2018 Benefit Guide Jacksonville ISD

JACKSONVILLE ISD

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

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Table of Contents

Benefit Contact Information How to Enroll Annual Benefit Enrollment 1. Benefit Updates

3 4-5 6-11 6

2. Section 125 Cafeteria Plan Guidelines

7

3. Annual Enrollment

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4. Eligibility Requirements

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5. Helpful Definitions 6. HSA vs FSA Comparison

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FLIP TO...

PG. 4 HOW TO HOW TO ENROLL ENROLL

11

TRS-ActiveCare Aetna

12-13

EECU Health Savings Account

14-17

Cigna Dental

18-21

Superior Vision The Hartford Long Term Disability

22-23

APL Cancer 5Star Family Protection Plan Term Life Insurance with Quality of Life Rider AUL a OneAmerica Company Life and AD&D

28-31

36-39

PG. 12

NBS Flexible Spending Account

40-43

YOUR BENEFITS

2

PG. 6 SUMMARY PAGES

24-27 32-35

Benefit Contact Information BENEFIT ADMINISTRATORS

DENTAL

FAMILY PROTECTION PLAN-

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

Group# 3338975 CIGNA (800) 244-6224 www.mycigna.com

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

JACKSONVILLE ISD BENFITS OFFICE

VISION

LIFE AND AD&D

(903) 586-6511 www.jisd.org

Group# 320510 Superior Vision (800) 507-3800 www.superiorvision.com

Group# G00614229 AUL A OneAmerica Company www.oneamerica.com

TRS ACTIVECARE MEDICAL

DISABILITY

FLEXIBLE SPENDING ACCOUNTS

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

Group# 873359 The Hartford (800) 523-2233 File a claim : (866) 278-2655 www.thehartford.com

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

HEALTH SAVINGS ACCOUNTS

CANCER

EECU (800) 333-9934 www.eecu.org

Group# 13042 American Public Life (APL) (800) 256-8606 www.ampublic.com

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MOBILE ENROLLMENT Enrollment made simple through your smartphone or tablet.

Text “FBS JISD” to 313131 and get access to everything you need to complete your benefits enrollment: 

Benefit Information



Online Support



Interactive Tools



And more.

PLAY VIDEO

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Text “FBS JISD” to 313131 OR SCAN

How to Log In

1 BENEFIT INFO

INTERACTIVE TOOLS

2 3

www.mybenefitshub.com/ jacksonvilleisd

CLICK LOGIN

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

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

ONLIINE SUPPORT

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

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

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Annual Benefit Enrollment

SUMMARY PAGES

Benefit Updates - What’s New: Due to ACA, you MUST login to www.mybenefitshub.com/jacksonvilleisd and either waive or elect medical insurance by 8/22/18 

UPDATE! The HCR FSA max contribution is increasing to $2,650.



UPDATE! The individual HSA max contribution is increasing to $3,450. The family HSA max contribution is increasing to $6,900

Even if you are declining insurance, you MUST login to www.mybenefitshub.com/jacksonvilleisd & elect/waive benefits.

Benefit elections will become effective 9/1/2018 (elections requiring evidence of insurability, such as life Insurance, may have a later effective date, if approved). After annual enrollment closes, benefit changes can only be made if you experience a qualifying event (& changes must be made within 30 days of event).

If you currently participate in a HealthCare or Dependent Care FSA, you MUST re-elect a new contribution amount every year to continue to participate. You cannot participate in the HealthCare FSA if you elect the HSA. HealthCare Reimbursement FSA funds can be rolled up to $500 from the following plan year.

Don’t Forget!     

You MUST login & complete your benefit enrollment from 7/1/1 - 8/22/18. Any changes made after 8/24/17 must be completed through the benefits administration office.

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

Your dependent Social Security numbers MUST be listed in THEbenefitsHUB. Update your profile information: (home address, phone numbers, email).

Update your beneficiary designation for the free Basic Life coverage & any Voluntary Life, Individual Life and/or AD&D coverage.

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SUMMARY PAGES

Section 125 Cafeteria Plan Guidelines A Cafeteria plan enables you to save money by using pre-tax dollars to pay for eligible group insurance premiums sponsored and offered by your employer.

Enrollment is automatic unless you decline this benefit.

Elections made during annual enrollment will become effective on the plan effective date and will remain in effect during the entire plan year.

CHANGES IN STATUS (CIS): Marital Status

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

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

A change in number of dependents includes the following: birth, adoption and placement for adoption.

Change in Number of Tax You can add existing dependents not previously enrolled whenever a dependent gains eligibility as a Dependents result of a valid change in status event.

Change in Status of Employment Affecting Coverage Eligibility

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

An event that causes an employee's dependent to satisfy or cease to satisfy coverage requirements Gain/Loss of Dependents' under an employer's plan may include change in age, student, marital, employment or tax dependent Eligibility Status status.

If a judgment, decree, or order from a divorce, annulment or change in legal custody requires that you provide accident or health coverage for your dependent child (including a foster child who is your dependent), you may change your election to provide coverage for the dependent child. If the order Judgment/Decree/Order requires that another individual (including your spouse and former spouse) covers the dependent child and provides coverage under that individual's plan, you may change your election to revoke coverage only for that dependent child and only if the other individual actually provides the coverage.

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

Programs

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SUMMARY PAGES

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

Where can I find forms?

to review, change or continue benefit elections each year.

For benefit summaries and claim forms, go to your benefit

Changes are not permitted during the plan year (outside of

website:

annual enrollment) unless a Section 125 qualifying event occurs.

www.mybenefitshub.com/jacksonvilleisd. 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

ISD benefit website: www.mybenefitshub.com/jacksonvilleisd.

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 the Jacksonville

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 3-4 weeks after your effective date. For most dental and vision plans, you can login to the carrier website and print a temporary ID card or simply give your provider the insurance company’s phone number and they can call and

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

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

If the insurance carrier provides ID cards, but there are no changes to the plan, you typically will not receive a new ID card each year.

Q&A Who do I contact with Questions?

For supplemental benefit questions, you can contact your Benefits/HR department or you can call Financial Benefit Services at 866-914-5202 for assistance.

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SUMMARY PAGES

Employee Eligibility Requirements

Dependent Eligibility Requirements

Supplemental Benefits: Eligible employees must work 20 or more

Dependent Eligibility: You can cover eligible dependent

regularly scheduled hours each work week.

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

Eligible employees must be actively at work on the plan effective

maximum age listed below. Dependents cannot be double

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

covered by married spouses within the Jacksonville ISD or as

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

both employees and dependents.

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

PLAN

CARRIER

MAXIMUM AGE

Medical

Aetna

To Age 26

Dental

Cigna

To Age 26

Vision

Superior Vision

To Age 26

Cancer

APL

To Age 26

Family Protection Plan w/ LTC

5Star Life

Issue to 24; Keep to 100

Voluntary Life and AD&D

One America

To Age 26

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

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SUMMARY PAGES

Helpful Definitions Actively at Work

In-Network

You are performing your regular occupation for the employer

Doctors, hospitals, optometrists, dentists and other providers

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

who have contracted with the plan as a network provider.

places of business or at some location to which the employer’s business requires you to travel. If you will not be actively at work beginning 9/1/2018 please notify your benefits administrator.

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

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

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

Plan Year September 1st through August 31st.

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

Calendar Year January 1st through December 31st

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

Guaranteed Coverage The amount of coverage you can elect without answering any medical questions or taking a health exam. Guaranteed coverage is only available during initial eligibility period.

Actively-at-work and/or pre-existing condition exclusion provisions do apply, as applicable by carrier.

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(including diagnostic and/or consultation services).

SUMMARY PAGES

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

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

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

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

Employer Eligibility

A qualified high deductible health plan.

All employers

Contribution Source Account Owner Underlying Insurance Requirement

Employee and/or employer Individual

Employee and/or employer Employer

High deductible health plan

None

Description

Minimum Deductible Maximum Contribution

$1,300 single (2018) $2,600 family (2018) $3,450 single (2018) $6,900 family (2018)

N/A $2,650

Permissible Use Of Funds

If used for non-qualified medical expenses, subject to current tax rate plus 20% penalty.

