2021-22 Hurst-Euless-Bedford ISD Benefit Guide

HEB ISD

BENEFIT GUIDE EFFECTIVE: 09/01/2021 - 8/31/2022 WWW.MYBENEFITSHUB.COM/HEBISD 1

Table of Contents Benefit Contact Information How to Enroll Employees Workers Compensation Sick Leave Bank Summary 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) 7. Health Insurance Summary TRS-ActiveCare Scott & White HMO Voya Hospital Indemnity Plan HSA Bank Health Savings Account (HSA) Cigna Dental Superior Vision The Standard Disability UNUM Critical Illness UNUM Life and AD&D NBS Flexible Spending Account (FSA) Legal Ease Legal Services Retirement Planning UNUM Employee Assistance Program (EAP)

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3 4-5 6-7 8 9 10-15 10 11 12 13 14

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PG. 4

HOW TO ENROLL

PG. 10

BENEFIT UPDATES

PG. 18

YOUR BENEFITS

15 16 18-20 21 22-25 26-29 30-45 46-47 48-53 54-57 58-63 64-69 70-73 74-75 76-77

Benefit Contact Information HEB ISD – BENEFITS OFFICE

HOSPITAL INDEMNITY

CRITICAL ILLNESS

Maria Ortiz Benefits & Workers Compensation Secretary (817) 399‐2056 mariaortiz@hebisd.edu

Voya Group # 70637‐0 (800) 955‐7736 www.voya.com

UNUM Group # 473094 (800) 858‐6843 www.unum.com

HEB ISD BENEFITS

DENTAL

LIFE AND AD&D

Financial Benefit Services (800) 583‐6908 www.mybenefitshub.com/hebisd

Cigna High/Low Group # 3340943 DHMO Group # P5XV0 (800) 244‐6224 www.cigna.com

UNUM Life Group # 657076 AD&D Group # 657075 (800) 858‐6843 www.unum.com

TRS-ACTIVECARE MEDICAL

VISION

FLEXIBLE SPENDING ACCOUNT

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

Superior Vision Group #30978 (800) 507‐3800 www.superiorvision.com

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

TRS HMO MEDICAL

DISABILITY

LEGAL SERVICES

Scott & White HMO (800) 321‐7947 https://trs.swhp.org/

The Standard Group #00‐648769‐0001 (800) 368‐1135 www.standard.com

Legal Ease (800) 248‐9000 www.legaleaseplan.com/content/heb

HEALTH SAVINGS ACCOUNT

CAREMARK PHARMACY

457 TCG ADMINISTRATORS

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

866-355-5999 (800) 943‐9179 https://info.caremark.com/trsactivecare http://tcgservices.com/documents/ #/255/457b

403B THE OMNI GROUP

EMPLOYEE ASSISTANCE PROGRAM (EAP)

(877) 544‐6664 www.omni403b.com

Employee Assistance Program (800) 854‐1446 http://www.unum.com/lifebalance 3

MOBILE APP DOWNLOAD Enrollment made simple through the new FBS Benefits App! Text “FBS HEB” to (800) 583-6908

and get access to everything you need to complete your benefits

“FBS HEB” to (800) 583-6908

enrollment: •

Enrollment Resources

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Online Support

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Interactive Tools

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And more!

App Group #: FBSHEB

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Text

OR SCAN

How to Log In

1 BENEFIT INFO

INTERACTIVE TOOLS

www.mybenefitshub.com/hebisd

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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.

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SUMMARY PAGES

Employees Plan Year

Leaves & Absences st

The plan year for all benefits is September 1 through August 31st.

Effective Dates for Insurance Health Insurance can begin your hire date or the 1st of the following month. Please make sure you notify the benefits office if you want your health insurance to begin on your hire date.

All other benefits will automatically begin the 1st of the month following your 1st day of employment.

New Hires New hires must enroll in benefits within 30 days of his/her hire date. Failure to complete elections during this timeframe will result in the forfeiture of coverage.

Teacher Retirement System of Texas (TRS) HEB ISD requires all employees to participate in TRS instead of Social Security. The membership contribution rate is 8% of your annual salary. You may contact TRS by calling 1-800-223-8778 or www.trs.state.tx.us to learn more about TRS Retirement.

TRS Insurance (TRS INS) Mandatory active member contribution to TRS-Care (Health Insurance for retirees) is .65% of your annual salary.

Paychecks Professional and paraprofessional employees receive a paycheck on the 20th of each month.

Auxiliary employees receive a paycheck on the 5th and 20th of each month. One-half of your monthly premium will be taken out of each paycheck.

Employee Access Center From the Employee Benefits website, you can log on to the Employee Access Center to change your address, view your paycheck stubs, see your current salary and benefit information and much more! Your login is your 6 digit unique HEB ID number and your default password is your social security number without the dashes.

You may also download the app for your phone by searching for eFinance Plus Employee in your app store. Type in “Hurst” as the employer name and then select “Hurst-Euless-Bedford Independent SD”. Follow the login instructions to view your account.

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Click on the link below to review HEB ISD’s Policies DEC (LOCAL) & DEC (REGULATION) - these policies contain the latest information regarding leaves & absences http://pol.tasb.org/ Home/Index/1110 Paid Leave Days Every school year all full-time employees in eligible positions will receive: • 5 local sick leave days • 5 state personal leave days • 10 vacation days (only available for 240 & 248 day employees) Availability of Days • Days for the current year are available for use at the beginning of the school year.

• If you start in the middle of a school year, the days are prorated based on the actual time employed.

• Unused days may carry over from year to year.

Order of Use • Employees have the right to designate the order of use for local sick & state personal leave days.

• For example, if you are absent due to sickness self, you have the right to have the day pulled from your local sick leave bank or your personal leave bank. As long as the absence is code sickness-using a personal day, the day will NOT be counted as one of your 5 allowed personal leave days during a school year.

State Personal Leave • Non-Discretionary Use: o Days may be used for any of the following: o illness of the employee o illness of a member of the employee’s immediate family o family emergency o death in the employee’s immediate family o during military leave • Discretionary Use: o You may use up to 5 days in a row. o You may use no more than 5 days per school year. o You must submit a written request to use a personal day at least three (3) workdays in advance. o The supervisor will determine if your request is approved or denied based on the effect your

SUMMARY PAGES

absence would have on the educational program or district operations, as well as the availability of substitutes. o Requests are approved on a first-come, firstserved basis. o You may not use a personal leave day on a restricted day (i.e. day before or after a holiday, etc.). Please review the restricted day calendar for the specific dates.

• If you worked for another public school district in the state of Texas, your service record will indicate if you are bringing any personal leave days with you.

• If you leave the district, your personal leave days will go with you.

Local Sick Leave • Local sick leave days may be used if you or immediate family members are sick.

• Definition of immediate family: o spouse o son or daughter, including a biological, adopted, step or foster child, a son- or daughter-in-law o parent, stepparent, parent-in-law o sibling, stepsibling, and sibling-in-law o grandparent and grandchild • Medical certification (doctor’s note) must be provided if: o The employee is absent more than 4 consecutive work days because of personal illness or illness in the immediate family o There is a questionable pattern of absences • If an employee runs out of sick days, the payroll system will automatically use a day from the next leave bank that has available days. (The next bank is typically your personal leave bank.)

FMLA (Family & Medical Leave Act) • Provides eligible employees up to 12 work-weeks of unpaid, job-protected leave in a 12-month period; and requires group health benefits to be maintained during the leave.

Employees are entitled to return to their same or an equivalent job at the end of their FMLA leave.

• Leave available for: o Birth of child or placement of a child for adoption or foster care o To care for the employee’s spouse, child, or parent who has a qualifying serious health condition o For the employee’s own qualifying serious health condition that makes the employee unable to perform the employee’s job

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Eligibility: o Have worked for HEB ISD for at least 12 months; AND o Have at least 1250 hours of service in the 12 months before taking leave.

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If you need to be out for more than 4 consecutive workdays due to sickness self or family sickness or want to request FMLA, please contact: Karen Rose, Benefits & Risk Manager, (817) 399-2056, karenrose@hebisd.edu

Bereavement (Funeral Leave) • Use of state leave and/or local sick leave for a death in the immediate family must not exceed ten workdays per occurrence, subject to the approval of the District. The ten workdays do not have to be used consecutively but must be taken within the employee’s duty year of when the family member’s death occurred.

• Use of state leave for the death of a non-immediate family member must not exceed a total of five workdays per school year, subject to the approval of the District.

Bereavement documentation may be required.

Worker Compensation Leave • • •

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If you choose to go to the doctor during working hours, you must use ½ or 1 full sick day.

If your doctor has taken you off work or your restrictions cannot be accommodated, you will use your available accrued sick, personal, or vacation leave for your absences.

Under District policy, if you become eligible to receive temporary income benefits (TIBS) from workers’ compensation, you may also be eligible for additional wage benefits if you have available accrued leave. If you do not have available accrued leave, your total income benefits will be paid by workers’ compensation on a percentage of your average weekly wage.

If eligible for FMLA, in accordance with the policies, DEC(Legal) and DEC-(Local) of HEB ISD, Family Medical Leave will begin after the fourth consecutive day of absence and can run concurrently with workers’ compensation leave for up to twelve weeks.

Employee Benefits Facebook We have created an HEB ISD Employee Benefits Facebook account. Please visit http://www.facebook.com/ hebbenefits and “Like” our page.

Human Resources Twitter Follow us on Twitter: @HEBISDPeople 7

Workers Compensation

SUMMARY PAGES

What to do when you are injured on the job 1. All on-the-job injuries MUST be reported to your supervisor immediately – even if you don’t think you will need medical treatment or need to be off of work.

2. The injured worker must complete the First Report of Injury form within 3 days of an injury. Contact your school nurse, your supervisor, or the Benefits Office to obtain a copy of the First Report of Injury form.

In case of an emergency…

If you are hurt at work and it is a life-threatening emergency, you should go to the nearest emergency room. If you are injured at work after normal business hours or while working outside your service area, you should go to the nearest care facility. After you receive emergency care, you may need ongoing care. You will need to select a treating doctor from the provider list. The doctor you choose will oversee the care you receive for your work-related injury. Except for emergency care, you must obtain all health care and specialist referrals through your treating doctor.

Seeking Medical Treatment If you are injured on the job and need to seek medical treatment, you must see a doctor that is on the District’s approved list of treating doctors. You have 30 days from the date of your injury to seek medical treatment.

1. Obtain a list of approved doctors from your supervisor, campus nurse, or the Benefits Office.

2. When you visit the doctor, you must give him/her the “Authorization for Treatment form”.

Employee’s Responsibilities 1. After each doctor’s appointment, you must contact HEB ISD Benefits Office – Maria Ortiz at 817-399-2056.

2. If the doctor gives you work restrictions, you may not return to work until you contact the Benefits Office and obtain approval to return to work.

3. You must schedule follow-up doctor appointments before or after school. If you choose to go to the doctor during work hours, you must use 1/2 or 1 full sick day.

4. You must attend all doctor’s appointments.

Workers Compensation Third Party Administrator (TPA) Contact Information TPA: TRISTAR Adjuster: Frank Walsh Phone Number: 1-877-500-0860 ext. 2835 Email: frank.walsh@tristargroup.net Fax: 214-492-5602 Mailing Address: TRISTAR PO Box 2805 Clinton, IA 52733-2805

Questions?

If you have questions, please contact Maria Ortiz in the Benefits Office at HEB ISD. Her phone number is 817-399-2056.

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Sick Leave Bank Summary

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PLEASE REFER TO POLICY DEC (LOCAL & REGULATION). BELOW IS ONLY A GENERAL SUMMARY OF THE POLICY.

The purpose of the sick leave bank is to provide additional sick leave days for members of the bank who have exhausted all available paid leave because of the catastrophic injury or illness of the employee or the employee’s immediate family member.

Qualifying Illness/Injury •

In order to become a member of the sick leave bank, an employee must donate 3 days of local leave. This is a onetime donation. Additional days may be needed, please see the policy for more details.

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Catastrophic illness or injury is a severe condition or combination of conditions affecting the mental or physical health of the employee or a member of the employee’s immediate family that requires the services of a licensed practitioner for a prolonged period of time and that forces the employee to exhaust all leave time earned by that employee and to lose compensation from the District. Such conditions typically require prolonged hospitalization or recovery; not a passing disorder or temporary ailment; or are expected to result in disability or death.

Complications of pregnancy and childbirth that pose an immediate medical threat Cancer-related intermittent treatment (i.e. chemo, radiation)

All local sick, state personal, old state and vacation days must be exhausted before days from the sick leave bank may be used.

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Sick leave bank days are available to use for an employee, spouse, or child’s illness or injury or a parent receiving hospice or end-of-life care.

Not Covered: • A procedure that could be scheduled, without detriment to the employee’s health, at a time more compatible with the member’s work responsibilities (i.e. Spring Break, Summer, Christmas Break)

The employee must be absent for no fewer than 20 workdays to be eligible to request days from the sick leave bank.

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Pre-existing Conditions – Absences caused by conditions existing at the time of application for bank membership will not be covered for one year from the date of enrollment in the bank

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Examples of conditions that are not covered – Hysterectomy, joint replacement (hip, knee, shoulder, etc.), general illness (flu, cold, etc.), non-complicated pregnancy, broken bone, general surgery, etc.

Applications for sick leave bank must be submitted within 15 workdays from the first date of missed work or 15 days prior to the exhaustion of all available leave days.

Maximum # of days that can be used: • Employee’s illness – 30 days per school year • Spouse or child’s illness – 30 days per school year; 60 days lifetime maximum • Parent -10 days per school year; 20 days lifetime maximum A committee will determine whether the request for sick leave days is approved or denied.

Members of the bank who, during the previous school year, found it necessary to use the benefits of the bank must donate three days or the actual number of days used, whichever is less, at the beginning of the next school year.

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Annual Benefit Enrollment

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Benefit Updates - What’s New: TRS-ACTIVECARE TRS offers four medical plans to new enrollees. Key plan highlights and changes for the 2021-2022 plan year include the following.

AC Primary This plan has the lowest monthly costs and copays of the ActiveCare plans. Your Primary Care Provider copay is $30 and TRS Virtual Health is $0.

• Rate increase for all coverage groups (EE, ES, EC, FAM) • No Benefits changes AC Primary+ This plan has copays and the lowest deductibles, maximum out-ofpockets, and coinsurance rates. Your Primary Care Provider copay is $30 and TRS Virtual Health is $0.

• Rate Increase for all coverage groups (EE, ES, EC, FAM) • No Benefit Changes AC HD This high deductible plan has the following changes for the new plan year: • Rate increase for all coverage groups (EE, ES, EC, FAM) • In-network deductible rose by $200 for individuals and $400 for families.

• In-network coinsurance rates rose from 20% to 30% • Out-of- network coinsurance rates rose from 40% to 50%.

• In- network maximum out-of-pocket rose by $100 for individuals and $200 for families.

All Changes are for medical only. There are no changes to prescription and coinsurance rates.

AC 2 Plan is closed to new enrollees. Current enrollees can choose to stay in the plan.

• Rate Increase for all coverage groups (EE, ES, EC, FAM) • No Benefit Changes Central and North Texas Scott & White Care Plan • Rate decrease for EE, ES, EC coverage • Rate Increase for Family Coverage • Deductible increasing to $1,150 Individual/$3,450 Family.

• Rx D deductible increasing to $200 (excludes generics).

• Generic copays increase to $10/$25.

BASIC LIFE WITH AD&D HEB ISD offers $5,000 life insurance with AD&D coverage to all full-time eligible employees at no cost to you. A beneficiary must be added to avoid funds being assigned to your Estate.

EMPLOYEE ASSISTANCE PROGRAM (EAP) Did you know that HEB ISD offers an Employee Assistance Program for help with stress, elder or childcare, grief or loss at no loss cost to you?

There is on-line support 24/7 and 3 person visits with a licensed Professional that is available to you, your spouse, and dependent children. Check the benefit website for more details regarding this free offer.

NEW HSA AMOUNTS FOR 2021 MAXIMUM CONTRIBUTIONS: Single $3600 / Family $7200 55+ Catch up Contributions: Single $4600 / Family $8200 DENTAL RATE INCREASED SLIGHTLY THIS YEAR. See the employee portal for new pricing information.

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Login and complete your supplemental benefit enrollment from 07/20/2021 - 08/17/2021

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Enrollment assistance is available by calling Financial Benefit Services at 866-914-5202 to speak to an enrollment representative Monday—Friday, 8 AM—7 PM. Bilingual assistance is available.

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Update your profile information: home address, phone numbers, email by visiting the Employee Access Center at: https://ef194eac1.hebisd.edu/eFP19.4/EmployeeAccessCenter/Web/ MultDBlogin.aspx

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IMPORTANT!! Due to the Affordable Care Act (ACA) reporting requirements, please add your dependent’s social security numbers in the online enrollment system. If you have questions, please contact your Benefits Administrator.

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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 30 days of your qualifying event and meet with your Benefit/HR Office to complete and sign the necessary paperwork in order to make a benefit election change. Benefit changes must be consistent with the qualifying event.

QUALIFYING EVENTS

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

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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/hebisd.

annual enrollment) unless a Section 125 qualifying event occurs.

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

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Changes, additions or drops may be made only during the

Benefits and Forms section.

annual enrollment period without a qualifying event.

How can I find a Network Provider?

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

district’s website: www.mybenefitshub.com/hebisd. Click on

included in the dependent profile. Additionally, you must

the benefit plan you need information on (i.e., Dental) and

notify your employer of any discrepancy in personal and/or

you can find provider search links under the Quick Links

benefit information.

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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.

section.

When will I receive ID cards?

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

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

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

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

Q&A Who do I contact with Questions?

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

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Employee Eligibility Requirements

Dependent Eligibility Requirements

Supplemental Benefits: Eligible employees must work 20 or more

Dependent Eligibility: You can cover eligible dependent

regularly scheduled hours each work week.

children under a benefit that offers dependent coverage,

Eligible employees must be actively at work on the plan effective date for new benefits to be effective, meaning you are physically capable of performing the functions of your job on the first day of work concurrent with the plan effective date. For example, if

provided you participate in the same benefit, through the maximum age listed below. Dependents cannot be double covered by married spouses within the district as both employees and dependents.

your 2021 benefits become effective on September 1, 2021, you must be actively-at-work on September 1, 2021 to be eligible for

your new benefits.

PLAN

CARRIER

MAXIMUM AGE

Please note, limits and exclusions may apply when obtaining coverage as a married couple or when obtaining coverage for dependents.

Medical

BCBSTX

To age 26

Dental

Cigna

To age 26

Vision

Superior Vision

To age 26

Potential Spouse Coverage Limitations: When enrolling in coverage, please keep in mind that some benefits may not allow you to cover your spouse as a dependent if your spouse is enrolled for coverage as an employee under the same employer. Review the applicable plan documents, contact Financial Benefit Services, or contact the insurance carrier for additional information on spouse eligibility.

Medical Flex

NBS

IRS Tax Dependent

Health Savings Account

HSA Bank

IRS Tax Dependent

Hospital Indemnity

Voya

To age 26

Voluntary Life

UNUM

To age 26

Critical Illness

UNUM

To age 26

Legal Services

Legal Ease

19 or to 26 if full time student*

*Please see LegalEase Plan Information document for full definition of covered dependent

FSA/HSA Limitations: Please note, in general, per IRS regulations, married couples may not enroll in both a Flexible Spending Account (FSA) and a Health Savings Account (HSA). If your spouse is covered under an FSA that reimburses for medical expenses then you and your spouse are not HSA eligible, even if you would not use your spouse's FSA to reimburse your expenses. However, there are some exceptions to the general limitation regarding specific types of FSAs. To obtain more information on whether you can enroll in a specific type of FSA or HSA as a married couple, please reach out to the FSA and/or HSA provider prior to enrolling or reach out to your tax advisor for further guidance.

