2020-21 Jacksonville ISD Benefit Guide by Higginbotham Public Sector

JACKSONVILLE ISD

BENEFIT GUIDE EFFECTIVE: 09/01/2020 - 8/31/2021 WWW.MYBENEFITSHUB.COM/JACKSONVILLEISD 1

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

3. Annual Enrollment

4. Eligibility Requirements

5. Helpful Definitions 6. HSA vs FSA Comparison

PG. 4

HOW TO ENROLL

PG. 6

SUMMARY PAGES

PG. 12

YOUR BENEFITS

10 11

TRS-ActiveCare Aetna

12-13

EECU Health Savings Account

14-15

Cigna Dental

16-21

Superior Vision The Hartford Long Term Disability

22-23

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

28-31

NBS Flexible Spending Account

42-45

FLIP TO...

24-27 32-33 36-41

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 BENEFITS 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

BCBS 866-355-5999 www.bcbstx.com/trsactivecare

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

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.

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.

ONLINE SUPPORT

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

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

Annual Benefit Enrollment

SUMMARY PAGES

Benefit Updates - What’s New: MEDICAL Effective 9/1/2020, the health plan administrator for TRSActiveCare medical benefits will change. Benefit and premium changes will apply to all TRS-ActiveCare plans for the next plan year. Plan Options: • TRS-ActiveCare Primary NEW– Requires selection of Primary Care Physician (PCP) • TRS-ActiveCare HD (formerly 1-HD)- If currently enrolled in TRS-AC1HD and make no changes, you will be enrolled in this plan. • TRS-ActiveCare Primary+ (formerly Select) -If currently enrolled in TRS-AC Select and make no changes, you will be enrolled in this plan. Requires selection of a Primary Care Physician (PCP) To review new premiums and plan options, refer to 202021 TRS-ActiveCare Plan Highlights on your benefit website.

EVERGREEN ELECTION SUMMARY OF CHANGES TO FSA CONTRIBUTIONS May I make new elections in future Plan Years? Yes, you may. For each new Plan Year, you may change the elections that you previously made. You may also choose not to participate in the Plan for the upcoming Plan Year. If you do not make new elections during the election period before a new Plan Year begins, we will assume you want your elections for benefits under the Plan to remain the for the upcoming Plan Year. FSA UPDATE! The FSA max contribution is increasing to $2,750. HSA UPDATE! The individual HSA max contribution is increasing to $3,550. The family HSA max contribution is increasing to $7,100

Don’t Forget! • • • • •

You MUST login & complete your benefit enrollment from 7/15/20 - 8/19/20. Any changes made after 8/19/20 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.

SUMMARY PAGES

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

CHANGES IN STATUS (CIS): Marital Status

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

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

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

Change in Status of Employment Affecting Coverage Eligibility

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

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

SUMMARY PAGES

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

Where can I find forms?

to review, change or continue benefit elections each year.

For benefit summaries and claim forms, go to your benefit

Changes are not permitted during the plan year (outside of

website: www.mybenefitshub.com/jacksonvilleisd. Click on

annual enrollment) unless a Section 125 qualifying event occurs.

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

•

Changes, additions or drops may be made only during the

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.

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 2020 benefits become effective on September 1, 2020, you must be actively-at-work on September 1, 2020 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 25

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 physicianâ&#x20AC;&#x2122;s statement confirming your dependentâ&#x20AC;&#x2122;s disability. Contact your HR/Benefit Administrator to request a continuation of coverage.

Helpful Definitions

SUMMARY PAGES

Actively at Work

In-Network

You are performing your regular occupation for the employer

Doctors, hospitals, optometrists, dentists and other providers

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

who have contracted with the plan as a network provider.

places of business or at some location to which the employer’s business requires you to travel. If you will not be actively at work beginning 9/1/2020 please notify your benefits administrator.

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

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

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

Plan Year September 1st through August 31st.

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

Calendar Year January 1st through December 31st

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

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

(including diagnostic and/or consultation services).

SUMMARY PAGES

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

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

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

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

Employer Eligibility

A qualified high deductible health plan.

All employers

Contribution Source

Employee and/or employer

Account Owner

Individual

Employer

Underlying Insurance Requirement

High deductible health plan

None

Description

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

$1,400 single (2020) $2,800 family (2020) $3,550 single (2020) $7,100 family (2019) If used for non-qualified medical expenses, subject to current tax rate plus 20% penalty. Permitted, but subject to current tax rate plus 20% penalty (penalty waived after age 65).

Year-to-year rollover of account balance?

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

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

Does the account earn interest?

Yes

Portable?

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

Minimum Deductible Maximum Contribution

Permissible Use Of Funds

FLIP TO FOR HSA INFORMATION

PG. 14

N/A $2,750 Reimbursement for qualified medical expenses (as defined in Sec. 213(d) of IRC). Not permitted

FLIP TO FOR FSA INFORMATION

PG. 42 11

2020-21 TRS-ActiveCare Plan Highlights Sept. 1, 2020 — Aug. 31, 2021 All TRS-ActiveCare participants have three plan options. Each is designed with the unique needs of our members in mind. TRS-ActiveCare 2 NEW: TRS-ActiveCare Primary • Lower premium • Copays for doctor visits

TRS-ActiveCare HD • Similar to current 1-HD • Lower premium • Compatible with health savings

before you meet deductible • Statewide network account (HSA) • PCP referrals required to see • Nationwide network with out-ofspecialists network coverage Plan summary • Not compatible with health • No requirement for PCPs or savings account (HSA) referrals • No out-of-network coverage • Must meet deductible before plan pays for non-preventive care If you make no changes Only employees that choose If you’re currently in TRSduring Annual this new plan during Annual ActiveCare 1-HD and you make no Enrollment, you’ll have Enrollment will be enrolled in it. change during Annual Enrollment, the following plan... this will be your plan next year.

TRS-ActiveCare Primary+ • Simpler version of the current Select

plan

• Lower deductible than HD and primary

(This plan is closed and not accepting new enrollees. If you’re currently enrolled in TRS-ActiveCare 2, you can remain in this plan.) • Closed to new enrollees • Current enrollees can choose to

stay in plan

• Lower deductible • Copays for many drugs and

plans • Copays for many services and drugs • Higher premium • Statewide network • PCP referrals required to see specialists • Not compatible with a health savings account (HSA) • No out-of-network coverage If you’re currently in TRS-ActiveCare Select and you make no changes during Annual Enrollment, this will be your plan next year.

If you’re currently in TRS-ActiveCare 2, and you make no changes during Annual Enrollment, you will remain in TRS-ActiveCare 2 next year.

$514 $1,264 $834 $1,588

$937 $2,222 $1,393 $2,627

services

• Nationwide network with out-of-

network coverage

• No requirement for PCPs or

referrals

Total Monthly Premiums Employee Only Employee and Spouse Employee and Children Employee and Family

$386 $1,089 $695 $1,301

$397 $1,120 $715 $1,338

Plan Features Type of Coverage Individual/Family Deductible Coinsurance Individual/Family Maximum Out-of-Pocket Network Primary Care Provider (PCP) Required

In-Network Coverage Only

In-Network

Out-of-Network

In-Network Coverage Only

$2,500/$5,000

$2,800/$5,600

$5,500/$11,000

$1,200/$3,600

In-Network

Out-of-Network

$1,000/$3,000

$2,000/$6,000

You pay 30% after deductible

You pay 20% You pay 40% after after deductible deductible

You pay 20% after You pay 40% after deductible deductible

You pay 20% after deductible

$8,150/$16,300

$6,900/$13,800 $20,250/$40,500

$6,900/$13,800

Statewide Network

Nationwide Network

Statewide Network

Nationwide Network

Yes

$7,900/$15,800

$23,700/$47,400

Doctor Visits Primary Care Specialist TRS Virtual Health

$30 copay $70 copay $0 per consultation

You pay 20% You pay 40% after after deductible deductible You pay 20% You pay 40% after after deductible deductible $30 per consultation

$30 copay $70 copay $0 per consultation

You pay 40% after deductible You pay 40% after $70 copay deductible $0 per consultation $30 copay

