2023-24 Midlothian ISD Benefit Guide

Benefit Contact Information

MIDLOTHIAN ISD BENEFITS MEDICAL - TRS DENTAL

Financial Benefit Services (800)583-6908

www.mybenefitshub.com/ midlothianisd

BCBSTX (866)355-5999

www.bcbstx.com/trsactivecare

Scott & White HMO (844)633-5325

www.trs.swhp.org

VISION CANCER

Superior Vision Group #326790 (800)507-3800

www.superiorvision.com

Allstate Group #21915

www.allstatenetwork.com

Cigna Group #3345041 (800)244-6224

www.cigna.com

ACCIDENT

Cigna Group #A1962227 (800)244-6224

www.cigna.com

IDENTITY THEFT DISABILITY LIFE AND AD&D

LifeLock

www.lifelock.com

The Standard Group #14494

www.standard.com

FLEXIBLE SPENDING ACCOUNT (FSA) INDIVIDUAL LIFE

Higginbotham (866)419-3519

https://flexservices.higginbotham.net/

Texas Life (800)283-9233

www.texaslife.com

The Standard Group #649889 (800)346-4489

www.standard.com

HEALTH SAVINGS ACCOUNT (HSA)

HSA Bank (800)357-6246

www.hsabank.com

MISD EXPRESS CARE CLINIC Cigna Group #HC961376 (800)244-6224

HOSPITAL INDEMNITY CRITICAL ILLNESS

Cigna Group #CI962123 (800)244-6224

www.cigna.com

www.cigna.com

Methodist Hospital Professional Bldg 979 Don Floyd Drive, Ste. 110 Midlothian, TX 76065 (972)775-5844

How to Log In

1 www.mybenefitshub.com/midlothianisd

2

3 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

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 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.

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 30 days of benefit eligibility 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/ midlothianisd. 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 Midlothian ISD benefit website: www.mybenefitshub.com/midlothianisd. 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 2023 benefits become effective on September 1, 2023, you must be actively-at-work on September 1, 2023 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.

Medical To age 26

Dental To age 26

Vision To age 26

Life To age 26

Cancer To age 26

Critical Illness To age 26

Accident To age 26

Hospital Indemnity To age 26

ID Theft To age 26

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 9/1/2023 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 preexisting condition exclusion provisions do apply, as applicable by carrier.

In-Network

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 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 prescriptions 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

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

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, taxfree. This also allows employees to pay for qualifying dependent care tax- free. Employer

Permissible Use Of Funds

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

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.

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

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

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

Not permitted

Year-to-year rollover of account balance?

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

No. Access to some funds may be extended if your employer’s plan contains a 2 1/2-month grace period. Does the account earn interest?

Dental Insurance Cigna EMPLOYEE BENEFITS

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/midlothianisd

Class II: Basic Restorative Restorative: fillings

Oral Surgery: simple extractions

Oral Surgery: oral surgical procedures Space Maintainers: non-orthodonic

Class III: Major Restorative Inlays and Onlays

Prosthesis Over Implant

Crowns: prefabricated stainless steel/resin

Crowns: permanent cast and porcelain

Bridges and Dentures

Endodontics: minor and major

Periodontics: minor and major

Oral Surgery: extractions of impacted teeth

Anesthesia: general and IV sedation

Repairs: bridges, crowns and inlays

Repairs: dentures, Denture Relines, Rebases and Adjustments

For full plan details, limits, and exclusions, please visit your benefit website at www.mybenefitshub.com/midlothianisd

Dental Insurance Cigna EMPLOYEE BENEFITS

Prophylaxis: routine cleanings

X-rays: routine

X-rays: non-routine

Fluoride Application

Sealants: per tooth

Class II: Basic Restorative Restorative: fillings

Oral Surgery: simple extractions

Oral Surgery: oral surgical porcedures

Space Maintainers: non-orthodontic

Class III: Major Restorative Inlays and Onlays

Prosthesis Over Implant

Crowns: prefabricated stainless steel/resin

Crowns: permanent cast and porcelain

Bridges and Dentures

Endodontics: minor and major

Periodontics: minor and major

Oral Surgery: extractions of impacted teeth

Anesthesia: general and IV sedation

Repairs: bridges, crowns and inlays

Repairs: dentures, Denture Relines, Rebases and Adjustments

For full plan details, limits, and exclusions, please visit your benefit website at www.mybenefitshub.com/midlothianisd

Vision Insurance Superior Vision EMPLOYEE BENEFITS

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/midlothianisd

LASIK vision correction5

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

1. Eye exam copay is a single payment due to the provider at the time of service.

2. Eyewear copay applies to eyeglass lenses / frame and contact lenses. Eyewear copay is a single payment that applies to the entire purchase of eyeglasses (frame and 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 and related professional services (fitting, evaluation and follow-up) are covered in lieu of eyeglass lenses and frames benefit

5. Lasik Vision Correction is in lieu of eyewear benefit, subject to routine regulatory filings and certain exclusions and limitations

Discount features

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

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.

Cancer Insurance

Allstate EMPLOYEE BENEFITS

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/midlothianisd

Receiving a cancer diagnosis can be one of life’s most frightening events. Unfortunately, statistics show you probably know someone who has been in this situation.