Reimbursement for qualified medical expenses (as defined in Sec. 213(d) of IRC).

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

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

Not permitted

Year-to-year rollover of account balance?

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

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

Does the account earn interest?

Yes

No

Portable?

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

No

FLIP TO FOR HSA INFORMATION

PG. 14

FLIP TO FOR FSA INFORMATION

PG. 40

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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

$500 copay per visit plus 20% after deductible

$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

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• 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 50% coinsurance for a 1- to 31-day supply3 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

$105 for a 60- to 90-day supply3 $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 50% coinsurance for a 1- to 31-day supply3

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 +Children +Family

Individual

Your Monthly Premium***

Full monthly premium*

Premium with min. state/ district contribution**

$142

$540

$1,035

$810

$701

$476

$1,374

$1,149

Your Monthly Premium***

Full monthly premium*

Premium with min. state/ district contribution**

$315

$782

$557

$1,327

$1,102

$1,855

$1,630

$876

$651

$1,163

$938

$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.) *** Completed by your benefits administrator. The state/district contribution may be greater than $225.

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EECU

HSA (Health Savings Account)

YOUR BENEFITS PACKAGE

PLAY VIDEO

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

The interest earned in an HSA is tax free.

Money withdrawn for medical spending never falls under taxable income.

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

HSA (Health Savings Account) What is an HSA?

How to Use Your Funds

Health Savings Account (HSA) enables you to save for and conveniently pay for qualified healthcare expenses, while you earn tax-free interest and pay no monthly service fees.

Opening a Health Savings Account provides both immediate and long term benefits. The money in your HSA is always yours, even if you change jobs, switch your health plan, become unemployed or retire. Your unused HSA balance rolls over from year to year. And best of all, HSAs have tax-free deposits, tax-free earnings and tax-free withdrawals. And after age 65, you can withdraw funds from your HSA penalty-free for any purpose.



HSA Debit Card – use your EECU HSA Mastercard® debit card to pay healthcare providers at point-of-sale or by following the instructions provided on a bill from a medical provider.



Online Bill Pay – sign up, at eecu.org, and use EECU’s free online banking and bill pay to make payments to medical providers directly from your HSA. Online Transfers – use EECU’s online banking or mobile app; reimburse yourself for out-of-pocket expenses by making a transfer from your HSA to your personal checking or savings account.

Check – optional HSA checks can be ordered upon request for a fee. You can use these checks to pay healthcare providers and suppliers.

EECU HSA Benefits

Save money tax-free for healthcare expenses –  contributions are not subject to federal income taxes and can be made by you, your employer or a third party*  No monthly service fee – so you can save more and earn  more  Earn competitive dividends on your entire balance – compounded daily and paid monthly from deposit to withdrawal  Conveniently pay for qualified healthcare expenses – Save your receipts – for all qualified medical with a free, no annual fee EECU HSA Debit Mastercard® expenses. EECU does not verify eligibility. or via EECU’s free online bill pay. (HSA checks are also You are responsible for making sure payments are for qualified medical expenses. available upon request, for a nominal fee**)  Free online, mobile and branch access – allows you to actively manage your account however you prefer  Comprehensive service and support – to assist you in optimizing your healthcare saving and spending How To Manage Your Account  Federally insured – to at least $250,000 by NCUA • Online - check your balance, pay healthcare providers and arrange deposits; sign-up for online banking at www.eecu.org.

2018 Annual HSA Contribution Limits • Mobile - EECU’s mobile app allows you to manage your Individual: $3,450 account on the go; download “EECU Mobile Banking” in Family: $6,900 Apple’s App Store and Google Play.

Catch-Up Contributions: Accountholders who meet the • Contact Member Service – call 800-333-9934 for help qualifications noted below are eligible to make an HSA with your HSA questions or transactions. You can also catch-up contribution of an additional $1,000. chat with us online at eecu.org or use our secure email.  Health Savings accountholder Member Service is available Monday through Friday  Age 55 or older (regardless of when in the year an from 8am – 6:30pm CT, Saturdays from 9am – 1pm CT accountholder turns 55) and closed on Sunday.  Not enrolled in Medicare (if an accountholder enrolls in • Account Statements – monthly statements show all your Medicare mid-year, catch-up contributions should be account activity for that period. You can receive free prorated) Authorized Signers who are 55 or older must have their own online statements or pay $2 per printed statement. 

HSA in order to make the catch-up contribution

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

How an HSA works: 



 

You can contribute to your HSA via payroll deduction, online banking transfer, or by sending a personal check to EECU. Your employer or third parties, such as a spouse or parent, may contribute to your account as well.

You can pay for qualified medical expenses with your EECU Debit Card directly to your medical provider or pay out-of-pocket. You can either choose to reimburse yourself or keep the funds in your HSA to grow your savings.

Unused funds will roll over year to year. After age 65, funds can be withdrawn for any purpose without penalty (subject to ordinary income taxes).

Check balances and account information via EECU’s Internet Banking 24/7.

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

When you open an account, EECU will request certain information to verify your identity and to process your application.

What are the annual IRS contribution limits?

Contributions made by all parties to an HSA cannot exceed the annual HSA limit set by the Internal Revenue Service (IRS). Anyone can contribute to your HSA, but only the accountholder and employer can receive tax deductions on those contributions. Combined annual contributions for the accountholder, employer, and third parties (i.e., parent, spouse, or anyone else) must not exceed these limits 2.

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Catch-up Contributions Accountholders who meet these qualifications are eligible to make an HSA catch-up contribution of $1,000: Health Savings accountholder; age 55 or older (regardless of when in the year an accountholder turns 55); not enrolled in Medicare (if an accountholder enrolls in Medicare mid-year, catch-up contributions should be prorated). Authorized signers who are 55 or older must have their own HSA in order to make the catch -up contribution.

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

How can you benefit from tax savings?

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

Examples of Qualified Expenses Use your HSA to pay for qualified medical expenses, as defined by the Internal Revenue Service, for yourself, your spouse or tax dependents. Here are some examples: • Acupuncture • Ambulance Service • Chiropractor • Dental Care • Doctor’s Fees • Hearing Aids

• Laboratory Fees • Prescription Drugs • Vaccines • Vision Care • Wheel Chairs • X-Rays

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

How the HSA Plan Works

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CIGNA

Dental

YOUR BENEFITS PACKAGE

PLAY VIDEO

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

Good dental care may improve your overall health.

Also Women with gum disease may be at greater risk of giving birth to a preterm or low birth weight baby.

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

Dental PPO - Low Option Cigna Dental Choice Plan Network Options

Reimbursement Levels

Monthly PPO Premiums

In-Network: Total Cigna DPPO Network

Out-of-Network: See Non-Network Reimbursement

Based on Contracted Fees

Maximum Allowable Charge

$750

$750

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

Tier

Rate

EE Only

$20.50

EE + Spouse

$44.72

EE + Child(ren)

$49.66

Family Coverage

$73.89

Annual Deductible Individual Family

Benefit Highlights

$100 $300

Plan Pays

$100 $300

You Pay

Plan Pays

You Pay

Class I: Diagnostic & Preventive Oral Exams Cleanings Bitewing X-rays Fluoride Application Sealants: per tooth Space Maintainers: non-orthodontic

Anything over 100% the Maximum No Deductible Allowable Charge

100% No Deductible

No Charge

80% After Annual Deductible

20% After Annual Deductible

80% After Annual Deductible

20% After Annual Deductible

50% After Annual Deductible

50% After Annual Deductible

50% After Annual Deductible

50% After Annual Deductible

Class II: Basic Restorative Full mouth / Panoramic / Periapical X-rays Emergency Care to Relieve Pain Restorative: fillings Oral Surgery: Simple Extractions

Class III: Major Restorative Inlays and Onlays Prosthesis Over Implant Crowns, Bridges and Dentures Endodontics: minor and major Periodontics: minor and major Anesthesia: general and IV sedation Repairs: Bridges, Crowns and Inlays Repairs: Dentures Denture Relines, Rebases and Adjustments Oral Surgery: All except Simple Extractions Extractions of Impacted Teeth Stainless Steel Crowns

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.