Potential Dependent Coverage Limitations: When enrolling for dependent coverage, please keep in mind that some benefits may not allow you to cover your eligible dependents if they are enrolled for coverage as an employee under the same employer. Review the applicable plan documents, contact Financial Benefit Services, or contact the insurance carrier for additional information on dependent eligibility.

Disclaimer: You acknowledge that you have read the limitations and exclusions that may apply to obtaining spouse and dependent coverage, including limitations and exclusions that may apply to enrollment in Flexible Spending Accounts and Health Savings Accounts as a married couple. You, the enrollee, shall hold harmless, defend, and indemnify Financial Benefit Services, LLC from any and all claims, actions, suits, charges, and judgments whatsoever that arise out of the enrollee's enrollment in spouse and/or dependent coverage, including enrollment in Flexible Spending Accounts and Health Savings Accounts.

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

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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 please notify your benefits administrator.

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

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.

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

Calendar Year

orders to take drugs, or received medical care or services

January 1st through December 31st

(including diagnostic and/or consultation services).

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

Guaranteed Coverage The amount of coverage you can elect without answering any medical questions or taking a health exam. Guaranteed

coverage is only available during initial eligibility period.

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

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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 tax-free.

Employer Eligibility

A qualified high deductible health plan.

All employers

Contribution Source

Employee

Employee

Account Owner

Individual

Employer

Underlying Insurance Requirement

High deductible health plan

None

Description

Minimum Deductible Maximum Contribution Permissible Use Of Funds Cash-Outs of Unused Amounts (if no medical expenses) Year-to-year rollover of account balance?

Does the account earn interest?

$1,400 single (2021) $2,800 family (2021) $3,600 single (2021) $7,200 family (2021) If used for non-qualified medical expenses, subject to current tax rate plus 20% penalty.

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

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

N/A $2,700 medical reimbursement $5,000 dependent care Reimbursement for qualified medical expenses (as defined in Sec. 213(d) of IRC).

Not permitted No.

Yes

No

Portable?

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

No

Are claims substantiated?

Only upon audit

Yes receipts may be required.

Can I access the entire amount No, money is available as it is contributed at the start of the plan year? to the account.

FLIP TO FOR HSA INFORMATION

PG. 26

Yes

FLIP TO FOR FSA INFORMATION

PG. 64 15

Health Insurance

SUMMARY PAGES

ActiveCare HD, Primary, Primary+, 2

HMO

Blue Cross Blue Shield 866-355-5999 www.bcbstx.com/trsactivecare Teladoc - https://member.teladoc.com/trsactivecare RediMD - www.redimd.com ActiveCare Primary In Network Benefits (Participant Pays)

ActiveCare HD (Participant Pays)

ActiveCare Primary+ (Participant Pays)

Scott & White HMO (Participant Pays)

Deductible must be met before benefits are paid; HSA Compatible

Medical Benefits Deductible Individual Family Maximum Out-of-Pocket

Scott & White 800-321-7947 https://trs.swhp.org/ MDLive - www.mdlive.com/swhp

$2,500 $5,000

$3,000 $6,000

$1,200 $3,600

$1,150 $3,450

$8,150 $16,300 30%

$7,000 $14,000 30%

$6,900 $13,800 20%

$7,450 $14,900 20%

$30 / $70 Plan pays 100% Plan pays 100%~ $50 30%* 30%*

30%* Plan pays 100% $30 consultation fee~ 30%* 30%* 30%*

$30 / $70 Plan pays 100% Plan pays 100%~ $50 20%* 20%*

$20>! / $70 Plan pays 100% Plan pays 100%^ $50 $500 copay* $150 copay/day + 20%*

NO Statewide Network

YES Nationwide Network

NO Statewide Network

NO Statewide Network

Primary Care Provider (PCP) required?

YES

NO

YES

NO

Referrals needed to see a specialist?

YES

NO

YES

NO

Subject to medical deductible $15§ 30%* 50%*

Subject to medical deductible 20%*§ 25%* 50%*

$0 Generic $200 Brand $15 25%# 50%#

30%*

20%*

20%#

$0 Generic $200 Brand $10@ 30%# 50%# preferred-15%# non-preferred-25%# Monthly Semi $317.48 $158.74 $1,137.70 $568.85 $647.16 $323.58 $1,343.42 $671.71

(includes deductible, coinsurance & copays)

Individual Family Coinsurance Office Visit Copay PCP / Specialist Preventive Care Virtual Health Urgent Care Emergency Room Inpatient Hospitalization Other Plan Features Out of Network Benefits?

Network

Prescription Drugs Drug Deductible Tier 1 - Generic Tier 2 - Preferred Brand Tier 3 - Non-Pref Brand Specialty Drugs Premiums Employee Only Employee & Spouse Employee & Child(ren) Employee & Family

Monthly $192 $951 $526 $1,180

Semi $96.00 $475.50 $263.00 $590.00

*

^

>

#

After the MEDICAL deductible has been met First in-person sick visit $0 copay !

No copay for PCP visits for dependents age 19 and under ~ Teladoc or RediMD 16

Monthly $204 $984 $547 $1,220

Semi $102.00 $492.00 $273.50 $610.00

Monthly $317 $1,109 $654 $1,450

Semi $158.50 $554.50 $327.00 $725.00

MDLive or MyBSWHealth After the PRESCRIPTION deductible has been met § Certain generic preventive drugs are covered 100% @ ACA Preventive Drugs - $0 copay

NOTES

17

2021-22 TRS-ActiveCare Plan Highlights Sept. 1, 2021 How to Calculate Your Monthly Premium

All TRS-ActiveCare participants have three plan options.

TRS-ActiveCare Primary • Lowest premium of the plans • Copays for doctor visits before you meet deductible • Statewide network • PCP referrals required to see specialists • Not compatible with a health savings account (HSA) • No out-of-network coverage

Total Monthly Premium Your District and State Contributions

Plan summary

Your Premium

TRS-

• Lower deductible t • Copays for many s • Higher premium th • Statewide network • PCP referrals requi • Not compatible wit • No out-of-network

Ask your Benefits Administrator for your district’s premiums.

Monthly Premiums

Total Premium Employee Only

Employee and Spouse

Wellness Benefits at No Extra Cost

Employee and Children Employee and Family

Your Premium

$417

$

$1,176

$

$751

$

$1,405

$

192 951 526 1,180

Total Premi $542 $1,334 $879 $1,675

Being healthy is easy with: • $0 preventive care • 24/7 customer service

Plan Features Type of Coverage Individual/Family Deductible Coinsurance

• One-on-one health coaches • Weight loss programs

Individual/Family Maximum Out-of-Pocket Network Primary Care Provider (PCP) Required

In-Network Coverage Only

In

$2,500/$5,000 You pay 30% after deductible

You

$8,150/$16,300 Statewide Network Yes

• Nutrition programs • Ovia® pregnancy support

Doctor Visits

• TRS Virtual Health

Primary Care Specialist

• Mental health support

TRS Virtual Health

$30 copay $70 copay $0 per consultation

• And much more!

Available for all plans.

See your Benefits Booklet for more details.

Things to Know • TRS’s Texas-sized purchasing power creates broad networks without county boundaries.

• Specialty drug insurance means you’re covered, no matter what life throws at you.

18

Immediate Care Urgent Care

$50 copay

Emergency Care

You pay 30% after deductible

TRS Virtual Health

$0 per consultation

You

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

Integrated with medical $15/$45 copay; $0 for certain generics

Preferred Brand

You pay 30% after deductible

You

Non-preferred Brand

You pay 50% after deductible

You

Specialty

You pay 30% after deductible

You

– Aug. 31, 2022 Each includes a wide range of wellness benefits.

-ActiveCare Primary+

han the HD and Primary plans ervices and drugs an the other plans k red to see specialists th a health savings account (HSA) coverage

Your Premium

um $ $ $ $

317 1,109 654 1,450

This plan is closed and not accepting new enrollees. If you’re currently enrolled in TRS-ActiveCare 2, you can remain in this plan.

TRS-ActiveCare HD • Compatible with a health savings account (HSA) • Nationwide network with out-of-network coverage • No requirement for PCPs or referrals • Must meet your deductible before plan pays for non-preventive care

Your Premium

Total Premium $429

$

$1,209

$

$772

$

$1,445

$

204 984 547 1,220

TRS-ActiveCare 2 • Closed to new enrollees • Current enrollees can choose to stay in this plan • Lower deductible • Copays for many drugs and services • Nationwide network with out-of-network coverage • No requirement for PCPs or referrals

Total Premium

Your Premium

$1,013

$

$2,402

$

$1,507

$

$2,841

$

788 2,177 1,282 2,616

In-Network

Out-of-Network

n-Network Coverage Only

In-Network

Out-of-Network

$1,200/$3,600

$3,000/$6,000

$5,500/$11,000

$1,000/$3,000

$2,000/$6,000

You pay 30% after deductible

You pay 50% after deductible

You pay 20% after deductible

You pay 40% after deductible

$7,000/$14,000

$20,250/$40,500

$7,900/$15,800

$23,700/$47,400

u pay 20% after deductible $6,900/$13,800 Statewide Network

Nationwide Network

Nationwide Network

Yes

No

No

$30 copay

You pay 30% after deductible

You pay 50% after deductible

$30 copay

$70 copay

You pay 30% after deductible

You pay 50% after deductible

$70 copay

$0 per consultation

$50 copay

You pay 50% after deductible

You pay 40% after deductible $0 per consultation

$30 per consultation

You pay 30% after deductible

You pay 40% after deductible

$50 copay

You pay 40% after deductible

You pay 30% after deductible

You pay a $250 copay plus 20% after deductible

$30 per consultation

$0 per consultation

$200 brand deductible

Integrated with medical

$200 brand deductible

$15/$45 copay

You pay 20% after deductible; $0 for certain generics

$20/$45 copay

u pay 25% after deductible

You pay 25% after deductible

u pay 50% after deductible

You pay 50% after deductible

You pay 25% after deductible ($40 min/$80 max)/ You pay 25% after deductible ($105 min/$210 max)

u pay 20% after deductible

You pay 20% after deductible

u pay 20% after deductible $0 per consultation

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) 19

Compare Prices for Common Medical Services

REMEMBER: Benefit

Log into Blue Access for MembersSM at www.bcbstx.com/trsactivecare to use the cost estimator tool. This will help you find the best prices.

TRS-ActiveCare Primary

TRS-ActiveCare Primary+

In-Network Only

In-Network Only

Office/Indpendent Lab: You pay $0

Office/Indpendent Lab: You pay $0

Outpatient: You pay 30% after deductible

Outpatient Costs

In-Network

Out-of-Network

TRS-ActiveCare 2 In-Network

You pay 30% after deductible

You pay 30% after deductible

You pay 40% after deductible

Outpatient: You pay 20% after deductible

Outpatient: You pay 20% after deductible

You pay 20% after deductible

You pay 30% You pay 50% after deductible after deductible

You pay 20% after deductible + $100 per procedure copay

You pay 40% after deductible + $100 per procedure copay

You pay 20% after deductible

You pay 30% You pay 50% after deductible after deductible

You pay 20% after deductible ($150 facility copay per incident)

You pay 40% after deductible ($150 facility copay per incident)

You pay 20% after deductible ($150 facility copay per day)

You pay 40% after deductible ($500 facility per day maximum)

You pay $500 copay + 20% after deductible

You pay $500 copay + 40% after deductible

Inpatient Hospital Costs

You pay 30% after deductible

You pay 20% after deductible

You pay 50% after deductible You pay 30% ($500 facility after deductible per day maximum)

Freestanding Emergency Room

You pay $500 copay + 30% after deductible

You pay $500 copay + 20% after deductible

You pay 30% You pay 50% after deductible after deductible + $500 copay + $500 copay

Facility – You pay 30% after deductible

Facility – You pay 20% after deductible

Facility – You pay 20% after deductible ($150 facility copay per day)

Professional Services – You pay $5,000 copay + 30% after deductible

Professional Services – You pay $5,000 copay + 20% after deductible

Professional Services – You pay $5,000 copay + 20% after deductible

Bariatric Surgery

Out-of-Network

Office/Indpendent Lab: You pay $0 You pay 30% You pay 50% after deductible after deductible

Diagnostic Labs*

High-Tech Radiology

TRS-ActiveCare HD

Not Covered

Not Covered

Not Covered

Only covered if rendered at a BDC+ facility.

Only covered if rendered at a BDC+ facility.

Annual Vision Examination (one per plan year; performed by an ophthalmologist or optometrist)

You pay $70 copay

You pay $70 copay

You pay 30% You pay 50% after deductible after deductible

You pay $70 copay

You pay 40% after deductible

Annual Hearing Exam (one per plan year)

$30 PCP copay $70 specialist copay

$30 PCP copay $70 specialist copay

You pay 30% You pay 50% after deductible after deductible

$30 PCP copay $70 specialist copay

You pay 40% after deductible

Only covered if rendered at a BDC+ facility.

*Pre-certification for genetic and specialty testing may apply. Contact your Personal Health Guide at 1-866-355-5999 with questions.

trs.texas.gov 20

Revised 06/02/21

my

Benefits Summary

Fully Covered Healthcare Services

Home Health Services

Preventive Services

No Charge

Home Health Care Visit

Standard Lab and X-Ray

No Charge

Worldwide Emergency Care

Disease Management and Complex Case Management

No Charge

Ambulance and Helicopter

Well Child Care Annual Exams

No Charge

Immunizations (age appropriate)

No Charge

Nurse Advice Line

Telehealth (MyBSWHealth and MDLIVE)

Annual out-of-pocket maximum (including medical and

prescription co-pays and co-insurance)

Lifetime Paid Benefit Maximum

Annual Benefit Maximum

Ask an SWHP Pharmacy representative how to save money on your prescriptions.

(includes combined Medical and Rx copays, deductibles and coinsurance)

None

$20 Copay

First Primary Care Visit for Illness - $0 Copay2

$20 copay

Specialty Care

$70 copay

Other Outpatient Services

20% after deductible3

Diagnostic/Radiology Procedures

20% after deductible

Expecting the Best® Maternity Program6

Available at BSW Pharmacies, in-network retail pharmacies and mail order

ACA Preventive*

$0 copay

$0 copay

Preferred Generic

$10 copay

$25 copay

Preferred Brand

30% after Rx deductible

30% after Rx deductible

Non-Preferred

50% after Rx deductible

50% after Rx deductible

trs.swhp.org BSWH: 855.388.3090 OptumRx: 855.205.9182

Specialty Medications (up to a 30-day supply)

Tier 1 Tier 2 Tier 3

No Charge

15% after Rx deductible 15% after Rx deductible 25% after Rx deductible

Diagnostic & Therapeutic Services

20% after deductible

Physical and Speech Therapy Manipulative Therapy4

20% of charges after deductible

$70 copay 20% without office visit $40 plus 20% with office visit

Wellness Wondr HealthTM 6

No Charge

No Charge

Well-Being Assessment6

No Charge

20% of charges after deductible

Digital Health Coaching6

No Charge

No Charge

Equipment and Supplies Preferred Diabetic Supplies and Equipment - Rx only

(Up to a 90-day supply)

(Up to a 30-day supply)

Mail Order

Maternity Care

Inpatient Delivery

Maintenance Quantity Retail Quantity

Online Refills

Inpatient Services

Prenatal Care

$200

Does not apply to preferred generic drugs

$7,450 Individual/ $14,900 Family

After-Hours Primary Care Clinics

Overnight hospital stay: includes all medical services including semi-private room or intensive care

Unlimited

Rx Deductible per Individual $1,150 Individual/ $3,450 Family

$0 Copay 2

Allergy Serum & Injections

$50 copay

Prescription Drugs

$0 copay go to trs.swhp.org

Primary Care Dependents1 (under age 19)

Eye Exam (one annually)

$500 copay after deductible

Urgent Care Facility

1-877-505-7947

Outpatient Services Primary Care1

$40 copay and 20% of charges after deductible

Emergency Room5

Plan Provisions Annual Deductible

$70 copay

1

$10/$25 copay; no deductible

Including all services billed with office visit Does not apply to wellness or preventive visits

2

Includes other services, treatments, or procedures received at time of office visit

3

35 visits per year maximum

4

Non-Preferred Diabetic Supplies and Equipment - Rx only Durable Medical Equipment/ Prosthetics

GR_TRS_SB-2021-22

30% after Rx deductible

Copay waived if admitted within 24 hours

5

6See member guide for additional information

20% after deductible

*See list of ACA preventive drugs on the Pharmacy Benefits page at trs.swhp.org.

21

VOYA 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 $10,000.

$8,800

9,600

10,400

2003

2008

2012

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

Hospital Indemnity Compass Hospital Confinement Indemnity Insurance

Enrollment at a glance

What Hospital Confinement Indemnity Insurance benefits are available?

The following list is a summary of the benefits provided by Hospital Confinement Indemnity Insurance. For a list of standard exclusions and limitations, go to the end of this document. For a complete description of your available benefits, exclusions and limitations, see your certificate of insurance and any riders.

What is Hospital Confinement Indemnity Insurance?

Hospital Confinement Indemnity Insurance pays a daily benefit if You employer offers you the opportunity to purchase a daily benefit amount of $100 or $200. The benefit amount is you have a covered stay in a hospital*, critical care unit or determined by the type of facility in which you are confined: rehabilitation facility that begins on or after your coverage effective date. The benefit amount is determined by the type of • Hospital—The benefit payment is 1x the daily benefit amount ($100 or $200), up to 30 days per confinement. facility and the number of days you stay. You have the option to elect Hospital Confinement Indemnity Insurance to meet your • Critical care unit (CCU)—The benefit payment is 2x the daily needs. Hospital Confinement Indemnity Insurance is a limited benefit amount ($200 or $400), up to 15 days per benefit policy. It is not health insurance and does not satisfy the confinement. requirement of minimum essential coverage under the • Rehabilitation facility—The benefit payment is one-half of Affordable Care Act. the daily benefit amount ($50 or $100), up to 30 days per Features of Hospital Confinement Indemnity Insurance include: confinement.

• Guaranteed Issue: No medical questions or tests are • Initial Confinement Benefit: This provides an additional required for coverage. payment of 10x the daily benefit amount after confinement • Flexible: You can use the benefit payments for any purpose in a hospital, critical care unit, or rehabilitation center. This you like. benefit is limited to a maximum of four Initial Confinement Benefits per calendar year for all covered persons, but no • Payroll deductions: Premiums paid through convenient more than one for each covered person. payroll deductions.

• Affordable coverage: Rates are typically lower when you Meet the Burwells purchase coverage through your employer.

Tom and Becky always knew they wanted kids but with busy • Portable: If you leave your current employer, you can take careers and active social lives, starting a family had never been a the policy with you and select from a variety of payment high priority. That is until one day when they received a big plans. *A hospital does not include an institution or part of an institution used as: a hospice care surprise—Becky was pregnant! Eight months later, little Andrew unit; a convalescent home; a rest or nursing facility; a free- standing surgical center; a came into the world. Fortunately, Becky had Hospital rehabilitative center; an extended care facility; a skilled nursing facility; or a facility primarily affording custodial, educational care, or care or treatment for persons suffering from mental Confinement Indemnity Insurance with the Initial Confinement diseases or disorders, or care for the aged, or drug or alcohol addiction. “Critical care unit” Benefit through her employer. The benefit she received from and “rehabilitative facility” are specifically defined in this policy. See the certificate for this coverage helped cover her medical deductibles and copays, details. as well as Tom’s parking and meals, during her two-day hospital How can Hospital Confinement Indemnity Insurance stay.

A simple way to help protect against the financial stress of a hospital stay.

For the employees of: Hurst-Euless-Bedford ISD

help?

