2018 Benefit Guide Dickinson ISD by Higginbotham Public Sector

DICKINSON ISD

BENEFIT GUIDE EFFECTIVE: 09/01/2018 - 8/31/2019 WWW.MYBENEFITSHUB.COM/ DICKINSONISD

Table of Contents

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

3 4-5 6-10 6 7 8 9 10 11-13 14-15 16-19 20-21 22-25 26-31 32-35 36-37 38-41 42-45 46-47 48-51

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

PG. 6 SUMMARY PAGES

PG. 12 YOUR BENEFITS

Benefit Contact Information

Benefit Contact Information DICKINSON ISD BENEFITS

VISION

CRITICAL ILLNESS

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

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

Unum (800) 442-0915 www.unum.com

DICKINSON ISD BENEFITS OFFICE

DISABILITY

BASIC, VOLUNTARY LIFE AND AD&D

Elidia “Lily” Galindo (281) 229-6050 egalindo@dickinsonisd.org

Unum (800) 442-0915 www.unum.com

Mutual of Omaha (800) 228-7104 www.mutualofomaha.com

MEDICAL

EAP

FLEXIBLE SPENDING ACCOUNT

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

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

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

TELEHEALTH

CANCER

INDIVIDUAL LIFE

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

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

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

DENTAL

ACCIDENT

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

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

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

everything you need to

“FBS DICKINSON”

complete your benefits

to 313131

enrollment: 

Benefit Information



Online Support



Interactive Tools



And more. PLAY VIDEO

Text

OR SCAN

How to Log In

1 BENEFIT INFO

INTERACTIVE TOOLS

2 3

www.mybenefitshub.com/dickinsonisd

CLICK LOGIN

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

Username: The first six (6) characters of your last name, followed by the first letter of your first name, followed by the last four (4) digits of your Social Security Number.

ONLINE SUPPORT

If you have less than six (6) characters in your last name, use your full last name, followed by the first letter of your first name, followed by the last four (4) digits of your Social Security Number.

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

Annual Benefit Enrollment

SUMMARY PAGES

Benefit Updates ‐ What’s New: 

Medical—TRS‐Ac veCare Select – Addi on of Memorial  Hermann Accountable Care Network – If you are currently enrolled in TRS‐Ac veCare Kelsey Select and reside in certain zip codes of Brazoria or Galveston County, you will have an op on to enroll in the TRS‐Ac veCare Select Memorial  Hermann Accountable Care Network plan eﬀec ve September 1, 2018. THEbenefitsHUB will show both the Kelsey and Memorial Hermann op ons to choose between, if applicable, based on the employee’s zip code. There is no diﬀerence in cost between the two plan op ons.



Medical—TRS‐Ac veCare 2: As of the September 1, 2018 plan year, no new enrollments will be allowed in this plan. If you currently are enrolled in TRS AC2, you may keep it, however if your are new to the TRS medical coverage or were considering a change to AC2, it will not be available to you.



NEW! Disability—UNUM: The new carrier is UNUM. Disability insurance protects one of your most valuable assets, your ability to earn a living. This insurance may replace up to 66.67% of your income if you become physically unable to work due to a sickness or injury. There are five elimina on  periods to select from. Pre‐exis ng condi on limita ons apply.



NEW! Accident—VOYA is the new carrier. Accident insurance is designed to supplement your medical insurance coverage by covering out‐of‐pocket costs experienced with an injury.  The plan also includes an Accidental Death and Dismemberment benefit.

 

NEW! Cri cal Illness—UNUM: Cri cal illness insurance is designed to supplement your medical and disability coverage, easing the financial impacts, by covering some of your addi onal expenses. New Carrier! Mutual of Omaha—Basic Life, Vol. Life and AD&D: The District s ll provides full me employees with a Basic Life and Basic AD&D policy. In addi on, employees may purchase addi onal group term life coverage. At this open enrollment, all benefit eligible employees will have the ability to purchase the lesser of 7 x annual salary or $200K on themselves, up to $50K for their spouse and up to $10K for their dependent children on a guarantee issue basis meaning no health ques ons are required. Employees who already have coverage in force through Sunlife that exceeds these GI amounts will be able to keep this amount of coverage with Mutual of Omaha also without having to answer health ques ons. AD&D is addi onal coverage. Employee guaranteed issue amount up to $250,000, with a maximum benefit of $500,000 or 5X salary. A er this enrollment, the guarantee issue amounts will only be available to new hires. NEW! Individual Life– 5Star: The new carrier is 5 Star. Permanent life is an individual life policy that provides a specified death benefit to your beneficiary at the me of death. Flexible Spending Account (FSA) Carrier ‐ Na onal Benefit Services (NBS) If you currently par cipate in a Healthcare or Dependent Care FSA, you MUST re‐elect a new contribu on amount every year to con nue to par cipate. The maximum Medical Flex annual contribu on will be $2,650.

Login and complete your supplemental benefit enrollment from 07/16/2018 ‐ 08/17/2018 Enrollment assistance is available by calling Financial Benefit Services at 866‐914‐5202 to speak to an enrollment representa ve Monday—Friday, 8 AM—5 PM from 07/16/2018—08/17/2018. Bilingual assistance is available.  Update your profile informa on: home address, phone numbers, email.  IMPORTANT!! Due to the Aﬀordable Care Act (ACA) repor ng requirements, please add your dependent’s social security numbers in the online enrollment system. If you have ques ons, please contact your Benefits Administrator. 6

SUMMARY PAGES

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

CHANGES IN STATUS (CIS):

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

QUALIFYING EVENTS

Marital Status

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

Change in Number of Tax Dependents

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

Change in Status of Employment Affecting Coverage Eligibility

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

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

SUMMARY PAGES

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

Where can I find forms?

to review, change or continue benefit elections each year.

For benefit summaries and claim forms, go to your school

Changes are not permitted during the plan year (outside of

district’s benefit website:

annual enrollment) unless a Section 125 qualifying event occurs.

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



Changes, additions or drops may be made only during the

the forms you need under the Benefits and Forms section.

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

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

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

included in the dependent profile. Additionally, you must

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

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



For benefit summaries and claim forms, go to your school

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

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

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

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

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

SUMMARY PAGES

Employee Eligibility Requirements

Dependent Eligibility Requirements

Supplemental Benefits: Eligible employees must work 20 or more

Dependent Eligibility: You can cover eligible dependent

regularly scheduled hours each work week.

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

Eligible employees must be ac vely at work on the plan eﬀec ve

maximum age listed below. Dependents cannot be double

date for new benefits to be eﬀec ve, meaning you are physically

covered by married spouses within Dickinson ISD or as both

capable of performing the func ons of your job on the first day of

employees and dependents.

work concurrent with the plan eﬀec ve date. For example, if your 2018 benefits become eﬀec ve on September 1, 2018, you must be ac vely‐at‐work on September 1, 2018 to be eligible for your new benefits. PLAN

CARRIER

MAXIMUM AGE

Medical

Aetna

To 26

Dental

Cigna

To 26

Vision

VSP

To 26

Cancer

American Public Life

To 26

Medical Flex

NBS

To 26

Disability

UNUM

N/A

Voluntary Life and AD&D

Mutual of Omaha

Unmarried to 26

Telehealth

MDLIVE

To 26

Accident

Voya

Unmarried to 26

Cri cal Illness

UNUM

To 26

Employee Assistance Program (EAP)

Lifeworks

To 26

Individual Life

5Star

To 25

If your dependent is disabled, coverage may be able to con nue past the maximum age under certain plans. If you have a disabled dependent who is reaching an ineligible age, you must provide a physician’s statement confirming your dependent’s disability. Contact your HR/Benefit Administrator to request a con nua on of coverage.