Immediate Care Urgent Care

Emergency Care TRS Virtual Health

$50 copay

You pay 20% You pay 40% after after deductible deductible

$50 copay

You pay 30% after deductible

You pay 20% after deductible

$0 per consultation

$30 per consultation

$0 per consultation

You pay 40% after deductible You pay a $250 copay plus 20% after deductible $0 per consultation

Integrated with medical

$200 brand deductible

$15/$45 copay

You pay 20% after deductible

$15/$45 copay

$50 copay

Prescription Drugs Drug Deductible Generics (30-Day Supply / 90-Day Supply) Preferred Brand

You pay 30% after deductible

You pay 25% after deductible

Non-preferred Brand

You pay 50% after deductible

Specialty

You pay 30% after deductible

You pay 20% after deductible

What’s New

Leverage Your $0 Preventive Care*

• • • •

• • • • • • • • •

Primary plan with a lower premium and copays Primary+ (formerly Select) decreased premiums by up to 8% Broader networks of health care providers Lower premiums for families with children

Did You Know • • •

Our provider search tool will be available in June. Choosing a PCP helps you meet your health goals faster. Generic medications save money! Ask your provider if your medicine has a generic. 12

$20/$45 copay You pay 25% after deductible ($40 min/$80 max)/ You pay 25% after deductible ($105 min/$210 max) You pay 50% after deductible ($100 min/$200 max)/ You pay 50% after deductible ($215 min/$430 max) You pay 20% after deductible ($200 min/$900 max)/ No 90-Day Supply of Specialty Medications

Annual routine physicals (ages 12+) Annual mammogram (ages 40+) Annual OBGYN exam & pap smear (ages 18+) Annual prostate cancer screening (ages 45+) Well-child care (unlimited up to age 12) Healthy diet/obesity counseling (unlimited to age 22; ages 22+ get twenty-six visits per year) Smoking cessation counseling (8 visits per year) Breastfeeding support (six per year) Colonoscopy (ages 50+ once every ten years)

*Available for all plans. See benefits guides for more details.

2020-21 Health Maintenance Organization Plans and Premiums for Select Regions of the State Remember: Remember that when you choose an HMO, youâ&#x20AC;&#x2122;re choosing a regional network. TRS also contracts with HMOs in certain regions of the state to bring participants in those areas another regional plan option. Central and North Texas Baylor Scott & White HMO

South Texas Blue Essentials HMO

Brought to you by TRS-ActiveCare

West Texas Blue Essentials HMO Brought to you by TRS-ActiveCare

You can choose this plan if you live in You can choose this plan if you live in You can choose this plan if you live in one these one these counties: Austin, Bastrop, one these counties: Cameron, Hildalgo, counties: Andrews, Armstrong, Bailey, Borden, Bell, Blanco, Bosque, Brazos, Burleson, Starr, Willacy Brewster, Briscoe, Callahan, Carson, Castro, Childress, Burnet, Caldwell, Collin, Coryell, Cochran, Coke, Coleman, Collingsworth, Comanche, Dallas, Denton, Ellis, Erath, Falls, Concho, Cottle, Crane, Crockett, Crosby, Dallam, Freestone, Grimes, Hamilton, Hays, Dawson, Deaf Smith, Dickens, Donley, Eastland, Ector, Hill, Hood, Houston, Johnson, Fisher, Floyd, Gaines, Garza, Glasscock, Gray, Hale, Lampasas, Lee, Leon, Limestone, Hall, Hansford, Hartley, Haskell, Hemphill, Hockley, Madison, McLennan, Milam, Mills, Howard, Hutchinson, Irion, Jones, Kent, Kimble, King, Navarro, Robertson, Rockwall, Knox, Lamb, Lipscomb, Llano, Loving, Lubbock, Lynn, Somervell, Tarrant, Travis, Walker, Martin, Mason, McCulloch, Menard, Midland, Waller, Washington, Williamson Mitchell, Moore, Motley, Nolan, Ochiltree, Oldham, Parmer, Pecos, Potter, Randall, Reagan, Reeves, Roberts, Runnels, San Saba, Schleicher, Scurry, Shackelford, Sherman, Stephens, Sterling, Stonewall, Sutton, Swisher, Taylor, Terry, Throckmorton, Tom Green, Upton, Ward, Wheeler, Winkler, Yoakum

Total Monthly Premiums Employee Only

$551.10

$491.54

$534.42

Employee and Spouse

$1,382.06

$1,182.52

$1,287.58

Employee and Children

$883.50

$766.96

$835.68

$1,478.56

$1,258.52

$1,370.12

In-Network Coverage Only

$950/$2,850

$500/$1,000

$950/$2,850

You pay 20% after deductible

You pay 25% after deductible

$7,450/$14,900

$4,500/$9,000

$7,450/$14,900

Primary Care

$20 copay

$25 copay

$20 copay

Specialist

$70 copay

$60 copay

$70 copay

$50 copay

$75 copay

$500 copay after deductible

You pay 20% after deductible

$50 copay $500 copay before deductible plus 25% after deductible

Employee and Family

Plan Features Type of Coverage Individual/Family Deductible Coinsurance

Individual/Family Maximum Out-of-Pocket

Doctor Visits

Immediate Care Urgent Care Emergency Care

Prescription Drugs Drug Deductible

Days Supply Generics Preferred Brand Non-preferred Brand Specialty

$150 (excl. generics)

$100

$150

30-Day Supply / 90-Day Supply

$5/$12.50 copay

$10/$30 copay

$5/$12.50 copay ACA Preventative: $0

30% after deductible

$40/$120 copay

30% after deductible

50% after deductible

$65/$195 copay

50% after deductible

15%/25% after deductible (preferred/ nonpreferred)

You pay 20% after deductible

15%/25% after deductible (preferred/nonpreferred)

trs.texas.gov 13

EECU

HSA (Health Savings Account)

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.

YOUR BENEFITS PACKAGE

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 This is a general overview of your plan benefits.inIfthe thesummary terms of plan this outline differlocated from your policy, the policy will govern. Additional plan description on the 14 details on covered expenses,Frisco limitations and exclusions are included in the summary plan description located on the ISD Benefits Website: www.mybenefitshub.com/friscoisd 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 – Save your receipts – for all qualified medical expenses. compounded daily and paid monthly from deposit to EECU does not verify eligibility. You are responsible for withdrawal making sure payments are for qualified medical expenses. • Conveniently pay for qualified healthcare expenses – with a free, no annual fee EECU HSA Debit Mastercard® or via EECU’s free online bill pay. (HSA checks are also available How To Manage Your Account upon request, for a nominal fee**) • Online - check your balance, pay healthcare providers and • Free online, mobile and branch access – allows you to arrange deposits; sign-up for online banking at actively manage your account however you prefer www.eecu.org. • Comprehensive service and support – to assist you in • Mobile - EECU’s mobile app allows you to manage your optimizing your healthcare saving and spending account on the go; download “EECU Mobile Banking” in • Federally insured – to at least $250,000 by NCUA Apple’s App Store and Google Play. • Contact Member Service – call 817-882-0800 for help with 2020 Annual HSA Contribution Limits your HSA questions or transactions. You can also chat with Individual: $3,550 us online at eecu.org or use our secure email. Member Family: $7,100 Service is available Monday through Friday from 8:00am – Catch-Up Contributions: Accountholders who meet the 7:00pm CT, Saturdays from 9am – 1pm CT and closed on qualifications noted below are eligible to make an HSA Sunday. catch-up contribution of an additional $1,000. • Account Statements – monthly statements show all your • Health Savings accountholder account activity for that period. You can receive free online • Age 55 or older (regardless of when in the year an statements or pay $2 per printed statement. accountholder turns 55) * Contributions, investment earnings, and distributions are tax free for federal tax purposes if • Not enrolled in Medicare (if an accountholder enrolls in used to pay for qualified medical expenses, and may or may not be subject to state taxation. Medicare mid-year, catch-up contributions should be A list of Eligible Medical Expenses can be found in IRS Publication 502, http://www.irs.gov/ pub/irs-pdf/p502.pdf. As described in IRS publication 969, http://www.irs.gov/pub/irs-pdf/ prorated) p969.pdf, certain over-the-counter medications (when prescribed by a doctor) are Authorized Signers who are 55 or older must have their own considered eligible medical expenses for HSA purposes. If an individual is 65 or older, there is no penalty to withdraw HSA funds. However, income taxes will apply if the distribution is not HSA in order to make the catch-up contribution used for qualified medical expenses. For more information consult a tax adviser or your state department of revenue. All contributions and distributions are your responsibility and must be within IRS regulatory limits. ** Call 817-882-0800 or stop-by an EECU branch to order standard checks at no charge (excludes shipping and handling) or order custom checks - prices vary.

