2022-23 Mansfield ISD Benefit Guide by Higginbotham Public Sector

2022 - 2023 Plan Year

MANSFIELD ISD

BENEFIT GUIDE EFFECTIVE: 09/01/2022 - 8/31/2023 WWW.MYBENEFITSHUB.COM/MANSFIELDISD

Table of Contents 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) Medical Basic Life and AD&D Health Savings Account (HSA) Flexible Spending Account (FSA) Hospital Indemnity MISD Staff Clinic Telehealth Dental Vision Disability Cancer Accident Critical Illness Voluntary Life and AD&D Employee Assistance Program (EAP) Individual Life Sick leave Bank 2

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HOW TO ENROLL

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SUMMARY PAGES

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YOUR BENEFITS

Benefit Contact Information MANSFIELD ISD BENEFITS

MEDICAL - TRS ACTIVECARE

MEDICAL - TRS HMO

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

BCBSTX (866) 355-5999 www.bcbstx.com/trsactivecare

Scott & White HMO (844) 633-5325 www.trs.swhp.org

HEALTH SAVINGS ACCOUNT (HSA)

FLEXIBLE SPENDING ACCOUNT (FSA) HOSPITIAL INDEMNITY

EECU (817) 882-0800 www.eecu.org

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

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

MISD STAFF CLINIC

TELEHEALTH

DENTAL

252 Matlock Rd., Suite #130, Mansfield, TX 76063 Phone: 817-453-8620 Fax: 817-473-7186

MDLIVE (888) 365-1663 www.mdlive.com/fbs

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

VISION

DISABILITY

CANCER

Davis Vision (800) 999-5431 www.davisvision.com

The Hartford Group #GLT-681960 (800) 547-5000 www.thehartford.com

American Public Life Group #18361 (800) 256-8606 www.ampublic.com

ACCIDENT

CRITICAL ILLNESS

LIFE AND AD&D

Voya Group #69514-9 (800) 955-7736 www.voya.com

OneAmerica Group #614903 (800) 553-5318 www.oneamerica.com

EMPLOYEE ASSISTANCE PROGRAM (EAP)

INDIVIDUAL LIFE

ComPsych (855) 387-9727 guidanceresources.com

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

All Your Benefits One App Employee benefits made easy through the FBS Benefits App! Text “FBS MISD” to (800) 583-6908 and get access to everything you need to complete your

benefits enrollment: •

Benefit Resources

•

Online Enrollment

•

Interactive Tools

•

And more!

App Group #: FBSMISD

Text

“FBS MISD”

to (800) 583-6908 OR SCAN

How to Log In 1

www.mybenefitshub.com/mansfieldisd

CLICK LOGIN

ENTER USERNAME & PASSWORD Your Username Is: Your email in THEbenefitsHUB. (Typically your work email) Your Password Is: Four (4) digits of your birth year followed by the last four (4) digits of your Social Security Number If you have previously logged in, you will use the password that you created, NOT the password format listed above.

Annual Benefit Enrollment

SUMMARY PAGES

Benefit Updates - What’s New: •

•

> Effective 9/1/2022, rates for ActiveCare Plans for 2022‐23 have decreased or remained the same! Blue Cross and Blue Shield of Texas (BCBSTX) will continue to offer the same plans. Refer to TRS Plan Highlights for full details. TRS‐ActiveCare Primary (requires Primary Care Physician*): This plan has the lowest premiums, $30 copays for primary care visits; $70 for specialist. There is no out‐of‐network coverage. $12 Teladoc (change from $0) and $0 RediMD Virtual Health visits. New Specialty Drug program through PrudentRx. Out‐of‐pocket for insulin— capped at $25 for 31‐day supply; $75 for 61—90 day supply. TRS‐ActiveCare Primary+ (requires Primary Care Physician*): This plan has lower deductibles and copays for many services and drugs. There is no out‐of‐network coverage. $12 Teladoc (change from $0) and $0 RediMD Virtual Health visits. New Specialty Drug program through PrudentRx. Out‐of‐pocket for insulin — capped at $25 for 31‐day supply; $75 for 61—90 day supply. TRS‐ActiveCare HD: This plan works with a Health Savings Account (HSA), has out‐of‐network coverage, and coinsurance rates instead of copays. You must meet the deductible before the plan will pay for non‐preventive services. Includes nationwide network and out‐of‐network coverage. $42 Teladoc Virtual Health (was $30) and $0 RediMD Virtual Health visits. The out‐of‐pocket in‐network amount increased by $50 for individual and $100 for family. TRS‐Ac veCare 2: This plan is closed to new enrollees; those currently enrolled may remain. $12 Teladoc (change from $0) and $0 RediMD Virtual Health visits. Out‐of‐pocket for insulin — capped at $25 for 31‐day supply; $75 for 61—90 day supply. > Dental Insurance – Your dental plan is moving from Lincoln Financial Group to Cigna and there has been a minimal increase in rates. > FSA Medical – increased annual election to $2,850. A medical FSA allows you to set aside a portion of your earnings to pay for qualified expenses, most commonly for medical costs, such as doctors, dentists, and optometrist copays. If you elect the FSA, you will receive a new debit card from Higginbotham. Please utilize your current funds prior to 8/31/22, remember you can use your flex dollars at www.fsastore.com. A dependent care FSA works just like a medical FSA but the pre-tax dollars you set aside are for the reimbursement of qualified day care expenses. Health Savings Account (HSA) – the IRS indexes maximum HSA contribution amounts and has increased the annual contribution amount for individual accounts from $3,600 to $3,650 and from $7,200 to $7,300 for family accounts. Both individual and family accounts can add $1,000 for catch up if the account holder is age 55 or older. > PASSWORD RESET - When you reset your password this year, make it something you will remember as passwords will not be reset moving forward.

Don’t Forget! • • • •

Login and complete your benefit enrollment from 07/18/2022 - 08/16/2022 Enrollment assistance is available by calling Financial Benefit Services at (866) 914-5202. Update your information: home address, phone numbers, email, and beneficiaries. REQUIRED!! Due to the Affordable Care Act (ACA) reporting requirements, you must add your dependent’s CORRECT social security numbers in the online enrollment system. If you have questions, please contact your Benefits Administrator.

Annual Benefit Enrollment

SUMMARY PAGES

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

CHANGES IN STATUS (CIS): Marital Status

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

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

A change in number of dependents includes the following: birth, adoption and placement for Change in Number of adoption. You can add existing dependents not previously enrolled whenever a dependent Tax Dependents gains eligibility as a result of a valid change in status event. Change in Status of Change in employment status of the employee, or a spouse or dependent of the employee, Employment Affecting that affects the individual's eligibility under an employer's plan includes commencement or Coverage Eligibility termination of employment. Gain/Loss of Dependents' Eligibility Status

Judgment/Decree/ Order

An event that causes an employee's dependent to satisfy or cease to satisfy coverage requirements under an employer's plan may include change in age, student, marital, employment or tax dependent 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 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

Annual Benefit Enrollment

SUMMARY PAGES

Annual Enrollment During your annual enrollment period, you have the opportunity to review, change or continue benefit elections each year. Changes are not permitted during the plan year (outside of annual enrollment) unless a Section 125 qualifying event occurs. •

Changes, additions or drops may be made only during the annual enrollment period without a qualifying event.

• Employees must review their personal information and verify that dependents they wish to provide coverage for are included in the dependent profile. Additionally, you must notify your employer of any discrepancy in personal and/or benefit information. •

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.

New Hire Enrollment All new hire enrollment elections must be completed in the online enrollment system within the first 30 days of benefit eligible employment. Failure to complete elections during this timeframe will result in the forfeiture of coverage.

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

Where can I find forms? For benefit summaries and claim forms, go to your benefit website: www.mybenefitshub.com/ mansfieldisd. Click the benefit plan you need information on (i.e., Dental) and you can find the forms you need under the Benefits and Forms section. How can I find a Network Provider? For benefit summaries and claim forms, go to the Mansfield ISD benefit website: www.mybenefitshub.com/mansfieldisd. Click on the benefit plan you need information on (i.e., Dental) and you can find provider search links under the Quick Links section. When will I receive ID cards? If the insurance carrier provides ID cards, you can expect to receive those 3-4 weeks after your effective date. For most dental and vision plans, you can login to the carrier website and print a temporary ID card or simply give your provider the insurance company’s phone number and they can call and 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.