19

Dental PPO - High Option Benefits Network Options Reimbursement Levels Policy Year Benefits Maximum Applies to: Class I, II, III, & IX expenses

Cigna Dental PPO - High Option Out-of-Network: In-Network: See Non-Network Total Cigna DPPO Network Reimbursement Based on Contracted Fees

Maximum Reimbursable Charge

$1,000

$1,000

$50 $150

$50 $150

Benefit Highlights

Tier

$35.06

EE + Spouse

$75.68

EE + Family

Plan Pays

You Pay

Plan Pays

You Pay

100% No Deductible

No Charge

100% No Deductible

No Charge

80% After Annual Deductible

20% After Annual Deductible

80% After Annual Deductible

20% After Annual Deductible

50% After Annual Deductible

50% After Annual Deductible

50% After Annual Deductible

50% After Annual Deductible

50% No Deductible

50% No Deductible

50% No Deductible

50% No Deductible

50% After Annual Deductible

50% After Annual Deductible

50% After Annual Deductible

50% After Annual Deductible

Rate

EE Only

EE + 1 Child(ren)

Annual Deductible Individual Family

Monthly PPO Premiums

$84.12 $123.88

Class I: Diagnostic & Preventive Oral Exams Cleanings X-rays: routine X-rays: non-routine Fluoride Application Sealants: per tooth Space Maintainers: non-orthodontic

Class II: Basic Restorative Emergency Care to Relieve Pain Restorative: fillings Endodontics: minor and major Osseous Surgery 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, Bridges and Dentures Stainless Steel/ Resin Crowns

Class IV: Orthodontia Coverage for Dependent Children to age 19 Lifetime Benefits Maximum: $1,500

Class IX: Implants

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.

20

Dental PPO - High and Low Options Benefit Plan Provisions: In-Network Reimbursement Non-Network Reimbursement

Cross Accumulation

Policy Year Benefits Maximum Annual Deductible Late Entrant Limitation Provision

Pretreatment Review Alternate Benefit Provision

Oral Health Integration Program

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. There’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.

Benefit Limitations: Missing Tooth Limitation Oral Exams X-rays (routine) X-rays (non-routine) Diagnostic Casts Cleanings Fluoride Application Sealants (per tooth) Space Maintainers Periodontal Treatment Inlays, Crowns and Bridges Dentures and Partials Denture and Bridge Repairs Denture Adjustments, Rebases and Relines Prosthesis Over Implant

For teeth missing prior to coverage with Cigna, the amount payable is 50% of the amount otherwise payable until covered for 12 months; thereafter, considered a Class III expense.

2 per plan year Bitewings: 2 per plan year Full mouth or panoramic: 1 every 36 consecutive months Payable only in conjunction with orthodontic workup 2 per plan year, including periodontal maintenance procedures following active therapy 1 per plan year for children under age 19 Limited to posterior tooth. 1 treatment per tooth every 36 months for children under age 14 Limited to non-orthodontic treatment for children under age 19 Various limitations depending on the service Replacement every 60 months if unserviceable and cannot be repaired Replacement every 60 months if unserviceable and cannot be repaired Reviewed if more than once Covered if more than 6 months after installation 1 every 60 months if unserviceable and cannot be repaired. Benefits are based on the amount payable for non-precious metals. No porcelain or white/tooth colored material on molar crowns or bridges.

Benefit Exclusions: Covered Expenses will not include, and no payment will be made for the following: Procedures and services not listed under Benefit Highlights; Diagnostic: cone beam imaging; Preventive Services: instruction for plaque control, oral hygiene and diet; Restorative: Porcelain or acrylic veneers of crowns or pontics on, or replacing the upper and lower first, second and 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 Allowable 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 the official plan documents will prevail.

21

SUPERIOR VISION YOUR BENEFITS PACKAGE

Vision

PLAY VIDEO

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

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

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

Vision Benefits

In-Network

Out-of-Network

Covered in full

Up to $35 retail

EE Only

$7.64

$125 retail allowance $150 retail allowance

Up to $70 retail Up to $80 retail

EE + Spouse

$13.00

EE + Child(ren)

$13.78

Covered in full

Up to $150 retail

EE + Family

$20.64

Exam Frames Contact Lenses1 Medically Necessary Contact Lenses

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

Monthly Premiums

Co-Pays Covered in full Covered in full Covered in full See description2 Covered in full

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

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

1

Contact lenses and related professional services (fitting, evaluation and followup) are covered in lieu of eyeglass lenses and frames benefit.

2 Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay.

Exam

$10

Materials

$25

Services/Frequency Exam

12 months

Frame

24 months

Lenses

12 months

Contact Lenses

12 months

(Based on date of service)

Discount Features Non-Covered Eyewear Discount: Members may also receive a discount of 20% from a participating provider’s usual and customary fees for eyewear purchases which exceed the benefit coverage (except disposable contact lenses, for which no discount applies). This includes eyeglass frames which exceed the selected benefit coverage, specialty lenses (i.e. progressives) and lens “extras” such as tints and coatings.

Eyewear purchased from a Walmart Vision Center does not qualify for this additional discount because of Walmart’s “Always Low Prices” policy.

SuperiorVision.com Customer Service 800.507.3800

The Plan discount features are not insurance.

All allowances are retail; the member is responsible for paying the provider directly for all non-covered items and/or any amount over the allowances, minus available discounts. These are not covered by the plan.

Discounts are subject to change without notice.

Disclaimer: All final determinations of benefits, administrative duties, and definitions are governed by the Certificate of Insurance for your vision plan. Please check with your Human Resources department if you have any questions 23

THE HARTFORD YOUR BENEFITS PACKAGE

Disability

PLAY VIDEO

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

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

34.6 months is the duration of the average disability claim.

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

Long Term Disability Disability is designed to provide a monthly income to an individual that is disabled due to an accident or illness. There are different plans available with benefits becoming available from the 1st day of disability to as late as the 180th day. For specific details on how benefits are paid, refer to carrier brochure. Your disability coverage amount and premium can be accessed during your enrollment.



Pre-existing Conditions



Your policy limits the benefits you can receive for a disability caused by a pre-existing condition. In general, if you were diagnosed or received care for a disabling condition within the 3 consecutive months just prior to the effective date of this policy, your benefit payment will be limited, unless: You have not received treatment for the disabling condition within 3 months, while insured under this policy, before the disability begins, or You have been insured under this policy for 12 months before your disability begins. You may also be covered if you have already satisfied the pre-existing condition requirement of your previous insurer. If your disability is a result of a pre-existing condition we will pay benefits for a maximum of 4 weeks.

Benefit Reductions Your benefit payments may be reduced by other income you receive or are eligible to receive due to your disability, such as:  Social Security Disability Insurance (please see www.mybenefitshub.com/jacksonvilleisd for exceptions)  Workers' Compensation  Other employer-based Insurance coverage you may have  Unemployment benefits  Settlements or judgments for income loss  Retirement benefits that your employer fully or partially pays for (such as a pension plan.)



Mental Illness, Alcoholism and Substance Abuse



Exclusions You cannot receive Disability benefit payments for disabilities that are caused or contributed to by:  War or act of war (declared or not)  Military service for any country engaged in war or other armed conflict  The commission of, or attempt to commit a felony  An intentionally self-inflicted injury

You can receive benefit payments for Long-Term Disabilities resulting from mental illness, alcoholism and substance abuse for a total of 24 months for all disability periods during your lifetime.

Any period of time that you are confined in a hospital or other facility licensed to provide medical care for mental illness, alcoholism and substance abuse does not count toward the 24 month lifetime limit.

What other benefits are included in my disability coverage? 

 



Your benefit payments will not be reduced by certain kinds of other income, such as:  Retirement benefits if you were already receiving them before you became disabled  The portion of your Long -Term Disability payment that you place in an IRS-approved account to fund your future retirement.  Your personal savings, investment, IRAs or Keoghs  Profit-sharing  Most personal disability policies  Social Security increases Coverage goes into effect subject to the terms and conditions of the policy. You must satisfy the definition of Actively at Work with your employer on the day your coverage takes effect.

Any case where your being engaged in an illegal occupation was a contributing cause to your disability You must be under the regular care of a physician to receive benefits

 

Workplace Modification provides for reasonable modifications made to a workplace to accommodate your disability and allow you to return to active full-time employment.