With Cancer insurance from Allstate Benefits, you can rest a little easier. Our coverage pays you a cash benefit to help with the costs associated with treatments, to pay for daily living expenses, and more importantly, to empower you to seek the care you need.

Here’s How It Works

You choose the coverage that’s right for you and your family. Our Cancer insurance pays cash benefits for cancer and 29 specified diseases to help with the cost of treatments and expenses as they happen. Benefits are paid directly to you unless otherwise assigned.

With the cash benefits you can receive from this coverage, you may not need to use the funds from your Health Savings Account (HSA) for cancer or specified disease treatments and expenses.

Meeting Your Needs

• Guaranteed Issue, meaning no medical questions to answer at initial enrollment

• Includes coverage for cancer and 29 specified diseases

• Benefits are paid directly to you unless otherwise assigned

• Coverage available for dependents

• Waiver of premium after 90 days of disability due to cancer for as long as your disability lasts (employee only)

• Coverage may be continued; refer to your certificate for details

• Additional benefits may be added to enhance your coverage

• With Allstate Benefits, you can protect your finances if faced with an unexpected cancer or specified disease diagnosis.

Benefits

HOSPITAL CONFINEMENT AND RELATED BENEFITS

• Continuous Hospital Confinement - inpatient admission and confinement

• Government or Charity Hospital - confinements in lieu of all other benefits, except Waiver of Premium

• Private Duty Nursing Services - full-time nursing services authorized by attending physician

• Extended Care Facility - within 14 days of a hospital stay; payable up to the number of days of the hospital stay

• At Home Nursing - private nursing care must begin within 14 days of a covered hospital stay; payable up to the number of days of the previous hospital stay

• Hospice Care Center or Team - terminal illness care in a facility or at home; one visit per day

RADIATION/CHEMOTHERAPY AND RELATED BENEFITS

• Radiation/Chemotherapy for Cancer - covered treatments to destroy or modify cancerous tissue

• Blood, Plasma and Platelets - transfusions, administration, processing, procurement, cross matching

• Hematological Drugs - boosts cell lines for white/red cell counts and platelets; payable when Radiation/ Chemotherapy for Cancer benefit is paid

• Medical Imaging - initial diagnosis or follow-up evaluation based on covered imaging exam

SURGERY AND RELATED BENEFITS

• Surgery* - based on Certificate Schedule of Surgical Procedures

• Anesthesia - 25% of Surgery benefit for anesthesia received by an anesthetist

• Bone Marrow or Stem Cell Transplant - autologous, nonautologous for treatment of cancer or specified disease other than Leukemia, or non-autologous for treatment of Leukemia

• Ambulatory Surgical Center - payable only if Surgery benefit is paid

• Second Opinion - second opinion for surgery or treatment by a doctor not in practice with your doctor

MISCELLANEOUS BENEFITS

• Inpatient Drugs and Medicine - not including drugs/medicine covered under the Radiation/Chemotherapy for Cancer or Anti-Nausea benefits

• Physician’s Attendance - one inpatient visit by one physician

• Ambulance - transfer to or from hospital where confined by a licensed service or hospital-owned ambulance

• Non-Local Transportation - obtaining treatment not available locally

• Outpatient Lodging - more than 100 miles from home

• Family Member Lodging and Transportation - adult family member travels with you during non-local hospital stays for specialized treatment. Transportation not paid if Non-Local Transportation benefit is paid

• Physical or Speech Therapy - to restore normal body function

• New or Experimental Treatment - payable if physician judges to be necessary and only for treatment not covered under other policy benefits

• Prosthesis - surgical implantation of prosthetic device for each amputation

• Hair Prosthesis - wig or hairpiece every two years due to hair loss

• Nonsurgical External Breast Prosthesis - initial prosthesis after a covered mastectomy

• Anti-Nausea Benefit - prescribed anti-nausea medication administered on outpatient basis

• Waiver of Premium** - must be disabled

OPTIONAL/ADDITIONAL BENEFITS

• Cancer Initial Diagnosis – for first-time diagnosis of cancer other than skin cancer

• Wellness Benefit – once per year for one of the 23 exams. See certificate for a list of wellness tests

SPECIFIED DISEASES

See policy certificate for full list of covered diseases.

Policy Specifications

Eligibility

Coverage may include you, your spouse or domestic partner, and children under age 26.

Termination of Coverage

Coverage under the policy ends on the date the policy is canceled; the last day premium payments were made; the last day of active employment, unless coverage is continued due to Temporary Layoff, Leave of Absence or Family and Medical Leave of Absence; the date you or your class is no longer eligible. ^Spouse/domestic partner coverage ends upon divorce/ termination of partnership or your death. Coverage for children ends when the child reaches age 26, unless he or she continues to meet the requirements of an eligible dependent.

Portability Privilege

Coverage may be continued under the Portability Provision when coverage under the policy ends.

Limits and Exclusions

Pre-Existing Condition Limitation: We do not pay benefits for a pre -existing condition during the 12-month period beginning on the date that person’s coverage starts. A pre-existing condition is a disease or condition for which symptoms existed within the 12-month period prior to the effective date, or medical advice or treatment was recommended or received from a medical professional within the 12-month period prior to the effective date. A pre-existing condition can exist even though a diagnosis has not yet been made.

