2023 Socorro ISD Benefit Guide

Benefit Contact Information

SISD BENEFITS ADMINISTRATION DENTAL

Socorro ISD (915) 937 0000 benefits@sisd.net www.mybenefitshub.com/socorroisd

HOSPITAL CARE

Cigna (800) 754 3207 www.cigna.com

LIFE AND AD&D

Unum

Basic Group #474618 Voluntary Group #474619 (800)445 0402 www.unum.com

Blue Cross Blue Shield of Texas (800) 521 2227 www.bcbstx.com

VISION

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

ACCIDENT DISABILITY

Mutual of Omaha (800) 775 8805 www.mutualofomaha.com

CRITICAL ILLNESS

Mutual of Omaha (800) 775 8805 www.mutualofomaha.com

New York Life (800) 644 5567 www.mynylgbs.com

EMERGENCY MEDICAL TRASPORTATION

MASA (800) 423 3226 www.masamts.com

How to Log In

CLICK LOGIN

3

ENTER USERNAME & PASSWORD

Your Username Is: The first six (6) characters of your last name, followed by the first letter of your first name, followed by the last four (4) digits of your Social Security Number.

Your Password is: Last Name (excluding punctuation) followed by the last four (4) digits of your Social Security Number.

Annual Benefit Enrollment

Benefit Updates What’s New:

• NEW! Dental carrier has changed to Blue Cross Blue Shield of Texas.

• NEW! Disability carrier has updated to New York Life.

• Critical Illness carrier has changed to Mutual of Omaha with additional covered illnesses and the option to cover your spouse up to 100%.

• NEW! Emergency Medical Transportation plan has been added as an option for employees to purchase.

• Lower Vision Rates

• NEW! Hospital Care benefit

Don’t Forget!

• Login and complete your benefit enrollment from 10/03/2022 10/31/2022

• Enrollment assistance is available by calling Financial Benefit Services at (866) 914 5202.

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

• REQUIRED!! Due to the Affordable Care Act (ACA) reporting requirements, you must add your dependent’s CORRECT social security numbers in the online enrollment system. If you have questions, please contact your Benefits Administrator.

Annual Benefit Enrollment

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 Benefits Office within 30 days of your qualifying event and meet with your Benefit/HR Office to complete and sign the necessary paperwork 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, 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 eligible employment. Failure to complete elections during this timeframe will result in the forfeiture of coverage.

Q&A

Who do I contact with Questions?

For supplemental benefit questions, you can contact your Benefits/HR department or you can call Financial Benefit Services at 866 914 5202 for assistance.

Where can I find forms?

For benefit summaries and claim forms, go to your benefit website: www.mybenefitshub.com/ socorroisd. 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 Socorro ISD benefit website: www.mybenefitshub.com/socorroisd. 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 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 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 Coverage

The amount of coverage you can elect without answering any medical questions or taking a health exam. Guaranteed coverage is only available during initial eligibility period. Actively at work and/or pre existing condition exclusion provisions do apply, as applicable by carrier.

In Network

PAGES

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

Out of Pocket Maximum

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

Plan Year

January 1st through December 31st

Pre Existing Conditions

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

Dental Insurance

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/socorroisd

Program

Benefit

Deductible:

Services

Diagnostic Services (Deductible does not apply)

Periodic oral evaluations

Problem focused oral evaluations

Comprehensive oral evaluations 90% 90%

Preventive Services (Deductible does not apply)

Prophylaxis (cleanings)

Topical fluoride applications 90% 90%

Diagnostic Radiographs (Deductible does not apply)

Full mouth and panoramic films

Bitewing films

Periapical films 90% 90%

Miscellaneous Preventive Services (Deductible does not apply)

Sealants

Space maintainers 90% 90%

Basic Restorative Dental Services

Amalgams

Resin based composite restorations 50% 50%

Non Surgical Extractions

Removal of retained coronal remnants

Removal of erupted tooth or exposed root 50% 50%

Non Surgical Periodontic Services

Periodontal scaling and root planing

Full mouth debridement

Periodontal maintenance procedures 50% 50%

Orthodontics (Deductible Waived)