Annual Benefit Enrollment

SUMMARY PAGES

Employee Eligibility Requirements

Dependent Eligibility Requirements

Supplemental Benefits: Eligible employees must work 20 or more regularly scheduled hours each work week.

Dependent Eligibility: You can cover eligible dependent children under a benefit that offers dependent coverage, provided you participate in the same benefit, through the maximum age listed below. Dependents cannot be double covered by married spouses within the district as both employees and dependents.

Eligible employees must be actively at work on the plan effective date for new benefits to be effective, meaning you are physically capable of performing the functions of your job on the first day of work concurrent with the plan effective date. For example, if your 2022 benefits become effective on September 1, 2022, you must be actively-at-work on September 1, 2022 to be eligible for your new benefits.

PLAN

MAXIMUM AGE

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

Medical

Through 26

Hospital Indemnity

Through 26

Telehealth

Through 26

Dental

Through 26

Vision

Through 26

Accident

Through 26

Cancer

Through 26

Life and AD&D

Through 26

Critical Illness

Through 26

Individual Life

Through 23

Health Savings Account (HSA)

IRS Tax Dependent

Flexible Spending Account (FSA)

Through 26 or IRS Tax Dependent

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

Dependent Flex

12 or younger or qualified individual unable to care for themselves & claimed as a dependent on your taxes

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

Potential Spouse Coverage Limitations: When enrolling in coverage, please keep in mind that some benefits may not allow you to cover your spouse as a dependent if your spouse is enrolled for coverage as an employee under the same employer. Review the applicable plan documents, contact Financial Benefit Services, or contact the insurance carrier for additional information on spouse eligibility. FSA/HSA Limitations: Please note, in general, per IRS regulations, married couples may not enroll in both a Flexible Spending Account (FSA) and a Health Savings Account (HSA). If your spouse is covered under an FSA that reimburses for medical expenses then you and your spouse are not HSA eligible, even if you would not use your spouse's FSA to reimburse your expenses. However, there are some exceptions to the general limitation regarding specific types of FSAs. To obtain more information on whether you can enroll in a specific type of FSA or HSA as a married couple, please reach out to the FSA and/or HSA provider prior to enrolling or reach out to your tax advisor for further guidance.

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

SUMMARY PAGES

Helpful Definitions Actively-at-Work

In-Network

You are performing your regular occupation for the employer on a full-time basis, either at one of the employer’s usual places of business or at some location to which the employer’s business requires you to travel. If you will not be actively at work beginning 9/1/2022 please notify your benefits administrator.

Doctors, hospitals, optometrists, dentists and other providers who have contracted with the plan as a network provider.

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.

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 preexisting condition exclusion provisions do apply, as applicable by carrier. 10

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

Plan Year September 1st through August 31st

Pre-Existing Conditions Applies to any illness, injury or condition for which the participant has been under the care of a health care provider, taken prescription drugs or is under a health care provider’s orders to take drugs, or received medical care or services (including diagnostic and/or consultation services).

SUMMARY PAGES

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

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

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

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

Employer Eligibility

A qualified high deductible health plan.

All employers

Contribution Source

Employee and/or employer

Account Owner

Individual

Employer

Underlying Insurance Requirement

High deductible health plan

None

Minimum Deductible

$1,400 single (2022) $2,800 family (2022)

N/A

Maximum Contribution

$3,650 single (2022) $7,300 family (2022)

$2,850 (2022)

Permissible Use Of Funds

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

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

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

Permitted, but subject to current tax rate plus 20% penalty (penalty waived after age Not permitted 65).

Description

Year-to-year rollover of account balance?

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

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

Does the account earn interest?

Yes

Portable?

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

FLIP TO FOR HSA INFORMATION

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FLIP TO FOR FSA INFORMATION

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Medical Insurance

EMPLOYEE BENEFITS

TRS ABOUT MEDICAL 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.

For full plan details, please visit your benefit website: www.mybenefitshub.com/mansfieldisd

Monthly Premium

District Contribution

Employee Cost

TRS ActiveCare HD Employee Only Employee & Spouse Employee & Child(ren) Employee & Family

$429.00

$250.00

$179.00

$1,209.00

$250.00

$959.00

$772.00

$250.00

$522.00

$1,445.00

$250.00

$1,195.00

TRS ActiveCare 2 Employee Only

$1,013.00

$250.00

$763.00

Employee & Spouse

$2,402.00

$250.00

$2,152.00

Employee & Child(ren)

$1,507.00

$250.00

$1,257.00

Employee & Family

$2,841.00

$250.00

$2,591.00

TRS ActiveCare Primary Employee Only Employee & Spouse Employee & Child(ren) Employee & Family

$417.00

$250.00

$167.00

$1,176.00

$250.00

$926.00

$751.00

$250.00

$501.00

$1,405.00

$250.00

$1,155.00

TRS ActiveCare Primary+ Employee Only Employee & Spouse Employee & Child(ren) Employee & Family

$525.00

$250.00

$275.00

$1,284.00

$250.00

$1,034.00

$845.00

$250.00

$595.00

$1,614.00

$250.00

$1,364.00

Central and North Texas Baylor Scott & White HMO Employee Only Employee & Spouse Employee & Child(ren)

Employee & Family 12

$569.24

$250.00

$319.24

$1,431.08

$250.00

$1,181.08

$915.65

$250.00

$665.65

$1,647.24

$250.00

$1,397.24

Basic Life and AD&D OneAmerica

EMPLOYEE BENEFITS

ABOUT LIFE AND AD&D 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.

For full plan details, please visit your benefit website: www.mybenefitshub.com/mansfieldisd

Who is eligible for this coverage? What is the coverage amount? What is the guaranteed issue? Is it portable (can I keep it if I leave my employer)? When is the coverage effective?

Additional AD&D Benefits

What does the Basic AD&D portion pay for?

Do my life insurance benefits decrease with age?

Any active employees of Mansfield Independent School District working 18 hours or more per week $10,000 Full benefit; $10,000 Yes First of the month following date of hire

Matches the basic life benefit at $10,000 Loss of: • Life • One hand or one foot • Sight in one eye • Both hands or both feet • Sight in both eyes • Speech and hearing • Thumb or index finger For conditions of: • Quadriplegia or loss of use of upper and lower limbs of the body • Paraplegia or loss of us of both lower limbs of the body • Hemiplegia or loss of use of upper and lower limbs on the same side of the body • Monoplegia or loss of use of one limb of the body • Severe burns To 65% at age 70-74 To 50% at age 75 +

Health Savings Account (HSA) EECU

EMPLOYEE BENEFITS

ABOUT HSA A Health Savings Account (HSA) is a personal savings account where the money can only be used for eligible medical expenses. Unlike a flexible spending account (FSA), the money rolls over year to year however only those funds that have been deposited in your account can be used. Contributions to a Health Savings Account can only be used if you are also enrolled in a High Deductible Health Care Plan (HDHP). For full plan details, please visit your benefit website: www.mybenefitshub.com/mansfieldisd

A Health Savings Account (HSA) is more than a way to help you and your family cover health care costs – it is also a tax-exempt tool to supplement your retirement savings and cover health expenses during retirement. An HSA can provide the funds to help pay current health care expenses as well as future health care costs. A type of personal savings account, an HSA is always yours even if you change health plans or jobs. The money in your HSA (including interest and investment earnings) grows tax-free and spends tax-free if used to pay for qualified medical expenses. There is no “use it or lose it” rule — you do not lose your money if you do not spend it in the calendar year — and there are no vesting requirements or forfeiture provisions. The account automatically rolls over year after year.

HSA Eligibility

time during the plan year, you are eligible to make the catch-up contribution for the entire plan year.

Qualified Expenses You can use your HSA for a wide range of qualified expenses, such as doctor’s visits, prescription drugs, lab work, medical equipment, contacts lenses, dental work, physical therapy…the list goes on! Refer to IRS Publication 502 for comprehensive guidelines.

