2021 Los Fresnos CISD Benefit Guide

LOS FRESNOS CISD

BENEFIT GUIDE EFFECTIVE: 01/01/2021 - 12/31/2021 WWW.MYBENEFITSHUB.COM/LOSFRESNOSCISD 1

Table of Contents Benefit Contact Information How to Enroll Annual Benefit Enrollment 1. Benefit Updates 2. Section 125 Cafeteria Plan Guidelines 3. Annual Enrollment 4. Eligibility Requirements 5. Helpful Definitions 6. Health Savings Account (HSA) vs. Flexible Spending Account (FSA) BCBSTX Medical and Pharmacy Plans EECU Health Savings Account (HSA) BCBSTX Dental Superior Vision The Hartford Disability APL Cancer VOYA Critical Illness The Hartford Accident AUL a OneAmerica Company Life and AD&D • Compsych Employee Assistance Program (EAP) NBS Flexible Spending Account MASA Medical Transport

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

FLIP TO...

PG. 4

HOW TO ENROLL

PG. 6

SUMMARY PAGES

PG. 12

YOUR BENEFITS

11 12-25 26-27 28-29 30-31 32-35 36-41 42-45 46-49 50-57 55 58-61 62-63

Benefit Contact Information BENEFIT ADMINISTRATORS

HEALTH SAVINGS ACCOUNT

FLEXIBLE SPENDING ACCOUNT

Financial Benefit Services EECU (800) 583-6908 (817) 882-0800 www.mybenefitshub.com/losfresnoscisd www.eecu.org

National Benefit Services (855) 399-3035 www.nbsbenefits.com

MEDICAL

DENTAL

VISION

Group #028371 Blue Cross Blue Shield (800) 521-2227 www.bcbstx.com

Group #029511 Blue Cross Blue Shield (800) 521-2227 www.bcbstx.com

Group #320870 Superior Vision (800) 507-3800 www.superiorvision.com

CANCER

DISABILITY

EMPLOYEE ASSISTANCE PROGRAM

Group #22636 American Public Life (800) 256-8606 www.ampublic.com

Group #681501 The Hartford (866) 278-2655 www.thehartfordatwork.com

AUL a OneAmerica Company (800) 537-6442 www.oneamerica.com

LIFE AND AD&D

ACCIDENT

CRITICAL ILLNESS

Group #617681 AUL a OneAmerica Company (800) 537-6442 www.oneamerica.com

Group #681501 The Hartford (866) 278-2655 www.thehartfordatwork.com

Group #70800-3CCI2 Voya (800) 955-7736 www.voya.com

MEDICAL TRANSPORT Group #MKLFCISD MASA (800) 423-3226 www.masamts.com

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

and get access to everything you need to complete your benefits

Text

“FBS LFCISD” to (800) 583-6908

enrollment: •

Enrollment Resources

•

Online Support

•

Interactive Tools

•

And more!

App Group #: FBSLFCISD

OR SCAN

How to Log In

1 BENEFIT INFO

INTERACTIVE TOOLS

2 3

www.mybenefitshub.com/losfresnoscisd

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 lowercase, followed by the first letter of your first name, followed by the last four (4) numbers of your

ONLINE SUPPORT

Social Security Number.

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) numbers of your Social Security Number.

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

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Annual Benefit Enrollment

SUMMARY PAGES

Benefit Updates - What’s New: HEALTH SAVINGS ACCOUNT (HSA) Employees who are enrolled in a high deductible health care plan the opportunity to contribute to an H.S.A to pay for eligible medical, dental and vision expenses. Individual maximum contribution is $3,600 and Family maximum annual contribution is $7,200 per year. You should log in and complete a walkthrough if you want to increase your contribution amounts for the 2021 plan year. An employee and a spouse may both contribute to their own Health Savings Account, but their combined total can not exceed the family maximum in any given tax year.

Don’t Forget!

Social Security Numbers for your dependents are required regardless if they are enrolled in coverage or not. Please make sure you have these items on hand when going through your open enrollment.

FLEXIBLE SPENDING ACCOUNTS (FSA) Tax sheltered flexible spending accounts allow an individual to set aside dollars to pay for future health care and dependent care expenses. Eligible expenses must be incurred within the plan year (01/01/2021 to 12/31/21) and contributions are “use it or lose it.” The 2021 maximum annual contribution is $2,750. Participating employees will receive a FSA MasterCard with your entire annual FSA contribution to spend throughout the entire school year. You can view account balance using the NBS smart phone app, or you call NBS at (800) 583-6903 and speak to a representative.

Important • • • •

Login and complete your benefit enrollment from 10/26/2020 - 11/20/2020 Enrollment assistance is available by calling Financial Benefit Services at (866) 914-5202 to speak to a representative Monday-Friday 8am–7pm, CST. Update your profile information: home address, phone numbers, email, beneficiaries REQUIRED: Provide correct dependent social security numbers

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SUMMARY PAGES

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

Enrollment is automatic unless you decline this benefit.

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

CHANGES IN STATUS (CIS):

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 Administrator 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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SUMMARY PAGES

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

Where can I find forms?

to review, change or continue benefit elections each year.

For benefit summaries and claim forms, go to your school

Changes are not permitted during the plan year (outside of

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

annual enrollment) unless a Section 125 qualifying event occurs.

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

•

Changes, additions or drops may be made only during the

the Benefits and Forms section.

annual enrollment period without a qualifying event.

How can I find a Network Provider?

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

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

included in the dependent profile. Additionally, you must

losfresnoscisd. Click on the benefit plan you need information

notify your employer of any discrepancy in personal and/or

on (i.e., Dental) and you can find provider search links under

benefit information.

•

For benefit summaries and claim forms, go to your school

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

the Quick Links section.

When will I receive ID cards?

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

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

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

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

Q&A Who do I contact with Questions?

For supplemental benefit questions, you can contact your Benefit Administrator or you can call Financial Benefit Services at (866) 914-5202 for assistance.

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SUMMARY PAGES

Employee Eligibility Requirements

Dependent Eligibility Requirements

Supplemental Benefits: Eligible employees must work 20 or more

Dependent Eligibility: You can cover eligible dependent

regularly scheduled hours each work week.

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

Eligible employees must be actively at work on the plan effective

maximum age listed below. Dependents cannot be double

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

covered within Los Fresnos CISD as both employees and

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

dependents.

work concurrent with the plan effective date. For example, if your 2021 benefits become effective on January 1, 2021, you must be actively-at-work on January 1, 2021 to be eligible for

your new benefits.

PLAN

CARRIER

MAXIMUM AGE

Telehealth

MDLIVE

To age 26

Vision

Superior Vision

To age 26

Disability

The Hartford

To age 26

Cancer

American Public Life

To age 26

Life & AD&D

OneAmerica

To age 26

Flexible Spending Account

NBS

To age 26

Medical Transportation

MASA

To age 26

Critical Illness

VOYA

To age 26

Accident

The Hartford

To age 26

If your dependent is disabled, coverage may be able to continue past the maximum age under certain plans. If you have a disabled dependent who is reaching an ineligible age, you must provide a physician’s statement confirming your dependent’s disability. Contact your 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 01/01/2021 please notify your benefits administrator.

Annual Enrollment The period during which existing employees are given the

opportunity to enroll in or change their current elections.

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

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

Plan Year January 1st through December 31st

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

Calendar Year January 1st through December 31st

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

Guaranteed Coverage The amount of coverage you can elect without answering

any medical questions or taking a health exam. Guaranteed coverage is only available during initial eligibility period.

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

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(including diagnostic and/or consultation services).

SUMMARY PAGES

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

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

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

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

Employer Eligibility

A qualified high deductible health plan.

All employers

Contribution Source Account Owner Underlying Insurance Requirement

Employee and/or employer Individual

Employee and/or employer Employer

High deductible health plan

None

Description

Minimum Deductible

$1,400 single (2021) $2,800 family (2021) $3,600 single (2021) $7,200 family (2021)

N/A

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

Catch-Up Contributions: Accountholders who meet the qualifications are eligible to make an HSA catch-up contribution of an additional $1,000.

Employees may use funds any way they wish. If used for non-qualified medical expenses, subject to current tax rate plus 20% penalty.

Permitted, but subject to current tax rate plus 10% penalty (penalty waived after age 65).

Year-to-year rollover of account balance?

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

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

Does the account earn interest?

Yes

No

Portable?

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

No

Maximum Contribution

Permissible Use Of Funds

FLIP TO FOR HSA INFORMATION

PG. 26

$2,750 (2021)

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

Not permitted

FLIP TO FOR FSA INFORMATION

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BCBSTX

Medical

YOUR BENEFITS PACKAGE

About this Benefit Major medical insurance is a type of health care coverage that provides benefits for a broad range of medical expenses that may be incurred either on an inpatient or outpatient basis.

More than 70% of adults across the United States are already being diagnosed with a chronic disease.

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 12 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Los Fresnos CISD Benefits Website: www.mybenefitshub.com/losfresnoscisd

Medical Plan Rates

High Deductible Plan w/HSA* Monthly Rate

District Contribution

12-Pay Deductions

18-Pay Deduction

24-Pay Deductions

Employee Only

$415.00

$415.00

$0.00

$0.00

$0.00

Employee & Spouse

$822.00

$415.00

$407.00

$271.33

$203.50

Employee & 1 Child

$680.00

$415.00

$265.00

$176.67

$132.50

Employee & Child(ren)

$735.00

$415.00

$320.00

$213.33

$160.00

Employee & Family

$967.00

$415.00

$552.00

$368.00

$276.00

$65.00

$43.33

$32.50

District HSA Contribution/Pay Cycle

Basic Plan (70/30) Employee Only

$510.00

$480.00

$30.00

$20.00

$15.00

Employee & Spouse

$926.00

$480.00

$446.00

$297.33

$223.00

Employee & 1 Child

$723.00

$480.00

$243.00

$162.00

$121.50

Employee & Child(ren)

$828.00

$480.00

$348.00

$232.00

$174.00

$1,089.00

$480.00

$609.00

$406.00

$304.50

Employee & Family

School Plan (80/20) Employee Only

$545.00

$480.00

$65.00

$43.33

$32.50

Employee & Spouse

$1,035.00

$480.00

$555.00

$370.00

$277.50

Employee & 1 Child

$779.00

$480.00

$299.00

$199.33

$149.50

Employee & Child(ren)

$893.00

$480.00

$413.00

$275.33

$206.50

$1,174.00

$480.00

$694.00

$462.67

$347.00

Employee & Family

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Basic Medical Plan Plan Provisions

Deductibles • Per- admission Deductible • Calendar Year Deductible Three- month Deductible carryover applies Co-Share Stop-Loss Amounts (Includes Calendar Year Deductible and Copayment Amounts) Copayment Amounts Required • Virtual visit - Medical and Behavioral Health

In-Network Benefits

Out-of-Network Benefits

None

$200 per- admission Deductible

$1,500 – per individual

$3,600 – per individual

$4,500 – per family

$10,800 – per family

$6,000 – per individual

$9,000 – per individual

$16,300 – per family

$36,000 – per family

$10 Copay

Does Not Apply

$45 Physician office visit • Physician office visit/consultation for Primary Care Providers $50 Physician office visit • Physician office visit/consultation for Specialty Care Providers • Outpatient Hospital Emergency Room/Treatment $150 outpatient Hospital Emergency Room/Treatment Room visit Room visit $60 Urgent Care Center visit • Urgent Care Center visit • Retail Health Clinic

Does Not Apply Does Not Apply $150 outpatient Hospital Emergency Room/Treatment Room visit Does Not Apply

$45 Retail Health Clinic visit

Does Not Apply

70% of Allowable Amount

50% of Allowable Amount after $200 per-admission Deductible

No penalty for failure to Preauthorize services

$250 penalty for failure to Preauthorize services

100% of Allowable Amount after $45 Copayment Amount 100% of Allowable Amount after $50 Copayment Amount

50% of Allowable Amount after Calendar Year Deductible 50% of Allowable Amount after Calendar Year Deductible

100% of Allowable Amount after $45/$50 Copayment Amount

50% of Allowable Amount after Calendar Year Deductible

70% of Allowable Amount after Calendar Year Deductible

50% of Allowable Amount after Calendar Year Deductible

100% of Allowable Amount

50% of Allowable Amount after Calendar Year Deductible

Inpatient Hospital Expenses All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units.