Below are a few examples of how your Hospital Confinement Indemnity Insurance benefit could be used (coverage amounts may vary): • Medical expenses, such as deductibles and copays • Travel, food and lodging expenses for family members • Child care • Everyday expenses like utilities and groceries

Who is eligible for Hospital Confinement Indemnity Insurance?

• • •

You—all active employees working 20+ hours per week.

Your spouse*— Coverage is available only if employee coverage is elected.

Your children**— to age 26. Coverage is available only if employee coverage is elected

*The use of “spouse” in this document means a person insured as a spouse as described in the certificate of insurance or rider. Please contact your employer for more information. **The definition of “child” may vary by state. Please contact your employer for more information. ± Employees in these states are not eligible for coverage: Colorado, Connecticut, Montana and New York

Benefits paid by Becky’s Hospital Confinement Indemnity Insurance- $200 daily benefit with Initial Confinement Benefit $1,500 $1,200 $40 $200

Health insurance deductible Co-insurance for two-day hospital stay Parking Meals

$2,940

Total expenses Daily benefit paid under Becky’s policy ($200 x 2 days) Initial Confinement Benefit (10x the $200 daily benefit amount)

$400

$2,000

The amounts shown are for illustrative purposes only. Actual costs/results may vary.

23

Hospital Indemnity What optional benefits are available?

When is my coverage effective?

You may choose to include the optional benefits below with your Hospital Confinement Indemnity Insurance coverage. For a list of standard exclusions and limitations, please refer to the end of this document. For a complete description of your available benefits, exclusions and limitations, see your certificate of insurance and any riders.

• Spouse Hospital Confinement Indemnity Insurance: If you have coverage on yourself, you may enroll your spouse, as long as your spouse is not covered under your employer’s plan as an employee. o Your spouse will be covered for the same Hospital Confinement Indemnity benefits as you are. o Guaranteed issue: No medical questions or tests are required for coverage.

• Children’s Hospital Confinement Indemnity Insurance: If you have coverage on yourself, your natural children, stepchildren, adopted children or children for whom you are a legal guardian are eligible to be covered under your employer’s plan, up to the age of 26. o Your children will be covered for the same Hospital Confinement Indemnity benefits as you are. o Guaranteed issue: No medical questions or tests are required for coverage. o One premium amount covers all of your eligible children. o If both you and your spouse are covered under the policy as an employee, then only one, but not both, may cover the same children for Hospital Confinement Indemnity Insurance. If the parent who is covering the children stops being insured as an employee then the other parent may apply for children’s coverage.

The effective date of coverage is the date you are eligible to begin filing claims. The confinement must start on or after the coverage effective date.

Annual enrollment • Your coverage becomes effective on September 1st, following the election of coverage. Coverage for your spouse and/or children becomes effective on the same date as your coverage.

How much does Hospital Confinement Indemnity Insurance cost?

All employees pay the same rate, no matter their age. See the chart below for the premium amounts.

Hospital Confinement Indemnity Monthly Rates by Level Coverage Type $100 $200 Employee

$16.19

$32.38

Employee + Spouse

$32.47

$64.95

Employee + Children

$24.18

$48.36

Employee + Family

$40.46

$80.93

24

Exclusions and limitations Exclusions for the Certificate, Initial Confinement Benefit, Spouse Hospital Confinement Indemnity Insurance and Children’s Hospital Confinement Indemnity Insurance are listed below. (These may vary by state.) Benefits are not payable for any loss caused in whole or directly by any of the following*: • Participation or attempt to participate in a felony or illegal activity.

• Operation of a motorized vehicle while intoxicated.

• Suicide, attempted suicide or any intentionally self-inflicted injury, while sane or insane.

• War or any act of war, whether declared or undeclared, other than acts of terrorism.

• Loss that occurs while on full-time active duty as a member of the armed forces of any nation. We will refund, upon written notice of such service, any premium which has been accepted for any period not covered as a result of this exclusion.

• Alcoholism, drug abuse, or misuse of alcohol or taking of drugs, other than under the direction of a doctor.

• Elective surgery, except when required for appropriate care as a result of the covered person’s injury or sickness.** • Riding in or driving any motor-driven vehicle in a race, stunt show or speed test.

• Operating, or training to operate, or service as a crew member of, or jumping, parachuting or falling from, any aircraft or hot air balloon, including those which are not motor-driven. Flying as a fare-paying passenger is not excluded.

• Engaging in hang-gliding, bungee jumping, parachuting, sail gliding, parasailing, parakiting, kite surfing or any similar activities.

• Practicing for, or participating in, any semiprofessional or professional competitive athletic contests for which any type of compensation or remuneration is received. *See the certificate and any riders for a complete list of available benefits, along with applicable provisions, exclusions and limitations. **Not applicable to Accident Benefit Rider.

Hospital Indemnity Questions?

For more information, please contact: Voya Employee Benefits Customer Service at (877) 236-7564 This offer is contingent upon participation requirements being met.

This is a summary of benefits only. A complete description of benefits, limitations, exclusions and termination of coverage will be provided in the certificate of insurance and riders. All coverage is subject to the terms and conditions of the group policy. If there is any discrepancy between this document and the group policy documents, the policy documents will govern. To keep coverage in force, premiums are payable up to the date of coverage termination. Hospital Confinement Indemnity Insurance is underwritten

by ReliaStar Life Insurance Company (Minneapolis, MN), a member of the Voya® family of companies. Policy Form #RL-HI-POL-12; Certificate Form #RL-HI-CERT-12; and Rider Forms: Spouse Hospital Confinement Indemnity Rider Form #RL-HI-SPR-12; Children’s Hospital Confinement Indemnity Rider Form #RL-HI-CHR-12; Initial Confinement Benefit Rider Form #RL-HI-ICN-12.

Form numbers, provisions and availability may vary by state.

CN0123-39719-0119 Hurst-Euless-Bedford ISD, Group #70637-0, Acct #001 Date Prepared: 04/15/2020 172510-02/01/2018 ReliaStar Life Insurance Company, a member of the Voya® family of companies

25

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

HSA (Health Savings Account) Health Savings Accounts 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?

2020 Annual HSA Contribution Limits Individual = $3,550 Family = $7,100 2021 Annual HSA Contribution Limits Individual = $3,600 Family = $7,200 Catch-up Contributions Accountholders who meet these qualifications are eligible to make an HSA catch-up contribution of $1,000: Health Savings accountholder; age 55 or older (regardless of when in the year an accountholder turns 55); not enrolled in Medicare (if an accountholder enrolls in Medicare mid-year, catch-up contributions should be prorated). Authorized signers who are 55 or older must have their own HSA in order to make the catch-up contribution.

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

How can you benefit from tax savings?

An HSA provides triple tax 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.

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

27

Health Savings Account (HSA) Examples of IRS-Qualified Medical Expenses4: • • • • • • • • •

• • •

• • • • •

•

Acupuncture Alcoholism treatment Ambulance services Annual physical examination Artificial limb or prosthesis Birth control products 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 invitro 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) Menstrual care products Nursing home Nursing services Obstetrician Osteopath Over-the-counter medicines (visit hsabank.com/QME for details) Oxygen Pregnancy test kit Podiatrist Prescription drugs and medicines Prenatal care & postnatal treatments Psychiatrist

1

• • • • •

• • • • • •

•

• •

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

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 1-800TAXFORM. 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 longterm care coverage; coverage while receiving unemployment compensation; for any healthcare coverage for those over age 65 including Medicare (except Medicare supplemental coverage).

For assistance, please contact the Client Assistance Center 800-357-6246 www.hsabank.com | 605 N. 8th Street, Ste. 320, Sheboygan, WI 53081 © 2017 HSA Bank. HSA Bank is a division of Webster Bank, N.A., Member FDIC. | HSA_EE_EV1_061917

28

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.

• Health Benefits Debit Card – Your HSA Bank Health Benefits Debit Card provides access to your HSA funds at point-of-sale with signature or PIN and at ATMs for withdrawals. The daily debit card limit for the Health Benefits Debit Card is $5,000 at merchants dedicated to healthcare (e.g. a doctor’s office or hospital) and $3,500 at merchants that are not healthcare specific but offer eligible medical products and/or services (e.g. a department or grocery store). The number of debit card transactions allowed per day is limited and varies based on how the card is used or types of transactions processed. These limits exist as a 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.

• 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-of-sale 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 © 2016 HSA Bank. HSA Bank is a division of Webster Bank, N.A., Member FDIC. How_to_use_your_HSA_AH_EV1_R_110916

29

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

Dental Rates Cigna

800-224-6224

www.cigna.com

The district offers a choice of three different dental plans. A summary of the respective plans follows.

PPO High

PPO Low

DHMO

Plan Pays 100%

Plan Pays 100%

Fixed Co-Pays

Plan Pays 80%

Plan Pays 70%

Deductible Applies

Deductible Applies

Fixed Co-Pays

Class III – Major Restorative

Plan Pays 50%

Plan Pays 50%

(crowns, bridges, dentures, etc.)

Deductible Applies

Deductible Applies

Plan Pays 50%

Not Covered

Fixed Co-Pays

Ortho. Lifetime Maximum

$1,000

Not Covered

N/A

Deductible (Per Plan Year)

$50 Person $150 Family

$25 Person $75 Family

None

$1,000

$750

$1,125

$875

$1,250

$1,000

$1,375

$1,125

Primary Care Dentist Required

No

No

Yes

Out of Network Benefits

Yes

Yes

No

Out of Network Reimbursement

Maximum Reimbursable Charge

Maximum Allowable Charge

None

Premiums

Monthly

SemiMonthly

Monthly

SemiMonthly

Monthly

SemiMonthly

Employee Only

$43.33

$21.67

$28.29

$14.15

$14.19

$7.10

Employee + 1

$86.08

$43.04

$58.28

$29.14

$26.96

$13.48

Employee + Family

$130.56

$65.28

$78.65

$39.33

$42.56

$21.28

Class I – Diagnostic & Preventative (cleanings, exams, x-rays, sealants, etc.)

Class II – Basic Restorative (fillings, extractions, oral surgery, etc.)

Orthodontics (Children & Adults)

Fixed Co-Pays

Progressive Maximum Benefit

Year 1 Year 2 (Contingent upon receiving preventive services in Year 1) Year 3 (Contingent upon receiving preventive services in Years 1 & 2) Year 4 (Contingent upon receiving preventive services in Years 2 & 3)

N/A

31

Dental PPO– High Plan Cigna Dental Benefit Summary Hurst-Euless-Bedford ISD #3340943 High Plan Renewal Date: 09/01/2020 Insured by: Cigna Health and Life Insurance Company

Monthly PPO Premiums

EE Only

$43.33

EE + Spouse

$86.08

Receiving regular dental care can not only catch minor problems before they become major EE + Child(ren) $130.56 and expensive to treat - it may even help improve your overall health. Gum disease is increasingly being linked to complications for pre-term birth, heart disease, stroke, diabetes, osteoporosis and other health issues. That’s why this dental plan includes Cigna Dental WellnessPlusSM features. When you or your family members receive any preventive care service in one plan year, the annual dollar maximum will increase in the following plan year. When you or your family members remain enrolled in the plan and continue to receive preventive care, the annual dollar maximum will increase in the following plan year, until it reaches the level specified below. Please refer to your plan materials for additional information on this plan feature.

Benefits Cigna Dental PPO - High Option Network Options In-Network: Total Cigna DPPO Network Out-of-Network: See Non-Network Reimbursement Maximum Reimbursable Charge Reimbursement Levels Based on Contracted Fees Progressive Maximum Benefit: Progressive Benefit Year 2: Increase contingent upon receiving Preventive Services in Plan Year 1.

Progressive Benefit Year 3: Increase contingent upon receiving Preventive Services in Plan Years 1 and 2. Progressive Benefit Year 4: Increase contingent upon receiving Preventive Services in Plan Years 2 and 3 Policy Year Benefits Maximum Year 1: $1,000 Year 2: $1,125 Year 1: $1,000 Year 2: $1,125 Year 3: $1,250 Year 4: $1,375 Year 3: $1,250 Year 4: $1,375 Applies to: Class I, II & III expenses Policy Year Deductible $50 $50 Individual Family $150 $150 Benefit Highlights Plan Pays You Pay Plan Pays You Pay Class I: Diagnostic & Preventive Oral Evaluations Prophylaxis: routine cleanings X-rays: routine Any amount over the Maximum 100% 100% No Charge X-rays: non-routine No Deductible No Deductible Reimbursable Charge Fluoride Application Sealants: per tooth Space Maintainers: non-orthodontic Emergency Care to Relieve Pain Class II: Basic Restorative Restorative: fillings Periodontics: minor and major Oral Surgery: minor and major 80% 20% 80% 20% Anesthesia: general and IV sedation After Deductible After Deductible After Deductible After Deductible Repairs: Bridges, Crowns and Inlays Repairs: Dentures Denture Relines, Rebases and Adjustments Crowns: prefabricated stainless steel / resin Class III: Major Restorative Inlays and Onlays 50% 50% 50% 50% Prosthesis Over Implant After Deductible After Deductible After Deductible After Deductible Crowns: permanent cast and porcelain Bridges and Dentures Endodontics: minor and major Class IV: Orthodontia 50% 50% 50% 50% Coverage for Employee and All Dependents No Deductible No Deductible No Deductible No Deductible Lifetime Benefits Maximum: $1,000

Benefit Plan Provisions: In-Network Reimbursement Non-Network Reimbursement Cross Accumulation 32

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 Allowable Charge. 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.

Dental PPO-High Plan Policy Year Benefits Maximum Policy Year Deductible Late Entrant Limitation Provision Pretreatment Review Alternate Benefit Provision

Oral Health Integration Program (OHIP)

Timely Filing Benefit Limitations:

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

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

Payment will be reduced by 50% for Class III and IV services for 12 months for eligible members that are allowed to enroll in this plan outside of the designated open enrollment period.

This provision does not apply to new hires.

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

When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses.

Cigna Dental Oral Health Integration Program offers enhanced dental coverage for customers with the following medical conditions: diabetes, heart disease, stroke, maternity, head and neck cancer radiation, organ transplants and chronic kidney disease. There’s no additional charge for the program, those who qualify get reimbursed 100% of coinsurance for certain related dental procedures. Eligible customers can also receive guidance on behavioral issues related to oral health and discounts on prescription and non-prescription dental products. Reimbursements under this program are not subject to the plan deductible, but will be applied to and are subject to the plan annual maximum.

Discounts on certain prescription and non-prescription dental products are available through Cigna Home Delivery Pharmacy only, and you are required to pay the entire discounted charge. For more information including how to enroll in this program and a complete list of program terms and eligible medical conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24.

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

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

Oral Evaluations 2 per policy year X-rays (routine) Bitewings: 2 per policy year Complete series of radiographic images and panoramic radiographic images: Limited to a combined total of 1 per 36 X-rays (non-routine) months Diagnostic Casts Payable only in conjunction with orthodontic workup Cleanings 2 per policy year, including periodontal maintenance procedures following active therapy Fluoride Application 1 per policy year for children under age 19 Sealants (per tooth) Limited to posterior tooth. 1 treatment per tooth every 36 months for children under age 14 Space Maintainers Limited to non-orthodontic treatment for children under age 19 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 Prosthesis Over Implant 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: Missing Tooth Limitation

         

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

33

Dental PPO– Low Plan Cigna Dental Benefit Summary Hurst-Euless-Bedford ISD #3340943 Low Plan Renewal Date: 09/01/2020 Insured by: Cigna Health and Life Insurance Company

Monthly PPO Premiums

EE Only

$28.29

EE + Spouse

$58.28

Receiving regular dental care can not only catch minor problems before they become major EE + Child(ren) $78.65 and expensive to treat - it may even help improve your overall health. Gum disease is increasingly being linked to complications for pre-term birth, heart disease, stroke, diabetes, osteoporosis and other health issues. That’s why this dental plan includes Cigna Dental WellnessPlusSM features. When you or your family members receive any preventive care service in one plan year, the annual dollar maximum will increase in the following plan year. When you or your family members remain enrolled in the plan and continue to receive preventive care, the annual dollar maximum will increase in the following plan year, until it reaches the level specified below. Please refer to your plan materials for additional information on this plan feature.

Benefits Cigna Dental PPO - High Option Network Options In-Network: Total Cigna DPPO Network Out-of-Network: See Non-Network Reimbursement Maximum Allowable Charge Reimbursement Levels Based on Contracted Fees Progressive Maximum Benefit: Progressive Benefit Year 2: Increase contingent upon receiving Preventive Services in Plan Year 1.

Progressive Benefit Year 3: Increase contingent upon receiving Preventive Services in Plan Years 1 and 2.

Progressive Benefit Year 4: Increase contingent upon receiving Preventive Services in Plan Years 2 and 3 Policy Year Benefits Maximum Year 1: $750 Year 2: $875 Year 1: $750 Year 2: $875 Year 3: $1,000 Year 4: $1,125 Year 3: $1,000 Year 4: $1,125 Applies to: Class I, II & III expenses Policy Year Deductible Individual $25 $25 Family $75 $75 Benefit Highlights Plan Pays You Pay Plan Pays You Pay Class I: Diagnostic & Preventive Oral Evaluations Prophylaxis: routine cleanings X-rays: routine 100% 100% Any amount over the Maximum X-rays: non-routine No Charge No Deductible No Deductible Allowable Charge Fluoride Application Sealants: per tooth Space Maintainers: non-orthodontic Emergency Care to Relieve Pain Class II: Basic Restorative Restorative: fillings Periodontics: minor and major Oral Surgery: minor and major 70% 30% 70% 30% Anesthesia: general and IV sedation After Deductible After Deductible After Deductible After Deductible Repairs: Bridges, Crowns and Inlays Repairs: Dentures Denture Relines, Rebases and Adjustments Crowns: prefabricated stainless steel / resin Class III: Major Restorative Inlays and Onlays 50% 50% 50% 50% Prosthesis Over Implant After Deductible After Deductible After Deductible After Deductible Crowns: permanent cast and porcelain Bridges and Dentures Endodontics: minor and major

Benefit Plan Provisions: In-Network Reimbursement Non-Network Reimbursement Cross Accumulation 34

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 Allowable Charge. 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.

Dental PPO-Low Plan Policy Year Benefits Maximum Policy Year Deductible Late Entrant Limitation Provision Pretreatment Review Alternate Benefit Provision

Oral Health Integration Program (OHIP)

Timely Filing Benefit Limitations: Missing Tooth Limitation Oral Evaluations X-rays (routine)

X-rays (non-routine) Cleanings Fluoride Application Sealants (per tooth) Space Maintainers Inlays, Crowns, Bridges, Dentures and Partials

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

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

Payment will be reduced by 50% for Class III and IV services for 12 months for eligible members that are allowed to enroll in this plan outside of the designated open enrollment period.

This provision does not apply to new hires.

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

When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses.

Cigna Dental Oral Health Integration Program offers enhanced dental coverage for customers with the following medical conditions: diabetes, heart disease, stroke, maternity, head and neck cancer radiation, organ transplants and chronic kidney disease. There’s no additional charge for the program, those who qualify get reimbursed 100% of coinsurance for certain related dental procedures. Eligible customers can also receive guidance on behavioral issues related to oral health and discounts on prescription and non-prescription dental products. Reimbursements under this program are not subject to the plan deductible, but will be applied to and are subject to the plan annual maximum.

Discounts on certain prescription and non-prescription dental products are available through Cigna Home Delivery Pharmacy only, and you are required to pay the entire discounted charge. For more information including how to enroll in this program and a complete list of program terms and eligible medical conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24.