Important HSA Information

• You will receive a debit card to manage your Health Savings Account. Keep in mind, available funds are limited to the balance in your HSA. • Always ask your health care provider to file claims with your medical provider so network discounts can be applied. You can pay the provider with your HSA debit card based on the balance due after discount. • You, not your employer, are responsible for maintaining ALL records and receipts for HSA reimbursements in the event of an IRS audit. • You may open an HSA at the financial institution of your choice, but only accounts opened through EECU are eligible for automatic payroll deduction.

You are eligible to open and contribute to an HSA if you are: • Enrolled in an HSA-eligible High Deductible Health Plan (HDHP) • Not enrolled in Medicare or TRICARE • If you enroll in an HSA and FSA, the FSA becomes a Limited Purpose FSA and may only be used for Dental and Vision, not medical expenses. • Not eligible to be claimed as a dependent on someone else’s tax return You can use the money in your HSA to pay for qualified medical expenses now or in the future. You can also use HSA funds to pay How To Use Your HSA health care expenses for your dependents, even if they are not • Online/Mobile: Sign-in for 24/7 account access to check your covered by the HDHP. balance, pay bills and more. • Call/Text: (817) 882-0800 EECU’s dedicated member service Maximum Contributions representatives are available to assist you with any questions. Your HSA contributions may not exceed the annual maximum Their hours of operation are Monday through Friday from 8:00 amount established by the Internal Revenue Service. The annual a.m. to 7:00 p.m. CT, Saturday 9:00 a.m. to 1:00 p.m. CT and contribution maximum for 2022 is based on the coverage option closed on Sunday. you elect: • Lost/Stolen Debit Card: Call the 24/7 debit card hotline at (800) • Individual – $3,650 333-9934. • Family (filing jointly) – $7,300 • Stop by a local EECU financial center for in-person assistance; If you are 55 or older, you may make a yearly catch-up find locations & service hours at www.eecu.org/locations. contribution of up to $1,000 to your HSA. If you turn 55 at any 20

Flexible Spending Account (FSA) NBS

EMPLOYEE BENEFITS

ABOUT FSA A Flexible Spending Account allows you to pay for eligible healthcare expenses with a pre-loaded debit card. You choose the amount to set aside from your paycheck every plan year, based on your employer’s annual plan limit. This money is use it or lose it within the plan year (unless your plan contains a $500 rollover or grace period provision).

For full plan details, please visit your benefit website: www.mybenefitshub.com/mansfieldisd

Health Care FSA

Dependent Care FSA

The Health Care FSA covers qualified medical, dental and vision expenses for you or your eligible dependents. You may contribute up to $2,850 annually to a Health Care FSA and you are entitled to the full election from day one of your plan year. Eligible expenses include: • Dental and vision expenses • Medical deductibles and coinsurance • Prescription copays • Hearing aids and batteries You may not contribute to a Health Care FSA if you enrolled in a High Deductible Health Plan (HDHP) and contribute to a Health Savings Account (HSA).

The Dependent Care FSA helps pay for expenses associated with caring for elder or child dependents so you or your spouse can work or attend school full time. You can use the account to pay for day care or baby sitter expenses for your children under age 13 and qualifying older dependents, such as dependent parents. Reimbursement from your Dependent Care FSA is limited to the total amount deposited in your account at that time. To be eligible, you must be a single parent or you and your spouse must be employed outside the home, disabled or a full-time student.

How the Health Care FSAs Work

•

Dependent Care FSA Guidelines

You can access the funds in your Health Care FSA two different ways: • • Use your NBS Debit Card to pay for qualified expenses, doctor visits and prescription copays. • Pay out-of-pocket and submit your receipts for • reimbursement:  Fax – 844-438-1496  Email – service@nbsbenefits.com  Online – my.nbsbenefits.com •  Call for Account Balance: 855-399-3035  Mail: PO Box 6980 West Jordan, UT 84084

Contact NBS • • • •

Hours of Operation: 6:00 AM – 6:00 PM MST, Mon-Fri Phone: (800) 274-0503 Email: service@nbsbenefits.com Mail: PO Box 6980 West Jordan, UT 84084

Overnight camps are not eligible for reimbursement (only day camps can be considered). If your child turns 13 midyear, you may only request reimbursement for the part of the year when the child is under age 13. You may request reimbursement for care of a spouse or dependent of any age who spends at least eight hours a day in your home and is mentally or physically incapable of self-care. The dependent care provider cannot be your child under age 19 or anyone claimed as a dependent on your income taxes.

Important FSA Rules •

•

The maximum per plan year you can contribute to a Health Care FSA is $2,850.00. The maximum per plan year you can contribute to a Dependent Care FSA is $5,000 when filing jointly or head of household and $2,500 when married filing separately. You cannot change your election during the year unless 21

Flexible Spending Account (FSA) NBS •

•

you experience a Qualifying Life Event. Your Health Care FSA debit card can be used for health care expenses only. It cannot be used to pay for dependent care expenses. The IRS has amended the “use it or lose it rule” to allow you to carry-over up to $500 in your Health Care FSA into the next plan year. The carry-over rule does not apply to your Dependent Care FSA.

Over-the-Counter Item Rule Reminder (OTC) Health care reform legislation requires that certain overthe-counter (OTC) items require a prescription to qualify as an eligible Health Care FSA expense. You will only need to obtain a one-time prescription for the current plan year. You can continue to purchase your regular prescription medications with your FSA debit card. However, the FSA debit card may not be used as payment for an OTC item, even when accompanied by a prescription.

FSAstore.com FSAstore.com offers thousands of FSA-eligible products and services to purchase using your FSA Debit Card or any major credit card. Competitive pricing and free shipping on orders over $50 can save you up to 40% using your FSA pretax dollars. Shop directly at FSAstore.com or have your physician submit prescriptions (when required). The FSAstore.com Services Channel allows you to search a database of more than 300,000 health care providers for nearby eligible services, such as acupuncture and chiropractic care. The FSAstore.com Learning Center focuses on answering common questions and keeping you informed about changes to your FSA benefits.

EMPLOYEE BENEFITS

Hospital Indemnity

EMPLOYEE BENEFITS

Cigna ABOUT HOSPITAL INDEMNITY This is an affordable supplemental plan that pays you should you be inpatient hospital confined. This plan complements your health insurance by helping you pay for costs left unpaid by your health insurance.

For full plan details, please visit your benefit website: www.mybenefitshub.com/mansfieldisd

SUMMARY OF BENEFITS Hospital Care coverage provides a benefit according to the schedule below when a Covered Person incurs a Hospital stay resulting from a Covered Injury or Covered Illness

Who Can Elect Coverage: •

• •

Hospital Indemnity Plan 1 Employee Only $17.29 Employee and Spouse $31.75 Employee and Child(ren) $28.72 Employee and Family $43.18

Plan 2 $34.15 $62.81 $56.87 $85.53

You: All active, Full-time Employees of the Employer who are regularly working in the United States a minimum of 18 hours per week and regularly residing in the United States who are United States citizens or permanent resident aliens and their Spouse and Dependent Children who are United States citizens or permanent resident aliens and are residing in the United States. You will be eligible for coverage on the first of the month following date of hire or Active Service. Your Spouse:* Up to age 100, as long as you apply for and are approved for coverage yourself. Your Child(ren): Birth to age 26; 26+ if disabled, as long as you apply for and are approved for coverage yourself.

.Available Coverage: The benefit amounts shown in this summary will be paid regardless of the actual expenses incurred and are paid on a per day basis unless otherwise specified. Benefits are only payable when all policy terms and conditions are met. Please read all the information in this summary to understand the terms, conditions, state variations, exclusions and limitations applicable to these benefits. See your Certificate of Insurance for more information. Benefit Waiting Period:* None, unless otherwise stated. No benefits will be paid for a loss which occurs during the Benefit Waiting Period.

Hospitalization Benefits

Plan 1

Plan 2

Hospital Admission - No Elimination Period. Limited to 1 day, 1 benefit(s) every 365 days.

