covered Person’s Effective Date, as this is not considered a first diagnosis of an Internal Cancer.

Pre-Existing Condition Exclusion

No benefits are payable for any loss incurred during the Pre-Existing Condition Exclusion Period following the Covered Person’s Effective Date of this rider as the result of a Pre-Existing Condition.

Waiting Period

This rider contains a Waiting Period during which no benefits will be paid. If any Internal Cancer is diagnosed before the end of the Waiting Period immediately following the Covered Person’s Effective Date of this rider, coverage will apply only to loss that is incurred after one year from the Covered Person’s Effective Date of this Rider.

Termination

This rider will terminate and coverage will end for all Covered Persons on the earliest of any of the following: the end of the grace period if the premium for this rider remains unpaid; the date the Policy or Certificate to which this rider is attached terminates; the end of the Certificate Month in which we receive a request from the Policyholder to terminate this rider; the date of your death; or the date the lump sum benefit amount for Internal Cancer has been paid for all Covered Persons under this rider. Coverage on an Eligible Dependent terminates under this rider when such person ceases to meet the definition of Eligible Dependent.

Pre-Existing Condition Exclusion

Waiting Period

This rider contains a Waiting Period during which no benefits will be paid. If any Heart Attack or Stroke is diagnosed before the end of the Waiting Period immediately following the Covered Person’s Effective Date of this rider, coverage will apply only to loss that is incurred after one year from the Covered Person’s Effective Date.

employer intended to be covered by ERISA, and will be administered and enforced under ERISA. Group policies issued to governmental entities and municipalities may be exempt from ERISA guidelines | Policy Form GC13APL | Limited Benefit Group Cancer Indemnity Insurance Series | Texas | (10/14) | City of Stephenville

APSB-22331(TX) MGM/FBS City of Stephenville

GC13 Limited Benefit Group Cancer Indemnity Insurance

5STAR

Family Protection Plan

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.

YOUR BENEFITS PACKAGE

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 42 City of Stephenville Benefits Website: www.mybenefitshub.com/cityofstephenville

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

Weekly Premium

Death Benefit

Accelerated Benefit

Your age at issue: 35

$10.00

$89,655

4% $3,586.20 a month

Affordability—With several options to choose from, select the coverage that best meets the needs of your family. Terminal Illness—This plan pays the insured 30% (25% in Connecticut and Michigan) of the policy coverage amount in a lump sum upon the occurrence of a terminal condition that will result in a limited life span of less than 12 months. Portability—You and your family continue coverage with no loss of benefits or increase in cost should you terminate employment after the first premium is paid. If this happens, we can simply bill you directly. Coverage can never be cancelled by the insurance company or your employer unless you stop paying premiums. Family Protection—Individual policies can be purchased on the employee, their spouse, children and grandchildren. Children & Grandchildren Plan— Individual life policies can be purchased for children and grandchildren ages newborn through 23. They are not eligible for the Quality of Life Rider. Convenience—Premiums are taken care of simply and easily through payroll deductions. Protection You Can Count On—Within 24 hours after receiving notice of an insured’s death, an emergency death benefit of the lesser of 50% of the coverage amount, or $10,000, will be mailed to the insured’s beneficiary, unless the death is within the two-year contestability period and/or under investigation. This product also contains no war or terrorism exclusions.

For example, in case of chronic illness, you would receive $3,586 each month up to $67,241.25. The remainder death benefit of $22,413.75 would be made payable to your beneficiary. This example is for illustration purposes only. You will need to review the chart for your exact benefit.

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

Family Protection Plan - Terminal Illness MONTHLY RATES WITH QUALITY OF LIFE RIDER DEFINED BENEFIT $10,000

$20,000

$25,000

$30,000

$40,000

$50,000

$75,000

$100,000

$125,000

$150,000

Family Protection Plan - Terminal Illness

UNITEDHEALTHCARE YOUR BENEFITS PACKAGE

Life and AD&D

PLAY VIDEO

About this Benefit Group term life is the most inexpensive way to purchase life insurance. You have the freedom to select an amount of life insurance coverage you need to help protect the well-being of your family. Accidental Death & Dismemberment is life insurance coverage that pays a death benefit to the beneficiary, should death occur due to a covered accident. Dismemberment benefits are paid to you, according to the benefit level you select, if accidentally dismembered.