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

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

2 per policy year Bitewings: 2 per policy year Complete series of radiographic images and panoramic radiographic images: Limited to a combined total of 1 per 36 months 2 per policy year, including periodontal maintenance procedures following active therapy 1 per policy year for children under age 19 Limited to posterior tooth. 1 treatment per tooth every 36 months for children under age 14 Limited to non-orthodontic treatment for children under age 19 Replacement every 60 months if unserviceable and cannot be repaired. Benefits are based on the amount payable for non-precious metals. No porcelain or white/tooth-colored material on molar crowns or bridges.

Denture and Bridge Repairs Reviewed if more than once Denture Adjustments, Rebases and Relines

Covered if more than 6 months after installation

Prosthesis Over Implant

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

Benefit Exclusions: Covered Expenses will not include, and no payment will be made for the following: Procedures and services not included in the list of covered dental expenses; Diagnostic: cone beam imaging; Preventive Services: instruction for plaque control, oral hygiene and diet; Restorative: veneers of porcelain, ceramic, resin, or acrylic materials on crowns or pontics on or replacing the upper and or lower first, second and/or third molars; Periodontics: bite registrations; splinting; Prosthodontics: precision or semi-precision attachments; initial placement of a complete or partial denture per plan guidelines; Implants: implants or implant related services; Orthodontics: orthodontic treatment; Procedures, appliances or restorations, except full dentures, whose main purpose is to: change vertical dimension; diagnose or treat conditions or dysfunction of the temporomandibular joint (TMJ); stabilize periodontally involved teeth; or restore occlusion; Athletic mouth guards; services performed primarily for cosmetic reasons; personalization; replacement of an appliance per benefit guidelines; Services that are deemed to be medical in nature; services and supplies received from a hospital; Drugs: prescription drugs Charges in excess of the Maximum Allowable Charge.

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

35

Dental DHMO Monthly DHMO Premiums

P5XV0 TX

CIGNA DENTAL CARE® (*DHMO) PATIENT CHARGE SCHEDULE This Patient Charge Schedule lists the benefits of the Dental Plan including covered procedures and patient charges.

Employee Only

$14.19

Employee + Spouse

$26.96

Employee + Child(ren)

$42.56

Important Highlights •

•

• • • • • • •

This Patient Charge Schedule applies only when covered dental services are performed by your Network Dentist, unless otherwise authorized by Cigna Dental as described in your plan documents. Not all Network Dentists perform all listed services and it is suggested to check with your Network Dentist in advance of receiving services.

This Patient Charge Schedule applies to Specialty Care when an appropriate referral is made to a Network Specialty Periodontist or Oral Surgeon. You should verify with the Network Specialty Dentist that your treatment plan has been authorized for payment by Cigna Dental. Prior authorization is not required for specialty referrals for Pediatric, Orthodontic and Endodontic services. You may select a Network Pediatric Dentist for your child under the age of 7 by calling Customer Service at 1.800.Cigna24 to get a list of Network Pediatric Dentists in your area. Coverage for treatment by a Pediatric Dentist ends on your child’s 7th birthday; however, exceptions for medical reasons may be considered on an individual basis. Your Network General Dentist will provide care upon your child’s 7th birthday.

Procedures not listed on this Patient Charge Schedule are not covered and are the patient’s responsibility at the dentist’s usual fees.

The administration of IV sedation, general anesthesia, and/or nitrous oxide is not covered except as specifically listed on this Patient Charge Schedule. The application of local anesthetic is covered as part of your dental treatment.

Cigna Dental considers infection control and/or sterilization to be incidental to and part of the charges for services provided and not separately chargeable.

This Patient Charge Schedule is subject to annual change in accordance with the terms of the group agreement.

Procedures listed on the Patient Charge Schedule are subject to the plan limitations and exclusions described in your plan book/certificate of coverage and/or group contract.

All patient charges must correspond to the Patient Charge Schedule in effect on the date the procedure is initiated.

The American Dental Association may periodically change CDT Codes or definitions. Different codes may be used to describe these covered procedures. The language in italics is intended to clarify the members’ benefit.

Code

Procedure Description

Office visit fee – (per patient, per office visit in addition to any other applicable patient charges) Office visit fee

Patient Charge $5.00

Diagnostic/preventive – Oral evaluations are limited to a combined total of 4 of the following evaluations during a 12 consecutive month period: periodic oral evaluations (D0120), comprehensive oral evaluations (D0150), comprehensive periodontal evaluations (D0180), and oral evaluations for patients under 3 years of age (D0145). The frequency of certain Covered Services, like cleanings, is limited. If your Network General Dentist certifies to Cigna Dental that, due to medical necessity, you require certain Covered Services more frequently than the limitation allows, Cigna Dental will waive the applicable limitation. The relevant Covered Services are identified with a ∆.

D9310 D9430 D9450 D0120 D0140 D0145 D0150

Consultation (diagnostic service provided by dentist or physician other than requesting dentist or physician) Office visit for observation – No other services performed Case presentation – Detailed and extensive treatment planning Periodic oral evaluation – Established patient Limited oral evaluation – Problem focused Oral evaluation for a patient under 3 years of age and counseling with primary caregiver Comprehensive oral evaluation – New or established patient Detailed and extensive oral evaluation - Problem focused, by report (limit 2 per calendar year; only covered in conjunction with Re-evaluation – Limited, problem focused (established patient; not post-operative visit) Re-evaluation – Post-operative office visit Comprehensive periodontal evaluation – New or established patient X-rays intraoral – Complete series of radiographic images (limit 2 every 3 years) ∆ X-rays intraoral – Periapical – First radiographic image

D0160 D0170 D0171 D0180 D0210 D0220 36

$10.00 $5.00 $0.00 $0.00 $0.00 $0.00 $0.00

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00

Dental DHMO Code

Procedure Description

D0230 D0240 D0250 D0251 D0270 D0272 D0273 D0274 D0277 D0330 D0350 D0351

Patient Charge $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

X-rays intraoral – Periapical – Each additional radiographic image X-rays intraoral – Occlusal radiographic image X-rays extraoral – 2D projection radiographic image created using a stationary radiation source, and detector Extra-oral posterior dental radiographic image (limit 1 per calendar year) X-rays (bitewing) – Single radiographic image X-rays (bitewings) – 2 radiographic images X-rays (bitewings) – 3 radiographic images X-rays (bitewings) – 4 radiographic images X-rays (bitewings, vertical) – 7 to 8 radiographic images X-rays (panoramic radiographic image) – (limit 1 every 3 years) ∆ 2D oral/facial photographic images obtained intra-orally or extra-orally 3D photographic image Cone beam CT capture and interpretation for TMJ series including two or more exposures (limit 1 per calendar year; D0368 $240.00 only covered in conjunction with Temporomandibular Joint (TMJ) evaluation) D0415 Collection of microorganisms for culture and sensitivity $0.00 D0425 Caries susceptibility tests $0.00 D0431 Oral cancer screening using a special light source $50.00 D0460 Pulp vitality tests $0.00 D0470 Diagnostic casts $0.00 D0472 Pathology report – Gross examination of lesion (only when tooth related) $0.00 D0473 Pathology report – Microscopic examination of lesion (only when tooth related) $0.00 D0474 Pathology report – Microscopic examination of lesion and area (only when tooth related) $0.00 D0486 Laboratory accession of brush biopsy sample, microscopic examination, preparation and transmission of written report $0.00 D1110 Prophylaxis (cleaning) – Adult (limit 2 per calendar year) ∆ $0.00 Additional prophylaxis (cleaning) – In addition to the 2 prophylaxes (cleanings) allowed per calendar year $45.00 D1120 Prophylaxis (cleaning) – Child (limit 2 per calendar year) ∆ $0.00 Additional prophylaxis (cleaning) – In addition to the 2 prophylaxes (cleanings) allowed per calendar year $35.00 Topical application of fluoride varnish (limit 2 per calendar year). There is a combined limit of a total of 2 D1206s and/ D1206 $0.00 or D1208s per calendar year. ∆ Additional topical application of fluoride varnish in addition to any combination of two (2) D1206s (topical application $15.00 of fluoride varnish) and/or D1208s (topical application of fluoride - excluding varnish) per calendar year Topical application of fluoride - Excluding varnish (limit 2 per calendar year) There is a combined limit of a total of 2 D1208 $0.00 D1208s and/ or D1206s per calendar year. ∆ Additional topical application of fluoride - Excluding varnish - In addition to any combination of two (2) D1206s (topical $15.00 applications of fluoride varnish) and/or D1208s (topical application of fluoride - excluding varnish) per calendar year D1310 Nutritional counseling for control of dental disease $0.00 D1320 Tobacco counseling for the control and prevention of oral disease $0.00 D1330 Oral hygiene instructions $0.00 D1351 Sealant – Per tooth $10.00 D1352 Preventive resin restoration in a moderate to high caries risk patient – Permanent tooth $10.00 D1353 Sealant repair – Per tooth $7.00 D1354 Interim caries arresting medicament application $0.00 D1510 Space maintainer – Fixed – Unilateral $25.00 D1515 Space maintainer – Fixed – Bilateral $25.00 D1520 Space maintainer – Removable – Unilateral $35.00 D1525 Space maintainer – Removable – Bilateral $35.00 D1550 Re-cement or re-bond space maintainer $5.00 D1555 Removal of fixed space maintainer $5.00 D1575 Distal shoe space maintainer – Fixed – Unilateral $28.00 Restorative (fillings, including polishing) D2140 D2150 D2160

Amalgam – 1 surface, primary or permanent Amalgam – 2 surfaces, primary or permanent Amalgam – 3 surfaces, primary or permanent

$0.00 $0.00 $0.00 37

Dental DHMO Code

Procedure Description

Patient Charge D2161 Amalgam – 4 or more surfaces, primary or permanent $0.00 D2330 Resin-based composite – 1 surface, anterior (primary or permanent) $0.00 D2331 Resin-based composite – 2 surfaces, anterior (primary or permanent) $0.00 D2332 Resin-based composite – 3 surfaces, anterior (primary or permanent) $0.00 D2335 Resin-based composite – 4 or more surfaces or involving incisal angle, anterior (primary or permanent) $0.00 D2390 Resin-based composite crown, anterior $35.00 D2391 Resin-based composite – 1 surface, posterior $55.00 D2392 Resin-based composite – 2 surfaces, posterior $65.00 D2393 Resin-based composite – 3 surfaces, posterior $75.00 D2394 Resin-based composite – 4 or more surfaces, posterior $85.00 Crown and bridge – All charges for crowns and bridges (fixed partial dentures) are per unit (each replacement or supporting tooth equals 1 unit).

Coverage for replacement of crowns and bridges is limited to 1 every 5 years.

For single crowns, retainer (“abutment”) crowns, and pontics: The charges below include the cost of predominantly base metal alloy. You may be charged up to these additional amounts, based on the type of material the dentist uses for your restoration: • No more than $150.00 per tooth for any noble metal alloys, high noble metal alloys, titanium or titanium alloys • No more than $75.00 per tooth for any porcelain fused to metal (only on molar teeth) • Porcelain/ceramic substrate crowns on molar teeth are not covered. In addition, you may be charged up to these additional amounts: • No more than $100.00 per tooth if an indirectly fabricated (“cast”) post and core is made of high noble metal alloy • No more than $150.00 per tooth/unit for crowns, inlays, onlays, post and cores, and veneers if your dentist uses same day in-office CAD/CAM (ceramic) services. Same day in-office CAD/CAM (ceramic) services refer to dental restorations that are created in the dental office by the use of a digital impression and an in-office CAD/CAM milling machine. Complex rehabilitation – An additional $125 charge per unit for multiple crown units/ complex rehabilitation (6 or more units of crown and/or bridge in same treatment plan requires complex rehabilitation for each unit – ask your dentist for the guidelines) D2510 Inlay – Metallic – 1 surface $185.00 D2520 Inlay – Metallic – 2 surfaces $185.00 D2530 Inlay – Metallic – 3 or more surfaces $185.00 D2542 Onlay – Metallic – 2 surfaces $185.00 D2543 Onlay – Metallic – 3 surfaces $185.00 D2544 Onlay – Metallic – 4 or more surfaces $185.00 D2610 Inlay – Porcelain/ceramic, 1 surface $185.00 D2620 Inlay – Porcelain/ceramic, 2 surfaces $185.00 D2630 Inlay – Porcelain/ceramic, 3 or more surfaces $185.00 D2642 Onlay – Porcelain/ceramic, 2 surfaces $185.00 D2643 Onlay – Porcelain/ceramic, 3 surfaces $185.00 D2644 Onlay – Porcelain/ceramic, 4 or more surfaces $185.00 D2650 Inlay – Resin-based composite, 1 surface $185.00 D2651 Inlay – Resin-based composite, 2 surfaces $185.00 D2652 Inlay – Resin-based composite, 3 or more surfaces $185.00 D2662 Onlay – Resin-based composite, 2 surfaces $185.00 D2663 Onlay – Resin-based composite, 3 surfaces $185.00 D2664 Onlay – Resin-based composite, 4 or more surfaces $185.00 D2710 Crown – Resin-based composite, indirect $185.00 D2712 Crown – 3/4 resin-based composite, indirect $185.00 D2720 Crown – Resin with high noble metal $185.00 D2721 Crown – Resin with predominantly base metal $185.00 D2722 Crown – Resin with noble metal $185.00 D2740 Crown – Porcelain/ceramic substrate $225.00 D2750 Crown – Porcelain fused to high noble metal $185.00 D2751 Crown – Porcelain fused to predominantly base metal $185.00 D2752 Crown – Porcelain fused to noble metal $185.00 D2780 Crown – 3/4 cast high noble metal $185.00 D2781 Crown – 3/4 cast predominantly base metal $185.00 D2782 Crown – 3/4 cast noble metal $185.00 D2783 Crown – 3/4 porcelain/ceramic $185.00 D2790 38 Crown – Full cast high noble metal $185.00

Dental DHMO Code

D2791 D2792 D2794 D2799 D2910 D2915 D2920 D2929 D2930 D2931 D2932 D2933 D2934 D2940 D2941 D2950 D2951 D2952 D2953 D2954 D2957 D2960 D2971 D2980 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6245 D6250 D6251 D6252 D6253 D6545 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624

Procedure Description

Crown – Full cast predominantly base metal Crown – Full cast noble metal Crown – Titanium Provisional crown Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration Re-cement or re-bond indirectly fabricated or prefabricated post and core Re-cement or re-bond crown Prefabricated porcelain/ceramic crown - Primary tooth Prefabricated stainless steel crown – Primary tooth Prefabricated stainless steel crown – Permanent tooth Prefabricated resin crown Prefabricated stainless steel crown with resin window Prefabricated esthetic coated stainless steel crown – Primary tooth Protective restoration Interim therapeutic restoration - Primary dentition Core buildup – Including any pins Pin retention – Per tooth – In addition to restoration Post and core – In addition to crown, indirectly fabricated Each additional indirectly prefabricated post – Same tooth Prefabricated post and core – In addition to crown Each additional prefabricated post – Same tooth Labial veneer (resin laminate) – Chairside Additional procedures to construct new crown under existing partial denture framework Crown repair, necessitated by restorative material failure Pontic – Cast high noble metal Pontic – Cast predominantly base metal Pontic – Cast noble metal Pontic – Titanium Pontic – Porcelain fused to high noble metal Pontic – Porcelain fused to predominantly base metal Pontic – Porcelain fused to noble metal Pontic – Porcelain/ceramic Pontic – Resin with high noble metal Pontic – Resin with predominantly base metal Pontic – Resin with noble metal Provisional Pontic Retainer – Cast metal for resin bonded fixed prosthesis Retainer inlay – Porcelain/ceramic, 2 surfaces Retainer inlay – Porcelain/ceramic, 3 or more surfaces Retainer inlay – Cast high noble metal, 2 surfaces Retainer inlay – Cast high noble metal, 3 or more surfaces Retainer inlay – Cast predominantly base metal, 2 surfaces Retainer inlay – Cast predominantly base metal, 3 or more surfaces Retainer inlay – Cast noble metal, 2 surfaces Retainer inlay – Cast noble metal, 3 or more surfaces Retainer onlay – Porcelain/ceramic, 2 surfaces Retainer onlay – Porcelain/ceramic, 3 or more surfaces Retainer onlay – Cast high noble metal, 2 surfaces Retainer onlay – Cast high noble metal, 3 or more surfaces Retainer onlay – Cast predominantly base metal, 2 surfaces Retainer onlay – Cast predominantly base metal, 3 or more surfaces Retainer onlay – Cast noble metal, 2 surfaces Retainer onlay – Cast noble metal, 3 or more surfaces Retainer inlay – Titanium

Patient Charge $185.00 $185.00 $185.00 $100.00 $0.00 $0.00 $0.00 $105.00 $25.00 $25.00 $35.00 $35.00 $105.00 $5.00 $5.00 $50.00 $10.00 $50.00 $50.00 $30.00 $30.00 $250.00 $50.00 $15.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 39

Dental DHMO Code

Procedure Description

Patient Charge $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $185.00 $0.00 $195.00

D6634 Retainer onlay – Titanium D6710 Retainer crown – Indirect resin based composite D6720 Retainer crown – Resin with high noble metal D6721 Retainer crown – Resin with predominantly base metal D6722 Retainer crown – Resin with noble metal D6740 Retainer crown – Porcelain/ceramic D6750 Retainer crown – Porcelain fused to high noble metal D6751 Retainer crown – Porcelain fused to predominantly base metal D6752 Retainer crown – Porcelain fused to noble metal D6780 Retainer crown – 3/4 cast high noble metal D6781 Retainer crown – 3/4 cast predominantly base metal D6782 Retainer crown – 3/4 cast noble metal D6783 Retainer crown – 3/4 porcelain/ceramic D6790 Retainer crown – Full cast high noble metal D6791 Retainer crown – Full cast predominantly base metal D6792 Retainer crown – Full cast noble metal D6794 Retainer crown – Titanium D6930 Re-cement or re-bond fixed partial denture D6950 Precision attachment Endodontics (root canal treatment, excluding final restorations) D3110 Pulp cap – Direct (excluding final restoration) $0.00 D3120 Pulp cap – Indirect (excluding final restoration) $0.00 D3220 Pulpotomy – Removal of pulp, not part of a root canal $10.00 D3221 Pulpal debridement (not to be used when root canal is done on the same day) $45.00 D3222 Partial pulpotomy for apexogenesis – Permanent tooth with incomplete root development $17.00 D3230 Pulpal therapy (resorbable filling) – Anterior, primary tooth (excluding final restoration) $30.00 D3240 Pulpal therapy (resorbable filling) – Posterior, primary tooth (excluding final restoration) $35.00 D3310 Anterior root canal – Permanent tooth (excluding final restoration) $80.00 D3320 Bicuspid root canal – Permanent tooth (excluding final restoration) $120.00 D3330 Molar root canal – Permanent tooth (excluding final restoration) $250.00 D3331 Treatment of root canal obstruction – Nonsurgical access $85.00 D3332 Incomplete endodontic therapy – Inoperable, unrestorable or fractured tooth $70.00 D3333 Internal root repair of perforation defects $85.00 D3346 Retreatment of previous root canal therapy – Anterior $135.00 D3347 Retreatment of previous root canal therapy – Bicuspid $175.00 D3348 Retreatment of previous root canal therapy – Molar $280.00 D3351 Apexification/recalcification – Initial visit (apical closure/calcific repair of perforations, root resorption, etc.) $75.00 D3352 Apexification/recalcification – Interim medication replacement (apical closure/calcific repair of perforations, root re- $65.00 sorption, etc.)

D3353 Apexification/recalcification – Final visit (includes completed root canal therapy – Apical closure/calcific repair of per- $65.00 forations, root resorption, etc.)