SUMMARY PAGES

Helpful Definitions Actively at Work

In-Network

You are performing your regular occupation for the employer

Doctors, hospitals, optometrists, dentists and other providers

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

who have contracted with the plan as a network provider.

places of business or at some location to which the employer’s business requires you to travel. If you will not be actively at work beginning 09/1/2018 please notify your benefits coordinator.

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. TRS Active Care medical deductible resets 09/01/2019.

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

Plan Year September 1, 2018 thru August 31, 2019.

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 (including diagnostic and/or consultation services).

Calendar Year January 1st through December 31st

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

Guaranteed Coverage The amount of coverage you can elect without answering any medical questions or taking a health exam. Guaranteed coverage is only available during initial eligibility period. Actively-at-work and/or pre-existing condition exclusion provisions do apply, as applicable by carrier. 10

TRS ACTIVECARE AETNA STATE PLANS GROUP # 866325 | DICKINSON INDEPENDENT SCHOOL DISTRICT 2018‐2019

ActiveCare 1-HD (District Pays $125.00 Per Check)

Cost to Employee (Per Paycheck)

Employee Only

$58.50

Employee and Child(ren)

$225.50

Employee and Spouse

$392.50

Employee and Family

$562.00

Family (Both Employees Employed at DISD)

$437.00

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

$218.50

ActiveCare Select Plan (District Pays $125.00 Per Check)

Cost to Employee (Per Paycheck)

Employee Only

$145.00

Employee and Child(ren)

$313.00

Employee and Spouse

$538.50

Employee and Family

$709.00

Family (Both Employees Employed at DISD)

$584.00

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

$292.00

ActiveCare 2 (District Pays $125.00 Per Check)

Cost to Employee (Per Paycheck)

Employee Only

$266.00

Employee and Child(ren)

$456.50

Employee and Spouse

$802.50

Employee and Family

$972.00

Family (Both Employees Employed at DISD)

$847.00

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

$423.50

2018 – 2019 TRS-ActiveCare Plan Highlights Effective September 1, 2018 through August 31, 2019 | In-Network Level of Benefits1

Deductible (per plan year) In-Network Out-of-Network Out-of-Pocket Maximum (per plan year; medical and prescription drug deductibles, copays, and coinsurance count toward the out-of-pocket maximum) In-Network Out-of-Network Coinsurance In-Network Participant pays (after deductible) Out-of-Network Participant pays (after deductible) Office Visit Copay Participant pays Diagnostic Lab Participant pays Preventive Care See below for examples Teladoc® Physician Services

High-Tech Radiology (CT scan, MRI, nuclear medicine) Participant pays Inpatient Hospital (preauthorization required) (facility charges) Participant pays Freestanding Emergency Room Participant pays

$500 copay per visit plus 20% after deductible

Emergency Room (true emergency use) Participant pays Outpatient Surgery Participant pays Bariatric Surgery Physician charges (only covered if performed at an IOQ facility) Participant pays Annual Vision Examination (one per plan year; performed by an ophthalmologist or optometrist using calibrated instruments) Participant pays Annual Hearing Examination Participant pays Preventive Care Routine physicals – annually age 12 and over Mammograms – 1 every year age 35 and over Smoking cessation counseling– 8 visits per 12 months

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

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

Drug Deductible Short-Term Supply at a Retail Location 20% coinsurance after deductible, except for certain generic preventive drugs that are covered at 100%.2 20% coinsurance after deductible 50% coinsurance after deductible Extended-Day Supply at Mail Order or Retail-Plus Pharmacy Location (60- to 90-day supply)5 20% coinsurance after deductible

$20 for a 1- to 31-day supply $20 for a 1- to 31-day supply $40 for a 1- to 31-day supply3 $40 for a 1- to 31-day supply3 3 50% coinsurance for a 1- to 31-day supply 50% coinsurance for a 1- to 31-day supply (Min. $654; Max. $130)3

$45 for a 60- to 90-day supply

$45 for a 60- to 90-day supply 3

$105 for a 60- to 90-day supply $105 for a 60- to 90-day supply3 3 50% coinsurance for a 60- to 90-day supply 50% coinsurance for a 60- to 90-day supply3 (min. $1804 , max $360)3 Specialty Medications 20% coinsurance after deductible 20% coinsurance 20% coinsurance (up to a 31-day supply) (min. $2004 , max $900) Short-Term Supply of a Maintenance Medication at Retail Location (up to a 31-day supply) 20% coinsurance after deductible 50% coinsurance after deductible

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

20% coinsurance after deductible 20% coinsurance after deductible 50% coinsurance after deductible

$35 for a 1- to 31-day supply $35 for a 1- to 31-day supply $60 for a 1- to 31-day supply $60 for a 1- to 31-day supply 3 50% coinsurance for a 1- to 31-day supply

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

When does the convenience fee apply? For example, if you are covered under TRS-ActiveCare Select, the first time you fill a 31-day supply of a generic maintenance drug at a retail pharmacy you will pay $20, then you will pay $35 each month that you fill a 31-day supply of that generic maintenance drug at a retail pharmacy. A 90-day supply of that same generic maintenance medication would cost $45, and you would save $225 over the year by filling a 90-day supply. A specialist is any physician other than family practitioner, internist, OB/GYN or pediatrician. 1 Illustrates benefits when in-network providers are used. For some plans non-network benefits are also available; there is no coverage for non-network benefits under the ActiveCare Select or ActiveCare Select Whole Health Plan; see Enrollment Guide for more information. Non-contracting providers may bill for amounts exceeding the allowable amount for covered services. Participants will be responsible for this balance bill amount, which maybe considerable. 2 For ActiveCare 1-HD, certain generic preventive drugs are covered at 100%. Participants do not have to meet the deductible ($2,750 - individual, $5,500 - family) and they pay nothing out of pocket for these drugs. Find the list of drugs at info.caremark.com/trsactivecare. 3 If a participant obtains a brand-name drug when a generic equivalent is available, they are responsible for the generic copay plus the cost difference between the brand-name drug and the generic drug. 4 If the cost of the drug is less than the minimum, you will pay the cost of the drug. 5 Participants can fill 32-day to 90-day supply through mail order.

Full monthly premium*

Premium with min. state/ district contribution**

$367

+Spouse

Your Monthly Premium***

Full monthly premium*

Premium with min. state/ district contribution**

$142

$540

$1,035

$810

+Children

$701

+Family

$1,374

Individual

Your Monthly Premium***

Full monthly premium*

Premium with min. state/ district contribution**

$315

$782

$557

$1,327

$1,102

$1,855

$1,630

$476

$876

$651

$1,163

$938

$1,149

$1,668

$1,443

$2,194

$1,969

Your Monthly Premium***

* If you are not eligible for the state/district subsidy, you will pay the full monthly premium. Please contact your Benefits Administrator for your monthly premium. ** The premium after state, $75 and district, $150 contribution is the maximum you pay per month. Ask your Benefits Administrator for your monthly cost. (This is the amount you will owe each month after all available subsidies are applied to your premium.) 13 *** Completed by your benefits administrator. The state/district contribution may be greater than $225.

MDLIVE YOUR BENEFITS PACKAGE

Telehealth

PLAY VIDEO

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

75%

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

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

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

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

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

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

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

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

How much does it cost? $10 per month One cost covers entire family with unlimited phone consultations.

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

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

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

Scan with your smartphone to get the app.