CIGNA

Dental

YOUR BENEFITS PACKAGE

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

Dental PPOâ&#x20AC;&#x201C; High Benefits

Monthly PPO Premiums

Cigna Dental PPO - Low Option

Based on Contracted Fees

Out-of-Network: See Non-Network Reimbursement Maximum Reimbursable Charge

$1,000

$50 $150

In-Network: Total Cigna DPPO Network

Network Options Reimbursement Levels Policy Year Benefits Maximum Applies to: Class I, II, III & IX expenses Policy Year Deductible Individual Family

Benefit Highlights

Plan Pays

You Pay

Plan Pays

You Pay

Tier

Rate

EE Only

$36.66

EE + Spouse

$77.93

EE + Child(ren)

$86.62

EE + Family

$127.57

Cigna Dental Benefit Summary

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

100% No Deductible

No Charge

100% No Deductible

No Charge

Jacksonville ISD # 3338975 High Plan Renewal Date: 09/01/2019

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

80% After Deductible

20% After Deductible

80% After Deductible

20% After Deductible

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

50% After Deductible

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

50% No Deductible

50% After Deductible

Class IX: Implants

50% After Deductible

Insured by: Cigna Health and Life Insurance Company 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.

Benefit Plan Provisions: In-Network Reimbursement

For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Fee Schedule or Discount Schedule.

Non-Network Reimbursement

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.

Cross Accumulation

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.

Policy Year Benefits Maximum

The plan will only pay for covered charges up to the yearly Benefits Maximum, when applicable. Benefitspecific Maximums may also apply.

Policy Year Deductible

This is the amount you must pay before the plan begins to pay for covered charges, when applicable. Benefit-specific deductibles may also apply. 17

Dental PPO– High Late Entrant Limitation Provision

Payment will be reduced by 50% for Class III, IV, and IX 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

Pretreatment review is available on a voluntary basis when dental work in excess of $200 is proposed.

Alternate Benefit Provision

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.

Oral Health Integration Program (OHIP)

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.

Timely Filing

Out of network claims submitted to Cigna after 365 days from date of service will be denied.

Benefit Limitations:

Missing Tooth Limitation

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

Oral Evaluations

2 per policy year

X-rays (routine)

Bitewings: 2 per policy year

X-rays (non-routine)

Complete series of radiographic images and panoramic radiographic images: Limited to a combined total of 1 per 36 months

Diagnostic Casts

Payable only in conjunction with orthodontic workup

Cleanings

2 per policy year, including periodontal maintenance procedures following active therapy

Fluoride Application

1 per policy year for children under age 19

Sealants (per tooth)

Limited to posterior tooth. 1 treatment per tooth every 36 months for children under age 14

Space Maintainers

Limited to non-orthodontic treatment for children under age 19

Replacement every 60 months if unserviceable and cannot be repaired. Benefits are based on the amount payable for Inlays, Crowns, Bridges, non-precious metals. No porcelain or white/tooth-colored material on molar crowns or bridges. Dentures and Partials Denture and Bridge Repairs Reviewed if more than once Denture Adjustments, Rebases and Relines

Covered if more than 6 months after installation

Prosthesis Over Implant

1 every 60 months if unserviceable and cannot be repaired. Benefits are based on the amount payable for nonprecious metals. No porcelain or white/tooth colored material on molar crowns or bridges.

Benefit Exclusions: Covered Expenses will not include, and no payment will be made for the following: • • • • • • • •

Procedures and services not included in the list of covered dental expenses; Diagnostic: cone beam imaging; Preventive Services: instruction for plaque control, oral hygiene and diet; Restorative: veneers of porcelain, ceramic, resin, or acrylic materials on crowns or pontics on or replacing the upper and or lower first, second and/or third molars; Periodontics: bite registrations; splinting; Prosthodontics: precision or semi-precision attachments; initial placement of a complete or partial denture per plan guidelines; 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; services performed primarily for cosmetic reasons; personalization; replacement of an appliance per benefit guidelines; Services that are deemed to be medical in nature; services and supplies received from a hospital; Drugs: prescription drugs Charges in excess of the Maximum Reimbursable Charge.

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. Cigna Dental PPO plans are insured and/or administered by Cigna Health and Life Insurance Company (CHLIC) or Connecticut General Life Insurance Company (CGLIC), with network management services provided by Cigna Dental Health, Inc. and certain of its subsidiaries. In Texas, the insured dental plan is known as Cigna Dental Choice, and this plan uses the national Cigna DPPO network. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation “Cigna Home Delivery Pharmacy” refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C. Policy forms (for insured dental plans) in OK: HP-POL99 (CHLIC), GM6000 ELI288 et al (CGLIC); OR: HP-POL68; TN: HP-POL69/HC-CER2V1 et al (CHLIC). The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. BSD77759 © 2017 Cigna / version 06192017

Dental PPOâ&#x20AC;&#x201D;Low Benefits

Monthly PPO Premiums

Cigna Dental PPO - Low Option

Tier Network Options Reimbursement Levels

In-Network: Total Cigna DPPO Network

Out-of-Network: See Non-Network Reimbursement

Based on Contracted Fees

Maximum Reimbursable Charge

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

$750

Policy Year Deductible Individual Family

$750

$100 $300

Benefit Highlights

Plan Pays

Class I: Diagnostic & Preventive Oral Evaluations Prophylaxis: routine cleanings X-rays: routine Fluoride Application Sealants: per tooth Space Maintainers: non-orthodontic Class II: Basic Restorative Restorative: fillings Oral Surgery: simple extractions only X-rays: non-routine Emergency Care to Relieve Pain Class III: Major Restorative Inlays and Onlays Prosthesis Over Implant Crowns: prefabricated stainless steel / resin Crowns: permanent cast and porcelain Bridges and Dentures Anesthesia: general and IV sedation Periodontics: minor and major Endodontics: minor and major Denture Relines, Rebases and Adjustments Repairs: Bridges, Crowns and Inlays Repairs: Dentures Oral Surgery: all except simple extractions Extractions of Impacted Teeth

100% No Deductible

$100 $300 You Pay

No Charge

Plan Pays

100% No Deductible

You Pay Any amount over the Maximum Allowable Charge

80% After Deductible

20% After Deductible

80% After Deductible

20% After Deductible

50% After Deductible

Rate

EE Only

$21.11

EE + Spouse

$46.05

EE + Child(ren)

$51.14

EE + Family

$76.09

Cigna Dental Benefit Summary Jacksonville ISD # 3338975 Low Plan Renewal Date: 09/01/2019 Insured by: Cigna Health and Life Insurance Company 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.

Benefit Plan Provisions: In-Network Reimbursement

For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Fee Schedule or Discount Schedule.

Non-Network Reimbursement

For services provided by a non-network dentist, Cigna Dental will reimburse according to the Maximum Allowable Charge. The dentist may balance bill up to their usual fees.

Cross Accumulation

Policy Year Benefits Maximum

The plan will only pay for covered charges up to the yearly Benefits Maximum, when applicable. Benefitspecific Maximums may also apply.

Policy Year Deductible

This is the amount you must pay before the plan begins to pay for covered charges, when applicable. Benefit-specific deductibles may also apply. 19

Dental PPO—Low Late Entrant Limitation Provision

Payment will be reduced by 50% for Class III 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

Pretreatment review is available on a voluntary basis when dental work in excess of $200 is proposed.

Alternate Benefit Provision

Oral Health Integration Program (OHIP)

Timely Filing

Out of network claims submitted to Cigna after 365 days from date of service will be denied.

