2023 Keller ISD Benefit Guide

KELLER ISD BENEFIT GUIDE

EFFECTIVE: 1/1/2023 - 12/31/2023

WWW.MYBENEFITSHUB.COM/KELLERISD

TO

PG. 5 HELPFUL DEFINITIONS PG. 9

Benefit Contact Information

KELLER ISD HUMAN RESOURCES/ BENEFITS MEDICAL (7/1/23 –12/31/24)

Keller ISD

(817)744-1080

www.kellerisd.net

Blue Cross Blue Shield TX

BCBS HDHP Group # 361790

BCBS Major Group # 361789

BCBS Essential Group # 361788

(800)521-2227

www.bcbstx.com

COBRA Services: National Benefit Services nbs.wealthcarecobra.com

(800)274-0503

FLEXIBLE SPENDING ACCOUNT FBS/ENROLLMENT

National Benefit Services

(800)274-0503

www.nbsbenefits.com

Financial Benefit Services

(469)385-4685

www.mybenefitshub.com/kellerisd

KELLER POINTE FITNESS PROGRAM HOSPITAL INDEMNITY

City of Keller

(817)743-4386

www.thekellerpointe.com

Voya Policy #680311

(800)955-7736

www.voya.com

HEALTH SAVINGS ACCOUNT CRITICAL ILLNESS

Optum Bank

(800)791-9361 option 1

www.uhc.com

Voya

Policy #680311

(800)955-7736

www.voya.com

MEDICAL (1/1/23 6/30/23) ACCIDENT

United Healthcare Group #715197

(800)241-1658

www.uhc.com

COBRA Services: (877) 797-7475

Member Services: (877) 311-7849

PHARMACY (7/1/23 12/31/24])

Prime Therapeutics

Blue Cross Blue Shield TX

(800)521-2227

myprime.com

Voya

Policy #680311

(800)955-7736

www.voya.com

PHARMACY (1/1/23 6/30/23)

ProActRx

(877)635-9545

www.ProActRx.com

DENTAL

Cigna (800)244-6224

www.mycigna.com

VISION

Superior Vision Policy #31159

(800)507-3800

www.superiorvision.com

DISCOUNT DENTAL & VISION

QCD

(800)229-0304

www.qcdofamerica.com

LONG TERM DISABILITY

The Hartford Policy #GLT-395309

(800)523-2233

File a claim: (866) 547-9124

www.thehartford.com

LIFE AND AD&D

The Hartford Policy #GLT-395309

(800)523-2233

www.thehartford.com

For full details on all your benefits, please visit your benefit website at: www.mybenefitshub.com/kellerisd

How to Log In

1 www.mybenefitshub.com/kellerisd

2 CLICK LOGIN

3 ENTER USERNAME & PASSWORD

Your Username Is: Your Keller ISD employee email address is your username.

Your Generic Password Is: Four (4) digits of your birth year followed by the last four (4) digits of your Social Security Number

During your annual open enrollment, your password is reset to the generic password. Once you change your password, you will log in with that password moving forward.

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.

Marital Status

Change in Number of Tax Dependents

Change in Status of Employment Affecting Coverage Eligibility

Gain/Loss of Dependents' Eligibility Status

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.

Judgment/Decree/ Order

Eligibility for Government Programs

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 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 Benefits in the 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/ kellerisd. 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 Keller ISD benefit website: www.mybenefitshub.com/kellerisd. 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 January 1, 2023, you must be actively-at-work on January 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.

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 Keller ISD Benefits, 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 Keller ISD Benefits, 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 1/1/2023 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 Issue

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

January 1 - December 31

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).

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

health

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

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

Not

permitted

Access to some funds may be extended if your employer’s plan contains

a

Keller Pointe EMPLOYEE BENEFITS

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

1. What are the prices for The Keller Pointe passes?

4. What does a family consist of?

Those individuals you claim as your dependent on your tax form, can be placed on your family pass. Be ready to give proof of dependency if asked by Keller Pointe.

5. What is a group exercise add-on?

Group exercise add-on allows all members on the pass to participate in both land and water aerobics offered at Keller Pointe.

6. Where is the facility?

The address is 405 Rufe Snow Dr. Keller, TX 76248.

2. What is the benefit to KISD employees by joining The Keller Pointe through payroll deduction?

The City of Keller and KISD have an agreement to provide KISD employees annual passes to Keller Pointe and you pay through payroll deduction.

3. Who qualifies as a resident vs. non-resident? A resident is one who lives within the city limits of the City of Keller. Look at your property tax record and see if you pay City of Keller taxes. Your postal address does not necessarily coincide with your city residency.

Sick Leave Bank

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

• To become a member, a one-time donation of 2 sick days are required, unless the Sick Leave Bank goes below a certain level. Once the donation has been made, the membership will continue the duration of the employment. You can enroll in the Sick Leave Bank during your Annual Open Enrollment.

• The purpose of the Sick Leave Bank is to provide additional sick leave days to members of the bank in the event of the employee or the employee's spouse, parent, son, or daughter experience a catastrophic illness or injury. To request days from the bank, an employee must have exhausted all paid leave and vacation leave.

• Sick leave days from the bank must be approved by the District's Sick Leave Bank Committee.

Basic Life and AD&D The Hartford

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/kellerisd

The group term Life and Accidental Death and Dismemberment (AD&D) insurance available through your employer gives extra protection that you and your family may need. Life and AD&D insurance offers financial protection by providing you coverage in case of an untimely death or an accident that destroys your income-earning ability. Life benefits are disbursed to your beneficiaries in a lump sum in the event of your death. To learn more about Life and AD&D insurance, visit www.thehartford.com/employeebenefits

Life and AD&D The Hartford EMPLOYEE BENEFITS

ASKED & ANSWERED WHO IS ELIGIBLE?

You are eligible if you are an active full time employee who works at least 20 hours per week on a regularly scheduled basis.

AM I GUARANTEED COVERAGE?

