2022-23 Santa Fe ISD Benefit Guide

Benefit Contact Information

SANTA FE ISD BENEFITS

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

TRS ACTIVECARE MEDICAL TELEHEALTH

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

HEALTH SAVINGS ACCOUNT (HSA) HOSPITAL INDEMNITY

GCEFCU (281) 487 9333 www.gcefcu.org

Aetna (800) 872 3862 www.aetna.com

VISION DISABILITY

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

CRITICAL ILLNESS

Unum (800) 635 5597 www.unum.com

Cigna (800) 244 6224 www.cigna.com

ACCIDENT

The Hartford (866) 547 4205 www.thehartford.com

FLEXIBLE SPENDING ACCOUNT (FSA) LEGAL SERVICES

Higginbotham (866) 419 3519 https://flexservices.higginbotham.net/

MetLife (800) 638 5433 www.metlife.com

RediMD (866) 989 2873 www.redimd.com

DENTAL

Cigna (800) 244 6224 www.cigna.com

LIFE AND AD&D

Lincoln Financial Group (800) 423 2765 www.lfg.com

EMERGENCY MEDICAL TRANSPORTATION

MASA (800) 423 3226 www.masamts.com

EMPLOYEE ASSISTANCE PROGRAM (EAP)

LifeWorks (888) 456 1324 www.us.lifeworks.com

CLICK LOGIN

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Annual Benefit Enrollment

Benefit Updates What’s New:

NEW FSA ADMINISTRATOR HIGGINBOTHAM

All employees who enroll will receive a new debit card. Employees are encouraged to use up current year funds prior to September 1ST a to ease the transition to Higginbotham.

Don

t Forget!

• Login and complete your benefit enrollment from 7/25/2022 8/12/2022

• Enrollment assistance is available by calling Financial Benefit Services at (866) 914 5202, Monday Friday 8am 6pm. Bilingual assistance is available

• Update your profile information: home address, phone numbers, email, beneficiaries

• REQUIRED: Provide correct dependent social security numbers

Annual Benefit Enrollment

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

CHANGES IN STATUS (CIS):

Marital Status

Change in Number of Tax Dependents

Change in Status of Employment Affecting Coverage Eligibility

Gain/Loss of Dependents' Eligibility Status

Judgment/Decree/ Order

Eligibility for Government Programs

QUALIFYING EVENTS

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

A change in number of dependents includes the following: birth, adoption and placement for adoption. 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 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 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.

Gain or loss of Medicare/Medicaid coverage may trigger a permitted election change.

Annual Benefit Enrollment

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 31 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/ santafeisd. 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 Santa Fe ISD benefit website: www.mybenefitshub.com/santafeisd. 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

Employee Eligibility Requirements

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

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.

Dependent Eligibility Requirements

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.

PLAN

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

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.

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

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

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

Helpful Definitions

Actively at Work

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.

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 pre existing condition exclusion provisions do apply, as applicable by carrier.

In Network

PAGES

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

Out of Pocket Maximum

The most an eligible or insured person can pay in co insurance for covered expenses.

Plan Year

September 1st through August 31st

Pre Existing Conditions

Applies to any illness, injury or condition for which the participant has been under the care of a health care provider, taken 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).

HSA vs. FSA

Description

Employer Eligibility

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

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.

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

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

A qualified high deductible health plan. All employers

Contribution Source Employee and/or employer

Employee and/or employer

Account Owner Individual Employer

Underlying Insurance Requirement

High deductible health plan

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

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

Permissible Use Of Funds

Cash Outs of Unused Amounts (if no medical expenses)

Year-to-year rollover of account balance?

Does the account earn interest?

Portable?

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

None

N/A

$2,850 (2022)

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

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

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

No. However, your employer’s plan contains a $500 rollover provision.