Orthodontic Diagnostic Procedures and Treatment: Adults and Dependents Eligible 50% 50%

Lifetime Maximum Benefit per Participant $1,500.00 $1,500.00

Program Basics High Plan

Benefit Period Maximum: Calendar Year

Calendar Year

Services

Diagnostic Services (Deductible does not apply)

Periodic oral evaluations

Individual $150.00 Family

Individual

Problem focused oral evaluations

Comprehensive oral evaluations 100% 100%

Preventive Services (Deductible does not apply)

Prophylaxis (cleanings)

Topical fluoride applications 100% 100%

Diagnostic Radiographs (Deductible does not apply)

Full mouth and panoramic films

Bitewing films

Periapical films 100% 100%

Miscellaneous Preventive Services (Deductible does not apply)

Sealants

Space maintainers 100% 100%

Basic Restorative Dental Services

Amalgams

Resin based composite restorations 80% 80%

Non Surgical Extractions

Removal of retained coronal remnants

Removal of erupted tooth or exposed root 80% 80%

Non Surgical Periodontic Services

Periodontal scaling and root planing

Full mouth debridement

Periodontal maintenance procedures 50% 50%

Orthodontics (Deductible Waived)

Orthodontic Diagnostic Procedures and Treatment: Adults and Dependents Eligible 50% 50%

Lifetime Maximum Benefit per Participant

ABOUT VISION

Employee

Employee

Copays/Allowances

Eyeglass

Contact Lenses

1

$10.13 $14.62

Employee + Child(ren) $10.77 $15.55

Family $15.60 $22.51

Services/frequency

calendar

1 pair per calendar year

per calendar year

more,

Aid Discounts

or

Through Your Hearing Network,

accessories. To learn more, visit superiorvision.com or contact your benefits coordinator.

Hospital Care Cigna

ABOUT HOSPITAL CARE

This is an affordable supplemental plan that pays you should you be in patient hospital confined. This plan complements your health insurance by helping you pay for costs left unpaid by your health insurance.

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

HOSPITALIZATION BENEFITS1

Benefit Type

Hospital Admission

No elimination period. Limited to 1 day, 1 benefit(s) every 30 days.

Hospital Chronic Condition Admission

No elimination period. Limited to 1 day, 1 benefit(s) every 30 days.

Hospital Stay

No elimination period. Limited to 30 days, 1 benefit(s) every 30 days.

Hospital Intensive Care Unit Stay

No elimination period. Limited to 30 days, 1 benefit(s) every 30 days.

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

Limited to 30 days, 1 benefit per newborn child. This benefit is payable to the employee even if child coverage is not elected.

Benefit Specific Conditions, Exclusions & Limitations

Benefit Amount

Plan 1 Plan 2

$1,500 $2,500

$50 $100

$100 per day $200 per day

$200 per day $400 per day

$500 per day $500 per day

$500 $500

$100 per day $100 per day

• 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 the 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 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, atthe 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.

Benefit Type

Substance Abuse Facility Care

No elimination period. Limited to 30 days, 30 day lifetime maximum.

Mental Illness and Nervous Disorder Facility Care

$50 per day $100 per day

No elimination period. Limited to 30 days, 30 day lifetime maximum. $50 per day $100 per day

Benefit Specific Conditions, Exclusions & Limitations

• Must be confined in such facility due to a Covered Injury or Covered Illness at the direction and under the care of a physician or licensed health care professional.

• Care must begin within 30 days of a 1 day Hospital or ICU Stay.

• Benefits are not payable during same period as a Hospital, ICU stay or other Facility Stay.

• Facility stays or care provided within 90 days for the same or a related Covered Injury or Covered Illness is considered one stay or one period of care.

• Benefits for care beginning during the Benefit Waiting Period will be payable after such period.