Benefit Limitations: Missing Tooth Limitation

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

Oral Evaluations

2 per policy year

X-rays (routine)

Bitewings: 2 per policy year

X-rays (non-routine)

Complete series of radiographic images and panoramic radiographic images: Limited to a combined total of 1 per 36 months

Cleanings

2 per policy year, including periodontal maintenance procedures following active therapy

Fluoride Application

1 per policy year for children under age 19

Sealants (per tooth)

Limited to posterior tooth. 1 treatment per tooth every 36 months for children under age 14

Space Maintainers

Limited to non-orthodontic treatment for children under age 19

Inlays, Crowns, Bridges, Dentures and Partials

Replacement 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.

Denture and Bridge Repairs

Reviewed if more than once

Denture Adjustments, Rebases and Relines

Covered if more than 6 months after installation

Prosthesis Over Implant

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 included in the list of covered dental expenses; Diagnostic: cone beam imaging; Preventive Services: instruction for plaque control, oral hygiene and diet; Restorative: veneers of porcelain, ceramic, resin, or acrylic materials on crowns or pontics on or replacing the upper and or lower first, second and/or third molars; Periodontics: bite registrations; splinting; Prosthodontics: precision or semi-precision attachments; initial placement of a complete or partial denture per plan guidelines; Implants: implants or implant related services; Orthodontics: orthodontic treatment; 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; services performed primarily for cosmetic reasons; personalization; replacement of an appliance per benefit guidelines; 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..

SUPERIOR VISION

Vision

YOUR BENEFITS PACKAGE

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

Vision Benefits In-Network Exam Covered in full Frames $125 retail allowance Lenses (standard) per pair Single Vision

Covered in full

Out-of-Network Up to $35 retail Up to $70 retail Up to $25 retail

Bifocal Covered in full Trifocal Covered in full Up to $45 retail Progressive See description1 Up to $45 retail Lenticular Covered in full Up to $80 retail Contact Lenses2 $150 retail allowance Up to $80 retail Medically Necessary Covered in full Up to $150 retail Contact Lenses

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

Monthly Premiums EE Only

$7.64

EE + Spouse

$13.00

EE + Child(ren)

$13.78

EE + Family

$20.64

Deductibles Exam

$10

Materials

$25

Services/Frequency Exam

12 months

Frame

24 months

Lenses

12 months

Contact Lenses

12 months

(Based on date of service)

1Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay 2 Contact lenses and related professional services (fitting, evaluation and follow-up) are covered in lieu of eyeglass lenses and frames benefit

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.

www.SuperiorVision.com To look up providers, please select: Superior Select Southwest Network 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 Superior Vision of Texas P.O. Box 967 Rancho Cordova, CA 95741 800.507.3800 SuperiorVision.com 0215-BSv2/TX

THE HARTFORD YOUR BENEFITS PACKAGE

Disability

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 24 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Jacksonville ISD Benefits Website: www.mybenefitshub.com/jacksonvilleisd

Long Term Disability Benefit Highlights for: Jacksonville Independent School District #873359

What is does “Actively at Work” mean?

Am I eligible?

What other benefits are included in my disability coverage?

You must be at work with your Employer on your regularly scheduled workday. On that day, you must be performing for wage or profit all of your regular duties in the usual way and for What is Long-Term Disability Insurance? your usual number of hours. If school is not in session due to Long-Term Disability Insurance pays you a portion of your normal vacation or school break(s), Actively at Work shall mean earnings if you cannot work because of a disabling illness or you are able to report for work with your Employer, performing injury. You have the opportunity to purchase Long-Term all of the regular duties of Your Occupation in the usual way for Disability Insurance through your employer. This highlight sheet is an overview of your Long-Term Disability your usual number of hours as if school was in session. How long do I have to wait before I can receive my benefit? Insurance. Once a group policy is issued to your employer, a certificate of insurance will be available to explain your coverage You must be disabled for at least the number of days indicated by the elimination period that you select before you can receive in detail. a Long-Term Disability benefit payment. Why do I need Long-Term Disability Coverage? For those employees electing an elimination period of 30 days Most accidents and injuries that keep people off the job happen or less, if your are confined to a hospital for 24 hours or more outside the workplace and therefore are not covered by due to a disability, the elimination period will be waived, and worker’s compensation. When you consider that nearly three in benefits will be payable from the first day of disability. 10 workers entering the workforce today will become disabled What is an elimination period? before retiring1, it’s protection you won’t want to be without. 1 Social Security Administration, Fact Sheet 2009. The elimination period that you select consists of two numbers. The first number shows the number of days you must be What is disability? disabled by an accident before your benefits can begin. The Disability is defined in The Hartford’s* contract with your second number indicates the number of days you must be employer. Typically, disability means that you cannot perform disabled by a sickness before your benefits can begin. one or more of the essential duties of your occupation due to injury, sickness, pregnancy or other medical condition covered I already have Disability coverage; do I have to do by the insurance, and as a result, your current monthly earnings anything? are 80% or less of your pre-disability earnings. If you are not changing the amount of your coverage or your Once you have been disabled for 24 months, you must be elimination period option, you do not have to do anything. If you prevented from performing one or more of the essential duties want to purchase Long-Term Disability insurance for the first of any occupation and as a result, your current monthly earnings time or change your coverage, please be sure to complete the are 66 2/3% or less of your pre-disability earnings. online enrollment, which indicates your election. You are eligible if you are an active employee who works at least 20 hours per week on a regularly scheduled basis.

•

How much coverage would I have? You may purchase coverage that will pay you a monthly flat dollar benefit in $100 increments between $200 and $7,500 that cannot exceed 66 2/3% of your current monthly earnings. Your plan includes a minimum benefit of 10% of your elected benefit. Earnings are defined in The Hartford’s contract with your employer.

When can I enroll? If you choose not to elect coverage during your annual enrollment period, you will not be eligible to elect coverage until the next annual enrollment period without a qualifying change in family status.

When is it effective? 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.

•

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, or in equal shares to your surviving children under the age of 25, equal to three times the last monthly gross benefit. 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 25

Long Term Disability through ComPsych®, a leading provider of employee assistance and work/life services. 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. 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.

other facility licensed to provide medical care for mental illness, alcoholism and substance abuse does not count toward the 24 month lifetime limit. • 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 preexisting condition requirement of your previous insurer. If your How long will my disability payments continue? Can disability is a result of a pre-existing condition we will pay benefits for a maximum of 4 weeks. the duration of my benefit be reduced? Benefit Duration is the maximum time for which we pay benefits Your benefit payments may be reduced by other income you for disability resulting from sickness or injury. Depending on the receive or are eligible to receive due to your disability, such as: • Social Security Disability Insurance or alternative plan schedule selected and the age at which disability occurs, (please see next section for exceptions) the maximum duration may vary. Please see the applicable • Workers’ Compensation schedules below based on your election of the Premium benefit • Other employer-based Insurance coverage you may have option. • Unemployment benefits How long will my disability benefits continue if I elect • Settlements or judgments for income loss • Retirement benefits that your employer fully or partially the Premium benefit option? pays for (such as a pension plan.) The table below applies to disabilities resulting from sickness or Your benefit payments will not be reduced by certain kinds of injury: other income, such as: • Retirement benefits if you were already receiving them Age Disabled Benefits Payable Prior to Age 63 To Normal Retirement Age or 48 months if greater before you became disabled Age 63 To Normal Retirement Age or 42 months if greater • The portion of your Long -Term Disability payment that you Age 64 36 months place in an IRS-approved account to fund your future Age 65 30 months retirement. Age 66 27 months • Your personal savings, investments, IRAs or Keoghs Age 67 24 months • Profit-sharing Age 68 21 months Age 69 and older 18 months • Most personal disability policies • Social Security increases Important Details 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 • Any case where your being engaged in an illegal occupation was a contributing cause to your disability • You must be under the regular care of a physician to receive benefits. Mental Illness, Alcoholism and Substance Abuse: • You can receive benefit payments for Long-Term Disabilities resulting from mental illness, alcoholism and substance abuse for a total of 24 months for all disability periods during your lifetime. • Any period of time that you are confined in a hospital or 26

This Benefit Highlights Sheet is an overview of the Long-Term Disability Insurance being offered and is provided for illustrative purposes only and is not a contract. It in no way changes or affects the policy as actually issued. Only the Insurance policy issued to the policyholder (your employer) can fully describe all of the provisions, terms, conditions, limitations and exclusions of your Insurance coverage. In the event of any difference between the Benefit Highlights Sheet and the Insurance policy, the terms of the Insurance policy apply. Underwritten by: Hartford Life and Accident Insurance Company 200 Hopmeadow Street Simsbury, CT 06089