Medical-Surgical Expenses • Office visit/consultation, (Primary Care Providers) including Lab and X- Rays • Office visit/consultation, (Specialty Care Providers) including Lab and X- Rays • Radiation Therapy and Chemotherapy in the office setting • Diabetic Management (training/nutritional) • Inpatient visits • Certain Diagnostic Procedures • Home Infusion Therapy • Physician surgical services in any setting • Allergy Injections (without office visit) • Independent Lab and X-Ray • Services and supplies provided by Digi-Rad X-Ray Mobile • Services and supplies provided by Los Fresnos Medicine Clinic and Rio Hondo Medicine Clinic Extended Care Expenses

100% of Allowable Amount up to a $60 maximum 100% of Allowable Amount after $10 Copayment Amount

90% of Allowable Amount after Calendar Year Deductible • Skilled Nursing Facility

60 days combined Calendar Year maximum

• Home Health Care

60 visits combined Calendar Year maximum

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• Hospice Care

Unlimited

Basic Medical Plan Plan Provisions

In-Network Benefits

Out-of-Network Benefits

Mental Health Care, Serious Mental Illness, and Substance Use Disorder (SUD) (Certain Services will require Preauthorization) Inpatient Services • Hospital Services (facility)

70% of Allowable Amount after Calendar Year Deductible

• Behavioral Health Practitioner Services

70% of Allowable Amount after Calendar Year Deductible

50% of Allowable Amount after $200 per- admission Deductible and after Calendar Year Deductible 50% of Allowable Amount after Calendar Year Deductible

100% of Allowable Amount after $45 Copayment Amount 70% of Allowable Amount after Calendar Year Deductible

50% of Allowable Amount after Calendar Year Deductible 50% of Allowable Amount after Calendar Year Deductible

Outpatient Services • Behavioral Health Practitioner Expenses (office setting) • Other Outpatient Services Emergency Care Accidental Injury & Emergency Care (including Accidental Injury & Emergency Care for Behavioral Health Services) • Facility Charges • Lab & X- Ray - without emergency room or treatment room • Physician Charges

70% of Allowable Amount after $150 outpatient Hospital emergency room Copayment Amount (waived if admitted) 100% of Allowable Amount 70% of Allowable Amount after Calendar Year Deductible

Non-Emergency Care (including Non-Emergency Care for Behavioral Health Services)

• Facility Charges

• Physician Charges

70% of Allowable Amount after Calendar Year Deductible

50% of Allowable Amount after $150 outpatient Hospital emergency room Copayment Amount (waived if admitted) and after Calendar Year Deductible 50% of Allowable Amount after Calendar Year Deductible

100% of Allowable Amount after $60 Copayment Amount

50% of Allowable Amount after Calendar Year Deductible

70% of Allowable Amount after $150 outpatient Hospital emergency room Copayment Amount (waived if admitted)

Urgent Care Services Urgent Care Center visit - including Lab & X- Ray services (excluding Certain Diagnostic Procedures) Ambulance Services Retail Health Clinic

70% of Allowable Amount after Calendar Year Deductible 100% of Allowable Amount after $45 Copayment Amount

50% of Allowable Amount after Calendar Year Deductible

100% of Allowable Amount

50% of Allowable Amount after Calendar Year Deductible

Preventative Care Services • Evidence-based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force (“USPSTF”) • Immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (“CDC”) with respect to the individual involved • Evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (“HRSA”) for infants, children, and adolescents

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Basic Medical Plan Plan Provisions

In-Network Benefits

Out-of-Network Benefits

100% of Allowable Amount

50% of Allowable Amount after Calendar Year Deductible

100% of Allowable Amount

100% of Allowable Amount

100% of Allowable Amount

50% of Allowable Amount after Calendar Year Deductible

100% of Allowable Amount after $45/$50 Copayment Amount

50% of Allowable Amount after Calendar Year Deductible

• Office visit

100% of Allowable Amount after $45/$50 Copayment Amount

50% of Allowable Amount after Calendar Year Deductible

• All other services

70% of Allowable Amount after Calendar Year Deductible

50% of Allowable Amount after Calendar Year Deductible

Preventive Care Services (Cont'd) • With respect to women, such additional preventive care and screenings, not described in the first bullet above, as provided for in comprehensive guidelines supported by the HRSA • Routine physical examinations, well baby care, immunizations, and routine Lab • Routine X- Rays, Routine EKG, Routine Diagnostic Medical Procedures (Independent Lab & X- Ray Provider) • Colonoscopy, Physician and facility charges • Healthy diet counseling and obesity screening/ counseling • Childhood immunizations Other Routine Services • Routine X- Rays, Routine EKG, Routine Diagnostic Medical Procedures • Annual Hearing Examination • Annual Vision Examination Speech and Hearing Services

1 per ear per 36- month period for hearing aids Chiropractic Services (35 visits maximum per Calendar Year) • Office visit

100% of Allowable Amount after $45/$50 Copayment Amount

50% of Allowable Amount after Calendar Year Deductible

• All other services

70% of Allowable Amount after Calendar Year Deductible

50% of Allowable Amount after Calendar Year Deductible

• Airrosti Provider

35 visits combined per Calendar Year maximum for above 100% of Allowable Amount after Does Not Apply $45 Copayment Amount 35 visits maximum per Calendar Year

Physical Medicine Services (35 visits maximum per Calendar Year) • Office visit/Office services

100% of Allowable Amount after $45/$50 Copayment Amount

50% of Allowable Amount after Calendar Year Deductible

• All other outpatient services

70% of Allowable Amount after Calendar Year Deductible

50% of Allowable Amount after Calendar Year Deductible

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Basic Medical Pharmacy Benefits Plan Provisions

Participating Pharmacy

Non-Participating Pharmacy

Retail Pharmacy 90 day supply with 1 Copayment Amount per 30-day supply at a Participating Pharmacy • Generic Drugs • Preferred Brand Name Drugs • Non- Preferred Brand Name Drugs

$0 Copayment Amount $30 Copayment Amount* or 30% of Allowable Amount, whichever is greater $30 Copayment Amount* or 30% of Allowable Amount, whichever is greater Specialty Pharmacy Provider $100 Copayment Amount* Specialty Drugs

Specialty Pharmacy Program Specialty Drugs- limited to a 30-day supply at a Specialty Pharmacy Provider Mail-Order Program One Copayment Amount per 90 day supply, up to a 90-day supply only • Generic Drugs

80% of Allowable Amount minus Copayment Amount 80% of Allowable Amount minus Copayment Amount 80% of Allowable Amount minus Copayment Amount Not Covered

$0 Copayment Amount

• Preferred Brand Name Drugs

$70 Copayment Amount*

• Non- Preferred Brand Name Drugs

$100 Copayment Amount*

Not Covered

Select Participating Pharmacy 100% of Allowable Amount Select Vaccinations Obtained through Participating 80% of Allowable Amount minus Any other Participating Pharmacy 80% Pharmacies** Copayment Amount of Allowable Amount minus Copayment Amount Prior Authorization Provision Applies Step Therapy Provision Applies Limitations on Quantities Dispensed Applies Diabetes Supplies are available under the Pharmacy Benefits portion of your Plan. All provisions of this portion of the Plan Prescribed and over- the- counter will be paid under the Generic Copayment level, prescription would be needed to apply the generic Copayment Amount at the time of purchase.

Tobacco cessation drugs (including both prescription and over- the- counter drugs) prescribed by a Health Care Practitioner are covered at no cost share and will not be subject to Deductibles, Copayment Amounts and Co- Share Amounts for two 90- day treatment regimens per benefit period as required by the United States Preventive Services Task Force as referenced in the Preventive Care section of the PHARMACY BENEFITS portion of the Plan.

Contraceptive drugs and devices obtained from a Participating Pharmacy that are identified on the BCBSTX website under Contraceptive - Pharmacy information (referenced in the medical portion of the Plan as part of Benefits for Preventive Care Services) will not be subject to Deductibles, Copayment Amounts, and Co- Share Amounts.

Additional contraceptive drugs and contraceptive devices are covered under the Pharmacy portion of the Plan and are subject to the applicable Copayment Amounts, Co- Share Amounts, and any pricing differences. * If you receive a Preferred Brand Name Drug or a Non- Preferred Brand Name Drug when a Generic Drug is available, you may incur additional costs. Refer to the Pharmacy Benefits portion of this Benefit Booklet for details. ** Select Participating Pharmacies that have contracted with BCBSTX to provide this service may have age, scheduling, or other requirements that will apply, so you are encouraged to contact them in advance. Vaccinations at all other pharmacies (participating and non- participating) will be payable at the non- participating benefit level. Childhood immunizations subject to state regulations are not available under this pharmacy benefit. Refer to your BCBSTX medical coverage for benefits available for childhood immunizations. A Select Participating Pharmacy is a Pharmacy that has specifically contracted with BCBSTX to administer vaccinations to Participants.

Not all Participating Pharmacies are Select Participating Pharmacies.

NOTE: In the How Member Payment is Determined subsection of the PHARMACY BENEFITS section, an explanation of how the prescription drug products are separated into tiers is shown.

Dependent Eligibility Dependent Child Age Limit to age 26.

Dependent children are not eligible for Maternity Care Preexisting Conditions Preexisting conditions are covered immediately.

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School Medical Plan Plan Provisions

Deductibles • Per- admission Deductible • Calendar Year Deductible Three- month Deductible carryover applies Applies to all Eligible Expenses Co-Share Stop-Loss Amounts (Includes Calendar Year Deductible and Copayment Amounts) Copayment Amounts Required • Virtual visit - MDLive

In-Network Benefits

Out-of-Network Benefits

None

$200 per- admission Deductible

$1,000 – per individual

$3,000 – per individual

$3,000 – per family

$9,000 – per family

$5,000 – per individual

$7,500 – per individual

$16,300 – per family

$22,5000 – per family

$10 Copay

Does Not Apply

$35 Physician office visit • Physician office visit/consultation for Primary Care Providers $40 Physician office visit • Physician office visit/consultation for Specialty Care Providers • Outpatient Hospital Emergency Room/Treatment $125 outpatient Hospital Emergency Room/Treatment Room visit Room visit $50 Urgent Care Center visit • Urgent Care Center visit • Retail Health Clinic

Does Not Apply Does Not Apply $125 outpatient Hospital Emergency Room/Treatment Room visit Does Not Apply

$35 Retail Health Clinic visit

Does Not Apply

80% of Allowable Amount after Calendar Year Deductible No penalty for failure to Preauthorize services

60% of Allowable Amount after $200 per- admission Deductible and after Calendar Year Deductible $250 penalty for failure to Preauthorize services

100% of Allowable Amount after $35 Copayment Amount 100% of Allowable Amount after $40 Copayment Amount

60% of Allowable Amount after Calendar Year Deductible 60% of Allowable Amount after Calendar Year Deductible

100% of Allowable Amount after $35/$40 Copayment Amount

60% of Allowable Amount after Calendar Year Deductible

80% of Allowable Amount after Calendar Year Deductible

60% of Allowable Amount after Calendar Year Deductible

100% of Allowable Amount

60% of Allowable Amount after Calendar Year Deductible

Inpatient Hospital Expenses All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units.

Medical-Surgical Expenses • Office visit/consultation, (Primary Care Providers) including Lab and X- Rays • Office visit/consultation, (Specialty Care Providers) including Lab and X- Rays • Radiation Therapy and Chemotherapy in the office setting • Diabetic Management (training/nutritional) • Inpatient visits • Certain Diagnostic Procedures • Home Infusion Therapy • Physician surgical services in any setting • Allergy Injections (without office visit) • Independent Lab and X-Ray • Services and supplies provided by Digi-Rad X-Ray Mobile • Services and supplies provided by Los Fresnos Medicine Clinic and Rio Hondo Medicine Clinic Extended Care Expenses

100% of Allowable Amount up to a $60 maximum 100% of Allowable Amount after $10 Copayment Amount

90% of Allowable Amount after Calendar Year Deductible • Skilled Nursing Facility

60 days combined Calendar Year maximum

• Home Health Care

60 visits combined Calendar Year maximum

18

• Hospice Care

Unlimited

School Medical Plan Plan Provisions

In-Network Benefits

Out-of-Network Benefits

Mental Health Care, Serious Mental Illness, and Substance Use Disorder (SUD) (Certain Services will require Preauthorization) Inpatient Services • Hospital Services (facility)

80% of Allowable Amount after Calendar Year Deductible

• Behavioral Health Practitioner Services

80% of Allowable Amount after Calendar Year Deductible

60% of Allowable Amount after $200 per- admission Deductible and after Calendar Year Deductible 60% of Allowable Amount after Calendar Year Deductible

100% of Allowable Amount after $35 Copayment Amount 80% of Allowable Amount after Calendar Year Deductible

60% of Allowable Amount after Calendar Year Deductible 60% of Allowable Amount after Calendar Year Deductible

Outpatient Services • Behavioral Health Practitioner Expenses (office setting) • Other Outpatient Services Emergency Care Accidental Injury & Emergency Care (including Accidental Injury & Emergency Care for Behavioral Health Services) • Facility Charges • Lab & X- Ray - without emergency room or treatment room • Physician Charges

80% of Allowable Amount after $125 outpatient Hospital emergency room Copayment Amount (waived if admitted) 100% of Allowable Amount 80% of Allowable Amount after Calendar Year Deductible

Non-Emergency Care (including Non-Emergency Care for Behavioral Health Services)

• Facility Charges

• Physician Charges

80% of Allowable Amount after Calendar Year Deductible

60% of Allowable Amount after $125 outpatient Hospital emergency room Copayment Amount (waived if admitted) and after Calendar Year Deductible 60% of Allowable Amount after Calendar Year Deductible

100% of Allowable Amount after $50 Copayment Amount

60% of Allowable Amount after Calendar Year Deductible

80% of Allowable Amount after $125 outpatient Hospital emergency room Copayment Amount (waived if admitted)

Urgent Care Services Urgent Care Center visit - including Lab & X- Ray services (excluding Certain Diagnostic Procedures) Ambulance Services Retail Health Clinic

70% of Allowable Amount after Calendar Year Deductible 100% of Allowable Amount after $35 Copayment Amount

60% of Allowable Amount after Calendar Year Deductible

100% of Allowable Amount

60% of Allowable Amount after Calendar Year Deductible

Preventative Care Services • Evidence-based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force (“USPSTF”) • Immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (“CDC”) with respect to the individual involved • Evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (“HRSA”) for infants, children, and adolescents

19

School Medical Plan Plan Provisions

In-Network Benefits

Out-of-Network Benefits

100% of Allowable Amount

60% of Allowable Amount after Calendar Year Deductible

100% of Allowable Amount

100% of Allowable Amount

100% of Allowable Amount

60% of Allowable Amount after Calendar Year Deductible

100% of Allowable Amount after $35/$40 Copayment Amount

60% of Allowable Amount after Calendar Year Deductible

• Office visit

100% of Allowable Amount after $35/$40 Copayment Amount

60% of Allowable Amount after Calendar Year Deductible

• All other services

80% of Allowable Amount after Calendar Year Deductible

60% of Allowable Amount after Calendar Year Deductible

Preventive Care Services (Cont'd) • With respect to women, such additional preventive care and screenings, not described in the first bullet above, as provided for in comprehensive guidelines supported by the HRSA • Routine physical examinations, well baby care, immunizations, and routine Lab • Routine X- Rays, Routine EKG, Routine Diagnostic Medical Procedures (Independent Lab & X- Ray Provider) • Colonoscopy, Physician and facility charges • Healthy diet counseling and obesity screening/ counseling • Childhood immunizations Other Routine Services • Routine X- Rays, Routine EKG, Routine Diagnostic Medical Procedures • Annual Hearing Examination • Annual Vision Examination Speech and Hearing Services

1 per ear per 36- month period for hearing aids Chiropractic Services (35 visits maximum per Calendar Year) • Office visit • All other services • All other Outpatient Services

• Airrosti Provider

100% of Allowable Amount after $35/$40 Copayment Amount 60% of Allowable Amount after Calendar Year Deductible 80% of Allowable Amount after Calendar Year Deductible 35 visits combined per Calendar Year maximum for above 80% of Allowable Amount after Calendar Year Deductible

60% of Allowable Amount after Calendar Year Deductible 60% of Allowable Amount after Calendar Year Deductible 60% of Allowable Amount after Calendar Year Deductible Does Not Apply

35 visits maximum per Calendar Year Physical Medicine Services (35 visits maximum per Calendar Year) • Office visit/Office services

100% of Allowable Amount after $35/$40 Copayment Amount

60% of Allowable Amount after Calendar Year Deductible

• All other outpatient services

80% of Allowable Amount after Calendar Year Deductible

60% of Allowable Amount after Calendar Year Deductible

20

School Medical Pharmacy Benefits Plan Provisions

Participating Pharmacy

Non-Participating Pharmacy

Retail Pharmacy 90 day supply with 1 Copayment Amount per 30-day supply at a Participating Pharmacy $0 Copayment Amount

80% of Allowable Amount minus Copayment Amount

• Preferred Brand Name Drugs

$35 Copayment Amount*

80% of Allowable Amount minus Copayment Amount

• Non- Preferred Brand Name Drugs

$50 Copayment Amount*

80% of Allowable Amount minus Copayment Amount

• Generic Drugs

Specialty Pharmacy Program Specialty Pharmacy Provider Specialty Drugs- limited to a 30-day supply at a $100 Copayment Amount* Specialty Pharmacy Provider Specialty Drugs Mail-Order Program One Copayment Amount per 90 day supply, up to a 90-day supply only • Generic Drugs

Not Covered

$0 Copayment Amount

• Preferred Brand Name Drugs

$70 Copayment Amount*

• Non- Preferred Brand Name Drugs

$100 Copayment Amount*

Not Covered

Select Participating Pharmacy 100% of Allowable Amount Select Vaccinations Obtained through Participating 80% of Allowable Amount minus Any other Participating Pharmacy 80% Pharmacies** Copayment Amount of Allowable Amount minus Copayment Amount Prior Authorization Provision Applies Step Therapy Provision Applies Limitations on Quantities Dispensed Applies Diabetes Supplies are available under the Pharmacy Benefits portion of your Plan. All provisions of this portion of the Plan Prescribed and over- the- counter will be paid under the Generic Copayment level, prescription would be needed to apply the generic Copayment Amount at the time of purchase.