D3410 Apicoectomy/periradicular surgery – Anterior $95.00 D3421 Apicoectomy/periradicular surgery – Bicuspid (first root) $95.00 D3425 Apicoectomy/periradicular surgery – Molar (first root) $95.00 D3426 Apicoectomy/periradicular surgery (each additional root) $60.00 D3427 Periradicular surgery without apicoectomy $95.00 D3430 Retrograde filling per root $60.00 D3450 Root amputation – Per root $95.00 D3920 Hemisection (including any root removal), not including root canal therapy $90.00 Periodontics (treatment of supporting tissues (gum and bone) of the teeth) - Periodontal regenerative procedures are limited to 1 regenerative procedure per site (or per tooth, if applicable), when covered on the patient charge schedule. The relevant procedure codes are D4263, D4264, D4266 and D4267. Localized delivery of antimicrobial agents is limited to 8 teeth (or 8 sites, if applicable) per 12 consecutive months when covered on the patient charge schedule. If your Network Dentist certifies to Cigna Dental that, due to medical necessity, you require certain Covered Services more frequently than the limitation allows, Cigna Dental will waive the applicable limitation. The relevant Covered Services are identified with 40 a ∆.

Dental DHMO Code

D4210 D4211 D4212 D4240 D4241 D4245 D4249 D4260 D4261 D4263 D4264 D4265 D4266 D4267 D4270 D4273

Procedure Description

Patient Charge $130.00 $80.00 $80.00 $150.00 $115.00 $165.00 $125.00 $295.00 $225.00 $205.00 $95.00 $95.00 $215.00 $255.00 $245.00 $75.00

Gingivectomy or gingivoplasty – 4 or more teeth per quadrant Gingivectomy or gingivoplasty – 1 to 3 teeth per quadrant Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth Gingival flap (including root planing) – 4 or more teeth per quadrant Gingival flap (including root planing) – 1 to 3 teeth per quadrant Apically positioned flap Clinical crown lengthening – Hard tissue Osseous surgery – 4 or more teeth per quadrant Osseous surgery – 1 to 3 teeth per quadrant Bone replacement graft – Retained natural tooth - First site in quadrant Bone replacement graft – Retained natural tooth - Each additional site in quadrant Biologic materials to aid in soft and osseous tissue regeneration Guided tissue regeneration – Resorbable barrier per site Guided tissue regeneration – Nonresorbable barrier per site (includes membrane removal) Pedicle soft tissue graft procedure Autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant or edentulous tooth position D4274 Mesial/distal wedge procedure single tooth (when not performed in conjunction with surgical procedures in the same $70.00 anatomical area) D4275 Non-autogenous connective tissue graft (including recipient site and donor material) first tooth, implant, or edentu- $380.00 lous tooth position in graft D4277 Free soft tissue graft procedure (including recipient and donor surgical sites), first tooth, implant or edentulous $245.00 (missing) tooth position in graft D4278 Free soft tissue graft procedure (including recipient and donor surgical sites), each additional contiguous tooth, im$125.00 plant or edentulous (missing) tooth position in same graft site D4283 Autogenous connective tissue graft procedure (including donor and recipient surgical sites) – Each additional contigu- $38.00 ous tooth, implant or edentulous tooth position in same graft site D4285 Non-autogenous connective tissue graft procedure (including recipient surgical site and donor materials) – Each addi- $190.00 tional contiguous tooth, implant or edentulous tooth position in same graft site D4341 Periodontal scaling and root planing – 4 or more teeth per quadrant (limit 4 quadrants per consecutive 12 months) ∆ $40.00 D4342 Periodontal scaling and root planing – 1 to 3 teeth per quadrant (limit 4 quadrants per consecutive 12 months) ∆ $30.00 D4346 Scaling in presence of generalized moderate or severe gingival inflammation – Full mouth, after oral evaluation (limit 1 $0.00 per calendar year) Additional scaling in presence of generalized moderate or severe gingival inflammation – Full mouth, after oral evalua- $45.00 tion (limit 3 per calendar year) D4355 Full mouth debridement to allow evaluation and diagnosis (1 per lifetime) $40.00 D4381 Localized delivery of antimicrobial agents per tooth $60.00 D4910 Periodontal maintenance (limit 4 per calendar year) (only covered after active therapy) ∆ $30.00 Additional periodontal maintenance procedures (beyond 4 per calendar year) $55.00 Periodontal charting for planning treatment of periodontal disease $0.00 Periodontal hygiene instruction $0.00 Prosthetics (removable tooth replacement – dentures) - Includes up to 4 adjustments within first 6 months after insertion – Replacement limit 1 every 5 years. Characterization is considered an upgrade with maximum additional charge to the member of $200.00 per denture.

D5110 Full upper denture $150.00 D5120 Full lower denture $150.00 D5130 Immediate full upper denture $165.00 D5140 Immediate full lower denture $165.00 D5211 Upper partial denture – Resin base (including clasps, rests and teeth) $150.00 D5212 Lower partial denture – Resin base (including clasps, rests and teeth) $150.00 D5213 Upper partial denture – Cast metal famework (including clasps, rests and teeth) $160.00 D5214 Lower partial denture – Cast metal framework (including clasps, rests and teeth) $160.00 D5221 Immediate maxillary partial denture – Resin base (including any conventional clasps, rests and teeth) $150.00 D5222 Immediate mandibular partial denture – Resin base (including conventional clasps, rests and teeth) $150.00 Immediate maxillary partial denture – Cast metal framework with resin denture base (including any conventional D5223 $160.00 41 clasps, rests and teeth

Dental DHMO Code

Procedure Description

Patient Charge

Immediate mandibular partial denture – Cast metal framework with resin denture bases (including any conventional $160.00 clasps, rests and teeth) D5225 Upper partial denture – Flexible base (including clasps, rests and teeth) $165.00 D5226 Lower partial denture – Flexible base (including clasps, rests and teeth) $165.00 D5281 Removable unilateral partial denture – One piece cast metal including clasps and teeth) $150.00 D5410 Adjust complete denture – Upper $10.00 D5411 Adjust complete denture – Lower $10.00 D5421 Adjust partial denture – Upper $10.00 D5422 Adjust partial denture – Lower $10.00 D5850 Tissue conditioning – Upper $10.00 D5851 Tissue conditioning – Lower $10.00 D5862 Precision attachment – By report $160.00 Repairs to prosthetics D5510 Repair broken complete denture base $30.00 D5520 Replace missing or broken teeth – Complete denture (each tooth) $30.00 D5610 Repair resin denture base $30.00 D5620 Repair cast framework $30.00 D5630 Repair or replace broken clasp - Per tooth $35.00 D5640 Replace broken teeth – Per tooth $30.00 D5650 Add tooth to existing partial denture $30.00 D5660 Add clasp to existing partial denture - Per tooth $35.00 D5670 Replace all teeth and acrylic on cast metal framework – Upper $165.00 D5671 Replace all teeth and acrylic on cast metal framework – Lower $165.00 Denture relining (limit 1 every 36 months) D5710 Rebase complete upper denture $60.00 D5711 Rebase complete lower denture $60.00 D5720 Rebase upper partial denture $60.00 D5721 Rebase lower partial denture $60.00 D5730 Reline complete upper denture – Chairside $35.00 D5731 Reline complete lower denture – Chairside $35.00 D5740 Reline upper partial denture – Chairside $35.00 D5741 Reline lower partial denture – Chairside $35.00 D5750 Reline complete upper denture – Laboratory $60.00 D5751 Reline complete lower denture – Laboratory $60.00 D5760 Reline upper partial denture – Laboratory $60.00 D5761 Reline lower partial denture – Laboratory $60.00 Interim dentures (limit 1 every 5 years) D5810 Interim complete denture – Upper $230.00 D5811 Interim complete denture – Lower $230.00 D5820 Interim partial denture – Upper $75.00 D5821 Interim partial denture – Lower $75.00 Implant/abutment supported prosthetics – All charges for crowns and bridges (fixed partial dentures) are per unit (each replacement on a supporting implant(s) equals 1 unit). Coverage for replacement of crowns and bridges and implant supported dentures is limited to 1 every 5 years.

For single crowns, retainer (“abutment”) crowns, and pontics: The charges below include the cost of predominantly base metal alloy. You may be charged up to these additional amounts, based on the type of material the dentist uses for your restoration: • No more than $150.00 per tooth for any noble metal alloys, high noble metal alloys, titanium or titanium alloys • No more than $75.00 per tooth for any porcelain fused to metal (only on molar teeth) • Porcelain/ceramic substrate crowns on molar teeth are not covered. In addition, you may be charged up to these additional amounts: • No more than $100.00 per tooth if an indirectly fabricated (“cast”) post and core is made of high noble metal alloy • No more than $150.00 per tooth/unit for crowns, inlays, onlays, post and cores, and veneers if your dentist uses same day in-office CAD/CAM (ceramic) services. Same day in-office CAD/CAM (ceramic) services refer to dental restorations that are created in the dental office by the use of a digital impression and an in-office CAD/CAM milling machine. Complex rehabilitation on implant/abutment supported prosthetic procedures – An additional $125 charge per unit for multiple crown units/complex rehabilitation (6 or more units of crown and/or bridge in same treatment plan requires complex rehabilitation for each unit – ask your dentist for the guidelines) D5224

42

Dental DHMO Patient Charge D6058 Abutment supported porcelain/ceramic crown $570.00 D6059 Abutment supported porcelain fused to metal crown (high noble metal) $680.00 D6060 Abutment supported porcelain fused to metal crown (predominantly base metal) $530.00 D6061 Abutment supported porcelain fused to metal crown (noble metal) $680.00 D6062 Abutment supported cast metal crown (high noble metal) $635.00 D6063 Abutment supported cast metal crown (predominantly base metal) $485.00 D6064 Abutment supported cast metal crown (noble metal) $635.00 D6065 Implant supported porcelain/ceramic crown $570.00 D6066 Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) $680.00 D6067 Implant supported metal crown (titanium, titanium alloy, high noble metal) $635.00 D6068 Abutment supported retainer for porcelain/ceramic fixed partial denture $515.00 D6069 Abutment supported retainer for porcelain fused to metal fixed partial denture (high noble metal) $665.00 D6070 Abutment supported retainer for porcelain fused to metal fixed partial denture (predominantly base metal) $515.00 D6071 Abutment supported retainer for porcelain fused to metal fixed partial denture (noble metal) $665.00 D6072 Abutment supported retainer for cast metal fixed partial denture (high noble metal) $635.00 D6073 Abutment supported retainer for cast metal fixed partial denture (predominantly base metal) $485.00 D6074 Abutment supported retainer for cast metal fixed partial denture (noble metal) $635.00 D6075 Implant supported retainer for ceramic fixed partial denture $515.00 D6076 Implant supported retainer for porcelain fused to metal fixed partial denture (titanium, titanium alloy, high noble met- $665.00 al) D6077 Implant supported retainer for cast metal fixed partial denture (titanium, titanium alloy, high noble metal) $635.00 D6085 Provisional implant crown $100.00 D6092 Re-cement implant/abutment supported crown $40.00 D6093 Re-cement implant/abutment supported fixed partial denture $40.00 D6094 Abutment supported crown (titanium) $635.00 D6110 Implant /abutment supported removable denture for edentulous arch – Maxillary $650.00 D6111 Implant /abutment supported removable denture for edentulous arch – Mandibular $650.00 D6112 Implant /abutment supported removable denture for partially edentulous arch – Maxillary $660.00 D6113 Implant /abutment supported removable denture for partially edentulous arch – Mandibular $660.00 D6114 Implant /abutment supported fixed denture for edentulous arch – Maxillary $650.00 D6115 Implant /abutment supported fixed denture for edentulous arch – Mandibular $650.00 D6116 Implant /abutment supported fixed denture for partially edentulous arch – Maxillary $660.00 D6117 Implant /abutment supported fixed denture for partially edentulous arch – Mandibular $660.00 D6194 Abutment supported retainer crown for fixed partial denture (titanium) $635.00 Oral surgery (includes routine postoperative treatment) - Surgical removal of impacted tooth – Not covered for ages below 15 unless pathology (disease) exists.

D7111 Extraction of coronal remnants – Deciduous tooth $5.00 D7140 Extraction, erupted tooth or exposed root – Elevation and/or forceps removal $5.00 D7210 Extraction, erupted tooth – Removal of bone and/or section of tooth $30.00 D7220 Removal of impacted tooth – Soft tissue $50.00 D7230 Removal of impacted tooth – Partially bony $70.00 D7240 Removal of impacted tooth – Completely bony $90.00 D7241 Removal of impacted tooth – Completely bony, unusual complications (narrative required) $110.00 D7250 Removal of residual tooth roots – Cutting procedure $40.00 D7251 Coronectomy - Intentional partial tooth removal $70.00 D7260 Oroantral fistula closure $110.00 D7261 Primary closure of a sinus perforation $110.00 D7270 Tooth stabilization of accidentally evulsed or displaced tooth $85.00 D7280 Exposure of an unerupted tooth (excluding wisdom teeth) $90.00 D7283 Placement of device to facilitate eruption of impacted tooth $90.00 Incisional biopsy of oral tissue – Hard (bone, tooth) (tooth related – not allowed when in conjunction with another D7285 $0.00 surgical procedure) Code

Procedure Description

43

Dental DHMO Code

Procedure Description

Incisional biopsy of oral tissue – Soft (all others) (tooth related – not allowed when in conjunction with another surgical procedure) Exfoliative cytological sample collection Brush biopsy – Transepithelial sample collection Alveoloplasty in conjunction with extractions – 4 or more teeth or tooth spaces per quadrant Alveoloplasty in conjunction with extractions – 1 to 3 teeth or tooth spaces per quadrant Alveoloplasty not in conjunction with extractions – 4 or more teeth or tooth spaces per quadrant Alveoloplasty not in conjunction with extractions – 1 to 3 teeth or tooth spaces per quadrant Removal of benign odontogenic cyst or tumor – Up to 1.25 cm Removal of benign odontogenic cyst or tumor – Greater than 1.25 cm Removal of lateral exostosis – Maxilla or mandible Removal of torus palatinus Removal of torus mandibularis Reduction of osseous tuberosity Incision and drainage of abscess – Intraoral soft tissue Incision and drainage of abscess – Intraoral soft tissue complicated Incision and drainage of abscess – Extraoral soft tissue Incision and drainage of abscess – Extraoral soft tissue – Complicated (includes drainage of multiple fascial spaces)

D7286 D7287 D7288 D7310 D7311 D7320 D7321 D7450 D7451 D7471 D7472 D7473 D7485 D7510 D7511 D7520 D7521

Patient Charge $0.00 $50.00 $50.00 $50.00 $50.00 $70.00 $70.00 $0.00 $0.00 $80.00 $60.00 $60.00 $60.00 $30.00 $30.00 $30.00 $30.00

Occlusal orthotic device, by report - (limit 1 per 24 months; only covered in conjunction with Temporomandibular $160.00 Joint (TMJ) treatment) D7881 Occlusal orthotic device adjustment $10.00 D7910 Suture of recent small wounds up to 5cm $25.00 D7960 Frenulectomy – Also known as frenectomy or frenotomy – Separate procedure not incidental to another procedure $40.00 D7963 Frenuloplasty $40.00 Orthodontics (tooth movement) - Orthodontic treatment (Maximum benefit of 24 months of interceptive and/or comprehensive treatment. Atypical cases or cases beyond 24 months require an additional payment by the patient.)

D8050 Interceptive orthodontic treatment of the primary dentition – Banding $400.00 D8060 Interceptive orthodontic treatment of the transitional dentition – Banding $400.00 D8070 Comprehensive orthodontic treatment of the transitional dentition – Banding $400.00 D8080 Comprehensive orthodontic treatment of the adolescent dentition – Banding $400.00 D8090 Comprehensive orthodontic treatment of the adult dentition – Banding $400.00 D8210 Removable appliance therapy $0.00 D8220 Fixed appliance therapy $0.00 D8660 Pre-orthodontic treatment examination to monitor growth and development $125.00 D8670 Periodic orthodontic treatment visit Children – Up to 19th birthday: 24-month treatment fee $1,344.00 Charge per month for 24 months $56.00 Adults: 24-month treatment fee $1,944.00 Charge per month for 24 months $81.00 D8680 Orthodontic retention – Removal of appliances, construction and placement of retainer(s) $275.00 D8681 Removable orthodontic retainer adjustment $0.00 D8693 Re-cement or re-bond fixed retainer $0.00 D8694 Repair of fixed retainers, includes reattachment $0.00 D8999 Unspecified orthodontic procedure – By report (orthodontic treatment plan and records) $270.00 General anesthesia/IV sedation – General anesthesia is covered when performed by an oral surgeon when medically necessary for covered procedures listed on the Patient Charge Schedule. IV sedation is covered when performed by a periodontist or oral surgeon when medically necessary for covered procedures listed on the Patient Charge Schedule. There is no coverage for general anesthesia or IV sedation when used for the purpose of anxiety control or patient management.

D9211 Regional block anesthesia $0.00 D9212 Trigeminal division block anesthesia $0.00 D9215 Local anesthesia $0.00 D7880

44

Dental DHMO Code

Procedure Description

Patient Charge $80.00 $80.00 $15.00 $25.00 $15.00 $15.00

D9223 Deep sedation/general anesthesia – Each 15 minute increment D9243 Intravenous moderate (conscious) sedation/analgesia – Each 15 minute increment D9610 Therapeutic parenteral drug, single administration D9612 Therapeutic parenteral drugs, 2 or more administrations, different medications D9630 Drugs or medicaments dispensed in the office for home use D9910 Application of desensitizing medicament Emergency services D9110 Palliative (emergency) treatment of dental pain – Minor procedure $5.00 D9120 Fixed partial denture sectioning $0.00 D9440 Office visit – After regularly scheduled hours $30.00 Miscellaneous services D9940 Occlusal guard – By report (limit 1 per 24 months) $100.00 D9941 Fabrication of athletic mouthguard (limit 1 per 12 months) $110.00 D9942 Repair and/or reline of occlusal guard $40.00 D9943 Occlusal guard adjustment $0.00 D9951 Occlusal adjustment – Limited $35.00 D9952 Occlusal adjustment – Complete $55.00 External bleaching for home application, per arch; includes materials and fabrication of custom trays (all other methD9975 $125.00 ods of bleaching are not covered) This may contain CDT Dental Procedure Codes and/or portions of, or excerpts from the Code on Dental Procedures and Nomenclature (CDT Code) contained within the current version of the “Dental Procedure Codes”, a copyrighted publication provided by the American Dental Association. The American Dental Association does not endorse any codes which are not included in its current publication.

After your enrollment is effective: Call the dental office identified in your Welcome Kit. If you wish to change dental offices, a transfer can be arranged at no charge by calling Cigna Dental at the toll free number listed on your ID card or plan materials.

Multiple ways to locate a (*DHMO) Network General Dentist:  Online provider directory at Cigna.com  Online provider directory on myCigna.com  Call the number located on your ID card to: • Use the Dental Office Locator via Speech Recognition • Speak to a Customer Service Representative EMERGENCY: If you have a dental emergency as defined in your group’s plan documents, contact your Network General Dentist as soon as possible. If you are out of your service area or unable to contact your Network Office, emergency care can be rendered by any dental office, dental clinic, or other comparable facility. Definitive treatment (e.g., root canal) is not considered emergency care and should be performed or referred by your Network General Dentist. Consult your group’s plan documents for a complete definition of dental emergency, your emergency benefit and a listing of Exclusions and Limitations.