This insurance is guaranteed issue – it is available without having to provide information about your health.

WHEN CAN I ENROLL?

Your employer automatically enrolled you for this coverage. If you have not already done so, you must designate a beneficiary.

WHEN DOES THIS INSURANCE BEGIN?

This insurance will become effective for you on the date you become eligible. You must be actively at work on the day your coverage takes effect.

WHEN DOES THIS INSURANCE END?

This insurance will end when you no longer satisfy the applicable eligibility conditions, premium is unpaid, you are no longer actively working, you leave your employer or the coverage is no longer offered.

CAN I KEEP THIS INSURANCE IF I LEAVE MY EMPLOYER OR AM NO LONGER A MEMBER OF THIS GROUP?

Yes, you can take this life coverage with you. Coverage may be continued for you under and individual conversion life certificate. The specific terms and qualifying events for conversation are described in the certificate. Portability on Basic Life and AD&D is not offered.

Medical Insurance

BCBS TX

ABOUT MEDICAL

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

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

/202

Summary of Benefits and Coverage: What this Plan Covers & What You Pay f or Covered Services

T he Summary of Benefits and Coverage (SBC) document will help you choose a health plan . The SBC shows you how you and the plan would share the cost for covered health care services.

NOTE: Information about the cost of this plan (called the premium ) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 18005212227 or at For general definitions of common terms, such as allowed amount , balance billing , coinsurance , copayment , deductible , provider , or other underlined terms, see the Glossary. You can view the Glossary at www.healthcare.gov/sbcglossary/ or call 18557564448 to request a copy.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible . See a list of covered preventive services at www.healthcare.gov/coverage/preventivecarebenefits/ .

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Network :

For In

For OutofNetwork :

Are there other deductibles for specific services?

You don’t have to meet deductibles for specific services. What is the outofpocket limit for this plan ?

Even though you pay these expenses, they don’t count toward the outofpocket limit .

Premiums , balancebilling charges, and health care this plan doesn’t cover.

This plan uses a provider network . You will pay less if you use a provider in the plan ’s network . You will pay the most if you use an outofnetwork provider , and you might receive a bill from a provider for the difference between the provider ’s charge and what your plan pays ( balance bil ling ). Be aware, your network provider might use an outofnetwork provider for some services (such as lab work). Check with your provider before you get services.

Yes. See www.bcbstx.com or call 18008102583 for a list of network providers .

Will you pay less if you use a network provider ?

You can see the specialist you choose without a referral .

No.

Do you need a referral to see a specialist ?

Coverage for: Individual / Family | Plan Type: HSA Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

What You Will Pay

You may have to pay for services that aren’t preventive . Ask your provider if the services needed are preventive . Then check what your plan will pay for. No Charge for child immunizations OutofNetwork through the 6th birthday. If you have a test

*For more information about limitations and exceptions, see the plan or policy document at

What You Will Pay

Retail covers a 30day supply. With appropriate prescription, up to a 90day supply is available. Mail order covers a 90day supply. OutofNetwork mail order is not covered. For OutofNetwork pharmacy, member must file claim . Payment of the difference between the cost of a brand name drug and a generic may be required if a generic drug is available. The costsharing for insulin included in the drug list will not exceed $25 per prescription for a 30day supply, regardless of the amount or type of insulin needed to fill the prescription.

For InNetwork benefit, specialty drugs must be obtained from InNetwork specialty pharmacy provider . Specialty retail limited to a 30day supply. Mail order is not covered.

You may have to pay for services that are not covered by the visit fee. For an example, see “If you have a test” on page 2.

*For more information about limitations and exceptions, see the plan or policy document at

What You Will Pay

Certain services must be preauthorized; refer to your benefit booklet* for details. Virtual visits are available, please refer to your plan policy for more details.

Cost sharing does not apply for preventive services . Depending on the type of services, a coinsurance or deductible may apply. Maternity care may include tests and service described elsewhere in the SBC (i.e. ultrasound).

*For more information about limitations and exceptions, see the plan or policy document at

What You Will Pay

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: For group health coverage contact the plan , Blue Cross and Blue Shield of Texas at 18005212227 or visit www.bcbstx.com . For group health coverage subject to ERISA, contact the U.S. Department of Labor’s Employee Benefits Security Administration at 1866444EBSA (3272) or www.dol.gov/ebsa/healthreform . For nonfederal governmental group health plans , contact Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 18772672323 x61565 or www.cciio.cms.gov . Church plans are not covered by the Federal COBRA continuati on coverage rules. If the coverage is insured, individuals should contact their State insurance regulator regarding their possible rights to continuation coverage under Sta te law. Other coverage options may be available to you too, including buying individ ual insurance coverage through the Health Insurance Marketplace . For more information about the Marketplace , visit www.HealthCare.gov or call 18003182596

Your Grievance and Appeals Rights: There are agencies t hat can help if you have a complaint against your plan for a denial of a claim . This complaint is called a grievance or appeal . For more information about your rights, look at the explanation of benefits you will receive for that medical claim . Your plan documents also provide complete information to submit a claim , appeal , or a grievance for any reason to your plan . For more inf ormation about your rights, this notice, or assistance, contact: For group health coverage subject to ERISA: Blue Cross and Blue Shield of Texas at 18005212227 or visit www.bcbstx.com , the U.S. Department of Labor's Employee Benefits Security Administration at 1866444EBSA (3272) or www.dol.gov/ebsa/healthreform , and the Texas Department of Insurance, Consumer Protection at 18002523439 or www.tdi.texas.gov . For nonfederal governmental group health plans and church plans that are group health plans , Blue Cross and Blue Shield of Texas at 18005212227 or www.bcbstx.com or contact t he Texas Department of Insurance, Consumer Protection at 18002523439 or www.tdi.texas.gov

. Additionally, a consumer assistance program can help you file your appeal . Contact the Texas Department of Insurance’s Consumer Health Assistance Program at 18002523439 or visit www.cms.gov/CCIIO/Resources/ConsumerAssistanceGrants/tx.html .