Survivor Benefit - If you die while receiving disability benefits, a benefit will be paid to your spouse, child or estate equal to three times the last monthly gross benefit.

Travel Assistance Program – Available 24/7, this program provides assistance to employees and their dependents who travel 100 miles from their home for 90 days or less.

Services include pre-trip information, emergency medical assistance and emergency personal services.

The Hartford's Ability Assist service is included as a part of your group Long Term Disability (LTD) insurance program. You have access to Ability Assist services both prior to a disability and after you’ve been approved for an LTD claim and are receiving LTD benefits. Once you are covered you are eligible for services to provide assistance with child/elder care, substance abuse, family relationships and more. In addition, LTD claimants and their immediate family members receive confidential services to assist them with the unique emotional, financial and legal issues that may result from a disability. Ability Assist services are provided through ComPsych®, a leading provider of employee assistance and work/life services.

Waiver of Premium – Once your disability claim is approved and you have satisfied your elimination period, your coverage premiums will be waived.

Identity Theft Protection – An array of identity fraud support services to help victims restore their identity.

Benefits include 24/7 access to an 800 number; direct contact with a certified caseworker who follows the case until it’s resolved; and a personalized fraud resolution kit with instructions and resources for ID theft victims.

25

Long Term Disability For the Premium benefit option – the table below applies to disabilities resulting from injury or sickness: Age Disabled Prior to Age 63 Age 63 Age 64 Age 65 Age 66 Age 67 Age 68 Age 69 and older

Benefits Payable To Normal Retirement Age or 48 months if greater To Normal Retirement Age or 42 months if greater 36 months 30 months 27 months 24 months 21 months 18 months

MONTHLY PREMIUMS Accident / Sickness Elimination Period in Days Annual Earnings

Monthly Earnings

Monthly Benefit

0/7

14 / 14

30 / 30

60 / 60

90 / 90

180 / 180

$3,600

$300

$200

$7.62

$6.44

$5.58

$4.56

$2.62

$1.88

$5,400

$450

$300

$11.43

$9.66

$8.37

$6.84

$3.93

$2.82

$7,200

$600

$400

$15.24

$12.88

$11.16

$9.12

$5.24

$3.76

$9,000

$750

$500

$19.05

$16.10

$13.95

$11.40

$6.55

$4.70

$10,800

$900

$600

$22.86

$19.32

$16.74

$13.68

$7.86

$5.64

$12,600

$1,050

$700

$26.67

$22.54

$19.53

$15.96

$9.17

$6.58

$14,400

$1,200

$800

$30.48

$25.76

$22.32

$18.24

$10.48

$7.52

$16,200

$1,350

$900

$34.29

$28.98

$25.11

$20.52

$11.79

$8.46

$18,000

$1,500

$1,000

$38.10

$32.20

$27.90

$22.80

$13.10

$9.40

$19,800

$1,650

$1,100

$41.91

$35.42

$30.69

$25.08

$14.41

$10.34

$21,600

$1,800

$1,200

$45.72

$38.64

$33.48

$27.36

$15.72

$11.28

$23,400

$1,950

$1,300

$49.53

$41.86

$36.27

$29.64

$17.03

$12.22

$25,200

$2,100

$1,400

$53.34

$45.08

$39.06

$31.92

$18.34

$13.16

$27,000

$2,250

$1,500

$57.15

$48.30

$41.85

$34.20

$19.65

$14.10

$28,800

$2,400

$1,600

$60.96

$51.52

$44.64

$36.48

$20.96

$15.04

$30,600

$2,550

$1,700

$64.77

$54.74

$47.43

$38.76

$22.27

$15.98

$32,400

$2,700

$1,800

$68.58

$57.96

$50.22

$41.04

$23.58

$16.92

$34,200

$2,850

$1,900

$72.39

$61.18

$53.01

$43.32

$24.89

$17.86

$36,000

$3,000

$2,000

$76.20

$64.40

$55.80

$45.60

$26.20

$18.80

$37,800

$3,150

$2,100

$80.01

$67.62

$58.59

$47.88

$27.51

$19.74

$39,600

$3,300

$2,200

$83.82

$70.84

$61.38

$50.16

$28.82

$20.68

$41,400

$3,450

$2,300

$87.63

$74.06

$64.17

$52.44

$30.13

$21.62

$43,200

$3,600

$2,400

$91.44

$77.28

$66.96

$54.72

$31.44

$22.56

$45,000

$3,750

$2,500

$95.25

$80.50

$69.75

$57.00

$32.75

$23.50

$46,800

$3,900

$2,600

$99.06

$83.72

$72.54

$59.28

$34.06

$24.44

$48,600

$4,050

$2,700

$102.87

$86.94

$75.33

$61.56

$35.37

$25.38

$50,400

$4,200

$2,800

$106.68

$90.16

$78.12

$63.84

$36.68

$26.32

$52,200

$4,350

$2,900

$110.49

$93.38

$80.91

$66.12

$37.99

$27.26

$54,000

$4,500

$3,000

$114.30

$96.60

$83.70

$68.40

$39.30

$28.20

$55,800

$4,650

$3,100

$118.11

$99.82

$86.49

$70.68

$40.61

$29.14

$57,600

$4,800

$3,200

$121.92

$103.04

$89.28

$72.96

$41.92

$30.08

$59,400

$4,950

$3,300

$125.73

$106.26

$92.07

$75.24

$43.23

$31.02

26

Long Term Disability MONTHLY PREMIUMS Accident / Sickness Elimination Period in Days Annual Earnings

