2020-21 Port Neches-Groves ISD Benefit Guide by Higginbotham Public Sector

PORT NECHES-GROVES ISD

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

Table of Contents

Benefit Contact Information How to Enroll Annual Benefit Enrollment 1. Benefit Updates 2. Section 125 Cafeteria Plan Guidelines 3. Annual Enrollment 4. Eligibility Requirements 5. Helpful Definitions 6. Health Savings Account (HSA) vs. Flexible Spending Account (FSA) TRS-ActiveCare HSA Bank Health Savings Account (HSA) Aetna Hospital Indemnity MDLIVE Telehealth Cigna Dental Superior Vision APL Cancer Unum Long Term Disability Cigna Life and AD&D 5Star Family Protection Plan Term Life Insurance with Quality of Life Rider ID Watchdog Identity Theft MASA Emergency Medical Transportation NBS Flexible Spending Account (FSA) 2

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

FLIP TO... PG. 4

HOW TO ENROLL

PG. 6

SUMMARY PAGES

PG. 12

YOUR BENEFITS

11 12-13 14-17 18-21 22-23 24-29 30-31 32-39 40-45 46-51 52-55 56-59 60-61 62-65

Benefit Contact Information PORT NECHES-GROVES ISD BENEFITS

VISION

FAMILY PROTECTION PLAN

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

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

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

MEDICAL

CANCER

TELEHEALTH

Blue Cross Blue Shield (866) 355-5999 www.bcbstx.com/trsactivecare

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

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

HEALTH SAVINGS ACCOUNT

DISABILITY

IDENTITY THEFT

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

UNUM Claims Info: (800) 583-6908 www.unum.com

IDWatchdog (866) 513-1518 www.idwatchdog.com

DENTAL

LIFE AND AD&D

FLEXIBLE SPENDING & FINANCIAL PLANNING ACCOUNT

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

Cigna (800) 583-6908 www.cigna.com

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

HOSPITAL INDEMNITY

EMERGENCY MEDICAL TRANSPORTATION

Aetna (800) 872-3862 www.aetna.com

MASA (800) 423-3226 www.masamts.com 3

MOBILE ENROLLMENT Enrollment made simple through your smartphone or tablet. Text “FBS PNG” to 313131 and get access to everything you need to complete your benefits enrollment:

•

Benefit Information

•

Online Support

•

Interactive Tools

•

And more.

Text “FBS PNG” to 313131 OR SCAN

How to Log In

1 BENEFIT INFO

INTERACTIVE TOOLS

2 3

www.mybenefitshub.com/ portnechesgrovesisd

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 Benefit Updates - What’s New: MEDICAL- NEW PROVIDER! Effective 9/1/2020, the health plan administrator for TRS-ActiveCare medical benefits will change. Benefit and premium changes will apply to all TRS-ActiveCare plans for the next plan year. Plan Options • ActiveCare Primary- NEW TRS PLAN! • ActiveCare HD (formerly 1-HD)- If currently enrolled in TRS-AC1HD and make no changes, you will be enrolled in this plan. • ActiveCare Primary+ (formerly Select)- If currently enrolled in TRS-AC Select and make no changes, you will be enrolled in this plan. To review new premiums and plan options, refer to 2020-21 TRS-ActiveCare Plan Highlights on your benefit website.

Don’t Forget! • •

Login and complete your benefit enrollment from 07/15/2020 - 08/18/2020 Enrollment assistance is available by calling Financial Benefit Services at (866) 914-5202. Hours: Monday - Friday 8am-7pm.

SUMMARY PAGES

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

CHANGES IN STATUS (CIS):

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

QUALIFYING EVENTS

Marital Status

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

Change in Number of Tax Dependents

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

Change in Status of Employment Affecting Coverage Eligibility

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

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

SUMMARY PAGES

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

Where can I find forms?

to review, change or continue benefit elections each year.

For benefit summaries and claim forms, go to your school

Changes are not permitted during the plan year (outside of

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

annual enrollment) unless a Section 125 qualifying event occurs.

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

•

Changes, additions or drops may be made only during the

need under the Benefits and Forms section.

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

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

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

included in the dependent profile. Additionally, you must

portnechesgrovesisd. Click on the benefit plan you need

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

•

For benefit summaries and claim forms, go to your school

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

information on (i.e., Dental) and you can find provider search links under the Quick Links section. When will I receive ID cards? If the insurance carrier provides ID cards, you can expect to receive those 3-4 weeks after your effective date. For most dental and vision plans, you can login to the carrier website and print a temporary ID card or simply give your provider the insurance company’s phone number and they can call and

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

verify your coverage if you do not have an ID card at that time. If you do not receive your ID card, you can call the

carrier’s customer service number to request another card. If the insurance carrier provides ID cards, but there are no changes to the plan, you typically will not receive a new ID card each year.

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

SUMMARY PAGES

Employee Eligibility Requirements

Dependent Eligibility Requirements

Supplemental Benefits: Eligible employees must work 17.5 or

Dependent Eligibility: You can cover eligible dependent

more 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 Port Neches-Groves ISD

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

or as 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

Life

Cigna

To age 26

Cancer

American Public Life

To age 26

Family Protection Plan

5Star

Issue to age 24, keep to age 121

Telehealth

MDLIVE

To age 26

Identity Theft Protection

IDWatchdog

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 Account Owner Underlying Insurance Requirement

Employee and/or employer Individual

Employee and/or employer Employer

High deductible health plan

None

Description

Minimum Deductible Maximum Contribution

Permissible Use Of Funds

$1,400 single (2020) $2,800 family (2020) $3,550 single (2020) $7,100 family (2020) Employees may use funds any way they wish. If used for non-qualified medical expenses, subject to current tax rate plus 20% penalty.

N/A $2,750 Reimbursement for qualified medical expenses (as defined in Sec. 213(d) of IRC).

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

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

Not permitted

Year-to-year rollover of account balance?

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

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

Does the account earn interest?

Yes

Portable?

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

FLIP TO FOR HSA INFORMATION

PG. 14

FLIP TO FOR FSA INFORMATION

PG. 62 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

TRS-ActiveCare 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.)

• Simpler version of the current Select

• Closed to new enrollees plan • Current enrollees can choose to before you meet deductible • Lower deductible than HD and primary stay in plan • Statewide network account (HSA) plans • Lower deductible • PCP referrals required to see • Nationwide network with out-of • Copays for many services and drugs • Copays for many drugs and specialists -network coverage • Higher premium services Plan summary • Not compatible with health • No requirement for PCPs or • Statewide network • Nationwide network with out-ofsavings account (HSA) referrals • PCP referrals required to see specialists network coverage • No out-of-network coverage • Must meet deductible before • Not compatible with a health savings • No requirement for PCPs or plan pays for non-preventive account (HSA) referrals care • No out-of-network coverage If you make no changes Only employees that choose If you’re currently in TRSIf you’re currently in TRS-ActiveCare Select If you’re currently in TRS-ActiveCare during Annual this new plan during Annual ActiveCare 1-HD and you make no and you make no changes during Annual 2, and you make no changes during Enrollment, you’ll have Enrollment will be enrolled in change during Annual Enrollment, Enrollment, this will be your plan next Annual Enrollment, you will remain the following plan... it. this will be your plan next year. year. in TRS-ActiveCare 2 next year.

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

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

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

Plan Features Type of Coverage Individual/Family Deductible Coinsurance Individual/Family Maximum Out-ofPocket 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

You pay 20% You pay 40% after You pay 30% after deductible after deductible deductible

You pay 20% after deductible

In-Network

Out-of-Network

$1,000/$3,000

$2,000/$6,000

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

$8,150/$16,300

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

$6,900/$13,800

$7,900/$15,800

$23,700/$47,400

Statewide Network

Nationwide Network

Statewide Network

Nationwide Network

Yes

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

You can choose this plan if you live in You can choose this plan if you live in one these counties: Austin, Bastrop, one these counties: Cameron, Bell, Blanco, Bosque, Brazos, Hildalgo, Starr, Willacy Burleson, Burnet, Caldwell, Collin, Coryell, Dallas, Denton, Ellis, Erath, Falls, Freestone, Grimes, Hamilton, Hays, Hill, Hood, Houston, Johnson, Lampasas, Lee, Leon, Limestone, Madison, McLennan, Milam, Mills, Navarro, Robertson, Rockwall, Somervell, Tarrant, Travis, Walker, Waller, Washington, Williamson

West Texas Blue Essentials HMO Brought to you by TRS-ActiveCare You can choose this plan if you live in one these counties: Andrews, Armstrong, Bailey, Borden, Brewster, Briscoe, Callahan, Carson, Castro, Childress, Cochran, Coke, Coleman, Collingsworth, Comanche, Concho, Cottle, Crane, Crockett, Crosby, Dallam, Dawson, Deaf Smith, Dickens, Donley, Eastland, Ector, Fisher, Floyd, Gaines, Garza, Glasscock, Gray, Hale, Hall, Hansford, Hartley, Haskell, Hemphill, Hockley, Howard, Hutchinson, Irion, Jones, Kent, Kimble, King, Knox, Lamb, Lipscomb, Llano, Loving, Lubbock, Lynn, Martin, Mason, McCulloch, Menard, Midland, 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

HSA BANK

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, limitations and exclusions are included in the summary plan description located on the Port Neches Groves ISD Benefits Website: www.mybenefitshub.com/portnechesgrovesisd Port Neches Groves ISD Benefits Website: www.mybenefitshub.com/portnechesgrovesisd

HSA (Health Savings Account) Start saving more on healthcare. A Health Savings Account (HSA) is an individually-owned, tax‐ advantaged account that you can use to pay for current or future IRS‐qualified medical expenses. With an HSA, you’ll have the potential to build more savings for healthcare expenses or additional retirement savings through self-directed investment options¹. How an HSA works: • You can contribute to your HSA via payroll deduction, online banking transfer, or by sending a personal check to HSA Bank. Your employer or third parties, such as a spouse or parent, may contribute to your account as well. • You can pay for qualified medical expenses with your Health Benefits Debit Card directly to your medical provider or pay out-of-pocket. You can either choose to reimburse yourself or keep the funds in your HSA to grow your savings. • Unused funds will roll over year to year. After age 65, funds can be withdrawn for any purpose without penalty (subject to ordinary income taxes). • Check balances and account information via HSA Bank’s Member Website or mobile device 24/7.

Are you eligible for an HSA? If you have a qualified High Deductible Health Plan (HDHP) either through your employer, through your spouse, or one you’ve purchased on your own - chances are you can open an HSA. Additionally: • You cannot be covered by any other non-HSA-compatible health plan, including Medicare Parts A and B. • You cannot be covered by TriCare. • You cannot be claimed as a dependent on another person’s tax return (unless it’s your spouse). • You must be covered by the qualified HDHP on the first day of the month. When you open an account, HSA Bank will request certain information to verify your identity and to process your application.

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

2020 Annual HSA Contribution Limits Individual: $3,550 Family: $7,100 According to IRS guidelines, each year you have until the tax filing deadline to contribute to your HSA (typically April 15 of the following year). Online contributions must be submitted by 2:00 p.m., Central Time, the business day before the tax filing deadline. Wire contributions must be received by noon, Central Time, on the tax filing deadline, and contribution forms with checks must be received by the tax filing deadline. Catch-Up Contributions: Accountholders who meet these qualifications are eligible to make an HSA catch-up contribution of $1,000: Health Savings accountholder; age 55 or older (regardless of when in the year an accountholder turns 55); not enrolled in Medicare (if an accountholder enrolls in Medicare mid-year, catch-up contributions should be prorated). Spouses who are 55 or older and covered under the accountholder’s medical insurance can also make a catch-up contribution into a separate HSA in their own name.

How can you benefit from tax savings? An HSA provides triple tax savings.3 Here’s how: • Contributions to your HSA can be made with pre-tax dollars and any after-tax contributions that you make to your HSA are tax deductible. • HSA funds earn interest and investment earnings are tax free. • When used for IRS-qualified medical expenses, distributions are free from tax.

IRS-Qualified Medical Expenses You can use your HSA to pay for a wide range of IRS-qualified medical expenses for yourself, your spouse, or tax dependents. An IRS-qualified medical expense is defined as an expense that pays for healthcare services, equipment, or medications. Funds used to pay for IRS-qualified medical expenses are always taxfree. HSA funds can be used to reimburse yourself for past medical expenses if the expense was incurred after your HSA was established. While you do not need to submit any receipts to HSA Bank, you must save your bills and receipts for tax purposes.