Yes No

Yes, portable year to year and between jobs. No

Medical

ABOUT MEDICAL

Major medical insurance is

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

plan

website: www.mybenefitshub.com/santafeisd

Monthly

Employee Only $407.00 $325.00 $82.00

Employee & Spouse $1,145.00 $325.00 $820.00

Employee & Child(ren) $731.00 $325.00 $406.00

Employee & Family $1,370.00 $325.00 $1,045.00

Employee Only

Employee & Spouse

Employee & Child(ren)

Employee

Employee Only

Employee & Spouse

Employee & Child(ren)

Employee &

Employee Only

Employee

Employee

$325.00 $70.00

$325.00

$325.00

TRS ActiveCare Primary+

$325.00

$325.00 $887.00

$325.00

$325.00

$325.00

Health Savings Account (HSA)

GCEFCU

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/santafeisd

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

You are eligible to open and contribute to an HSA if you are:

• Enrolled in an HSA eligible HDHP

• Not covered by another plan that is not a qualified HDHP, such as your spouse’s health plan

• Not enrolled in a Health Care Flexible Spending Account, nor should your spouse be contributing towards a Health Care Flexible Spending Account

• Not eligible to be claimed as a dependent on someone else’s tax return

• Not enrolled in Medicare or TRICARE

• Not receiving Veterans Administration benefits

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 health care expenses for your dependents, even if they are not covered under your HDHP.

Maximum Contributions

Your HSA contributions may not exceed the annual maximum amount established by the Internal Revenue Service. The annual contribution maximum for 2022 is based on the coverage option you elect:

• Individual $3,650

• Family (filing jointly) $7,300

You decide whether to use the money in your account to pay for qualified expenses or let it grow for future use. If you are 55 or older, you may make a yearly catch up contribution of up to $1,000 to your HSA. If you turn 55 at any time during the plan year, you are eligible to make the catch up contribution for the entire plan year.

Opening an HSA

To get started with your new HSA, you will enroll with Santa Fe ISD. Afterwards, Gulf Coast Educators FCU will service your HSA, and mail your new benefit cards to the address listed in THEbenefitsHUB. You will have the option to make pre tax deductions straight from your paycheck, or transfer funds as you are able.

Important HSA Information

• 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.

How to Use your HSA

Participant Account Web Access: www.gcefcu.org

Participants may call Gulf Coast Educators FCU and talk to a representative during regular business hours, Monday Friday, 7 am to 7 pm CST, and on Saturday from 9 am to 12 pm CST.

Participants may also log into their GCEFCU online banking account at any time to view their balance, account history, and make transfers to their HSA.

Hospital Indemnity Aetna

ABOUT HOSPITAL INDEMNITY

This is an affordable supplemental plan that pays you should you be in patient 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/santafeisd

Employee Only

Hospital Indemnity

$17.18

Employee and Spouse $34.83

Employee and Child(ren) $27.54

Employee and Family $45.53

Inpatient Benefits

Hospital stay admission

Provides a lump sum benefit for the initial day of your stay in a hospital.

Maximum 1 stay per plan year

Hospital stay daily

Pays a daily benefit, for each day of your stay in a non ICU room of a hospital, beginning on day two.

EMPLOYEE BENEFITS

$1,000

Maximum 30 days per plan year $100

Hospital stay (ICU) daily

Pays a daily benefit, for each day of your stay in an ICU room of a hospital, beginning on day two.

Maximum 30 days per plan year $200

Newborn routine care

Pays a lump sum benefit after the birth of your newborn with an inpatient stay. This would not pay for an outpatient birth. $100 Observation unit

Pays a lump sum benefit for the initial day of your observation.

Maximum 1 day per plan year $100

Substance abuse stay daily

Pays a daily benefit for each day you have a stay in a substance abuse treatment facility, beginning on day one.

Maximum 30 days per plan year $100

Mental disorder stay daily

Pays a daily benefit for each day you have a stay in a mental disorder treatment facility, beginning on day one.

Maximum 30 days per plan year $100

Rehabilitation unit stay daily

Pays a daily benefit for each day of your stay in a rehabilitation unit immediately after your hospital stay, beginning on day one.

Maximum 30 days per plan year $50

Important note:

All daily stay benefits count toward the combined plan year maximum.

Dental Insurance 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/santafeisd

Dental

Dental Coverage

Our dental plan helps you maintain good oral health through affordable options for preventive care, including regular checkups and other dental work. Premium contributions are deducted from your paycheck on a pretax basis. Coverage is provided through Cigna

DPPO Plan

PPO DHMO

Employee Only $32.45 $9.98

Employee and Spouse $72.28 $19.97

Employee and Child(ren) $71.05 $22.46

Employee and Family $107.36 $33.43

You may select the dental provider of your choice, but your level of coverage may vary based on the provider you see for services. You could pay more if you use an out of network provider.