Monthly Earnings

Monthly Benefit

0/7

14 / 14

30 / 30

60 / 60

90 / 90

180 / 180

$61,200

$5,100

$3,400

$129.54

$109.48

$94.86

$77.52

$44.54

$31.96

$63,000

$5,250

$3,500

$133.35

$112.70

$97.65

$79.80

$45.85

$32.90

$64,800

$5,400

$3,600

$137.16

$115.92

$100.44

$82.08

$47.16

$33.84

$66,600

$5,550

$3,700

$140.97

$119.14

$103.23

$84.36

$48.47

$34.78

$68,400

$5,700

$3,800

$144.78

$122.36

$106.02

$86.64

$49.78

$35.72

$70,200

$5,850

$3,900

$148.59

$125.58

$108.81

$88.92

$51.09

$36.66

$72,000

$6,000

$4,000

$152.40

$128.80

$111.60

$91.20

$52.40

$37.60

$73,800

$6,150

$4,100

$156.21

$132.02

$114.39

$93.48

$53.71

$38.54

$75,600

$6,300

$4,200

$160.02

$135.24

$117.18

$95.76

$55.02

$39.48

$77,400

$6,450

$4,300

$163.83

$138.46

$119.97

$98.04

$56.33

$40.42

$79,200

$6,600

$4,400

$167.64

$141.68

$122.76

$100.32

$57.64

$41.36

$81,000

$6,750

$4,500

$171.45

$144.90

$125.55

$102.60

$58.95

$42.30

$82,800

$6,900

$4,600

$175.26

$148.12

$128.34

$104.88

$60.26

$43.24

$84,600

$7,050

$4,700

$179.07

$151.34

$131.13

$107.16

$61.57

$44.18

$86,400

$7,200

$4,800

$182.88

$154.56

$133.92

$109.44

$62.88

$45.12

$88,200

$7,350

$4,900

$186.69

$157.78

$136.71

$111.72

$64.19

$46.06

$90,000

$7,500

$5,000

$190.50

$161.00

$139.50

$114.00

$65.50

$47.00

$91,800

$7,650

$5,100

$194.31

$164.22

$142.29

$116.28

$66.81

$47.94

$93,600

$7,800

$5,200

$198.12

$167.44

$145.08

$118.56

$68.12

$48.88

$95,400

$7,950

$5,300

$201.93

$170.66

$147.87

$120.84

$69.43

$49.82

$97,200

$8,100

$5,400

$205.74

$173.88

$150.66

$123.12

$70.74

$50.76

$99,000

$8,250

$5,500

$209.55

$177.10

$153.45

$125.40

$72.05

$51.70

$100,800

$8,400

$5,600

$213.36

$180.32

$156.24

$127.68

$73.36

$52.64

$102,600

$8,550

$5,700

$217.17

$183.54

$159.03

$129.96

$74.67

$53.58

$104,400

$8,700

$5,800

$220.98

$186.76

$161.82

$132.24

$75.98

$54.52

$106,200

$8,850

$5,900

$224.79

$189.98

$164.61

$134.52

$77.29

$55.46

$108,000

$9,000

$6,000

$228.60

$193.20

$167.40

$136.80

$78.60

$56.40

$109,800

$9,150

$6,100

$232.41

$196.42

$170.19

$139.08

$79.91

$57.34

$111,600

$9,300

$6,200

$236.22

$199.64

$172.98

$141.36

$81.22

$58.28

$113,400

$9,450

$6,300

$240.03

$202.86

$175.77

$143.64

$82.53

$59.22

$115,200

$9,600

$6,400

$243.84

$206.08

$178.56

$145.92

$83.84

$60.16

$117,000

$9,750

$6,500

$247.65

$209.30

$181.35

$148.20

$85.15

$61.10

$118,800

$9,900

$6,600

$251.46

$212.52

$184.14

$150.48

$86.46

$62.04

$120,600

$10,050

$6,700

$255.27

$215.74

$186.93

$152.76

$87.77

$62.98

$122,400

$10,200

$6,800

$259.08

$218.96

$189.72

$155.04

$89.08

$63.92

$124,200

$10,350

$6,900

$262.89

$222.18

$192.51

$157.32

$90.39

$64.86

$126,000

$10,500

$7,000

$266.70

$225.40

$195.30

$159.60

$91.70

$65.80

$127,800

$10,650

$7,100

$270.51

$228.62

$198.09

$161.88

$93.01

$66.74

$129,600

$10,800

$7,200

$274.32

$231.84

$200.88

$164.16

$94.32

$67.68

$131,400

$10,950

$7,300

$278.13

$235.06

$203.67

$166.44

$95.63

$68.62

$133,200

$11,100

$7,400

$281.94

$238.28

$206.46

$168.72

$96.94

$69.56

$135,000

$11,250

$7,500

$285.75

$241.50

$209.25

$171.00

$98.25

$70.50

27

APL

Cancer

YOUR BENEFITS PACKAGE

PLAY VIDEO

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

Breast Cancer is the most commonly diagnosed cancer in women.

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

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

GC3 Limited Benefit Group Cancer Indemnity Insurance Jacksonville 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* Benefits

Level 1 Base Plan

Level 2 Base Plan

Radiation Therapy/Chemotherapy/ Immunotherapy Benefit

$500 per calendar month of treatment

$1,500 per calendar month of treatment

Hormone Therapy Benefit

$50 per treatment, up to 12 per calendar year

$50 per treatment, up to 12 per calendar year

Surgical Schedule Benefit

$1,600 max per operation; $15 per surgical unit

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

Anesthesia Benefit

25% of the amount paid for covered surgery

25% of the amount paid for covered surgery

Hospital Confinement Benefit

$100 per day 1-90 days; $100 per day, 91+ days in lieu of other benefits

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

US Government/Charity Hospital/HMO

$100 per day in lieu of most other benefits

$300 per day in lieu of most other benefits

Outpatient Hospital or Ambulatory Surgical Center Benefit

$200 per day of surgery

$600 per day of surgery

Drugs & Medicine Benefit - Inpatient

$150 per confinement

$150 per confinement

Drugs & Medicine Benefit - Outpatient

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

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

Transportation & Outpatient Lodging Benefit

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

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

Family Member Transportation & Lodging Benefit

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

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

Blood, Plasma & Platelets Benefit

$150 per day, up to $7,500 per calendar year

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

Bone Marrow/Stem Cell Transplant

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

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

Experimental Treatment Benefit

Pays as any non-experimental benefit

Pays as any non-experimental benefit

Attending Physician Benefit

$30 per day of confinement

$50 per day of confinement

Surgical Prosthesis Benefit

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

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

Hair Prosthesis Benefit

$50 per hair prosthetic, 2 lifetime max

$50 per hair prosthetic, 2 lifetime max

Dread Disease Benefit

$100 per day, 1-90 days of hospital confinement

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

Hospice Care Benefit

$50 per day, $9,000 lifetime max

$100 per day, $18,000 lifetime max

Inpatient Special Nursing Services

$150 per day of confinement

$150 per day of confinement

Ambulance Ground Benefit

$200 per ground trip

$200 per ground trip

Ambulance Air Benefit

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

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

Extended Care Benefit

$100 per day

$300 per day

Home Health Care Benefit

$100 per day

$300 per day

Second & Third Surgical Opinions

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

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

Waiver of Premium

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

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

Physical/Speech Therapy Benefit

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

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

Diagnostic Testing Benefit Rider

$50; 1 person, per calendar year

$50; 1 person, per calendar year

Critical Illness Rider: Cancer/Heart Attack/Stroke

$2,500 lump sum benefit

$2,500 lump sum benefit

Up to $600 max of 30 days per ICU confinement; $100 ambulance per ICU admission

Up to $600 max of 30 days per ICU confinement; $100 ambulance per ICU admission

Riders

Optional Benefit Rider Intensive Care Unit Rider Monthly Premium**

Level 1

Level 1 + ICU Rider

Level 2

Level 2 + ICU Rider

Individual

$14.80

$17.80

$29.40

$32.40

One Parent

$20.60

$24.80

$40.40

$44.60

Two Parent

$26.40

$32.70

$51.50

$57.80

*Premium and amount of benefits provided vary dependent upon the level selected at time of application. **Total premium includes the policy and riders of 29 the option selected.

APSB-22356(TX) MGM/FBS Jacksonville ISD-0315

GC3 Limited Benefit Group Cancer Indemnity Insurance Eligibility

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

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

Base Policy

All diagnosis of cancer must be positively diagnosed by a legally licensed doctor of medicine certified by the American Board of Pathology or American Board of Osteopathic Pathology. This policy/certificate pays only for loss resulting from definitive cancer treatment including direct extension, metastatic spread or recurrence. Proof must be submitted to support each claim. This policy/certificate also covers other conditions or diseases directly caused by cancer or the treatment of cancer.

No benefits are payable for any covered person for any loss incurred during the first year of this policy/certificate as a result of a Pre-Existing Condition. A PreExisting Condition is a specified disease for which, within 12 months prior to the covered person’s effective date of coverage, medical advice, consultation or treatment, including prescribed medications, was recommended by or received from a member of the medical profession, or for which symptoms manifested in such a manner as would cause an ordinarily prudent person to seek diagnosis, medical advice or treatment. Pre-Existing Conditions specifically named or described as excluded in any part of this contract are never covered.

This policy/certificate contains a 30-day waiting period during which no benefits will be paid under this policy/certificate. If any covered person has a specified disease diagnosed before the end of the 30-day period immediately following the covered person’s effective date, coverage for that person will apply only to loss that is incurred after one year from the effective date of such person’s coverage. If any covered person is diagnosed as having a specified disease during the 30-day period immediately following the effective date, you may elect to void the policy/certificate from the beginning and receive a full refund of premium. All benefits payable only up to the maximum amount listed in the schedule of benefits in the policy/certificate.

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

Diagnostic Testing Benefit Rider

We will pay the indemnity amount for one generally medically recognized internal cancer screening test per covered person per calendar year.

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

30

APSB-22356(TX) MGM/FBS Jacksonville ISD-0315

30

Critical Illness Rider

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

Pre-Existing Condition, as used in this rider means any sickness or condition for which prior to the Effective Date of coverage, medical advice, consultation or treatment, including prescribed medications, was recommended by or received from a member of the medical profession, or for which symptoms manifested in such a manner as would cause an ordinarily prudent person to seek diagnosis, medical advice or treatment.

Hospital Intensive Care Unit Rider

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

GC3 Limited Benefit Group Cancer Indemnity Insurance Conditionally Renewable

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

We can change Your premiums if We change premiums for all similar Certificates issued to the Policyholder. We must give the Policyholder at least 60 days written notice before We change Your premiums.

Continuation Rider Continuation

Coverage is continued when the Insured (You) cease employment with the employer through whom You originally became insured under the Policy.