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

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

CIGNA

Dental

YOUR BENEFITS PACKAGE

PLAY VIDEO

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

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

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

Dental PPO Cigna Dental Choice Plan Network Options

Reimbursement Levels Policy Year Benefits Maximum Applies to:

In-Network: Total Cigna DPPO Network

Out-of-Network: See Non-Network Reimbursement

Based on Contracted Fees

Maximum Reimbursable Charge

$1,500

$50 $150

Tier

Monthly Rates

Dental PPO Employee Only

$36.24

Employee + Spouse

$83.74

Employee + Child(ren)

$89.54

Employee + Family

$106.56

Class I, II, III, & IX expenses

Policy Year Deductible Individual Family

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

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

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

Class IV: Orthodontia Coverage for Employee and All Dependents

Plan Pays

You Pay

Plan Pays

You Pay

100% No Deductible

No Charge

100% No Deductible

No Charge

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

20% After Deductible

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

50% After Deductible

50% No Deductible

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

Lifetime Benefits Maximum: $1,500

Class IX: Implants

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

50% After Deductible

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

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

Timely Filing

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

Benefit Limitations: Missing Tooth Limitation

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

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

This document provides a summary only. It is not a contract. If there are any differences between this summary and the official plan documents, the terms of 18 the official plan documents will prevail.

VSP YOUR BENEFITS PACKAGE

Vision

PLAY VIDEO

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

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

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

Vision Benefit WellVision Exam

Description Your Coverage with a VSP Provider

Copay

Frequency

$10

Every plan year*

$25

See frame and lenses

 Focuses on your eyes and overall wellness

Prescription Glasses    

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

Included in Prescription Glasses

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

Included in Prescription Glasses

Lens Enhancements

   

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

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

Contacts (instead of glasses)

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

Every 12 months

$20

As needed

Frame

Lenses

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

Extra Savings

Your Monthly Contribution

Every 12 months

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

$9.90 Member only

$20.96 Member + family

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

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

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

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

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

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

Single Vision Lenses ..........................up to $30 Coverage with a participating retail chain may be different. Once your benefit is effective, visit vsp.com for details. Coverage information is subject to change. In the event of a conflict between this information and your organization’s contract with VSP, the terms of the contract will prevail. Based on applicable laws, benefits may vary by location. 800-877-7195 21 www.vsp.com

UNUM YOUR BENEFITS PACKAGE

Disability

PLAY VIDEO

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

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

34.6 months is the duration of the average disability claim.

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

Educator Options Voluntary Long Term Disability Please read carefully the following description of your Unum Educator Select Income Protection Plan insurance.

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

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

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

Elimination Period The Elimination Period is the length of time of continuous disability, due to sickness or injury, which must be satisfied before you are eligible to receive benefits. You may choose an Elimination Period (injury/sickness) of 0/7, 14/14, 30/30, 60/60, 90/90 or 180/180 days. If, because of your disability, you are hospital confined as an inpatient, benefits begin on the first day of inpatient confinement. Inpatient means that you are confined to a hospital room due to your sickness or injury for 23 or more consecutive hours. (Applies to Elimination Periods of 30 days or less.)

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

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

Next Steps How to Apply/Effective Date of Coverage To apply for coverage, complete your enrollment form within 60 days of your eligibility date. Please see your Plan Administrator for your effective date. If you do not enroll during the initial enrollment period, you may apply only during an annual enrollment.

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

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

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

Product: Educator Select Income Protection Plan

Injury (Days) Sickness (Days) Maximum Annual Monthly Monthly Earnings Earnings Benefit 3600 300 200 5400 450 300 7200 600 400 9000 750 500 10800 900 600 12600 1050 700 14400 1200 800 16200 1350 900 18000 1500 1000 19800 1650 1100 21600 1800 1200 23400 1950 1300 25200 2100 1400 27000 2250 1500 28800 2400 1600 30600 2550 1700 32400 2700 1800 34200 2850 1900 36000 3000 2000 37800 3150 2100 39600 3300 2200 41400 3450 2300 43200 3600 2400 45000 3750 2500 46800 3900 2600 48600 4050 2700 50400 4200 2800 52200 4350 2900 54000 4500 3000 55800 4650 3100 57600 4800 3200 59400 4950 3300 61200 5100 3400 63000 5250 3500 64800 5400 3600 66600 5550 3700 68400 5700 3800 70200 5850 3900 72000 6000 4000 73800 6150 4100 75600 6300 4200 7740024 6450 4300

ADEA II Duration of Benefits Elimination Period (Days) 0* 7*

14* 14*

30* 30*

60 60

90 90

180 180

6.28 9.42 12.56 15.70 18.84 21.98 25.12 28.26 31.40 34.54 37.68 40.82 43.96 47.10 50.24 53.38 56.52 59.66 62.80 65.94 69.08 72.22 75.36 78.50 81.64 84.78 87.92 91.06 94.20 97.34 100.48 103.62 106.76 109.90 113.04 116.18 119.32 122.46 125.60 128.74 131.88 135.02

5.52 8.28 11.04 13.80 16.56 19.32 22.08 24.84 27.60 30.36 33.12 35.88 38.64 41.40 44.16 46.92 49.68 52.44 55.20 57.96 60.72 63.48 66.24 69.00 71.76 74.52 77.28 80.04 82.80 85.56 88.32 91.08 93.84 96.60 99.36 102.12 104.88 107.64 110.40 113.16 115.92 118.68

4.68 7.02 9.36 11.70 14.04 16.38 18.72 21.06 23.40 25.74 28.08 30.42 32.76 35.10 37.44 39.78 42.12 44.46 46.80 49.14 51.48 53.82 56.16 58.50 60.84 63.18 65.52 67.86 70.20 72.54 74.88 77.22 79.56 81.90 84.24 86.58 88.92 91.26 93.60 95.94 98.28 100.62

3.04 4.56 6.08 7.60 9.12 10.64 12.16 13.68 15.20 16.72 18.24 19.76 21.28 22.80 24.32 25.84 27.36 28.88 30.40 31.92 33.44 34.96 36.48 38.00 39.52 41.04 42.56 44.08 45.60 47.12 48.64 50.16 51.68 53.20 54.72 56.24 57.76 59.28 60.80 62.32 63.84 65.36

2.62 3.93 5.24 6.55 7.86 9.17 10.48 11.79 13.10 14.41 15.72 17.03 18.34 19.65 20.96 22.27 23.58 24.89 26.20 27.51 28.82 30.13 31.44 32.75 34.06 35.37 36.68 37.99 39.30 40.61 41.92 43.23 44.54 45.85 47.16 48.47 49.78 51.09 52.40 53.71 55.02 56.33

1.92 2.88 3.84 4.80 5.76 6.72 7.68 8.64 9.60 10.56 11.52 12.48 13.44 14.40 15.36 16.32 17.28 18.24 19.20 20.16 21.12 22.08 23.04 24.00 24.96 25.92 26.88 27.84 28.80 29.76 30.72 31.68 32.64 33.60 34.56 35.52 36.48 37.44 38.40 39.36 40.32 41.28

Disability DICKINSON INDEPENDENT SCHOOL DISTRICT Costs below are based on a Monthly payroll deduction (Employer billing mode is based on 12 Payments per year) Plan A Product: Educator Select Income Protection Plan Injury (Days) Sickness (Days) Maximum Annual Monthly Monthly Earnings Earnings Benefit 79200 6600 4400 81000 6750 4500 82800 6900 4600 84600 7050 4700 86400 7200 4800 88200 7350 4900 90000 7500 5000 91800 7650 5100 93600 7800 5200 95400 7950 5300 97200 8100 5400 99000 8250 5500 100800 8400 5600 102600 8550 5700 104400 8700 5800 106200 8850 5900 108000 9000 6000 109800 9150 6100 111600 9300 6200 113400 9450 6300 115200 9600 6400 117000 9750 6500 118800 9900 6600 120600 10050 6700 122400 10200 6800 124200 10350 6900 126000 10500 7000 127800 10650 7100 129600 10800 7200 131400 10950 7300 133200 11100 7400 135000 11250 7500 136800 11400 7600 138600 11550 7700 140400 11700 7800 142200 11850 7900 144000 12000 8000