2019 Annual HSA Contribution Limits Individual: $3,500 Family: $7,000 15

How the HSA Plan Works Examples of IRS-Qualified Medical Expenses4: Acupuncture Alcoholism treatment Ambulance services Annual physical examination Artificial limb or prosthesis Birth control pills (by prescription) Chiropractor Childbirth/delivery Convalescent home (for medical treatment only) Crutches Doctor’s fees Dental treatments (including x-rays, braces, dentures, fillings, oral surgery) Dermatologist Diagnostic services Disabled dependent care Drug addiction therapy Fertility enhancement (including in-vitro fertilization) Guide dog (or other service animal)

Gynecologist Hearing aids and batteries Hospital bills Insurance premiums5 Laboratory fees Lactation expenses Lodging (away from home for outpatient care) Nursing home Nursing services Obstetrician Osteopath Oxygen Pregnancy test kit Podiatrist Prescription drugs and medicines (over-the-counter drugs are not IRSqualified medical expenses unless prescribed by a doctor) Prenatal care & postnatal treatments Psychiatrist Psychologist Smoking cessation programs

Special education tutoring Surgery Telephone or TV equipment to assist the hearing or vision impaired Therapy or counseling Medical transportation expenses Transplants Vaccines Vasectomy Vision care (including eyeglasses, contact lenses, lasik surgery) Weight loss programs (for a specific disease diagnosed by a physician – such as obesity, hypertension, or heart disease) Wheelchairs X-rays

Please call the number on the back of your HSA Bank debit card or visit us at www.hsabank.com

1 Investment accounts are not FDIC insured, may lose value and are not a deposit or other obligation of, or guarantee by the bank. Investment losses which are replaced are subject to the annual contribution limits of the HSA. 2 HSA funds contributed in excess of these limits are subject to penalty and tax unless the excess and earnings are withdrawn prior to the due date, including any extensions for filing Federal Tax returns. Accountholders should consult with a qualified tax advisor in connection with excess contribution removal. The Internal Revenue Service requires HSA Bank to report withdrawals that are considered refunds of excess contributions. In order for the withdrawal to be accurately reported, accountholders may not withdraw the excess directly. Instead, an excess contribution refund must be requested from HSA Bank and an Excess Contribution Removal Form completed. 3 Federal Tax savings are available no matter where you live and HSAs are taxable in AL, CA, and NJ. HSA Bank does not provide tax advice. Consult your tax professional for tax‐related questions. 4 This list is not comprehensive. It is provided to you with the understanding that HSA Bank is not engaged in rendering tax advice. The information provided is not intended to be used to avoid Federal tax penalties. For more detailed information, please refer to IRS Publication 502 titled, “Medical and Dental Expenses”. Publications can be ordered directly from the IRS by calling 1-800-TAXFORM. If tax advice is required, you should seek the services of a professional. 5 Insurance premiums only qualify as an IRS-qualified medical expense: while continuing coverage under COBRA; for qualified long-term care coverage; coverage while receiving unemployment compensation; for any healthcare coverage for those over age 65 including Medicare (except Medicare supplemental coverage). 16

How the HSA Plan Works How to use your HSA It’s easy to manage your Health Savings Account (HSA) online. Access real-time account balances, transaction history and statements, as well as track your expenses online. Sign up for online banking today. •

•

Mobile App* – Use your iOS (iPhone, iPod Touch, iPad) or Android-powered device to check available balances in your account and view HSA transaction details, save and store receipts using your device’s camera, receive account balances and configurable alerts via text message, and access customer service contact information. myHealth PortfolioSM – Use this tool to track your healthcare expenses, submit and retain receipts and claims from multiple insurance and financial account providers. Also view expenses by provider, description, and more.

How to deposit funds into your HSA. To maximize HSA tax and savings benefits, begin funding your account as soon as you can. HSA Bank offers several convenient methods for making contributions to your HSA. •

• •

Payroll Deductions – If your employer offers this option, HSA Bank will facilitate recurring pre-tax payroll deductions. Contact your employer to complete the appropriate paperwork. Online Transfers – On HSA Bank’s member website, you can transfer funds from an external bank account, such as a personal checking or savings account, to your HSA. Check – Mail your personal check and completed Contribution Form to: HSA Bank, PO Box 939, Sheboygan, WI 53082

How to pay for healthcare expenses from your HSA.** Whether you want to reimburse yourself for an IRS-Qualified medical expense paid out-of-pocket or you want to pay directly from your HSA, HSA Bank offer multiple options for accessing your funds. NOTE: all transactions are limited to your available cash balance. •

•

Online Transfers – On HSA Bank’s Member Website or mobile app, you can reimburse yourself for out-of-pocket expenses by making a one-time or reoccurring online transfer from your HSA to your personal checking or savings account. There is a daily limit of $2,500. Online Bill Pay – Use this feature to pay medical providers directly from your HSA. There is no daily limit.

HSA Bank’s Health Benefits Debit Card can be used for point-ofsale transactions in two ways, signature or PIN. For signature, swipe card, press credit on the keypad, and sign the receipt. To pay using a PIN (fee per PIN transaction may apply† ), swipe your card, select debit on the keypad, and enter your PIN. To withdraw HSA funds from an ATM (fee per ATM withdrawal may apply† ), be sure to select the “checking” option (not savings) when asked the type of account you are withdrawing from. HSA Bank limits point-ofsale debit card transactions to medical merchants. As a mechanism for fraud protection, HSA Bank has set daily limits on debit card transactions. These limits are listed in your Deposit Account Agreement and Disclosures Booklet. Debit card transactions are also limited to your current balance.

*The HSA Bank Mobile App is free to download. However, you should check with your wireless provider for any associated fees for accessing the internet from your device. **You can pay for a wide range of IRS-qualified medical expenses with your HSA, including many that aren’t typically covered by health insurance plans. This includes deductibles, co-insurance, prescriptions, dental and vision care, and more. For a complete list of IRS-qualified medical expenses, visit irs.gov or hsabank.com/IRSQualifiedExpenses. † For applicable fees, see your HSA Bank Interest and Fee Schedule or Explanation of HSA Bank Fee Changes document.

For assistance, please contact the Client Assistance Center: 800-357-6246 www.hsabank.com 605 N. 8th Street, Ste. 320, Sheboygan, WI 53081

Health Benefits Debit Card – Your HSA Bank Health Benefits Debit Card provides access to your HSA funds at point-ofsale with signature or PIN and at ATMs for withdrawals. HSA Bank imposes a daily debit card limit of $3,000 to safeguard against fraudulent activity. Transaction fees may apply when used with a PIN.† Checks – A book of 50 checks can be ordered upon request for an additional fee.† You can use these checks to pay providers or reimburse yourself for expenses already incurred. There is no daily limit on dollar amounts. 17

AETNA YOUR BENEFITS PACKAGE

Hospital Indemnity

About this Benefit Hospital Confinement Indemnity Insurance pays a daily benefit if you have a covered stay in a hospital*, critical care unit and rehabilitation facility. The benefit amount is determined based on the type of facility and the number of days you stay. Hospital Confinement Indemnity Insurance is a limited benefit policy. It is not health insurance and does not satisfy the requirement of minimum essential coverage under the Affordable Care Act.

The median hospital costs per stay have steadily grown to over $10,500 per day.

$9,600

$10,400

$10,700

2008

2012

2018

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 18 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Port Neches Groves ISD Benefits Website: www.mybenefitshub.com/portnechesgrovesisd

Hospital Indemnity Plan Description Our hospital indemnity plan provides fixed payments directly to members when they have a covered inpatient hospital stay.

Plan Eligibility • • •

Employee eligibility as defined by the Client. A minimum of at least 15 hours per week is required Eligible dependents include: Legal spouse, domestic partner, children under age 26 and provided they meet the definition of dependent child as defined by the state Retirees are not considered actively at work and therefore not eligible for this plan

Plan Highlights • • • • • • • •

Guaranteed Issue Rate Guarantee for 24 months subject to all other terms in this Proposal 4 Tier Coverage options include: Employee, Employee & Spouse, Employee & Children, and Family HSA compatible Benefits paid to the employee Pre-ex waived Simplified Claims Process for Aetna medical members Online claims process for employees not enrolled in an Aetna medical plan

Plan Features • • • • •

Lump-sum payment for first day of inpatient stay, when stay begins during the plan year Daily benefit payment beginning on the second day Additional per day payment in an intensive care unit (ICU) Waiver of Premium Portable

Value Added Programs Access to Aetna Discount Programs: Including blood pressure monitors, gym memberships, weight-loss programs, books and magazine subscriptions, eye care, hearing and dental products and more.

MONTHLY RATES Quoted Rates are guaranteed for 90 days from the date of this Proposal. Commission Percentage: Employer Contribution:

15% 0%

Hospital Indemnity (HSA) Plan 2

Plan 4

Employee

$18.44

Employee

$36.89

Employee & Spouse

$38.91

Employee & Spouse

$77.83

Employee & Children

$28.40

Employee & Children

$56.79

Family

$45.47

Family

$90.94

Any changes in benefit level or conditions stated above may result in a change in rates. The quoted rates are anticipated to be valid as of the Effective Date and apply only to the benefit level and conditions stated above and are subject to the terms and conditions set forth in the policy, and related documents for each product as well as applicable law. 19

Hospital Indemnity Hospital Indemnity Plan Benefits Covered Benefit for Impatient Stays

Plan 2

Plan 4

$1,000

$2,000

$100

$200

$400

$100

$200

$100

$200

$100

$200

$100

$200

$50

$100

Hospital stay - Admission Provides a lump sum benefit for the initial day of your stay in a hospital. Maximum 1 stay per plan year Hospital stay - Daily Pays a daily benefit, beginning on day two of your stay in a non-ICU room of a hospital.

Maximum 30 days per plan year Hospital stay - (ICU) Daily Pays a daily benefit, beginning on day two of your stay in an ICU room of a hospital. Maximum 30 days per plan year Newborn routine care Provides a lump-sum benefit after the birth of your newborn. This will not pay for an outpatient birth. Observation unit Provides a lump sum benefit for the initial day of your stay in an observation unit as the result of an illness or accidental injury. Maximum 1 day per plan year Substance abuse stay - Daily Pays a daily benefit for each day you have a stay in a hospital or substance abuse treatment facility for the treatment of substance abuse. Maximum 30 days per plan year Mental disorder stay - Daily Pays a daily benefit for each day you have a stay in a hospital or mental disorder treatment facility for the treatment of mental disorders. Maximum 30 days per plan year Rehabilitation unit stay - Daily Pays a benefit each day of your stay in a rehabilitation unit immediately after your hospital stay due to an illness or accidental injury. Maximum 30 days per plan year Important Note: All daily inpatient stay benefits begin on day two and count toward the plan year maximum.

Hospital Indemnity Plan Exclusions and Limitations This plan has exclusions and limitations. Refer to the actual policy and certificate to determine which benefits are not payable. The following is a partial list of services and supplies that are generally not covered. However, the plan may contain exceptions to this list based on state mandates or the plan design purchased.