Cigna Dental Choice Plan

Individual $50

Family $150

Deductible applies to: Type 2 & 3

Benefit Levels

2 &

Type 1 Diagnostic & Preventative 100% 100%

Type 2 Basic Services 80% 80%

Type 3 Major Services 50% 50%

Type 4 Orthodontic Services for Adults and Dependent Children 50% 50%

Benefits Based On

Maximum Benefit (per covered person):

Types 1, 2 & 3 combined $1,000 Per Plan Year $1,000 Per Plan Year Type 4, while covered by the plan $1,000 Lifetime $1,000 Lifetime

DHMO Plan

• You choose your primary care dentist when you enroll. To find a participating dentist, visit http://ldc.lfg.com and select Find a Dentist. (You can also print your dental ID card from this site once your coverage begins.)

• This dental plan offers a detailed list of covered procedures, each with a dollar copayment (see the Summary of Benefits on Benefits Portal for details). You pay for services provided during your visit.

• Emergency care away from home is covered up to a set dollar limit.

• You can change your primary care dentist at any time by calling the customer service number listed on your dental ID card.

• Covers most preventive and diagnostic care services at no charge

• Also covers a wide variety of specialty services lowering your out of pocket costs with no deductibles or maximums

Vision Insurance Superior 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/santafeisd

EMPLOYEE BENEFITS

Vision Monthly Premiums Copays

Services/Frequency

Employee Only $9.14 Exam $10 Exam 12 months

Employee and Spouse $18.09 Materials1 $15 Frame 12 months

Employee and Child(ren) $17.72

Contact lens fitting $25 Contact lens fitting 12 months

Employee and Family $26.93 (standard & specialty)

Benefits through Superior National network

Lenses 12 months

Contact lenses 12 months (based on date of service)

In network Out of network

Exam (ophthalmologist)

Covered in full

Up to $42 retail Exam (optometrist) Covered in full Up to $42 retail

Frames $150 retail allowance

Up to $60 retail

Contact lens fitting (standard2) Covered in full Not covered

Contact lens fitting (specialty2) $50 retail allowance Not covered Lenses (standard) per pair

Single vision Covered in full

Up to $26 retail

Bifocal Covered in full Up to $34 retail

Trifocal Covered in full

Up to $50 retail Lenticular Covered in full Up to $80 retail

Progressives lens upgrade See description3 Up to $50 retail

Ultraviolet coat Covered in full Not covered

Factory scratch coat Covered in full Not covered

Polycarbonate for dependent children Covered in full Not covered

Contact lenses4 $150 retail allowance

Medically necessary contact lenses Covered in full

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

1 Materials co pay applies to lenses and frames only, not contact lenses

Up to $100 retail

Up to $210 retail

2 Standard contact lens fitting applies to a current contact lens user who wears disposable, daily wear, or extended wear lenses only. Specialty contact lens fitting applies to new contact wearers and/or a member who wear toric, gas permeable, or multi focal lenses.

3 Covered to provider’s in office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co pay.

4 Contact lenses are in lieu of eyeglass lenses and frames benefit

Vision Insurance Superior Vision EMPLOYEE BENEFITS

Discount features

Look for providers in the provider directory who accept discounts, as some do not; please verify their services and discounts (range from 10% 30%) prior to service as they vary.

Discounts on covered materials

Frames: 20% off amount over allowance

Lens options: 20% off retail

Progressives: 20% off amount over retail lined trifocal lens, including lens options

Specialty contact lens fit: 10% off retail, then apply allowance

Maximum member out of pocket

The following options have out of pocket maximums5 on standard (not premium, brand, or progressive) lenses.

Single vision Bifocal & trifocal

Tints, solid or gradients $25 $25

Anti reflective coat $50 $50

Polycarbonate $40 20% off retail

High index 1.6 $55 20% off retail

Photochromics $80 20% off retail

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

Discounts on non covered exam, services and materials

Exams, frames, and prescription lenses: 30% off retail

Lens options, contacts, miscellaneous options: 20% off retail

Disposable contact lenses: 10% off retail

Retinal imaging: $39 maximum out of pocket

LASIK

Laser vision correction (LASIK) is a procedure that can reduce or eliminate your dependency on glasses or contact lenses. This corrective service is available to you and your eligible dependents at a special discount (20 50%) with your Superior Vision plan.