ADEA II Duration of Benefits Elimination Period (Days) 0* 7*

14* 14*

30* 30*

60 60

90 90

180 180

138.16 141.30 144.44 147.58 150.72 153.86 157.00 160.14 163.28 166.42 169.56 172.70 175.84 178.98 182.12 185.26 188.40 191.54 194.68 197.82 200.96 204.10 207.24 210.38 213.52 216.66 219.80 222.94 226.08 229.22 232.36 235.50 238.64 241.78 244.92 248.06 251.20

121.44 124.20 126.96 129.72 132.48 135.24 138.00 140.76 143.52 146.28 149.04 151.80 154.56 157.32 160.08 162.84 165.60 168.36 171.12 173.88 176.64 179.40 182.16 184.92 187.68 190.44 193.20 195.96 198.72 201.48 204.24 207.00 209.76 212.52 215.28 218.04 220.80

102.96 105.30 107.64 109.98 112.32 114.66 117.00 119.34 121.68 124.02 126.36 128.70 131.04 133.38 135.72 138.06 140.40 142.74 145.08 147.42 149.76 152.10 154.44 156.78 159.12 161.46 163.80 166.14 168.48 170.82 173.16 175.50 177.84 180.18 182.52 184.86 187.20

66.88 68.40 69.92 71.44 72.96 74.48 76.00 77.52 79.04 80.56 82.08 83.60 85.12 86.64 88.16 89.68 91.20 92.72 94.24 95.76 97.28 98.80 100.32 101.84 103.36 104.88 106.40 107.92 109.44 110.96 112.48 114.00 115.52 117.04 118.56 120.08 121.60

57.64 58.95 60.26 61.57 62.88 64.19 65.50 66.81 68.12 69.43 70.74 72.05 73.36 74.67 75.98 77.29 78.60 79.91 81.22 82.53 83.84 85.15 86.46 87.77 89.08 90.39 91.70 93.01 94.32 95.63 96.94 98.25 99.56 100.87 102.18 103.49 104.80

42.24 43.20 44.16 45.12 46.08 47.04 48.00 48.96 49.92 50.88 51.84 52.80 53.76 54.72 55.68 56.64 57.60 58.56 59.52 60.48 61.44 62.40 63.36 64.32 65.28 66.24 67.20 68.16 69.12 70.08 71.04 72.00 72.96 73.92 74.88 75.84 76.80

APL

Cancer

YOUR BENEFITS PACKAGE

PLAY VIDEO

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

Breast Cancer is the most commonly diagnosed cancer in women.

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

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

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

SUMMARY OF BENEFITS

Plan 1

Cancer Treatment Policy Benefits

Level 1

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

$10,000

$50 per treatment

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

Plan 2

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

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

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

$9,000

$900

$2,000 / $200

Patient Care Rider Benefits

Level 4

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

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

Attending Physician - Per day of Hospital Confinement

$50

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

$300 / $600

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

$300 per day

Donor

$300 per day

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

$300 per day

Hospice Care - Up to maximum of 365 days per lifetime

$300 per day

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

$300/ $600 Level 2

$300 / $600 Lev el 2

Cancer Treatment Center Evaluation or Consultation - 1 per lifetime

$750

Evaluation or Consultation Travel and Lodging - 1 per lifetime

$350

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

$300 / $300

$150 per confinement $50 per prescription $150

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

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

GC14 Limited Benefit Group Cancer Indemnity Insurance Level 2

Level 2

$300 per day

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

$150 per day

$150

$25 per visit / $1,000

Waive Premium

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

Level 2

Lump Sum Benefit - Maximum 1 per Covered Person per lifetime

Not Available

$5,000

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

Not Available

$7,500

Intensive Care Unit

Not Available

$600 per day

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

Not Available

$300 per day

Hospital Intensive Care Unit Rider Benefits

TOTAL MONTHLY PREMIUMS BY PLAN** Issue Ages 18 +

Individual

Individual & Spouse

1 Parent Family

2 Parent Family

Plan 1

Plan 2

Plan 1

Plan 2

Plan 1

Plan 2

Plan 1

Plan 2

$21.46

$29.06

$45.48

$61.86

$26.86

$37.50

$50.82

$70.24

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

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

Pre-Existing Condition Exclusion

Cancer Treatment Benefits

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

Eligibility

Waiting Period

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

Limitations and Exclusions

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

Only Loss for Cancer

The policy pays only for loss resulting from definitive cancer treatment including direct extension, metastatic spread or recurrence. Proof must be submitted to support each claim. The policy also covers other conditions or diseases directly caused by cancer or the treatment of cancer. The policy does not cover any other disease, sickness or incapacity which existed prior to the diagnosis of cancer, even though after contracting cancer it may have been complicated, aggravated or affected by cancer or the treatment of cancer. 28

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

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

GC14 Limited Benefit Group Cancer Indemnity Insurance Termination of Certificate

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

Termination of Coverage

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

Surgical Benefits Limitations and Exclusions

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

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

Limitations and Exclusions

Only Loss for Cancer or Dread Disease

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

Miscellaneous Benefits Waiver of Premium

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

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

Limitations and Exclusions

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

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

Limitations and Exclusions

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

Pre-Existing Condition Exclusion

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

Waiting Period

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

Termination

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

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

Limitations and Exclusions

For a newborn child born within the 10-month period following the effective date, no benefits under this rider will be provided for confinements that begin within the first 30 days following the birth of such child. No benefits under this rider will be provided during the first two years following the effective date for confinements caused by any heart condition when any heart condition was diagnosed or treated prior to the end of the 30-day period following the covered person’s effective date. The heart condition causing the confinement need not be the same condition diagnosed or treated prior to the effective date. 29

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

Termination

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

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

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

2305 Lakeland Drive | Flowood, MS 39232 ampublic.com | 800.256.8606 Underwritten by American Public Life Insurance Company. This is a brief description of the coverage. For detailed benefits, limitations, exclusions and other provisions, please refer to the policy/certificate/riders. This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. | This policy is considered an employee welfare benefit plan established and/or maintained by an association or employer intended to be covered by ERISA, and will be administered and enforced under ERISA. Group policies issued to governmental entities and municipalities may be exempt from ERISA guidelines. | Policy Form GC14 Series | TX | Limited Benefit Group Cancer Indemnity Insurance | (10/14) | MGM/FBS | Dickinson ISD 30

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

GC14 Limited Benefit Group Cancer Indemnity Insurance Dickinson ISD

VOYA YOUR BENEFITS PACKAGE

Accident

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About this Benefit

2/3

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

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

usually live paycheck to paycheck.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 32 Dickinson ISD Benefits Website: www.mybenefitshub.com/dickinsonisd

Accident What accident benefits are available? The following list is a summary of the benefits provided by Accident Insurance. You may be required to seek care for your injury within a set amount of time.

EVENT

Note that there may be some variations by state. For a list of standard exclusions and limitations, go to the end of this document. For a complete description of your available benefits, exclusions and limitations, see your certificate of insurance and any benefits.