Hospital Indemnity Benefits will not be paid for any stay or other service for an illness or accidental injury related to the following: 1. Certain competitive or recreational activities, including but not limited to: ballooning, bungee jumping, parachuting, skydiving; 2. Any semi-professional or professional competitive athletic contest, including officiating or coaching, for which you receive any payment; 3. Act of war, riot, war; 4. Operating, learning to operate or serving as a pilot or crew member of any aircraft, whether motorized or not; 5. Assault, felony, illegal occupation, or other criminal act; 6. Care provided by a spouse, parent, child, sibling or any other household member; 7. Cosmetic services and plastic surgery, with certain exceptions; 8. Custodial Care; 9. Hospice services, except as specifically provided in the Benefits under your plan section of the certificate; 10. Self-harm, suicide, except when resulting from a diagnosed disorder; 11. Violating any cellular device use laws of the state in which the accident occurred, while operating a motor vehicle; 12. Care or services received outside the United States or its territories; 13. Education, training or retraining services or testing; 14. Accidental injury sustained while intoxicated or under the influence of any drug intoxicant; 15. Exams except as specifically provided in the Benefits under your plan section of the certificate; 16. Dental and orthodontic care and treatment; 17. Family planning services; 18. Any care, prescription drugs, and medicines related to infertility; 19. Nutritional supplements, including but not limited to: food items, infant formulas, vitamins; 20. Outpatient cognitive rehabilitation, physical therapy, occupational therapy, or speech therapy for any reason; 21. Vision-related care

• • • • •

Streamlined implementation and file exchange with other Aetna plans Ability to enroll on your chosen platform Enrollment strategy and marketing plan development support Fast and accurate enrollment materials Member access to Aetna's discount programs

Why Voluntary Plans? • • • • •

Complement cost containment strategies Increase enrollment in high‐deductible health plans (HDHPs) Provide a financial safety‐net to help employees with medical and non‐medical expenses Provide employees alternative options for funding out‐of‐ pocket exposure Enhance benefits offerings to attract and retain talent

Additional coverage Extra protection Financial security

Happy, healthy, productive employees

Count on us for voluntary solutions: Accident. Critical Illness, and Hospital Indemnity Insurance plans are offered and/or underwritten by Aetna Life Insurance Company (Aetna). THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. The Aetna Hospital Indemnity Plan is a hospital confinement indemnity plan. This plan provides limited benefits. The benefit payments are not intended to cover the full cost of medical care. You are responsible for making sure the provider's bills get paid. These benefits are paid in addition to any other health coverage you may have. This plan does not count as Minimum Essential Coverage under the Affordable Care Act.

Why Aetna Voluntary? • • • • • •

15 years of voluntary benefits experience Flexibility and group level customizations through plan designs and riders Online access to coverage, claims and plan documents through a personalized member portal Simplified Claims Process – online claims process with no paper proof required for Aetna medical members Competitive rates and billing flexibility Discounts may apply when packaging with other Aetna plans

MDLIVE

Telehealth

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

YOUR BENEFITS PACKAGE

75%

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included 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 Port Neches Groves ISD Benefits Website: www.mybenefitshub.com/portnechesgrovesisd Port Neches Groves ISD Benefits Website: www.mybenefitshub.com/portnechesgrovesisd

Telehealth Need a doctor?

Download the MDLIVE Mobile App

No long wait. No big bill. Always open. With MDLIVE, you can visit with a doctor 24/7 from your home, office or on-the-go.

Quality care now goes where you do. With MDLIVE, you can visit with a doctor or counselor 24/7 from your home, office or on-the-go.

Welcome to MDLIVE! Your anytime, anywhere doctor’s office.

Welcome to MDLIVE!

We treat over 50 routine medical conditions including:

Your virtual doctor is here. Join for free today!

• • • • • • •

The MDLIVE mobile app makes connecting with doctors and behavioral health counselors fast, easy and convenient.

Your anytime, anywhere doctor’s office. Avoid waiting rooms and the inconvenience of going to the Avoid waiting rooms and the inconvenience of going to the doctor’s office. Visit a doctor or counselor by phone, secure video doctor’s office. Visit a doctor by phone, secure video, or MDLIVE or MDLIVE app. Pediatricians are available 24/7, and family App. Pediatricians are available 24/7, and family members are also members are also eligible. eligible. • U.S. board-certified doctors with an average of 15 years of • U.S. board certified doctors and licensed counselors with an experience. average of 15 years of experience. • Consultations are convenient, private and secure. • Consultations are convenient, private and secure • Prescriptions can be sent to your nearest pharmacy, if • Prescriptions can be sent to your nearest pharmacy, if medically necessary. medically necessary.

Acne Allergies Cold / Flu Constipation Cough Diarrhea Ear Problems

• • • • • •

Fever Headache Insect Bites Nausea / Vomiting Pink Eye Rash

Your Monthly Premium is

• • • • •

Respiratory Problems Sore Throats Urinary Problems / UTI Vaginitis And More

No smartphone? No worries! Register your account using a computer or phone.

Download the app. Join for free. Visit a doctor. consultmdlive.com 888-365-1663

$0 (Employer Paid) Join for free. Visit a doctor. consulmdlive.com 888-365-1663

Copyright © 2019 MDLIVE Inc. All Rights Reserved. MDLIVE may not be available in certain states and is subject to state regulations. MDLIVE does not replace the primary care physician, is not an insurance product and may not be able to substitute for traditional in person care in every case or for every condition. MDLIVE does not prescribe DEA controlled substances and may not prescribe non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. MDLIVE does not guarantee patients will receive a prescription. Healthcare professionals using the platform have the right to deny care if based on professional judgment a case is inappropriate for telehealth or for misuse of services. MDLIVE and the MDLIVE logo are registered trademarks of MDLIVE, Inc. and may not be used without written permission. For complete terms of use visit https://www.MDLIVE.com/terms-of-use/.

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

Dental PPO - High Option Cigna Dental Benefit Summary Port Neches-Groves ISD â&#x20AC;&#x201C; High Plan Plan Renewal Date: 09/01/2020 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.

Network Options Reimbursement Levels Policy Year Benefits Maximum Applies to: Class I, II, & III expenses Policy Year Deductible Individual Family Benefit Highlights Class I: Diagnostic & Preventive Oral Evaluations Prophylaxis: routine cleanings X-rays: routine X-rays: non-routine Fluoride Application Sealants: per tooth Space Maintainers: non-orthodontic Class II: Basic Restorative Emergency Care to Relieve Pain 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 Class III: Major Restorative Denture Relines, Rebases and Adjustments Inlays and Onlays Prosthesis Over Implant Crowns: prefabricated stainless steel / resin Crowns: permanent cast and porcelain Bridges and Dentures Class IV: Orthodontia Coverage for Dependent Children to age 19 Lifetime Benefits Maximum: $1,000

Cigna Dental Choice Plan In-Network Total Cigna DPPO Network Based on Contracted Fees

EE Only

$28.08

EE + Spouse

$66.56

EE + Child(ren)

$79.28

EE + Family

$109.62

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

$1,000

$50 $150

Plan Pays

You Pay

Plan Pays

You Pay

100% No Deductible

No Charge

100% No Deductible

No Charge

80% After Deductible

20% After Deductible

80% After Deductible

20% After Deductible

50% After Deductible

50% No Deductible

Benefit Plan Provisions: In-Network Reimbursement Non-Network Reimbursement

Cross Accumulation Policy Year Benefits Maximum

For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Fee Schedule or Discount Schedule. For services provided by a non-network dentist, Cigna Dental will reimburse according to the Maximum Reimbursable Charge. The MRC is calculated at the 90th percentile of all provider charges in the geographic area. The dentist may balance bill up to their usual fees. All deductibles, plan maximums, and service specific maximums cross accumulate between in and out of network. Benefit frequency limitations are based on the date of service and cross accumulate between in and out of network. The plan will only pay for covered charges up to the yearly Benefits Maximum, when applicable. Benefit-specific Maximums may also apply. 25

Dental PPO - High Option Policy Year Deductible Pretreatment Review Alternate Benefit Provision Oral Health Integration Program (OHIP)

Timely Filing Benefit Limitations: Missing Tooth Limitation

This is the amount you must pay before the plan begins to pay for covered charges, when applicable. Benefit -specific deductibles may also apply. Pretreatment review is available on a voluntary basis when dental work in excess of $200 is proposed. When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses. Cigna Dental Oral Health Integration Program offers enhanced dental coverage for customers with the following medical conditions: diabetes, heart disease, stroke, maternity, head and neck cancer radiation, organ transplants and chronic kidney disease. There’s no additional charge for the program, those who qualify get reimbursed 100% of coinsurance for certain related dental procedures. Eligible customers can also receive guidance on behavioral issues related to oral health and discounts on prescription and nonprescription dental products. Reimbursements under this program are not subject to the plan deductible, but will be applied to and are subject to the plan annual maximum. Discounts on certain prescription and non-prescription dental products are available through Cigna Home Delivery Pharmacy only, and you are required to pay the entire discounted charge. For more information including how to enroll in this program and a complete list of program terms and eligible medical conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24. Out of network claims submitted to Cigna after 365 days from date of service will be denied.

Oral Evaluations

For teeth missing prior to coverage with Cigna, the amount payable is 50% of the amount otherwise payable until covered for 24 months; thereafter, considered a Class III expense. 2 per policy year

X-rays (routine)

Bitewings: 2 per policy year

X-rays (non-routine)

Diagnostic Casts

Complete series of radiographic images and panoramic radiographic images: Limited to a combined total of 1 per 36 months Payable only in conjunction with orthodontic workup

Cleanings

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

Fluoride Application

2 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 16

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 Prosthesis Over Implant

Covered if more than 6 months after installation 1 every 60 months if unserviceable and cannot be repaired. Benefits are based on the amount payable for non-precious metals. No porcelain or white/tooth colored material on molar crowns or bridges.

Benefit Exclusions:Covered Expenses will not include, and no payment will be made for the following: Procedures and services not 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; 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.© 2017 Cigna / version 06192017

Dental PPO - Low Option Cigna Dental Benefit Summary Port Neches-Groves ISD â&#x20AC;&#x201C; Low Plan Plan Renewal Date: 09/01/2020 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.

Network Options Reimbursement Levels Policy Year Benefits Maximum Applies to: Class I, II, & III expenses Policy Year Deductible Individual Family Benefit Highlights Class I: Diagnostic & Preventive Oral Evaluations Prophylaxis: routine cleanings X-rays: routine X-rays: non-routine Fluoride Application Sealants: per tooth Space Maintainers: non-orthodontic Class II: Basic Restorative Emergency Care to Relieve Pain Restorative: fillings Periodontics: minor and major Oral Surgery: minor Class III: Major Restorative Endodontics: minor and major Oral Surgery: major Anesthesia: general and IV sedation Repairs: Bridges, Crowns and Inlays Repairs: Dentures Denture Relines, Rebases and Adjustments Inlays and Onlays Prosthesis Over Implant Crowns: prefabricated stainless steel / resin Crowns: permanent cast and porcelain Bridges and Dentures

Cigna Dental Choice Plan In-Network Total Cigna DPPO Network Based on Contracted Fees

EE Only

$18.34

EE + Spouse

$35.14

EE + Child(ren)

$41.82

EE + Family

$64.98

Out-of-Network See Non-Network Reimbursement Maximum Allowable Charge

$1,000

$50 $150

Plan Pays

You Pay

Plan Pays

You Pay

100% No Deductible

No Charge

100% No Deductible

No Charge

80% After Deductible

20% After Deductible

80% After Deductible

20% After Deductible

50% After Deductible

Benefit Plan Provisions: In-Network Reimbursement Non-Network Reimbursement

Cross Accumulation Policy Year Benefits Maximum

Dental PPO - High Option Policy Year Deductible Pretreatment Review Alternate Benefit Provision Oral Health Integration Program (OHIP)

Timely Filing 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 24 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 2 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 16 Space Maintainers Limited to non-orthodontic treatment for children under age 19 Inlays, Crowns, Bridges, Replacement every 60 months if unserviceable and cannot be repaired. Benefits are based on the amount payable for Dentures and Partials 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, Covered if more than 6 months after installation Rebases and Relines 1 every 60 months if unserviceable and cannot be repaired. Benefits are based on the amount payable for non-precious Prosthesis Over Implant metals. No porcelain or white/tooth colored material on molar crowns or bridges.