Contact QualSight LASIK at (877) 201 3602 for more information. superiorvision.com (800) 507 3800

Disability Insurance Cigna

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/santafeisd

SUMMARY OF BENEFITS

If you had an unexpected illness or injury and were unable to work, how long would you be able to pay your bills and take care of your family?

Disability insurance pays a portion of your salary if you’re unable to work due to a covered disability.

By purchasing coverage through your employer, you also benefit from cost effective group rates and convenient payroll deduction.

Eligibility:

Disability per $100 in benefit

Elimination Period Premium Select 0/7 $3.41 $3.18 14/14 $2.65 $2.46 30/30 $2.08 $1.89 60/60 $1.77 $1.51 90/90 $1.45 $1.16 180/180 $0.97 $0.78

If you are an active employee working at least 20 hours per week, you will be eligible immediately.

Guaranteed Issue*:

Initial Enrollment: If you are eligible on or before the policy’s effective date, you may enroll for coverage during the Initial Enrollment without submitting any evidence of good health.

New Hires: If you were hired after the policy’s effective date, you may elect coverage once eligible without submitting any evidence of good health.

Annual Enrollment: During annual enrollment, you may enroll for the first time or make coverage changes, if already participating, without submitting any evidence of good health.

*The Pre Existing Condition Limitation, as outlined in the Benefit Reductions, Conditions, Limitations and Exclusions section, will apply.

Benefit Waiting Period

Employee Options

Select Monthly Benefit: Flat dollar benefit in $100 increments between $200 and $7,500 that cannot exceed 66 2/3% of your Covered Earnings

Select from Six Options: Accident/Sickness

0 days/7 days 14 days/14 days 30 days/30 days 60 days/60 days 90 days/90 days 180 days/180 days

Please refer to the “Maximum Benefit Period” Schedules below for more details

Disability Insurance Cigna

Maximum Benefit Period Schedule

Premium Plan

The later of your SSNRA* or the Maximum Benefit Period listed below.

Age When Disability Begins Maximum Benefit Period

Age 62 or under

Age 63

Age 64

Age 65

Age 66

Age 67

Age 68

Age 69 or older

Select Plan

The later of your SSNRA* or the date the 42nd Monthly Benefit is payable.

The later of your SSNRA* or the date the 36th Monthly Benefit is payable.

The later of your SSNRA* or the date the 30th Monthly Benefit is payable.

The date the 24th Monthly Benefit is payable.

The date the 21st Monthly Benefit is payable.

The date the 18th Monthly Benefit is payable.

The date the 15th Monthly Benefit is payable.

The date the 12th Monthly Benefit is payable.

For Disabilities Resulting From an Accident

The date the 36th Monthly Benefit is payable.

Age When Disability Begins Maximum Benefit Period

Age 62 or under The later of your SSNRA* or the date the 42nd Monthly Benefit is payable.

Age 63 The later of your SSNRA* or the date the 36th Monthly Benefit is payable.

Age 64

Age 65

Age 66

Age 67

Age 68

Age 69 or older

The later of your SSNRA* or the date the 30th Monthly Benefit is payable.

The date the 24th Monthly Benefit is payable.

The date the 21st Monthly Benefit is payable.

The date the 18th Monthly Benefit is payable.

The date the 15th Monthly Benefit is payable.

The date the 12th Monthly Benefit is payable.

*SSNRA means the Social Security Normal Retirement Age in effect under the Social Security Act on the Policy Effective Date.

Pre existing Condition Limitation: We will not pay benefits for any period of Disability caused or contributed to by, or resulting from, a Pre existing Condition. A "Pre existing Condition" means any Injury or Sickness for which you received medical treatment, care or services including diagnostic measures, took prescribed drugs or medicines within 12 months before your effective date of insurance.

The Pre existing Condition Limitation will apply to any added benefits or increases in benefits. This limitation will not apply to a period of Disability that begins after you are covered for at least 12 months after your effective date of insurance, or the effective date of any added or increased benefits.

Pre existing Condition Waiver: We will waive the Pre Existing Condition Limitation for the first 4 weeks of Disability even if you have a Pre Existing Condition. The Disability Benefits as shown in the Schedule of Benefits will continue beyond 4 weeks only if the Pre Existing Condition Limitation does not apply.