Tobacco cessation drugs (including both prescription and over- the- counter drugs) prescribed by a Health Care Practitioner are covered at no cost share and will not be subject to Deductibles, Copayment Amounts and Co-Share Amounts for two 90- day treatment regimens per benefit period as required by the United States Preventive Services Task Force as referenced in the Preventive Care section of the PHARMACY BENEFITS portion of the Plan.

Contraceptive drugs and devices obtained from a Participating Pharmacy that are identified on the BCBSTX website under Contraceptive - Pharmacy information (referenced in the medical portion of the Plan as part of Benefits for Preventive Care Services) will not be subject to Deductibles, Copayment Amounts, and Co-Share Amounts.

Additional contraceptive drugs and contraceptive devices are covered under the Pharmacy portion of the Plan and are subject to the applicable Copayment Amounts, Co- Share Amounts, and any pricing differences. * If you receive a Preferred Brand Name Drug or a Non- Preferred Brand Name Drug when a Generic Drug is available, you may incur additional costs. Refer to the Pharmacy Benefits portion of this Benefit Booklet for details. ** Select Participating Pharmacies that have contracted with BCBSTX to provide this service may have age, scheduling, or other requirements that will apply, so you are encouraged to contact them in advance. Vaccinations at all other pharmacies (participating and non- participating) will be payable at the non- participating benefit level. Childhood immunizations subject to state regulations are not available under this pharmacy benefit. Refer to your BCBSTX medical coverage for benefits available for childhood immunizations. A Select Participating Pharmacy is a Pharmacy that has specifically contracted with BCBSTX to administer vaccinations to Participants.

Not all Participating Pharmacies are Select Participating Pharmacies.

NOTE: In the How Member Payment is Determined subsection of the PHARMACY BENEFITS section, an explanation of how the prescription drug products are separated into tiers is shown.

Dependent Eligibility Dependent Child Age Limit to age 26.

Dependent children are not eligible for Maternity Care Preexisting Conditions Preexisting conditions are covered immediately.

21

HD Medical Plan w/HSA Plan Provisions

Deductibles • Per- admission Deductible • Calendar Year Deductible Three- month Deductible carryover applies Applies to all Eligible Expenses Co-Share Stop-Loss Amounts (Includes Calendar Year Deductible and Copayment Amounts) Copayment Amounts Required • Virtual visit - MDLive • Physician office visit/consultation for Primary Care Providers • Physician office visit/consultation for Specialty Care Providers • Outpatient Hospital Emergency Room/Treatment Room visit • Urgent Care Center visit • Retail Health Clinic

In-Network Benefits

Out-of-Network Benefits

None

None

$2,800– per individual

$5,000 – per individual

$7,500 – per family

$15,000 – per family

$6,500 – per individual

$18,000 – per individual

$13,800 – per family

$36,000 – per family

$44 Before Deductible is Met Covered at 100% After Deductible 80% After Deductible

Does Not Apply 50% After Deductible

80% After Deductible

50% After Deductible

80% After Deductible

50% After Deductible

80% After Deductible

50% After Deductible

80% After Deductible

50% After Deductible

80% After Deductible

50% After Deductible

No penalty for failure to Preauthorize services

$250 penalty for failure to Preauthorize services

80% After Deductible

50% After Deductible

80% After Deductible

50% After Deductible

80% After Deductible

50% After Deductible

80% After Deductible

50% After Deductible

Inpatient Hospital Expenses

All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units.

Medical-Surgical Expenses • Office visit/consultation, (Primary & Specialty Care Providers) including Lab and X- Rays • Office visit/consultation, (Specialty Care Providers) including Lab and X- Rays • Radiation Therapy and Chemotherapy in the office setting • Diabetic Management (training/nutritional) • Inpatient visits • Certain Diagnostic Procedures • Home Infusion Therapy • Physician surgical services in any setting • Allergy Injections (without office visit) • Independent Lab and X-Ray • Services and supplies provided by Digi-Rad X-Ray Mobile • Services and supplies provided by Los Fresnos Medicine Clinic and Rio Hondo Medicine Clinic Extended Care Expenses

80% After Deductible 50% After Deductible 100% of Allowable Amount up to a $60 maximum after Calendar Year Deductible 100% of Allowable Amount up to a $60 maximum after Calendar Year Deductible 90% of Allowable Amount after Calendar Year Deductible

• Skilled Nursing Facility

60 days combined Calendar Year maximum

• Home Health Care

60 visits combined Calendar Year maximum

• Hospice Care 22

Unlimited

HD Medical Plan w/HSA Plan Provisions

In-Network Benefits

Out-of-Network Benefits

Mental Health Care, Serious Mental Illness, and Substance Use Disorder (SUD) (Certain Services will require Preauthorization) Inpatient Services • Hospital Services (facility)

80% of Allowable Amount after Calendar Year Deductible

• Behavioral Health Practitioner Services

80% of Allowable Amount after Calendar Year Deductible

50% of Allowable Amount after $200 per-admission Deductible and after Calendar Year Deductible 50% of Allowable Amount after Calendar Year Deductible

• Behavioral Health Practitioner Expenses (office setting)

80% After Deductible

50% After Deductible

• Other Outpatient Services

80% After Deductible

50% After Deductible

Outpatient Services

Emergency Care Accidental Injury & Emergency Care (including Accidental Injury & Emergency Care for Behavioral Health Services) • Facility Charges

80% After Deductible

50% After Deductible

• Lab & X- Ray - without emergency room or treatment room

80% After Deductible

50% After Deductible

• Physician Charges

80% After Deductible

50% After Deductible

Non-Emergency Care (including Non-Emergency Care for Behavioral Health Services) • Facility Charges

80% After Deductible

50% After Deductible

• Physician Charges

80% After Deductible

50% After Deductible

80% After Deductible

50% After Deductible

Urgent Care Services Urgent Care Center visit - including Lab & X- Ray services (excluding Certain Diagnostic Procedures) Ambulance Services Retail Health Clinic

80% of Allowable Amount after Calendar Year Deductible 80% After Deductible

50% After Deductible

100% of Allowable Amount

50% of Allowable Amount after Calendar Year Deductible

Preventative Care Services • Evidence-based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force (“USPSTF”) • Immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (“CDC”) with respect to the individual involved • Evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (“HRSA”) for infants, children, and adolescents

23

HD Medical Plan w/HSA Plan Provisions

In-Network Benefits

Out-of-Network Benefits

100% of Allowable Amount

50% of Allowable Amount after Calendar Year Deductible

100% of Allowable Amount

50% of Allowable Amount

• Routine X- Rays, Routine EKG, Routine Diagnostic Medical Procedures

80% After Deductible

50% After Deductible

• Annual Hearing Examination • Annual Vision Examination

80% After Deductible

50% After Deductible

• Office visit

80% After Deductible

50% After Deductible

• All other services

80% After Deductible

50% After Deductible

Preventive Care Services (Cont'd) • With respect to women, such additional preventive care and screenings, not described in the first bullet above, as provided for in comprehensive guidelines supported by the HRSA • Routine physical examinations, well baby care, immunizations, and routine Lab • Routine X- Rays, Routine EKG, Routine Diagnostic Medical Procedures (Independent Lab & X- Ray Provider) • Colonoscopy, Physician and facility charges • Healthy diet counseling and obesity screening/ counseling • Childhood immunizations Other Routine Services

Speech and Hearing Services

1 per ear per 36- month period for hearing aids Chiropractic Services (35 visits maximum per Calendar Year) • Office visit

80% After Deductible

50% After Deductible

• All other services

80% After Deductible

50% After Deductible

35 visits combined per Calendar Year maximum for above • Airrosti Provider

80% After Deductible

50% After Deductible

35 visits maximum per Calendar Year Physical Medicine Services (35 visits maximum per Calendar Year) • Office visit/Office services

80% After Deductible

50% After Deductible

• All other outpatient services

80% After Deductible

50% After Deductible

24

HD Medical Plan w/HSA Pharmacy Benefits Plan Provisions

Participating Pharmacy

Retail Pharmacy 90 day supply with 1 Copayment Amount per 30-day supply at a Participating Pharmacy $0 Copayment Amount • Generic Drugs After Calendar Year Deductible • Preferred Brand Name Drugs

$35 Copayment Amount* After Calendar Year Deductible

• Non- Preferred Brand Name Drugs

$35 Copayment Amount* After Calendar Year Deductible

Specialty Pharmacy Program Specialty Drugs- limited to a 30-day supply at a Specialty Pharmacy Provider

Specialty Pharmacy Provider $100 Copayment Amount* After Calendar Year Deductible Specialty Drugs

Non-Participating Pharmacy

Out-of-Network Pharmacy Benefit: You must pay 100% of the charges and submit for reimbursement. You will be reimbursed the amount that would have been charged by a network pharmacy less the required deductible and coinsurance.

Not Covered

Mail-Order Program One Copayment Amount per 90 day supply, up to a 90-day supply only. After calendar year deductible is met the following copays apply.

• Generic Drugs

$0 Copayment Amount

• Preferred Brand Name Drugs

$70 Copayment Amount*

• Non- Preferred Brand Name Drugs

$100 Copayment Amount*

Not Covered

Select Participating Pharmacy: 100% of Allowable Amount Select Vaccinations Obtained through Participating 80% of Allowable Amount minus Any other Participating Pharmacy: 80% Pharmacies** Copayment Amount of Allowable Amount minus Copayment Amount Prior Authorization Provision Applies Step Therapy Provision Applies Limitations on Quantities Dispensed Applies Diabetes Supplies are available under the Pharmacy Benefits portion of your Plan. All provisions of this portion of the Plan Prescribed and over- the- counter will be paid under the Generic Copayment level, prescription would be needed to apply the generic Copayment Amount at the time of purchase.

Tobacco cessation drugs (including both prescription and over- the- counter drugs) prescribed by a Health Care Practitioner are covered at no cost share and will not be subject to Deductibles, Copayment Amounts and Co-Share Amounts for two 90- day treatment regimens per benefit period as required by the United States Preventive Services Task Force as referenced in the Preventive Care section of the PHARMACY BENEFITS portion of the Plan.

Contraceptive drugs and devices obtained from a Participating Pharmacy that are identified on the BCBSTX website under Contraceptive - Pharmacy information (referenced in the medical portion of the Plan as part of Benefits for Preventive Care Services) will not be subject to Deductibles, Copayment Amounts, and Co-Share Amounts.

Additional contraceptive drugs and contraceptive devices are covered under the Pharmacy portion of the Plan and are subject to the applicable Copayment Amounts, Co- Share Amounts, and any pricing differences. * If you receive a Preferred Brand Name Drug or a Non- Preferred Brand Name Drug when a Generic Drug is available, you may incur additional costs. Refer to the Pharmacy Benefits portion of this Benefit Booklet for details. ** Select Participating Pharmacies that have contracted with BCBSTX to provide this service may have age, scheduling, or other requirements that will apply, so you are encouraged to contact them in advance. Vaccinations at all other pharmacies (participating and non- participating) will be payable at the non- participating benefit level. Childhood immunizations subject to state regulations are not available under this pharmacy benefit. Refer to your BCBSTX medical coverage for benefits available for childhood immunizations. A Select Participating Pharmacy is a Pharmacy that has specifically contracted with BCBSTX to administer vaccinations to Participants.

Not all Participating Pharmacies are Select Participating Pharmacies.

NOTE: In the How Member Payment is Determined subsection of the PHARMACY BENEFITS section, an explanation of how the prescription drug products are separated into tiers is shown.

Dependent Eligibility Dependent Child Age Limit to age 26.

Dependent children are not eligible for Maternity Care Preexisting Conditions Preexisting conditions are covered immediately.

25

EECU

HSA (Health Savings Account)

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

YOUR BENEFITS PACKAGE

The interest earned in an HSA is tax free.

Money withdrawn for medical spending never falls under taxable income.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included This is a general overview of your plan benefits.inIfthe thesummary terms of plan this outline differlocated from your policy, the policy will govern. Additional plan description on the 26 details on covered expenses, limitations and exclusions arewww.mybenefitshub.com/losfresnoscisd included in the summary plan description located on the Los Fresnos CISD Benefits Website: Los Fresnos CISD Benefits Website: www.mybenefitshub.com/losfresnoscisd

HSA (Health Savings Account) What is an HSA?