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 30 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Port Neches Groves ISD Benefits Website: www.mybenefitshub.com/portnechesgrovesisd Port Neches Groves ISD Benefits Website: www.mybenefitshub.com/portnechesgrovesisd

Vision - Superior National Network Port Neches-Groves ISD

Monthly Premiums

Proposed Effective Date: September 1, 2020 Vision Plan with Discount Features Superior National Network Voluntary

Benefits

In-Network

Exam Covered in full (ophthalmologist) Exam (optometrist) Covered in full Frames $130 retail allowance Contact Lens Fitting Covered in full (standard2) Contact Lens Fitting $50 retail allowance (specialty2) Contact Lenses3 $120 retail allowance Medically Necessary Covered in Full Contact Lenses

Out-of-Network

Progressive Lenticular Factory Scratch Coat Ultraviolet Coat Polycarbonate children only

$10.72 $21.25 $20.82 $31.67

Co-Pays

Up to $42

Exam Materials1 Contact Lens Fitting

Up to $37 Up to $68

$10 $10 $25

Services/Frequency

Not covered

Exam Frame Contact Lens Fitting Lenses Contact Lenses

Not covered Up to $100 Up to $210

Lenses (standard) per pair Single Vision Bifocal Trifocal

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

12 months 12 months 12 months 12 months 12 months

Superior National Network Covered in full Covered in full Covered in full Covered at lined Trifocal level Covered in full Covered in full Covered in full

Up to $32 Up to $46 Up to $61 Up to $84 Not covered Not covered

Covered in full

Not covered

•

Up to $61

Rate Assumptions ● Rates are guaranteed for 4 years. ● Minimum requirements: ● Minimum 10 enrolled employees. ● The employer pays 0% of the employee premium and 0% of the dependent premium. This quote is valid for effective dates within 90 days of the proposed effective date noted above. The proposed rates are based on the information provided to prepare this quote and the parameters outlined in this quote. This quote is subject to adjustment if actual information is materially different than that provided, or if there are changes from the parameters outlined in this quote. Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements All allowances are at a retail value; the insured is responsible for any charges in excess of this retail allowance.

•

We offer a broad provider network of MDs, ODs, national and regional optical retail chains (in network) including LensCrafters, Target Optical, Pearle Vision and additional providers as noted below. - Benefit allowances remain the same across the full provider network so you receive the same level of benefits regardless of the in-network provider chosen. - More one-hour and same-day service options providing members with swift solutions to vision care. - Freedom to choose the same or different providers for exam and materials. - In-network online shopping through leading retailers Glasses.com, 1-800 Contacts, and ContactsDirect A National LASIK Network of laser vision correction providers, featuring QualSight, offers Superior Vision members a discount on services. These discounts should be verified prior to service. A National Hearing Network of hearing care professionals, featuring Your Hearing Network, offers Superior Vision members discounts on services, hearing aids and accessories. These discounts should be verified prior to service.

Superior Value •

•

Separate Stand-alone Contact Lens Fitting Benefit. Contact lenses are covered as a separate benefit—so the full materials allowance can be used for materials. Members may also receive additional discounts, including 20% off lens upgrades and 30% off additional pairs of glasses. Discounts are provided by participating providers. Members should verify if their provider participates in the discount feature before receiving service.

Materials co-pay applies to lenses and frames only, not contact lenses Standard Contact Lens Fitting applies to a current contact lens user who wears disposable, daily wear, or extended wear lenses only. Specialty Contact Lens Fitting applies to new contact wearers and/or a member who wears toric, gas permeable, or multi-focal lenses. 3 Contact lenses are in lieu of eyeglass lenses and frames benefit 2

Underwritten by: National Guardian Life Insurance Company National Guardian Life Insurance Company is not affiliated with the Guardian Life Insurance Company of America, aka The Guardian or Guardian Life 11090 White Rock Road, Suite 175 | Rancho Cordova, CA 95670 (800) 923-6766 | superiorvision.com

or more information or additional group quotes, please contact: John Parker Regional Sales Executive 800-923-6766 x2350 John.baker@versanthealth.com

superiorvision.com 31

AMERICAN PUBLIC LIFE

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 32 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Port Neches Groves ISD Benefits Website: www.mybenefitshub.com/portnechesgrovesisd

GC12 Limited Benefit Group Cancer Indemnity Insurance Port Neches Grove ISD

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

Summary of Benefits Benefits

Option 1 Base Plan

Option 2 Base Plan

Level 1

Diagnostic Testing - 1 test per Calendar Year

$50 per test

Follow-Up Diagnostic Testing - 1 test per Calendar Year

$100 per test

Medical Imaging – 1 per Calendar Year

$500 per test

Cancer Treatment Benefits

Level 1

Level 4

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

$10,000

$20,000

$50 per treatment

Level 1

$30 Unit Dollar Amount Maximum $3,000 per operation

[$30 Unit Dollar Amount Maximum $3,000 per operation

25% of amount paid for covered surgery

$6,000

$600

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

$1,000 $100

Patient Care Benefits

Level 1

$100 $200 $100 $200

Outpatient Facility - Per day surgery is performed

$200

Attending Physician - Per day of Hospital Confinement

$30

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

$100 $100

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

$100 per day

Donor

$100 per day

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

$100 per day

Hospice Care Up to maximum of 365 days per lifetime

$100 per day

$100 $100

Cancer Screening Benefits

Hormone Therapy - Maximum of 12 treatments per Calendar Year Surgical Benefits Surgical Anesthesia Bone Marrow Transplant - Maximum per lifetime Stem Cell Transplant - Maximum per lifetime

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

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

APSB-22338(TX) MGM/FBS Port Neches Grove ISD

GC12 Limited Benefit Group Cancer Indemnity Insurance Miscellaneous Benefits

Level 1

Cancer Treatment Center Evaluation or Consultation - 1 per lifetime

N/A

Evaluation or Consultation Travel and Lodging - 1 per lifetime

N/A

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

$150 per Confinement $50 per Prescription

$150

Actual coach fare or $.40 per mile

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

$.40 per mile

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

$50 per day

Actual coach fare or $.40 per mile

$.40 per mile

$50 per day

Blood, Plasma and Platelets

$300 per day

Experimental Treatment

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

Second and Third Surgical Opinion Second Surgical Opinion Third Surgical Opinion Drugs and Medicine Inpatient Outpatient - Maximum $150 per month Hair Piece (Wig) - 1 per lifetime Transportation Travel by bus, plane or train

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

Ambulance Ground Air Maximum of 2 trips per Hospital Confinement for all modes of transportation combined

$200 per trip

$2,000 per trip

Inpatient Special Nursing Services - Per day of Hospital Confinement

$150 per day

Outpatient Special Nursing Services Up to same number of Hospital Confinement days

$150 per day

N/A

$25 per visit $1,000

Waive Premium

Medical Equipment - Maximum of 1 benefit per Calendar Year Physical, Occupational, Speech, Audio Therapy & Psychotherapy Maximum per Calendar Year Waiver of Premium

APSB-22338(TX) MGM/FBS Port Neches Grove ISD

GC12 Limited Benefit Group Cancer Indemnity Insurance Benefit Riders Internal Cancer First Occurrence Benefit Rider

Level 1

Level 2

Lump Sum Benefit Maximum 1 per Covered Person per lifetime

$2,500

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

$3,750

Heart Attack/Stroke First Occurrence Benefit Rider

Level 1

Lump Sum Benefit Maximum 1 per Covered Person per lifetime

$2,500

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

$3,750

Intensive Care Unit

$600 per day

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

$300 per day

Hospital Intensive Care Unit Rider

Monthly Premiums* OPTION 1 TOTAL MONTHLY PREMIMS BY PLAN**

Issue Ages

Individual

Individual & Spouse

1 Parent Family

2 Parent Family

18+

$20.64

$43.80

$26.70

$49.80

OPTION 2 TOTAL MONTHLY PREMIUMS BY PLAN**

Issue Ages

Individual

Individual & Spouse

1 Parent Family

2 Parent Family

18+

$26.90

$56.62

$34.14

$63.86

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

APSB-22338(TX) MGM/FBS Port Neches Grove ISD

GC12 Limited Benefit Group Cancer Indemnity Insurance

Plan Benefit Highlights Cancer Screening Benefits Diagnostic Testing

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

Follow-Up Diagnostic Testing

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

Anesthesia

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

Bone Marrow/Stem Cell Transplant

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

Prosthesis

Medical Imaging

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

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

Cancer Treatment Benefits

Patient Care Benefits

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

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

Radiation Therapy, Chemotherapy or Immunotherapy

Hormone Therapy

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

Surgical Benefits Surgical

Pays an indemnity amount when a surgical operation is performed on a Covered Person for a covered diagnosed Cancer, Skin Cancer or for reconstructive surgery due to Cancer. The indemnity amount is payable up to the maximum per operation amount chosen and will be calculated by multiplying the surgical unit value assigned to the procedure, as shown in the most current Physician’s Relative Value Table, by the Unit Dollar Amount. This benefit will be paid for surgery performed in or out of the Hospital. Two or more surgical procedures performed through the same incision will be considered one operation and benefits will be limited to the most expensive procedure. Diagnostic surgeries that result in a negative diagnosis of Cancer are not covered under this benefit. Bone Marrow or Stem Cell Transplant surgeries are paid under the Bone Marrow or Stem Cell Transplant benefits. Surgeries required to implant a permanent prosthetic device are covered under the Prosthesis benefit. This benefit is payable for reconstructive breast surgery performed on a non-diseased breast to establish symmetry with a diseased breast when the reconstructive surgery of the diseased breast is performed while covered under this policy. Reconstructive surgery to the non-diseased breast must occur within 24 months of the reconstructive surgery of the diseased breast.

APSB-22338(TX) MGM/FBS Port Neches Grove ISD

Hospital Confinement

Outpatient Facility

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

Attending Physician

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

Extended Care Facility

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

Home Health Care

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

GC12 Limited Benefit Group Cancer Indemnity Insurance Hospice Care

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

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

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

Miscellaneous Benefits

Cancer Treatment Cancer Evaluation or Consultation

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

Second & Third Surgical Opinion

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

Drugs & Medicine

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

Transportation & Lodging

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

APSB-22338(TX) MGM/FBS Port Neches Grove ISD

Family Transportation & Lodging

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

Blood, Plasma & Platelets

Pays the indemnity amount for blood, plasma and platelets. This benefit does not include coverage for any laboratory processes or colony stimulating factors. Benefits for Blood, Plasma and Platelets are ONLY provided under this benefit.

Ambulance

Pays the indemnity amount, up to two trips per confinement, for either licensed air or ground ambulance transportation of a Covered Person to a Hospital or from one medical facility to another where the Covered Person is admitted as an Inpatient and Hospital confined for at least 18 consecutive hours for the treatment of Cancer. If both air and ground ambulance is required on the same day, we will only pay the highest benefit amount.

Physical, Occupational, Speech, Audio Therapy or Psychotherapy

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

Waiver of Premium

When the Certificate is in force and the Insured becomes Disabled, we will waive all premiums due including premiums for any riders attached to the Certificate. Disability must be due to Cancer and occur while receiving treatment for such Cancer for which benefits are payable under the Policy. The Insured must remain Disabled for 60 continuous days before this benefit will begin. The Waiver of Premium will begin on the next premium due date following the 60 consecutive days of Disability. This benefit will continue for as long as the Insured remains Disabled until the earliest of either the date the Insured is no longer Disabled or the date coverage ends according to the Termination provisions in the Certificate. Proof of Disability must be provided for each new period of Disability before a new Waiver of Premium benefit is payable. Other Benefits include: s Donor s Dread Disease s Experimental Treatment s Hair Piece s Inpatient Special Nursing Services s Medical Equipment s Outpatient Special Nursing Services 37

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

GC12 Limited Benefit Group Cancer Indemnity Insurance Important Policy Provisions Eligibility

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

Limitations & Exclusions

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

Only Loss for Cancer or Dread Disease

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

Pre-Existing Condition Exclusion

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

Waiting Period

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

Termination of Coverage

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

Optionally Renewable

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

Portability (Voluntary Plans Only)

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

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

Termination of Certificate

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

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

Underwritten by American Public Life Insurance Company. This is a brief description of the coverage. For complete benefits, limitations, exclusions and other provisions, please refer to the policy and riders. This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. | This policy is considered an employee welfare benefit plan established and/or maintained by an association or employer intended to be covered by ERISA, and will be administered and enforced under ERISA. Group policies issued to governmental entities and municipalities may be exempt from ERISA guidelines. | This product contains Limitations & Exclusions | Policy Form GC12APL Limited Benefit Group Cancer Indemnity Insurance Series | Texas | (04/13) | Port Neches Grove 38 ISD

APSB-22338(TX) MGM/FBS Port Neches Grove ISD

UNUM YOUR BENEFITS PACKAGE

Long Term 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 40 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Port Neches Groves ISD Benefits Website: www.mybenefitshub.com/portnechesgrovesisd

Long Term Disability Policy # 124864 Please read carefully the following description of your Unum Educator Select Income Protection Plan insurance.