* The term “DHMO” is used to refer to product designs that may differ by state of residence of enrollee, including but not limited to, prepaid plans, managed care plans, and plans with open access features. “Cigna,” “Cigna Dental Care” and the “Tree of Life” logo are registered service marks, of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company (“CGLIC”), Cigna Health and Life Insurance Company (“CHLIC”), Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. (“CDHI”) and its subsidiaries. The Cigna Dental Care plan is provided by Cigna Dental Health Plan of Arizona, Inc.; Cigna Dental Health of California, Inc.; Cigna Dental Health of Colorado, Inc.; Cigna Dental Health of Delaware, Inc.; Cigna Dental Health of Florida, Inc., a Prepaid Limited Health Services Organization licensed under Chapter 636, Florida Statutes; Cigna Dental Health of Kansas, Inc. (Kansas and Nebraska); Cigna Dental Health of Kentucky, Inc. (Kentucky and Illinois); Cigna Dental Health of Maryland, Inc.; Cigna Dental Health of Missouri, Inc.; Cigna Dental Health of New Jersey, Inc.; Cigna Dental Health of North Carolina, Inc.; Cigna Dental Health of Ohio, Inc.; Cigna Dental Health of Pennsylvania, Inc.; Cigna Dental Health of Texas, Inc.; and Cigna Dental Health of Virginia, Inc. In other states, the Cigna Dental Care plan is underwritten by CGLIC, CHLIC, or Cigna HealthCare of Connecticut, Inc., and administered by CDHI. 863997 b 07/17 © 2017 Cigna. Some content provided under license.

45

SUPERIOR

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

Vision Benefits Exam (ophthalmologist) Exam (optometrist) Frames Contact Lens Fitting (standard₂) Contact Lens Fitting (specialty₂) Progressive Lens Upgrade Contact Lenses4

In-Network

Out-of-Network

Covered in full

Up to $42 retail

EE Only

$7.18

Covered in full $130 retail allowance

Up to $37 retail Up to $68 retail

EE + 1 Dependent

$13.94

EE + Family

$20.47

Covered in full

Not Covered

$50 retail allowance

Not Covered

See description

3

Up to $61 retail

$150 retail allowance Up to $100 retail

Lenses (standard) per pair Single Vision Bifocal Trifocal

Covered in full Covered in full Covered in full

Up to $32 retail Up to $46 retail Up to $61 retail

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

Monthly Premiums

Co-Pays Exam Materials

$10 ₁

$25

Contact Lens Fitting (standard & specialty)

$0

Services/Frequency Exam

12 months

Frame

12 months

Contact Lens Fitting

12 months

Lenses

12 months

Contact Lenses

12 months

1

Materials co-pay applies to lenses and frames only, not contact lenses 2 The specialty contact lens fitting is for new contact lens wearers and/or a member who wears toric, gas permeable, or multifocal lenses.

3 Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay 4 Contact lenses are in lieu of eyeglass lenses and frames benefit

SuperiorVision.com Customer Service 800.507.3800

Discount Features Look for providers in the Provider Directory who accept discounts, as some do not; please verify their services and discounts (range from 10%-40%) prior to service as they vary.

Discounts on Covered Materials Frames: 20% off amount over allowance Lens options: 20% off retail Progressives: 20% off amount over retail lined trifocal lens, including lens options The following options have out-of-pocket maximums5 on standard (not premium, brand, or progressive) lenses.

5

Discounts and maximums may vary by lens type. Please check with your provider.

Ultraviolet coat Tints, solid or gradients Anti-reflective coat Polycarbonate High index 1.6 Photochromics

Maximum Member Out-of-Pocket Single Vision Bifocal & Trifocal $15 $15 $25 $25 $50 $50 $40 20% off retail $55 20% off retail $80 20% off retail

Discounts on Non-Covered Exam and Materials Exams, frames, and prescription lenses: 30% off retail Lens options, contacts, other prescription materials: 20% off retail Disposable contact lenses: 10% off retail Refractive Surgery Superior Vision has a nationwide network of refractive surgeons and leading LASIK networks who offer members a discount. These discounts range from 5%-50%, and are the best possible discounts available to Superior Vision.

The Plan discount features are not insurance.

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

Discounts are subject to change without notice.

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

Superior Vision Services, Inc. P.O. Box 967 Rancho Cordova, CA 95741 800.507.3800 SuperiorVision.com The Superior Vision Plan is 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 NVIGRP 5-07 1017-BSv2/TX

47

THE STANDARD 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 48 details on covered expenses, limitations and exclusions are included in the summary plan description located on the HEB ISD Benefits Website: www.mybenefitshub.com/hebisd

Long Term Disability Voluntary Long Term Disability Insurance Standard Insurance Company has developed this document to provide you with information about the optional insurance coverage you may select through the Hurst Euless Bedford Independent School District. Written in non- technical language, this is not intended as a complete description of the coverage. If you have additional questions, please check with your human resources representative.

Employer Plan Effective Date The group policy effective date is September 1, 2011.

Eligibility To become insured, you must be: • A regular employee of the Hurst Euless Bedford Independent School District, excluding temporary or seasonal employees, fulltime members of the armed forces, leased employees or independent contractors • Actively at work at least 20 hours each week • A citizen or resident of the United States or Canada

Employee Coverage Effective Date Please contact your human resources representative for more information regarding the following requirements that must be satisfied for your insurance to become effective. You must satisfy: • Eligibility requirements • An eligibility waiting period of the first day of the month that follows the date you become an eligible employee • An evidence of insurability requirement, if applicable • An active work requirement. This means that if you are not actively at work on the day before the scheduled effective date of insurance, your insurance will not become effective until the day after you complete one full day of active work as an eligible employee.

Benefit Amount You may select a monthly benefit amount in $100 increments from $200 to $11,000; based on the tables and guidelines presented in the Rates section of these Coverage Highlights. The monthly benefit amount must not exceed 66 2/3 percent of your monthly earnings.

Benefits are payable for non-occupational disabilities only. Occupational disabilities are not covered. Plan Maximum Monthly Benefit: 66 2/3 percent of predisability earnings Plan Minimum Monthly Benefit: 10 percent of your LTD benefit before reduction by deductible income

Benefit Waiting Period and Maximum Benefit Period The benefit waiting period is the period of time that you must be continuously disabled before benefits become payable. Benefits are not payable during the benefit waiting period. The maximum benefit period is the period for which benefits are payable. The benefit waiting period and maximum benefit period associated with your plan options are shown below: Option 1 2 3 4 5 6

Accidental Injury 0 days 14 days 30 days 60 days 90 days 180 days

Options 1-6: Maximum Benefit Period To Age 65 for Sickness and Accident If you become disabled before age 62, LTD benefits may continue during disability until you reach age 65. If you become disabled at age 62 or older, the benefit duration is determined by your age when disability begins:

Other Disability 7 days 14 days 30 days 60 days 90 days 180 days

Maximum Benefit Period To Age 65 for both Sickness and Accident To Age 65 for both Sickness and Accident To Age 65 for both Sickness and Accident To Age 65 for both Sickness and Accident To Age 65 for both Sickness and Accident To Age 65 for both Sickness and Accident

Age

Maximum Benefit Period

Age

Maximum Benefit Period

62

3 years 6 months

66

1 year 9 months

63

3 years

67

1 year 6 months

64

2 years 6 months

68

1 year 3 months

65

2 years

69+

1 year 49

Long Term Disability First Day Hospital Benefit With this benefit, if an insured employee is admitted as a hospital • inpatient for at least four hours during the Benefit Waiting Period, the Benefit Waiting Period will be satisfied. Benefits become payable on the date of hospitalization; the maximum benefit period also begins on that date. This feature is included only on LTD plans with Benefit Waiting Periods of 30 days or less.

exceed 100 percent of predisability earnings. After that period, only 50 percent of work earnings are deducted.

Rehabilitation Plan Provision – Subject to The Standard’s prior approval, rehabilitation incentives may include training and education expense, family (child and elder) care expenses, and job-related and job search expenses.

When Benefits End

Preexisting Condition Exclusion A general description of the preexisting condition exclusion is included in the Group Voluntary Long Term Disability Insurance for Educators and Administrators brochure. If you have questions, please check with your human resources representative.

Preexisting Condition Period: The 90-day period just before your insurance becomes effective Exclusion Period: 12 months

Preexisting Condition Waiver For the first 45 days of disability, The Standard will pay full benefits even if you have a preexisting condition. After 45 days, The Standard will continue benefits only if the preexisting condition exclusion does not apply.

Own Occupation Period For the plan’s definition of disability, as described in your brochure, the own occupation period is the first 12 months for which LTD benefits are paid.

Any Occupation Period The any occupation period begins at the end of the own occupation period and continues until the end of the maximum benefit period.

Other LTD Features • •

•

• •

Employee Assistance Program (EAP) – This program offers support, guidance and resources that can help an employee resolve personal issues and meet life’s challenges.

Special Dismemberment Provision – If an employee suffers a lost as a result of an accident, the employee will be considered disabled for the applicable Minimum Benefit Period and can extend beyond the end of the Maximum Benefit Period Reasonable Accommodation Expense Benefit – Subject to The Standard’s prior approval, this benefit allows us to pay up to $25,000 of an employer’s expenses toward work-site modifications that result in a disabled employee’s return to work.

Survivor Benefit – A Survivor Benefit may also be payable.

This benefit can help to address a family’s financial need in the event of the employee’s death.

Return to Work (RTW) Incentive – The Standard’s RTW Incentive is one of the most comprehensive in the employee benefits history. For the first 12 months after returning to work, the employee’s LTD benefit will not be reduced by work earnings until work earnings plus the LTD benefit 50

LTD benefits end automatically on the earliest of: • The date you are no longer disabled • The date your maximum benefit period ends • The date you die • The date benefits become payable under any other LTD plan under which you become insured through employment during a period of temporary recovery • The date you fail to provide proof of continued disability and entitlement to benefits

Rates Employees can select a monthly LTD benefit ranging from a minimum of $200 to a maximum amount based on how much they earn. Referencing the appropriate attached charts, follow these steps to find the monthly cost for your desired level of monthly LTD benefit and benefit waiting period: 1. Find the maximum LTD benefit by locating the amount of your earnings in either the Annual Earnings or Monthly Earnings column. The LTD benefit amount shown associated with these earnings is the maximum amount you can receive. If your earnings fall between two amounts, you must select the lower amount.

2. Select the desired monthly LTD benefit between the minimum of $200 and the determined maximum amount, making sure not to exceed the maximum for your earnings.

3. In the same row, select the desired benefit waiting period to see the monthly cost for that selection.

If you have questions regarding how to determine your monthly LTD benefit, the benefit waiting period, or the premium payment of your desired benefit, please contact your human resources representative.

Group Insurance Certificate If you become insured, you will receive a group insurance certificate containing a detailed description of the insurance coverage. The information presented above is controlled by the group policy and does not modify it in any way. The controlling provisions are in the group policy issued by Standard Insurance Company.

Long Term Disability Options 1-6: Maximum Benefit Period To Age 65 for both Sickness & Accident 0-7

14-14

30-30

60-60

90-90

180-180

300

Monthly Disability Benefit 200

9.74

7.78

6.76

4.38

3.80

2.94

5,400

450

300

14.61

11.67

10.14

6.57

5.70

4.41

7,200

600

400

19.48

15.56

13.52

8.76

7.60

5.88

9,000

750

500

24.35

19.45

16.90

10.95

9.50

7.35

10,800

900

600

29.22

23.34

20.28

13.14

11.40

8.82

12,600

1,050

700

34.09

27.23

23.66

15.33

13.30

10.29

14,400

1,200

800

38.96

31.12

27.04

17.52

15.20

11.76

16,200

1,350

900

43.83

35.01

30.42

19.71

17.10

13.23

18,000

1,500

1,000

48.70

38.90

33.80

21.90

19.00

14.70

19,800

1,650

1,100

53.57

42.79

37.18

24.09

20.90

16.17

21,600

1,800

1,200

58.44

46.68

40.56

26.28

22.80

17.64

23,400

1,950

1,300

63.31

50.57

43.94

28.47

24.70

19.11

25,200

2,100

1,400

68.18

54.46

47.32

30.66

26.60

20.58

27,000

2,250

1,500

73.05

58.35

50.70

32.85

28.50

22.05

28,800

2,400

1,600

77.92

62.24

54.08

35.04

30.40

23.52

30,600

2,550

1,700

82.79

66.13

57.46

37.23

32.30

24.99

32,400

2,700

1,800

87.66

70.02

60.84

39.42

34.20

26.46

34,200

2,850

1,900

92.53

73.91

64.22

41.61

36.10

27.93

36,000

3,000

2,000

97.40

77.80

67.60

43.80

38.00

29.40

37,800

3,150

2,100

102.27

81.69

70.98

45.99

39.90

30.87

39,600

3,300

2,200

107.14

85.58

74.36

48.18

41.80

32.34

41,400

3,450

2,300

112.01

89.47

77.74

50.37

43.70

33.81

43,200

3,600

2,400

116.88

93.36

81.12

52.56

45.60

35.28

45,000

3,750

2,500

121.75

97.25

84.50

54.75

47.50

36.75

46,800

3,900

2,600

126.62

101.14

87.88

56.94

49.40

38.22

48,600

4,050

2,700

131.49

105.03

91.26

59.13

51.30

39.69

50,400

4,200

2,800

136.36

108.92

94.64

61.32

53.20

41.16

52,200

4,350

2,900

141.23

112.81

98.02

63.51

55.10

42.63

54,000

4,500

3,000

146.10

116.70

101.40

65.70

57.00

44.10

55,800

4,650

3,100

150.97

120.59

104.78

67.89

58.90

45.57

57,600

4,800

3,200

155.84

124.48

108.16

70.08

60.80

47.04

59,400

4,950

3,300

160.71

128.37

111.54

72.27

62.70

48.51

61,200

5,100

3,400

165.58

132.26

114.92

74.46

64.60

49.98

63,000

5,250

3,500

170.45

136.15

118.30

76.65

66.50

51.45

64,800

5,400

3,600

175.32

140.04

121.68

78.84

68.40

52.92

66,600

5,550

3,700

180.19

143.93

125.06

81.03

70.30

54.39

68,400

5,700

3,800

185.06

147.82

128.44

83.22

72.20

55.86

70,200

5,850

3,900

189.93

151.71

131.82

85.41

74.10

57.33

72,000

6,000

4,000

194.80

155.60

135.20

87.60

76.00

58.80

Annual Earnings

Monthly Earnings

3,600

Accident/Sickness Benefit Waiting Period Cost Per Month

51

Long Term Disability Options 1-6: Maximum Benefit Period To Age 65 for both Sickness & Accident

52

0-7

14-14

30-30

60-60

90-90

180-180

6,150

Monthly Disability Benefit 4,100

199.67

159.49

138.58

89.79

77.90

60.27

6,300

4,200

204.54

163.38

141.96

91.98

79.80

61.74

77,400

6,450

4,300

209.41

167.27

145.34

94.17

81.70

63.21

79,200

6,600

4,400

214.28

171.16

148.72

96.36

83.60

64.68

81,000

6,750

4,500

219.15

175.05

152.10

98.55

85.50

66.15

82,800

6,900

4,600

224.02

178.94

155.48

100.74

87.40

67.62

84,600

7,050

4,700

228.89

182.83

158.86

102.93

89.30

69.09

86,400

7,200

4,800

233.76

186.72

162.24

105.12

91.20

70.56

88,200

7,350

4,900

238.63

190.61

165.62

107.31

93.10

72.03

90,000

7,500

5,000

243.50

194.50

169.00

109.50

95.00

73.50

91,800

7,650

5,100

248.37

198.39

172.38

111.69

96.90

74.97

93,600

7,800

5,200

253.24

202.28

175.76

113.88

98.80

76.44

95,400

7,950

5,300

258.11

206.17

179.14

116.07

100.70

77.91

97,200

8,100

5,400

262.98

210.06

182.52

118.26

102.60

79.38

99,000

8,250

5,500

267.85

213.95

185.90

120.45

104.50

80.85

100,800

8,400

5,600

272.72

217.84

189.28

122.64

106.40

82.32

102,600

8,550

5,700

277.59

221.73

192.66

124.83

108.30

83.79

104,400

8,700

5,800

282.46

225.62

196.04

127.02

110.20

85.26

106,200

8,850

5,900

287.33

229.51

199.42

129.21

112.10

86.73

108,000

9,000

6,000

292.20

233.40

202.80

131.40

114.00

88.20

109,800

9,150

6,100

297.07

237.29

206.18

133.59

115.90

89.67

111,600

9,300

6,200

301.94

241.18

209.56

135.78

117.80

91.14

113,400

9,450

6,300

306.81

245.07

212.94

137.97

119.70

92.61

115,200

9,600

6,400

311.68

248.96

216.32

140.16

121.60

94.08

117,000

9,750

6,500

316.55

252.85

219.70

142.35

123.50

95.55

118,800

9,900

6,600

321.42

256.74

223.08

144.54

125.40

97.02

120,600

10,050

6,700

326.29

260.63

226.46

146.73

127.30

98.49

122,400

10,200

6,800

331.16

264.52

229.84

148.92

129.20

99.96

124,200

10,350

6,900

336.03

268.41

233.22

151.11

131.10

101.43

126,000

10,500

7,000

340.90

272.30

236.60

153.30

133.00

102.90

127,800

10,650

7,100

345.77

276.19

239.98

155.49

134.90

104.37

129,600

10,800

7,200

350.64

280.08

243.36

157.68

136.80

105.84

131,400

10,950

7,300

355.51

283.97

246.74

159.87

138.70

107.31

133,200

11,100

7,400

360.38

287.86

250.12

162.06

140.60

108.78

135,000

11,250

7,500

365.25

291.75

253.50

164.25

142.50

110.25

136,800

11,400

7,600

370.12

295.64

256.88

166.44

144.40

111.72

138,600

11,550

7,700

374.99

299.53

260.26

168.63

146.30

113.19

140,400

11,700

7,800

379.86

303.42

263.64

170.82

148.20

114.66

142,200

11,850

7,900

384.73

307.31

267.02

173.01

150.10

116.13

144,000

12,000

8,000

389.60

311.20

270.40

175.20

152.00

117.60

Annual Earnings

Monthly Earnings

73,800 75,600

Accident/Sickness Benefit Waiting Period Cost Per Month

Long Term Disability Options 1-6: Maximum Benefit Period To Age 65 for both Sickness & Accident 0-7

14-14

30-30

60-60

90-90

180-180

12,150

Monthly Disability Benefit 8,100

394.47

315.09

273.78

177.39

153.90

119.07

147,600

12,300

8,200

399.34

318.98

277.16

179.58

155.80

120.54

149,400

12,450

8,300

404.21

322.87

280.54

181.77

157.70

122.01

151,200

12,600

8,400

409.08

326.76

283.92

183.96

159.60

123.48

153,000

12,750

8,500

413.95

330.65

287.30

186.15

161.50

124.95

154,800

12,900

8,600

418.82

334.54

290.68

188.34

163.40

126.42

156,600

13,050

8,700

423.69

338.43

294.06

190.53

165.30

127.89

158,400

13,200

8,800

428.56

342.32

297.44

192.72

167.20

129.36

160,200

13,350

8,900

433.43

346.21

300.82

194.91

169.10

130.83

162,000

13,500

9,000

438.30

350.10

304.20

197.10

171.00

132.30

163,800

13,650

9,100

443.17

353.99

307.58

199.29

172.90

133.77

165,600

13,800

9,200

448.04

357.88

310.96

201.48

174.80

135.24

167,400

13,950

9,300

452.91

361.77

314.34

203.67

176.70

136.71

169,200

14,100

9,400

457.78

365.66

317.72

205.86

178.60

138.18

171,000

14,250

9,500

462.65

369.55

321.10

208.05

180.50

139.65

172,800

14,400

9,600

467.52

373.44

324.48

210.24

182.40

141.12

174,600

14,550

9,700

472.39

377.33

327.86

212.43

184.30

142.59

176,400

14,700

9,800

477.26

381.22

331.24

214.62

186.20

144.06

178,200

14,850

9,900

482.13

385.11

334.62

216.81

188.10

145.53

180,000

15,000

10,000

487.00

389.00

338.00

219.00

190.00

147.00

181,800

15,150

10,100

491.87

392.89

341.38

221.19

191.90

148.47

183,600

15,300

10,200

496.74

396.78

344.76

223.38

193.80

149.94

185,400

15,450

10,300

501.61

400.67

348.14

225.57

195.70

151.41

187,200

15,600

10,400

506.48

404.56

351.52

227.76

197.60

152.88

189,000

15,750

10,500

511.35

408.45

354.90

229.95

199.50

154.35

190,800

15,900

10,600

516.22

412.34

358.28

232.14

201.40

155.82

192,600

16,050

10,700

521.09

416.23

361.66

234.33

203.30

157.29

194,400

16,200

10,800

525.96

420.12

365.04

236.52

205.20

158.76

196,200

16,350

10,900

530.83

424.01

368.42

238.71

207.10

160.23

198,000

16,500

11,000

535.70

427.90

371.80

240.90

209.00

161.70

Annual Earnings

Monthly Earnings

145,800

Accident/Sickness Benefit Waiting Period Cost Per Month

SI 14494-648769

53

UNUM

Critical Illness

YOUR BENEFITS PACKAGE

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

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

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

Critical Illness Critical Illness insurance provides financial protection by paying a lump sum benefit if you are diagnosed with a covered critical illness.