How to Use Your Funds

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

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

•

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

•

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

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

EECU HSA Benefits •

•

Save money tax-free for healthcare expenses – contributions are not subject to federal income taxes and can be made by • you, your employer or a third party* • No monthly service fee – so you can save more and earn more • Earn competitive dividends on your entire balance – Save your receipts – for all qualified medical expenses. compounded daily and paid monthly from deposit to EECU does not verify eligibility. You are responsible for withdrawal making sure payments are for qualified medical expenses.

• Conveniently pay for qualified healthcare expenses – with a free, no annual fee EECU HSA Debit Mastercard® or via EECU’s free online bill pay. (HSA checks are also available How To Manage Your Account upon request, for a nominal fee**) • Online - check your balance, pay healthcare providers and • Free online, mobile and branch access – allows you to arrange deposits; sign-up for online banking at actively manage your account however you prefer www.eecu.org.

• Comprehensive service and support – to assist you in • Mobile - EECU’s mobile app allows you to manage your optimizing your healthcare saving and spending account on the go; download “EECU Mobile Banking” in • Federally insured – to at least $250,000 by NCUA Apple’s App Store and Google Play.

• Contact Member Service – call 817-882-0800 for help with 2021 Annual HSA Contribution Limits your HSA questions or transactions. You can also chat with Individual: $3,600 us online at eecu.org or use our secure email. Member Family: $7,200 Service is available Monday through Friday from 8:00am – Catch-Up Contributions: Accountholders who meet the 7:00pm CT, Saturdays from 9am – 1pm CT and closed on qualifications noted below are eligible to make an HSA Sunday. catch-up contribution of an additional $1,000.

• Account Statements – monthly statements show all your • Health Savings accountholder account activity for that period. You can receive free online • Age 55 or older (regardless of when in the year an statements or pay $2 per printed statement. accountholder turns 55) * Contributions, investment earnings, and distributions are tax free for federal tax purposes if • Not enrolled in Medicare (if an accountholder enrolls in used to pay for qualified medical expenses, and may or may not be subject to state taxation.

Medicare mid-year, catch-up contributions should be A list of Eligible Medical Expenses can be found in IRS Publication 502, http://www.irs.gov/ pub/irs-pdf/p502.pdf. As described in IRS publication 969, http://www.irs.gov/pub/irs-pdf/ prorated) p969.pdf, certain over-the-counter medications (when prescribed by a doctor) are Authorized Signers who are 55 or older must have their own considered eligible medical expenses for HSA purposes. If an individual is 65 or older, there is no penalty to withdraw HSA funds. However, income taxes will apply if the distribution is not HSA in order to make the catch-up contribution used for qualified medical expenses. For more information consult a tax adviser or your state department of revenue. All contributions and distributions are your responsibility and must be within IRS regulatory limits. ** Call 817-882-0800 or stop-by an EECU branch to order standard checks at no charge (excludes shipping and handling) or order custom checks - prices vary.

27

BCBSTX

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 28 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Los Fresnos CISD Benefits Website: www.mybenefitshub.com/losfresnoscisd

Dental Plan PLAN OVERALL PAYMENT PROVISIONS

DENTAL BENEFITS

Deductibles Calendar Year Deductible Three month Deductible carryover applies

$50 – per individual $150 – per family

Maximum Calendar Year Benefits per Participant for Categories I, II, III, IV, V, VI, VII, VIII, IX, X

$ 1,250

Does not apply to Orthodontic I.

Diagnostic & Preventive Care Services

90% of Allowable Amount

II. Miscellaneous Services

80% of Allowable Amount after Calendar Year Deductible

III. Restorative Services

80% of Allowable Amount after Calendar Year Deductible

IV. General Services

80% of Allowable Amount after Calendar Year Deductible

V. Endodontic Services

80% of Allowable Amount after Calendar Year Deductible

VI. Periodontal Services

80% of Allowable Amount after Calendar Year Deductible

VII. Oral Surgery Services

80% of Allowable Amount after Calendar Year Deductible

VIII. Crowns, Inlays/Onlays Services

50% of Allowable Amount after Calendar Year Deductible

IX. Prosthodontic Services

50% of Allowable Amount after Calendar Year Deductible

OPTIONAL COVERAGE X. Implant Services

50% of Allowable Amount after Calendar Year Deductible

XI. Orthodontic Services All Participants $1,250 maximum lifetime benefit

50% of Allowable Amount

Predetermination Amount

$300

Dependent Child Age Limit

Age 26 MONTHLY PREMIUMS 12-Pay Deductions

18-Pay Deductions

24-Pay Deductions

Employee Only

$30.00

$20.00

$15.00

Employee + Spouse

$58.00

$38.67

$29.00

Employee + 1 Child

$45.00

$30.00

$22.50

Employee + Child(ren)

$60.00

$40.00

$30.00

Employee + Family

$87.00

$58.00

$43.50

29

SUPERIOR VISION

Vision

YOUR BENEFITS PACKAGE

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

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

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included This is a general overview of your plan benefits.inIfthe thesummary terms of plan this outline differlocated from your policy, the policy will govern. Additional plan description on the 30 details on covered expenses, limitations and exclusions arewww.mybenefitshub.com/losfresnoscisd included in the summary plan description located on the Los Fresnos CISD Benefits Website: Los Fresnos CISD Benefits Website: www.mybenefitshub.com/losfresnoscisd

Vision Benefits

In-Network Exam Covered in full $130 retail Frames allowance Lenses (standard) per pair Single Vision Bifocal Trifocal Progressive Lenticular Contact Lenses2 Medically Necessary Contact Lenses

Covered in full

Out-of-Network Up to $35 retail

EE Only

$8.30

Up to $70 retail

EE + 1 Dependent

$14.15

EE + Family

$20.79 Co-Pays

Up to $25 retail

Covered in full Covered in full Up to $45 retail See description1 Up to $45 retail Covered in full Up to $80 retail $150 retail Up to $80 retail allowance Covered in full

Monthly Premiums

Up to $150 retail

Exam

$10

Materials

$10

Services/Frequency Exam Frame Lenses Contact Lenses

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

12 months 12 months 12 months 12 months

(Based on date of service)

1 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 2 Contact lenses and related professional services (fitting, evaluation and follow-up) are covered in lieu of eyeglass lenses and frames benefit

Discount Features Non-Covered Eyewear Discount: Members may also receive a discount of 20% from a participating provider’s usual and customary fees for eyewear purchases which exceed the benefit coverage (except disposable contact lenses, for which no discount applies). This includes eyeglass frames which exceed the selected benefit coverage, specialty lenses (i.e. progressives) and lens “extras” such as tints and coatings. Eyewear purchased from a Walmart Vision Center does not qualify for this additional discount because of Walmart’s “Always Low Prices” policy.

SuperiorVision.com Customer Service 800.507.3800 The Plan discount features are not insurance.

All allowances are retail; the member is responsible for paying the provider directly for all non-covered items and/or any amount over the allowances, minus available discounts. These are not covered by the plan. Discounts are subject to change without notice.

Disclaimer: All final determinations of benefits, administrative duties, and definitions are governed by the Certificate of Insurance for your vision plan. Please check with your Human Resources department if you have any questions Superior Vision of Texas P.O. Box 967 Rancho Cordova, CA 95741 800.507.3800 SuperiorVision.com 0116-BSv2/TX

31

THE HARTFORD YOUR BENEFITS PACKAGE

Disability

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

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

34.6 months is the duration of the average disability claim.

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

Long Term Disability What is Long-Term Disability Insurance?

What does “Actively at Work” mean?

Long-Term Disability Insurance pays you a portion of your earnings if you cannot work because of a disabling illness or injury. You have the opportunity to purchase Long-Term Disability Insurance through your employer.

This highlight sheet is an overview of your Long-Term Disability Insurance. Once a group policy is issued to your employer, a certificate of insurance will be available to explain your coverage in detail.

You must be at work with your Employer on your regularly scheduled workday. On that day, you must be performing for wage or profit all of your regular duties in the usual way and for your usual number of hours. If school is not in session due to normal vacation or school break(s), Actively at Work shall mean you are able to report for work with your Employer, performing all of the regular duties of Your Occupation in the usual way for your usual number of hours as if school was in session.

How long do I have to wait before I can receive my benefit?

Why do I need Long-Term Disability Coverage?

You must be disabled for at least the number of days indicated Most accidents and injuries that keep people off the job happen by the elimination period that you select before you can receive outside the workplace and therefore are not covered by a Long-Term Disability benefit payment. worker’s compensation. When you consider that nearly three in For those employees electing an elimination period of 30 days 10 workers entering the workforce today will become disabled or less, if your are confined to a hospital for 24 hours or more before retiring1, it’s protection you won’t want to be without. due to a disability, the elimination period will be waived, and 1 Social Security Administration, Fact Sheet 2009. benefits will be payable from the first day of disability.

What is disability?

Disability is defined in The Hartford’s* contract with your employer. Typically, disability means that you cannot perform one or more of the essential duties of your occupation due to injury, sickness, pregnancy or other medical condition covered by the insurance, and as a result, your current monthly earnings are 80% or less of your pre-disability earnings.

Once you have been disabled for 24 months, you must be prevented from performing one or more of the essential duties of any occupation and as a result, your current monthly earnings are 66 2/3% or less of your pre-disability earnings.

What is an elimination period?

The elimination period that you select consists of two numbers.

The first number shows the number of days you must be disabled by an accident before your benefits can begin. The second number indicates the number of days you must be disabled by a sickness before your benefits can begin.

I already have Disability coverage; do I have to do anything?

If you are not changing the amount of your coverage or your elimination period option, you do not have to do anything. If you want to purchase Long-Term Disability insurance for the first Am I eligible? time or change your coverage, please be sure to complete the You are eligible if you are an active employee who works at least online enrollment, which indicates your election.

20 hours per week on a regularly scheduled basis.

How much coverage would I have?

You may purchase coverage that will pay you a monthly flat dollar benefit in $100 increments between $200 and $8,000 that cannot exceed 66 2/3% of your current monthly earnings.

Your plan includes a minimum benefit, greater of 10% of your elected benefit or $100. Earnings are defined in The Hartford’s contract with your employer.

What other benefits are included in my disability coverage?

•

•

When can I enroll?

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

When is it effective?

Coverage goes into effect subject to the terms and conditions of the policy. You must satisfy the definition of Actively at Work with your employer on the day your coverage takes effect.

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

Survivor Benefit - If you die while receiving disability benefits, a benefit will be paid to your spouse, or in equal shares to your surviving children under the age of 25, equal to three times the last monthly gross benefit.

The Hartford's Ability Assist service is included as a part of your group Long Term Disability (LTD) insurance program.

You have access to Ability Assist services both prior to a disability and after you’ve been approved for an LTD claim and are receiving LTD benefits. Once you are covered you are eligible for services to provide assistance with child/ elder care, substance abuse, family relationships and more.

In addition, LTD claimants and their immediate family members receive confidential services to assist them with

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Long Term Disability the unique emotional, financial and legal issues that may result from a disability. Ability Assist services are provided through ComPsych®, a leading provider of employee assistance and work/life services.

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

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

Identity Theft Protection – An array of identity fraud support services to help victims restore their identity. Benefits include 24/7 access to an 800 number; direct contact with a certified caseworker who follows the case until it’s resolved; and a personalized fraud resolution kit with instructions and resources for ID theft victims.

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

Pre-existing Conditions: Your policy limits the benefits you can • receive for a disability caused by a pre-existing condition. In general, if you were diagnosed or received care for a disabling condition within the 3 consecutive months just prior to the effective date of this policy, your benefit payment will be limited, unless: You have not received treatment for the • disabling condition within 3 months, while insured under this policy, before the disability begins, or You have been insured under this policy for 12 months before your disability begins.

You may also be covered if you have already satisfied the preexisting condition requirement of your previous insurer. If your disability is a result of a pre-existing condition we will pay How long will my disability payments continue? Can benefits for a maximum of 4 weeks.

Your benefit payments may be reduced by other income you the duration of my benefit be reduced?

Benefit Duration is the maximum time for which we pay benefits receive or are eligible to receive due to your disability, such as: for disability resulting from sickness or injury. Depending on the • Social Security Disability Insurance or alternative plan (please see next section for exceptions) schedule selected and the age at which disability occurs, the • Workers’ Compensation maximum duration may vary. Please see the schedules below.

• Other employer-based Insurance coverage you may have • Unemployment benefits How long will my disability benefits continue if I elect • Settlements or judgments for income loss the Premium benefit option?

• Retirement benefits that your employer fully or partially The table below applies to disabilities resulting from sickness or pays for (such as a pension plan.) injury: Your benefit payments will not be reduced by certain kinds of Age Disabled Benefits Payable other income, such as: Prior to Age 63 To Normal Retirement Age or 48 months if greater • Retirement benefits if you were already receiving them Age 63 To Normal Retirement Age or 42 months if greater before you became disabled Age 64 36 months • The portion of your Long -Term Disability payment that you Age 65 30 months place in an IRS-approved account to fund your future Age 66 27 months retirement.

Age 67 24 months • Your personal savings, investments, IRAs or Keoghs Age 68 21 months Age 69 and older 18 months • Profit-sharing • Most personal disability policies Important Details • Social Security increases Exclusions: You cannot receive Disability benefit payments for disabilities that are caused or contributed to by: This Benefit Highlights Sheet is an overview of the Long-Term • War or act of war (declared or not) Disability Insurance being offered and is provided for illustrative • Military service for any country engaged in war or other purposes only and is not a contract. It in no way changes or armed conflict affects the policy as actually issued. Only the Insurance policy • The commission of, or attempt to commit a felony issued to the policyholder (your employer) can fully describe all • An intentionally self-inflicted injury of the provisions, terms, conditions, limitations and exclusions • Any case where your being engaged in an illegal occupation of your Insurance coverage. In the event of any difference was a contributing cause to your disability between the Benefit Highlights Sheet and the Insurance policy, • You must be under the regular care of a physician to receive the terms of the Insurance policy apply. benefits.

Mental Illness, Alcoholism and Substance Abuse: Underwritten by: • You can receive benefit payments for Long-Term Disabilities Hartford Life and Accident Insurance Company resulting from mental illness, alcoholism and substance 200 Hopmeadow Street abuse for a total of 24 months for all disability periods Simsbury, CT 06089 during your lifetime.