Your Plan Eligibility You are eligible for disability coverage if you are an active employee in the United States working a minimum of 17.5 hours per week. The date you are eligible for coverage is the later of: the plan effective date; or the day after you complete the waiting period.

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

Benefit Amount You may purchase a monthly benefit in $100 units, starting at a minimum of $200, up to 66 2/3% of your monthly earnings rounded to the nearest $100, but not to exceed a monthly maximum benefit of $7,500. Please see your Plan Administrator for the definition of monthly earnings. The total benefit payable to you on a monthly basis (including all benefits provided under this plan) will not exceed 100% of your monthly earnings unless the excess amount is payable as a Cost of Living Adjustment. However, if you are participating in Unum’s Rehabilitation and Return to Work Assistance program, the total benefit payable to you on a monthly basis (including all benefits provided under this plan) will not exceed 110% of your monthly earnings (unless the excess amount is payable as a Cost of Living Adjustment).

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

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

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

Pre-Existing Condition Exclusion Benefits will not be paid for disabilities caused by, contributed to by, or resulting from a pre-existing condition. You have a pre-existing condition if: • you received medical treatment, consultation, care or services including diagnostic measures, or took prescribed drugs or medicines in the 3 months just prior to your effective date of coverage; and • the disability begins in the first 12 months after your effective date of coverage.

Federal Income Taxation The taxability of benefits depends on how premium was taxed during the plan year in which you become disabled. If you paid 100% of the premium for the plan year with post-tax dollars, your benefits will not be taxed. If premium for the plan year is paid with pre-tax dollars, your benefits will be taxed. If premium for the plan year is paid partially with post-tax dollars and partially with pre-tax dollars, or if you and your Employer share in the cost, then a portion of your benefits will be taxed.

Additional Benefits Work/Life Balance Employee Assistance Program1 Work-life balance is a comprehensive resource providing access to professional assistance for a wide range of personal and work-related issues. The service is available to you and your family members twentyfour hours a day, 365 days a year, and provides resources to help employees find solutions to everyday issues such as financing a car or selecting child care, as well as more serious problems such as alcohol or drug addiction, divorce, or relationship problems. Services include: toll-free phone access to master’s-level consultants, up to three face-to-face sessions to help with more serious issues; and online resources. There is no additional charge for utilizing the program. Participation is confidential and strictly voluntary, and employees do not have to have filed a disability claim or be receiving benefits to use the program. However, if you become disabled and are receiving benefits, Unum's On Claim Support can provide additional resources including: coaching on how to communicate effectively with medical personnel, conducting consumer research for medical equipment and supplies, assessing emotional needs and locating counseling resources. 41

Long Term Disability Return to Work/ Work Incentive Benefit Unum supports efforts that enable a disabled employee to remain on the job or return to work as soon as possible. If you are disabled but working part time with monthly disability earnings of 20% or more of your indexed monthly earnings, during the first 12 months, the monthly benefit will not be reduced by any earnings until the gross disability payment plus your disability earnings, exceeds 100% of your indexed monthly earnings. The monthly benefit will then be reduced by that amount.

Rehabilitation and Return to Work Assistance Unum has a vocational Rehabilitation and Return to Work Assistance program available to assist you in returning to work. We will make the final determination of your eligibility for participation in the program, and will provide you with a written Rehabilitation and Return to Work Assistance plan developed specifically for you. This program may include, but is not limited to the following benefits: • coordination with your Employer to assist your return to work; • adaptive equipment or job accommodations to allow you to work; • vocational evaluation to determine how your disability may impact your employment options; • job placement services; • resume preparation; • job seeking skills training; or • education and retraining expenses for a new occupation.

You may receive your survivor benefit prior to your death if you are receiving monthly payments and your physician certifies in writing that you have been diagnosed as terminally ill and your life expectancy has been reduced to less than 12 months. This benefit is only payable once and if you elect to receive this benefit, no survivor benefit will be payable to your eligible survivor upon your death. (Note this “Accelerated Survivor Benefit” is not available in Connecticut.) Dependent Care Expense Benefit If you are disabled and participating in Unum’s Rehabilitation and Return to Work Assistance program, Unum will pay a Dependent Care Expense Benefit when you are disabled and you provide satisfactory proof that you: • are incurring expenses to provide care for a child under the age of 15; • and/or start incurring expenses to provide care for a child age 15 or older or a family member who needs personal care assistance. The payment will be $350 per month per dependent, to a maximum of $1,000 per month for all dependent care expenses combined.

Education Benefit

If you are disabled and receiving monthly disability benefits, you may receive an additional monthly Education Benefit of $200 for each child who is an eligible student. Benefits will be payable in between terms provided the eligible student is enrolled for the next scheduled term. Eligible student means your unmarried dependent child(ren) who are: If you are participating in a Rehabilitation and Return to Work Assistance • less than 25 years of age; and program, we will also pay an additional disability benefit of 10% of your • attending an accredited post-secondary school beyond the 12th grade level on a full-time basis. gross disability payment to a maximum of $1,000 per month. In addition, we will make monthly payments to you for 3 months following the date your disability ends, if we determine you are no longer disabled while: Worldwide Emergency Travel Assistance • you are participating in a Rehabilitation and Return to Work Services2 Assistance program; and Whether your travel is for business or pleasure, our worldwide • you are not able to find employment. emergency travel assistance program is there to help you when an (This benefit is not allowed in New Jersey.) unexpected emergency occurs. With one phone call anytime of the day or night, you, your spouse and dependent children can get immediate assistance anywhere in the world3. Emergency travel assistance is Worksite Modification available to you when you travel to any foreign country, including If a worksite modification will enable you to remain at work or return to neighboring Canada or Mexico. It is also available anywhere in the work, a designated Unum professional will assist in identifying what’s United States for those traveling more than 100 miles from home. Your needed. A written agreement must be signed by you, your employer and spouse and dependent children do not have to be traveling with you to Unum, and we will reimburse your employer for the greater of $1,000 or be eligible. However, spouses traveling on business for their employer the equivalent of two months of your disability benefit. are not covered by this program.

Waiver of Premium After you have received disability payments under the plan for 90 consecutive days, from that point forward you will not be required to pay premiums as long as you are receiving disability benefits.

Survivor Benefit Unum will pay your eligible survivor a lump sum benefit equal to 3 months of your gross disability payment.

Conversion If you are covered under your group's disability plan for 12 consecutive months and you end employment, you may be eligible to convert your disability coverage to coverage under Unum’s group conversion policy. The conversion coverage may not be the same coverage offered under your employer’s group plan and there are certain times that you may not convert your coverage. Please see your certificate booklet for details.

This benefit will be paid if, on the date of your death, your disability had continued for 180 or more consecutive days, and you were receiving or were entitled to receive payments under the plan. If you have no eligible survivors, payment will be made to your estate, unless there is none. In Pre-existing Condition Exclusion that case, no payment will be made. However, we will first apply the Benefits will not be paid for disabilities caused by, contributed to by, or survivor 42 benefit to any overpayment which may exist on your claim.

Other Important Provisions

Long Term Disability resulting from a pre-existing condition. You have a pre-existing condition if: • you received medical treatment, consultation, care or services including diagnostic measures, or took prescribed drugs or medicines in the 3 months just prior to your effective date of coverage; and • the disability begins in the first 12 months after your effective date of coverage.

Continuity of Coverage If you are actively at work at the time you convert to Unum’s plan and become disabled due to a pre-existing condition, benefits may be payable if you were: • in active employment and insured under the plan on its effective date; and • insured by the prior plan at the time of change. To receive a payment, you must satisfy the pre-existing condition under the Unum policy or the prior carrier’s policy. If you satisfy Unum’s pre- existing condition provision, payments will be determined by the Unum policy. If you only satisfy the pre-existing condition provision for the prior carrier’s policy, the claim will be administered according to the Unum policy. However, • the payments will be the lesser of the benefit payable under the terms of the prior plan or the benefit under the Unum plan; • the elimination period will be the shorter of the elimination period under the prior plan or the elimination period under the Unum plan; and • benefits will end on the earlier of the end of the maximum period of payment under the Unum plan or the date benefits would have ended under the prior plan.

compensation or similar occupational benefit laws, sabbatical or assault leave plans and the amount of earnings you receive from an extended sick leave plan as described in Louisiana Revised Statutes or any other act or law with similar intent. After you have received monthly disability payments for 12 months, your gross disability payment will be reduced by such items as additional deductible sources of income you receive or are entitled to receive under: state compulsory benefit laws; automobile liability insurance; legal judgments and settlements; certain retirement plans; salary continuation or sick leave plans; other group or association disability programs or insurance; and amounts you or your family receive or are entitled to receive from Social Security or similar governmental programs. Regardless of deductible sources of income, an employee who qualifies for disability benefits is guaranteed to receive a minimum benefit amount of 25% of the gross disability payment.

Mental Illness/Self-Reported Symptoms The lifetime cumulative maximum benefit period for all disabilities due to mental illness and disabilities based primarily on self-reported symptoms is 12 months. Only 12 months of benefits will be paid for any combination of such disabilities even if the disabilities are not continuous and/or are not related. Payments would continue beyond 12 months only if you are confined to a hospital or institution as a result of the disability.

Instances When Benefits Would Not Be Paid

Benefits will not be paid for disabilities caused by, contributed to by, or resulting from: • intentionally self-inflicted injuries; • active participation in a riot; Definition of Disability • commission of a crime for which you have been convicted; You are disabled when Unum determines that: • loss of professional license, occupational license or certification; • you are limited from performing the material and substantial duties • pre-existing conditions (see definition). of your regular occupation due to your sickness or injury; • you have a 20% or more loss in indexed monthly earnings due to Unum will not cover a disability due to war, declared or undeclared, or the same sickness or injury; and any act of war. • during the elimination period you are unable to perform any of the Unum will not pay a benefit for any period of disability during which you material and substantial duties of your regular occupation. are incarcerated. After benefits have been paid for 24 months, you are disabled when Unum determines that due to the same sickness or injury, you are Termination of Coverage unable to perform the duties of any gainful occupation for which you are Your coverage under the policy ends on the earliest of the following: reasonably fitted by education, training or experience. • The date the policy or plan is cancelled; You must be under the regular care of a physician in order to be • The date you no longer are in an eligible group; considered disabled. • The date your eligible group is no longer covered; • The last day of the period for which you made any required Gainful Occupation contributions; Gainful occupation means an occupation that is or can be expected to • The later of the last day you are in active employment except as provide you with an income within 12 months of your return to work, provided under the covered layoff or leave of absence provision; or that exceeds 80% of your indexed monthly earnings if you are working if applicable, the last day of your contract with your Employer but or 60% of your indexed monthly earnings if you are not working. not beyond the end of your Employer’s current school contract year.

Benefit Integration

Your disability benefit will be reduced by deductible sources of income and any earnings you have while disabled. Your gross disability payment will be reduced immediately by such items as disability income or other amounts you receive or are entitled to receive from workers

Unum will provide coverage for a payable claim which occurs while you are covered under the policy or plan. 43

Long Term Disability Next Steps How to Apply/ Effective Date of Coverage Current employees: To apply for coverage, complete your enrollment form by the enrollment deadline. Please see your Plan Administrator for your effective date.

This plan highlight is a summary provided to help you understand your insurance coverage from Unum. Some provisions may vary or not be available in all states. Please refer to your certificate booklet for your complete plan description. If the terms of this plan highlight summary or your certificate differ from your policy, the policy will govern. For complete details of coverage, please refer to policy form number C.FP1, et al.

New Hires: To apply for coverage, complete your enrollment form within 1,2 The work-life balance employee assistance program, provided by 60 days of your eligibility date. Please see your Plan Administrator for HealthAdvocate, is available with select Unum insurance offerings. Terms and availability of service are subject to change. Service provider does not provide legal your effective date. If you do not enroll during the initial enrollment period, you may apply only during an annual enrollment.

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

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

advice; please consult your attorney for guidance. Services are not valid after coverage terminates. Please contact your Unum representative for details. Worldwide emergency travel assistance services are provided by Assist America, Inc. Services are available with selected Unum insurance offerings. Exclusions, limitations and prior notice requirements may apply, and service features, terms and eligibility criteria are subject to change. The services are not valid after termination of coverage and may be withdrawn at any time. Please contact your Unum representative for full details. 3

All Worldwide emergency travel assistance must be arranged by Assist America, which pays for all services it provides. Medical expenses such as prescriptions or physician, lab or medical facility fees are paid by the employee or the employeeâ&#x20AC;&#x2122;s health insurance. Underwritten by: Unum Life Insurance Company of America 2211 Congress Street, Portland, Maine 04122, www.unum.com ÂŠ2007 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.