Does this plan provide Minimum Essential Coverage ? Yes Minimum Essential Coverage generally includes plans , health insurance available through the Marketplace or ot her individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage , you may not be eligible for the premium tax credit .

Does this plan meet the Minimum Value Standards ? Yes

If your plan doesn’t meet the Minimum Value Standards , you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace .

Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 18005212227.

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tum awag sa 18005212227.

Chinese ( 中文 ): 如果需要中文的帮助， 请拨打这个号码 18005212227. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 18005212227.

To see examples of how this plan might cover costs for a sample medical situation, see the next section.

the other costs of these

be responsible

The

Health care coverage is important for everyone. We provide free communication aids and services for anyone with a disability or who needs language assistance. We do not discriminate on the basis of race, color, national origin, sex, gender identity, age, sexual orientation, health st atus or disability.

To receive language or communication assistance free of charge, please call us at 8557106984.

If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance .

Phone:

Office of Civil Rights Coordinator

8556647270 (voicemail) 300 E. Randolph St.

8556616960

TTY/TDD:

Fax:

8556616965 35th Floor

Chicago, Illinois 60601

You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at: U.S. Dept. of Health & Human Services

Phone:

8003681019 200 Independence Avenue SW

Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

8005377697 Room 50 9F, HHH Building 1019

TTY/TDD:

Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html

bcbstx.com

Washington, DC 20201

12

T he Summary of Benefits and Coverage (SBC) document will help you choose a health plan . The SBC shows you how you and the plan would share the cost for covered health care services.

Coverage Period: 07/01/2023 –Page 1 of 8

NOTE: Information about the cost of this plan (called the premium ) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 18005212227 or at For general definitions of common terms, such as allowed amount , balance billing , coinsurance , copayment , deductible , provider , or other underlined terms, see the Glossary. You can view the Glossary at www.healthcare.gov/sbcglossary/ or call 18557564448 to request a copy.

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible . See a list of c overed preventive services at www.healthcare.gov/coverage/preventivecarebenefits/ .

You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services.

The outofpocket limit is the most you could pay in a year for covered services. If you have other family members in this plan , they have to meet their own outofpocket limits until the overall family outofpocket limit has been met.

Even though you pay these expenses, they don’t count toward the outofpocket limit .

This plan uses a provider network . You will pay less if you use a provider in the plan ’s network . You will pay the most if you use an outofnetwork provider , and you might receive a bill from a provider for the difference between the provider ’s charge and what your plan pays ( balance bil ling ). Be aware, your network provider might use an outofnetwork provider for some services (such as lab work). Check with your provider before you get services.

You can see the specialist you choose without a referral .

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:

-

For In

Yes. Per occurrence: $ 150 Individual / $ 300 Family prescription drug deductible . There are no other specific deductibles .

Are there other deductibles for specific services?

For InNetwork : $ 8 ,5 5 0 Individual / $1 7 , 1 00 Family For OutofNetwork : $ 25 , 65 0 Individual / $ 51 , 3 00 Family

What is the outofpocket limit for this plan ?

What is not included in the outofpocket limit ?

Yes. See www.bcbstx.com or call 18008102583 for a list of network providers .

Will you pay less if you use a network provider ?

No.

Do you need a referral to see a specialist ?

Coverage for: Individual / Family | Plan Type: PPO Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

You may have to pay for services that aren’t preventive . Ask your provider if the services needed are preventive . Then check what your plan will pay for. No Charge for

through

*For more information about limitations and exceptions, see the plan or policy document at

What You Will Pay

Retail covers a 30day supply. With appropriate prescription, up to a 90day supply is available. Mail order covers a 90day supply.

mail order is not covered. Payment of the difference between the cost of a brand name drug and a generic may be required if a generic drug is available. For OutofNetwork pharmacy, member must file claim . The costsharing for insulin included in the drug list will not exceed $25 per prescription for a 30day supply, regardless of the amount or type of insulin needed to fill the prescription.

of -

You may have to pay for services that are not covered by the visit fee. For an example, see “If you have a test” on page 2.

*For more information about limitations and exceptions, see the plan or policy document at

What You Will Pay

must be preauthorized; refer to your benefit booklet* for details.

visits are available, please refer to your plan policy for more details.

ment applies to first prenatal visit (per pregnancy).Cost sharing does not apply for preventive services . Depending on the type of services, a copayment , coinsurance , or deductible may apply. Maternity care may include tests and service described elsewhere in the SBC (i.e. ultrasound).

Copay

*For more information about limitations and exceptions, see the plan or policy document at

What You Will Pay

*For more information about limitations and exceptions, see the plan or policy document at

Services & Other

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services

• Privateduty nursing

• Routine foot care

• Infertility treatment

• Longterm care

• Acupuncture

• Cosmetic surgery

• Routine eye care (Adult)

• Nonemergency care when traveling outside the U.S.

• Hearing aids (1 per ear per 36month period)

• Dental care (Adult)

• Weight loss programs Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

• Bariatric surgery

• Chiropractic care ( 20 vi sits per year )

*For more information about limitations and exceptions, see the plan or policy document at

https://policy-srv.box.com/s/ob4df4lxyx0qsb4em2tb8g5z9s5sikg2.