Who is eligible for this coverage?

All employees in active employment in the United States working at least 20 hours per week and their eligible spouses and children (up to age 26 regardless of student or marital status).

What are the Critical Illness coverage amounts?

The following coverage amounts are available.

For you: Select one of the following Choice $10,000, $20,000 or $30,000 For your Spouse: 100% of employee coverage amount For your Children: 100% of employee coverage amount

Can I be denied coverage?

Coverage is guarantee issue.

When is coverage effective?

Please see your Plan Administrator for your effective date of coverage.

Insurance coverage will be delayed if you are not in active employment because of an injury, sickness, temporary layoff, or leave of absence on the date that insurance would otherwise become effective.

What critical illness conditions are covered?

Covered Conditions* Percentage of Coverage Amount Critical Illnesses Coronary Artery Disease (major) 50% Coronary Artery Disease (minor) 10% End Stage Renal (Kidney) Failure 100% Heart Attack (Myocardial Infarction) 100% Major Organ Failure Requiring Transplant 100% Stroke 100% Cancer Invasive Cancer (including all Breast Cancer) 100% Non-Invasive Cancer 25% Skin Cancer $500 Supplemental Critical Illnesses Benign Brain Tumor 100% Coma 100% Loss of Hearing 100% Loss of Sight 100% Loss of Speech 100% Infectious Disease 25% Occupational Human Immunodeficiency Virus (HIV) or Hepatitis 100% Permanent Paralysis 100% Progressive Diseases Amyotrophic Lateral Sclerosis (ALS) 100% Dementia (including Alzheimer’s Disease) 100% Functional Loss 100% Multiple Sclerosis (MS) 100% Parkinson’s Disease 100% Additional Critical Illnesses for your Children Cerebral Palsy 100% Cleft Lip or Palate 100% Cystic Fibrosis 100% Down Syndrome 100% Spina Bifida 100% *Please refer to the policy for complete definitions of covered conditions.

Covered Condition Benefit The covered condition benefit is payable once per covered condition per insured.

Unum will pay a covered condition benefit for a different covered condition if: • the new covered condition is medically unrelated to the first covered condition; or • the dates of diagnosis are separated by more than 180 days.

55

Critical Illness Reoccurring Condition Benefit We will pay the reoccurring condition benefit for the diagnosis of the same covered condition if the covered condition benefit was previously paid and the new date of diagnosis is more than 180 days after the prior date of diagnosis.

The benefit amount for any reoccurring condition benefit is 100% of the percentage of coverage amount for that condition.

The following Covered Conditions are eligible for a reoccurring condition benefit:

• • • • • Are wellness screenings covered?

Benign Brain Tumor Coma Coronary Artery Disease (Major) Coronary Artery Disease (Minor) End Stage Renal (Kidney) Failure

• • • • •

Heart Attack (Myocardial Infarction) Invasive Cancer (includes all Breast Cancer) Major Organ Failure Requiring Transplant Non-Invasive Cancer Stroke

Each insured is eligible to receive one Be Well Benefit per calendar year.

Be Well Benefit For you, your spouse and your children: $100 If the employee’s Critical Illness Coverage Amount is: • $10,000 • $20,000 • $30,000

The Be Well Benefit Amount for you, your spouse and your children is: $100 $100 $100

Be Well Screenings include tests for the following: cholesterol and diabetes, cancer and cardiovascular function. They also include imaging studies, immunizations and annual examinations by a Physician. See certificate for details.

How much does the coverage cost?

56

Option 1: $10,000 EE, $10,000 SP, $100 Be Well Benefit Age Employee Cost Spouse Cost Less than age 25 $7.12 $7.12 25-29 $8.02 $8.02 30-34 $9.12 $9.12 35-39 $11.02 $11.02 40-44 $13.32 $13.32 45-49 $16.32 $16.32 50-54 $19.82 $19.82 55-59 $25.52 $25.52 60-64 $34.02 $34.02 65-69 $47.62 $47.62 70-74 $71.92 $71.92 75-79 $104.12 $104.12 80-84 $149.62 $149.62 85 or over $238.62 $238.62 Option 2: $20,000 EE, $20,000 SP, $100 Be Well Benefit Age Employee Cost Spouse Cost Less than age 25 $9.22 $9.22 25-29 $11.02 $11.02 30-34 $13.22 $13.22 35-39 $17.02 $17.02 40-44 $21.62 $21.62 45-49 $27.62 $27.62 50-54 $34.62 $34.62 55-59 $46.02 $46.02 60-64 $63.02 $63.02 65-69 $90.22 $90.22 70-74 $138.82 $138.82 75-79 $203.22 $203.22 80-84 $294.22 $294.22 85 or over $472.22 $472.22

Option 3: $30,000 EE, $30,000 SP, $100 Be Well Benefit Age Employee Cost Spouse Cost Less than age 25 $11.32 $11.32 25-29 $14.02 $14.02 30-34 $17.32 $17.32 35-39 $23.02 $23.02 40-44 $29.92 $29.92 45-49 $38.92 $38.92 50-54 $49.42 $49.42 55-59 $66.52 $66.52 60-64 $92.02 $92.02 65-69 $132.82 $132.82 70-74 $205.72 $205.72 75-79 $302.32 $302.32 80-84 $438.82 $438.82 85 or over $705.82 $705.82

Your rate is based on your insurance age, which is your age immediately prior to and including the anniversary/ effective date.

Spouse rate is based on the Employee’s insurance age, which is their age immediately prior to and including the anniversary/effective date .

Critical Illness Do my critical illness insurance benefits decrease with age?

Critical Illness benefits do not decrease due to age.

Are there any exclusions or limitations?

We will not pay benefits for a claim that is caused by, contributed to by, or occurs as a result of any of the following: • committing or attempting to commit a felony; • being engaged in an illegal occupation or activity; • injuring oneself intentionally or attempting or committing suicide, whether sane or not; • active participation in a riot, insurrection, or terrorist activity. This does not include civil commotion or disorder, injury as an innocent bystander, or Injury for self-defense; • participating in war or any act of war, whether declared or undeclared; • combat or training for combat while serving in the armed forces of any nation or authority, including the National Guard, or similar government organizations; • voluntary use of or treatment for voluntary use of any prescription or nonprescription drug, alcohol, poison, fume, or other chemical substance unless taken as prescribed or directed by the Insured’s Physician; • being intoxicated; and • a Date of Diagnosis that occurs while an Insured is legally incarcerated in a penal or correctional institution.

Additionally, no benefits will be paid for a Date of Diagnosis that occurs prior to the coverage effective date.

Pre-existing Conditions We will not pay benefits for a claim when the covered loss occurs in the first 12 months following an insured’s coverage effective date and the covered loss is caused by, contributed to by, or occurs as a result of any of the following: • a pre-existing condition; or • complications arising from treatment or surgery for, or medications taken for, a pre-existing condition.

An insured has a pre-existing condition if, within the 3 months just prior to their coverage effective date, they have an injury or sickness, whether diagnosed or not, for which: • medical treatment, consultation, care or services, or diagnostic measures were received or recommended to be received during that period; • drugs or medications were taken, or prescribed to be taken during that period; or • symptoms existed.

The pre-existing condition provision applies to any Insured’s initial coverage and any increases in coverage. Coverage effective date refers to the date any initial coverage or increases in coverage become effective.

Is the coverage portable (can I keep it if I leave my employer)?

If you have been insured for at least 12 months and your employment with your employer ends or you are no longer in an eligible group you can apply for ported coverage and pay the first premium within 31 days to continue coverage for yourself, your spouse and your children.

If your spouse’s coverage ends as a result of your death, divorce or annulment, your spouse may elect to continue spouse and children coverage, as long as premium is paid as required.

When does my coverage end?

If you choose to cancel coverage, it will end on the first of the month following the date you provide notification to your employer. Otherwise, coverage ends on the earliest of: • the date the policy is cancelled by your employer; • the date you no longer are in an eligible group; • the date your eligible group is no longer covered; • the date of your death • the last day of the period any required contributions are made; • the last day you are in active employment.

If you choose to cancel your Spouse’s coverage, it will end on the first of the month following the date you provide notification to your employer. Otherwise, your spouse’s coverage will end on the earliest of: • the date your coverage ends; • the date your spouse is no longer eligible for coverage; • the date your spouse no longer meets the definition of a spouse; • the date of your spouse’s death; or • the date of divorce or annulment.

Your children’s coverage will end on the earliest of: • the date your coverage ends; • the date your children are no longer eligible for coverage; or • the date your children no longer meet the definition of children.

The limited benefits provided are a supplement to major medical coverage and are not a substitute for major medical coverage or other minimal essential coverage as required by federal law. Lack of minimal essential coverage may result in an additional tax payment being due.

This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. For complete details of coverage and availability, please refer to Policy Form GCIP16-1 et al or contact your Unum representative. © 2018 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.

Underwritten by Unum Insurance Company, Portland, Maine

57

UNUM

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

#1

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 58 details on covered expenses, limitations and exclusions are included in the summary plan description located on the HEB ISD Benefits Website: www.mybenefitshub.com/hebisd

Basic Life and AD&D Hurst-Euless-Bedford Independent School District

Basic Life and AD&D Insurance Plan Highlights Policy Number 657075 Who is eligible for this coverage?

All actively employed employees working at least 20 hours each week for your employer in the U.S.

What is the coverage amount?

Your employer is providing you with $5,000 of term life insurance. You will also receive $5,000 of Accidental Death and Dismemberment insurance.

Is it portable (can I keep it if I leave my employer)?

If you retire, reduce your hours or leave your employer, you can continue coverage for yourself at the group rate.

What does my AD&D insurance pay for?

The full benefit amount is paid for loss of: - Life - Both hands or both feet or sight of both eyes - One hand and one foot - One hand and the sight of one eye - Speech and hearing

Does this plan include help with work-life balance?

Yes. Our work-life balance employee assistance program (EAP) provides professional advice for a wide range of personal and work-related issues. The service is available to you and your family members 24 hours a day, 365 days a year. It provides resources to help you 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. There is no additional charge for using the program, and you do not have to have filed a disability claim or be receiving benefits to use the program.

What else is included with this policy?

Worldwide emergency travel assistance is included with this long term disability plan. Emergency travel assistance is available to you, your spouse* and your dependent children when you travel to any foreign country, including Canada or Mexico. It is also available anywhere in the United States when you travel just 100 or more miles from home. * A spouse traveling on business for his or her employer is not covered by the program.

*Delayed effective date of coverage Insurance coverage will be delayed if you are not an active employee because of an injury, sickness, temporary layoff, or leave of absence on the date that insurance would otherwise become effective.

The work-life balance employee assistance program is provided by Ceridian Corporation and is 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 service is not valid after termination of coverage and may be withdrawn at any time. Please contact your Unum representative for full details.

Worldwide emergency travel assistance services, provided by Assist America, Inc., are available with select Unum insurance offerings. Terms and availability of service are subject to change and prior notification requirements. Services are not valid after coverage terminates. Please contact your Unum representative for details.

The policy provisions may vary or not be available in all states. The policy has exclusions and limitations which may affect any benefits payable. For complete details of coverage, please refer to Policy Form Underwritten by Unum Life Insurance Company of America, Portland, Maine© 2016 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and it’s insuring subsidiaries.

EN-1771 (7-16) FOR EMPLOYEES

59

Life and AD&D Hurst-Euless-Bedford Independent School District

Voluntary Life and AD&D Insurance Plan Highlights Policy Number 657076 Who is eligible for this coverage?

All actively employed employees working at least 20 hours each week for your employer in the U.S. and their eligible spouses and children (up to age 26).

What are the coverage amounts?

Employee: up to 5 times salary in increments of $10,000; not to exceed $500,000.

Spouse: up to 100% of employee coverage amount in increments of $5,000; not to exceed $75,000.

Child: up to 100% of employee coverage amount not to exceed $10,000. The maximum death benefit for a child between the ages of live birth and six months is $500.

What are the AD&D coverage amounts?

Employee: up to 10 times salary in increments of $10,000; not to exceed $500,000.

Spouse: 50% of employee coverage amount; not to exceed $250,000.

Child: 15% of employee coverage amount; not to exceed $30,000.

Spouse & Child: Spouse 40% of employee coverage amount and Child 10% of employee coverage amount; not to exceed $30,000.

Note: You may purchase AD&D coverage for yourself regardless of whether you purchase term life coverage. In order to purchase AD&D coverage for your dependents, you must buy coverage for yourself.

Can I be denied coverage?

Current employees: If you and your eligible dependents are enrolled in the plan and wish to increase your life insurance coverage, you may apply on or before the enrollment deadline for any amount of additional coverage up to $300,000 for yourself and any amount of additional coverage up to $50,000 for your spouse.

Any life insurance coverage over the guaranteed amount(s) will be subject to answers to health questions.

If you and your eligible dependents are not currently enrolled in the plan, you may apply for coverage on or before the enrollment deadline and will be required to answer health questions for any amount of coverage.

New employees: To apply for coverage, complete your enrollment within 31 days of your eligibility period. If you apply for coverage after 31 days, or if you choose coverage over the amount you are guaranteed, you will need to complete a medical questionnaire which you can get from your plan administrator.

How do I apply?

Please see your plan administrator.

When is coverage effective?

Please see your plan administrator for your effective date.

Insurance coverage will be delayed if you are not in active employment because of an injury, sickness, temporary layoff, or leave of absence on the date that insurance would otherwise become effective.

For your dependent spouse and children, insurance coverage will be delayed if that dependent is totally disabled on the date that insurance would otherwise be effective. Totally disabled means that as a result of an injury, sickness or disorder, your dependent spouse and children: are confined in a hospital or similar institution; are confined at home under the care of a physician for a sickness or injury; or your spouse has a life-threatening condition. Exception: Infants are insured from live birth.

60

Life and AD&D How much does the coverage cost?

Term Life Rate Chart Age band

Employee rate per $10,000

Spouse rate per $5,000

<20 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90-94 95+

$0.24 $0.38 $0.40 $0.53 $0.75 $0.95 $1.36 $2.24 $3.96 $5.72 $10.09 $16.15 $15.44 $15.44 $28.44 $46.44 $70.50

$0.12 $0.19 $0.20 $0.265 $0.375 $0.475 $0.68 $1.12 $1.98 $2.86 $5.045 $8.075 $7.72 $7.72 $14.22 $23.22 $35.25

Child life monthly rate is $1.20 for $10,000. One life premium covers all children.

AD&D Rate Chart Employee Employee & Family

AD&D cost Per $10,000 Per $10,000

Monthly Cost $0.24 $0.33

Term Life Calculation Worksheet Coverage amount Employee Spouse

Increment $10,000 $5,000

Rate

Monthly cost

Anniversary aging: Your rate is based on your insurance age, which is your age immediately prior to and including the anniversary/effective date.

Spouse aging: Spouse rate is based on employee’s insurance age.

AD&D Calculation Worksheet Coverage amount Employee Employee + Family

Increment $10,000 $1,000

Rate

Monthly cost

61

Life and AD&D Is the coverage portable (can I keep it if I leave my employer)?

If you retire, reduce your hours or leave your employer, you can continue coverage for yourself your spouse and your dependent children at the group rate.

Are there any life insurance exclusions or limitations?

Life insurance benefits will not be paid for deaths caused by suicide within the first 24 months after the date your coverage becomes effective. If you increase or add coverage, these enhancements will not be paid for deaths caused by suicide within the first 24 months after you make these changes.

Will my premiums be waived if I’m disabled?

If you become disabled (as defined by your plan) and are no longer able to work, your life premium payments will be waived until your disability period ends.

What does my AD&D insurance pay for?

The full benefit amount is paid for loss of: • life; • both hands or both feet or sight of both eyes; • one hand and one foot; • one hand or one foot and the sight of one eye; • speech and hearing.

Other losses may be covered as well. Please contact your plan administrator.

Does this plan include help with work-life balance?

Yes. Our work-life balance employee assistance program (EAP) provides professional advice for a wide range of personal and work-related issues. The service is available to you and your family members 24 hours a day, 365 days a year. It provides resources to help you 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. There is no additional charge for using the program, and you do not have to have filed a disability claim or be receiving benefits to use the program.

What else is included with this policy?

Worldwide emergency travel assistance is included with this long term disability plan. Emergency travel assistance is available to you, your spouse* and your dependent children when you travel to any foreign country, including Canada or Mexico. It is also available anywhere in the United States when you travel just 100 or more miles from home. * A spouse traveling on business for his or her employer is not covered by the program.

Are there any AD&D exclusions or limitations?

Accidental death and dismemberment benefits will not be paid for losses caused by, contributed to by, or resulting from: • disease of the body; diagnostic, medical or surgical treatment or mental disorder as set forth in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM); • suicide, self-destruction while sane, intentionally self-inflicted injury while sane or self-inflicted injury while insane; • war, declared or undeclared, or any act of war; • active participation in a riot; • committing or attempting to commit a crime under state or federal law; • the voluntary use of any prescription or non-prescription drug, poison, fume or other chemical substance unless used according to the prescription or direction of your or your dependent’s doctor.

This exclusion does not apply to you or your dependent if the chemical substance is ethanol; • intoxication – “being intoxicated” means you or your dependent’s blood alcohol level equals or exceeds the legal limit for operating a motor vehicle in the state or jurisdiction where the accident occurred.

62

Life and AD&D When does my coverage You and your dependents’ coverage under the Summary of Benefits ends on the earliest of: end?

• the date the policy or plan is cancelled; • the date you no longer are in an eligible group; • the date your eligible group is no longer covered; • the last day of the period for which you made any required contributions; • the last day you are in active employment unless continued due to a covered layoff or leave of absence or due to an injury or sickness, as described in the certificate of coverage.

In addition, coverage for any one dependent will end on the earliest of: • the date your coverage under a plan ends; • the date your dependent ceases to be an eligible dependent; • for a spouse, the date of a divorce or annulment ; • for dependent coverage, the date of your death.

Unum will provide coverage for a payable claim that occurs while you and your dependents are covered under the policy or plan.

Worldwide emergency travel assistance services, provided by Assist America, Inc., are available with select Unum insurance offerings. Terms and availability of service are subject to change and prior notification requirements. Services are not valid after coverage terminates. Please contact your Unum representative for details.

This information is not intended to be a complete description of the insurance coverage available. The policy or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which may affect any benefits payable. For complete details of coverage and availability, please refer to Policy Form C.FP-1 et al or contact your Unum representative. © 2016 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.

Underwritten by Unum Life Insurance Company of America, Portland, Maine EN-1773 (7-16) FOR EMPLOYEES

63

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.