Exclusions and Limitations: We do not pay for any loss except for losses due to cancer or a specified disease. Benefits are not paid for conditions caused or aggravated by cancer or a specified disease. Treatment and services must be needed due to cancer or a specified disease and be received in the United States or its territories.

Hospice Care Team Limitation: Services are not covered for food or meals, well-baby care, volunteers or support for the family after covered person’s death.

Blood, Plasma and Platelets Limitation: Does not include immunoglobulins or blood replaced by donors.

For the Surgery, New or Experimental Treatment and Prosthesis benefits, we pay 50% of the applicable maximum when specific charges are not obtainable as proof of loss.

For the Radiation/Chemotherapy for Cancer benefit, we do not pay for: any other chemical substance which may be administered with or in conjunction with radiation/ chemotherapy; treatment planning, consultation or management; the design and construction of treatment devices; basic radiation dosimetry calculation; any type of laboratory tests; X-ray or other imaging used for diagnosis or monitoring; the diagnostic tests related to these treatments; or any devices or supplies including intravenous solutions and needles related to these treatments

Accident Insurance Cigna EMPLOYEE BENEFITS

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/midlothianisd

Accidental Injury coverage provides a fixed cash benefit according to the schedule below when a Covered Person suffers certain Injuries or undergoes a broad range of medical treatments or care resulting from a Covered Accident. See State Variations (marked by *) below.

Who Can Elect Coverage:

You: All active, Full-time Employees of the Employer who are regularly working in the United States a minimum of 17.5 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:

This Accidental Injury plan provides 24 hour 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 terms, conditions, state variations, exclusions and limitations applicable to these benefits. See your Certificate of Insurance for more information.

Per covered non-surgically-repaired dislocation $200-$3,500

Follow-Up Care Plan

Follow-up Physician Office Visit $100

Follow-up Physical Therapy Visit $75

Enhanced Accident Benefits Plan

Small Lacerations (Less than or equal to 6 inches long and requires 2 or more sutures) $150

Large Lacerations (more than 6 inches long and requires 2 or more sutures) $800

Concussion $200

Coma (lasting 7 days with no response) $15,000

Additional Accidental Injury benefits included - See certificate for details, including limitations & exclusions. Virtual Care accepted for Initial Physician Office Visit and Follow-Up Care. Wellness Treatment, Health Screening Test & Preventive Care Benefit* Plan

Wellness Treatment, Health Screening Test and Preventive Care Benefit:* Examples include (but are not limited to) routine gynecological exams, general health exams, mammography and certain blood tests. Benefit paid for all covered persons is 100% of the benefit shown. Also includes COVID-19 Immunization. Virtual Care accepted.

$50

Accident Insurance Cigna EMPLOYEE

Portability Feature: You, your spouse, and child(ren) can continue 100% of your coverage at the time your coverage ends. You must be under the age of 100 in order to continue your coverage. Rates may change and all coverage ends at age 100. Applies to United States Citizens and Permanent Resident Aliens residing in the United States.

Important Definitions and Policy Provisions:

• Coverage Type: Benefits are paid when a Covered Injury results, directly and independently of all other causes, from a Covered Accident.

• Covered Accident: A sudden, unforeseeable, external event that results, directly and independently of all other causes, in a Covered Injury or Covered Loss and occurs while the Covered Person is insured under this Policy; is not contributed to by disease, sickness, mental or bodily infirmity; and is not otherwise excluded under the terms of this Policy.

• Covered Injury: Any bodily harm that results directly and independently of all other causes from a Covered Accident.

• Covered Person: An eligible person who is enrolled for coverage under this Policy.

• Covered Loss: A loss that is the result, directly and independently of other causes, from a Covered Accident suffered by the Covered Person within the applicable time period described in the Policy.

• Hospital: An institution that is licensed as a hospital pursuant to applicable law; primarily and continuously engaged in providing medical care and treatment to sick and injured persons; managed under the supervision of a staff of medical doctors; provides 24-hour nursing services by or under the supervision of a graduate registered Nurse (R.N.); and has medical, diagnostic and treatment facilities with major surgical facilities on its premises, or available to it on a prearranged basis, and charges for its services. The term Hospital does not include a clinic, facility, or unit of a Hospital for: rehabilitation, convalescent, custodial, educational, or nursing care; the aged, treatment of drug or alcohol addiction.

• When your coverage begins: Coverage begins on the later of the program's effective date, the date you become eligible, or the first of the month following the date your completed enrollment form is received unless otherwise agreed upon by Cigna. Your coverage will not begin unless you are actively at work on the effective date. Coverage for all Covered Persons will not begin on the effective date if hospital, facility or home confined, disabled or receiving disability benefits or unable to perform activities of daily living.

• When your coverage ends: Coverage ends on the earliest of the date you and your dependents are no longer eligible, the date the group policy is no longer in force, or the date for the last period for which required premiums are paid. For your dependent, coverage also ends when your coverage ends, when their premiums are not paid or when they are no

longer eligible. (Under certain circumstances, your coverage may be continued. Be sure to read the provisions in your Certificate.)

• 30 Day Right To Examine Certificate: If a Covered Person is not satisfied with the Certificate for any reason, it may be returned to us within 30 days after receipt. We will return any premium that has been paid and the Certificate will be void as if it had never been issued.