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: For group health coverage contact the plan , Blue Cross and Blue Shield of Texas at 18005212227 or visit www.bcbstx.com . For group health coverage subject to ERISA, contact the U.S. Department of Labor’s Employee Benefits Security Administration at 1866444EBSA (3272) or www.dol.gov/ebsa/healthreform . For nonfederal governmental group health plans , contact Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 18772672323 x61565 or www.cciio.cms.gov . Church plans are not covered by the Federal COBRA continuation coverage rules. If th e coverage is insured, individuals should contact their State insurance regulator regarding their possible rights to continuation coverage under Sta te law. Other coverage options may be available to you too, including buying individual insurance coverage t hrough the Health Insurance Marketplace . For more information about the Marketplace , visit www.HealthCare.gov or call 18003182596

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim . This complaint is called a grievance or appeal . For more information about your rights, look at the explanation of benefits you will receive for that medica l claim . Your plan documents also provide complete information to submit a claim , appeal , or a grievance for any reason to your plan . For more information about your rights, this notice, or assistance, contact: For group health coverage subject to ERISA: B lue Cross and Blue Shield of Texas at 18005212227 or visit www.bcbstx.com , the U.S. Department of Labor's Employee Benefits Security Administration at 1866444EBSA (3272) or www.dol.gov/ebsa/healthreform , and the Texas Department of Insurance, Consumer Protection at 18002523439 or www.tdi.texas.gov . For nonfederal governmental group health plans and church plans that are group health plans , Blue Cross and Blue Shield of Texas at 18005212227 or www.bcbstx.com or contact the Texas Department of Insurance, Consumer Protection at 18002523439 o r

. Additionally, a consumer assistance program can help you file your appeal . Contact the Texas Department of Insurance’s Consumer Health Assistance Program at 18002523439 or visit www.cms.gov/CCIIO/Resources/ConsumerAssistanceGrants/tx.html .

www.tdi.texas.gov

Does this plan provide Minimum Essential Coverage ? Yes Minimum Essential Coverage generally includes plans , health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other c overage. If you are eligible for certain types of Minimum Essential Coverage , you may not be eligible for the premium tax credit .

Does this plan meet the Minimum Value Standards ? Yes

If your plan doesn’t meet the Minimum Value Standards , you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace .

Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 18005212227.

Tagalog (Tagalog ): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 18005212227.

Chinese ( 中文 ): 如果需要中文的帮助， 请拨打这个号码 18005212227. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 18005212227.

To see examples of how this plan might cover costs for a sample medical situation, see the next section.

covered services.

would be responsible for the other costs of these

The

Health care coverage is important for everyone. We provide free communication aids and services for anyone with a disability or who needs language assistance. We do not discriminate on the basis of race, color, national origin, sex, gender identity, age, sexual orientation, health status or disability.

To receive language or communication assistance free of charge, please call us at 8557106984.

If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance . Office of Civil Rights Coordinator

Phone:

8556647270 (voicemail) 300 E. Randolph St.

8556616960

TTY/TDD:

Fax:

8556616965 35th Floor

Chicago, Illinois 60601

You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at: U.S. Dept. of Health & Human Services

Phone:

8003681019 200 Independence Avenue SW

Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

8005377697 Room 50 9F, HHH Building 1019

TTY/TDD:

Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html

bcbstx.com

Washington, DC 20201

T he Summary of Benefits and Coverage (SBC) document will help you choose a health plan . The SBC shows you how you and the plan would share the cost for covered health care services.

see the

Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan , each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible .

This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost sharing and before you meet your deductible . See a list of covered preventive services at www.healthcare.gov/coverage/preventivecarebenefits/ .

You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services.

Even though you pay these expenses, they don’t count toward the outofpocket limit .

This plan uses a provider network . You will pay less if you use a provider in the plan ’s network . You will pay the most if you use an outofnetwork provider , and you might receive a bill from a provider for the difference between the provider ’s charge and what your plan pays ( balance bil ling ). Be aware, your network provider might use an outofnetwork provider for some services (such as lab work). Check with your provider before you get services.

You can see the specialist you choose without a referral .

https://policy-srv.box.com/s/829uxjg83oa6bt5s2csjzb06ea7z2ubo.

NOTE: Information about the cost of this plan (called the premium ) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 18005212227 or at For general definitions of common terms, such as allowed amount , balance

Are

Family

/ $ 4

Yes. Per occurrence: $ 20 0

:

For InNetwork

Premiums , balancebilling charges, and health care this plan doesn’t cover.

What is not included in the outofpocket limit ?

Yes. See www.bcbstx.com or call 18008102583 for a list of network providers .

Will you pay less if you use a network provider ?

No.

Do you need a referral to see a specialist ?

You may have to pay for services that aren’t preventive . Ask your provider if the services needed are preventive . Then check what your plan will pay for. No Charge for child

OutofNetwork through the 6th birthday.

*For more information about limitations and exceptions, see the plan or policy document at

What You Will Pay

Retail covers a 30day supply. With appropriate prescription, up to a 90day supply is available. Mail order covers a 90day supply. OutofNetwork mail order is not covered. Payment of the difference between the cost of a brand name drug and a generic may be required if a generic drug is available. For OutofNetwork pharmacy, member must file claim . The costsharing for insulin included in the drug list will not exceed $25 per prescription for a 30day supply, regardless of the amount or type of insulin needed to fill the prescription.

may have to pay for services that are not covered by the visit fee. For an example, see “If you have a test” on page 2.

*For more information about limitations and exceptions, see the plan or policy document at

What You Will Pay

must be preauthorized; refer to your benefit booklet* for details.

visits are available, please refer to your plan policy for more details.

ment applies to first prenatal visit (per pregnancy).Cost sharing does not apply for preventive services . Depending on the type of services, a copayment , coinsurance , or deductible may apply. Maternity care may include tests and service described elsewhere in the SBC (i.e. ultrasound).

Copay

*For more information about limitations and exceptions, see the plan or policy document at

What You Will Pay

*For more information about limitations and exceptions, see the plan or policy document at

Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services

• Privateduty nursing

• Routine foot care

• Weight loss programs

• Infertility treatment

• Longterm care

• Nonemergency care when traveling outside the U.S.