• For Substance Abuse Facility Care, the exclusions that apply to this benefit are in the Common Exclusions Section, except: (5) 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; (6) 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.

Accident Insurance Mutual

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/socorroisd

This insurance offers financial protection by paying a cash benefit if you or an insured dependent are injured as a result of a covered accident. Unless otherwise stated, the benefit amount payable is the same for you and your insured dependent(s).

Two accident plans are available to you, Option 1 (High Plan) and Option 2 (Low Plan). You have the flexibility to enroll for the plan that best meets your (and your family’s) supplemental insurance needs.

ELIGIBILITY ALL ELIGIBLE EMPLOYEES

Eligibility

Accident

High Plan Low Plan

Employee $12.00 $5.00

Employee + Spouse $18.50 $7.50

Employee + Child(ren) $23.00 $10.00

Family $31.50 $13.50

You must be actively working a minimum of 30 hours per week to be eligible for coverage.

Dependent Eligibility Requirement To be eligible for coverage, your dependents must be able to perform normal activities, and not be confined (at home, in a hospital, or in any other care facility), and any child(ren) must be under age 26. In order for your spouse and/or children to be eligible for coverage, you must elect coverage for yourself.

Premium Payment

The premiums for this insurance are paid in full by you.

Accident Insurance Mutual of Omaha

BENEFITS High Plan

Rehab. Facility Confinement (Up to 30 days per accident)

$200 per day

BENEFITS

Low Plan

$50 per day

Surgical Up to $2,500 Up to $1,000 Diagnostic Up to $400 Up to $100

Follow Up Care1 Treatment / service required within 365 days of accident; Medical device is once per accident per insured person

Physician Follow Up Office Visit $125; Up to 6 per accident

$50; Up to 6 per accident

Therapy Services $75; Up to 6 per accident $25; Up to 6 per accident

Medical Device $300 $50 Prosthetic Device(s) $1,250; Up to 2 per accident

Additional Benefits1 Benefits are payable within 365 days of accident

Transportation (Up to 3 trips per accident)

Lodging (Up to 30 nights per accident)

$500; Up to 2 per accident

$450 per trip $150 per trip

$150 per night $100 per night Childcare (Up to 30 days per accident) $30 per day $20 per day

Catastrophic Benefits1,4 Benefits are payable within 365 days of accident; Once per accident per insured person

Principal Sum (PS)

You: $70,000

Spouse: $35,000 Child(ren): $10,000

You: $10,000

Spouse: $5,000 Child(ren): $5,000

Common Carrier Accidental Death 300% of PS 300% of PS

Transportation of Remains Up to $5,000 Up to $5,000 Dismemberment & Paralysis

Up to 100% of PS Reasonable Modifications

Up to 100% of PS

Up to 10% of PS

Up to 10% of PS Coma 25% of PS 50% of PS SERVICES

Hearing Discount Program The Hearing Discount program provides you and your family discounted hearing products, including hearing aids and batteries. Call 1 888 534 1747 or visit www.amplifonusa.com/ mutualofomaha to learn more.

Disability Insurance

York

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/socorroisd

A disability doesn’t always mean a serious handicap. It can be any illness or injury that prevents you from earning your salary. Consider what would happen if you couldn’t work or pay your bills. How might this affect your savings and your lifestyle?

Disability insurance from New York Life Group Benefit Solutions (NYL GBS), can help provide the financial protection and assurance you’ll need if you experience a covered illness or injury that keeps you out of work.

Who’s eligible for disability insurance, and what are the plan options?

All active, Full Time Employees of the Employer regularly working a minimum of 30 hours per week in the United States, who are citizens or permanent resident aliens of the United States. Coverage is available for Long term disability (LTD).

Why is disability insurance important?

Disability insurance can pay you benefits if you suffer a covered disability. Think of it as insurance for a portion of your paycheck. Payments may come directly to you or someone you designate and can help pay for things like:

• Groceries

• The Mortgage

• Utilities

• Medical Bills

Basic Life and AD&D Unum

ABOUT BASIC 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/socorroisd

Who is eligible for this coverage?