Benefit Conditions and Limitations: Refer to the certificate of coverage for details on Common Exclusions and Specific Exclusions and Limitations.

Identity Theft LifeLock EMPLOYEE BENEFITS

ABOUT IDENTITY THEFT PROTECTION

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

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

Every two seconds, someone is a victim of identity theft.

In fact, identity theft was the number one consumer reported crime to the Federal Trade Commission in 2012 – there were over 16.6 million victims, a number expected to increase significantly.

And identity theft is more than just your credit history – the average number of records compromised by data breaches from 2008-2012 was 146 million, and as a result breach victims are four times more likely to have their identities stolen.

And did you know that children are at greater risk? According to a recent news article, police agencies are saying children are now the fastest growing segment of identity theft victims.

Add it all up, and the costs are staggering – in 2012 alone, identity theft cost nearly $24.7 billion.

You have a home security system that alerts you if someone tries to rob your house. To be protected, you need an alarm system for your identity. When LifeLock detects suspicious activity within their network, they notify members before the damage is done. LifeLock detection is different than traditional credit monitoring and offers a comprehensive set of features to protect against identity theft. Legal and remediation services only help after identity theft has occurred. As the industry leader, LifeLock provides proactive protection.

Worrying about your credit isn’t enough

Many people believe their credit card company protects them. You can’t take their word for it because a credit card company protects itself, but not other accounts. If a fraudster opens a new Visa or MasterCard account, gets a payday loan, or starts a new wireless account in your name, one credit card company alone can’t help.

Some consumers believe they can take a DIY approach to monitor credit on their own. However, you can sometimes do three things on your own:

1. Get one free credit report a year, but what do you do the rest of the year?

2. Set up fraud alerts that last 90 days and then you have to reset it.

3. Put a credit freeze on after you’ve been victimized. All three of these can be inconvenient, and of limited value.

Choose the LifeLock service that’s right for you

• LifeLock Standard™ identity theft protection uses innovative monitoring technology and alert tools to help proactively safeguard your credit and finances.

• LifeLock Ultimate® service provides peace of mind knowing you have the most comprehensive identity theft protection available. Enhanced services include bank account application and takeover alerts, online credit reports and credit scores.

• LifeLock Junior™ is a proactive defense system rolled into family plans that helps keep your child’s information safe. A child’s clean and unmonitored credit file is a gold mine for identity thieves, with critical misuse and damage potentially going completely undetected for years.

How to enroll:

• Enroll through your employer.

• Provide the name, Social Security number, date of birth, address, email and phone number for you and each dependent you wish to enroll.††

• Select your level of coverage.*

• Your LifeLock coverage will begin upon successful completion of your enrollment.

• You will receive a welcome email from LifeLock with instructions on how to take full advantage of your LifeLock membership.

Identity Theft LifeLock

Disability Insurance The Standard EMPLOYEE BENEFITS

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/midlothianisd

Eligibility

To become insured, you must be:

• A regular, full-time employee of the Midlothian Independent School District, excluding temporary or seasonal employees, full-time members of the armed forces, leased employees or independent contractors.

• Actively at work at least 17.5 hours each week

• A citizen or resident of the United States or Canada

Employee Coverage Effective Date

• Please contact your human resources representative for more information regarding the following requirements that must be satisfied for you insurance to become effective. You must satisfy:

• Eligibility requirements

• An eligibility waiting period (check with your human resources representative)

• An evidence of insurability requirement, if applicable

• An active work requirement. This means that if you are not actively at work on the day before the scheduled effective date of insurance, your insurance will not become effective until the day after you complete one day of active work as an eligible employee.

Benefit Amount

You may select a monthly benefit in $100 increments from $200 to $8,000; based on guidelines. The monthly benefit amount must not exceed 70 percent of your monthly earnings.

• Maximum Monthly Benefit: 70 percent of your pre-disability earnings

• Minimum Monthly Benefit: 25 percent of your LTD benefit before reduction by disability income

Benefit Waiting Period and Maximum Benefit Period

The benefit waiting period is the period of time that you must be continuously disabled before benefits become payable. Benefits are not payable during the benefit waiting period. The maximum benefits period is the period for which benefits are payable. The benefit waiting period and maximum benefit period associated with your plan options are shown below:

Disability Insurance The Standard EMPLOYEE

Options 1-6: Maximum Benefits Period to Age 65 for Sickness and Accident

If you become disabled before age 62, LTD benefits may continue during disability until you reach age 65. If you become disabled at age 62 or older, the benefit duration is determined by your age when disability begins:

Any Occupation Period

The any occupation period begins at the end of the won occupation period and continues until the end of the maximum benefit period.

Other LTD Features:

• Employee Assistance Program (EAP)

• Family Care Expense Adjustment

• Special Dismemberment Provision

• Reasonable Accommodate Expense Benefit

• Survivor Benefit

• Return to Work (RTW) Incentive

• Rehabilitation Plan Provision

*See certificate of coverage for more information on these features.

When Benefits End

LTD benefits end automatically on the earliest of:

• The date you are no longer disabled

First Day Hospital Benefit

With this benefits, if an insured employee is hospital confined for at least four hours, is admitted as an impatient and is charged room and board during the benefit waiting period, the benefits waiting period will be satisfied. Benefits become payable on the date of hospitalization; the maximum benefit period also being on that date. This feature is included only on LTD plans with benefits waiting periods of 30 days or less.