Long Term Disability Jacksonville Independent School District Premium Option â&#x20AC;&#x201C; Monthly Premium Cost (based on 12 payments per year) - Rates effective 9/1/2016 Accident / Sickness Elimination Period in Days Annual Monthly Monthly Earnings Earnings Benefit

0/7

14/14

30/30

60/60

90/90

180/180

Accident / Sickness Elimination Period in Days Annual Monthly Monthly Earnings Earnings 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

$70,200 $5,850

$3,900 $148.59 $125.58 $108.81 $88.92

$51.09

$36.66

$5,400

$450

$300

$11.43

$9.66

$8.37

$6.84

$3.93

$2.82

$72,000 $6,000

$4,000 $152.40 $128.80 $111.60 $91.20

$52.40

$37.60

$7,200

$600

$400

$15.24

$12.88

$11.16

$9.12

$5.24

$3.76

$73,800 $6,150

$4,100 $156.21 $132.02 $114.39 $93.48

$53.71

$38.54

$9,000

$750

$500

$19.05

$16.10

$13.95

$11.40

$6.55

$4.70

$75,600 $6,300

$4,200 $160.02 $135.24 $117.18 $95.76

$55.02

$39.48

$10,800

$900

$600

$22.86

$19.32

$16.74

$13.68

$7.86

$5.64

$77,400 $6,450

$4,300 $163.83 $138.46 $119.97 $98.04

$56.33

$40.42

$12,600 $1,050

$700

$26.67

$22.54

$19.53

$15.96

$9.17

$6.58

$79,200 $6,600

$4,400 $167.64 $141.68 $122.76 $100.32 $57.64

$41.36

$14,400 $1,200

$800

$30.48

$25.76

$22.32

$18.24

$10.48

$7.52

$81,000 $6,750

$4,500 $171.45 $144.90 $125.55 $102.60 $58.95

$42.30

$16,200 $1,350

$900

$34.29

$28.98

$25.11

$20.52

$11.79

$8.46

$82,800 $6,900

$4,600 $175.26 $148.12 $128.34 $104.88 $60.26

$43.24

$18,000 $1,500

$1,000

$38.10

$32.20

$27.90

$22.80

$13.10

$9.40

$84,600 $7,050

$4,700 $179.07 $151.34 $131.13 $107.16 $61.57

$44.18

$19,800 $1,650

$1,100

$41.91

$35.42

$30.69

$25.08

$14.41

$10.34

$86,400 $7,200

$4,800 $182.88 $154.56 $133.92 $109.44 $62.88

$45.12

$21,600 $1,800

$1,200

$45.72

$38.64

$33.48

$27.36

$15.72

$11.28

$88,200 $7,350

$4,900 $186.69 $157.78 $136.71 $111.72 $64.19

$46.06

$23,400 $1,950

$1,300

$49.53

$41.86

$36.27

$29.64

$17.03

$12.22

$90,000 $7,500

$5,000 $190.50 $161.00 $139.50 $114.00 $65.50

$47.00

$25,200 $2,100

$1,400

$53.34

$45.08

$39.06

$31.92

$18.34

$13.16

$91,800 $7,650

$5,100 $194.31 $164.22 $142.29 $116.28 $66.81

$47.94

$27,000 $2,250

$1,500

$57.15

$48.30

$41.85

$34.20

$19.65

$14.10

$93,600 $7,800

$5,200 $198.12 $167.44 $145.08 $118.56 $68.12

$48.88

$28,800 $2,400

$1,600

$60.96

$51.52

$44.64

$36.48

$20.96

$15.04

$95,400 $7,950

$5,300 $201.93 $170.66 $147.87 $120.84 $69.43

$49.82

$30,600 $2,550

$1,700

$64.77

$54.74

$47.43

$38.76

$22.27

$15.98

$97,200 $8,100

$5,400 $205.74 $173.88 $150.66 $123.12 $70.74

$50.76

$32,400 $2,700

$1,800

$68.58

$57.96

$50.22

$41.04

$23.58

$16.92

$99,000 $8,250

$5,500 $209.55 $177.10 $153.45 $125.40 $72.05

$51.70

$34,200 $2,850

$1,900

$72.39

$61.18

$53.01

$43.32

$24.89

$17.86

$100,800 $8,400

$5,600 $213.36 $180.32 $156.24 $127.68 $73.36

$52.64

$36,000 $3,000

$2,000

$76.20

$64.40

$55.80

$45.60

$26.20

$18.80

$102,600 $8,550

$5,700 $217.17 $183.54 $159.03 $129.96 $74.67

$53.58

$37,800 $3,150

$2,100

$80.01

$67.62

$58.59

$47.88

$27.51

$19.74

$104,400 $8,700

$5,800 $220.98 $186.76 $161.82 $132.24 $75.98

$54.52

$39,600 $3,300

$2,200

$83.82

$70.84

$61.38

$50.16

$28.82

$20.68

$106,200 $8,850

$5,900 $224.79 $189.98 $164.61 $134.52 $77.29

$55.46

$41,400 $3,450

$2,300

$87.63

$74.06

$64.17

$52.44

$30.13

$21.62

$108,000 $9,000

$6,000 $228.60 $193.20 $167.40 $136.80 $78.60

$56.40

$43,200 $3,600

$2,400

$91.44

$77.28

$66.96

$54.72

$31.44

$22.56

$109,800 $9,150

$6,100 $232.41 $196.42 $170.19 $139.08 $79.91

$57.34

$45,000 $3,750

$2,500

$95.25

$80.50

$69.75

$57.00

$32.75

$23.50

$111,600 $9,300

$6,200 $236.22 $199.64 $172.98 $141.36 $81.22

$58.28

$46,800 $3,900

$2,600

$99.06

$83.72

$72.54

$59.28

$34.06

$24.44

$113,400 $9,450

$6,300 $240.03 $202.86 $175.77 $143.64 $82.53

$59.22

$48,600 $4,050

$2,700 $102.87 $86.94

$75.33

$61.56

$35.37

$25.38

$115,200 $9,600

$6,400 $243.84 $206.08 $178.56 $145.92 $83.84

$60.16

$50,400 $4,200

$2,800 $106.68 $90.16

$78.12

$63.84

$36.68

$26.32

$117,000 $9,750

$6,500 $247.65 $209.30 $181.35 $148.20 $85.15

$61.10

$52,200 $4,350

$2,900 $110.49 $93.38

$80.91

$66.12

$37.99

$27.26

$118,800 $9,900

$6,600 $251.46 $212.52 $184.14 $150.48 $86.46

$62.04

$54,000 $4,500

$3,000 $114.30 $96.60

$83.70

$68.40

$39.30

$28.20

$120,600 $10,050 $6,700 $255.27 $215.74 $186.93 $152.76 $87.77

$62.98

$55,800 $4,650

$3,100 $118.11 $99.82

$86.49

$70.68

$40.61

$29.14

$122,400 $10,200 $6,800 $259.08 $218.96 $189.72 $155.04 $89.08

$63.92

$57,600 $4,800

$3,200 $121.92 $103.04 $89.28

$72.96

$41.92

$30.08

$124,200 $10,350 $6,900 $262.89 $222.18 $192.51 $157.32 $90.39

$64.86

$59,400 $4,950

$3,300 $125.73 $106.26 $92.07

$75.24

$43.23

$31.02

$126,000 $10,500 $7,000 $266.70 $225.40 $195.30 $159.60 $91.70

$65.80

$61,200 $5,100

$3,400 $129.54 $109.48 $94.86

$77.52

$44.54

$31.96

$127,800 $10,650 $7,100 $270.51 $228.62 $198.09 $161.88 $93.01

$66.74

$63,000 $5,250

$3,500 $133.35 $112.70 $97.65

$79.80

$45.85

$32.90

$129,600 $10,800 $7,200 $274.32 $231.84 $200.88 $164.16 $94.32

$67.68

$64,800 $5,400

$3,600 $137.16 $115.92 $100.44 $82.08

$47.16

$33.84

$131,400 $10,950 $7,300 $278.13 $235.06 $203.67 $166.44 $95.63

$68.62

$66,600 $5,550

$3,700 $140.97 $119.14 $103.23 $84.36

$48.47

$34.78

$133,200 $11,100 $7,400 $281.94 $238.28 $206.46 $168.72 $96.94

$69.56

$68,400 $5,700

$3,800 $144.78 $122.36 $106.02 $86.64

$49.78

$35.72

$135,000 $11,250 $7,500 $285.75 $241.50 $209.25 $171.00 $98.25

$70.50

APL

Cancer

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.