Low Plan

High Plan

$800 $125

$1,200 $175

Blood, plasma, platelets Hospital admission Hospital confinement Per day up to 365

$400 $1,000 $300

$600 $1,250 $375

Critical care unit confinement per day, up to 15 days Rehabilitation facility confinement per day for 90 days Coma Duration of 14 or more days

$475 $125 $11,500

$600 $200 $17,000

Transportation per trip, up to 3 per accident Lodging Per day, up to 30 days

$500 $120

$750 $180

Family care per child, up to 45 days

$15

$25

Accident Hospital Care Surgery Open abdominal, thoracic Surgery exploratory or without repair

Accident Care Initial doctor visit

$60

$90

Urgent care facility treatment Emergency room treatment Ground ambulance

$150 $150 $240

$225 $225 $360

$1,000 $60 $30

$1,500 $90 $45

Medical equipment Physical or occupational therapy up to six per accident Speech therapy up to 6 per accident

$40 $30 $30

$120 $45 $45

Prosthetic device (one) Prosthetic device (two or more) Major diagnostic exam

$500 $800 $80

$750 $1,200 $240

Outpatient surgery (one per accident) X-ray

$150 $30

$225 $45

$1,000 $4,500

$1,250 $7,500

$10,000 25% of the burn benefit $250 crown, $60 extraction $60 $225 $150

$15,000 25% of the burn benefit $350 crown, $90 extraction $100 $350 $225

Torn Knee Cartilage surgical repair Laceration1 treated no sutures Laceration1 sutures up to 2”

$500 $20 $40

$800 $30 $60

Laceration1 sutures 2” – 6” Laceration1 sutures over 6” Ruptured Disk surgical repair

$160 $320 $500

$240 $480 $800

Air ambulance Follow-up doctor treatment Chiropractic treatment up to 6 per accident

Common Injuries Burns second degree, at least 36% of the body Burns 3rd degree, at least 9 but less than 35 square inches of the body Burns 3rd degree, 35 or more square inches of the body Skin Grafts Emergency dental work Eye Injury removal of foreign object Eye Injury surgery Torn Knee Cartilage surgery with no repair or if cartilage is shaved

Accident EVENT Tendon/Ligament/Rotator Cuff One, surgical repair Tendon/Ligament/Rotator Cuff Two or more, surgical repair Tendon/Ligament/Rotator Cuff Exploratory Arthroscopic Surgery with no repair Concussion Paralysis paraplegia Paralysis quadriplegia Dislocations Hip joint Knee Ankle or foot bone (s) Other than toes Shoulder Elbow Wrist Finger/toe Hand bone(s) Other than fingers Lower jaw Collarbone Partial dislocations Fractures Hip Leg Ankle Kneecap Foot Excluding toes, heel Upper arm Forearm, Hand, Wrist Except fingers Finger, Toe Vertebral body Vertebral processes Pelvis Except coccyx Coccyx Bones of face Except nose Nose Upper jaw Lower jaw Collarbone Rib or ribs Skull â&#x20AC;&#x201C; simple Except bones of face Skull â&#x20AC;&#x201C; depressed Except bones of face Sternum Shoulder blade Chip fractures

Low Plan

High Plan

$275

$425

$550

$825

$800

$1,225

$150 $10,750 $16,000 Closed/open reduction2 $2,550/$5,100 $1,600/$3,200

$225 $16,000 $24,000 Closed/open reduction2 $3,850/$7,700 $2,400/$4,800

$1,000/$2,000

$1,500/$3,000

$1,000/$2,000 $750/$1,500 $750/$1,500 $175/$350

$1,600/$3,200 $1,100/$2,200 $1,100/$2,200 $275/$550

$750/$1,500

$1,100/$2,200

$750/$1,500 $750/$1,500 25% of the closed reduction amount Closed/open reduction3 $2,000/$4,000 $1,500/$3,000 $1,200/$2,400 $1,200/$2,400

$1,100/$2,200 $1,100/$2,200 25% of the closed reduction amount Closed/open reduction3 $3,000/$6,000 $2,500/$5,000 $1,800/$3,600 $1,800/$3,600

$1,200/$2,400

$1,800/$3,600

$1,400/$2,800

$2,100/$4,200

$1,200/$2,400

$1,800/$3,600

$160/$320 $2,240/$4,480 $960/$1,920

$240/$480 $3,360/$6,720 $1,440/$2,880

$2,250/$4,500

$3,200/$6,400

$200/$400

$400/$800

$800/$1,600

$1,200/$2,400

$400/$800 $1,000/$2,000 $960/$1,920 $960/$1,920 $300/$600

$600/$1,200 $1,500/$3,000 $1,440/$2,880 $1,440/$2,880 $400/$800

$1,000/$2,000

$1,400/$2,800

$2,000/$4,000

$3,000/$6,000

$240/$480 $1,200/$2,400 25% of the closed reduction amount

$360/$720 $1,800/$3,600 25% of the closed reduction amount

Laceration benefits are a total of all lacerations per accident. Closed Reduction of Dislocation = Non-surgical reduction of a completely separated joint. Open Reduction of Dislocation = Surgical reduction of a completely separated joint. 3 Closed Reduction of Fracture = Non-surgical. Open Reduction of Fracture = Surgical. 34 2

Accident Common Carrier: If the death occurs as a result of a covered accident on a common carrier, a higher benefit will be payable. Common carrier means any commercial transportation that operates on a regularly scheduled basis between predetermined points or cities. Accidental Death Benefits Employee Spouse Children Other Accident Employee Spouse Children Accidental Dismemberment Benefits Loss of both hand or both feet or sight in both eyes Loss of one hand or one foot AND the sight of one eye Loss of one hand AND one foot Loss of one hand OR one foot Loss of Two or more fingers or toes Loss of one finger or one toe

Low Plan High Plan

Low Plan $65,000 $30,000 $15,000

High Plan $100,000 $50,000 $25,000

$30,000 $12,500 $6,000 Benefit

$50,000 $20,000 $10,000

$20,000

$28,000

$14,000

$22,000

$14,000 $7,500

$22,000 $12,500

$1,200

$1,800

$750

$1,250

Monthly Rates (12 Pay Periods) Employee Employee Employee and and Spouse Children $7.44 $12.10 $14.36 $10.78 $17.54 $20.80

Family $19.02 $27.56

What does my Accident Insurance include? The benefits listed below are included with your Accident Insurance coverage. For a list of standard exclusions and limitations, please refer to the end of this document. For a complete description of your available benefits, exclusions and limitations, see your certificate of insurance and any benefits.  Sports Accident Benefit: If your accident occurs while participating in an organized sporting activity as defined in the certificate; the accident hospital care, accident care or common injuries benefit will be increased by 25%; to a maximum additional benefit of $1000.  Accidental Death and Dismemberment (AD&D) coverage: If you are severely injured or die as a result of a covered accident, an AD&D benefit may be payable to you or your beneficiary.  Common carrier: If the death occurs as a result of a covered accident on a common carrier, a higher benefit will be payable. Common carrier means any commercial transportation that operates on a regularly scheduled basis between predetermined points or cities.

Exclusions and limitations Exclusions for the Certificate, Spouse Accident Insurance, and Children’s Accident Insurance and AD&D are listed below. (These may vary by state.) Benefits are not payable for any loss caused in whole or directly by any of the following*:  Participation or attempt to participate in a felony or illegal activity.  An accident while the covered person is operating a motorized vehicle while intoxicated. Intoxication means the covered person’s blood alcohol content meets or exceeds the legal presumption of intoxication under the laws of the state where the accident occurred.  Suicide, attempted suicide or any intentionally selfinflicted injury, while sane or insane.  War or any act of war, whether declared or undeclared, other than acts of terrorism.  Loss sustained while on active duty as a member of the armed forces of any nation. We will refund, upon written notice of such service, any premium which has been accepted for any period not covered as a result of this exclusion.  Alcoholism, drug abuse, or misuse of alcohol or taking of drugs, other than under the direction of a doctor.  Riding in or driving any motor-driven vehicle in a race, stunt show or speed test.  Operating, or training to operate, or service as a crew member of, or jumping, parachuting or falling from, any aircraft or hot air balloon, including those which are not motor-driven. Flying as a fare-paying passenger is not excluded. Performing these acts as part of your employment with the employer is not excluded.  Engaging in hang-gliding, bungee jumping, parachuting, sail gliding, parasailing, parakiting, kite surfing or any similar activities.  Practicing for, or participating in, any semi-professional or professional competitive athletic contests for which any type of compensation or remuneration is received.  Any sickness or declining process caused by a sickness.  Work for pay, profit or gain. *See the certificate of insurance and riders for a complete list of available benefits, exclusions and limitations.

UNUM

Critical Illness

YOUR BENEFITS PACKAGE

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

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 36 Dickinson ISD Benefits Website: www.mybenefitshub.com/dickinsonisd

Critical Illness How can critical illness insurance help?