Preexisting conditions Exclusion

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

Preexisting Condition Waiver

If your insurance has been in force for 12 months or more, for the first 90 days of disability after the benefit waiting period, the Preexisting Condition provision will not be applied to an increase in your benefit amount. After 90 days of benefits, the Preexisting Condition provision will apply to increase of more than $300. The Preexisting Condition applies immediately if you:

• Decrease your benefit waiting period by more than one level; or

• Increase your maximum benefit period

If a disability is deemed to be a preexisting condition, benefits are payable under the prior elections, if any.

If your insurance has been in force for less than 12 months and your disability is found to be a preexisting condition, you may be eligible for up to 90 days of benefits if you are disabled and meet all applicable policy provisions.

Own Occupation Period

For the plan’s definition of disability, as described in your brochure, the own occupation period is the first 24 months for which LTD benefits are paid.

• The date your maximum benefit period ends

• The date you die

• The date benefits become payable under other LTD plan which you coming insured through employment during a period of temporary recovery

• The date you fail to provide proof of continued disability and entitlement to benefits

Voluntary Life The Standard

ABOUT VOLUNTARY TERM LIFE

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.

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

Voluntary Term Life

Help protect your loved ones from financial hardship. Life insurance coverage is designed to help provide financial support and stability to your family should you pass away.

About This Coverage

How much can I apply for?

• For you:$10,000-$500,000 in increments of $10,000

• For your spouse: $10,000-$250,000 in increments of $5,000

• For your child(ren):$10,000

What is the guarantee issue maximum?

• For you: Up to $150,000

• For your spouse: Up to $50,000

Additional Features

• Accelerated Benefit: If you become terminally ill, you be eligible to receive up to 75 percent of your life benefit to a maximum of $500,000

• Travel Assistance: Available 24 hours a day, this service connects you to resources when you’re traveling at least 100 miles from home or in a foreign country up to 180 days.

• Live Services Toolkit: This service allows you and your beneficiaries access to online content for will preparation, identity theft support and other tools and calculators, and provides your beneficiaries with services for grief, and legal and financial matters.

How Much Insurance To You Need:

After a serious accident or death in the family, there are many unexpected expenses. Your benefits could help your family pay for: Outstanding debt, burial expenses, medical bills, your children’s education and daily expenses. To estimate your insurance needs, you’ll need to cinside your unique circumstances. Use the online calculator at www.standard.com/ life/needs

A Few Important Details

• Medical Underwriting Approval for Life Coverage – required for coverage amounts higher than the guaranteed issue, all late applicants (applying 31 days after becoming eligible), requests for coverage increases, reinstatements, employees eligible but not insured under the prior life insurance plan.

• Coverage Effective Date for Life Coverage – to become insured, you must: meet eligibility requirements, serve and eligibility waiting period, receive medical underwriting approval (if applicable), apply for coverage and agree to pay premiums and be actively at work (able to perform normal duties of your job) on the day before insurance is scheduled to be effective.

• When Your Insurance Ends – your insurance ends when any of the following occur: the date the last period ends for which a premium was paid, the date your employment terminates, the date you cease to meet eligibility requirements, the date the group policy, or your employer’s coverage under the group policy, terminates. The date your Life insurance ends, your AD&D coverage will also end.

Voluntary AD&D The Standard

ABOUT VOLUNTARY AD&D

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/midlothianisd

Voluntary Accidental Death and Dismemberment (AD&D) Insurance

Accidental Death & Dismemberment (AD&D) insurance provides an extra layer of protection if you die or become dismembered in an accident. You can also cover your eligible spouse and child (ren).

About This Coverage

The benefit is paid if you are seriously injured or pass away as a result of a covered accident.

What does my AD&D benefit provide?

For You: If you elect Life insurance, you may elect AD&D insurance in increments of $10,000 from $10,000 to $500,000

Additional Features

• Seat Belt and Air Bag Benefit(s): The Standard may pay an additional benefit if you die while wearing a seatbelt, provided certain conditions are met. If the car’s air bags deploy during an accident, an air bag benefits may also be payable.

• Family Benefits Package: Eligible family members may be entitled to receive additional financial help for child care, college or career training. Included are the Child Care Benefit, Higher Education Benefit and Career Adjustment Benefit.

• Repatriation Benefit: Provides a reimbursement for expenses associated with transporting your body back to a mortuary near your home in case you death occurs away from your primary place of residence.

Eligibility

To be eligible for this plan you must be an active employee of Midlothian Independent School District and regularly working at least 17.5 hours each week. An eligible employee does not include a full-time member of the armed forces, a temporary, leased or seasonal employee, or independent contractor.

Employee Coverage Effective Date

You must satisfy:

• Eligibility requirements

• An eligibility waiting period (check with your HR for details)

• An active work requirement. This means that if you are not actively at work on the day before the scheduled effective date of insurance, your insurance will not become effective until the day after you complete one day of active work as an eligible employee.