YOUR BENEFITS PACKAGE

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 28 details on covered expenses, limitations and exclusions are included in the summary plan description located on the 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

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

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

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

Family Member Transportation & Lodging Benefit

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

Blood, Plasma & Platelets Benefit

$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

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

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

Ambulance Ground Benefit

$200 per ground trip

Ambulance Air Benefit

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

Extended Care Benefit

$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

Waiver of Premium

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

Physical/Speech Therapy Benefit

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

Diagnostic Testing Benefit Rider

$50; 1 person, per calendar year

Critical Illness Rider: Cancer/Heart Attack/Stroke

$2,500 lump sum benefit

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

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

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

5STAR

Individual Life

About this Benefit Group termlife lifeis isa policy the most to Individual thatinexpensive provides a way specified purchase life insurance. You have at thethe freedom death benefit to your beneficiary time ofto select amount of lifeofinsurance death.an The advantage having ancoverage individualyou lifeneed to help protect theopposed well-being your family. insurance plan as to aofgroup supplemental term life plan is that this plan is guaranteed renewable, portable and typically premiums remain the same over the life of the policy.

YOUR BENEFITS PACKAGE

Experts recommend at least

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

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

Term Life with Terminal Illness and Quality of Life Rider Family Protection Plan with Terminal Illness Term Life Insurance to age 100 Prepare for the future. Protect your loved ones. CUSTOMIZABLE With several options to choose from, select the coverage that best meets the needs of your family. TERMINAL ILLNESS ACCELERATION OF BENEFITS Coverage that pays 30% (25% in CT and MI) of the 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 (24 months in IL). PORTABLE Coverage continues with no loss of benefits or increase in cost if you terminate employment after the first premium is paid. We simply bill you directly.

Nearly

85%

of people said they thought most people need life insurance.

Yet only

59%

said that they have coverage themselves.

And

33%

wish their spouse or partner had more life insurance.*

FAMILY PROTECTION You can get coverage for your spouse and financially dependent children 14 days through 23 years old, even if you don’t elect coverage on yourself. No matter what the future brings, you and your family are protected. CONVENIENT Easy payment through payroll deduction. QUALITY OF LIFE Benefit that accelerates a portion of the death benefit on a monthly basis, up to 75% of your benefit, and is payable directly to you on a tax favored basis for the following: • Permanent inability to perform at least two of the six Activities of Daily Living (ADLs) without substantial assistance; or • Permanent severe cognitive impairment, such as dementia, Alzheimer’s disease and other forms of senility, requiring substantial supervision. PROTECTION YOU CAN COUNT ON Within one business day of notification, payment of 50% of coverage or $10,000 whichever is less is mailed to the beneficiary, unless the death is within the two-year contestability period and/or under investigation. This coverage has no war or terrorism exclusions. Underwritten by 5Star Life Insurance Company (a Lincoln, Nebraska company); Administered by NTT Data at 777 Research Drive, Lincoln, NE 68521 FPPi product available in all states and some U.S. Territories except: CA, DE, FL, NY, ND. SD. Quality of Life rider not available in CA. FPPg product available in all states and some U.S. Territories except: CA, DE, FL, NY, ND. SD, VI FPPi/gQOLFlyerR1119 FPPduoQOL_MKT_FLYER_1119

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

18-25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46

$10,000 $9.90 $9.91 $9.98 $10.08 $10.23 $10.43 $10.64 $10.87 $11.11 $11.40 $11.72 $12.08 $12.46 $12.88 $13.33 $13.83 $14.38 $14.98 $15.60 $16.26 $16.93 $17.67

$20,000 $13.28 $13.34 $13.46 $13.66 $13.95 $14.35 $14.76 $15.23 $15.72 $16.30 $16.93 $17.65 $18.44 $19.25 $20.17 $21.15 $22.25 $23.46 $24.70 $26.02 $27.37 $28.83

$30,000 $16.68 $16.75 $16.96 $17.26 $17.68 $18.28 $18.90 $19.61 $20.33 $21.20 $22.16 $23.23 $24.40 $25.63 $27.00 $28.48 $30.13 $31.96 $33.81 $35.78 $37.80 $40.00

Employee Coverage Amounts $40,000 $50,000 $75,000 $20.07 $23.46 $31.94 $20.16 $23.59 $32.13 $20.44 $23.92 $32.62 $20.84 $24.42 $33.37 $21.40 $25.13 $34.44 $22.20 $26.12 $35.94 $23.04 $27.16 $37.50 $23.97 $28.34 $39.25 $24.93 $29.55 $41.06 $26.10 $31.00 $43.26 $27.37 $32.59 $45.63 $28.80 $34.37 $48.31 $30.36 $36.34 $51.25 $32.00 $38.38 $54.32 $33.83 $40.67 $57.76 $35.80 $43.13 $61.44 $38.00 $45.87 $65.57 $40.44 $48.92 $70.12 $42.90 $52.00 $74.75 $45.53 $55.30 $79.69 $48.23 $58.67 $84.75 $51.17 $62.33 $90.26

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

$18.43 $19.19 $20.02 $20.93 $21.94 $23.11 $24.42 $25.88 $27.44 $29.19 $30.99 $32.84 $34.74 $36.71 $38.77 $40.93 $43.22 $45.72

$30.35 $31.88 $33.55 $35.36 $37.39 $39.74 $42.33 $45.27 $48.37 $51.87 $55.49 $59.19 $62.97 $66.94 $71.05 $75.37 $79.95 $84.93

$42.28 $44.58 $47.08 $49.81 $52.83 $56.35 $60.26 $64.65 $69.31 $74.56 $79.98 $85.53 $91.21 $97.15 $103.33 $109.80 $116.68 $124.16

$54.20 $57.27 $60.60 $64.24 $68.26 $72.96 $78.17 $84.03 $90.23 $97.23 $104.46 $111.86 $119.43 $127.36 $135.60 $144.23 $153.40 $163.37

$66.13 $69.96 $74.13 $78.67 $83.71 $89.59 $96.09 $103.42 $111.17 $119.92 $128.96 $138.21 $147.67 $157.59 $167.88 $178.67 $190.13 $202.59

$95.94 $101.69 $107.94 $114.75 $122.32 $131.13 $140.87 $151.88 $163.50 $176.63 $190.19 $204.06 $218.25 $233.13 $248.57 $264.75 $281.94 $300.62

$125.75 $133.42 $141.75 $150.84 $160.91 $172.66 $185.67 $200.33 $215.83 $233.33 $251.41 $269.91 $288.83 $308.66 $329.25 $350.83 $373.75 $398.67

$155.56 $165.15 $175.57 $186.92 $199.52 $214.21 $230.46 $248.80 $268.17 $290.04 $312.64 $335.77 $359.42 $384.21 $409.94 $436.92 $465.56 $496.71

$185.38 $196.88 $209.38 $223.01 $238.13 $255.75 $275.26 $297.25 $320.51 $346.76 $373.88 $401.63 $430.01 $459.75 $490.63 $523.00 $557.38 $594.76

$48.50

$90.50

$132.51

$174.50

$216.50

$321.50

$426.50

$531.50

$636.51

Age on Eff. Date

$100,000 $40.42 $40.66 $41.34 $42.34 $43.75 $45.75 $47.84 $50.17 $52.58 $55.50 $58.67 $62.25 $66.16 $70.25 $74.83 $79.75 $85.25 $91.34 $97.50 $104.08 $110.83 $118.17

$125,000 $48.89 $49.21 $50.04 $51.29 $53.07 $55.56 $58.16 $61.09 $64.11 $67.75 $71.71 $76.18 $81.09 $86.19 $91.92 $98.06 $104.94 $112.54 $120.25 $128.48 $136.92 $146.09