Covered Conditions

Critical Illness insurance helps offset the financial effects of a catastrophic illness by paying a lump sum benefit when employees or their family members are diagnosed with a covered illness. The benefit is based on the amount of coverage inforce, the illness diagnosed and all other terms and provisions of the policy.

Critical Illnesses:  Coronary Artery Disease (major) (50%)  Coronary Artery Disease (minor) (10%)  End Stage Renal (Kidney) Failure  Heart Attack (Myocardial Infarction)  Major Organ Failure Requiring Transplant  Stroke

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

Guarantee Issue

Pre-Existing Condition Benefit Waiting Period Portability Wellness Benefit Recurrence Benefit Premium Rate Information

Employee - $10,000 to $30,000 in increments of $10,000 Spouse/Child - 100% of Employee Coverage Amount Employee - $30,000 Spouse /Child– 100% of Employee Coverage Amount 3/12 exclusion 0 days Included $50 per insured per calendar year 100% Paid by the Employee Wellness benefit premium is in addition to the base premium.

Additional Critical Illnesses for your Children:  Cerebral Palsy  Cleft Lip or Palate  Cystic Fibrosis  Down Syndrome  Spina Bifida Supplemental Critical Illnesses:  Benign Brain Tumor  Coma  Loss of Hearing  Infectious Disease (25%)  Loss of Sight  Loss of Speech  Occupational Human Immunodeficiency Virus (HIV) or Hepatitis  Permanent Paralysis Progressive Diseases:  Amyotrophic Lateral Sclerosis (ALS)  Dementia (including Alzheimer's Disease)  Functional Loss  Multiple Sclerosis (MS)  Parkinson's Disease Employee/Spouse Cost

Age

$10,000

$20,000

$30,000

<25 25 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 65 - 69 70 - 74 75 - 79 80 - 84 85+

$2.63 $2.93 $3.33 $4.03 $4.93 $6.43 $8.23 $10.13 $14.23 $21.73 $39.13 $66.33 $113.43 $206.63

$3.73 $4.33 $5.13 $6.53 $8.33 $11.33 $14.93 $18.73 $26.93 $41.93 $76.73 $131.13 $225.33 $411.73

$4.83 $5.73 $6.93 $9.03 $11.73 $16.23 $21.63 $27.33 $39.63 $62.13 $114.33 $195.93 $337.23 $616.83 37

MUTUAL OF OMAHA YOUR BENEFITS PACKAGE

Life and AD&D

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

Motor vehicle crashes are the

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 38 Dickinson ISD Benefits Website: www.mybenefitshub.com/dickinsonisd

Basic Life and AD&D We’ve Got You Covered As an active employee of Dickinson Independent School District, you have access to a life insurance policy from United of Omaha Life Insurance Company. It replaces the income you would have provided, and helps pay funeral costs, manage debt and cover ongoing expenses.

How much insurance is enough? When determining how much life insurance you need, think about the expenses you may encounter now and through every stage of your life. Coverage guidelines and benefits are outlined in the chart below.

feature allows you to secure additional life insurance protection in the event your needs change (ex. you get married or have a child). Amounts over the Guarantee Issue will require evidence of insurability (information about your health). Conversion— If your employment ends, you may apply for an individual life insurance policy from Mutual of Omaha without having to provide evidence of insurability (information about your health). You will be responsible for the premium for the coverage. Additional AD&D Benefits— In addition to basic AD&D benefits, you are protected by the following benefits: Child Education, Seat Belt, Airbag, Common Carrier.

Services

Benefits

Travel Assistance— The Travel Assistance program is an added benefit that provides assistance for your travels over 100 miles away from home or outside the country. Employee Assistance Program (EAP)—The EAP program provides you and your loved ones access to trained professionals and resources for assistance with personal and workplace issues. Hearing Discount Program— The Hearing Discount Program provides you and your family discounted hearing products, including hearing aids and batteries. Call 1-888-534-1747 or visit www.amplifonusa.com/mutualofomaha to learn more. Will Prep— We work with Willing® to offer employees discounted online will preparation tools. In just a few clicks you can complete a customized plan to protect your family and property (valid in all Living Care/ Accelerated Death Benefit— 80% of the amount of the life insurance benefit is available to you if terminally ill, not to 50 states). To get started visit www.willing.com/mutualofomaha exceed $8,000. Waiver of Premium— If it is determined that you are totally disabled, your life insurance benefit will continue without Insurance benefits and guarantee issue amounts are subject to payment of premium, subject to certain conditions. age reductions: Annual Benefit Amount Increase— If you enroll for even the - At age 75, amounts reduce to 45% minimum amount of coverage during your initial enrollment, you Information about the AD&D exclusions for this plan will be have the ability to enroll for additional coverage at your next included in the summary of coverage, which you will receive after enrollment by up to $10,000, provided the total amount of enrolling. insurance does not exceed your maximum benefit amount. This Life Insurance Benefit Amount Employer Paid: $10,000 In the event of death, the benefit paid will be equal to the benefit amount after any age reductions less any living care/accelerated death benefits previously paid under this plan. Accidental Death & Dismemberment (AD&D) Benefit Amount Employer Paid: The Principal Sum amount is equal to the amount of your life insurance benefit.

Features

Age Reductions and Exclusions

Eligibility Requirement Premium Payment

ELIGIBILITY - ALL ELIGIBLE EMPLOYEES You must be actively working a minimum of 20 hours per week to be eligible for coverage. The premiums for this insurance are paid in full by the policyholder. There is no cost to you for this insurance.

Voluntary Life and AD&D in the event your needs change (ex. you get married or have a child). Amounts over the Guarantee Issue will require evidence of Voluntary Term Life Benefits insurability (informa on about your health).  This plan includes the op on to select coverage for your Portability— Allows you to con nue this insurance program for spouse and dependent children. Children include those, up yourself and your dependents should you leave your employer to age 26. for any reason, without having to provide evidence of insurability  In the event of death, the benefit paid will be equal to the (informa on about your health). You will be responsible for the benefit amount a er any age reduc ons less any living care/ premium for the coverage. accelerated death benefits previously paid under this plan. Conversion— If your employment ends, you may apply for an  At this open enrollment, all benefit eligible employees will individual life insurance policy from Mutual of Omaha without have the ability to purchase the lesser of 7 x annual salary or having to provide evidence of insurability (informa on about $200K on themselves, up to $50K for their spouse and up to your health). You will be responsible for the premium for the $10K for their dependent children on a guarantee issue basis coverage. meaning no health ques ons are required. Addi onal AD&D Benefits— In addi on to basic AD&D benefits, you are protected by the following benefits: Child Educa on, Seat Voluntary AD&D Benefits Belt, Airbag, Common Carrier.  For you, your spouse and your dependent child(ren): The Principal Sum amount is equal to the amount of the life Services insurance benefit. Hearing Discount Program— The Hearing Discount Program  AD&D is addi onal coverage that is available if you or your dependents are injured or die as a result of an accident, and provides you and your family discounted hearing products, including hearing aids and ba eries. Call 1‐888‐534‐1747 or visit the injury or death is independent of sickness and all other www.amplifonusa.com/mutualofomaha to learn more. causes. The benefit amount depends on the type of loss Will Prep— We work with Willing® to oﬀer employees discounted incurred, and is either all or a por on of the Principal Sum.  Employee guaranteed issue amount up to $250,000, with a online will prepara on tools. In just a few clicks you can complete a customized plan to protect your family and property (valid in all maximum benefit of $500,000 or 5X salary. 50 states). To get started visit www.willing.com/mutualofomaha AD&D COVERAGE RATE