You may elect to increase or decrease coverage during Annual Enrollment. If you are insured for the maximum benefit amount allowed based on your Covered Earnings and you receive an increase in Covered Earnings, the Pre Existing Condition Limitation will not apply to the increased amount if you elect, during the following Annual Enrollment, to increase your benefit to the new maximum amount.

If you are insured under the disability plan you may enroll in a plan option with a shorter Benefit Waiting Period during a subsequent annual enrollment. If you become Disabled and are subject to the Pre Existing Condition Limitation for any period of Disability caused or contributed by, or resulting from, a Pre Existing Condition, benefits may be paid on a limited basis as outlined in the Pre Existing Condition Waiver provision. Once benefits have been exhausted under the Pre Existing Condition Waiver provision they may recommence if the Benefit Waiting Period of the previously elected option and all other provisions of the plan are satisfied

If you are insured under the disability plan you may enroll in a plan option with a shorter Benefit Waiting Period during a subsequent annual enrollment. If you become Disabled and are subject to the Pre Existing Condition Limitation for any period of Disability caused or contributed by, or resulting from, a Pre Existing Condition, benefits may be paid if the Benefit Waiting Period of the previously elected option and all other provisions of the plan are satisfied.

Life and AD&D Lincoln Financial Group

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/santafeisd

$0.41

$0.53

$0.79

$1.25

0

$0.16

$0.21

$0.27

$0.40

$0.63

$0.96

$1.45

Life and AD&D Lincoln Financial Group

Employee

BENEFITS

Voluntary Group Life AD&D

Newly hired employee guaranteed coverage amount $200,000

Continuing employee guaranteed coverage annual increase amount

Maximum coverage amount

$500,000

Choice of $10,000 or $20,000 N/A

7 times your annual salary ($500,000 maximum in increments of $10,000)

7 times your annual salary ($500,000 maximum in increments of $10,000)

Minimum coverage amount $10,000 $10,000

Spouse

Newly hired employee guaranteed coverage amount $30,000

Continuing employee guaranteed coverage annual increase amount

Maximum coverage amount

Up to 50% of employee coverage not to exceed $250,000

Choice of $5,000 or $10,000 Choice of $5,000 or $10,000

50% of the employee coverage amount ($250,000 maximum in increments of $5,000)

50% of the employee coverage amount ($250,000 maximum in increments of $5,000)

Minimum coverage amount $5,000 $5,000

Dependent Children

6 months to age 26 guaranteed coverage amount $10,000 $10,000

Age 1 day to 6 months guaranteed coverage amount $1,000 $1,000

Critical Illness Insurance Unum

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/santafeisd

Critical Illness insurance

$10,000 EE, $10,000

Well

Age

<25 $3.94

25 29 $4.94

30 34 $6.14

35 39 $8.04

40

$10.44

$13.54

$17.04

$22.94

$31.54

$45.44

$70.44

$103.54

$150.54

$242.24

Spouse rates based on Employee's age.

Who is eligible for this coverage?

What are the Critical Illness coverage amounts?

Illness Monthly

Age

<25 $6.04 <25 $8.14

25 29 $8.04

30 34 $10.44

35 39 $14.24

$19.04

$25.24

$32.24

$44.04

$61.24

$89.04

$139.04

$205.24

$299.24

$482.64

Spouse rates based on Employee's age.

25 29 $11.14

30 34 $14.74

39 $20.44

$27.64

$36.94

$47.44

$65.14

$90.94

$132.64

$207.64

$306.94

$447.94

$723.04

Spouse rates based on Employee's age.

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

The following coverage amounts are available.

For you: Select one of the following $10,000, $20,000 or $30,000

For your Spouse: 100% of employee coverage amount

For your Children: 100% of employee coverage amount Can I be denied coverage? Coverage is guarantee issue.

When is coverage effective? Please see your Plan Administrator for your effective date of coverage.

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

What critical illness conditions are covered?

Covered

Critical

Coronary Artery Disease (major)

Coronary Artery Disease (minor)

End Stage Renal (Kidney) Failure

Heart Attack (Myocardial Infarction)

Major Organ Failure Requiring Transplant

Stroke

Percentage

10% 100% 100% 100% 100%

Amount

Critical Illness Insurance

Unum

What critical illness conditions are covered?

Cont’d.