$150,000 $57.38 $57.75 $58.76 $60.26 $62.38 $65.38 $68.50 $72.01 $75.63 $80.00 $84.76 $90.13 $96.00 $102.13 $109.00 $116.38 $124.63 $133.76 $143.01 $152.88 $163.00 $174.00

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

$10,000 $49.13 $52.62 $56.58 $61.09 $66.18

$20,000 $91.75 $98.73 $106.67 $115.68 $125.85

$30,000 $134.38 $144.85 $156.75 $170.28 $185.53

Employee Coverage Amounts $40,000 $50,000 $75,000 $177.00 $219.63 $326.19 $190.97 $237.08 $352.38 $206.83 $256.92 $382.13 $224.87 $279.46 $415.94 $245.20 $304.88 $454.06

$100,000 $432.75 $467.67 $507.33 $552.42 $603.25

$125,000 $539.31 $582.96 $632.54 $688.90 $752.44

$150,000 $645.88 $698.25 $757.75 $825.38 $901.63

*Quality of Life not available ages 66 - 70. Quality of Life benefits not available for children. Child life coverage available only on children and grandchildren of employee (age on application date: 14 days through 23 years). $7.15 monthly for $10,000 coverage per child.

FPPiDBQOLMonthlyRates

9/18 35

AUL A ONEAMERICA COMPANY

Life and AD&D

YOUR BENEFITS PACKAGE

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

Motor vehicle crashes are the

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

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

Life and AD&D Group Term Life including matching AD&D Coverage •

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

Life and AD&D insurance coverage amount of $15,000 at no cost to you • Waiver of premium benefit • Accelerated life benefit • Additional AD&D Benefits: Seat Belt, Air Bag, Repatriation, Child Timely Enrollment: Enrolling timely means you have enrolled during Higher Education, Child Care, Paralysis/Loss of Use, Severe the initial enrollment period when benefits were first offered by Burns AUL, or as a newly hired employee within 31 days following Coverage options are available to eligible employees This invitation to inquire allows eligible employees an opportunity to inquire further about AUL's group completion of any applicable waiting period. insurance and is limited to a brief description of any losses for which benefits are payable. The contract has exclusions, limitations reduction of benefits, and terms under which the contract may be continued in force or discontinued.

Why should you consider purchasing life insurance protection at your workplace? Many of us lead busy lives and seldom take time to think about life’s risks. Consider the following reasons many people purchase group TERM life insurance: • Replacing income • Paying off mortgage • Providing funds for college education • Paying for medical / burial / final expenses • Preparing for life events, such as: • Marriage • Growing family • Home Purchase • Transferring wealth to family • Making a charitable gift • Supporting aging parents Advantages of shopping at work include: • Affordable group rates • Convenient payroll deduction • Guaranteed issue for timely applicant • Easy access 1.

Employees find significant value in obtaining non-medical products in their workplace. (Source: Shopping on the Job: Life and Disability Insurance Sales at the Workplace, LIMRA Research Briefings, March, 2012.)

50% of U.S. households have unmet life insurance needs: 58 million say they do not have enough life insurance. (Source: Household

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. Guaranteed Increase in Benefit: If eligible, this benefit allows you to increase your coverage every year as your life insurance needs change. You and your spouse may be able to 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. 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 Conversion: 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 Insurability. You must apply within 31 days from the last day you are eligible.

Trends in the U.S. Life Insurance Ownership, LIMRA, 2010.)

Accelerated Life Benefit: If diagnosed with a terminal illness and have Nearly 1 in 5 Americans go through their workplace to purchase less than 12 months to live, you may apply to receive 25%, 50% or life insurance. For employees that have the option, 75% 75% of your life insurance benefit to use for whatever you choose. ultimately decide to purchase life insurance. (Source: To Shop or Not To Shop for Life Insurance. Turning Shoppers Into Buyers, LIMRA, 2011.) Waiver of Premium: If approved, this benefit waives your and your 4. While employees have many possible resources for benefit dependents' insurance premium in case you become totally disabled information, they rely most on the information created by and are unable to collect a paycheck. their employer. Reductions: Upon reaching certain ages, your original benefit AUL's Group Voluntary Term Life Insurance Terms and Definitions amount will reduce to a percentage as shown in the following Eligible Employees: This benefit is available for employees who are schedule. actively at work on the effective date and working a minimum of 20 Age: 65 70 hours per week. 3.

Flexible Choices: Since everyone's needs are different, this plan offers flexibility for you to choose a benefit amount that fits your needs and budget. Guaranteed Issue Amounts: This is the most coverage you can purchase without having to answer any health questions. If you

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 payable. The contract has exclusions, limitations reduction of benefits, and terms under which the contract may be continued in force or discontinued.Products and financial services provided by American United Life Insurance Company® a ONEAMERICA® company. Visit us at www.oneamerica.com for more information.

Life and AD&D Voluntary Term Life Coverage 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

$10,000

$.45

$.55

$.65

$1.00

$1.55

$2.40

$3.67

$5.89

$9.79

$14.61 $26.72

75+

$20,000

$.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

$1.65

$1.95

$3.00

$4.65

$7.20

$11.01 $17.67 $29.37 $43.83 $80.16

$50,000

$1.80

$2.20

$2.60

$4.00

$6.20

$9.60

$14.68 $23.56 $39.16 $58.44 $106.88

$80,000

$2.25

$2.75

$3.25

$5.00

$7.75

$12.00 $18.35 $29.45 $48.95 $73.05 $133.60

$90,000

$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

$5.50

$6.50

$10.00 $15.50 $24.00 $36.70 $58.90 $97.90 $146.10 $267.20

$150,000

$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

$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

$.55

$.65

$1.00

$1.55

$2.40

$3.67

$5.89

$9.79

$14.61 $26.72

$20,000

$.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

$1.65

$1.95

$3.00

$4.65

$7.20

$11.01 $17.67 $29.37 $43.83 $80.16

$40,000

$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

$2.75

$3.25

$5.00

$7.75

$12.00 $18.35 $29.45 $48.95 $73.05 $133.60

$60,000

$2.70

$3.30

$3.90

$6.00

$9.30

$14.40 $22.02 $35.34 $58.74 $87.66 $160.32

CHILD(REN) OPTIONS (Premium shown for Child(ren) reflects the cost for all eligible dependent children)

Option 1: Option 2: Option 3: Option 4:

Child(ren) 6 months to age 26

Child(ren) live birth to 6 months

Monthly Payroll Deduction Life Amount

$2,500 $5,000 $7,500 $10,000

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

$0.50 $1.00 $1.50 $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. 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 payable. The contract has exclusions, limitations reduction of benefits, and terms under which the contract may be continued in force or discontinued. Products and financial services provided by American United Life Insurance Company®

Life and AD&D NEEDS ASSESSMENT WORKSHEET

Life insurance protection: How much is enough? The importance of protection Understanding the importance of and reasons for having life insurance can come from many life experiences — going through a personal loss or seeing the impact of loss on others. The question always begs, “How much life insurance do I really need?” You might have purchased insurance offered through your work, and some you may have purchased on your own, but what is that number? How much life insurance is truly enough? Really, that answer depends on you, since your circumstances and financial goals are different from anyone else. Use the following equation and related financial considerations to help develop a ballpark figure of how much life insurance you should consider to protect those you love. Any gap you identify through this exercise represents the amount of life insurance needed to take care of your loved ones’ financial needs should something happen to you.