Benefits

$0.20

$10,000

Age Reduc ons and Exclusions

Insurance benefits and guarantee issue amounts are subject to age reduc ons: Features  At age 65, amounts reduce to 65% Living Care/ Accelerated Death Benefit— 80% of the amount of  At age 70, amounts reduce to 50% the life insurance benefit is available to you if terminally ill, not to  Spouse coverage terminates when you reach age 70. exceed $250,000. Life insurance benefits will not be paid if the insured’s death is Waiver of Premium— If it is determined that you are totally the result of suicide within two years from the date coverage disabled, your life insurance benefit will con nue without begins. If this occurs, the sum of the premiums paid will be payment of premium, subject to certain condi ons. returned to the beneficiary. The same applies for any future Annual Benefit Amount Increase— If you enroll for even the minimum amount of coverage during your ini al enrollment, you increases in coverage under this plan. Informa on about the AD&D exclusions for this plan will be have the ability to enroll for addi onal coverage at your next included in the summary of coverage, which you will receive a er enrollment by up to $10,000, provided the total amount of insurance does not exceed your maximum benefit amount. This enrolling. feature allows you to secure addi onal life insurance protec on

Eligibility Requirement

ELIGIBILITY ‐ ALL ELIGIBLE EMPLOYEES You must be ac vely working a minimum of 20 hours per week to be eligible for coverage.

Dependent Eligibility Requirement

To be eligible for coverage, your dependents must be able to perform normal ac vi es, and not be con‐ fined (at home, in a hospital, or in any other care facility), and any child(ren) must be under age 26. In or‐ der for your spouse and/or children to be eligible for coverage, you must elect coverage for yourself.

Premium Payment

The premiums for this insurance are paid in full by you.

Voluntary Life Voluntary Life Coverage Selec on and Premium Calcula on Please note that the premium amounts presented below may vary slightly from the amounts provided on your enrollment form, due to rounding.

3) Your premium amount is found in the box where the row (your age) and the column (benefit amount) intersect. 4) Enter the benefit and premium amounts into their respec‐ ve areas in the Voluntary Life and sec on of your enroll‐ To select your benefit amount and calculate your premium, do ment form. the following: If the benefit amount you want to select is greater than any 1) Locate the benefit amount you want from the top row of amount in the table below, select the benefit amount from the the employee premium table. Your benefit amount must be top row that when mul plied by another number results in the in an increment of $10,000. Refer to the Coverage Guide‐ benefit amount you want. For example, if you want $150,000 in lines sec on for minimums and maximums, if needed. coverage, you obtain your premium amount by mul plying the 2) Find your age bracket in the far le column. rate for $50,000 mes 3. Age

$10,000

EMPLOYEE PREMIUM TABLE (12 PAYROLL DEDUCTIONS PER YEAR) $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000

0 ‐ 29 30 ‐ 34 35 ‐ 39 40 ‐ 44 45 ‐ 49 50 ‐ 54 55 ‐ 59 60 ‐ 64 65+

$0.60 $0.70 $0.90 $1.30 $2.20 $3.70 $5.80 $8.70 $14.50

$1.20 $1.40 $1.80 $2.60 $4.40 $7.40 $11.60 $17.40 $29.00

$1.80 $2.10 $2.70 $3.90 $6.60 $11.10 $17.40 $26.10 $43.50

$2.40 $2.80 $3.60 $5.20 $8.80 $14.80 $23.20 $34.80 $58.00

$3.00 $3.50 $4.50 $6.50 $11.00 $18.50 $29.00 $43.50 $72.50

$3.60 $4.20 $5.40 $7.80 $13.20 $22.20 $34.80 $52.20 $87.00

$4.20 $4.90 $6.30 $9.10 $15.40 $25.90 $40.60 $60.90 $101.50

$4.80 $5.60 $7.20 $10.40 $17.60 $29.60 $46.40 $69.60 $116.00

$90,000

$100,000

$5.40 $6.30 $8.10 $11.70 $19.80 $33.30 $52.20 $78.30 $130.50

$6.00 $7.00 $9.00 $13.00 $22.00 $37.00 $58.00 $87.00 $145.00

Follow the method described above to select a benefit amount and calculate premiums for op onal dependent spouse and/or child (ren) coverage. Your spouse’s rate is based on your age, so find your age bracket in the far le column of the Spouse Premium Table. Your spouse’s premium amount is found in the box where the row (the age) and the column (benefit amount) intersect. Your spouse’s benefit amount must be in an increment of $5,000. Refer to the Coverage Guidelines sec on for minimums and maximums, if needed. Age 0 ‐ 29 30 ‐ 34 35 ‐ 39 40 ‐ 44 45 ‐ 49 50 ‐ 54 55 ‐ 59 60 ‐ 64 65 ‐ 69

$5,000 $0.30 $0.35 $0.45 $0.65 $1.10 $1.85 $2.90 $4.35 $7.25

$10,000 $0.60 $0.70 $0.90 $1.30 $2.20 $3.70 $5.80 $8.70 $14.50

SPOUSE PREMIUM TABLE (12 PAYROLL DEDUCTIONS PER YEAR) $15,000 $20,000 $25,000 $30,000 $35,000 $0.90 $1.20 $1.50 $1.80 $2.10 $1.05 $1.40 $1.75 $2.10 $2.45 $1.35 $1.80 $2.25 $2.70 $3.15 $1.95 $2.60 $3.25 $3.90 $4.55 $3.30 $4.40 $5.50 $6.60 $7.70 $5.55 $7.40 $9.25 $11.10 $12.95 $8.70 $11.60 $14.50 $17.40 $20.30 $13.05 $17.40 $21.75 $26.10 $30.45 $21.75 $29.00 $36.25 $43.50 $50.75

$40,000 $2.40 $2.80 $3.60 $5.20 $8.80 $14.80 $23.20 $34.80 $58.00

$45,000 $2.70 $3.15 $4.05 $5.85 $9.90 $16.65 $26.10 $39.15 $65.25

$50,000 $3.00 $3.50 $4.50 $6.50 $11.00 $18.50 $29.00 $43.50 $72.50

*Regardless of how many children you have, they are included in the "All Children" premium amounts listed in the table above. ALL CHILDREN PREMIUM TABLE (12 PAYROLL DEDUCTIONS PER YEAR)* $5,000

$10,000

$0.50

$1.00

5STAR

Individual Life

YOUR BENEFITS PACKAGE

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

Experts recommend at least

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

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

Term Life with Terminal Illness and Quality of Life Rider The Family Protection Plan: Term Life Insurance with Terminal Illness Coverage to Age 100 Nearly 85% of Americans say most people need life insurance; unfortunately only 62% have coverage and a staggering 33% say they don’t have enough life insurance, including one-fourth who already have life insurance coverage.** Nobody wants to be a statistic - especially during a period of grief. That’s why 5Star Life Insurance Company developed its FPP policy - to ensure you and your loved ones are covered during a period of loss.

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.

DID YOU KNOW? Protecting your financial well being is easier than you think. It’s like trading in a daily latte for peace of mind.

$4.30 per day to start your morning with a $1.75

gourmet coffee OR per day to enrich your employee benefits package

It’s less expensive than you think.

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 (ages 15 days to age 24). Quality of Life Benefit - Following a diagnosis of either a chronic illness or cognitive impairment, this rider accelerates a portion of the death benefit on a monthly basis – 4%; up to 75% of your benefit, and payable directly to you on a tax favored basis for the following:  Permanent inability to perform at least two of the six Activities of Daily Living (ADLs) without substantial assistance; or  Permanent severe cognitive impairment, such as dementia, Alzheimer’s disease and other forms of senility, requiring substantial supervision. 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 twoyear contestability period and/or under investigation. This product also contains no war or terrorism exclusions.