PORT NECHES-GROVES INDEPENDENT SCHOOL DISTRICT Costs below are based on a Monthly payroll deduction (Employer billing mode is based on 12 Payments per year) Plan A Product: Educator Select Income ADEA II Duration of Benefits Protection Plan Elimination Period (Days)

Annual Earnings 3600 5400 7200 9000 10800 12600 14400 16200 18000 19800 21600 23400 25200 27000 28800 30600 32400 34200 36000 37800 39600 41400 43200 45000 46800 48600 44

Injury (Days) Sickness (Days) Monthly Earnings Maximum Monthly Benefit 300 450 600 750 900 1050 1200 1350 1500 1650 1800 1950 2100 2250 2400 2550 2700 2850 3000 3150 3300 3450 3600 3750 3900 4050

200 300 400 500 600 700 800 900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 2000 2100 2200 2300 2400 2500 2600 2700

0* 7*

14* 14*

30* 30*

60 60

90 90

180 180

9.02 13.53 18.04 22.55 27.06 31.57 36.08 40.59 45.10 49.61 54.12 58.63 63.14 67.65 72.16 76.67 81.18 85.69 90.20 94.71 99.22 103.73 108.24 112.75 117.26 121.77

7.20 10.80 14.40 18.00 21.60 25.20 28.80 32.40 36.00 39.60 43.20 46.80 50.40 54.00 57.60 61.20 64.80 68.40 72.00 75.60 79.20 82.80 86.40 90.00 93.60 97.20

5.40 8.10 10.80 13.50 16.20 18.90 21.60 24.30 27.00 29.70 32.40 35.10 37.80 40.50 43.20 45.90 48.60 51.30 54.00 56.70 59.40 62.10 64.80 67.50 70.20 72.90

4.06 6.09 8.12 10.15 12.18 14.21 16.24 18.27 20.30 22.33 24.36 26.39 28.42 30.45 32.48 34.51 36.54 38.57 40.60 42.63 44.66 46.69 48.72 50.75 52.78 54.81

3.52 5.28 7.04 8.80 10.56 12.32 14.08 15.84 17.60 19.36 21.12 22.88 24.64 26.40 28.16 29.92 31.68 33.44 35.20 36.96 38.72 40.48 42.24 44.00 45.76 47.52

2.72 4.08 5.44 6.80 8.16 9.52 10.88 12.24 13.60 14.96 16.32 17.68 19.04 20.40 21.76 23.12 24.48 25.84 27.20 28.56 29.92 31.28 32.64 34.00 35.36 36.72

Long Term Disability PORT NECHES-GROVES INDEPENDENT SCHOOL DISTRICT Costs below are based on a Monthly payroll deduction (Employer billing mode is based on 12 Payments per year) Plan A ADEA II Duration of Benefits Elimination Period (Days)

Product: Educator Select Income Protection Plan

Annual Earnings 50400 52200 54000 55800 57600 59400 61200 63000 64800 66600 68400 70200 72000 73800 75600 77400 79200 81000 82800 84600 86400 88200 90000 91800 93600 95400 97200 99000 100800 102600 104400 106200 108000 109800 111600 113400 115200 117000 118800 120600 122400 124200 126000 127800 129600 131400 133200 135000

Injury (Days) Sickness (Days) Monthly Earnings Maximum Monthly Benefit 4200 4350 4500 4650 4800 4950 5100 5250 5400 5550 5700 5850 6000 6150 6300 6450 6600 6750 6900 7050 7200 7350 7500 7650 7800 7950 8100 8250 8400 8550 8700 8850 9000 9150 9300 9450 9600 9750 9900 10050 10200 10350 10500 10650 10800 10950 11100 11250

2800 2900 3000 3100 3200 3300 3400 3500 3600 3700 3800 3900 4000 4100 4200 4300 4400 4500 4600 4700 4800 4900 5000 5100 5200 5300 5400 5500 5600 5700 5800 5900 6000 6100 6200 6300 6400 6500 6600 6700 6800 6900 7000 7100 7200 7300 7400 7500

0* 7*

14* 14*

30* 30*

60 60

90 90

180 180

126.28 130.79 135.30 139.81 144.32 148.83 153.34 157.85 162.36 166.87 171.38 175.89 180.40 184.91 189.42 193.93 198.44 202.95 207.46 211.97 216.48 220.99 225.50 230.01 234.52 239.03 243.54 248.05 252.56 257.07 261.58 266.09 270.60 275.11 279.62 284.13 288.64 293.15 297.66 302.17 306.68 311.19 315.70 320.21 324.72 329.23 333.74 338.25

100.80 104.40 108.00 111.60 115.20 118.80 122.40 126.00 129.60 133.20 136.80 140.40 144.00 147.60 151.20 154.80 158.40 162.00 165.60 169.20 172.80 176.40 180.00 183.60 187.20 190.80 194.40 198.00 201.60 205.20 208.80 212.40 216.00 219.60 223.20 226.80 230.40 234.00 237.60 241.20 244.80 248.40 252.00 255.60 259.20 262.80 266.40 270.00

75.60 78.30 81.00 83.70 86.40 89.10 91.80 94.50 97.20 99.90 102.60 105.30 108.00 110.70 113.40 116.10 118.80 121.50 124.20 126.90 129.60 132.30 135.00 137.70 140.40 143.10 145.80 148.50 151.20 153.90 156.60 159.30 162.00 164.70 167.40 170.10 172.80 175.50 178.20 180.90 183.60 186.30 189.00 191.70 194.40 197.10 199.80 202.50

56.84 58.87 60.90 62.93 64.96 66.99 69.02 71.05 73.08 75.11 77.14 79.17 81.20 83.23 85.26 87.29 89.32 91.35 93.38 95.41 97.44 99.47 101.50 103.53 105.56 107.59 109.62 111.65 113.68 115.71 117.74 119.77 121.80 123.83 125.86 127.89 129.92 131.95 133.98 136.01 138.04 140.07 142.10 144.13 146.16 148.19 150.22 152.25

49.28 51.04 52.80 54.56 56.32 58.08 59.84 61.60 63.36 65.12 66.88 68.64 70.40 72.16 73.92 75.68 77.44 79.20 80.96 82.72 84.48 86.24 88.00 89.76 91.52 93.28 95.04 96.80 98.56 100.32 102.08 103.84 105.60 107.36 109.12 110.88 112.64 114.40 116.16 117.92 119.68 121.44 123.20 124.96 126.72 128.48 130.24 132.00

38.08 39.44 40.80 42.16 43.52 44.88 46.24 47.60 48.96 50.32 51.68 53.04 54.40 55.76 57.12 58.48 59.84 61.20 62.56 63.92 65.28 66.64 68.00 69.36 70.72 72.08 73.44 74.80 76.16 77.52 78.88 80.24 81.60 82.96 84.32 85.68 87.04 88.40 89.76 91.12 92.48 93.84 95.20 96.56 97.92 99.28 100.64 102.00

CIGNA

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 46 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Port Neches Groves ISD Benefits Website: www.mybenefitshub.com/portnechesgrovesisd

Life and AD&D Life Insurance Who Needs Life Insurance? You do. Single or married. Buying your first home or preparing for retirement. Raising children or sending them off to college. No matter where you are in life, insurance should be part of your financial plan. By purchasing this insurance product through your employer, you benefit from: • Affordable group rates • Convenient payroll deduction • Access to knowledgeable service representatives.

Who Is Eligible For Coverage? You — If you are an active, full-time employee and work 17.5 or more hours per week for your employer, you will be eligible to elect insurance for you and your dependents on the first of the month coinciding with or following the date of hire. Your Spouse — Up to age 70 is eligible provided that you apply for and are approved for coverage for yourself. Your Unmarried, Dependent Children — At least 14 days old and under age 26, as long as you apply for and are approved for coverage for yourself. One low premium will insure all your eligible children, regardless of the number of children you have. No one may be covered more than once under this plan. If covered as an employee, you can not also be covered as a dependent.

How Much Coverage Can You Buy? You — You can select life insurance coverage in units of $10,000. The maximum for any employee is the lesser of 7 times your annual salary or $500,000. The guaranteed coverage amount for you is $200,000. Your Spouse — You may select coverage for your spouse in units of $5,000 to a maximum of $100,000. The cost of coverage will be based on your spouse’s age. The guaranteed coverage amount for your spouse is $50,000. Your Unmarried, Dependent Children — You may select coverage for your unmarried, dependent children in units of $2,000 to a maximum of $10,000. The maximum benefit for children under six months is $500. The guaranteed coverage amount for your child(ren) is $10,000.

Guaranteed Coverage If you and your dependents are eligible and you apply during the initial enrollment period, or within 31 days after you are eligible to elect coverage, you are entitled to choose any of the offered amounts of coverage up to the guaranteed coverage amount, as shown on your application, without having to provide evidence of good health.

If you apply for an amount of coverage for yourself or your spouse greater than the guaranteed coverage amount, coverage in excess of the guaranteed coverage amount will not be issued until the insurance company approves acceptable evidence of good health. If you apply for coverage for yourself or your spouse more than 31 days from the date you become eligible to elect coverage under this plan, the guaranteed coverage amounts will not apply. Coverage will not be issued until the insurance company approves acceptable evidence of good health.

How Much Your Coverage Will Cost The monthly cost of insurance for you and your spouse will depend on your ages and the amount of insurance you wish to purchase. As shown in the following chart, the cost of insurance increases with the age of the insured. Note that at age 65, your benefits are reduced. To calculate your monthly cost: 1. Find your age group in the following table; 2. Multiply the rate by the number of coverage units you want; 3. Calculate the cost of coverage for your spouse, using your spouse's age, then calculate the cost of coverage for your children; 4. Add the premiums for you, your spouse and your children to get your total monthly cost.

Example Employee (age 28) Spouse (age 24) Children

25 units x ($250,000) 20 units x ($100,000) 5 units x ($10,000)

$.66 per unit

= $16.50

$.33 per unit

= $6.60

$.24 per unit

= $1.20

Total Monthly Cost

$24.30

To calculate your cost, complete this chart: Employee

_______ units x $.___. ___per unit = $.___. ___

Spouse

_______ units x $.___. ___per unit = $.___. ___

Children

_______ units x $.___. ___per unit = $.___. ___ Total Monthly Cost

$.___. ___

When You Reach Age 65 By the time you reach age 65, chances are that your children will be grown and your mortgage paid. At age 65, providing you are still employed, your coverage will decrease to 65% of the benefit amount. It will decrease to 50% at age 70. 47

Life and AD&D Employee/ Spouse Age

Employee Monthly Cost per $10,000 Unit

Spouse Monthly Cost per $5,000 Unit

Under 30 30 to 34 35 to 39 40 to 44 45 to 49 50 to 54 55 to 59 60 to 64 65 to 69 70 to 74 75 to 79 80 & over

$.660 .770 .990 1.430 2.400 4.150 6.450 10.040 18.020 32.430 53.400 74.690

$.330 .385 .495 .715 1.200 2.075 3.225 5.020 9.010

The monthly cost for children is $.24 per $2,000 of coverage. One premium will insure all your eligible children, regardless of the number of children you have. Costs are subject to change.