You will have the option to continue this Certificate (including any Riders, if applicable) by paying the premiums directly to Us at Our home office.

Premiums must be paid within thirty-one (31) days after employment with your employer terminates. Premium rates required under this Continuation provision will be the same rates as those charged under the Employer’s Policy as if You had continued employment. We will bill You for these premiums after You notify Us to continue this coverage. Coverage will continue until the earlier of: (1) the Policy under which You originally became insured ends; or (2) You stop paying premiums under this option (subject to the terms of the Grace Period).

Termination of Coverage

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

Termination of Rider Coverage

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

Conversion

If the Employer’s Policy is terminated, this Certificate will terminate. Upon termination of the Employer’s Policy, the employee (You) will be entitled to convert to an individual policy of insurance issued by Us without evidence of insurability provided the required premiums have been paid on your behalf and You notified Us in writing within thirty-one (31) days of the Employer’s Policy termination. Premiums for the individual policy of insurance will be figured from the premium rate table in effect on the date of conversion.

Subject to the terms of this provision, a covered child who ceases to be eligible may convert to an individual policy of insurance and a covered spouse who ceases to be eligible for coverage because of divorce or annulment may convert to an individual policy.

Terms of this provision include: (1) Application for the individual policy and payment of the first premium must be made within 60 days after coverage ceases under the Policy/Certificate. Premiums will be figured from the premium rate table in effect on the date of conversion. (2) The individual policy will be issued without proof of insurability. It will provide benefits that most nearly approximates those of the Policy/Certificate.

(3) The individual policy will take effect the day after coverage ceases under the Policy/Certificate. However, no benefits will be payable under the individual policy for any loss for which benefits are payable under the Policy/Certificate. (4) The Pre-Existing Condition Limitation and Time Limit on Certain Defenses provisions for the individual policy will be figured from the Covered Person’s Effective Date of coverage under the Policy/ Certificate. (5) Any benefit maximums will be figured from the Effective Date of the Policy/Certificate.

This rider is subject to all the provisions of the Policy and Certificate to which it is attached that are not in conflict with this rider.

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

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

31

APSB-22356(TX) MGM/FBS Jacksonville ISD-0315

5STAR

Individual Life

YOUR BENEFITS PACKAGE

PLAY VIDEO

About this Benefit Individual life is a policy that provides a specified death benefit to your beneficiary at the time of death.

The advantage of having an individual life insurance plan as opposed to a group supplemental term life plan is that this plan is guaranteed renewable, portable and typically premiums remain the same over the life of the policy.

Experts recommend at least

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

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

Individual Life with Terminal Illness and Quality of Life Rider The Family Protection Plan: Individual Life Insurance with Terminal Illness Coverage to Age 100 With the Family Protection Plan (FPP), you can provide financial stability for your loved ones should something happen to you.

You have peace of mind that you are covered up to age 100.* No matter what the future brings, you and your family will be protected.

If faced with a chronic medical condition that required continuous care, would you be able to protect yourself?

Traditionally, expenses associated with treatment and care necessitated by a chronic injury or illness have accounted for 86% of all health care spending and can place strain on your assets when you need them most. To provide protection during this time of need, 5Star Life Insurance Company (5Star Life) is pleased to offer the Quality of Life Rider, which is included with your FPP life insurance coverage.

This rider accelerates a portion of the death benefit on a monthly basis—4% each month as scheduled by your employer at the group level, and payable directly to you on a tax favored basis.

You can receive up to 75% of the current face amount of the life benefit, following a diagnosis of either a chronic illness or cognitive impairment that requires substantial assistance.

Benefits are paid for the following:  Permanent inability to perform at least two of the six Activities of Daily Living (ADLs) without substantial assistance, or  A permanent severe cognitive impairment, such as dementia, Alzheimer’s disease and other forms of senility requiring substantial supervision.

Example

Weekly Premium

Death Benefit

Accelerated Benefit

Your age at issue: 35

$10.00

$89,655

4% $3,586.20 a month

Affordability—With several options to choose from, select the coverage that best meets the needs of your family.

Terminal Illness—This plan pays the insured 30% (25% in Connecticut and Michigan) of the policy coverage amount in a lump sum upon the occurrence of a terminal condition that will result in a limited life span of less than 12 months.

Portability—You and your family continue coverage with no loss of benefits or increase in cost should you terminate employment after the first premium is paid. If this happens, we can simply bill you directly. Coverage can never be cancelled by the insurance company or your employer unless you stop paying premiums.

Family Protection—Individual policies can be purchased on the employee, their spouse, children and grandchildren.

Children & Grandchildren Plan—Policies can be purchased for children and grandchildren ages 15 days to age 24.

Convenience—Premiums are taken care of simply and easily through payroll deductions.

Protection You Can Count On—Within 24 hours after receiving notice of an insured’s death, an emergency death benefit of the lesser of 50% of the coverage amount, or $10,000, will be mailed to the insured’s beneficiary, unless the death is within the two-year contestability period and/or under investigation.

This product also contains no war or terrorism exclusions.

For example, in case of chronic illness, you would receive $3,586 each month up to $67,241.25.

The remainder death benefit of $22,413.75 would be made payable to your beneficiary.

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

33

Family Protection Plan - Terminal Illness Age on Employee Coverage Amounts Spouse Coverage Amounts Eff. $10,000 $25,000 $50,000 $75,000 $100,000 $125,000 $150,000 $10,000 $20,000 $30,000 $40,000 $50,000 Date