All actively employed employees working at least 30 hours each week for your employer in the U.S.

What is the coverage amount?

Your employer is providing you with one of the following options: Option 1: If you are participating in the District’s medical plan: $30,000 of term life insurance and $60,000 of Accidental Death and Dismemberment insurance. Or

Option 2: If you are not participating in the District’s medical plan: $50,000 of term life insurance and $60,000 of Accidental Death and Dismemberment insurance.

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

If you retire, reduce your hours or leave your employer, you can continue coverage at the group rate. Portability is not available for people who have a medical condition that could shorten their life expectancy but they may be able to convert their term life policy to an individual life insurance policy.

When is coverage effective?

Please see your plan administrator for your effective date.

What does my AD&D insurance pay for?

The full benefit amount is paid for loss of:

• Life

• Both hands or both feet or sight of both eyes

• One hand and one foot

• One hand and the sight of one eye

• Speech and hearing

Do my Life/AD&D insurance benefits decrease with age?

Coverage amounts will reduce according to the following schedule:

Age: Insurance amount reduces to:

70 50% of original amount

Coverage may not be increased after a reduction.

*Delayed effective date of coverage

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

Voluntary Life and AD&D

Unum

ABOUT VOLUNTARY 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/socorroisd

Who is eligible for this coverage?

BENEFITS

All actively employed employees working at least 30 hours each week for your employer in the U.S. and their eligible spouses and children to age 26.

What are the Life/AD&D coverage amounts?

• Employee: up to 7 times salary in increments of $10,000; not to exceed $500,000.

• Spouse: up to 100% of employee amount in increments of $5,000; not to exceed $250,000.

• Child: up to 100% of employee coverage amount not to exceed $10,000. The maximum death benefit for a child between the ages of live birth and six months is $1,000.

Note: In order to purchase life and AD&D coverage for your dependents, you must buy coverage for yourself.

Can I be denied coverage?

Current employees: If you and your eligible dependents are enrolled in the plan and wish to increase your life insurance coverage, you may apply on or before the enrollment deadline for any amount of additional coverage up to $200,000 for yourself and any amount of additional coverage up to $50,000 for your spouse. Any life insurance coverage over the guaranteed amount(s) will be subject to answers to health questions.

If you and your eligible dependents are not currently enrolled in the plan, you may apply for coverage on or before the enrollment deadline and will be required to answer health questions for any amount of coverage.

New employees: To apply for coverage, complete your enrollment within 31 days of your eligibility period. If you apply for coverage after 31 days, or if you choose coverage over the amount you are guaranteed, you will need to complete a medical questionnaire which you can get from your plan administrator. You may also be required to take certain medical tests at Unum’s expense.

When is coverage effective?

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

For your dependent spouse and children, insurance coverage will be delayed if that dependent is totally disabled on the date that insurance would otherwise be effective. Totally disabled means that as a result of an injury, sickness, or disorder, your dependent spouse and children: are confined in a hospital or similar institution; or are confined at home under the care of a physician for a sickness or injury. Exception: Infants are insured from live birth.

Do my life insurance benefits decrease with age?

Coverage amounts will reduce according to the following schedule:

Age: Insurance amount reduces to: 70 50% of original amount

Coverage may not be increased after a reduction.

Voluntary Life and AD&D Unum

Is the coverage portable (can I keep it if I leave my employer?

If you retire, reduce your hours or leave your employer, you can continue coverage for yourself your spouse and your dependent children at the group rate. Portability is not available for people who have a medical condition that could shorten their life expectancy but they may be able to convert their term life policy to an individual life insurance policy.

Are there any life insurance exclusions or limitations?

Life insurance benefits will not be paid for deaths caused by suicide within the first 24 months after the date your coverage becomes effective. If you increase or add coverage, these enhancements will not be paid for deaths caused by suicide within the first 24 months after you make these changes.

Will my premiums be waived if I’m disabled?