$1,500

$3,000

Hospital Chronic Condition Admission - No Elimination Period. Limited to 1 day, 1 benefit(s) every 90 days.

$50

Hospital Stay - No Elimination Period. Limited to 30 days, 1 benefit(s) every 30 days.

$100

$200

Hospital Intensive Care Unit (ICU) Stay - No Elimination Period. Limited to 30 days, 1 benefit(s) every 30 days.

$100

$200

Hospital Observation Stay - 24 hour Elimination Period. Limited to 72 hours.

$100 per 24-hour period

Hospital Indemnity Cigna

EMPLOYEE BENEFITS

including any prescribed drug for which the Covered Person has been provided a written warning against operating a vehicle while taking it. “Under the influence of alcohol”, for purposes of Hospital Admission: Must be admitted as an Inpatient due to a this exclusion, means intoxicated, as defined by the law of the Covered Injury or Covered Illness. Excludes: treatment in an state in which the Covered Injury or Covered Illness occurred. emergency room, provided on an outpatient basis, or for re(excludes WA residents);• Those not necessary, as determined by admission for the same Covered Injury or Covered Illness Us in accordance with generally accepted standards of medical (including chronic conditions). practice, for the diagnosis, care or treatment of the physical or Hospital Chronic Condition Admission: Must be admitted as an mental condition involved. This applies even if they are Inpatient due to a covered chronic condition and treatment for a prescribed, recommended, or approved by the attending covered chronic condition must be provided by a specialist in that physician;• Elective or cosmetic surgery. This does not include field of medicine. Excludes: treatment in an emergency room, reconstructive, cosmetic surgery: provided on an outpatient basis, or for re-admission for the same a) incidental to or following surgery for trauma, infection or other Covered Injury or Covered Illness (including chronic conditions). disease of the involved part; or b) due to congenital Hospital Stay: Must be admitted as an Inpatient and confined to disease or anomaly of a Covered Dependent child which has the Hospital, due to a Covered Injury or Covered Illness, at the resulted in a functional defect;• Dental surgery, unless the direction and under the care of a physician. If also eligible for the surgery is the result of an accidental injury. In addition, benefits ICU Stay Benefit, only 1 benefit will be paid for the same Covered will not be paid for services or treatment rendered by a Injury or Covered Illness, whichever is greater. Hospital stays Physician, Nurse or any other person who is: employed or within 90 days for the same or a related Covered Injury or retained by the Subscriber or providing homeopathic, aromaCovered Illness is considered one Hospital Stay. therapeutic or herbal therapeutic services or living in the Covered Intensive Care Unit (ICU) Stay: Must be admitted as an Inpatient Person’s household or a parent, sibling, spouse or child of the and confined in an ICU of a Hospital, due to a Covered Injury or Covered Person. Covered Illness, at the direction and under the care of a physician. If also eligible for the Hospital Stay Benefit, only 1 Policy Provisions benefit will be paid for the same Covered Injury or Covered When your coverage begins: Coverage begins on the later of the Illness, whichever is greater. ICU stays within 90 days for the program’s effective date, the date you become eligible, the first same or a related Covered Injury or Covered Illness is considered of the month following the date your completed enrollment form one ICU stay. is received or if evidence of insurability is required, the first of the Hospital Observation Stay: Must be receiving treatment for a month after we have approved you (or your dependent) for Covered Injury or Covered Illness in a Hospital, including an coverage in writing unless otherwise agreed upon by Cigna. Your observation room, or ambulatory surgical center, for more than coverage will not begin unless you are actively at work on the 24 hours on a non-inpatient basis and a charge must be incurred. effective date. Coverage for Covered Persons will not begin on This benefit is not payable if a benefit is payable under the the effective date if the covered person is confined to a hospital, Hospital Stay Benefit or Hospital Intensive Care Unit Stay Benefit. facility or at home; disabled or receiving disability benefits or

Benefit-Specific Conditions, Exclusions & Limitations (Hospital Care)

unable to perform activities of daily living. Deferral of the effective date will not apply to the Newborn Nursery Care Exclusions:* In addition to any benefit-specific exclusion, benefits Admission and Stay Benefit. will not be paid for any Covered Injury or Covered Illness which is When your coverage ends: Coverage for any Covered Person ends caused by or results from any of the following (unless otherwise on the earliest of the date they are no longer eligible, the date provided for in the policy): • Intentionally self-inflicted injury, the group policy is no longer in force, or the date for the last suicide or any attempted threat while sane or insane; • period for which required premiums are paid. For your Spouse Commission or attempt to commit a felony or an assault; • and Dependent Child(ren), if applicable, coverage also ends when Declared or undeclared war or act of war;• A Covered Injury or your coverage ends, when their premiums are not paid or when Covered Illness that occurs while on active duty service in the they are no longer eligible. (Under certain circumstances, your military, naval or air force of any country or international coverage may be continued if you stop working. Be sure to read organization. Upon our receipt of proof of service, we will refund the Continuation of Insurance provisions in your Certificate. any premium paid for this time. Reserve or National Guard active duty training is not excluded unless it extends beyond 31 days;• Voluntary ingestion of any narcotic, drug, poison, gas or fumes, unless prescribed or taken under the direction of a Physician and taken in accordance with the prescribed dosage (excludes WA residents);• Operating any type of vehicle while under the influence of alcohol or any drug, narcotic or other intoxicant

Common Exclusions and Limitations

Mansfield ISD Staff Clinic MISD

EMPLOYEE BENEFITS

ABOUT MANSFIELD ISD STAFF CLINIC The Mansfield ISD Staff Clinic is a low-cost, convenient health clinic for district employees, spouses and dependents.

For full plan details, please visit your benefit website: www.mybenefitshub.com/mansfieldisd

About the Clinic Address: 252 Matlock Rd., Suite #130, Mansfield, TX 76063 Phone: 817-453-8620 Fax: 817-473-7186 The MISD staff clinic, located inside Methodist Family Health Center, is a walk-in clinic meaning employees do not schedule specific appointment times. In December 2019, the clinic began offering call ahead scheduling with limited space availability. Employees and their dependents can try calling ahead for an appointment or visit the clinic. Clinic personnel will inform the patient of a time to be seen by a provider based upon the number of patients being taken that day. Walk-in patients will then have the option to wait at the clinic to be seen by a provider or return to the clinic at the time designated by the clinic personnel. Occasionally, due to medical personnel availability, there will be days in which not all employees desiring to be seen will be able to visit a medical provider that same day.

Hours of Operation Monday - Friday | Noon - 7:30 p.m. Offices are closed daily from 3:00 p.m. - 4:00 p.m. (NOTE: Hours are subject to change with limited notice. It is always a good idea to call ahead before visiting the clinic. The clinic is closed on major holidays.)

Telehealth

EMPLOYEE BENEFITS

MDLIVE ABOUT TELEHEALTH Telehealth provides 24/7/365 access to board-certified doctors via telephone or video consultations that can diagnose, recommend treatment and prescribe medication. Telehealth makes care more convenient and accessible for non-emergency care when your primary care physician is not available.

For full plan details, please visit your benefit website: www.mybenefitshub.com/mansfieldisd Alongside your medical coverage is access to quality telehealth services through MDLIVE. Connect anytime day or night with a board-certified doctor via your mobile device or computer. While MDLIVE does not replace your primary care physician, it is a convenient and cost-effective option when you need care and: • Have a non-emergency issue and are considering a convenience care clinic, urgent care clinic or emergency room for treatment • Are on a business trip, vacation or away from home • Are unable to see your primary care physician

When to Use MDLIVE: At a cost that is the same or less than a visit to your physician, use telehealth services for minor conditions such as: • Sore throat • Headache • Stomachache • Cold • Flu • Allergies • Fever • Urinary tract infections Do not use telemedicine for serious or life-threatening emergencies.

Registration is Easy Register with MDLIVE so you are ready to use this valuable service when and where you need it. • Online – www.mdlive.com/fbs • Phone – 888-365-1663 • Mobile – download the MDLIVE mobile app to your smartphone or mobile device • Select –“MDLIVE as a benefit” and “FBS” as your Employer/Organization when registering your account. Telehealth Employee & Family

$12.00

Dental Insurance

EMPLOYEE BENEFITS

Cigna ABOUT DENTAL Dental insurance is a coverage that helps defray the costs of dental care. It insures against the expense of routine care, dental treatment and disease.