• Acupuncture

• Cosmetic surgery

• Dental care (Adult)

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)

• Routine eye care (Adult)

• Hearing aids (1 per ear per 36month period)

• Bariatric surgery

• Chiropractic care ( 20 vi sits per year )

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: For group health coverage contact the plan , Blue Cross and Blue Shield of Texas at 18005212227 or visit www.bcbstx.com . For group health coverage subject to ERISA, contact the U.S. Department of Labor’s Employee Benefits Security Administration at 1866444EBSA (3272) or www.dol.gov/ebsa/healthreform . For nonfederal governmental group health plans , contact Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 18772672323 x61565 or www.cciio.cms.gov . Church plans are not covered by the Federal COBRA continuation coverage rules. If th e coverage is insured, individuals should contact their State insurance regulator regarding their possible rights to continuation coverage under Sta te law. Other coverage options may be available to you too, including buying individual insurance coverage t hrough the Health Insurance Marketplace . For more information about the Marketplace , visit www.HealthCare.gov or call 18003182596

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim . This complaint is called a grievance or appeal . For more information about your rights, look at the explanation of benefits you will receive for that medica l claim . Your plan documents also provide complete information to submit a claim , appeal , or a grievance for any reason to your plan . For more information about your rights, this notice, or assistance, contact: For group health coverage subject to ERISA: B lue Cross and Blue Shield of Texas at 18005212227 or visit www.bcbstx.com , the U.S. Department of Labor's Employee Benefits Security Administration at 1866444EBSA (3272) or www.dol.gov/ebsa/healthreform , and the Texas Department of Insurance, Consumer Protection at 18002523439 or www.tdi.texas.gov . For nonfederal governmental group health plans and church plans that are group health plans , Blue Cross and Blue Shield of Texas at 18005212227 or www.bcbstx.com or contact the Texas Department of Insurance, Consumer Protection at 18002523439 o r

. Additionally, a consumer assistance program can help you file your appeal . Contact the Texas Department of Insurance’s Consumer Health Assistance Program at 18002523439 or visit www.cms.gov/CCIIO/Resources/ConsumerAssistanceGrants/tx.html .

www.tdi.texas.gov

Does this plan provide Minimum Essential Coverage ? Yes Minimum Essential Coverage generally includes plans , health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other c overage. If you are eligible for certain types of Minimum Essential Coverage , you may not be eligible for the premium tax credit .

Does this plan meet the Minimum Value Standards ? Yes

If your plan doesn’t meet the Minimum Value Standards , you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace .

Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 18005212227.

Tagalog (Tagalog ): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 18005212227.

Chinese ( 中文 ): 如果需要中文的帮助， 请拨打这个号码 18005212227. Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 18005212227.

To see examples of how this plan might cover costs for a sample medical situation, see the next section.

covered services.

would be responsible for the other costs of these

The

Health care coverage is important for everyone. We provide free communication aids and services for anyone with a disability or who needs language assistance. We do not discriminate on the basis of race, color, national origin, sex, gender identity, age, sexual orientation, health status or disability.

To receive language or communication assistance free of charge, please call us at 8557106984.

If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance . Office of Civil Rights Coordinator

Phone:

8556647270 (voicemail) 300 E. Randolph St.

8556616960

TTY/TDD:

Fax:

8556616965 35th Floor

Chicago, Illinois 60601

You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at: U.S. Dept. of Health & Human Services

Phone:

8003681019 200 Independence Avenue SW

Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

8005377697 Room 50 9F, HHH Building 1019

TTY/TDD:

Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html

bcbstx.com

Washington, DC 20201

Hospital Indemnity Voya EMPLOYEE BENEFITS

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/kellerisd

What is Hospital Confinement Indemnity Insurance?

Hospital Confinement Indemnity Insurance pays a daily benefit if you have a covered stay in a hospital*, critical care unit or rehabilitation facility. The benefit amount is determined by the type of facility and the number of days you stay. You have the option to elect Hospital Confinement Indemnity Insurance to meet your needs. Hospital Confinement Indemnity Insurance is a limited benefit policy. It is not health insurance and does not satisfy the requirement of minimum essential coverage under the Affordable Care Act.

Features of Hospital Confinement Indemnity Insurance include:

• Guaranteed issue: No medical questions or tests are required for coverage.

• Flexible: You can use the benefit payments for any purpose you like.

• Portable: If you leave your current employer or retire, you can take the policy with you and select from a variety of payment plans.

*A hospital does not include an institution or part of an institution used as: a hospice care unit; a convalescent home; a rest or nursing facility; a free- standing surgical center; a rehabilitative center; an extended care facility; a skilled nursing facility; or a facility primarily affording custodial, educational care, or care or treatment for persons suffering from mental diseases or disorders, or care for the aged, or drug or alcohol addiction.

“Critical care unit” and “rehabilitative facility” are specifically defined in this policy. See the certificate for details.

How can Hospital Confinement Indemnity Insurance help?

Below are a few examples of how your Hospital Confinement Indemnity Insurance benefit could be used (coverage amounts may vary):

• Medical expenses, such as deductibles and copays

• Travel, food, and lodging expenses for family members

• Childcare

• Everyday expenses like utilities and groceries

Who is eligible for Hospital Confinement Indemnity Insurance?

• You - all active employees working 20+ hours per week.

• Your spouse* - coverage is available only if employee coverage is elected.

• Your children - to age 26. Coverage is available only if employee coverage is elected.

*The use of “spouse” in this document means a person insured as a spouse as described in the certificate of insurance or rider. Please contact your employer for more information.

What Hospital Confinement Indemnity Insurance benefits are available?

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

• You have the option to purchase a daily benefit amount of $100, $200, or $300

• The benefit amounts paid depend on the type of facility and the number of days of confinement:

• Hospital The benefit is 1x the daily benefit amount ($100, $200 or $300), up to 30 days per confinement.

• Critical care unit (CCU) The benefit is 2x the daily benefit amount ($200, $400 or $600), up to 15 days per confinement

• Rehabilitation facility The benefit is one-half of the daily benefit amount ($50, $100 or $150), up to 30 days per confinement.

Critical Illness Insurance Voya EMPLOYEE BENEFITS

ABOUT CRITICAL ILLNESS

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

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

What is Critical Illness Insurance?