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•

Long Term Disability Los Fresnos Consolidated Independent School District Premium Plan – Monthly Premium Cost (based on 12 payments per year) Accident / Sickness Elimination Period in Days Annual Monthly Monthly Earnings Earnings Benefit

0/7

14/14

30/30

60/60

90/90

180/180

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

0/7

14/14

30/30

60/60

90/90

180/180

$3,600

$300

$200

$6.60

$4.78

$3.50

$2.96

$2.52

$1.88

$81,000 $6,750

$4,500 $148.50 $107.55 $78.75

$66.60

$56.70

$42.30

$5,400

$450

$300

$9.90

$7.17

$5.25

$4.44

$3.78

$2.82

$82,800 $6,900

$4,600 $151.80 $109.94 $80.50

$68.08

$57.96

$43.24

$7,200

$600

$400

$13.20

$9.56

$7.00

$5.92

$5.04

$3.76

$84,600 $7,050

$4,700 $155.10 $112.33 $82.25

$69.56

$59.22

$44.18

$9,000

$750

$500

$16.50

$11.95

$8.75

$7.40

$6.30

$4.70

$86,400 $7,200

$4,800 $158.40 $114.72 $84.00

$71.04

$60.48

$45.12

$10,800

$900

$600

$19.80

$14.34

$10.50

$8.88

$7.56

$5.64

$88,200 $7,350

$4,900 $161.70 $117.11 $85.75

$72.52

$61.74

$46.06

$12,600 $1,050

$700

$23.10

$16.73

$12.25

$10.36

$8.82

$6.58

$90,000 $7,500

$5,000 $165.00 $119.50 $87.50

$74.00

$63.00

$47.00

$14,400 $1,200

$800

$26.40

$19.12

$14.00

$11.84

$10.08

$7.52

$91,800 $7,650

$5,100 $168.30 $121.89 $89.25

$75.48

$64.26

$47.94

$16,200 $1,350

$900

$29.70

$21.51

$15.75

$13.32

$11.34

$8.46

$93,600 $7,800

$5,200 $171.60 $124.28 $91.00

$76.96

$65.52

$48.88

$18,000 $1,500

$1,000

$33.00

$23.90

$17.50

$14.80

$12.60

$9.40

$95,400 $7,950

$5,300 $174.90 $126.67 $92.75

$78.44

$66.78

$49.82

$19,800 $1,650

$1,100

$36.30

$26.29

$19.25

$16.28

$13.86

$10.34

$97,200 $8,100

$5,400 $178.20 $129.06 $94.50

$79.92

$68.04

$50.76

$21,600 $1,800

$1,200

$39.60

$28.68

$21.00

$17.76

$15.12

$11.28

$99,000 $8,250

$5,500 $181.50 $131.45 $96.25

$81.40

$69.30

$51.70

$23,400 $1,950

$1,300

$42.90

$31.07

$22.75

$19.24

$16.38

$12.22

$100,800 $8,400

$5,600 $184.80 $133.84 $98.00

$82.88

$70.56

$52.64

$25,200 $2,100

$1,400

$46.20

$33.46

$24.50

$20.72

$17.64

$13.16

$102,600 $8,550

$5,700 $188.10 $136.23 $99.75

$84.36

$71.82

$53.58

$27,000 $2,250

$1,500

$49.50

$35.85

$26.25

$22.20

$18.90

$14.10

$104,400 $8,700

$5,800 $191.40 $138.62 $101.50 $85.84

$73.08

$54.52

$28,800 $2,400

$1,600

$52.80

$38.24

$28.00

$23.68

$20.16

$15.04

$106,200 $8,850

$5,900 $194.70 $141.01 $103.25 $87.32

$74.34

$55.46

$30,600 $2,550

$1,700

$56.10

$40.63

$29.75

$25.16

$21.42

$15.98

$108,000 $9,000

$6,000 $198.00 $143.40 $105.00 $88.80

$75.60

$56.40

$32,400 $2,700

$1,800

$59.40

$43.02

$31.50

$26.64

$22.68

$16.92

$109,800 $9,150

$6,100 $201.30 $145.79 $106.75 $90.28

$76.86

$57.34

$34,200 $2,850

$1,900

$62.70

$45.41

$33.25

$28.12

$23.94

$17.86

$111,600 $9,300

$6,200 $204.60 $148.18 $108.50 $91.76

$78.12

$58.28

$36,000 $3,000

$2,000

$66.00

$47.80

$35.00

$29.60

$25.20

$18.80

$113,400 $9,450

$6,300 $207.90 $150.57 $110.25 $93.24

$79.38

$59.22

$37,800 $3,150

$2,100

$69.30

$50.19

$36.75

$31.08

$26.46

$19.74

$115,200 $9,600

$6,400 $211.20 $152.96 $112.00 $94.72

$80.64

$60.16

$39,600 $3,300

$2,200

$72.60

$52.58

$38.50

$32.56

$27.72

$20.68

$117,000 $9,750

$6,500 $214.50 $155.35 $113.75 $96.20

$81.90

$61.10

$41,400 $3,450

$2,300

$75.90

$54.97

$40.25

$34.04

$28.98

$21.62

$118,800 $9,900

$6,600 $217.80 $157.74 $115.50 $97.68

$83.16

$62.04

$43,200 $3,600

$2,400

$79.20

$57.36

$42.00

$35.52

$30.24

$22.56

$120,600 $10,050 $6,700 $221.10 $160.13 $117.25 $99.16

$84.42

$62.98

$45,000 $3,750

$2,500

$82.50

$59.75

$43.75

$37.00

$31.50

$23.50

$122,400 $10,200 $6,800 $224.40 $162.52 $119.00 $100.64 $85.68

$63.92

$46,800 $3,900

$2,600

$85.80

$62.14

$45.50

$38.48

$32.76

$24.44

$124,200 $10,350 $6,900 $227.70 $164.91 $120.75 $102.12 $86.94

$64.86

$48,600 $4,050

$2,700

$89.10

$64.53

$47.25

$39.96

$34.02

$25.38

$126,000 $10,500 $7,000 $231.00 $167.30 $122.50 $103.60 $88.20

$65.80

$50,400 $4,200

$2,800

$92.40

$66.92

$49.00

$41.44

$35.28

$26.32

$127,800 $10,650 $7,100 $234.30 $169.69 $124.25 $105.08 $89.46

$66.74

$52,200 $4,350

$2,900

$95.70

$69.31

$50.75

$42.92

$36.54

$27.26

$129,600 $10,800 $7,200 $237.60 $172.08 $126.00 $106.56 $90.72

$67.68

$54,000 $4,500

$3,000

$99.00

$71.70

$52.50

$44.40

$37.80

$28.20

$131,400 $10,950 $7,300 $240.90 $174.47 $127.75 $108.04 $91.98

$68.62

$55,800 $4,650

$3,100 $102.30 $74.09

$54.25

$45.88

$39.06

$29.14

$133,200 $11,100 $7,400 $244.20 $176.86 $129.50 $109.52 $93.24

$69.56

$57,600 $4,800

$3,200 $105.60 $76.48

$56.00

$47.36

$40.32

$30.08

$135,000 $11,250 $7,500 $247.50 $179.25 $131.25 $111.00 $94.50

$70.50

$59,400 $4,950

$3,300 $108.90 $78.87

$57.75

$48.84

$41.58

$31.02

$136,800 $11,400 $7,600 $250.80 $181.64 $133.00 $112.48 $95.76

$71.44

$61,200 $5,100

$3,400 $112.20 $81.26

$59.50

$50.32

$42.84

$31.96

$138,600 $11,550 $7,700 $254.10 $184.03 $134.75 $113.96 $97.02

$72.38

$63,000 $5,250

$3,500 $115.50 $83.65

$61.25

$51.80

$44.10

$32.90

$140,400 $11,700 $7,800 $257.40 $186.42 $136.50 $115.44 $98.28

$73.32

$64,800 $5,400

$3,600 $118.80 $86.04

$63.00

$53.28

$45.36

$33.84

$142,200 $11,850 $7,900 $260.70 $188.81 $138.25 $116.92 $99.54

$74.26

$66,600 $5,550

$3,700 $122.10 $88.43

$64.75

$54.76

$46.62

$34.78

$144,000 $12,000 $8,000 $264.00 $191.20 $140.00 $118.40 $100.80 $75.20

$68,400 $5,700

$3,800 $125.40 $90.82

$66.50

$56.24

$47.88

$35.72

$70,200 $5,850

$3,900 $128.70 $93.21

$68.25

$57.72

$49.14

$36.66

$72,000 $6,000

$4,000 $132.00 $95.60

$70.00

$59.20

$50.40

$37.60

$73,800 $6,150

$4,100 $135.30 $97.99

$71.75

$60.68

$51.66

$38.54

$75,600 $6,300

$4,200 $138.60 $100.38 $73.50

$62.16

$52.92

$39.48

$77,400 $6,450

$4,300 $141.90 $102.77 $75.25

$63.64

$54.18

$40.42

$79,200 $6,600

$4,400 $145.20 $105.16 $77.00

$65.12

$55.44

$41.36

35

AMERICAN PUBLIC LIFE

Cancer

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

YOUR BENEFITS PACKAGE

Breast Cancer is the most commonly diagnosed cancer in women.

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

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

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

SUMMARY OF BENEFITS

Plan 1

Cancer Treatment Policy Benefits

Level 1

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

$10,000

Hormone Therapy - Maximum of 12 treatments per calendar year

$50 per treatment

Experimental Treatment

paid in same manner and under the same maximums as any other benefit Level 2

Surgical Rider Benefits

$30 unit dollar amount Max $3,000 per operation

Surgical Anesthesia

25% of amount paid for covered surgery

Bone Marrow Transplant - Maximum per lifetime

$6,000

Stem Cell Transplant - Maximum per lifetime

$600

Prosthesis - Surgical Implantation/Non-Surgical (not Hair Piece) 1 device per site, per lifetime

$1,000 / $100

Internal Cancer First Occurrence Rider Benefits

Level 1

Lump Sum Benefit - Maximum 1 per Covered Person per lifetime

$2,500

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

$3,750

Hospital Intensive Care Unit Rider Benefits Intensive Care Unit

$600 per day

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

$300 per day

TOTAL MONTHLY PREMIUMS BY PLAN** Issue Ages

Individual

Individual & Spouse

1 Parent Family

2 Parent Family

18 +

$13.42

$28.36

$17.60

$32.50

**Total premium includes the Plan selected and any applicable rider premium. Premiums are subject to increase with notice.

The premium and amount of benefits vary dependent upon the Plan selected at time of application.

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

Cancer Treatment Benefits Eligibility

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

Limitations and Exclusions

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

Only Loss for Cancer

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

Pre-Existing Condition Exclusion

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

Waiting Period

The policy and any attached riders contain a waiting period during which no benefits will be paid. If any covered person has a specified disease diagnosed before the end of the waiting period immediately following the covered person’s effective date, coverage for that person will apply only to loss that is incurred after one year from the covered person’s effective date. If any covered person is diagnosed as having a specified disease during the waiting period immediately following the covered person’s effective date, you may elect to void the certificate from the beginning and receive a full refund of premium.

If the policy replaced group specified disease cancer coverage from any company that terminated within 30 days of the certificate effective date, the waiting period will be waived for those covered persons that were covered under the prior coverage. However, the pre-existing condition exclusion provision will still apply.

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APSB-22339(TX)-0518 FBS Los Fresnos CISD

GC14 Limited Benefit Group Specified Disease Cancer Indemnity Insurance Termination of Certificate

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

Termination of Coverage

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

We may end the coverage of any Covered Person who submits a fraudulent claim.

Surgical Benefits Limitations and Exclusions

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

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

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

Limitations and Exclusions

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

Pre-Existing Condition Exclusion

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

Waiting Period

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

Termination

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

38 APSB-22339(TX)-0518 FBS Los Fresnos CISD

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

Limitations and Exclusions

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

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

Termination

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

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

Portability (Voluntary Plans Only) When you no longer meet the definition of Insured, you will have the option to continue this coverage, including any attached riders. No Evidence of Insurability will be required. Portability must meet all of the following conditions: the certificate has been continuously in force for the last 12 months; we receive a request and payment of the first premium for the portability coverage no later than 30 days after the date you no longer qualify as an eligible insured; and the policy, under which this certificate was issued, continues to be in force on the date you cease to qualify for coverage. All future premiums due will be billed directly to you. You are responsible for payment of all premiums for the portability coverage.

The benefits, terms and condition of the portability coverage will be the same as those elected under the certificate immediately prior to the date you exercised portability. Portability coverage may include any eligible dependents who were covered under the certificate at the time you ceased to qualify as an eligible insured. No new eligible dependents may be added to the portability coverage except as provided in the New Born and Adopted Children provision.

No increases in coverage will be allowed while you are exercising your rights under this rider. The premium for the portability coverage will be based on the premium tables used for such coverage at the time of the portability request.

Coverage under this rider will terminate in accordance with the provisions of the Termination of Coverage in the certificate. If the policy is no longer in force, then portability coverage is not available.

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

SUMMARY OF BENEFITS

Plan 2

Cancer Treatment Policy Benefits

Level 4

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

$20,000

Hormone Therapy - Maximum of 12 treatments per calendar year

$50 per treatment

Experimental Treatment

paid in same manner and under the same maximums as any other benefit Level 2

Surgical Rider Benefits

$30 unit dollar amount Max $3,000 per operation

Surgical Anesthesia

25% of amount paid for covered surgery

Bone Marrow Transplant - Maximum per lifetime

$6,000

Stem Cell Transplant - Maximum per lifetime

$600

Prosthesis - Surgical Implantation/Non-Surgical (not Hair Piece) 1 device per site, per lifetime

$1,000 / $100

Internal Cancer First Occurrence Rider Benefits

Level 2

Lump Sum Benefit - Maximum 1 per Covered Person per lifetime

$5,000

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

$7,500

Hospital Intensive Care Unit Rider Benefits Intensive Care Unit

$600 per day

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

$300 per day

TOTAL MONTHLY PREMIUMS BY PLAN** Issue Ages

Individual

Individual & Spouse

1 Parent Family

2 Parent Family

18 +

$19.68

$41.18

$25.04

$46.56

**Total premium includes the Plan selected and any applicable rider premium. Premiums are subject to increase with notice.

The premium and amount of benefits vary dependent upon the Plan selected at time of application.