For full plan details, please visit your benefit website: www.mybenefitshub.com/mansfieldisd

DHMO PLAN IMPORTANT HIGHLIGHTS • This Patient Charge Schedule applies only when covered dental services are performed by your Network Dentist, unless otherwise authorized by Cigna Dental as described in your plan documents. Not all Network Dentists perform all listed services, and it is suggested to check with your Network Dentist in advance of receiving services. • This Patient Charge Schedule applies to Specialty Care when an appropriate referral is made to a Network Specialty Periodontist or Oral Surgeon. You should verify with the Network Specialty Dentist that your treatment plan has been authorized for payment by Cigna Dental. Prior authorization is not required for specialty referrals for Pediatric, Orthodontic and Endodontic services. You may select a Network Pediatric Dentist for your child under the age of 7 by calling Customer Service at 1.800.Cigna24 to get a list of Network Pediatric Dentists in your area. Coverage for treatment by a Pediatric Dentist ends on your child’s 7th birthday; however, exceptions for medical reasons may be considered on an individual basis. Your Network General Dentist will provide care upon your child’s 7th birthday. • Procedures not listed on this Patient Charge Schedule are not covered and are the patient’s responsibility at the dentist’s usual fees. › The administration of IV sedation, general anesthesia, and/or nitrous oxide is not covered except as specifically listed on this Patient Charge Schedule. The application of local anesthetic is covered as part of your dental treatment. • Cigna Dental considers infection control and/or sterilization to be incidental to and part of the charges for services provided and not separately chargeable. • This Patient Charge Schedule is subject to annual change in accordance with the terms of the group agreement. • Procedures listed on the Patient Charge Schedule are subject to the plan limitations and exclusions described in your plan book/certificate of coverage and/or group contract.

• All patient charges must correspond to the Patient Charge Schedule in effect on the date the procedure is initiated. • The American Dental Association may periodically change CDT Codes or definitions. Different codes may be used to describe these covered procedures. The language in italics is intended to clarify the members’ benefit. After your enrollment is effective: Call the dental office identified in your Welcome Kit. If you wish to change dental offices, a transfer can be arranged at no charge by calling Cigna Dental at the toll free number listed on your ID card or plan materials. Multiple ways to locate a (*DHMO) Network General Dentist: • Online provider directory at Cigna.com • Online provider directory on myCigna.com • Call the number located on your ID card to:  Use the Dental Office Locator via Speech Recognition  Speak to a Customer Service Representative EMERGENCY: If you have a dental emergency as defined in your group’s plan documents, contact your Network General Dentist as soon as possible. If you are out of your service area or unable to contact your Network Office, emergency care can be rendered by any dental office, dental clinic, or other comparable facility. Definitive treatment (e.g., root canal) is not considered emergency care and should be performed or referred by your Network General Dentist. Consult your group’s plan documents for a complete definition of dental emergency, your emergency benefit and a listing of Exclusions and Limitations.

Employee Employee + Spouse Employee + Child(ren) Family

Dental DHMO $12.35 $24.07 $26.04 $37.65

Low Plan $27.67 $54.94 $55.91 $83.40

High Plan $43.35 $86.06 $87.58 $130.66 27

Dental Insurance

EMPLOYEE BENEFITS

Cigna Network Options

Reimbursement Levels Policy Year Benefits Maximum Applies to: Class I,II,III, & IX expenses Policy Year Deductibles Individual Family Benefit Highlights Class I: Diagnostic Oral Evaluations, Prophylaxis: routine cleanings, X-rays (routing and non-routine) and more* Class II: Basic Restorative Fillings, Oral Surgery and more* Class III*: Major Restorative Inlays and Onlays, Prosthesis Over Implant and more* Class IV: Orthodontia Coverage for employees and all dependents (children to age 26) Lifetime Max: $1,000 Class IX: Implants

Cigna Dental Choice – LOW PLAN In-Network Based on Contracted Fees

Out-of-Network Maximum Allowable Charge

$1,250

$50 $150

Plan Pays

You Pay

Plan Pays

100% No Deductible

No Charge

100% No Deductible

You Pay Any amount over the Maximum Allowable Charge

80% After Deductible

20% After Deductible

80% After Deductible

20% After Deductible

50% After Deductible

50% No Deductible

50% After Deductible

Cigna Dental Choice – HIGH PLAN Network Options

Reimbursement Levels Policy Year Benefits Maximum Applies to: Class I,II,III, & IX expenses Policy Year Deductibles Individual Family Benefit Highlights

Class I: Diagnostic Oral Evaluations, Prophylaxis: routine cleanings, X-rays (routing and non-routine) and more* Class II: Basic Restorative Fillings, Oral Surgery and more* Class III*: Major Restorative Inlays and Onlays, Prosthesis Over Implant and more* Class IV: Orthodontia Coverage for employees and all dependents (children to age 26) Lifetime Max: $1,250 Class IX: Implants

In-Network

Out-of-Network

Based on Contracted Fees

Maximum Reimbursable Charge

$1,250

$50 $150

Plan Pays

You Pay

Plan Pays

You Pay

100% No Deductible

No Charge

100% No Deductible

No Charge

80% After Deductible

20% After Deductible

80% After Deductible

20% After Deductible

50% After Deductible

50% No Deductible

50% After Deductible

*For more information on coverage, please review the plan information at www.mybenefitshub.com/mansfieldisd.

Vision Insurance

EMPLOYEE BENEFITS

Davis Vision ABOUT VISION Vision insurance provides coverage for routine eye examinations and can help with covering some of the costs for eyeglass frames, lenses or contact lenses.

For full plan details, please visit your benefit website: www.mybenefitshub.com/mansfieldisd

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

$7.20 $12.26 $13.00 $19.48

Frequency Exam: 12 months Lenses & lens upgrades: 12 months Frame: 12 months Contacts, evaluation & fitting: 12 months

Using Your Client Code: Log in using your client code (Mansfield ISD Client Code: 7511) at davisvision.com/member to find a list of in-network providers near you and access your benefit information. The Exclusive Collection: The Exclusive Collection of frames is available at nearly 9,000 locations across the U.S. Log in to browns frames, and find a Collection near you. Free Breakage Warranty: Your glasses are covered with our FREE on-year breakage warranty. Some limitations apply. Find a network provider…Enter your client code in the “Member Sign In” section of our website at davisvision.com/member to locate a provider near you including Visionworks.

Sign up during open enrollment – for more details about the plan, visit davisvision.com/member and enter your Client Code or Options & upgrades call 1 (877) 923-2847 and enter your Client Code when Lens options prompted. Clear plastic single-vision, bifocal, trifocal or lenticular lenses (any RX) Exams and Services Polycarbonate Lenses (Children / Adults) Eye Exam Copay: $10 High-Index Lenses 1.67 Contacts evaluations, fitting and follow up: High-Index Lenses 1.74 • Collection Lens: Covered in full Polarized Lenses • Non-Collection Lens: $0 copay Plus 15% savings Progressive Lenses Lens copay: $25 (Standard / Premium / Ultra / Ultimate)

Frame

Anti-Reflective (AR) Coating

VisionWorks: $200 + Additional 20% off any overage Other Locations: $150 + Additional 20% off any overage -orThe Exclusive Collection copay • Fashion: Covered in full • Designer: Covered in full • Premier: Covered in full

(Standard / Premium / Ultra / Ultimate)

• •

Contacts $150 + Additional 15% off any overage -orThe Exclusive Collection of Contact Lenses: Covered in Full

$0 $0 or $30 $55 $120 $75

$50 / $90 / $140 / $175

$35 / $48 / $60 / $85 Ultraviolet Coating $12 Tinting of Plastic Lenses (Solid / Gradient) $0 Plastic Photochromic Lenses (Transitions® Signature™) $65 Scratch-Resistant Coating $0 Premium Scratch-Resistant Coating $30 Scratch-Protection Plan (Single-Vision/Multifocal) $20 | $40 Trivex Lenses $50 Blue Light Filtering $15

Vision Insurance Davis Vision Additional savings Retinal imaging (Member charge) Additional pairs of eyeglasses

$39 30% discount2

Out-of-network benefits You may receive services from an out-of-network provider, although you will receive the greatest value and maximize your benefit dollars if you select a provider who participates in the network. Out-of-network reimbursement schedule (up to) • Eye Examination: $40 • Frame: $70 • Single-Vision Lenses: $40 • Bifocal / Progressive Lenses: $60 • Trifocal Lenses: $80 • Lenticular Lenses: $100 • Elective Contact Lenses: $105 • Visually Required Contacts: $225 1. 2.