34

$7.56

$12.40

$20.46

$28.52

$36.58

$44.65

$52.71

$7.56

$7.58

$12.46

$20.58

$28.71

$36.83

$44.96

$53.08

$7.58

$10.78 $10.83

$14.01 $14.08

17.23 17.33

20.46 20.58

$7.65

$12.63

$20.92

$29.21

$37.50

$45.79

$54.08

$7.65

$10.97

$14.28

17.60

20.92

$7.74

$12.85

$21.38

$29.90

$38.42

$46.94

$55.46

$7.74

$11.15

$14.56

17.97

21.38

$7.88

$13.21

$22.08

$30.96

$39.83

$48.71

$57.58

$7.88

$11.43

$14.98

18.53

22.08

$8.07

$13.67

$23.00

$32.33

$41.67

$51.00

$60.33

$8.07

$11.80

$15.53

19.27

23.00

$8.27

$14.17

$24.00

$33.83

$43.67

$53.50

$63.33

$8.27

$12.20

$16.13

20.07

24.00

$8.49

$14.73

$25.13

$35.52

$45.92

$56.31

$66.71

$8.49

$12.65

$16.81

20.97

25.13

$8.73 $9.00

$15.31 $16.00

$26.29 $27.67

$37.27 $39.33

$48.25 $51.00

$59.23 $62.67

$70.21 $74.33

$8.73 $9.00

$13.12

$17.51

21.90

26.29

$13.67

$18.33

23.00

27.67

$9.30

$16.75

$29.17

$41.58

$54.00

$66.42

$78.83

$9.30

$14.27

$19.23

24.20

29.17

$9.64

$17.60

$30.88

$44.15

$57.42

$70.69

$83.96

$9.64

$14.95

$20.26

25.57

30.88

$10.02

$18.54

$32.75

$46.96

$61.17

$75.38

$89.58

$10.02

$15.70

$21.38

27.07

32.75

$10.41

$19.52

$34.71

$49.90

$65.08

$80.27

$95.46

$10.41

$16.48

$22.56

28.63

34.71

$10.84

$20.60

$36.88

$53.15

$69.42

$85.69

$101.96

$10.84

$17.35

$23.86

30.37

36.88

$11.31

$21.77

$39.21

$56.65

$74.08

$91.52

$108.96

$11.31

$18.28

$25.26

32.23

39.21

$11.83

$23.08

$41.83

$60.58

$79.33

$98.08

$116.83

$11.83

$19.33

$26.83

34.33

41.83

$12.41

$24.52

$44.71

$64.90

$85.08

$105.27

$125.46

$12.41

$20.48

$28.56

36.63

44.71

$13.00

$26.00

$47.67

$69.33

$91.00

$112.67

$134.33

$13.00

$21.67

$30.33

39.00

47.67

$13.63

$27.56

$50.79

$74.02

$97.25

$120.48

$143.71

$13.63

$22.92

$32.21

41.50

50.79

$14.28

$29.19

$54.04

$78.90

$103.75

$128.60

$153.46

$14.28

$24.22

$34.16

44.10

54.04

$14.97

$30.92

$57.50

$84.08

$110.67

$137.25

$163.83

$14.97

$25.60

$36.23

46.87

57.50

$15.69

$32.73

$61.13

$89.52

$117.92

$146.31

$174.71

$15.69

$27.05

$38.41

49.77

61.13

$16.43

$34.56

$64.79

$95.02

$125.25

$155.48

$185.71

$16.43

$28.52

$40.61

52.70

64.79

$17.22

$36.54

$68.75

$100.96

$133.17

$165.38

$197.58

$17.22

$30.10

$42.98

55.87

68.75

$18.08

$38.69

$73.04

$107.40

$141.75

$176.10

$210.46

$18.08

$31.82

$45.56

59.30

73.04

$19.04

$41.10

$77.88

$114.65

$151.42

$188.19

$224.96

$19.04

$33.75

$48.46

63.17

77.88

$20.16

$43.90

$83.46

$123.02

$162.58

$202.15

$241.71

$20.16

$35.98

$51.81

67.63

83.46

$21.40

$47.00

$89.67

$132.33

$175.00

$217.67

$260.33

$21.40

$38.47

$55.53

72.60

89.67

$22.79

$50.48

$96.63

$142.77

$188.92

$235.06

$281.21

$22.79

$41.25

$59.71

78.17

96.63

$64.13

84.07

104.00

$24.27

$54.17

$104.00

$153.83

$203.67

$253.50

$303.33

$24.27

$44.20

$25.93

$58.33

$112.33

$166.33

$220.33

$274.33

$328.33

$25.93

$47.53

$69.13

90.73

112.33

$74.31

97.63

120.96

$27.66

$62.65

$120.96

$179.27

$237.58

$295.90

$354.21

$27.66

$50.98

$29.42

$67.04

$129.75

$192.46

$255.17

$317.88

$380.58

$29.42

$54.50

$79.58

104.67

129.75

$85.01

111.90

138.79

$31.23

$71.56

$138.79

$206.02

$273.25

$340.48

$407.71

$31.23

$58.12

$33.12

$76.29

$148.25

$220.21

$292.17

$364.13

$436.08

$33.12

$61.90

$90.68

119.47

148.25

$96.56

127.30

158.04

$35.08

$81.19

$158.04

$234.90

$311.75

$388.60

$465.46

$35.08

$65.82

$37.13

$86.31

$168.29

$250.27

$332.25

$414.23

$496.21

$37.13

$69.92

$102.71

135.50

168.29

$109.26

144.23

179.21

$39.31

$91.77

$179.21

$266.65

$354.08

$441.52

$528.96

$39.31

$74.28

$41.68 $44.33

$97.71 $191.08 $104.33 $204.33

$284.46 $304.33

$377.83 $404.33

$471.21 $504.33

$564.58 $604.33

$41.68 $44.33

$79.03

$116.38

153.73

191.08

$84.33

$124.33

164.33

204.33

$44.93

$105.81 $207.29

$308.77

$410.25

$511.73

$613.21

$44.93

$85.52

$126.11

166.70

207.29

$48.25

$114.13 $223.92

$333.71

$443.50

$553.29

$663.08

$48.25

$92.17

$136.08

180.00

223.92

$52.03

$123.58 $242.83

$362.08

$481.33

$600.58

$719.83

$52.03

$99.73

$147.43

195.13

242.83

$56.33

$134.31 $264.29

$394.27

$524.25

$654.23

$784.21

$56.33

$108.32

$160.31

212.30

264.29

$61.17

$146.42 $288.50

$430.58

$572.67

$714.75

$856.83

$61.17

$118.00

$174.83

231.67

288.50

Family Protection Plan - Terminal Illness *Qualify of Life not available ages 66-70. Quality of Life benefits not available for children.

Child life coverage available only on children and grandchildren of employee (age on application date: 15 days to age 24). $4.98 monthly for $10,000 coverage and $9.97 monthly for $20,000 coverage.

35

AUL A ONEAMERICA COMPANY YOUR BENEFITS PACKAGE

Life and AD&D

PLAY VIDEO

About this Benefit Group term life is the most inexpensive way to purchase life insurance. You have the freedom to select an amount of life insurance coverage you need to help protect the well-being of your family.

Accidental Death & Dismemberment is life insurance coverage that pays a death benefit to the beneficiary, should death occur due to a covered accident.

Dismemberment benefits are paid to you, according to the benefit level you select, if accidentally dismembered.

Motor vehicle crashes are the

#1

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 36 Jacksonville ISD Benefits Website: www.mybenefitshub.com/jacksonvilleisd

Life and AD&D AUL's Group Voluntary Term Life Insurance Terms and Definitions Eligible Employees: This benefit is available for employees who are actively at work on the effective date and working a minimum of 20 hours per week.

Continuation of Coverage Options: Portability Should your coverage terminate for any reason, you may be eligible to take this term life insurance with you without providing Evidence of Insurability. You must apply within 31 days from the last day you are eligible. The Portability option is available until you reach age 70.

OR Flexible Choices:

Since everyone's needs are different, this plan offers flexibility for Conversion you to choose a benefit amount that fits your needs and budget. Should your life insurance coverage, or a portion of it, cease for any reason, you may be eligible to convert your Group Term Coverage to Individual Coverage without providing Evidence of Guaranteed Issue Amounts: Insurability. You must apply within 31 days from the last day you This is the most coverage you can purchase without having to are eligible. answer any health questions. If you decline insurance coverage now and decide to enroll later, you will need to provide Evidence of Insurability.

Employee Guaranteed Issue Amount

$250,000

Spouse Guaranteed Issue Amount

$60,000

Child Guaranteed Issue Amount

$10,000

Timely Enrollment: Enrolling timely means you have enrolled during the initial enrollment period when benefits were first offered by AUL, or as a newly hired employee within 31 days following completion of any applicable waiting period.

Evidence of Insurability: If you elect a benefit amount over the Guaranteed Issue Amount shown above for you or your eligible dependents, or you do not enroll timely, you will need to submit a Statement of Insurability form for review. Based on health history, you and / or your dependents will be approved or declined for insurance coverage

by AUL.

Accelerated Life Benefit: If diagnosed with a terminal illness and have less than 12 months to live, you may apply to receive 25%, 50% or 75% of your life insurance benefit to use for whatever you choose.

Waiver of Premium: If approved, this benefit waives your and your dependents' insurance premium in case you become totally disabled and are unable to collect a paycheck.

Reductions: Upon reaching certain ages, your original benefit amount will reduce to a percentage as shown in the following schedule.

Age:

65

70

Reduces To:

65%

50%

This invitation to inquire allows eligible employees an opportunity to inquire further about AUL's group insurance and is limited to a brief description of any losses for which benefits are Guaranteed Increase in Benefit: payable. The contract has exclusions, limitations reduction of If eligible, this benefit allows you to increase your coverage every benefits, and terms under which the contract may be continued year as your life insurance needs change. You may be able to in force or discontinued. increase your benefit amount by $10,000 every year until you reach the guaranteed issue amount, without providing Evidence of Insurability.

NOTE: If Evidence of Insurability is applied for and denied, please be aware Guaranteed Increase in Benefits will not be made available to you in the future.

37

Life and AD&D Monthly Payroll Deduction Illustration About your benefit options:    

You may select a minimum benefit of $10,000 up to a maximum amount of $500,000, in increments of $10,000, not to exceed 7 times your annual base salary only, rounded to the next higher $10,000.

Amounts requested above $250,000 for an Employee, $60,000 for a Spouse, or any amount not requested timely will require Evidence of Insurability.

Employee must select coverage to select any Dependent coverage.

Dependent coverage cannot exceed 100% of the Voluntary Term Life amount selected by the Employee.