* Life insurance product underwritten by 5Star Life insurance Company (a Baton Rouge, Louisiana company) with an administrative office at 909 N. Washington Street, Alexandria, VA 22314

Family Protection Plan - Terminal Illness MONTHLY RATES WITH QUALITY OF LIFE RIDER DEFINED BENEFIT

18-25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45

$10,000 $7.56 $7.59 $7.65 $7.74 $7.88 $8.07 $8.27 $8.50 $8.73 $9.01 $9.30 $9.64 $10.02 $10.41 $10.85 $11.31 $11.83 $12.41 $13.00 $13.63 $14.27

$20,000 $10.78 $10.83 $10.97 $11.15 $11.43 $11.80 $12.20 $12.65 $13.11 $13.67 $14.27 $14.95 $15.70 $16.48 $17.35 $18.29 $19.33 $20.48 $21.66 $22.91 $24.22

$30,000 $14.01 $14.09 $14.28 $14.56 $14.99 $15.53 $16.14 $16.81 $17.51 $18.34 $19.23 $20.26 $21.39 $22.56 $23.86 $25.26 $26.83 $28.56 $30.34 $32.21 $34.16

Employee Coverage Amounts $40,000 $50,000 $75,000 $17.24 $20.46 $28.53 $17.33 $20.59 $28.71 $17.60 $20.92 $29.21 $17.96 $21.38 $29.90 $18.54 $22.09 $30.96 $19.27 $23.00 $32.34 $20.06 $24.00 $33.84 $20.97 $25.12 $35.52 $21.90 $26.29 $37.27 $23.00 $27.67 $39.33 $24.20 $29.17 $41.59 $25.57 $30.88 $44.15 $27.07 $32.76 $46.96 $28.64 $34.71 $49.89 $30.37 $36.87 $53.15 $32.23 $39.21 $56.65 $34.33 $41.83 $60.58 $36.63 $44.71 $64.90 $39.00 $47.67 $69.33 $41.50 $50.79 $74.02 $44.10 $54.05 $78.90

46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

$14.97 $15.70 $16.43 $17.22 $18.08 $19.04 $20.16 $21.40 $22.79 $24.26 $25.94 $27.66 $29.42 $31.23 $33.12 $35.08 $37.12 $39.31 $41.68 $44.34

$25.60 $27.05 $28.51 $30.10 $31.82 $33.75 $35.98 $38.46 $41.25 $44.20 $47.53 $50.98 $54.50 $58.12 $61.90 $65.82 $69.91 $74.29 $79.04 $84.33

$36.24 $38.41 $40.61 $42.98 $45.56 $48.46 $51.81 $55.54 $59.71 $64.13 $69.14 $74.31 $79.58 $85.01 $90.69 $96.56 $102.71 $109.26 $116.38 $124.34

$46.87 $49.77 $52.70 $55.87 $59.30 $63.17 $67.63 $72.60 $78.17 $84.06 $90.73 $97.63 $104.67 $111.90 $119.46 $127.30 $135.50 $144.23 $153.73 $164.33

Age on Eff. Date

$57.51 $61.13 $64.79 $68.75 $73.04 $77.88 $83.46 $89.67 $96.63 $104.00 $112.34 $120.96 $129.75 $138.79 $148.25 $158.04 $168.29 $179.21 $191.09 $204.34

$84.09 $89.52 $95.03 $100.96 $107.39 $114.65 $123.02 $132.33 $142.77 $153.83 $166.33 $179.27 $192.46 $206.02 $220.21 $234.90 $250.27 $266.65 $284.46 $304.33

$100,000 $36.59 $36.83 $37.50 $38.41 $39.84 $41.67 $43.66 $45.92 $48.25 $51.00 $54.00 $57.42 $61.17 $65.09 $69.42 $74.08 $79.33 $85.08 $91.00 $97.25 $103.75

$125,000 $44.65 $44.96 $45.80 $46.94 $48.71 $51.01 $53.50 $56.31 $59.23 $62.67 $66.42 $70.69 $75.37 $80.27 $85.68 $91.52 $98.08 $105.27 $112.67 $120.48 $128.60

$150,000 $52.71 $53.09 $54.08 $55.46 $57.59 $60.33 $63.34 $66.71 $70.21 $74.34 $78.83 $83.96 $89.59 $95.46 $101.96 $108.96 $116.83 $125.46 $134.34 $143.71 $153.46

$110.67 $117.92 $125.25 $133.17 $141.75 $151.42 $162.58 $175.00 $188.92 $203.66 $220.33 $237.58 $255.17 $273.25 $292.16 $311.75 $332.25 $354.08 $377.83 $404.33

$137.25 $146.32 $155.48 $165.37 $176.10 $188.19 $202.15 $217.67 $235.07 $253.50 $274.34 $295.89 $317.87 $340.48 $364.13 $388.60 $414.23 $441.52 $471.21 $504.34

$163.84 $174.71 $185.71 $197.58 $210.46 $224.96 $241.71 $260.34 $281.21 $303.33 $328.34 $354.21 $380.58 $407.71 $436.09 $465.46 $496.21 $528.96 $564.58 $604.34

Family Protection Plan - Terminal Illness MONTHLY RATES WITH QUALITY OF LIFE RIDER DEFINED BENEFIT Age on Eff. Date 66* 67* 68* 69* 70*

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

$20,000 $85.52 $92.17 $99.73 $108.32 $118.00

$30,000 $126.11 $136.08 $147.43 $160.31 $174.83

Employee Coverage Amounts $40,000 $50,000 $75,000 $166.70 $207.29 $308.77 $180.00 $223.92 $333.71 $195.13 $242.83 $362.08 $212.30 $264.29 $394.27 $231.67 $288.50 $430.58

$100,000 $410.25 $443.50 $481.33 $524.25 $572.67

$125,000 $511.73 $553.29 $600.58 $654.23 $714.75

$150,000 $613.21 $663.08 $719.83 $784.21 $856.83

*Quality of Life not available ages 66 - 70. Quality of Life benefits not available for children. Child life coverage available only on children and grandchildren of employee (age on effective date: age 14 days to 23 years). $4.98 monthly for $10,000 coverage and $9.97 monthly for $20,000 coverage.

LIFEWORKS

EAP (Employee Assistance Program)

YOUR BENEFITS PACKAGE

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

38%

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

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

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

Description

Emotions and Stress

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

Parenting

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

Midlife and Retirement

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

Addictive Behaviors

Drug and alcohol abuse, eating disorders, gambling

Education

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

Caring of older adults

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

Disability

Special needs programs, advocacy and specific disabilities information

Everyday Issues

Community resources and consumer information

Financial Issues

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

Legal Issues

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

Work

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

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



Telephone: (888) 456-1324   

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

Mobile 

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

In-Person 



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

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

NBS

FSA (Flexible Spending Account)

YOUR BENEFITS PACKAGE

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

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 48 Dickinson ISD Benefits Website: www.mybenefitshub.com/dickinsonisd

FSA (Flexible Spending Account) NBS Flexcard

When Will I Receive My Flex Card?

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

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

NBS Contact Information: NBS Prepaid MasterCard® Debit Card

Current plan participants:

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

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

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

FSA Annual Contribution Max: $2,650

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

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

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

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

FSA Frequently Asked Questions What is a Flexible Spending Account?

How Do I File A Claim?

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.

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

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

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

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

        

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

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

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

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

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

Get Your Money 1. 2. 3. 4.

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

NBS Flexcard—FSA Pre-paid Benefit Card Dickinson ISD does sponsor the use of the NBS Flexcard. You may use the card to pay merchants or service providers that accept credit cards, so there is no need to pay cash up front then wait for reimbursement.

Account Information Participants may call NBS and talk to a representative during our regular business hours, Monday–Friday, 7am to 6pm Mountain Time. Participants can also obtain account information using the Automated Voice Response Unit, 24 hours a day, 7 days a week at (801) 838-7324 or toll free (888) 353-9125. For immediate access to your account information at any time, log on to our website www.NBSbenefits.com. Information includes:    

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

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