Excludes Maui Jim® eyewear. Some limitations apply to additional discounts; discounts not applicable at all in-network providers. 3. Contact lens coverage varies by product selection. Visually Required contacts are covered in full with prior approval. 4. The Davis Vision Exclusive Collection of Contact Lenses is available at participating providers. Evaluation, fitting and follow-up care for Collection contacts are covered in full. Davis Vision has done its best to accurately reflect plan coverage herein. If differences exist between this document and the plan contract, the contract will prevail.

EMPLOYEE BENEFITS

Disability Insurance

EMPLOYEE BENEFITS

The Hartford ABOUT DISABILITY 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.

For full plan details, please visit your benefit website: www.mybenefitshub.com/mansfieldisd

Educator Disability Insurance Overview What is Educator Disability Income Insurance? Educator Disability insurance combines the features of a shortterm and long-term disability plan into one policy. The coverage pays you a portion of your earnings if you cannot work because of disabling illness or injury. The plan gives you the flexibility to choose a level coverage to suit your need. You have the opportunity to purchase Disability Insurance through your employer. This highlight sheet is an overview of your Disability Insurance. Once a group policy is issued to your employer, a certificate of insurance will be available to explain your coverage in detail. Why do I need Disability Insurance Coverage? • More than half of all personal bankruptcies and mortgage foreclosures are a consequence of disability. • The average worker faces a 1 in 3 chance of suffering a job loss lasting 90 days or more due to a disability • Only 50% of American adults indicate they have enough savings to cover three months of living expenses in the vent they’re not earning any income.

Eligibility and Enrollment Eligibility You are eligible if you are an active employee who works at least 18 hours per week on a regularly scheduled basis. Enrollment You can enroll in coverage within 31 days of your date of hire or during your annual enrollment period.

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.

Features of the Plan Benefit Amount You may purchase coverage that will pay you a monthly flat dollar benefit in $100 increments between $200 and $7,500 that cannot exceed 66 2/3% of your current monthly earnings. Earnings are defined in The Hartford’s contract with your employer. Elimination Period You must be disabled for at least the number of days indicated by the elimination period that you select before you can receive a Disability benefit payment. 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.

For those employees electing an elimination period of 30 days or less, if you are confined to a hospital for 24 hours or more due to a disability, the elimination period will be waived, and benefits will be payable from the first day of hospitalization Partial Disability Partial Disability is covered provided you have at least a 20% loss of earnings and duties of your job.

Effective Date Coverage goes into effect subject to the terms and conditions of Other Important Benefits the policy. You must satisfy the definition of Actively at Work with Survivor Benefit - If you die while receiving disability benefits, a benefit will be paid to your spouse or child under age 26, equal to your employer on the day your coverage takes effect. three times your last monthly gross benefit. Actively at Work The Hartford's Ability Assist service is included as a part of your You must be at work with your Employer on your regularly group Long Term Disability (LTD) insurance program. You have scheduled workday. On that day, you must be performing for 31

Disability Insurance

EMPLOYEE BENEFITS

The Hartford access to Ability Assist services both prior to a disability and after you’ve been approved for an LTD claim and are receiving LTD benefits. Once you are covered you are eligible for services to provide assistance with child/elder care, substance abuse, family relationships and more. In addition, LTD claimants and their immediate family members receive confidential services to assist them with the unique emotional, financial and legal issues that may result from a disability. Ability Assist services are provided through

Continuity of Coverage If you were insured under your district’s prior plan and not receiving benefits the day before this policy is effective, there will not be a loss in coverage, and you will get credit for your prior carrier’s coverage.

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 pretrip information, emergency medical assistance and emergency personal services.

Any day within such period of Recovery, will not count toward the Elimination Period.

Recurrent Disability - What happens if I Recover but become Disabled again? Periods of Recovery during the Elimination Period will not interrupt the Elimination Period, if the number of days You return ComPsych®, a leading provider of employee assistance and work/ to work as an Active Employee are less than one-half (1/2) the life services. number of days of Your Elimination Period.

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

Provisions of the Plan Definition of Disability Disability is defined as 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 conditions covered by the insurance, and as a result, your current monthly earnings are 80% or less of your pre-disability earnings.

One you have been disabled for 24 months, you must be prevented from performing one or more essential duties of any occupation, and as a result, your monthly earnings are 66 2/3% or less of your pre-disability earnings. Pre-Existing Condition Limitation 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 been insured under this policy for 12 months before your disability begins. If your disability is a result of a pre-existing condition, we will pay benefits for a maximum of 4 weeks. 32

Benefit Integration Your benefit may be reduced by other income your receive or are eligible to receive due to your disability, such as: Social Security Disability Insurance, State Teacher Retirement Disability plans, Worker’s Compensation, Other employer-based disability insurance coverage you may have, unemployment benefits, retirement benefits that your employer fully or partially pays for (such as a pension plan), etc. Disability - per $100 in benefit

Elimination Period 0/7 14/14 30/30 60/60 90/90 180/180

Rate $3.00 $2.56 $2.20 $1.74 $0.98 $0.70

Cancer Insurance

EMPLOYEE BENEFITS

APL ABOUT CANCER 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.

For full plan details, please visit your benefit website: www.mybenefitshub.com/mansfieldisd

Treatment for cancer is often lengthy and expensive. While your health insurance helps pay the medical expenses for cancer treatment, it does not cover the cost of non-medical expenses, such as out-of-town treatments, special diets, daily living, and household upkeep. In addition to these nonmedical expenses, you are responsible for paying your health plan deductibles and/or coinsurance. Cancer insurance through American Public Life helps pay for these direct and indirect treatment costs so you can focus on your health.

Cancer Low Plan Employee $20.00 Employee + Spouse $42.76 Employee + Child(ren) $25.40 Family $48.14

High Plan $36.10 $77.08 $44.52 $85.56

Should you need to file a claim contact APL at 800-256-8606 or online at www.ampublic.com. You can find additional claim forms and materials at www.mybenefitshub.com/mansfieldsisd. Summary of Benefits Cancer Treatment Policy Benefits Radiation, Therapy, Chemotherapy, Immunotherapy -Max per 12-month period Hormone therapy – Max of 12 treatments per calendar eyer Experimental Treatment Cancer Screening Rider Benefits Diagnostic Testing – 1 test per calendar year Follow-Up Diagnostic Testing – 1 test per calendar year Medical Imaging – per calendar year Surgical Rider Benefits Surgical Anesthesia Bone Marrow Transplant – Max per lifetime Stem Cell Transplant – Max per lifetime Prosthesis – Surgical Implants / Non-Surgical (not Hair Piece) 1 device per site, per lifetime Internal Cancer First Occurrence Rider Benefits Lump Sum Benefit – Max 1 per Covered Person per lifetime Lump Sum for Eligible Dependent Children – Max 1 per Covered Person per lifetime Heart Attack/Stroke First Occurrence Rider Benefits Lump Sum Benefit – Max 1 per Covered Person per lifetime Lump Sum for Eligible Dependent Children – Max 1 per Covered Person per lifetime Hospital Intensive Care Unit Rider Benefits Intensive Care Unit Step Down Unit – Max of 45 days per Confinement for any combination of Intensive Care Unit or Step Down Unit

Plan 1 Plan 2 $10,000 $20,000 $50 per treatment $50 per treatment Paid in the same manner and under the same maximums as any other benefit Plan 1 Plan 2 $50 per test $50 per test $100 per test $100 per test $500 per test / 1 per calendar year Plan 1 Plan 2 $30 unit dollar amount $60 unit dollar amount Max $3,000 per Max $6,000 per operation operation 25% of amount paid for covered surgery $6,000 $12,000 $600 $1,200 $1,000 / $100 $3,000 / $300 Plan 1 Plan 2 $5,000 $10,000 $7,500 $15,000 Plan 1 Plan 2 $5,000 $10,000 $7,500 $15,000 Plan 1 Plan 2 $600 per ay $600 per day $300 per day

$300 per day 33

Accident Insurance

EMPLOYEE BENEFITS

Voya ABOUT ACCIDENT Do you have kids playing sports, are you a weekend warrior, or maybe accident prone? Accident plans are designed to help pay for medical costs associated with accidents and benefits are paid directly to you.