Covered Conditions*

Cancer

Invasive Cancer (including all Breast Cancer)

Non Invasive Cancer

Skin Cancer

Supplemental Critical Illnesses

Benign Brain Tumor

Coma

Loss of Hearing

Loss of Sight

Loss of Speech

Infectious Disease

Occupational Human Immunodeficiency Virus (HIV) or Hepatitis

Permanent Paralysis

Progressive Diseases

Amyotrophic Lateral Sclerosis (ALS)

Dementia (including Alzheimer’s Disease)

Functional Loss

Multiple Sclerosis (MS)

Parkinson’s Disease

Additional Critical Illnesses for your Children

Cerebral Palsy

Cleft Lip or Palate

Cystic Fibrosis

Down Syndrome Spina Bifida

Percentage of Coverage Amount

100% 25% $500

100% 100% 100% 100% 100% 25% 100% 100%

100% 100% 100% 100% 100%

100% 100% 100% 100% 100%

*Please refer to the policy for complete definitions of covered conditions.

Covered Condition Benefit

The covered condition benefit is payable once per covered condition per insured.

Unum will pay a covered condition benefit for a different covered condition if:

• the new covered condition is medically unrelated to the first covered condition; or

• the dates of diagnosis are separated by more than 180 days.

Reoccurring Condition Benefit

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

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

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

• Benign Brain Tumor

• Coma

• Coronary Artery Disease (Major)

• Coronary Artery Disease (Minor)

• End Stage Renal (Kidney) Failure

Are wellness screenings covered?

• Heart Attack (Myocardial Infarction)

• Invasive Cancer (includes all Breast Cancer)

• Major Organ Failure Requiring Transplant

• Non Invasive Cancer

• Stroke

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

Be Well Benefit

For you, your spouse and your children: $50

If the employee’s Critical Illness

Coverage Amount is:

The Be Well Benefit Amount for you, your spouse and your children is: $10,000 $50 $20,000 $50 $30,000 $50

Be Well Screenings include tests for the following:

cholesterol and diabetes, cancer and cardiovascular function. They also include imaging studies, immunizations and annual examinations by a Physician. See certificate for details.

Accident Insurance

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/santafeisd

GROUP VOLUNTARY ACCIDENT INSURANCE BENEFIT HIGHLIGHTS

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

PREMIUMS

The amounts shown are monthly amounts (12 payments/deductions per year)

COVERAGE TIER

LOW PLAN HIGH PLAN

Employee Only $3.88 ($0 .13 per day) $7.85 ($0 .26 per day)

Employee & Spouse $6.10 ($0 .20 per day) $12.34 ($0 .41 per day)

Employee & Child(ren) $6.77 ($0 .22 per day) $14.10 ($0 .46 per day)

Employee & Family $10.54 ($0 .35 per day) $21.81 ($0 .72 per day)

COVERAGE INFORMATION

You have a choice of two accident plans, which allows you the flexibility to enroll for the coverage that best meets your needs. 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 under each plan are the same for you and your dependent(s).

PLAN INFORMATION

Coverage Type

BENEFITS

EMERGENCY, HOSPITAL & TREATMENT CARE

Accident Follow Up

Up to 3 visits per accident

LOW PLAN HIGH PLAN

On and off job (24 hour)On and off job (24 hour)

$50 $75

Up to 10 visits each per accident $15 $25 Ambulance Air

Physical Therapy

Blood/Plasma/Platelets

Daily Hospital Confinement

Daily ICU Confinement

Diagnostic Exam

Emergency Dental

Emergency Room

Hospital Admission

Initial Physician Office Visit

Lodging

Medical Appliance

Rehabilitation Facility

Transportation

Urgent Care

Once per accident $750

Once per accident $300 $400

Up to 365 days per lifetime $100 $200

Up to 30 days per accident $200 $400

Once per accident $100 $200

Once per accident

Up to $100 Up to $200

Once per accident $50 $100

Once per accident $1,000 $2,000

Once per accident $25 $50

Up to 30 nights per lifetime $100 $200

Once per accident $100 $200

Up to 15 days per lifetime $100 $200

Up to 3 trips per accident $200 $400

Once per accident $50 $50

Once per accident $50 $50

Accident Insurance

BENEFITS

SPECIFIED INJURY & SURGERY LOW PLAN HIGH PLAN

Abdominal/Thoracic Surgery

Arthroscopic Surgery

Once per accident

BENEFITS

LOW PLAN HIGH PLAN

$1,000 $2,000

Once per accident $150 $300

Burn Once per accident

Burn Skin Graft

Concussion

Dislocation

Up to $5,000 Up to $10,000

Once per accident for third degree burn(s) 25% of burn benefit 25% of burn benefit