Motor vehicle crashes are the

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 46 City of Stephenville Benefits Website: www.mybenefitshub.com/cityofstephenville

Supplemental Life and AD&D Am I eligible? You are eligible if you are an active, full-time Employee who works at least 30 hours per week on a regularly scheduled basis.

How much Employee Supplemental Life and AD&D can I purchase? You can purchase Supplemental Life and AD&D Insurance from a minimum of $20,000 to a $500,000 maximum. However, coverage cannot exceed 5 times your Annual Earnings. Annual Earnings are defined in UnitedHealthcare’s contract with your employer.

How much Spouse Supplemental Life and AD&D can I purchase?

What does Supplemental AD&D provide me? Accidental Death & Dismemberment (AD&D) provides benefits due to certain injuries or death from an accident.* The covered injuries or death can occur up to 180 days after the accident. The AD&D Insurance pays certain percentages of the benefit amount based on the injury sustained. Refer to the certificate of coverage for the complete AD&D Benefit schedule. Coverage includes 10% additional benefit for use of Seatbelt only or Seatbelt and Air Bag for loss of life. Your total benefit for all losses due to the same accident will not be more than 100% of the amount of coverage provided to you. *Some state variations may apply.

What is a beneficiary?

If you elect Employee Supplemental Life and AD&D Insurance for yourself, you may choose to purchase Spouse Supplemental Life and AD&D Insurance from a minimum of $5,000 to a maximum of $250,000. However, coverage cannot exceed 50% of the employee’s Supplemental Life and AD&D amount. You may not elect coverage for your Spouse if they are already covered as an Employee under this policy.

Your beneficiary is a person (or persons) or legal entity (entities) who receives a benefit payment if you die while you are covered under the policy. You, as the employee, must select your beneficiary when you complete your enrollment application; your selection is legally binding. You are automatically the beneficiary for any Spouse or Child(ren) coverage.

How much Child(ren) Supplemental Life and AD&D can I purchase?

Are any resources available for beneficiaries?

If you elect Supplemental Life and AD&D Insurance for yourself, you may choose to purchase Child(ren)* Supplemental Life and AD&D Insurance from $1,000 minimum to a maximum of $10,000 for each child. However, coverage cannot exceed 50% of the employee’s Supplemental Life and AD&D amount. *Eligible Child(ren) are from 14 days to age 26.

Beneficiary Services: Provides beneficiaries with services for grief consultation, financial/legal assistance and referral to community resources. For more information, call 866-302-4480. See below for more details.

What is the highest amount of Supplemental Life I can buy without filling out a medical questionnaire? (Guarantee Issue Limit)

You must be Actively at Work with your employer on the day your coverage takes effect. This coverage, like most group benefit insurance, requires that a certain percentage of eligible employees participate. If that group participation minimum is not met, the insurance coverage that you have elected may not be in effect.

Are there other limitations to enrollment?

New Hire: Employee- You may elect up to $130,000. Amounts greater will require evidence of good health/insurability. Current Employee– If you did not elect during your initial enrollment will need to complete and Evidence of Insurability Form. Spouse- You may elect up to $50,000. Amounts greater will require evidence of good health/insurability. Child(ren)- You may elect up to $10,000. 47

Supplemental Life and AD&D Does my coverage reduce as I get older? Yes, Employee Supplemental Life and AD&D coverage reduces to 65% of the face amount at age 65; to 50% of the original amount at age 70. Spouse Supplemental Life and AD&D coverage reduces the same as the employee’s. All coverage terminates upon employee’s retirement.

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

Dependent Spouse Portability is subject to a maximum of $250,000. Dependent Child Portability is subject to a maximum of $10,000.