For full plan details, please visit your benefit website: www.mybenefitshub.com/mansfieldisd

What is Accident Insurance?

How to File a Claim:

Accident Insurance pays you benefits for specific injuries and events resulting from a covered accident that occurs, on or after your coverage effective date. The benefit amount depends on the type of injury and care received. You have the option to elect Accident Insurance to meet your needs. Accident 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.

• • • • • • • •

Other features of Accident Insurance include: • • • •

Guaranteed issue: No medical questions or tests are required for coverage. Flexible: You can use the benefit payments for any purpose you like. Payroll deductions: Premiums are paid through convenient payroll deductions. Portable: If you leave your current employer, you can take your coverage with you.

How can Accident Insurance help? • • • •

Medical expenses, such as deductibles and copays Home healthcare costs Lost income due to lost time at work Everyday expenses like utilities and groceries

•

www.voya.com Click contact and services Select Claims and then “start a claim” Complete the questionnaire so that a custom claim form package can be generated for you. Download your claim forms. Fill out each form by the appropriate party. Father additional supporting documents. Submit your completed and signed forms and supporting documents.  Upload at voya.com  Click on the contact and services  Select “Upload a form” Mail and or Fax information provided on the top of your claim form package.

If you have any questions about the claim process, call 1-888-238-4840

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

Low Plan High Plan $11.53 $19.05 $19.29 $31.33 $21.83 $35.46 $29.59 $47.74

Critical Illness Insurance Voya

EMPLOYEE BENEFITS

ABOUT CRITICAL ILLNESS Critical illness insurance can be used towards medical or other expenses. It provides a lump sum benefit payable directly to the insured upon diagnosis of a covered condition or event, like a heart attack or stroke. The money can also be used for non-medical costs related to the illness, including transportation, child care, etc.

For full plan details, please visit your benefit website: www.mybenefitshub.com/mansfieldisd

What is Critical Illness Insurance? Critical Illness Insurance pays a lump-sum benefit if you are diagnosed after your effective date of coverage with a covered illness or condition listed below. Please review certificates of coverage for any limitations that may apply. 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.

Module B >Multiple sclerosis >Amyotrophic lateral sclerosis (ALS) >Parkinson’s disease

>Alzheimer’s disease >Infectious disease

How can Critical Illness Insurance help? Below are a few examples of how your Critical Illness Insurance benefit could be used (coverage amounts may vary): • Medical expenses, such as deductibles and copays • Childcare Features of Critical Illness Insurance include: • Guaranteed Issue: No medical questions or tests required for • Home healthcare costs • Mortgage payment/rent and home maintenance coverage. • • •

Flexible: You can use the benefit money for any purpose you like. Payroll deductions: Premiums are paid through convenient payroll deductions. Portable: Should you leave your current employer or retire, you can take your coverage with you.

For what critical illnesses and conditions are benefits available? Critical Illness Insurance provides a benefit for the following illnesses and conditions. Covered illnesses/conditions are broken out into groups called “modules”. Benefits are paid at 100% of the Maximum Critical Illness Benefit amount unless otherwise stated. For a complete description of your benefits, along with applicable provisions, conditions on benefit determination, exclusions and limitations, see your certificate of insurance and any riders. Base Module >Heart attack >Major organ failure >Stroke >Permanent paralysis >Coronary artery bypass (25%) >End stage renal (kidney) failure >Coma Module A >Benign brain tumor >Deafness

>Occupational HIV >Blindness

Who is eligible for Critical Illness Insurance? • You—all active employees working at least 15 hours per week. • Your spouse*— coverage is available only if employee coverage is elected. • Your child(ren)— to age 26. Coverage is available only if employee coverage is elected. *The use of “spouse” in this document means a person insured as a spouse as described in the certificate of insurance or rider. This may include domestic partners or civil union partners as defined by the group policy. Please contact your employer for more information. What Maximum Critical Illness Benefit am I eligible for? • For you - You have the opportunity to purchase a Maximum Critical Illness Benefit of $5,000-$30,000 in $5,000 increments. • For your spouse - You have the opportunity to purchase a Maximum Critical Illness Benefit of $5,000-$30,000 in $5,000 increments. • For your children - You have the opportunity to purchase a Maximum Critical Illness Benefit of $1,000, $2,500, $5,000,$10,000 or $20,000 for each covered child.

Critical Illness Insurance

EMPLOYEE BENEFITS

Voya How many times can I receive the Maximum Critical Illness • Benefit? Usually you are only able to receive the Maximum Critical Illness Benefit for one covered illness or disease within each module. Your plan includes the Restoration Benefit, which provides a onetime restoration of 100% of the maximum benefit amount in order to pay an additional benefit if you experience a second covered illness for a different condition. Your plan also includes the Recurrence Benefit, which allows you to receive a benefit for the same condition a second time. It’s important to note that in • order for the second covered illness or the second occurrence of the illness to be covered, it must occur after 12 consecutive months without the occurrence of any covered critical illness named in your certificate, including the illness from the first benefit payment. If a partial benefit is paid out, it will not reduce the available maximum benefit amount for the illnesses or diseases in that same module. If you have reached the benefit limit by receiving the maximum benefit in each module, you may choose to end your coverage; however, if you have coverage for your spouse and/or child(ren), you must continue your coverage in order to keep their coverage active. Please see the certificate of coverage for details.

What optional benefits are available? You may choose to include the optional benefits below with your critical illness coverage. For a list of standard exclusions and limitations, please refer to the end of this document. For a complete description of your available benefits, along with applicable provisions, exclusions and limitations, see your certificate of insurance and any riders. Wellness Benefit: This provides an annual benefit payment if you complete a health screening test. You may only receive a benefit once per year, even if you complete multiple health screening tests. Employee 0-29 30-39 40-49 50-59 60-64 65-69 70+ Spouse 0-29 30-39 40-49 50-59 60-64 65-69 70+ Child 18-25 36

$5,000.00 $2.95 $3.45 $5.95 $12.05 $19.10 $24.85 $35.90 $5,000.00 $3.50 $3.95 $6.80 $14.95 $23.60 $26.95 $40.70 $1,000.00 $0.39

$10,000.00 $5.90 $6.90 $11.90 $24.10 $38.20 $49.70 $71.80 $10,000.00 $7.00 $7.90 $13.60 $29.90 $47.20 $53.90 $81.40 $2,500.00 $0.98

Spouse Critical Illness Insurance: If you have coverage for yourself, you may enroll your spouse, as long as your spouse is not covered under the Policy as an employee.  Your spouse will receive coverage for the same covered conditions as you.  Your spouse will be able to receive a benefit the same number of times as you, as outlined above.  Guaranteed issue: No medical questions or tests required for coverage Children’s Critical Illness Insurance: As long as you have critical illness coverage on yourself, your natural child(ren), stepchild(ren), adopted child(ren) or child(ren) for whom you are a legal guardian are eligible to be covered under your employer’s plan, up to the age of 26.  Your children are covered for the same covered conditions as you are with the exception of carcinoma in situ and coronary artery bypass; however, actual benefit amounts may vary.  Your child(ren) will be able to receive a benefit the same number of times as you, as outlined above.  One premium amount covers all of your eligible children.  Guaranteed issue: No medical questions or tests required for coverage.  If both you and your spouse are covered under the policy as an employee, then only one, but not both, may cover the same child(ren) under this benefit. If the parent who is covering the child(ren) stops being insured as an employee then the other parent may apply for children’s coverage.