When Your Insurance Ends

Your insurance ends automatically when any of the following occur: the date the last period ends for which premium was paid, the date your employment terminates, the ate you cease to meet eligibility requirements, the date the group policy – or your employer’s coverage under the group’s policy – terminates, for each elective insurance coverage, the date that coverage terminates under the group policy, the date your Life coverage ends, your AD&D coverage will end as well.

Voluntary AD&D - per $10,000 in coverage Employee $0.20

Flexible Spending Account (FSA)

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/midlothianisd

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 $3,050 annually to a Health Care FSA and you are entitled to the full election from day one of your plan year. Eligible expenses include, but are not limited to, 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).

Higginbotham Benefits Debit Card

The Higginbotham Benefits Debit Card gives you immediate access to funds in your Health Care FSA when you make a purchase without needing to file a claim for reimbursement.

Dependent Care FSA

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.

Things to Consider Regarding the Dependent Care FSA

• 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 $3,050. 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.

• You can continue to file claims incurred during the plan year for another 90 days (November 30th).

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

Over-the-Counter Item Rule Reminder

Health care reform legislation requires that certain over-thecounter (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

Flexible Spending Account (FSA)

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

Higginbotham Flex Mobile App

Easily access your Health Care FSA on your smartphone or tablet with the Higginbotham mobile app. Search for Higginbotham in your mobile device’s app store and download as you would any other app.

• View Accounts – Includes detailed account and balance information

• Card Activity – Account information

• SnapClaim – File a claim and upload receipt photos directly from your smartphone

• Manage Subscriptions – Set up email notifications to keep up -to-date on all account and Health Care FSA debit card activity

• Log in using the same username and password you use to log in to the Higginbotham Portal. Note: You must register on the Higginbotham Portal in order to use the mobile app.

FSAstore.com

FSAstore.com offers thousands of FSA-eligible products and services to purchase using your Higginbotham Benefits 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 www.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.

Basic Life and AD&D The Standard

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/midlothianisd

Who is eligible for this coverage?

What is the coverage amount?

What is the guaranteed issue?

EMPLOYEE BENEFITS

Any active employees of Midlothian Independent School District working 17.5 hours or more per week

$40,000

Full benefit; $40,000

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

When is the coverage effective?

Waiver of Premium

Additional AD&D Benefits

Date of hire

• Eligible to waive at age 60

• Waived to age 65

Matches the basic life benefit at $40,000

• Loss of life at 100%

• Loss of one hand or foot at 50%

• Loss of sight in one eye at 50%

What does the Basic AD&D portion pay for?

• Any combination of the above listed losses at 100%

• Seat belt benefit – payable up to $10,000

• Air Bag Benefit – payable up to $5,000

• Family Benefits Package – included

• To 65% at age 65

Do my life insurance benefits decrease with age?

• To 50% at age 70

• To 35% at age 75

Individual Life Insurance Texas Life EMPLOYEE BENEFITS

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 and rates, please visit your benefit website: www.mybenefitshub.com/midlothianisd

Voluntary permanent life insurance can be an ideal complement to the group term and optional term your employer might provide. Designed to be in force when you die, this voluntary universal life product is yours to keep, even when you change jobs or retire, as long as you pay the necessary premium. Group and voluntary term, on the other hand, typically are not portable if you change jobs and, even if you can keep them after you retire, usually cost more and decline in death benefit. The policy, purelife-plus, is underwritten by Texas Life Insurance Company, and it has the following features:

• High Death Benefit. With one of the highest death benefits available at the worksite, purelife-plus gives your loved ones peace of mind.

• Minimal Cash Value. Designed to provide a high death benefit at a reasonable premium, purelife-plus provides peace of mind for you and your beneficiaries while freeing investment dollars to be directed toward such tax-favored retirement plans as 403(b), 457 and 401(k).

• Long Guarantees. Enjoy the assurance of a policy that has a guaranteed death benefit to age 121 and level premium that guarantees coverage for a significant period of time.

• Refund of Premium. Unique in the marketplace, purelifeplus offers you a refund of 10 years’ premium, should you surrender the policy if the premium you pay when you buy the policy ever increases. (Conditions apply.)

• Accelerated Death Benefit Rider. Should you be diagnosed as terminally ill with the expectation of death within 12 months (24 months in Illinois), you will have the option to receive 92% (84% in Illinois) of the death benefit, minus a $150 ($100 in Florida) administrative fee. This valuable living benefit gives you peace of mind knowing that, should you need it, you can take the large majority of your death benefit while still alive. (Conditions apply.)

You may apply for this permanent, portable coverage, not only for yourself, but also for your spouse, children and grandchildren by answering just 3 questions:

During the last six months, has the proposed insured:

a. Been actively at work on a full time basis, performing usual duties?

b. Been absent from work due to illness or medical treatment for a period of more than five consecutive working days?

c. Been disabled or received tests, treatment or care of any kind in a hospital or nursing home or received chemotherapy, hormonal therapy for cancer, radiation therapy, dialysis treatment, or treatment for alcohol or drug abuse?

Health Savings Account (HSA) HSA Bank

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/midlothianisd

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 (TRS ActiveCare HD)

• 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.

Opening an HSA

If you meet the eligibility requirements, you may open an HSA administered by HSABank. You will receive a debit card to manage your HSA account reimbursements. Keep in mind, available funds are limited to the balance in your HSA.