Exclusions AD&D Insurance does not cover losses caused by or contributed by: Disease, bodily or mental infirmity, suicide or intentionally self-inflicted injury, commission of an assault or felony, war, use of any drug unless prescribed by physician, driving while intoxicated, engaging in any hazardous activities, or travel in a private aircraft.*

If you become totally disabled before age 60 and your disability lasts for at least 9 months, your Employee Supplemental Life Insurance premium may be waived.

Other exclusions may apply depending upon your coverage. Once a group policy is issued to your employer, a certificate of coverage will be available to explain your benefits in detail.

What is Accelerated Death Benefit?

As is standard with most term life Insurance, this Insurance coverage includes certain limitations and exclusions:  Death by suicide (two years)*.

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

Can I keep my Life coverage if I leave my employer? Yes, subject to the contract, you have the option of:  Converting your group Life coverage to your own individual policy (policies).  If you leave your employer, Portability is an option that allows you to continue your Supplemental Life Insurance coverage. To be eligible, you must terminate your employment prior to age 70. This option allows you to continue all or a portion of your Life Insurance coverage under a separate Portability term policy. Portability is subject to a minimum of $5,000 and a maximum of $500,000 and does include coverage for your Spouse and Children. You must elect portability for your own coverage in order to elect portability for your Spouse and or Children. To elect Portability, you must apply and pay the premium within 30 days of the termination of your Life Insurance.

* Some state variations may apply

Supplemental Life and AD&D Employee & Spouse* Supplemental Life – Current Monthly Cost by Age Band Coverage $10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 $90,000 $100,000

Age <25 0.79 1.58 2.37 3.16 3.95 4.74 5.53 6.32 7.11 7.90

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

0.79 1.58 2.37 3.16 3.95 4.74 5.53 6.32 7.11 7.90

0.98 1.96 2.94 3.92 4.90 5.88 6.86 7.84 8.82 9.80

1.38 2.76 4.14 5.52 6.90 8.28 9.66 11.04 12.42 13.80

2.26 4.52 6.78 9.04 11.30 13.56 15.82 18.08 20.34 22.60

3.34 6.68 10.02 13.36 16.70 20.04 23.38 26.72 30.06 33.40

5.40 10.80 16.20 21.60 27.00 32.40 37.80 43.20 48.60 54.00

7.07 14.14 21.21 28.28 35.35 42.42 49.49 56.56 63.63 70.70

12.77 25.54 38.31 51.08 63.85 76.62 89.39 102.16 114.93 127.70

* Spouse rate is based on employee’s age and cannot exceed 50% of the employee’s Supplemental Life amount

Child(ren) Supplemental Life $5,000

$10,000

0.91

1.82

Employee** Only Supplemental AD&D – Current Monthly Cost $10,000

$20,000

$30,000

$40,000

$50,000

$60,000

$70,000

$80,000

$90,000

$100,000

0.26

0.52

0.78

1.04

1.30

1.56

1.82

2.08

2.34

2.60

Employee** & Family Supplemental AD&D – Current Monthly Cost $10,000

$20,000

$30,000

$40,000

$50,000

$60,000

$70,000

$80,000

0.42

0.84

1.26

1.68

2.10

2.52

2.94

3.36

$90,000 $100,000 3.78

4.20

** You cannot purchase Supplemental AD&D Insurance without purchasing Supplemental Life Insurance. If you elect Supplemental AD&D Insurance, the amount elected must be equal to the amount of Supplemental Life elected.

NBS

FSA (Flexible Spending Account)

YOUR BENEFITS PACKAGE

PLAY VIDEO

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

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 50 City of Stephenville Benefits Website: www.mybenefitshub.com/cityofstephenville

FSA (Flexible Spending Account) NBS Flexcard

When Will I Receive My Flex Card?