Other Benefit Features Accelerated Death Benefit — Terminal Illness

If you or your spouse is diagnosed by two unaffiliated physicians as terminally ill with a life expectancy of 12 months or less, the accelerated payment benefit for terminal illness provides for up to 50% of the life insurance coverage amount in force or $100,000, whichever is less, to be paid to the insured. This benefit is payable only once in the insured's lifetime, and will reduce the life insurance death benefit. The terminal illness benefit may be taxable. As with all tax matters, an insured should consult with a personal tax advisor to assess the impact of this benefit. Annual Enrollment Period Each year, during your enrollment period, you have the opportunity to enroll in the plan or increase your voluntary coverage. We do require evidence of good health for all new coverage selections. Continuation for Disability for Employees Age 60 or over If your active service ends due to disability, this plan provides a continuation of coverage feature. If you are disabled at age 60 or over, your coverage will continue while you are disabled. This benefit will remain in force until the earliest of the following dates: the date you are no longer disabled, the date the policy terminates, the date you are disabled for 12 consecutive months, or the day after the last period for which premiums are paid. You are considered disabled if, because of injury or sickness, you are unable to perform all the material duties of your Regular Occupation, or you are receiving disability benefits under your Employer’s plan. “Regular Occupation” means your occupation, as routinely performed in the general labor market, at the time your disability begins. 48

Extended Death Benefit with Waiver of Premium Extended Death Benefit If you become Disabled — The extended death benefit ensures that if you become disabled prior to age 60, and die before it is determined if you qualify for Waiver of Premium, we will pay the life insurance benefit if you remain disabled during that period. If you qualify for this benefit and have insured your spouse or children, their coverage is also extended. No additional premium payment is required for the extended coverage. You are considered disabled if, because of injury or sickness, you are unable to perform the material duties of your Regular Occupation, or you are receiving disability benefits under your Employer’s plan. “Regular Occupation” means your occupation, as routinely performed in the general labor market, at the time your disability begins. Waiver of Premium If you become totally disabled — To make sure you can keep the life insurance protection you need during a difficult period of your life, this plan provides a waiver of premium feature. If you are totally disabled prior to age 60 and can't work for at least 9 months, you won't need to pay premiums for your coverage while you are disabled, provided the insurance company approves you for this benefit. You are considered totally disabled when you are completely unable to engage in any occupation for wage or profit because of injury or sickness. This benefit will remain in force until To Age 65, subject to proof of continuing disability each year. If you qualify for this benefit and have insured your spouse or children, the premium for their coverage is also waived. Rehabilitation During a Period of Disability If the insurance company determines that you are a suitable candidate for rehabilitation, the insurance company may require you to participate in an assessment and rehabilitation plan, not to exceed 18 months. A rehabilitation plan may consist of educational, vocational or physical rehabilitation or may include modified work or work on a part-time basis. If you refuse such assistance without good cause (a medical reason preventing participation, in whole or in part, in the rehabilitation plan), insurance under this plan will end.

What Is Not Covered The plan will not pay benefits if loss of life is the result of suicide that occurs within the first two years of coverage.

When Your Coverage Begins and Ends The date your coverage begins is called its “effective date.” Your employer will let you know the effective date of your coverage. If you are not actively at work on the effective date of coverage, your coverage will not begin until you return to work. For coverage for your spouse and/or children to be effective, they must not be hospitalized or confined at home under the care of a doctor. Your coverage cannot be terminated as long as you remain eligible, the premium is paid and the group policy remains in force.

Life and AD&D For your spouse and children, coverage ends when your coverage ends, when their premiums are not paid or when they are no longer eligible.

Questions?

Cigna Group Insurance has courteous, knowledgeable customer service representatives who can assist you with the completion of your enrollment form by calling 1-800-732-1603 toll-free anytime from Monday through Friday, 8 a.m. to 6 p.m. Eastern If You Leave Your Employer time. Cigna does not have your coverage election information To help you keep your life insurance coverage during the years when your family needs financial protection, the plan allows you on file. For specific benefit/account inquiries on what is available under your plan, please contact your Human Resources to continue all of your voluntary coverage if you leave your department. employer. Premiums may change at this time. Just make arrangements to pay your premiums directly to the insurance This portion of the plan provides life insurance only. company after you leave your current employer. Coverage may be continued for you and your spouse until age 70. Coverage may also be continued for your children. As long as the group policy remains in force, the option of continuing this coverage is available. Converting Your Coverage to Permanent Life Insurance If group life insurance coverage is reduced or ends for any reason except nonpayment of premiums, you can convert to an individual policy. No medical certification is needed. To convert coverage, you must apply for the conversion policy and pay the first premium payment within 31 days after your group coverage ends. Family members may convert their coverage as well. Converted policies are subject to certain benefits and limits as outlined in the conversion brochure which may be requested as needed. Premiums may change at this time.

Accident Insurance Who Needs Personal Accident Insurance?

You do. Accident insurance can help you pay expenses if you or your spouse is seriously injured or killed in a covered accident. This insurance can help ensure that tragedy doesn’t take both an emotional and a financial toll on your family. By purchasing this insurance through your employer, you benefit from: • Affordable group rates • Convenient payroll deduction

Apply Today

Who Is Eligible For Coverage?

Designating Your Beneficiary

No one may be covered more than once under this plan. If covered as an employee, you cannot also be covered as a dependent.

You – You are eligible for coverage if you are an active full-time In order to apply for coverage, you must complete an application form. Be sure to answer all questions accurately, and employee, working 17.5 or more hours per week. You will be eligible to elect insurance for yourself and your dependents on indicate how much coverage you wish to have. the first of the month coincident with or next following the date of hire. Payroll Deduction You pay your premiums through payroll deduction. The total Your Family – You may elect to cover your lawful spouse under depends on how much coverage you select, your age, your age 70 and your unmarried dependent children who are under spouse’s age and the amount of coverage you buy for your age 26. Children must be dependent upon you for support and spouse and children. maintenance.

Your term life benefit will automatically be paid to the first beneficiary listed below who is living at the time of your death if you do not designate a specific beneficiary: 1. Your Spouse 4. Your Siblings

2. Your Child(ren) 5. Your Estate

3. Your Parents

If you wish to designate different beneficiaries, or to indicate percentages, you may do so on your application. If the listed beneficiary is a trustee or a trust, you will need to indicate the trustee's name, the name of the trust and the date of the trust agreement. The trust document must be presented in order for the claim to be processed. How Your Claims Are Paid Your employer has all the forms your beneficiary will need and can provide assistance in completing them.

Benefit Reductions When the covered person reaches age 65, his or her benefits will be reduced to 65% of the benefit amount selected; at age 70 or over, 50%. Coverage for your spouse ends when he or she reaches age 70. These reductions also apply if you elect coverage after age 64.

How Much Coverage Can You Buy? You – You may select from $10,000 to $500,000 of coverage in units of $10,000 at an affordable price. Your Family – Your Spouse’s benefit amount will be 40% of yours or 50% if you have no dependent children, subject to a maximum benefit of $100,000. Each of your covered children’s benefit amount will be 10% of yours or 15% if you have no eligible spouse, subject to a maximum benefit of $10,000. 49

Life and AD&D Each family member’s coverage is a percentage of the benefit amount you select. It will depend on who your insured family members are at the time of a covered accidental loss.

coverage. We will refund premium if you do not notify us of this and it is determined at the time of a claim that premium has been overpaid.

You may need to request changes to your existing coverage if, in the future, you no longer have dependents who qualify for Your Monthly Cost Your cost will depend on the benefit amount and coverage option you select from the chart below. Your Benefit Amount $500,000 250,000

Monthly Cost for You and Your Family

Monthly Cost for You Only $12.50 6.25

200,000

5.00

150,000

3.75

100,000

$4.50

2.50

50,000

2.25

1.25

10,000

0.45

0.25

See Benefit Reductions. Costs are subject to change.

The rate per $1,000 of coverage is $0.025 for Employee Only, or $0.045 for the Employee and Family Plan. To calculate your cost, divide the amount you select by 1,000 and multiply that number by the appropriate cost. For example, if you choose the Family Plan and select $220,000 of coverage, then: $220,000 ÷ 1,000 = 220 220 x $0.045 = $9.90 Your Monthly Cost

A Valuable Combination of Benefits Personal Accident Insurance helps protect you against losses due to accidents. A covered accident is a sudden, unforeseeable, external event, resulting directly and independently of all other causes, in a covered injury or covered loss that occurs while coverage is in force. To help survivors of severe accidents adjust to new living circumstances, we will pay benefits according to the chart below.

If, within 365 days of a covered accident, bodily injuries result in: • Loss of life, or • Total paralysis of upper and lower limbs, or • Loss of any combination of two: hands, feet or eyesight, or • Loss of speech and hearing in both ears • Total paralysis of both lower or upper limbs • Total paralysis of upper and lower limbs on one side of the body, or • Loss of hand, foot or sight in one eye, or • Loss of speech or • loss of hearing in both ears • Total paralysis of one upper or lower limb, or • Loss of all four fingers of the same hand, or • Loss of thumb and index finger of the same hand • Loss of all toes of the same foot • Coma

We will pay this % of the benefit amount: 100% 75%

50%

25% 20% 1%

If the same accident causes more than one of these losses, we will pay only one amount, but it will be the largest amount that applies. Loss of a hand or foot means complete severance through or above the wrist or ankle joint. Loss of sight means the total, permanent loss of all vision in the eye. Loss of speech means total, permanent and irrecoverable loss of audible communication. Loss of hearing means total and permanent loss of the ability to hear any sound in both ears. Loss of sight, speech and hearing must be irrecoverable by natural, surgical or artificial means. Loss of a thumb and index finger or four fingers, means complete severance through or above the metacarpophalangeal joints (the joints between the fingers and the hand). Paralysis means total loss of use, without severance, of a limb. This loss must be determined by a doctor to be complete and not reversible. Loss of Toes means complete severance through the metatarsalphalangeal joint. Severance means complete and permanent separation and dismemberment of the limb from the body. 50

Life and AD&D Your coverage will continue as long as you remain an eligible employee, pay your premium when due and we agree with your Plan benefits are not payable if an injury or a loss results, directly or employer to continue this group policy. For your spouse and indirectly, from or is caused by, self-inflicted injuries or suicide while dependent children, coverage ends when your coverage terminates, sane or insane; commission or attempt to commit a felony or an when their premiums are not paid or when he or she is no longer assault; any act of war, declared or undeclared; any active eligible, whichever occurs first. participation in a riot or insurrection; bungee jumping; parachuting; skydiving; parasailing; hang-gliding; sickness, disease, physical or Totally disabled means, if the covered person is employed, he/she is mental impairment, or surgical or medical treatment thereof, or unable to perform any work for which he/she is (or may reasonably bacterial or viral infection, regardless of how contracted. (This does become) qualified by education, training or experience. If the covered not include bacterial infection that is the natural and foreseeable person is not employed, totally disabled means he/she is unable to result of an accidental external cut or wound or accidental food perform all the activities of daily living without human supervision or poisoning.) assistance.

What Is Not Covered

Benefits are also not payable if the loss occurs while the covered person is voluntarily using any drug, narcotic, poison, gas or fumes except one prescribed by a licensed physician and taken as prescribed; while operating any type of vehicle while under the influence of alcohol (intoxicated is defined by the law of the state in which the covered accident occurred) or any drug, narcotic or other intoxicant including any prescribed drug for which the covered person has been provided a written warning against operating a vehicle while taking it; while the covered person is engaged in the activities of active duty service in the military, navy or air force of any country or international organization (this does not include Reserve or National Guard training, unless it extends beyond 31 days); traveling in an aircraft that is owned, leased or controlled by the sponsoring organization or any of its subsidiaries or affiliates (an aircraft will be deemed to be ''controlled'' by the sponsoring organization if the aircraft may be used as the sponsoring organization wishes for more than 10 straight days, or more than 15 days in any year); flying in, boarding or alighting from an aircraft or any craft designed to fly above the earth’s surface, except as a passenger on a regularly scheduled commercial airline; that is: an ultra-light or glider, designed to be used in outerspace; being used by any military authority, except the Air Mobility Command or its foreign equivalent; being flown by the covered person or in which the covered person is a member of the crew; being used for parachuting, hang-gliding, crop dusting, spraying or seeding, giving and receiving flying instruction, fire fighting, sky writing, skydiving, pipeline or power line inspection, aerial photography or exploration, racing or endurance tests, stunts or acrobatic flying, or any operation that requires a special permit from the FAA, even if it is granted (this does not apply if the permit is required only because of the territory flown over or landed on).

When Your Coverage Begins and Ends Current employees can sign up during this enrollment period. New employees have 31 days from the date they become eligible to enroll. Coverage becomes effective on the later of the program’s effective date, the date you become eligible, the date we receive your completed enrollment form, or the date you authorize any necessary payroll deductions. Provided the application has been received and the appropriate premium paid, dependent coverage will start when your coverage begins. If you are not actively at work, the effective date of your insurance will be deferred until you are actively at work. For insurance for your spouse and/or children to become effective, he/she must not be an inpatient in a hospital, receiving chemotherapy or radiation therapy on an outpatient basis, confined at home and under the care of a physician for sickness or injury or totally disabled.