Up to 3 per year $200 $400

Once per joint per lifetime

Up to $3,000 Up to $6,100

Once per accident $200 $300 Fracture

Eye Injury

Hernia Repair

Once per bone per accident

Up to $3,000 Up to $6,000

Once per accident $100 $200

Knee Cartilage

Once per accident

Up to $500 Up to $750 Laceration

Up to $200 Up to $400 Ruptured Disc

Once per accident

Once per accident $500 $ 1,000 Tendon/Ligament/Rotator Cuff Up to 2 per accident

CATASTROPHIC

Accidental Death

Within 90 days; Spouse @ 50% and child @ 25%

Up to $750 Up to $1,000

$25,000 $ 50,000

Common Carrier Death

Within 90 days

3 times death benefit 3 times death benefit Coma

Once per accident

Up to $10,000 Up to $10,000

Dismemberment

Once per accident

Up to $10,000 Up to $50,000 Paralysis

Once per accident Up to $10,000 Up to $50,000 Prosthesis

Up to 2 per accident

Up to $1,000 Up to $1,500

FEATURES

Ability

Emergency Medical Transport

ABOUT MEDICAL TRANSPORT

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 can include emergency transportation via ground ambulance, air ambulance and helicopter, depending on the plan.

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

A MASA MTS Membership provides the ultimate peace of mind at an affordable rate for emergency ground and air transportation service within the United States and Canada, regardless of whether the provider is in or out of a given group healthcare benefits network. If a member has a high deductible health plan that is compatible with a health savings account, benefits will become available under the MASA membership for expenses incurred for medical care (as defined under Internal Revenue Code (“IRC”) section 213 (d)) once a member satisfies the applicable statutory minimum deductible under IRC section 223(c) for high deductible health plan coverage that is compatible with a health savings account.

Emergent Air Transportation In the event of a serious medical emergency, Members have access to emergency air transportation into a medical facility or between medical facilities.

Emergent Ground Transportation In the event of a serious medical emergency, Members have access to emergency ground transportation into a medical facility or between medical facilities.

Non Emergency Inter Facility Transportation In the event that a member is in stable condition in a medical facility but requires a heightened level of care that is not available at their current medical facility, Members have access to non emergency air or ground transportation between medical facilities.

Repatriation/Recuperation Suppose you or a family member is hospitalized more than 100 miles from your home. In that case, you have benefit coverage for air or ground medical transportation into a medical facility closer to your home for recuperation.

Should you need assistance with a claim contact MASA at 800 643 9023. You can find full benefit details at www.mybenefitshub.com/santafeisd

Flexible Spending Account (FSA) Higginbotham

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 (your plan contains a $500 rollover or grace period provision).

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

Health 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).

Limited Purpose Health Care FSA

A Limited Purpose Health Care FSA is available if you enrolled in the HDHP medical plan and contribute to an HSA. You can use a Limited Purpose Health Care FSA to pay for eligible out of pocket dental and vision expenses only, such as:

• Dental and orthodontia care (i.e., fillings, X rays and braces)

• Vision care (e.g., eyeglasses, contact lenses and LASIK surgery)

How the Health Care and Limited

Purpose FSAs Work

You can access the funds in your Health Care or Limited Purpose FSA two different ways:

• Use your Higginbotham Benefits Debit Card to pay for qualified expenses, doctor visits and prescription copays.

• Pay out of pocket and submit your receipts for reimbursement:

Fax 866 419 3516

Email flexclaims@higginbotham.net

Online https:// flexservices.higginbotham.net

Higginbotham Benefits Debit Card

The Higginbotham Benefits Debit Card gives you immediate access to funds in your Health Care or Limited Purpose FSA when you make a purchase without needing to file a claim for reimbursement. If you use the debit card to pay anything other than a copay amount, you will need to submit an itemized receipt or an Explanation of Benefits (EOB). If you do not submit your receipts, you will receive a request for substantiation. You will have 60 days to submit your receipts after receiving the request for substantiation before your debit card is suspended. Check the expiration date on your card to see when you should order a replacement card(s).