Maximum Contributions

Your HSA contributions may not exceed the annual maximum amount established by the Internal Revenue Service. The annual contribution maximum for 2023 is based on the coverage option you elect:

• Individual – $3,850

• Family (filing jointly) – $7,750

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.

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.

• You may open an HSA at the financial institution of your choice, but only accounts opened through HSABank are eligible for automatic payroll deduction and company contributions.

How to Use your HSA

• HSA Bank Mobile App – Download to check available balances, view HSA transaction details, save and store receipts, scan items in-store to see if they’re qualified, and access customer service contact information.

• myHealth PortfolioSM – Track your healthcare expenses, manage receipts and claims from multiple providers, and view expenses by provider, description, and more.

• Account preferences – Designate a beneficiary, add an authorized signer, order additional debit cards, and keep important information up to date.

• Access online at: http://www.hsabank.com

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/midlothianisd

Hospitalization Benefits Plan 1 Plan 2

Hospital Admission

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:

• You: All active, Full-time Employees of the Employer who are regularly working in the United States a minimum of 17.5 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.

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 $50 Hospital Stay No Elimination Period. Limited to 30 days. $100 $200

Hospital Intensive Care Unit (ICU) Stay No Elimination Period. Limited to 30 days. $100 $200

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

Newborn Nursery Care Admission

Limited to 1 day, 1 benefit per newborn child. This benefit is payable to the employee even if child coverage is not elected.

Newborn Nursery Care Stay*

$100 per 24-hour period

$100 per 24-hour period

$500 $500

$100 $100

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

• Hospital Admission: Must be admitted as an Inpatient due to a Covered Injury or Covered Illness. Excludes: treatment in an emergency room, provided on an outpatient basis, or for re admission for the same Covered Injury or Covered Illness (including chronic conditions).

• Hospital Chronic Condition Admission: Must be admitted as an Inpatient due to a covered chronic condition and treatment for a covered chronic condition must be provided by a specialist in that field of medicine. Excludes: treatment in an emergency room, provided on an outpatient basis, or

29

Hospital Indemnity Cigna EMPLOYEE BENEFITS

for re-admission for the same Covered Injury or Covered Illness (including chronic conditions).

• Hospital Stay: Must be admitted as an Inpatient and confined to the Hospital, due to a Covered Injury or Covered Illness, at the direction and under the care of a physician. If also eligible for the ICU Stay Benefit, only 1 benefit will be paid for the same Covered Injury or Covered Illness, whichever is greater. Hospital stays within 90 days for the same or a related Covered Injury or Covered Illness is considered one Hospital Stay.

• Intensive Care Unit (ICU) Stay: Must be admitted as an Inpatient and confined in an ICU of a Hospital, due to a Covered Injury or Covered Illness, at the direction and under the care of a physician. If also eligible for the Hospital Stay Benefit, only 1 benefit will be paid for the same Covered Injury or Covered Illness, whichever is greater. ICU stays within 90 days for the same or a related Covered Injury or Covered Illness is considered one ICU stay.

• Hospital Observation Stay: Must be receiving treatment for a Covered Injury or Covered Illness in a Hospital, including an observation room, or ambulatory surgical center, for more than 24 hours on a non-inpatient basis and a charge must be incurred. This benefit is not payable if a benefit is payable under the Hospital Stay Benefit or Hospital Intensive Care Unit Stay Benefit.

• Newborn Nursery Care Admission and Newborn Nursery Care Stay: Must be admitted as an Inpatient and confined in a Hospital immediately following birth at the direction and under the care of a physician.

Common Exclusions and Limitations

Exclusions:* In addition to any benefit-specific exclusion, benefits will not be paid for any Covered Injury or Covered Illness which is caused by or results from any of the following (unless otherwise provided for in the policy): • Intentionally self-inflicted injury, suicide or any attempted threat while sane or insane; • Commission or attempt to commit a felony or an assault; • Declared or undeclared war or act of war;• A Covered Injury or Covered Illness that occurs while on active duty service in the military, naval or air force of any country or international organization. Upon our receipt of proof of service, we will refund 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 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 this exclusion, means intoxicated, as defined by the law of the state in

which the Covered Injury or Covered Illness occurred. (excludes WA residents);• Those not necessary, as determined by Us in accordance with generally accepted standards of medical practice, for the diagnosis, care or treatment of the physical or mental condition involved. This applies even if they are prescribed, recommended, or approved by the attending physician;• Elective or cosmetic surgery. This does not include reconstructive, cosmetic surgery:

a) incidental to or following surgery for trauma, infection or other disease of the involved part; or b) due to congenital disease or anomaly of a Covered Dependent child which has resulted in a functional defect;• Dental surgery, unless the surgery is the result of an accidental injury. In addition, benefits will not be paid for services or treatment rendered by a Physician, Nurse or any other person who is: employed or retained by the Subscriber or providing homeopathic, aroma- therapeutic or herbal therapeutic services or living in the Covered Person’s household or a parent, sibling, spouse or child of the Covered Person.

Policy Provisions

• Portability Feature: You, your spouse, and child(ren) can continue 100% of your coverage at the time your coverage ends. You must be covered under the policy and be under the age of 100 in order to continue your coverage. Rates may change and all coverage ends at age 100. Applies to United States Citizens and Permanent Resident Aliens residing in the United States.