Critical Illness Insurance pays a lump-sum benefit if you are diagnosed with a covered illness or condition. Critical Illness Insurance is a limited benefit policy. It is not health insurance and does not satisfy the requirement of minimum essential coverage under the Affordable Care Act.

For what critical illnesses and conditions are benefits available?

Base Module

How many times can I receive the Maximum Critical Illness Benefit?

Usually you are only able to receive the Maximum Critical Illness Benefit for one covered illness or disease within each module.

Your plan includes the Restoration Benefit*, which provides a one-time restoration of 100% of the maximum benefit amount in order to pay an additional benefit if you experience a second covered illness for a different condition.

• Heart attack

• Stroke

• Coronary artery bypass (25%)

• Coma

• Cancer

• Skin cancer (10%)

• Benign brain tumor

• Deafness

• Major organ failure

• Permanent paralysis

• End stage renal (kidney) failure

Cancer Module

• Carcinoma in situ (25%)

Module A

• Occupational HIV

• Blindness

Who is eligible for Critical Illness Insurance?

• You all active employees working 20 hours per week.

• Your spouse* coverage is available only if employee coverage is elected.

• Your child(ren) to age 26. coverage is available only if employee coverage is elected.

*The use of “spouse” in this document means a person insured as a spouse as described in the certificate of insurance or rider. This may include domestic partners or civil union partners as defined by the group policy. Please contact your employer for more information.

What Maximum Critical Illness Benefit am I eligible for?

• For you: $5,000-$30,000 in $5,000 increments.

• For your spouse: $5,000-$15,000 in $5,000 increments, not to exceed 50% of employee election.

• For each covered child(ren): $1,000, $2,500, $5,000 or $10,000, not to exceed 50% of employee election.

Your plan also includes the Recurrence Benefit*, which allows you to receive a benefit for the same condition a second time. It’s important to note that in order for the second covered illness or the second occurrence of the illness to be covered, it must occur after 12 consecutive months without the occurrence of any covered critical illness named in your certificate, including the illness from the first benefit payment.

If a partial benefit is paid out, it will not reduce the available maximum benefit amount for the illnesses or diseases in that same module. If you have reached the benefit limit by receiving the maximum benefit in each module, you may choose to end your coverage; however, if you have coverage for your spouse and/or child(ren), you must continue your coverage in order to keep their coverage active. Please see the certificate of coverage for details.

*This benefit does not apply to the cancer module.

Accident Insurance Voya 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/kellerisd

What is Accident Insurance?

Accident Insurance pays you benefits for specific injuries and events resulting from a covered accident. The amount paid depends on the type of injury and care received. Accident Insurance is a limited benefit policy. It is not health insurance and does not satisfy the requirement of minimum essential coverage under the Affordable Care Act.

You may qualify to receive benefits for items listed below, as long as they are the result of a covered accident. See the certificate of insurance and any riders for specific details.

• Accident hospital care

• Follow-up care

• Common Injuries

Other features of Accident Insurance include:

• Guaranteed Issue: No medical questions or tests required for coverage.

• Flexible: You can use the benefit money for any purpose you like.

• Payroll deductions: Premiums are paid through convenient payroll deductions.

How can Accident Insurance help?

Below are a few examples of how your Accident Insurance benefits could be used:

• Medical expenses, such as deductibles and copays

• Home healthcare costs

• Lost income due to lost time at work

• Everyday expenses like utilities and groceries

Who is eligible for Accident Insurance?

• You all active employees working 20+ hours per week**.

• Your spouse* coverage is available only if employee coverage is elected.

• Your child(ren) to age 26. Coverage is available only if employee coverage is elected.

*The use of “spouse” in this document means a person insured as a spouse as described in the certificate of insurance or rider. Please contact your employer for more information.

What accident benefits are available?

The following list includes the benefits provided by Accident Insurance. The benefit amounts paid depend on the type of injury and care received. You may be required to seek care for your injury within a set amount of time. Note that there may be some variation by state. For a list of standard exclusions and limitations, go to the end of this document. For a complete description of your available benefits, along with applicable provisions, exclusions and limitations, see your certificate of insurance and any riders.

3rd degree, at least 9 but less than 35 square inches of the

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/kellerisd

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 Dental.

How to Find a Dentist Visit hcpdirectory.cigna.com/ or call 800-244-6224 to find an in-network dentist. Your network will be Total Cigna DPPO.

How to Request a New ID Card

You can request your dental id card by contacting Cigna directly at 800-244-6224. You can also go to www.mycigna.com and register/login to access your account. In addition, you can download the “MyCigna” app on your smartphone and access your id card right there on your phone.

Class I - Preventive & Diagnostic Care

Oral Evaluations, Prophylaxis: routine, cleanings, X-rays: routine, X-rays: non-routine, Fluoride, Application, Sealants: per tooth, Space Maintainers: non-orthodontic , Emergency Care to Relieve Pain

Class II - Basic Restorative Care

Restorative: fillings, Endodontics: minor and major , Periodontics: minor and major , Oral Surgery: minor and major, Anesthesia: general and IV sedation, Repairs: dentures

Class III - Major Restorative Care Inlays and Onlays, Prosthesis Over Implant, Crowns: prefabricated stainless steel / resin, Crowns: permanent cast and porcelain, Bridges and Dentures, Repairs: bridges, crowns and inlays, Denture Relines, Rebases and Adjustments

IV - Orthodontia

for Dependent Children to age 19

In-Network Reimbursement For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Fee Schedule or Discount Schedule. Non-Network Reimbursement For services provided by a non-network dentist, Cigna Dental will reimburse according to the Maximum Reimbursable Charge. The MRC is calculated at the 90th percentile of all provider charges in the geographic area. The dentist may balance bill up to their usual fees.