Immediate Financial Obligations

Consider items like:

• Funeral and burial costs • Mortgage • Car and personal loans

• Credit card debt • Taxes • Medical expenses

Ongoing/Future Financial Obligations

Consider items like:

• • • • •

Food, housing, utilities Transportation Health care Clothing Insurance

Ongoing/Future Sources of Income

• Child(ren)’s education expenses

• Retirement • Income • Replacement

Consider items like:

• • • •

Spouse’s continued earnings Savings Investments Life Insurance you already own (group + personal)

Amount Needed

Though you might not be able to purchase the desired amount of life insurance all at once, making progress toward this goal over time can be a great approach. Speak to a financial professional today — and protect the ones that matter most to you! © 2014 OneAmerica Financial Partners, Inc. All rights reserved. G-26295 10/28/14

Life and AD&D Voluntary Term AD&D Coverage 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

Family AD&D

Volume

Monthly Deduction

Employee Volume

Spouse Volume

Child Volume

Monthly Deduction

$ 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

$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

$ 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

$ 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

$ 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

$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

NBS

FSA (Flexible Spending Account)

YOUR BENEFITS PACKAGE

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

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

FLIP TOâ&#x20AC;Ś

PG. 11

FOR HSA VS. FSA COMPARISON

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

FSA (Flexible Spending Account) How do I receive reimbursements? During the course of the plan year, you may submit requests for reimbursement of expenses you have incurred. Expenses are Congratulations! considered "incurred" when the service is performed, not Your employer has established a "flexible benefits plan" to help necessarily when it is paid for. You can get submit a claim online you pay for your out-of-pocket health and daycare expenses. at: my.nbsbeneits.com One of the most important features of the plan is that the Please note: Policies other than company sponsored policies (i.e. benefits being offered are paid for with a portion of your pay spouseâ&#x20AC;&#x2122;s or dependentsâ&#x20AC;&#x2122; individual policies) may not be paid before federal income or social security taxes are withheld. This through the flexible beneits plan. Furthermore, qualified longmeans that you will pay less tax and have more money to spend term care insurance plans may not be paid through the flexible and save. However, if you receive a reimbursement for an benefits plan. expense under the plan, you cannot claim a federal income tax NBS Benefits Card credit or deduction on your return. Your employer may Health Flexible spending account: sponsor the use of the The health flexible spending account (FSA) enables you to pay NBS Benefits Card, for expenses allowed under Section 105 and 213(d) of the making access to your Internal Revenue Code which are not covered by our insured flex dollars easier than medical plan. ever. You may use the The most that you can contribute to your Health FSA each plan card to pay merchants year is set by the IRS. This amount can be adjusted for increases or service providers in cost-of-living in accordance with Code Section 125(i)(2). that accept credit cards such as hospitals and pharmacies, so there is no need to pay cash up front then wait for Premium expense plan: reimbursement. A premium expense portion of the plan allows you to use preOrthodontic expenses that are paid fully up-front at the time of tax dollars to pay for specific premiums under various insurance initial service are reimbursable in full after the initial service has programs we offer you. been performed and payment has been made. Ongoing orthodontia payments are reimbursable only as they are paid. Dependent care Flexible spending account: The dependent care flexible spending account (DCFSA) enables Account Information you to pay for out-of-pocket, work-related dependent daycare Participants may call NBS and talk to a representative during our costs. Please see the Summary Plan Description for the regular business hours, Monday-Friday, 7 a.m. to 7 p.m. Central definition of an eligible dependent. The law places limits on the Time. Participants can also obtain account information using the amount of money that can be paid to you in a calendar year. Automated Voice Response Unit, 24 hours a day, 7 days a week Generally, your reimbursement may not exceed the lesser of: at (385) 988-6423 or toll free at (800) 274-0503. For immediate (a) $5,000 (if you are married filing a joint return or you are access to your account information at any time, log on to our head of a household) or $2,500 (if you are married filing website at my.nbsbenefits.com or download the NBS Mobile separate returns); (b) your taxable compensation; (c) your App. spouse's actual or deemed earned income. Also, in order to have the reimbursements made to you and be What can I save with an FSA? excluded from your income, you must provide a statement from FSA No FSA the service provider including the name, address and, in most cases, the taxpayer identification number of the service Annual taxable income $24,000 $24,000 provider as well as the amount of such expense and proof that Health FSA $1,500 $0 the expense has been incurred. Dependent care FSA $1,500 $0 Determining contributions Total pre-tax contributions -$3,000 $0 Before each plan year begins, you will select the benefits you want and how much contributions should go toward each Taxable income after FSA $21,000 $24,000 benefit. It is very important that you make these choices Income taxes -$6,300 -$7,200 carefully based on what you expect to spend on each covered benefit or expense during the plan year. After-tax income $14,700 $16,800 Generally, you cannot change the elections you have made after After-tax health and welfare expenses $0 -$3,000 the beginning of the plan year. However, there are certain limited situations when you can change your elections if you Take-home pay $14,700 $13,800 have a "change in status". Please refer to your Summary Plan You saved $900 $0 Description for a change in status listing.

Plan Highlights Flexible Spending Plans

FSA (Flexible Spending Account) NBS Mobile App When you're on the go, save time and hassle with the NBS Mobile App. Submit claims, check your balances, view transactions, and submit documentation using your device's camera.

Easy and convenient •

•

Designed to work just as other iOS and Android apps which makes it easy to learn and use. Shares user authentication with the NBS portal. Registered users can download the app and log in immediately to gain access to their benefit accounts, with no need to register their phone or your account.

It's secure •

No sensitive account information is ever stored on your mobile device and secure encryption is used to protect all transmissions.

Mobile app features The NBS mobile app supports a wide variety of features, empowering you to proactively manage your account. • View account balances • View claims • View reimbursement history • Submit claims • Submit documentation using your device's camera • Pay providers • Setup a variety of SMS alerts • Edit your personal information • View contribution details • View plan information • View calendar deadlines • Contact a service representative • View Benefits Card information

FSA (Flexible Spending Account) Sample Expenses Medical expenses • • • • •

• • • • • •

Acupuncture Addiction programs Adoption (medical expenses for baby birth) Alternative healer fees Ambulance Body scans Breast pumps Care for mentally handicapped Chiropractor Copayments Crutches

Dental expenses • •

• • • • • •

Artificial teeth Copayments Deductible Dental work Dentures Orthodontia expenses Preventative care at dentist office Bridges, crowns, etc.

Vision expenses • • •

• • • • •

Braille - books & magazines Contact lenses Contact lens solutions Eye exams Eye glasses Laser surgery Office fees Guide dog and upkeep/other animal aid

Diabetes (insulin, glucose monitor) Eye patches Fertility treatment First aid (i.e. bandages, gauze) Hearing aids & batteries Hypnosis (for treatment of illness) Incontinence products (i.e. Depends, Serene) Joint support bandages and hosiery Lab fees Monitoring device (blood pressure, cholesterol)

• • • • • •

• • • •

Physical exams Pregnancy tests Prescription drugs Psychiatrist/psychologist (for mental illness) Physical therapy Speech therapy Vaccinations Vaporizers or humidifiers Weight loss program fees (if prescribed by physician) Wheelchair

• • • • •

Items that generally do not qualify for reimbursement • • • • • • • • • • •

•

• • •

Personal hygiene (deodorant, soap, body powder, sanitary products) Addiction products Allergy relief (oral meds, nasal spray) Antacids and heartburn relief Anti-itch and hydrocortisone creams Athlete's foot treatment Arthritis pain relieving creams Cold medicines (i.e. syrups, drops, tablets) Cosmetic surgery Cosmetics (i.e. makeup, lipstick, cotton swabs, cotton balls, baby oil) Counseling (i.e. marriage/family) Dental care - routine (i.e. toothpaste, toothbrushes, dental floss, anti-bacterial mouthwashes, fluoride rinses, teeth whitening/ bleaching) Exercise equipment Fever & pain reducers (i.e. Aspirin, Tylenol) Hair care (i.e. hair color, shampoo, conditioner, brushes, hair loss

• • • • • • • •

• •

• • • • • •

products) Health club or fitness program fees Homeopathic supplement or herbs Household or domestic help Laser hair removal Laxatives Massage therapy Motion sickness medication Nutritional and dietary supplements (i.e. bars, milkshakes, power drinks, Pedialyte) Skin care (i.e. sun block, moisturizing lotion, lip balm) Sleep aids (i.e. oral meds, snoring strips) Smoking cessation relief (i.e. patches, gum) Stomach & digestive relief (i.e. Pepto- Bismol, Imodium) Tooth and mouth pain relief (Orajel, Anbesol) Vitamins Wart removal medication Weight reduction aids (i.e. Slimfast, appetite suppressant

These expenses may be eligible if they are prescribed by a physician (if medically necessary for a specific condition).

8523 South Redwood Road, West Jordan, Utah 84088 (800) 274-0503 service@nbsbenefits.com www.nbsbenefits.com

NOTES