Critical Illness $15,000.00 $8.85 $10.35 $17.85 $36.15 $57.30 $74.55 $107.70 $15,000.00 $10.50 $11.85 $20.40 $44.85 $70.80 $80.85 $122.10 $5,000.00 $1.95

$20,000.00 $11.80 $13.80 $23.80 $48.20 $76.40 $99.40 $143.60 $20,000.00 $14.00 $15.80 $27.20 $59.80 $94.40 $107.80 $162.80 $10,000.00 $3.90

$25,000.00 $14.75 $17.25 $29.75 $60.25 $95.50 $124.25 $179.50 $25,000.00 $17.50 $19.75 $34.00 $74.75 $118.00 $134.75 $203.50 $20,000.00 $7.80

$30,000.00 $17.70 $20.70 $35.70 $72.30 $114.60 $149.10 $215.40 $30,000.00 $21.00 $23.70 $40.80 $89.70 $141.60 $161.70 $244.20

Voluntary Life and AD&D OneAmerica

EMPLOYEE BENEFITS

For full plan details, please visit your benefit website: www.mybenefitshub.com/mansfieldisd

What you need to know about your Voluntary Term Life Benefits Flexible Options: • Employee: $10,000 to $500,000, in $10,000 increments • Spouse: $10,000 to $250,000, in $5,000 increments, not to exceed 100% of the employee’s amount Guaranteed Issue: • Employee: $200,000 • Spouse: $50,000 • 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. 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 will reduce according to the employee's Age: 70 75 reduction schedule. Reduces To: 65% 50%

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% of the employee AD&D benefit AD&D Guaranteed Issue: • Employee: $500,000 • Spouse: $250,000 • Child: $50,000

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 Age: 70 75 65% 50% employee’s reduction schedule. Reduces To: Voluntary Group Life - per $10,000 in coverage Age Employee Spouse 0-29 $0.40 $0.40 30-34 $0.56 $0.56 35-39 $0.64 $0.64 40-44 $0.72 $0.72 45-49 $1.12 $1.12 50-54 $1.68 $1.68 55-59 $3.12 $3.12 60-64 $4.72 $4.72 65-69 $9.12 $9.12 70-74 $14.80 $14.80 75+ $18.40 $18.40 Spouse rates based on Employee's age. Voluntary Group Life: Child(ren) - $10,000 in coverage 0-26 $1.80 Voluntary AD&D - per $10,000 in coverage Employee Only $0.30 Family $0.60 37

Employee Assistance Program (EAP) ComPsych | OneAmerica

EMPLOYEE BENEFITS

ABOUT EAP An Employee Assistance Program (EAP) is a program that assists you in resolving problems such as finding child or elder care, relationship challenges, financial or legal problems, etc. This program is provided by your employer at no cost to you.

For full plan details, please visit your benefit website: www.mybenefitshub.com/mansfieldisd

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 company-sponsored, 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 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 6 sessions per issue per year) and other resources for: › Stress, anxiety and depression › Job pressures › Relationship/marital conflicts › Grief and loss › Problems with children › Substance abuse

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 38

Work-Life Solutions 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

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 Call Your ComPsych Guidance Resources program anytime for confidential assistance. Call: 855.365.4754 TDD: 800.697.0353 Go online: guidanceresources.com Your company Web ID: ONEAMERICA3

Individual Life Insurance

EMPLOYEE BENEFITS

5Star ABOUT INDIVIDUAL LIFE Individual insurance is a policy that covers a single person and is intended to meet the financial needs of the beneficiary, in the event of the insured’s death. This coverage is portable and can continue after you leave employment or retire.

For full plan details, please visit your benefit website: www.mybenefitshub.com/mansfieldisd

Enhanced coverage options for employees. Easy and flexible enrollment for employers. The 5Star Life Insurance Company’s Family Protection Plan offers both Individual and Group products with Terminal Illness coverage to age 121, making it easy to provide the right benefit for you and your employees. CUSTOMIZABLE With several options to choose from, employees select the coverage that best meets the needs of their families.

QUALITY OF LIFE Optional benefit that accelerates a portion of the death benefit on a monthly basis, up to 75% of your benefit, and is payable directly to you on a tax favored basis for the following: •

Permanent inability to perform at least two of the six Activities of Daily Living (ADLs) without substantial assistance; or

•

Permanent severe cognitive impairment, such as dementia, Alzheimer’s disease and other forms of senility, requiring substantial supervision.

TERMINAL ILLNESS ACCELERATION OF BENEFITS Coverage that pays 30% (25% in CT and MI) of the coverage amount in a lump sum upon the occurrence of a terminal condition Find full details and rates at that will result in a limited life span of less than 12 months www.mybenefitshub.com/mansfieldisd. (24 months in IL). Should you need to file a claim, contact 5Star directly at (866) 863-9753. PORTABLE Coverage continues with no loss of benefits or increase in cost if employment terminates after the first premium is paid. We simply bill the employee directly. CONVENIENCE Easy payments through payroll deduction. FAMILY PROTECTION Coverage is available for spouses and financially dependent children, even if the employee doesn’t elect coverage on themselves.

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

*Financially dependent children 14 days to 23 years old.

PROTECTION TO COUNT ON Within one business day of notification, payment of 50% of coverage or $10,000 whichever is less is mailed to the beneficiary, unless the death is within the two-year contestability period and/or under investigation. This coverage has no war or terrorism exclusions.

Sick Leave Bank MISD

EMPLOYEE BENEFITS

For full plan details, please visit your benefit website: www.mybenefitshub.com/mansfieldisd

Section I Purpose and Definition The purpose of the Sick Leave Bank (SLB) is to provide additional paid sick leave days for members of the Bank who have exhausted all available paid leave in the event of the catastrophic illness or injury of the employee or the employee’s immediate family member. Immediate family member is defined as the employee’s spouse, dependent children, and the employee’s parents.

Section II Membership Eligibility is limited to all full-time personnel of the Mansfield Independent School District. Full-time shall be defined as thirty or more hours of duty per week. Application for membership must be made during the open enrollment period prior to September 1 or within 30 days of employment. An employee must be able to donate two (2) local leave days to become a member. Their application for membership in the Bank will become active when the two (2) days are earned. If a member uses any days during the Bank year, he/she will be required to remain a member the next Bank year and two (2) local days will be subtracted from their leave balance. If the number of days in the bank falls below the number of SLB members, each member will be required to contribute one (1) extra day at the beginning of the next SLB year. The Sick Leave Bank year runs from September 1 until August 31 of the following year. The Sick Leave Bank Committee will determine whether the request for sick leave days is approved or denied in accordance with the SLB Guidelines and Procedures. For additional information, review the MISD Sick Leave Bank Guidelines and Procedures.

Notes

2022 - 2023 Plan Year

Enrollment Guide General Disclaimer: This summary of benefits for employees is meant only as a brief description of some of the programs for which employees may be eligible. This summary does not include specific plan details. You must refer to the specific plan documentation for specific plan details such as coverage expenses, limitations, exclusions, and other plan terms, which can be found at the Mansfield ISD Benefits Website. This summary does not replace or amend the underlying plan documentation. In the event of a discrepancy between this summary and the plan documentation the plan documentation governs. All plans and benefits described in this summary may be discontinued, increased, decreased, or altered at any time with or without notice. Rate Sheet General Disclaimer: The rate information provided in this guide is subject to change at any time by your employer and/or the plan provider. The rate information included herein, does not guarantee coverage or change or otherwise interpret the terms of the specific plan documentation, available at the Mansfield ISD Benefits Website, which may include additional exclusions and limitations and may require an application for coverage to determine eligibility for the health benefit plan. To the extent the information provided in this summary is inconsistent with the specific plan documentation, the provisions of the specific plan documentation will govern in all cases.

2022-23 Mansfield ISD Benefit Guide

Articles inside

Individual Life

Sick leave Bank

Critical Illness

Accident

MISD Staff Clinic

How to Enroll

Cancer

Telehealth

Vision

Flexible Spending Account (FSA

Health Savings Account (HSA

Disability