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

Cancer Treatment Benefits Eligibility

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

Limitations and Exclusions

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

Only Loss for Cancer

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

Pre-Existing Condition Exclusion

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

Waiting Period

The policy and any attached riders contain a waiting period during which no benefits will be paid. If any covered person has a specified disease diagnosed before the end of the waiting period immediately following the covered person’s effective date, coverage for that person will apply only to loss that is incurred after one year from the covered person’s effective date. If any covered person is diagnosed as having a specified disease during the waiting period immediately following the covered person’s effective date, you may elect to void the certificate from the beginning and receive a full refund of premium.

If the policy replaced group specified disease cancer coverage from any company that terminated within 30 days of the certificate effective date, the waiting period will be waived for those covered persons that were covered under the prior coverage. However, the pre-existing condition exclusion provision will still apply.

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APSB-22339(TX)-0518 FBS Los Fresnos CISD

GC14 Limited Benefit Group Specified Disease Cancer Indemnity Insurance Termination of Certificate

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

Termination of Coverage

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

We may end the coverage of any Covered Person who submits a fraudulent claim.

Surgical Benefits Limitations and Exclusions

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

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

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

Limitations and Exclusions

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

Pre-Existing Condition Exclusion

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

Waiting Period

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

Termination

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

40 APSB-22339(TX)-0518 FBS Los Fresnos CISD

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

Limitations and Exclusions

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

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

Termination

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

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

Portability (Voluntary Plans Only) When you no longer meet the definition of Insured, you will have the option to continue this coverage, including any attached riders. No Evidence of Insurability will be required. Portability must meet all of the following conditions: the certificate has been continuously in force for the last 12 months; we receive a request and payment of the first premium for the portability coverage no later than 30 days after the date you no longer qualify as an eligible insured; and the policy, under which this certificate was issued, continues to be in force on the date you cease to qualify for coverage. All future premiums due will be billed directly to you. You are responsible for payment of all premiums for the portability coverage.

The benefits, terms and condition of the portability coverage will be the same as those elected under the certificate immediately prior to the date you exercised portability. Portability coverage may include any eligible dependents who were covered under the certificate at the time you ceased to qualify as an eligible insured. No new eligible dependents may be added to the portability coverage except as provided in the New Born and Adopted Children provision.

No increases in coverage will be allowed while you are exercising your rights under this rider. The premium for the portability coverage will be based on the premium tables used for such coverage at the time of the portability request.

Coverage under this rider will terminate in accordance with the provisions of the Termination of Coverage in the certificate. If the policy is no longer in force, then portability coverage is not available.

GC14 Limited Benefit Group Specified Disease Cancer Indemnity Insurance

2305 Lakeland Drive | Flowood, MS 39232 ampublic.com | 800.256.8606 Underwritten by American Public Life Insurance Company. This is a brief description of the coverage. For complete benefits, limitations, exclusions and other provisions, please refer to the policy/certificate/riders. This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. | This policy is considered an employee welfare benefit plan established and/or maintained by an association or employer intended to be covered by ERISA, and will be administered and enforced under ERISA. Group policies issued to governmental entities and municipalities may be exempt from ERISA guidelines. | Policy Form GC14 Series | TX | Limited Benefit Group Specified Disease Cancer Indemnity Insurance | (09/17) | FBS | Los Fresnos CISD

APSB-22339(TX)-0518 FBS Los Fresnos CISD

41

VOYA

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 42 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Los Fresnos CISD Benefits Website: www.mybenefitshub.com/losfresnoscisd

Critical Illness COMPASS CRITICAL ILLNESS INSURANCE ENROLLMENT AT A GLANCE FOR THE EMPLOYEES OF: LOS FRESNOS CISD, GROUP #70800-3

What is Critical Illness Insurance?

•

It pays a lump-sum benefit if you are diagnosed with a covered illness or condition on or after your coverage effective date.

• You have the option to elect Critical Illness Insurance.

Critical Illness 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.

• Carcinoma in situ (25% of critical illness benefit amount) *A sudden cardiac arrest is not in itself considered a heart attack. ** Major organ transplant means the irreversible failure of your heart, lung, pancreas, entire kidney or liver, or any combination thereof, determined by a physician specialized in care of the involved organ.

Major Organ Module • Type 1 Diabetes • Transient ischemic attacks (TIA) (10% of critical illness benefit) • Ruptured or dissecting aneurysm (10% of critical illness benefit) • Abdominal aortic aneurysm (10% of critical illness benefit) Features of Critical Illness Insurance include: • Thoracic aortic aneurysm (10% of critical illness benefit) • Guaranteed Issue: No medical questions or tests are required • Open heart surgery for valve replacement or repair (10% of for coverage. critical illness benefit) • Flexible: You can use the benefit payments for any purpose • Severe burns you like.

• Transcatheter heart valve replacement or repair (10% of • Portable: If you leave your current employer or retire, you critical illness benefit) can take your coverage with you. (Provision may vary by • Coronary angioplasty (10% of critical illness benefit) state.)

• Implantable/internal cardioverter defibrillator (ICD) placement (10% of critical illness benefit) Who is eligible for Critical Illness • Pacemaker placement (10% of critical illness benefit)

Insurance and what are the coverage amounts?

Enhanced Cancer Module • Benign brain tumor • Skin cancer (10% of critical illness benefit) You— all active employees working 20+ hours per week.

• You may also elect a Critical Illness benefit amount of $5,000 • Bone marrow transplant (25% of critical illness benefit) • Stem cell transplant (25% of critical illness benefit) -$30,000 in $5,000 increments Your spouse— Coverage is available only if employee coverage is Additional Child Diseases Module elected.

(This module applies to your insured children only, and is in • You may also elect a Critical Illness benefit amount of $5,000 addition to the other modules available.)

-$30,000 in $5,000 increments • Cerebral palsy • You may elect a spouse Critical Illness benefit amount up to • Congenital birth defects 100% of your benefit amount.

• Cystic fibrosis Your children— birth to age 26. Coverage is available only if • Down syndrome employee coverage is elected.

• You may also elect a children’s Critical Illness benefit amount • Gaucher disease, type II or III • Infantile Tay-Sachs of $1,000, $2,500, $5,000 or $10,000.

• Niemann-Pick disease • Pompe disease What benefits are available?

• Sickle cell anemia Critical Illness Insurance provides a benefit payment upon the • Type 1 diabetes diagnosis of an illness or condition shown below. Covered • Type IV glycogen storage disease illnesses/conditions are broken out into groups called • Zellweger syndrome “modules.” Benefits are payable at 100% of the Critical Illness benefit amount unless otherwise stated.

Base Module • Heart attack* • Cancer • Stroke • Major organ transplant** • Coronary artery bypass (25% of critical illness benefit amount)

What additional benefits does my Critical Illness Insurance include?

The benefits listed below are also included with your Critical Illness coverage.

Wellness Benefit: This provides an annual benefit payment if you complete a health screening test.

43

Critical Illness • • •

Your annual benefit amount is $50 for completing a health screening test.

Your spouse’s annual benefit amount is $50 for completing a health screening test.

The annual benefit amount for each child is $25 with an annual maximum of $100 for all children.

How many times can I receive a benefit payment?

The total maximum benefit amount equals two times the Critical Illness benefit amount for each covered condition.

Once the total maximum benefit for a covered condition has been paid, no further benefits are payable for that same covered condition.

Please refer to your certificate of insurance and riders for more information.

What do you mean by different diagnosis?

To be eligible for a benefit payment, the diagnosis must be a “different diagnosis” than any previously diagnosed illness or condition. This can mean any of the following: • An insured person has a diagnosis of a covered critical illness that is different from a previously diagnosed illness or condition. A cancer that has spread to a different area of the body is not a different illness/condition than the previously diagnosed cancer.

• An insured person receives a subsequent diagnosis of a covered critical illness that is for the same illness or condition* as a critical illness for which benefits were payable under the critical illness insurance policy. The subsequent diagnosis must occur more than 12 months after the date of the previous diagnosis.

• An insured person receives a subsequent diagnosis of a covered critical illness that is for the same illness or condition* as an illness/condition previously diagnosed prior to his/her coverage effective date under the critical illness insurance policy. The subsequent diagnosis must occur more than 12 months after the date of the previous diagnosis. *Including a cancer that has spread to a different area of the body

Are there any exclusions or limitations?

The employee's and spouse's critical illness benefit amount and total maximum benefit amount will reduce to 50% on the employee's 70th birthday. Premiums do not reduce.

Exclusions and limitations vary by state and by your employer’s plan. Please review your certificate of coverage for details.

44

How much does Critical Illness Insurance cost?

See the chart(s) below for your cost.

Employee Coverage Monthly Rates Includes Wellness Benefit Rider Non-Tobacco User Attained Age Under 25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70+

$5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $2.15 $2.30 $2.50 $3.10 $4.25 $6.25 $9.40 $13.95 $18.20 $24.35 $36.50

$4.30 $6.45 $4.60 $6.90 $5.00 $7.50 $6.20 $9.30 $8.50 $12.75 $12.50 $18.75 $18.80 $28.20 $27.90 $41.85 $36.40 $54.60 $48.70 $73.05 $73.00 $109.50

$8.60 $9.20 $10.00 $12.40 $17.00 $25.00 $37.60 $55.80 $72.80 $97.40 $146.00

$10.75 $11.50 $12.50 $15.50 $21.25 $31.25 $47.00 $69.75 $91.00 $121.75 $182.50

$12.90 $13.80 $15.00 $18.60 $25.50 $37.50 $56.40 $83.70 $109.20 $146.10 $219.00

Tobacco User Attained Age Under 25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70+

$5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $3.55 $7.10 $3.80 $7.60 $4.20 $8.40 $5.35 $10.70 $7.65 $15.30 $11.55 $23.10 $17.80 $35.60 $26.80 $53.60 $35.20 $70.40 $47.30 $94.60 $71.25 $142.50

$10.65 $11.40 $12.60 $16.05 $22.95 $34.65 $53.40 $80.40 $105.60 $141.90 $213.75

$14.20 $15.20 $16.80 $21.40 $30.60 $46.20 $71.20 $107.20 $140.80 $189.20 $285.00

$17.75 $19.00 $21.00 $26.75 $38.25 $57.75 $89.00 $134.00 $176.00 $236.50 $356.25

$21.30 $22.80 $25.20 $32.10 $45.90 $69.30 $106.80 $160.80 $211.20 $283.80 $427.50

Critical Illness Spouse Coverage Monthly Rates Includes Wellness Benefit Rider Non-Tobacco User Attained Age Under 25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70+

$5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $2.15 $2.30 $2.50 $3.10 $4.25 $6.25 $9.40 $13.95 $18.20 $24.35 $36.50

$4.30 $6.45 $4.60 $6.90 $5.00 $7.50 $6.20 $9.30 $8.50 $12.75 $12.50 $18.75 $18.80 $28.20 $27.90 $41.85 $36.40 $54.60 $48.70 $73.05 $73.00 $109.50

$8.60 $9.20 $10.00 $12.40 $17.00 $25.00 $37.60 $55.80 $72.80 $97.40 $146.00

$10.75 $11.50 $12.50 $15.50 $21.25 $31.25 $47.00 $69.75 $91.00 $121.75 $182.50

$12.90 $13.80 $15.00 $18.60 $25.50 $37.50 $56.40 $83.70 $109.20 $146.10 $219.00

Children Coverage Monthly Rates Includes Wellness Benefit Rider Coverage Amount

Rate

$1,000

$0.57

$2,500

$1.43

$5,000

$2.85

$10,000

$5.70

Tobacco User Attained Age Under 25 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70+

$5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $3.55 $7.10 $3.80 $7.60 $4.20 $8.40 $5.35 $10.70 $7.65 $15.30 $11.55 $23.10 $17.80 $35.60 $26.80 $53.60 $35.20 $70.40 $47.30 $94.60 $71.25 $142.50

$10.65 $11.40 $12.60 $16.05 $22.95 $34.65 $53.40 $80.40 $105.60 $141.90 $213.75

$14.20 $15.20 $16.80 $21.40 $30.60 $46.20 $71.20 $107.20 $140.80 $189.20 $285.00

$17.75 $19.00 $21.00 $26.75 $38.25 $57.75 $89.00 $134.00 $176.00 $236.50 $356.25

$21.30 $22.80 $25.20 $32.10 $45.90 $69.30 $106.80 $160.80 $211.20 $283.80 $427.50

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. Critical Illness Insurance is underwritten by ReliaStar Life Insurance Company (Minneapolis, MN), a member of the Voya® family of companies. Policy form #RL-CI4-POL-16; Certificate form #RL-CI4-CERT-16; Spouse Critical Illness Rider form #RL-CI4-SPR-16; Children's Critical Illness Rider form #RL-CI4-CHR-16; Wellness Benefit Rider form #RL-CI4-WELL-16; Form numbers, provisions and availability may vary by state.

CN0213-40132-0219 Los Fresnos CISD, Group 70800-3, Acct #0001 Date Prepared:09/25/2018 200555-03012018

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THE HARTFORD YOUR BENEFITS PACKAGE

Accident

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

2/3 of disabling injuries suffered by American workers are not work related.

American workers 36% ofreport they always or

usually live paycheck

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

Accident COVERAGE INFORMATION This insurance provides benefits when injuries, medical treatment and/or services occur as the result of a covered accident. Unless otherwise noted, the benefit amounts payable Los Fresnos Consolidated Independent School District under each plan are the same for you and your dependent(s).

With Accident insurance, you’ll receive payment(s) associated exclusions and limitations, see your certificate of insurance and with a covered injury and related services. You can use the payment in any way you choose – from expenses not covered by any benefits. your major medical plan to day-to-day costs of living such as the mortgage or your utility bills.