Dental Insurance Cigna EMPLOYEE BENEFITS

Oral Evaluations, Prophylaxis: routine cleanings , X-rays: routine, Fluoride Application

per tooth, Space Maintainers: non-orthodontic, Emergency Care to Relieve Pain

Restorative Care

Onlays, Prosthesis Over Implant, Crowns: prefabricated stainless steel / resin, Crowns: permanent cast and porcelain, Bridges and Dentures, Oral Surgery: major, Anesthesia: general and IV sedation, Periodontics: minor and major, Endodontics: minor and major, Repairs: bridges, crowns and inlays, Repairs: dentures, Denture Relines, Rebases and Adjustments

Plan Provisions:

-Network Reimbursement For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse thedentist according to a Fee Schedule or Discount Schedule.

Non-Network Reimbursement For services provided by a non-network dentist, Cigna Dental will reimburse according to theMaximum Allowable Charge. The dentist may balance bill up to their usual fees.

Late Entrant Limitation Provision Payment will be reduced by 50% for Class III services for 12 months for eligible members thatare allowed to enroll in this plan outside of the designated open enrollment period. This provision does not apply to new hires.

DHMO PLAN

If you enroll in the DHMO plan, you must select a Primary Care Dentist (PCD) from the DHMO network directory to manage your care. Each eligible dependent may choose their own PCD. The Patient Charge Schedule applies only when covered dental services are performed by your performed by your in-network dentist through Cigna. Not all Network Dentists perform all listed services and it is suggested to check with your Network Dentist in advance of receiving services. Dental services are unlimited; you pay fixed copays, there are no deductibles and there are no claim forms to file. There is no coverage for services provided without a referral from your PCD or if you seek care from out-of-network providers. Please refer to link below for patient charge schedule details on your benefit website.

How do I find an In-network Dentist? Visit: https://hcpdirectory.cigna.com/ or call 800-244-6224 to find an in-network dentist. Your network will be Cigna Dental Care DHMO.

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/kellerisd

How to Print your Vision ID Card:

To obtain your Superior Vision ID card, log onto www.mybenefitshub.com/KellerISD and download a generic card from the vision tab. Once you have printed your card, simply write your name on the front of the card.

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

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

Dental & Vision Discount Program

QCD

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

Dental Discount Program

The QCD of America Dental & Vision Benefit Program is a managed cost program offering a large selection of highly qualified private practice dental and optical professionals.

The QCD Philosophy

QCD believes that you should pay the lowest monthly cost possible for comprehensive dental and vision benefit coverage for your family. The member benefits from significant cost savings when and if services are used.

Why Select QCD?

When selecting dental benefits, QCD makes good financial sense. QCD allows you to allocate more of your benefit expenditures to your rising medical costs. A single dental procedure (Root Canal and Crown) could cost you as much as $2000 with no coverage. The QCD program will allow you to save up to 60% on the total cost – that could be as much as $1200 in savings and enough to fund your family’s monthly dental and vision benefit costs for several years.

• No Claim Forms, Deductibles or Coverage Maximums

• Immediate Coverage for all Pre-Existing Conditions

• Orthodontics (Braces) for Children and Adults

Need more information?

• Contact QCD Membership Services Department 972.726.0444 or 1.800.229.0304

• See the last page for your enrollment form

• Visit the QCD website at www.qcdofamerica.com

• Print ID cards at: https://www.qcdofamerica.com/ printcard/

• Find a dentist at: https://www.qcdofamerica.com/find-adentist/

• Please enter Group ID KELLR to print ID cards. You will also need your subscriber ID#. Contact the QCD office if you do not have this information.

• Please select any dentist within the QCD Affiliated Dentist Team and make an appointment.

• Please be sure to identify yourself as a QCD member and the reduced fee schedule will apply to all charges.

• Please call the QCD Member Services Department at 972.726.0444 or 1.800.229.0304 for assistance.

• Information may be obtained from the web site at www.qcdofamerica.com

Dental & Vision Discount Program

Vision Discount Program

Davis Vision is pleased to provide you with a no-cost, traditional vision Discount Program that provides significant discounts on eye exams, lenses, frames and additional eyewear options. For more details, see the Accessing Provider Information section on the reverse side.

The Discount Program entitles you to the following discounts off usual and customary fees:

Lens 1-2-3! Membership – Free Membership Up to 50% Laser Vision Correction Discount Up to 25% off Provider’s U & C Up to 25%

Eye Examination – Members will receive a 15% discount on their comprehensive eye examination including dilation (when professionally indicated).

Eyewear (Frames and Spectacle Lenses or Contact Lenses) –Members will be entitled to substantial and verifiable savings on all of their eyewear needs. Discounts are uniform nationally and represent pricing well below Average Retail Prices. These discounts are based on published industry standard costs, not markdowns from artificially inflated prices.

Significant Savings – Client surveys indicate that programs providing discounts off retail prices of eyeglasses are subject to abuse due to the high associated markups of over 300% throughout the optical industry. Consequently, these programs do not result in a true “value-add” for the beneficiary. The proposed fixed-fee discounted pricing schedule provides both verifiable savings and benefit uniformity for all members from coast to coast.

Disability Insurance The Hartford 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/kellerisd

EDUCATOR DISABILITY INSURANCE OVERVIEW

What is Educator Disability Income Insurance?

Educator Disability insurance combines the features of a short-term and long-term disability plan into one policy. The coverage pays you a portion of your earnings if you cannot work because of a disabling illness or injury. The plan gives you the flexibility to choose a level of coverage to suit your need. You have the opportunity to purchase Disability Insurance through your employer. This highlight sheet is an overview of your Disability Insurance. Once a group policy is issued to your employer, a certificate of insurance will be available to explain your coverage in detail.

Why do I need Disability Insurance Coverage?

• More than half of all personal bankruptcies and mortgage foreclosures are a consequence of disability

• The average worker faces a 1 in 3 chance of suffering a job loss lasting 90 days or more due to a disability

• Only 50% of American adults indicate they have enough savings to cover three months of living expenses in the event they’re not earning any income

ELIGIBILITY AND ENROLLMENT

Eligibility

Enrollment

You are eligible if you are an active employee who works at least 20 hours per week on a regularly scheduled basis.