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

NBS Prepaid MasterCard® Debit Card

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

For a list of sample expenses, please refer to the City of Stephenville benefit website: www.mybenefitshub.com/cityofstephenville

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

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

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

FSA Annual Contribution Max:

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

$2,650

Dependent Care Annual Max: $5,000

Account Information: Participant Account Web Access: www.participant.nbsbenefits.com Participants may call NBS and talk to a representative during regular business hours, Monday-Friday, 8 am to 7 pm Central Time. Participants can also obtain account information using the Automated Voice Response Unit, 24 hours a day, 7 days a week at (801) 838-7324 or toll free (800) 274-0503. For immediate access to your account information at any time, log on to the NBS website: www.NBSbenefits.com Detailed claim history and processing status Health Care and Dependent Care account balances Health Care and Dependent Care account balances Claim forms, Direct Deposit form, worksheets, etc. Online claim FAQs 51

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

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

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

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

        

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

Dependent Care Expense Account Example Expenses:    

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

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

What Happens If I Don’t Use All of My Funds by The End of the Plan Year (April 30th)? Eligible expenses must be incurred within the plan year +75 day grace period. Contributions are use-it-or- lose-it. Remember to retain all your receipts (including receipts for card swipes).

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

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

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

Get Your Money 1. 2. 3. 4.

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

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

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

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

NBS

457(b) Plan

YOUR BENEFITS PACKAGE

About this Benefit A 457(b) plan is a tax-deferred compensation plan provided for employees of certain taxexempt, governmental organizations or public education institutions. Only 22% of workers are very confident they will have enough money in retirement.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 54 City of Stephenville Benefits Website: www.mybenefitshub.com/cityofstephenville

457(b) Plan What are the benefits of contributing to a 457 Plan? LOWER TAXES The 457 contributions you make can be on a pre-tax basis. This means that the money used to invest in the 457 plan is not taxed until the funds are withdrawn. For example, if your federal marginal income tax rate is 25%, and you contribute $100 a month to a 457 plan, you have reduced your federal income taxes by nearly $25. In effect, your $100 contribution costs you only $75. The tax savings grow with the size of your 457 contribution. TAX-DEFERRED GROWTH In your 457 plan, interest and earnings grow tax-deferred. This means that your interest will grow tax-free until the time of your withdrawal. The compounding interest on your 457 plan allows your account to grow more quickly than money saved in a taxable account where interest and earnings are taxed each year. TAKING THE INITIATIVE Contributing to a 457 plan helps you take control of your future retirement needs. Other sources of retirement income, including state pension plans and Social Security, often do not adequately replace a person’s salary upon retirement. A 457 plan can be a great way to supplement your income at retirement. POSSIBLE TAX CREDITS Pre-tax contributions may put you in a lower tax bracket reducing your overall tax rate. HIGHER LIMITS Annual contribution limits are much higher than those of an IRA.

How much can you contribute to a 457 Plan? You may elect to save:  100% of your income up to $18,500 (2018)  Extra $6,000 if age 50+  Limits are completely separate from those made to 403(b) or 401(k) accounts

(“SRA”) can be found by visiting the (NBS) website at NBSbenefits.com/403b or by contacting NBS (contact information below). Once you have chosen an approved vendor, please open a 457 account directly with them. To begin investing, send the completed SRA form to NBS who will work with your employer to begin contributions.

Investment Choices Annuity contracts made available through insurance companies or custodial accounts through a retirement account custodian are allowed in 457 plans. You will need to contact the vendor for a comprehensive listing and information regarding the available investment options.

Transfers As a participant in the 457 Plan, you have the option to move funds, or “transfer” tax-free between different vendors within the same plan.

Rollovers You also have the option of rolling retirement funds from previous employers to your current employer’s plan thus simplifying retirement management.

Distributions from the Plan You or your beneficiary will be able to withdraw your vested balance when one of the following occurs: 1. Retirement 2. Termination of Employment 3. Attainment of Age 70 ½ 4. Total Disability 5. Death *The vendors may require additional paperwork.

Loans You may borrow up to 50% of your vested balance up to $50,000 (whichever is less). Contact your current vendor about their specific loan provisions.

REQUIRED MINIMUM DISTRIBUTIONS (RMD) Distributions are required at age 70 ½. Exceptions may apply.

Unforeseeable Emergency

How to Enroll in the Plan

An unforeseeable emergency distribution may be allowed if you satisfy certain criteria. Contact NBS for more information about the requirements.

Your employer has provided investment option(s) for you. A list of approved vendor(s) and the Salary Reduction Agreement

NOTES