GROUP VOLUNTARY ACCIDENT INSURANCE BENEFIT HIGHLIGHTS

To learn more about Accident insurance, visit thehartford.com/ employeebenefits

More than 3.5 million children ages 14 and younger get hurt annually playing sports or participating in recreational activities.1

PLAN INFORMATION Coverage Type BENEFITS EMERGENCY, HOSPITAL & TREATMENT CARE Accident Follow-Up Up to 3 visits per accident Acupuncture/Chiropractic Care/PT Up to 10 visits each per accident Ambulance – Air Once per accident Ambulance – Ground Once per accident Blood/Plasma/Platelets Once per accident Child Care Up to 30 days per accident while insured is confined Daily Hospital Confinement Up to 365 days per lifetime Daily ICU Confinement Up to 30 days per accident Diagnostic Exam Once per accident Emergency Dental Once per accident Emergency Room Once per accident Hospital Admission Once per accident Initial Physician Office Visit Once per accident Lodging Up to 30 nights per lifetime Medical Appliance Once per accident Rehabilitation Facility Up to 15 days per lifetime Transportation Up to 3 trips per accident Urgent Care Once per accident X-ray Once per accident SPECIFIED INJURY & SURGERY Abdominal/Thoracic Surgery Once per accident Arthroscopic Surgery Once per accident Burn Once per accident Burn – Skin Graft Once per accident for third degree burn(s) Concussion Up to 3 per year Dislocation Once per joint per lifetime Eye Injury Once per accident Fracture Once per bone per accident Hernia Repair Once per accident Joint Replacement Once per accident Knee Cartilage Once per accident Laceration Once per accident Ruptured Disc Once per accident Tendon/Ligament/Rotator Cuff Up to 2 per accident FEATURES Ability Assist® EAP2 – 24/7/365 access to help for financial, legal or emotional issues HealthChampionSM2 – Administrative & clinical support following serious illness or injury

OPTION 1 Off-job only OPTION 1 $100 $50 $1,200 $400 $300 $30 $300 $600 $300 Up to $450 $200 $1,500 $100 $150 $150 $150 $500 $100 $75 OPTION 1 $2,000 $400 Up to $15,000 25% of burn benefit $200 Up to $8,000 Up to $600 Up to $9,000 $200 $3,000 Up to $1,000 Up to $600 $1,000 Up to $1,500 OPTION 1 Included Included

47

Accident PREMIUMS The amounts shown are monthly amounts (12 payments/ deductions per year): 3 COVERAGE TIER Employee Only

$11.78 ($0.39 per day)

Employee & Spouse

$18.56 ($0.61 per day)

Employee & Child(ren)

$20.12 ($0.66 per day)

Employee & Family

$31.50 ($1.04 per day)

ASKED & ANSWERED WHO IS ELIGIBLE? You are eligible for this insurance if you are an active full-time employee who works at least 20 hours per week on a regularly scheduled basis, and are less than age 80.

Your spouse and child(ren) are also eligible for coverage. Any child(ren) must be under age 26.

AM I GUARANTEED COVERAGE? This insurance is guaranteed issue coverage – it is available without having to provide information about your or your family’s health. All you have to do is elect the coverage to become insured.

HOW MUCH DOES IT COST AND HOW DO I PAY FOR THIS INSURANCE? Premiums are provided above. You may elect insurance for you only, or for you and your dependent(s), by choosing the applicable coverage tier.

Premiums will be automatically paid through payroll deduction, as authorized by you during the enrollment process. This ensures you don’t have to worry about writing a check or missing a payment.

WHEN CAN I ENROLL? You may enroll during any scheduled enrollment period, or within 31 days of the date you have a change in family status.

WHEN DOES THIS INSURANCE BEGIN? Insurance will become effective in accordance with the terms of the certificate (usually the first day of the month following the date you elect coverage).

You must be actively at work with your employer on the day your coverage takes effect. Your spouse and child(ren) must be performing normal activities and not be confined (at home or in a hospital/care facility).

WHEN DOES THIS INSURANCE END? This insurance will end when you or your dependents no longer satisfy the applicable eligibility conditions, or when you reach the age of 80, premium is unpaid, you are no longer actively working, you leave your employer, or the coverage is no longer offered.

48

CAN I KEEP THIS INSURANCE IF I LEAVE MY EMPLOYER OR AM NO LONGER A MEMBER OF THIS GROUP? Yes, you can take this coverage with you. Coverage may be continued for you and your dependent(s) under a group portability policy. Your spouse may also continue insurance in certain circumstances. The specific terms and qualifying events for portability are described in the certificate.

1“Sports Injury Statistics.” Stanford Children’s Health, n.d. Web. 30 June 2017. http://www.stanfordchildrens.org/en/topic/ default?id=sports-injury-statistics-90-P02787 2 HealthChampionSM and Ability Assist® services are provided through The Hartford by ComPsych®. ComPsych is not affiliated with The Hartford and is not a provider of insurance services.

The Hartford is not responsible and assumes no liability for the goods and services provided by ComPsych 3Rates and/or benefits may be changed.

Prepare. Protect. Prevail. With The Hartford. ®

LOS FRESNOS CONSOLIDATED INDEPENDENT SCHOOL DISTRICT ACCIDENT BHS_PUBLICATION DATE: 9/19/2018 00086304 The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Home Office is Hartford, CT. 5962g NS 08/16 © 2016 The Hartford Financial Services Group, Inc. All rights reserved.

This Benefit Highlights document explains the general purpose of the insurance described, but in no way changes or affects the policy as actually issued. In the event of a discrepancy between this document and the policy, the terms of the policy apply. Benefits are subject to state availability. Policy terms and conditions vary by state. Complete details are in the Certificate of Insurance issued to each insured individual and the Master Policy as issued to the policyholder. Accident Form Series includes GBD-2000, GBD-2300, or state equivalent.

49

AUL A ONEAMERICA COMPANY

Life and AD&D

YOUR BENEFITS PACKAGE

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

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

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

Motor vehicle crashes are the

#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 50 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Los Fresnos CISD Benefits Website: www.mybenefitshub.com/losfresnoscisd

Life and AD&D Income protection for your loved ones No matter what your current situation is: single, married, Are you eligible? Benefits are available to employees who with or without children; life insurance helps replace your are actively at work on the effective date of coverage and income, and will assist your family in paying final expenses. working the minimum number of hours per week stated in It will also allow your loved ones to continue any future the contract. plans, such as college education or savings.

Your premiums and benefits may vary. Actual premiums and benefit amounts will be calculated by OneAmerica Why you need it and may change upon reaching certain ages, according to There are several reasons you need life insurance. In contract terms, and are subject to change. Volumes and addition to paying for burial expenses, consider life benefit amounts shown may be subject to reductions due insurance an option to pay for the mortgage, medical to age. expenses and fund college education. If you work or have Enroll timely for guaranteed issue coverage. You may be savings, then you have the income to pay these bills. eligible for coverage without having to answer any health However, consider what happens when your loved ones questions if you enroll during the initial enrollment period no longer have your financial support. when benefits are first offered by OneAmerica®, or if you enroll as a newly hired employee within 31 days after any How much is enough Figuring out how much life insurance you need is hard to applicable waiting period. decide. You want to make sure you have enough to Enrolling later requires approval. If you decline coverage protect your family. To help you answer this question, use now, you will lose your only chance to apply for group the calculator to estimate your expenses to think about insurance coverage without having to first undergo medical underwriting. If you decide to enroll later, you will which bills would need income protection.

Typically, life insurance offered through work is less need to submit a Statement of Insurability form for expensive than if you purchased it on your own. Consider review. OneAmerica will then decide to approve or deny your coverage based on your health history. You may not purchasing life insurance today. be approved for any type of coverage at a later date if you have any current or future medical conditions.

What you need to know:

What you need to do: Carefully review the contents of this packet. Enclosed is personal information about the benefits offered to you by OneAmerica on behalf of your employer. This is your opportunity to learn more about group insurance from OneAmerica, but it is not a complete explanation of benefits. For more information, consult the contract about exclusions, limitations, reduction of benefits, and terms under which the contract may be continued in force or discontinued.

Review the Notices and Limitations. Visit www.employeebenefits.aul.com to find the Notices and Limitations, G-14320 (05 Prudent) 12/28/12. Go to Forms, Policy/Employee Admin, and Notices and Limitations.

THE NEED FOR LIFE INSURANCE Protecting the ones you care about most “How will my loved ones be taken care of when I’m gone?” This question isn’t something anyone wants to think about, but if someone depends on you for financial support, then life insurance is your answer.

Estimate your expenses below Income and possessions

Amount

Annual income Number of years until retirement Subtotal (annual income x years) Debt and final expenses

Credit card(s), car payment(s), etc.

Funeral and burial expenses ($7,000 is a Subtotal (debt) Educational costs College expenses

Subtotal (education) Total needed for your life insurance

$

51

Basic and Voluntary Life What you need to know about your Basic Life and AD&D Benefits Guaranteed Issue:

Employee: $10,000

Accidental Death and Dismemberment (AD&D): Additional life insurance benefits may be payable in the event of an accident which results in death or dismemberment as defined in the contract. Additional AD&D benefits include seat belt, air bag, repatriation, child higher education, child care, paralysis/loss of use, severe burns, disappearance, and exposure.

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

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

70 Reduces To:

50%

Basic Employee Life and AD&D Coverage Your Life and AD&D insurance coverage amount is $10,000.

Coverage is provided at no cost to you.

What you need to know about your Voluntary Term Life Benefits Flexible Options: Employee: $10,000 to $500,000, in $10,000 increments, not to exceed 5 times your annual salary Spouse under age 70: $10,000 to $250,000, in $5,000 increments, not to exceed 50% of the employee’s amount Guaranteed Issue: Employee: $250,000 Spouse: $30,000 Child: $10,000 Dependent Life Coverage: Optional dependent life coverage is available to eligible employees. You must select employee coverage in order to cover your spouse and/or child(ren).

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

Guaranteed Increase in Benefit: You may be eligible to increase your coverage annually until you reach your maximum amount without providing evidence of insurability.

Reductions: Upon reaching certain ages, your original benefit amount will reduce to the percentage shown in the following schedule. The amounts of dependent life insurance and dependent AD&D principal sum will reduce according to the employee's reduction schedule.

Reduces To:

52

70 50%

Voluntary Life PAYROLL DEDUCTION ILLUSTRATION: MONTHLY EMPLOYEE OPTIONS

Life Options

0-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75+

$10,000

$.30

$.30

$.30

$.40

$.70

$.80

$1.30

$2.10

$3.70

$4.80

$9.10

$14.70 $14.70

$20,000

$.60

$.60

$.60

$.80

$1.40

$1.60

$2.60

$4.20

$7.40

$9.60

$18.20 $29.40 $29.40

$30,000

$.90

$.90

$.90

$1.20

$2.10

$2.40

$3.90

$6.30

$11.10 $14.40 $27.30 $44.10 $44.10

$40,000

$1.20

$1.20

$1.20

$1.60

$2.80

$3.20

$5.20

$8.40

$14.80 $19.20 $36.40 $58.80 $58.80

$50,000

$1.50

$1.50

$1.50

$2.00

$3.50

$4.00

$6.50

$10.50 $18.50 $24.00 $45.50 $73.50 $73.50

$80,000

$2.40

$2.40

$2.40

$3.20

$5.60

$6.40

$10.40 $16.80 $29.60 $38.40 $72.80 $117.60 $117.60

$100,000

$3.00

$3.00

$3.00

$4.00

$7.00

$8.00

$13.00 $21.00 $37.00 $48.00 $91.00 $147.00 $147.00

$150,000

$4.50

$4.50

$4.50

$6.00

$10.50 $12.00 $19.50 $31.50 $55.50 $72.00 $136.50 $220.50 $220.50

$200,000

$6.00

$6.00

$6.00

$8.00

$14.00 $16.00 $26.00 $42.00 $74.00 $96.00 $182.00 $294.00 $294.00

$250,000

$7.50

$7.50

$7.50

$10.00 $17.50 $20.00 $32.50 $52.50 $92.50 $120.00 $227.50 $367.50 $367.50 SPOUSE ONLY OPTIONS

Life Options

0-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75+

$5,000

$.15

$.15

$.15

$.20

$.35

$.40

$.65

$1.05

$1.85

$2.40

$4.55

$7.35

$7.35

$10,000

$.30

$.30

$.30

$.40

$.70

$.80

$1.30

$2.10

$3.70

$4.80

$9.10

$14.70 $14.70

$15,000

$.45

$.45

$.45

$.60

$1.05

$1.20

$1.95

$3.15

$5.55

$7.20

$13.65 $22.05 $22.05

$20,000

$.60

$.60

$.60

$.80

$1.40

$1.60

$2.60

$4.20

$7.40

$9.60

$18.20 $29.40 $29.40

$30,000

$.90

$.90

$.90

$1.20

$2.10

$2.40

$3.90

$6.30

$11.10 $14.40 $27.30 $44.10 $44.10

CHILD(REN) OPTIONS

Option 1

Child(ren) 6 months to age 26

Child(ren) live birth to 6 months

$10,000

$1,000

Monthly Payroll Deduction Life Amount $1.00

Note: Employee and Spouse premiums are based on your age as of 01/01 and amount of coverage chosen. Child premiums are for all eligible children combined.

OneAmerica® is the marketing name for the companies of OneAmerica.

Los Fresnos Consolidated ISD Class: 1 Rate Effective Date: 1/1/2019

53

Voluntary AD&D What you need to know about your Voluntary AD&D Benefits Flexible AD&D Options:

Employee: Up to $500,000, in $10,000 increments Spouse: 50% of the employee AD&D benefit Child: $10,000

AD&D Guaranteed Issue: Employee: $500,000 Spouse: $250,000 Child: $10,000 Accidental Death and Dismemberment (AD&D): If AD&D is selected, additional life insurance benefits may be payable in the event of an accident which results in death or dismemberment as defined in the contract.

Dependent AD&D Coverage: Optional dependent AD&D coverage is available to eligible employees. You must select employee coverage in order to cover your spouse and/or child(ren). If employee AD&D is declined, no dependent AD&D will be included.

Reductions: Upon reaching certain ages, your original benefit amount will reduce to the percentage shown in the following schedule. The amounts of dependent AD&D principal sum will reduce according to the employee's reduction schedule.