Important FSA Rules

• The maximum per plan year you can contribute to a Health Care or Limited Purpose FSA is $2,850. 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 you experience a Qualifying Life Event.

• Your Health Care or Limited Purpose FSA debit card can be used for health care expenses only. It cannot be used to pay for dependent care expenses.

• Health Care FSA into the next plan year. The carry over rule does not apply to your Dependent Care FSA.

Flexible Spending Account (FSA)

Higginbotham

Over the Counter Item Rule Reminder

EMPLOYEE BENEFITS

Health care reform legislation requires that certain over the 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.

Higginbotham Portal

The Higginbotham Portal provides information and resources to help you manage your FSAs.

• Access plan documents, letters and notices, forms, account balances, contributions and other plan information

• Update your personal information

• Utilize Section 125 tax calculators

• Look up qualified expenses

• Submit claims

• Request a new or replacement Benefits Debit Card

Register on the Higginbotham Portal

Visit https://flexservices.higginbotham.net and click Register. Follow the instructions and scroll down to enter your information.

• Enter your Employee ID, which is your Social Security number with no dashes or spaces.

• Follow the prompts to navigate the site.

• If you have any questions or concerns, contact Higginbotham:

Phone 866 419 3519

Email flexclaims@higginbotham.net

Fax 866 419 3516

Legal Services MetLife

ABOUT LEGAL SERVICES

Legal plans provide benefits that cover the most common legal needs you may encounter like creating a standard will, living will, healthcare power of attorney or buying a home.

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

• MetLaw covers you, your spouse and dependents.

• Telephone and office consultations for an unlimited number of personal legal matters with an attorney of your choice

• E Services Attorney locator, law firm e panel, law guide, free, download able legal documents, financial plan ning, insurance and work/life resources

Estate Planning Documents

• Simple and Complex Wills

• Trusts (Revocable and Irrevocable)

• Powers of Attorney

• (Healthcare, Financial, Childcare)

• Healthcare Proxies

• Living Wills

• Codicils

Document Review

• Any Personal Legal Documents

Family Law

• Prenuptial Agreement

• Protection from Domestic Violence

• Adoption and Legalization

• Guardianship or Conservatorship

• Name Change

Immigration Assistance

• Advice and Consultation

• Review of Immigration Documents

• Preparation of Affidavits and Powers of Attorney

Elder Law Matters

• Consultations and Document Review for issues related to your parents including Medicare, Medicaid, Prescription Plans, Nursing Home Agreements, leases, notes, deeds, wills and powers of attorney as these affect the participant

Real Estate Matters

For More Information:

Visit our website info.legalplans.com and enter access code: GetLaw or call our Client Service Center at 1 800 821 6400

Monday Friday from 8 a.m. 7 p.m. (Eastern Time).

Legal Services

Employee and Family $22.50

Financial Matters

• Sale, Purchase or Refinancing of Your Primary, Second or Vacation Home

• Eviction and Tenant Problems (Primary Residence)

• Home Equity Loans for Your Primary, Second or Vacation Home

• Zoning Applications

• Boundary or Title Disputes

• Property Tax Assessment

• Security Deposit Assistance (For Tenant)

Document Preparation

• Affidavits

• Deeds

• Demand Letters

• Mortgages

• Promissory Notes

Traffic Offenses*

• Defense of Traffic Tickets (excludes DUI)

• Driving Privilege Restoration (Includes License Suspension due to DUI)

Personal Property Protection

• Consultations and Document Review for Personal Property Issues

• Assistance for disputes over goods and services

• Negotiations with Creditors

• Debt Collection Defense

• Identity Theft Defense

• Personal Bankruptcy

• Tax Audit Representation (Municipal, State or Federal)

• Foreclosure Defense

• Tax Collection Defense

Juvenile Matters

• Juvenile Court Defense, including Criminal Matters

• Parental Responsibility Matters

Defense of Civil Lawsuits

• Administrative Hearings

• Civil Litigation Defense

• Incompetency Defense

• School Hearings

• Pet Liabilities

Consumer Protection

• Disputes over Consumer Goods and Services

• Small Claims Assistance

Family Matters™**

• Available for an additional fee

• Separate plan for parents of participants for Estate Planning Documents

• Easy Enrollment online or by phone

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 Santa Fe 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 Santa Fe 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.