Changing from the Group Plan to Individual Coverage If this group coverage is reduced or ends for any reason except nonpayment of premium or age, you can convert to an individual policy. No medical certification is needed. To continue coverage, you must apply for the conversion policy and pay the first premium in effect for your age and occupation within 31 days after your group coverage ends. Family members may convert their coverage as long as they have not reached the maximum age limitation. Converted policies are subject to certain benefits and limits as outlined in your certificate, should you become insured under the plan.

Signing Up Is Easy No medical examination is required to apply! Just follow these steps. 1. Choose the benefit amount and coverage options that are right for you. 2. Fill out the accident section of your insurance application and return it to your Human Resource Department. Don’t forget to… Use the full name of your beneficiary. For example, use ''Mary Jones Smith'' not ''Mrs. John A. Smith.'' If you have any questions about the plan, please contact your Human Resources Department.

This portion of the plan provides ACCIDENT insurance only. It pays benefits for bodily injury. It does not provide coverage for sickness. This information is a brief description of the important features of the plan. It is not a contract. Terms and conditions of life insurance coverage are set forth in Group Policy No. FLX-964746 on Policy Form TL-004700, issued in Texas. Terms and conditions of accident insurance coverage are set forth in Group Policy No. OK 966329 on Policy Form No. GA-00-1000.00, issued in Texas. The group policy is subject to the laws of the jurisdiction in which it is issued. The availability of this offer may change. Please keep this material as a reference. Coverage is underwritten by Life Insurance Company of North America 1601 Chestnut Street Philadelphia, PA 19192 “Cigna” is a registered service mark, and the “Tree of Life” logo and “GO YOU” are service marks, of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided exclusively by such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Life Insurance Company of North America, Cigna Life Insurance Company of New York, and Connecticut General Life Insurance Company. All models are used for illustrative purposes only.

5STAR LIFE

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 52 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Port Neches Groves ISD Benefits Website: www.mybenefitshub.com/portnechesgrovesisd

Term Life with Terminal Illness and Quality of Life Rider Family Protection Plan with Terminal Illness Term Life Insurance to age 121 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 55

ID WATCHDOG

Identity Theft

YOUR BENEFITS PACKAGE

About this Benefit Identity theft protection monitors and alerts you to identity threats. Resolution services are included should your identity ever be compromised while you are covered.

An identity is stolen every 2 seconds, and takes over

300 hours

to resolve, causing an average loss of $9,650.

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 56 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Port Neches Groves ISD Benefits Website: www.mybenefitshub.com/portnechesgrovesisd

Identity Theft Because There’s Only One You. Your identity is important — it’s what makes you, you. You’ve spent a lifetime building your name and financial reputation. Let us help you better protect it. And, we’ll even go one step further and help you better protect the identities of your family.

1 in 18 consumers were victims of identity theft in 2018.1 Easy & Affordable Identity Protection With ID Watchdog®, you have an easy and affordable way to help better protect and monitor the identities of you and your family. You’ll be alerted to potentially suspicious activity and enjoy the peace of mind that comes with the support of dedicated resolution specialists. And, a customer care team that’s available any time, every day. WHY CHOOSE ID WATCHDOG Credit Lock With our online and in-app feature, lock your Equifax® credit report2 — and your child’s Equifax credit report — to help provide additional protection against unauthorized access to your credit.

More for Families Our family plan helps you better protect your loved ones, with each adult getting their own account with all plan features. And, we offer more features that help protect minors than any other provider.

ID Watchdog Monthly Rates 1B

Platinum

Individual Plan

$7.95

$11.95

Family Plan

$14.95

$22.95

Dedicated Resolution Specialists If you become a victim, you don’t have to face it alone. One of our certified resolution specialists will fully manage the case for you until your identity is restored.

ID Watchdog Is Here for You ID Watchdog is everywhere you can’t be — monitoring credit reports, social media, transaction records, public records and more — to help you better protect your identity. And don’t worry, we’re always here for you. In fact, our U.S.-based customer care team is available 24/7/365 at 866.513.1518. See our unique features and pricing and take a step to help better protect your identity today.

1 2019 Identity Fraud Study, Javelin Research, March 2019 2 Locking your Equifax credit report will prevent access to it by certain third parties. Locking your Equifax credit report will not prevent access to your credit report at any other credit reporting agency. Entities that may still have access to your Equifax credit report include: companies like ID Watchdog, which provide you with access to your credit report or credit score, or monitor your credit report as part of a subscription or similar service; companies that provide you with a copy of your credit report or credit score, upon your request; federal, state and local government agencies and courts in certain circumstances; companies using the information in connection with the underwriting of insurance, or for employment, tenant or background screening purposes; companies that have a current account or relationship with you, and collection agencies acting on behalf of those whom you owe; companies that authenticate a consumer’s identity for purposes other than granting credit, or for investigating or preventing actual or potential fraud; and companies that wish to make pre-approved offers of credit or insurance to you. To opt out of such pre-approved offers, visit www.optoutprescreen.com 57

Identity Theft Unique Features Included in All ID Watchdog Plans The Powerful Features You Want — All at an Affordable Price Monitor & Detect • Dark Web Monitoring1* •

Manage & Alert • Child Credit Lock3 | 1 Bureau* •

Financial Accounts Monitoring

•

Subprime Loan Monitoring *

•

Social Network Alerts*

•

Public Records Monitoring*

•

Registered Sex Offender Reporting*

•

USPS Change of Address Monitoring

•

Identity Profile Report

High-Risk Transactions Monitoring2*

Support & Restore • Identity Theft Resolution Specialists (Resolution for Pre-existing Conditions)* •

24/7/365 U.S.-based Customer Care Center

Customizable Alert Options

•

Lost Wallet Vault & Assistance

•

Breach Alert Emails

•

Mobile App

Deceased Family Member Fraud Remediation

•

Fraud Alert & Credit Freeze Assistance

*Helps better protect children | 1 Bureau = Equifax® | Multi-Bureau = Equifax, TransUnion® | 3 Bureau = Equifax, Experian®, TransUnion

What You Need to Know The credit scores provided are based on the VantageScore® 3.0 model. For three-bureau VantageScore credit scores, data from Equifax, Experian, and TransUnion are used respectively. Any one-bureau VantageScore uses Equifax data. Third parties use many different types of credit scores and are likely to use a different type of credit score to assess your creditworthiness. PLAN OPTIONS

ID WATCHDOG® 1B

ID WATCHDOG® PLATINUM

Credit Report(s)4 & VantageScore Credit Score(s)

1 Bureau Monthly

1 Bureau Daily & 3 Bureau Annually

Credit Score Tracker

1 Bureau Monthly

1 Bureau Daily

Credit Report Monitoring5

1 Bureau

3 Bureau

Credit Report Lock6

1 Bureau

Multi-Bureau

Identity Theft Insurance7

Up to $1M

401K/HSA Stolen Funds Reimbursement7

Up to $500k

SPECIAL EMPLOYEE PRICING PER MONTH

IDWATCHDOG® 1B

IDWATCHDOG® PLATINUM

Employee (Includes 1 child <18)

$7.95

$11.95

Employee + Family

$14.95

$22.95

Enroll in this valuable benefit today. Take steps to help better protect your identity.

Identity Theft 1 Dark Web Monitoring scans thousands of internet sites where consumers’ personal information is suspected of being bought and sold, and is constantly adding new sites to those it searches. However, the internet addresses of these suspected internet trading sites are not published and frequently change, so there is no guarantee that ID Watchdog is able to locate and search every possible internet site where consumers’ personal information is at risk of being traded. 2 The monitored network does not cover all businesses or transactions. 3 Locking your child’s Equifax credit report helps prevent access to it by lenders and creditors. It will not prevent access to your child’s credit report at any other credit reporting agency. 4 Under certain circumstances, access to your Equifax Credit Report may not be available as certain consumer credit files maintained by Equifax contain credit histories, multiple trade accounts, and/or an extraordinary number of inquiries of a nature that prevents or delays the delivery of your Equifax Credit Report. If a remedy for the failure is not available, the product subscription will be cancelled and a full refund will be made. 5 Monitoring from TransUnion® and Experian® will take several days to begin. 6 Locking your Equifax or TransUnion credit report will prevent access to it by certain third parties. Locking your Equifax or TransUnion credit report will not prevent access to your credit report at any other credit reporting agency. Entities that may still have access to your Equifax or TransUnion credit report include: companies like ID Watchdog and TransUnion Interactive, Inc. which provide you with access to your credit report or credit score, or monitor your credit report as part of a subscription or similar service; companies that provide you with a copy of your credit report or credit score, upon your request; federal, state, and local government agencies and courts in certain circumstances; companies using the information in connection with the underwriting of insurance, or for employment, tenant or background screening purposes; companies that have a current account or relationship with you, and collection agencies acting on behalf of those whom you owe; companies that authenticate a consumer’s identity for purposes other than granting credit, or for investigating or preventing actual or potential fraud; and companies that wish to make pre-approved offers of credit or insurance to you. To opt out of pre-approved offers, visit www.optoutprescreen.com. 7 The Identity Theft Insurance is underwritten and administered by American Bankers Insurance Company of Florida, an Assurant company. Please refer to the actual policies for terms, conditions, and exclusions of coverage. Coverage may not be available in all jurisdictions. Review the Summary of Benefits (www.idwatchdog.com/ terms/insurance). © 2019 ID Watchdog. Other product and company names are property of their respective owners. EE79376CG0819

MASA YOUR BENEFITS PACKAGE

Medical Transport

About this Benefit Medical Transport covers emergency transportation to and from appropriate medical facilities by covering the out-of-pocket costs that are not covered by insurance. It includes emergency transportation via ground ambulance, air ambulance and helicopter.

A ground ambulance can cost up to

$2,400

and a helicopter transportation fee can cost

over $30,000

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 60 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Port Neches Groves ISD Benefits Website: www.mybenefitshub.com/portnechesgrovesisd

Medical Transport Coverage against unplanned medical emergencies is surprisingly affordable

MASA MTS protects you when your insurance falls short.

Facts You Should Know

• • • • •

• • • •

Emergent Ground Ambulance transports can easily surpass $2,000 and can reach as high as $5,000. Emergent Air Ambulance transports frequently cost more than $40,000, reaching as high as $70,000. If you are in need of specialized care and can be transported on an non-emergent basis, it is common for a medically equipped plane to cost more than $20,000. Most people assume that their health insurance will cover most, if not all, of the costs for these transports. Usually, the opposite is true, leaving you with financially crippling bills.

Coverage available for spouses/domestic partners and dependents up to age 26. BENEFIT

EMERGENT PLUS $14/mo

Emergent Ground Transportation

U.S./Canada

Emergent Air Transportation

U.S./Canada

Non- Emergent Air Transportation

U.S./Canada

Repatriation

U.S./Canada

One low fee for peace of mind for emergent transport costs No deductibles Easy claim process No health questions Anyone can join

MASA MTS provides peace of mind. Any Ground. Any Air. Anywhere. Be prepared for the unexpected with a MASA membership. No matter where you live, you could have access to vital emergency medical transportation for a minimal monthly fee. That membership could one day save your life, and, every day, it will give you peace of mind like nothing else. When is your next medical emergency planned? Are you prepared?

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 FOR HSA VS. FSA COMPARISON

PG. 11

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 62 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Port Neches Groves ISD Benefits Website: www.mybenefitshub.com/portnechesgrovesisd

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 Annual taxable income $24,000 $24,000 cases, the taxpayer identification number of the service 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 Taxable income after FSA $21,000 $24,000 want and how much contributions should go toward each Income taxes -$6,300 -$7,200 benefit. It is very important that you make these choices carefully based on what you expect to spend on each covered After-tax income $14,700 $16,800 benefit or expense during the plan year. $0 -$3,000 Generally, you cannot change the elections you have made after After-tax health and welfare expenses Take-home pay $14,700 $13,800 the beginning of the plan year. However, there are certain limited situations when you can change your elections if you You saved $900 $0 have a "change in status". Please refer to your Summary Plan 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).

NOTES