EMPLOYEE ONLY OPTIONS (based on Employee's age as of 09/01) Life Options

0-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75+

$10,000

$.45

$.45

$.45

$.55

$.65

$1.00

$1.55

$2.40

$3.67

$5.89

$9.79

$14.61

$26.72

$20,000

$.90

$.90

$.90

$1.10

$1.30

$2.00

$3.10

$4.80

$7.34

$11.78

$19.58

$29.22

$53.44

$30,000

$1.35

$1.35

$1.35

$1.65

$1.95

$3.00

$4.65

$7.20

$11.01

$17.67

$29.37

$43.83

$80.16

$40,000

$1.80

$1.80

$1.80

$2.20

$2.60

$4.00

$6.20

$9.60

$14.68

$23.56

$39.16

$58.44 $106.88

$50,000

$2.25

$2.25

$2.25

$2.75

$3.25

$5.00

$7.75

$12.00

$18.35

$29.45

$48.95

$73.05 $133.60

$80,000

$3.60

$3.60

$3.60

$4.40

$5.20

$8.00 $12.40 $19.20

$29.36

$47.12

$78.32 $116.88 $213.76

$100,000

$4.50

$4.50

$4.50

$5.50

$6.50

$10.00 $15.50 $24.00

$36.70

$58.90

$97.90 $146.10 $267.20

$150,000

$6.75

$6.75

$6.75

$8.25

$9.75

$15.00 $23.25 $36.00

$55.05

$88.35 $146.85 $219.15 $400.80

$200,000

$9.00

$9.00

$9.00

$11.00 $13.00 $20.00 $31.00 $48.00

$73.40 $117.80 $195.80 $292.20 $534.40

$250,000

$11.25 $11.25 $11.25 $13.75 $16.25 $25.00 $38.75 $60.00

$91.75 $147.25 $244.75 $365.25 $668.00

SPOUSE ONLY OPTIONS (based on Employee's Age as of 09/01) Life Options

0-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75+

$10,000

$.45

$.45

$.45

$.55

$.65

$1.00

$1.55

$2.40

$3.67

$5.89

$9.79

$14.61

$26.72

$20,000

$.90

$.90

$.90

$1.10

$1.30

$2.00

$3.10

$4.80

$7.34

$11.78

$19.58

$29.22

$53.44

$30,000

$1.35

$1.35

$1.35

$1.65

$1.95

$3.00

$4.65

$7.20

$11.01

$17.67

$29.37

$43.83

$80.16

$40,000

$1.80

$1.80

$1.80

$2.20

$2.60

$4.00

$6.20

$9.60

$14.68

$23.56

$39.16

$58.44 $106.88

$50,000

$2.25

$2.25

$2.25

$2.75

$3.25

$5.00

$7.75

$12.00

$18.35

$29.45

$48.95

$73.05 $133.60

$60,000

$2.70

$2.70

$2.70

$3.30

$3.90

$6.00

$9.30

$14.40

$22.02

$35.34

$58.74

$87.66 $160.32

38

Life and AD&D CHILD(REN) OPTIONS (Premium shown for Child(ren) reflects the cost for all eligible dependent children) Child(ren) 6 months to age 26

Child(ren) live birth to 6 months

Monthly Payroll Deduction Life Amount

Option 1:

$2,500

$1,000

$.50

Option 2:

$5,000

$1,000

$1.00

Option 3:

$7,500

$1,000

$1.50

Option 4:

$10,000

$1,000

$2.00

About Premiums: The premiums shown above may vary slightly due to rounding; actual premiums will be calculated by American United Life Insurance Company® (AUL), and may increase upon reaching certain age brackets, according to contract terms, and are subject to change.

Monthly Payroll Deduction Illustration About your benefit options:   

You may select a minimum benefit of $10,000 up to a maximum amount of $500,000, in increments of $10,000.

Employee must select coverage to select any Dependent coverage.

The Spouse benefit is equal to 50% of the amount elected by the Employee, the Child benefit is equal to 10% of the amount elected by the Employee.

Employee Only AD&D Volume $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

10,000 20,000 30,000 40,000 50,000 60,000 70,000 80,000 90,000 100,000 150,000 200,000 250,000 300,000 350,000 400,000 450,000 500,000

Monthly Deduction $ 0.176 $ 0.352 $ 0.528 $ 0.704 $ 0.880 $ 1.056 $ 1.232 $ 1.408 $ 1.584 $ 1.760 $ 2.640 $ 3.520 $ 4.400 $ 5.280 $ 6.160 $ 7.040 $ 7.920 $ 8.800

Family AD&D Employee Volume $ 10,000 $ 20,000 $ 30,000 $ 40,000 $ 50,000 $ 60,000 $ 70,000 $ 80,000 $ 90,000 $ 100,000 $ 150,000 $ 200,000 $ 250,000 $ 300,000 $ 350,000 $ 400,000 $ 450,000 $ 500,000

Spouse Volume $ 5,000 $ 10,000 $ 15,000 $ 20,000 $ 25,000 $ 30,000 $ 35,000 $ 40,000 $ 45,000 $ 50,000 $ 75,000 $ 100,000 $ 125,000 $ 150,000 $ 175,000 $ 200,000 $ 225,000 $ 250,000

Child Volume $ 1,000 $ 2,000 $ 3,000 $ 4,000 $ 5,000 $ 6,000 $ 7,000 $ 8,000 $ 9,000 $ 10,000 $ 15,000 $ 20,000 $ 25,000 $ 30,000 $ 35,000 $ 40,000 $ 45,000 $ 50,000

Monthly Deduction $ 0.318 $ 0.636 $ 0.954 $ 1.272 $ 1.590 $ 1.908 $ 2.226 $ 2.544 $ 2.862 $ 3.180 $ 4.770 $ 6.360 $ 7.950 $ 9.540 $ 11.130 $ 12.720 $ 14.310 $ 15.900 39

NBS

FSA (Flexible Spending Account)

YOUR BENEFITS PACKAGE

PLAY VIDEO

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

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

FLIP TO‌ PG. 11 FOR HSA VS. FSA COMPARISON

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the 40 Jacksonville ISD Benefits Website: www.mybenefitshub.com/jacksonvilleisd

FSA (Flexible Spending Account) NBS Flexcard

When Will I Receive My Flex Card?

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

You must file web or paper claims or enroll in continual reimbursement.

NBS Prepaid MasterCard® Debit Card

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

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

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

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

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

FSA Annual Contribution Max:

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

$2,650

Dependent Care Annual Max: $5,000

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

Online claim FAQs 41

FSA Frequently Asked Questions What is a Flexible Spending Account?

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

How does a Flexible Spending Account Benefit Me? A Cafeteria plan enables you to save money on group insurance, health-related expenses, and dependent-care expenses. You may save as much as 35 percent on the cost of each benefit option!

Eligible expenses must be incurred within the plan year and contributions are use-it-or- lose-it. Remember to retain all your receipts.

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

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

        

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

Dependent Care Expense Account Example Expenses:    

Before and After School and/or Extended Day Programs The actual care of the dependent in your home.

Preschool tuition.

The base costs for day camps or similar programs used as care for a qualifying individual.

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

42

What Happens If I Don’t Use All of My Funds by The End of the Plan Year (August 31st)?

Eligible expenses must be incurred within the plan year +75 day grace period. Contributions are use-it-or roll up to $500.

Remember to retain all your receipts (including receipts for card swipes).

How Do I File A Claim?

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

How To Receive Your Dependent Care Reimbursement Faster.

A Direct Deposit form is available on the Benefits Website which will help you get reimbursed quicker!

How the FSA Plan Works You designate an annual election of pre-tax dollars to be deposited into your health and dependent-care spending accounts. Your total election is divided by the number of pay periods in the Plan year and deducted equally from each paycheck before taxes are calculated. By the end of the Plan year, your total election will be fully deposited.

However, you may make a claim for eligible health FSA expenses as soon as they are incurred during the Plan year. Eligible claims will be paid up to your total annual election even if you have not yet contributed that amount to your account.

Get Your Money 1.

2.

3.

4.

Complete and sign a claim form (available on our website) or an online claim.

Attach documentation; such as an itemized bill or an Explanation of Benefits (EOB) statement from a health insurance provider.

Fax or mail signed form and documentation to NBS. Receive your non-taxable reimbursement after your claim is processed either by check or direct deposit.

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

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

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

43

WWW.MYBENEFITSHUB.COM/ JACKSONVILLEISD 44