You can enroll in coverage within 31 days of your date of hire or during your annual enrollment period.

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

Actively at Work

FEATURES OF THE PLAN

Benefit Amount

Elimination Period

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

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

Earnings are defined in The Hartford’s contract with your employer.

You must be disabled for at least the number of days indicated by the elimination period that you select before you can receive a disability benefit payment. The elimination period that you select consists of two numbers. The first number shows the number of days you must be disabled by an accident before your benefits can begin. The second number indicates the number of days you must be disabled by a sickness before your benefits can begin.

For those employees electing an elimination period of 30 days or less, if your are confined to a hospital for 24 hours more due to a disability, the elimination period will be waived, and benefits will be payable from the first day of hospitalization.

Disability Insurance The Hartford EMPLOYEE BENEFITS

PROVISIONS OF THE PLAN

Definition of Disability

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

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

Pre-Existing Condition Limitation

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

If your disability is a result of a pre-existing condition, we will pay benefits for a maximum of 4 weeks.

How to File a Claim

Instructions on how to file a claim can be found on your Employee Benefits Portal under Disability. To File a Claim, Call this Number: 866-278-2655.

Voluntary Life Insurance

The Hartford

ABOUT LIFE INSURANCE

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/kellerisd

AM I GUARANTEED COVERAGE?

If you are newly eligible and elect an amount that exceeds the guaranteed issue amount of $250,000, you will need to provide evidence of insurability that is satisfactory to The Hartford before the excess can become effective.

If you are currently participating in this coverage you may increase your current coverage by 2 increments, not to exceed $250,000, without providing evidence of insurability. If you were previously eligible and are electing coverage for the first time, you may elect coverage in the amount of 2 increments, without providing evidence of insurability. Additional coverage amounts will require evidence of insurability that is satisfactory to The Hartford before the excess can become effective.

For your spouse coverage, if you are newly eligible and elect an amount that exceeds the guaranteed issue amount of $20,000, your spouse will need to provide evidence of insurability that is satisfactory to The Hartford before the excess can become effective.

If your spouse is currently participating in this coverage you may increase your spouse's current coverage by 1 Increments, not to exceed $20,000 without providing evidence of insurability. If you were previously eligible and are electing spouse coverage for the first time, you may elect coverage in the amount of 2 Increments. Additional coverage amounts will require your spouse to provide evidence of insurability that is satisfactory to The Hartford before the excess can become effective.

GROUP LIFE INSURANCE REDUCTION

To 65% at age 65; 45% at age 70; 30% at age 75; 20% at age 80

NOTE: Spouse rates based on employee's age

Voluntary AD&D Insurance The Hartford

ABOUT AD&D INSURANCE

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/kellerisd

Covered accidents or death can occur up to 365 days after the accident.

not exceed 100% of your coverage amount.

To 65% at age 65; 45% at age 70; 30% at age 75; 20% at age 80

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.

EMPLOYEE BENEFITS

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

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 $2,400 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), but you may contribute to a Health Savings Account (HSA).

How the Health Care FSAs Work

You can access the funds in your Health Care FSA two different ways: Use your NBS Debit Card to pay for qualified expenses, doctor visits and prescription copays. Pay out-of-pocket and submit your receipts for reimbursement:

• Fax – 844-438-1496

• Email – service@nbsbenefits.com

• Online – my.nbsbenefits.com

• Call for Account Balance: 855-399-3035

• Mail: PO Box 6980

West Jordan, UT 84084

Contact NBS

• Hours of Operation: 6:00 AM – 6:00 PM MST, Mon-Fri

• Phone: (800) 274-0503

• Email: service@nbsbenefits.com

• Mail: PO Box 6980

West Jordan, UT 84084

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.

Flexible Spending Account (FSA)

Dependent Care FSA Guidelines

• Overnight camps are not eligible for reimbursement (only day camps can be considered).

• If your child turns 13 mid-year, you may only request reimbursement for the part of the year when the child is under age 13.

• You may request reimbursement for care of a spouse or dependent of any age who spends at least eight hours a day in your home and is mentally or physically incapable of self-care.

• The dependent care provider cannot be your child under age 19 or anyone claimed as a dependent on your income taxes.

Important FSA Rules

The maximum per plan year you can contribute to a Health Care FSA is $2,400. 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 30 days (up until date).

• 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 (OTC)

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.

Flexible Spending Accounts

Most medical, dental and vision care expenses that are not covered by your health plan (such as copayments, coinsurance, deductibles, eyeglasses and doctor-prescribed over-thecounter medications)

$2,400

Saves on eligible expenses not covered by insurance, reduces your taxable income

Dependent Care FSA

Dependent care expenses (such as day care, after-school programs, or elder care programs) so you and your spouse can work or attend school full-time

$5,000 single

$2,500 if married and filing separate tax returns

Reduces your taxable income

Health Savings Account (HSA) Optum Bank EMPLOYEE BENEFITS

ABOUT HSA

A Health Savings Account (HSA) is a personal savings account where the money can only be used for eligible medical expenses. Unlike a flexible spending account (FSA), the money rolls over year to year however only those funds that have been deposited in your account can be used. Contributions to a Health Savings Account can only be used if you are also enrolled in a High Deductible Health Care Plan (HDHP).

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

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 (High Deductible Health Plan)

• 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 – $3,850

• Family (filing jointly) – $7,750

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

If you meet the eligibility requirements, you may open an HSA administered by United Healthcare. 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.

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 United HealthCare are eligible for automatic payroll deduction and company contributions.

Instructions on how to make a Wellness Center HSA payment on the KISD Web Store: The URL for the Keller ISD Web Store is: https://intouch.kellerisd.net

Please follow instructions on the landing page. Once the transaction is complete, a printable receipt will automatically popup on your screen.

2023 PlanYear

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 Keller 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 Keller 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.