• When your coverage begins: Coverage begins on the later of the program’s effective date, the date you become eligible, the first of the month following the date your completed enrollment form is received or if evidence of insurability is required, the first of the month after we have approved you (or your dependent) for coverage in writing unless otherwise agreed upon by Cigna. Your coverage will not begin unless you are actively at work on the effective date. Coverage for Covered Persons will not begin on the effective date if the covered person is confined to a hospital, facility or at home; disabled or receiving disability benefits or unable to perform activities of daily living. Deferral of the effective date will not apply to the Newborn Nursery Care Admission and Stay Benefit.

• When your coverage ends: Coverage for any Covered Person ends on the earliest of the date they are no longer eligible, the date the group policy is no longer in force, or the date for the last period for which required premiums are paid. For your Spouse and Dependent Child(ren), if applicable, coverage also ends when your coverage ends, when their premiums are not paid or when they are no longer eligible. (Under certain circumstances, your coverage may be continued if you stop working. Be sure to read the Continuation of Insurance provisions in your Certificate.

Critical Illness Insurance Cigna 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/midlothianisd

Critical Illness insurance provides a cash benefit when a Covered Person is diagnosed with a covered critical illness or event after coverage is in effect.

Who Can Elect Coverage:

• You: All active, Full-time Employees of the Employer who are regularly working in the United States a minimum of 17.5 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 will be paid regardless of the actual expenses incurred. The benefit descriptions are a summary only. There are terms, conditions, state variations, exclusions and limitations applicable to these benefits. Please read all of the information in this Summary and your Certificate of Insurance for more information. All Covered Critical Illness Conditions must be due to disease or sickness.

Critical Illness Insurance

Wellness Treatment, Health Screening Test and Preventive Care Benefit* Benefit Amount

Examples includes (but are not limited to) routine gynecological exams, general health exams, mammography, and certain blood tests. The benefit amount shown will be paid regardless of the actual expenses incurred and is paid on a per day basis. Also includes COVID-19 Immunization. Virtual Care accepted.

Benefits

Initial Critical Illness Benefit

Recurrence Benefit

$50 1 per year

Benefit for a diagnosis made after the effective date of coverage for each Covered Condition shown above. The amount payable per Covered Condition is the Initial Benefit Amount multiplied by the applicable percentage shown. Each Covered Condition will be payable one time per Covered Person, subject to the Maximum Lifetime Limit. A 180 days separation period between the dates of diagnosis is required.*

Benefit for the diagnosis of a subsequent and same Covered Condition for which an Initial Critical Illness Benefit has been paid, payable after a 12 month separation period from diagnosis of a previous Covered Condition, subject to the Maximum Lifetime Limit.

Skin Cancer Benefit Pays benefit stated above.

Express Care Clinic

ABOUT EXPRESS CARE CLINIC

The clinic is open year round including district summer, fall, winter, and spring breaks.

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

Welcome to the MISD Express Care. This is a low cost, convenient walk-in clinic for Midlothian ISD employees, spouses, and dependents. The clinic is designed to provide high-quality treatment for common acute conditions, such as flu, sinus infections, asthma attacks, skin conditions, strep, UTIs and other conditions. When employees visit the clinic, the MISD Express Care personnel will schedule them for a specific time, between 3 to 7 p.m. The scheduled time will be based on the number of patients that have come in prior to them and have paid the non-refundable visit fee of $10 to save their appointment time. All appointments are first-come, first-serve. Once an appointment time is scheduled, the employee is then given the option to wait at the clinic to be seen or return to the clinic at their designated time.

Occasionally, due to limited appointment availability, there may be days in which not all employees desiring to be seen will be able to visit a medical provider that same day.

To help ensure employees receive care when and where they need it most, MISD Express Care also offers on-demand virtual video visits, between 8:00AM-8:00PM, for the same $10 visit fee. Employees can request a virtual visit by calling one of our dedicated schedulers at 214-730-6828 and press option 2. When employees call they will be asked a few short questions and will be scheduled for a virtual video visit with Kelly Copeland, Nurse Practitioner.

Due to MISD Express Care’s commitment to high-quality care delivery, there are some conditions that are not appropriate to be treated virtually at which time employees will be refunded the cost of the virtual visit and directed to be seen in person at the MISD Express Care clinic for a non-refundable visit fee of $10.

Clinic Contact

MISD Express Care Clinic

Methodist Hospital Professional Building

979 Don Floyd Drive, Ste. 110 Midlothian, TX 76065

Phone: 972-775-5844

Fax: 972-775-4620

Clinic Hours

Mon-Fri 3:00PM – 7:00PM

As of July 8, 2020, employees may now call the number above for an appointment time during the clinic hours and not have to wait for the next available time.

Virtual Clinic Hours

Mon-Fri 8:00AM – 8:00PM

Holiday Hours

The MISD Express Care Clinic will be closed on most major holidays.

Closures are subject to change. It is advised to call before going to the clinic.

NOTE: The clinic is open year round including district summer, fall, winter, and spring breaks

2023 - 2024 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 Midlothian 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 Midlothian 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. WWW.MYBENEFITSHUB.COM/MIDLOTHIANISD