Reduces To: Employee AD&D $10,000 $20,000 $30,000 $40,000 $50,000 $60,000 $70,000 $80,000 $90,000 $100,000 $110,000 $120,000 $130,000 $140,000 $150,000 $160,000 $170,000 $180,000 $190,000 $200,000 $210,000 $220,000 $230,000 $240,000 $250,000

EE Only

EE & SP

$0.20 $0.40 $0.60 $0.80 $1.00 $1.20 $1.40 $1.60 $0.80 $2.00 $2.20 $2.40 $2.60 $2.80 $3.00 $3.20 $3.40 $3.60 $3.80 $4.00 $4.20 $4.40 $4.60 $4.80 $5.00

$0.30 $0.60 $0.90 $1.20 $1.50 $1.80 $2.10 $2.40 $2.70 $3.00 $3.30 $3.60 $3.90 $4.20 $4.50 $4.80 $5.10 $5.40 $5.70 $6.00 $6.30 $6.60 $6.90 $7.20 $7.50

70 50%

Payroll Deduction Illustration: Monthly AD&D Options Employee EE & CH Family EE Only AD&D $0.70 $0.80 $260,000 $5.20 $0.90 $1.10 $270,000 $5.40 $1.10 $1.40 $280,000 $5.60 $1.30 $1.70 $290,000 $5.80 $1.50 $2.00 $300,000 $6.00 $1.70 $2.30 $310,000 $6.20 $1.90 $2.60 $320,000 $6.40 $2.10 $2.90 $330,000 $6.60 $2.30 $3.20 $340,000 $6.80 $2.50 $3.50 $350,000 $7.00 $2.70 $3.80 $360,000 $7.20 $2.90 $4.10 $370,000 $7.40 $3.10 $4.40 $380,000 $7.60 $3.30 $4.70 $390,000 $7.80 $3.50 $5.00 $400,000 $8.00 $3.70 $5.30 $410,000 $8.20 $3.90 $5.60 $420,000 $8.40 $4.10 $5.90 $430,000 $8.60 $4.30 $6.20 $440,000 $8.80 $4.50 $6.50 $450,000 $9.00 $4.70 $6.80 $460,000 $9.20 $4.90 $7.10 $470,000 $9.40 $5.10 $7.40 $480,000 $9.60 $5.30 $7.70 $490,000 $9.80 $5.50 $8.00 $500,000 $10.00

OneAmerica® is the marketing name for the companies of OneAmerica.

Los Fresnos Consolidated ISD Class: 1 Rate Effective Date: 1/1/2019 54

EE & SP

EE & CH

Family

$7.80 $8.10 $8.40 $8.70 $9.00 $9.30 $9.60 $9.90 $10.20 $10.50 $10.80 $11.10 $11.40 $11.70 $12.00 $12.30 $12.60 $12.90 $13.20 $13.50 $13.80 $14.10 $14.40 $14.70 $15.00

$5.70 $5.90 $6.10 $6.30 $6.50 $6.70 $6.90 $7.10 $7.30 $7.50 $7.70 $7.90 $8.10 $8.30 $8.50 $8.70 $8.90 $9.10 $9.30 $9.50 $9.70 $9.90 $10.10 $10.30 $10.50

$8.30 $8.60 $8.90 $9.20 $9.50 $9.80 $10.10 $10.40 $10.70 $11.00 $11.30 $11.60 $11.90 $12.20 $12.50 $12.80 $13.10 $13.40 $13.70 $14.00 $14.30 $14.50 $14.70 $15.20 $15.50

ComPsych GuidanceResources® Program “Employee Assistance Program" this benefit is provided by BISD and no additional charge to the employee.

Call Your ComPsych® GuidanceResources® program anytime for confidential assistance.

Call: 855.387.9727 TDD: 800.697.0353 Go online: guidanceresources.com Your company Web ID: ONEAMERICA3 Personal issues, planning for life events or simply managing daily life can affect your work, health and family. Your GuidanceResources program provides support, resources and information for personal and work-life issues. The program is companysponsored, confidential and provided at no charge to you and your dependents. This flyer explains how GuidanceResources can help you and your family deal with everyday challenges.

Confidential Counseling

Work-Life Solutions

3 Session Plan This no-cost counseling service helps you address stress, relationship and other personal issues you and your family may face. It is staffed by GuidanceConsultantsSM—highly trained master’s and doctoral level clinicians who will listen to your concerns and quickly refer you to in-person counseling (up to 3 sessions per year) and other resources for: › Stress, anxiety and depression › Job pressures › Relationship/marital conflicts › Grief and loss › Problems with children › Substance abuse

Delegate your “to-do” list.

Our Work-Life specialists will do the research for you, providing qualified referrals and customized resources for: › Child and elder care › College planning › Moving and relocation › Pet care › Making major purchases › Home repair

Financial Information and Resources Discover your best options.

Speak by phone with our Certified Public Accountants and Certified Financial Planners on a wide range of financial issues including: › Getting out of debt › Retirement planning › Credit card or loan problems › Estate planning › Tax questions › Saving for college

Legal Support and Resources Expert info when you need it.

Talk to our attorneys by phone. If you require representation, we’ll refer you to a qualified attorney in your area for a free 30minute consultation with a 25% reduction in customary legal fees thereafter. Call about: › Divorce and family law › Real estate transactions › Debt and bankruptcy › Civil and criminal actions › Landlord/tenant issues › Contracts

GuidanceResources® Online Knowledge at your fingertips.

GuidanceResources Online is your one stop for expert information on the issues that matter most to you… relationships, work, school, children, wellness, legal, financial, free time and more. › Timely articles, HelpSheetsSM, tutorials, streaming videos and self-assessments › “Ask the Expert” personal responses to your questions › Child care, elder care, attorney and financial planner searches

Free Online Will Preparation Get peace of mind.

EstateGuidance® lets you quickly and easily write a will on your computer. Just go to www.guidanceresources.com and click on the EstateGuidance link. Follow the prompts to create and download your will at no cost. Online support and instructions for executing and filing your will are included. You can: › Name an executor to manage your estate › Choose a guardian for your children › Specify your wishes for your property › Provide funeral and burial instructions

Your ComPsych® GuidanceResources® Program CALL ANYTIME Call: 855.387.9727 TDD: 800.697.0353 Online: guidanceresources.com Your company Web ID: ONEAMERICA3 OneAmerica is the marketing name for American United Life Insurance Company® (AUL). AUL markets ComPsych services. ComPsych Corporation is not an affiliate of AUL and is not a OneAmerica company. Copyright © 2016 ComPsych Corporation. All rights reserved. To view the ComPsych HIPAA privacy notice, please go to www.guidanceresources.com/privacy.

55

Life and AD&D Upon verification of coverage, Generali Global Assistance will arrange and cover the cost of the following services, subject to policy limits and Providing you peace of mind when traveling eligibility: Emergencies happen, but help is now only a phone call or email away.

• Emergency evacuation: $1,000,000 Combined Single Limit (CSL) Generali Global Assistance® offers a suite of services to help you in your • Medically necessary repatriation: Included in CSL time of need — from small inconveniences like losing your medication to • Repatriation or cremation of remains: Up to $25,000 life-threatening situations — all delivered with a caring, human touch.

If traveling alone: Find comfort in knowing you and your loved ones are protected by the • Visit of family member or friend: Up to $5,000 Travel Assistance benefit when traveling more than 100 miles from • Return of minor children: Up to $5,000 home on a trip that lasts 90 days or less for business or pleasure. The • Traveling companion transportation: Up to $5,000 Travel Assistance benefit protects you when covered under a OneAmeri• Vehicle return: Up to $2,500 ca® group life insurance contract. It also extends coverage to your • Bereavement transportation: Up to $2,500 spouse, domestic partner and children, even when they are traveling • Pet return: Up to $1,000 without you.

TRAVEL ASSISTANCE

Note: Group life products are issued and underwritten by American United Life Insurance Company® (AUL), Indianapolis, In., a OneAmerica company. Not available in all states or may vary by state. Travel assisMedical assistance services tance provided by Generali Global Assistance. Generali Global Assistance • Medical and dental referral to assist in finding physicians, dentists is not an affiliate of AUL, and is not a OneAmerica Company. Generali and medical facilities.

Global Assistance provides noted services worldwide for covered individ• Replacement of medication or eyeglasses that have been lost or uals. Services may be unavailable in countries currently under U.S. ecostolen, with guarantee of reimbursement by you. nomic or trade sanctions. A list • Medical monitoring and review of documentation utilizing profesof affected counties is available at treasury.gov/resource-center/ sancsional case managers and medical professionals to ensure appropri- tions/Programs/Pages/Programs.aspx. Please refer to your policy for ate care is received. covered limits and eligibility details.

• Visitation with a family member or a friend if you are traveling alone and must be hospitalized for at least seven days or are listed When contacting Generali Global Assistance, be prepared to provide: as in critical condition.

• The name of your employer • Dependent children assistance in the event you are hospitalized, • A phone number where you can be reached including payment for their trip home and a qualified escort to accompany them.

• Traveling companion assistance in the event they must cancel their For assistance call: travel arrangements due to medical emergencies.

1-866-294-2469 (US/Canada) • Emergency evacuation in the event you must be transported to a +1-240-330-1509 (call collect from other locations) medical facility or home under medical supervision.

• Repatriation or cremation of remains in the event of death while or email ops@europassistance-usa.com traveling.

• Trip interruption to arrange alternate transportation and accommodations necessary due to a medical emergency.

• Emergency medical payment to cover medical and dental care expenses in the case of sudden, unexpected illness or injury during your trip, with guarantee of reimbursement by you.

The Travel Assistance benefit requires no additional premium; however, exclusions do apply.

Personal assistance services • Pre-trip informational services including: visa, passport, immunization requirements, weather conditions, travel advisories and more.

• Language interpretation for all major languages.

• Location or replacement of lost or stolen items such as luggage, documents and personal possessions.

• Emergency cash advance subject to guarantee of reimbursement by you.

• Emergency travel arrangements when appropriate, such as airline changes or hotel and car rental reservations.

• Legal assistance and advanced bail bond will be arranged, where permitted by law, with guarantee of reimbursement by you.

• Emergency message relay via toll- free, direct or collect access.

• Vehicle return arranged and paid for if you become physically unable to operate a non-commercial vehicle due to a medical emergency.

• Pet return home coordinated if covered traveler is hospitalized.

56

© 2017 OneAmerica Financial Partners, Inc. All rights reserved.

ONEAMERICA® IS THE MARKETING NAME FOR THE COMPANIES OF ONEAMERICA | ONEAMERICA.COM G-29706 05/09/17

57

NBS

FSA (Flexible Spending Account)

YOUR BENEFITS PACKAGE

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

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

FLIP TO…

PG. 11

FOR FSA FACTS

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 Los Fresnos CISD Benefits Website: www.mybenefitshub.com/losfresnoscisd

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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MASA YOUR BENEFITS PACKAGE

Medical Transport

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

A ground ambulance can cost up to

$2,400

and a helicopter transportation fee can cost

over $30,000

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan 62 details on covered expenses, limitations and exclusions are included in the summary plan description located on the Los Fresnos CISD Benefits Website: www.mybenefitshub.com/losfresnoscisd

Medical Transport FOR EMPLOYEES

Emergencies can happen to anyone, anytime, and anywhere!

No matter what, MASA MTS has you covered!

THE TRUTH...

MASA MTS CLAIM INSTRUCTIONS AND BENEFIT GUIDE

ACCESS OF SERVICES Americans today suffer from a false sense of security that their medical coverage will pay for all costs associated with emergency or • Services rendered under Non-Emergent Air Transportation critical care transport. The reality is that a majority of Americans are (HOSPITAL TO HOSPITAL) and Repatriation/Recuperation must be only partially covered for these high costs. coordinated and/or provided directly by MASA MTS. • In the event that such Services are not rendered directly by MASA Most healthcare policies will only pay based off of the “Usual and MTS, all requests for post-service payment and/or Customary Charges” while Medicare pays based off a set fee reimbursement will be denied for violation of the “Access of schedule, both leaving you with the remainder of the bill.

Services” provision of this Agreement.

You face the possibility that your medical coverage will deny the claim leaving you responsible for the ENTIRE bill.

With MASA, you will have ZERO out of pocket expenses for any emergent air or ground transport from ANYWHERE in the U.S., REGARDLESS who transports you!

We provide medical emergency transportation solutions AND cover your out of pocket medical transport cost when your insurance falls short.

“All I had to do was send the bill which was never paid by Medicare and TriCare for Life --- and the rest is history. When MASA received that bill, it was paid and all amounts owed satisfied.” --- MASA Member, 2015

MASA MTS for Employees Ensures...

• • • •

NO health questions NO age limits NO claim forms NO deductibles

• NO provider network limitations

• NO dollar limits on emergency transport costs

MASA EMERGENT - $9/MO What is Covered?

• Emergency Helicopter Transport • Emergency Ground Ambulance Transport Only MASA MTS for Employees can provide you with complete protection.

If You Have A Medical Emergency, Please Call 911 GLOBAL TRANSPORT HOTLINE 24 Hour – Access to Services 800-643-9023 Email: Fax: Mail:

Claims Dept

ambulanceclaims@masaglobal.com 877-681-2399 MASA ATTN: Claims Dept 1250 South Pine Island Road Suite #500 Plantation, FL 33324 800-643-9023

INTERFACILITY-TRANSFERS (HOSPITAL TO HOSPITAL) • Contact MASA’s Transport Department to schedule all hospital to hospital transfers.

• MASA’s Transport Department will coordinate with the provider.

REPATRIATION/RECUPERATION • MASA will arrange Member’s non-emergent, Repatriation/ Recuperation transportation, in the event Member is hospitalized in a Medical Facility more than one hundred (100) statute miles from Member’s Residence and Member’s treating physician and MASA MTS’s Medical Director determines it is feasible and medically appropriate to transfer Member to a Medical Facility nearer to Member’s Residence for recuperation. (Said benefit MUST be coordinated by MASA).

NOTE: All Services under this Agreement are limited to the continental United States, Alaska, Hawaii and Canada, and must originate and conclude therein. Dependents must be under the age of 26 and live with the Member to qualify for coverage under the Emergent Plus plan.

SUBMITTING CLAIMS ONLINE • Go to www.masamts.com • Click on “Member Login” located in top right hand corner. Click on Register and enter your member ID number and birthdate and create a password.

• Once you have signed-in then click on the Claims Tab, and then click on “Submit New Claim”.

• Upload the Bill/Invoice and the EOB, if available. Be sure to include your Member number on the bill/invoice.

NEW CLAIM INSTRUCTIONS • Submit the bill from the ambulance company to MASA with Member’s MASA number clearly displayed.

• Submit the bill via E-Mail, Fax or Mail.

• Attach the EOB and run notes, if readily available.

• Contact the claims department directly with any questions.

DOCUMENTS NEEDED BY MASA TO PROCESS A CLAIM • Bill/Health Insurance Claim Form a/k/a “HICFA”.

• Run notes/Trip notes from provider.

• Explanation of Benefits a/k/a “EOB” NOTE: All claims must be submitted to MASA within 180 days of the date of service 63

WWW.MYBENEFITSHUB.COM/LOSFRESNOSCISD 64