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

FLIP TO…

PG. 15

FOR HSA VS. FSA COMPARISON

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 64 details on covered expenses, limitations and exclusions are included in the summary plan description located on the HEB ISD Benefits Website: www.mybenefitshub.com/hebisd

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 spouse’s or dependents’ individual policies) may not be paid before federal income or social security taxes are withheld. This through the flexible beneits plan. Furthermore, qualified longmeans that you will pay less tax and have more money to spend term care insurance plans may not be paid through the flexible and save. However, if you receive a reimbursement for an benefits plan. expense under the plan, you cannot claim a federal income tax NBS Benefits Card credit or deduction on your return.

Your employer may Health Flexible spending account: sponsor the use of the The health flexible spending account (FSA) enables you to pay NBS Benefits Card, for expenses allowed under Section 105 and 213(d) of the making access to your Internal Revenue Code which are not covered by our insured flex dollars easier than medical plan. ever. You may use the The most that you can contribute to your Health FSA each plan card to pay merchants year is set by the IRS. This amount can be adjusted for increases or service providers in cost-of-living in accordance with Code Section 125(i)(2). that accept credit cards such as hospitals and pharmacies, so there is no need to pay cash up front then wait for Premium expense plan: reimbursement.

A premium expense portion of the plan allows you to use preOrthodontic expenses that are paid fully up-front at the time of tax dollars to pay for specific premiums under various insurance initial service are reimbursable in full after the initial service has programs we offer you. been performed and payment has been made. Ongoing orthodontia payments are reimbursable only as they are paid.

Dependent care Flexible spending account: The dependent care flexible spending account (DCFSA) enables Account Information you to pay for out-of-pocket, work-related dependent daycare Participants may call NBS and talk to a representative during our costs. Please see the Summary Plan Description for the regular business hours, Monday-Friday, 7 a.m. to 7 p.m. Central definition of an eligible dependent. The law places limits on the Time. Participants can also obtain account information using the amount of money that can be paid to you in a calendar year.

Automated Voice Response Unit, 24 hours a day, 7 days a week Generally, your reimbursement may not exceed the lesser of: at (385) 988-6423 or toll free at (800) 274-0503. For immediate (a) $5,000 (if you are married filing a joint return or you are access to your account information at any time, log on to our head of a household) or $2,500 (if you are married filing website at my.nbsbenefits.com or download the NBS Mobile separate returns); (b) your taxable compensation; (c) your App. spouse's actual or deemed earned income.

Also, in order to have the reimbursements made to you and be What can I save with an FSA? excluded from your income, you must provide a statement from FSA No FSA the service provider including the name, address and, in most cases, the taxpayer identification number of the service Annual taxable income $24,000 $24,000 provider as well as the amount of such expense and proof that Health FSA $1,500 $0 the expense has been incurred.

Dependent care FSA $1,500 $0 Determining contributions Total pre-tax contributions -$3,000 $0 Before each plan year begins, you will select the benefits you want and how much contributions should go toward each Taxable income after FSA $21,000 $24,000 benefit. It is very important that you make these choices Income taxes -$6,300 -$7,200 carefully based on what you expect to spend on each covered benefit or expense during the plan year.

After-tax income $14,700 $16,800 Generally, you cannot change the elections you have made after After-tax health and welfare expenses $0 -$3,000 the beginning of the plan year. However, there are certain limited situations when you can change your elections if you Take-home pay $14,700 $13,800 have a "change in status". Please refer to your Summary Plan You saved $900 $0 Description for a change in status listing.

Plan Highlights Flexible Spending Plans

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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

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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).

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FSA (Flexible Spending Account) FLEXIBLE BENEFITS PLAN Hurst-Euless-Bedford Independent School District Employer ID NBS444674

PLAN HIGHLIGHTS Login at: my.nbsbenefits.com

WHAT TYPE OF BENEFITS ARE AVAILABLE Under our Plan, you can choose the following benefits. Each benefit allows you to save taxes at the same time because the amount you elect is set aside on a pre-tax basis.

Health Flexible Spending Account: The Health Flexible Spending Account (FSA) enables you to pay for expenses allowed under Section 105 and 213(d) of the Internal Revenue Code which are not covered by our insured medical plan. The most that you can contribute to your Health FSA each Plan Year is $2,700. Please note: If you contribute to this benefit you cannot elect a Health Savings Account (HSA) Benefit.

Congratulations! Hurst-Euless-Bedford Independent School District has established a "Flexible Benefits Plan" to help you pay for your out-of-pocket medical expenses. One of the most important features of the Plan is that the benefits being offered are paid for with a portion of your pay before Federal income or Social Security taxes are withheld. This means that you will pay less tax and have more money to spend and save. However, if you receive a reimbursement for an expense under the Plan, you Health Savings Account: A Health Savings Account allows participants insured by a cannot claim a Federal income tax credit or deduction on your Qualified High Deductible Insurance Plan to save for deductibles return. and other expenses not covered under the Plan. If you participate in this benefit you cannot participate in the Health Flexible DETERMINING CONTRIBUTIONS Spending Account benefit.

Before each Plan Year begins, you will select the benefits you want and how much of the contributions should go toward each Dependent Care Flexible Spending Account: benefit. It is very important that you make these choices carefully The Dependent Care Flexible Spending Account (DCAP) enables you to pay for out-of-pocket, work-related dependent day-care based on what you expect to spend on each covered benefit or cost. Please see the Summary Plan Description for the definition expense during the Plan Year. of eligible dependent. The law places limits on the amount of Generally, you cannot change the elections you have made after money that can be paid to you in a calendar year. Generally, your the beginning of the Plan Year. However, there are certain reimbursement may not exceed the lesser of: (a) $5,000 (if you limited situations when you can change your elections if you have are married filing a joint return or you are head of a household) a “change in status”. Please refer to your Summary Plan or $2,500 (if you are married filing separate returns; (b) your Description for a change in status listing. taxable compensation; (c) your spouse’s actual or deemed earned income. Also, in order to have the reimbursements made to you and be excluded from your income, you must provide a GENERAL PLAN INFORMATION statement from the service provider including the name, address, Plan Year End:………………………………………………...……...August 31st and in most cases, the taxpayer identification number of the Run-out Period:…………………………………..……………………...…90 Days service provider, as well as the amount of such expense and Maximum Medical Limit…………..…...……..Current IRS limit $2,700 proof that the expense has been incurred. …See Code Section 125(i)(2) or current enrollment information Maximum Dependent Care Limit:……..……………………..……..$5,000

Premium Expense Plan: A Premium Expense portion of the Plan allows you to use pre-tax Deadlines to Use Funds (Use-it-or-Lose-it) Health FSA……………….…...…,November 29 following Plan Year End dollars to pay for specific premiums under various insurance DCAP………………………..…...…November 29 following Plan Year End programs that we offer you.

FSA Mid-year termination…… 90 days following termination date Please note: Policies other than company sponsored policies (i.e.

DCAP Mid-year termination….90 days following termination date spouse's or dependents' individual policies etc.) may not be paid through the Flexible Benefits Plan. Furthermore, qualified longterm care insurance plans may not be paid through the Flexible WHEN AM I ELIGIBLE TO PARTICIPATE Benefits Plan.

If you work 20 hours or more each week for the company, you will be eligible to join the Plan when you have met the eligibility requirements for our group medical plan.

During the course of the Plan Year, you may submit requests for

HOW DO I RECEIVE REIMBURSEMENTS

You will enter the Plan on the same day that you join our group medical plan.

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reimbursement of expenses you have incurred. Expenses are considered “incurred” when the service is performed, not necessarily when it is paid for. You can get a claim form at www.NBSbenefits.com.

FSA (Flexible Spending Account) Claim forms must be submitted no later than 90 days after the end of the Plan Year for the Health Flexible Spending Account and the Dependent Care Flexible Spending Account. Any contributions remaining at the end of the Plan Year will be forfeited.

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

Terminated Employees have 90 Days after their date of termination to submit receipts for services prior to their termination date.

WHO ARE HIGHLY COMPENSATED & KEY EMPLOYEES Under the Internal Revenue Code, "highly compensated employees" and "key employees" generally are Participants who are officers, shareholders or highly paid.

If you are within these categories, the amount of contributions and benefits for you may be limited so that the Plan as a whole does not unfairly favor those who are highly paid, their spouses or their dependents. Please refer to your Summary Plan Description for more information. You will be notified of these limitations if you are affected.

Updated: 6/23/2020

NBS Welfare Benefit Service Center 8523 S. Redwood Road West Jordan, UT 84088 801-532-4000 or 1-800- 274-0503 Fax: 1-800-478-1528 Hurst-Euless-Bedford Independent School District Flexible Benefits Plan Hurst-Euless-Bedford Independent School District Plan Contact Person: Maria Ortiz 1849 Central Drive Bedford, Texas 76022 (817) 399-2056

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LEGAL EASE

YOUR BENEFITS PACKAGE

Legal Services

About this Benefit Finding the right type of attorney when a need arises can be one of the more stressful tasks when dealing with a legal matter. The right help is essential. There are many types of attorneys depending upon what type of issue someone may be facing. We help with this first step. We use our experience and relationships with our network providers to match you to the right type of attorney you need in the right location, with availability to set up a consultation with you. We see this step as a way to save you time, so you can get back to your busy schedule of work, kids or whatever may be just as important.

$1,500 Is the average cost of a basic will and estate planning package. The average yearly premium paid by Texas Legal Members is only $300.

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

Legal Services We all make some sort of plan in life.

But do we ever consider the possibility of a legal problem?

Plan Proudly Offered to HEB ISD Employees Enroll Now in the New LegalGUARD Plan

Why do you need legal coverage?

Never have to worry if it’s worth calling an attorney again.

You never know when a legal matter may affect you or your family, and there are times in life when it is a good idea to consult an attorney. Legal issues are complicated and disorienting. As many as 7 out of 10 of people you know will have the need for an attorney this year, according to the American Bar Association. This means that each year, only 30% of us will be lucky enough not to deal with the stress of a legal issue. And without the right help, legal matters are tough. Without legal benefits, issues can average anywhere from $500.00 to $7,000.00 per issue. The LegalGUARD Plan helps protect you, your family and your savings from unexpected legal costs for many issues.

We also always follow up to ensure everything is going well and to see how else we can be of assistance. We believe that quality service is essential, especially in a world today where quality service can be scarce.

So if you have a legal, financial, or identity need, to start getting the help you need, just give us a call. It’s that easy. We will guide you through the steps and be right with you the entire way.

LegalGUARD Plan Benefits Benefits are designed to meet the typical needs of an employee and their family. There are no deductibles to worry about for covered services. Benefits cover the attorney’s time. Other costs, such as filing fees, are not covered by legal benefits. Listed below are the types of matters that are covered by the new LegalGUARD Plan. The LegalGUARD plan offers convenience of In Network and Out of Network benefits. Many of the below areas are fully covered, unless noted.

Consultation • Office Consultation* • Telephone Advice

Consumer • Consumer Dispute • Small Claims Court Representation* We understand that when you have a legal need, it is the most important event in your life at that moment. We also know that • Document Preparation: Simple Deed finding the right attorney on your own can be stressful and dominate much of your time and attention. Protect yourself and Promissory Note Consumer Dispute Correspondence Installment Sales your family with the great value of the LegalGUARD Plan.

Agreement Simple Affidavit We have been putting people in touch with quality local General Power of Attorney attorneys and helping them solve problems since 1971. Our processes are designed to help you save time and to make things Lease Agreement – Tenant Only less stressful. Also, the providers in our network must meet the Time Share Agreement most rigorous credentials standards in the market today.

Estate Planning and Wills • Simple Will or Codicil* How does the plan work?

• Living Will The right help when you need it the most.

• Health Care Power of Attorney • Living Trust Document Finding the right type of attorney when a need arises can be one • Probate of Small Estate* of the more stressful tasks when dealing with a legal matter. The right help is essential. There are many types of attorneys Financial depending upon what type of issue someone may be facing. We • Debt Collection Defense help with this first step. We use our experience and relationships Pre-litigation defense activities with our network providers to match you to the right type of Trial defense* attorney you need in the right location, with availability to set up • Bankruptcy (chapter 7 or 13)* a consultation with you. We see this step as a way to save you • Tax Audit* time, so you can get back to your busy schedule of work, kids or • Foreclosure* whatever may be just as important. This step alone can save you • Financial Planning* hours. If you use an In Network attorney, you don’t have to • Savings Coaching* hassle with forms. LegalEASE works directly with the provider to • Budgeting Coaching* provide your benefits.

• Credit Coaching* 71

Legal Services • •

Savings Coaching* Debt Management Programs*

Home • Purchase of Primary Residence • Sale of Primary Residence • Refinancing of Primary Residence • Landlord/Tenant Dispute* Civil • Civil Litigation Defense* Family • Uncontested Separation* • Consent/default Divorce* • Uncontested Divorce* • Contested Divorce* • Name Change • Guardianship/Conservatorship* • Governmental Agency Adoptions* • Stepparent Adoptions* • Juvenile Court Proceedings

We’re here when you need us.

Enrollment Questions Call: 1(800) 248-9000 More Information at: https://www.legaleaseplan.com/content/heb

Plan Cost: The LegalGUARD Plan is only $16.91 per month, via payroll deduction.

The LegalGUARD Plan + Family Coverage is only $18.88 per month, via payroll deduction.

LegalGUARD Covered Family Member Definition:

Criminal • Traffic Defense (resulting in suspension or revocation of license) • Administrative Proceeding (regarding suspension or revocation of license) • Misdemeanor Defense*

The Member’s lawful spouse and children. Eligible Family Members are the Member’s spouse and Member’s unmarried dependent children, including stepchild, legally adopted child, child placed in the home for adoption and foster child, up to age 19, and from age 19 up to 26 years if they are enrolled in an accredited school or college as full-time student(s) and are primarily dependent upon the Member for support.

Elder/Parents • Consultation • Review Documents* • Standard Wills Prepared* • Codicil* • Amendment to a single document* • Amendment(s) to spousal document* • Living Will* • Powers of Attorney*

Limitations and Exclusions Apply.

This benefit summary is intended only to highlight benefits and should not be relied upon to fully determine coverage. More complete descriptions of benefits and the terms under which they are provided are received upon enrolling in the plan. Group legal plans are administered by LegalEASE or The LegalEASE Group, Houston, Texas.

Product available in all states. Underwritten by Virginia Surety Company, Inc. Please contact LegalEASE for complete details. © 2015 The LegalEASE Group. All rights reserved.

HurstEulessBedfordIndependentSchoolDistrict_2015

Enrollment Questions Call: 1(800) 248-9000 More Information at: https://www.legaleaseplan.com/content/heb

Meet LegalEASEsm We believe people deserve to have a sense of safety and security, a peace of mind, when it comes to being protected in legal matters. How we do it is by providing an in-depth pool of resources to accommodate your legal needs. The LegalGUARD plan is underwritten by Virginia Surety Company, Inc. LegalEASE Corporate Headquarters 5850 San Felipe, Suite 600 Houston, Texas 77057 Member Services: 1(888) 416-4313 72

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Retirement Planning

YOUR YOUR BENEFITS BENEFITS PACKAGE PACKAGE

About this Benefit A 403(b) plan is a U.S. tax-advantaged retirement savings plan available for public education organizations.

A 457(b) plan is a tax-deferred compensation plan provided for employees of certain tax-exempt, governmental organizations or public education institutions.

Only 22% of workers are very confident they will have enough money in retirement.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 74 details on covered expenses, limitations and exclusions are included in the summary plan description located on the HEB ISD Benefits Website: www.mybenefitshub.com/hebisd

Retirement Planning You may enroll in a 403(b) and/or 457(b) anytime during the year!

403(b) Plan

457(b) Plan

The Omni Group 877-544-6664 www.omni403b.com

TCG Administrators 800-943-9179 http://tcgservices.com/documents/#/255/457b

What is a 403(b)?

A 403(b) plan is a retirement plan for certain employees of public schools, tax-exempt organizations, and ministers. Contributions are made under a Salary Reduction Agreement (SRA) with your employer. This agreement allows your employer to withhold money from your paycheck to be contributed directly into a 403(b) account for your benefit. Usually, you do not pay income tax on these contributions until you withdraw them from the account.

What is a 457(b)?

The 457(b) plan is a type of deferred- compensation retirement plan that is available for governmental employers. The employer provides the plan and the employee defers compensation into it on a pre-tax basis.

For the most part, the plan operates similarly to a 401(k) or 403(b) plan. The key difference is that there is no penalty for withdrawal before the age of 59½ (but subject to income tax).

You have 35 + companies to choose from with a variety of investment types available (fixed annuity, fixed index annuity, variable annuity, investment advisory services, or mutual funds)

HEB ISD has selected 1 company to provide our employees with the 457(b) plan. TCG Administrators offers several investment options.

Visit the website for a list of fees of service plan providers.

How to Enroll: Step 1: Set up your 403b account with an approved vendor

How to Enroll: Complete the Salary Reduction Agreement with TCG Administrators

Step 2: Complete the Salary Reduction Agreement with The Omni Group

Plan password for enrolling online: hurst457

There is an additional tax penalty on any funds withdrawn prior to retirement age

No penalty for early withdrawal (upon separation of service)

Maximum Contributions: Annual Maximum - $19,500 Over age 50 Catch-up - $6,500

Maximum Contributions: Annual Maximum - $19,500 Over age 50 Catch-up - $6,500

75

UNUM

EAP (Employee Assistance Program)

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

38%

YOUR BENEFITS PACKAGE

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 76 details on covered expenses, limitations and exclusions are included in the summary plan description located on the HEB ISD Benefits Website: www.mybenefitshub.com/hebisd

Employee Assistance Program Help, when you need it most

Who is covered?

With your Employee Assistance Program and Work/Life Balance Unum’s EAP services are available to all eligible employees, their services, confidential assistance is as close as your phone or com- spouses or domestic partners, dependent children, parents and puter. parents-in-law.

Employee Assistance Program (EAP) Your EAP is designed to help you lead a happier and more productive life at home and at work. Call for confidential access to a Licensed Professional Counselor* who can help you.

A Licensed Professional Counselor can help you with: • Stress, depression, anxiety • Relationship issues, divorce • Job stress, work conflicts • Family and parenting problems • Anger, grief and loss • And more

Work/Life Balance You can also reach out to a specialist for help with balancing work and life issues.

Just call and one of our Work/Life Specialists can answer your questions and help you find resources in your community.

Ask our Work/Life Specialists about: • Child care • Elder care • Legal questions • Identity theft • Financial services, debt management, credit report issues • Even reducing your medical/dental bills!

• And more

Employee Assistance Program — Work/Life Balance Toll-free 24/7 access: 1-800-854-1446 (multi-lingual) www.unum.com/lifebalance

Help is easy to access: Online/phone support: Unlimited, confidential, 24/7.

In-person: You can get up to 3 visits available at no additional cost to you with a Licensed Professional Counselor. Your counselor may refer you to resources in your community for ongoing support. * The counselors must abide by federal regulations regarding duty to warn of harm to self or others. In these instances, the consultant may be mandated to report a situation to the appropriate authority.

Unum’s Employee Assistance Program and Work/Life Balance services, provided by HealthAdvocate, are available with select Unum insurance offerings. Terms and availability of service are subject to change. Service provider does not provide legal advice; please consult your attorney for guidance. Services are not valid after coverage terminates. Please contact your Unum representative for details.

Insurance products are underwritten by the subsidiaries of Unum Group. unum.com © 2018 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.EN-2058 (4-18) FOR EMPLOYEES

Always by your side • • • • • •

Expert support 24/7 Convenient website Short-term help Referrals for additional care Monthly webinars Medical Bill SaverTM—helps you save on medical bills

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