If you become disabled (as defined by your plan) and are no longer able to work, your life premium payments will be waived until your disability period ends.

What does my AD&D insurance pay for?

The full benefit amount is paid for loss of:

• life;

• both hands or both feet or sight of both eyes;

• one hand and one foot;

• one hand or one foot and the sight of one eye;

• speech and hearing.

Other losses may be covered as well. Please contact your plan administrator.

Voluntary Group Life with AD&D

Age band Employee rate per $10,000 Spouse rate per $5,000 <25 $0.65 $0.33 25 29 $0.65 $0.33 30 34 $0.80 $0.40 35 39 $0.88 $0.44 40 44 $0.95 $0.48 45 49 $1.33 $0.67 50 54 $2.00 $1.00 55 59 $3.43 $1.72 60 64 $5.15 $2.58 65 69 $9.73 $4.87 70 74 $15.65 $7.83 75+ $15.65 $7.83

Notes

• Child Life/AD&D monthly rate is $1.00 for $10,000. One Life/AD&D premium covers all children.

• Your rate is based on your insurance age, which is your age immediately prior to and including the anniversary/effective date.

• Spouse rate is based on the employee’s insurance age, which is their age immediately prior to and including the anniversary/effective date.

Critical Illness Insurance Mutual of Omaha

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/socorroisd

BENEFIT CATEGORY CONDITION

Heart/Circulatory/Motor Function

Heart Attack, Heart Transplant, Stroke, ALS (Lou Gehrig's), Advanced Alzheimer's, Advanced Parkinson's

% OF CI PRINCIPAL SUM

100%

Heart Valve Surgery, Coronary Artery Bypass, Aortic Surgery 25%

Major Organ Transplant/Placement on UNOS List, End Stage Renal Failure 100% Organ

Childhood/Developmental *benefits only available to children

Acute Respiratory Distress Syndrome (ARDS) 25%

Cerebral Palsy, Structural Congenital Defects, Genetic Disorders, Congenital Metabolic Disorders, Type 1 Diabetes

100%

Cancer Cancer (Invasive) 100%

Bone Marrow Transplant 50% Carcinoma in Situ, Benign Brain Tumor 25%

3

Principal Sum, up to

Principal Sum, up to $15,000

*benefit

ADDITIONAL BENEFITS

Policy Benefit Maximum

The maximum payout amount is 400% of the CI Principal Sum amount for each insured person. If the policy benefit maximum is reached for an insured person, the coverage will terminate. Dependents will remain insured if you continue to satisfy the eligibility requirements of the policy.

Health Screening Benefit Pays a flat, annual benefit of $50 for a health screening test.

Additional Occurrence Benefit Once benefits have been paid for a Critical Illness, no additional benefits are payable for that same Critical Illness for each insured person. Benefits are still payable for any other Critical Illness in the same benefit category, for each insured person.

Reoccurrence Benefit The reoccurrence benefit is equal to 100% of the Critical Illness principal sum.

Portability When insurance ends, you have the right to continue group Critical Illness insurance for yourself and your dependents.

Critical Illness Insurance

Mutual of Omaha

CONDITIONS & LIMITATIONS

Benefit Waiting Period

SERVICES

Hearing Discount Program

Advocacy

There is no benefit waiting period.

The Hearing Discount Program provides you and your family discounted hearing products, including hearing aids and batteries. Call 1 888 534 1747 or visit www.amplifonusa.com/ mutualofomaha to learn more.

Advocacy services give an employee who has been diagnosed with a medical condition access to skilled clinicians and nurses for personalized, problem solving assistance in a one on one setting. Call 1 866 372 5577 Monday Friday 7 A.M. to 7 P.M. CST or email careadvocates@gilsbar.com for assistance.

Critical Illness

Employee $10,000.00 $20,000.00 $30,000.00

> 29 $2.30 $4.60 $6.90 30 39 $3.80 $7.60 $11.40 40 49 $7.50 $15.00 $22.50 50 59 $13.50 $27.00 $40.50 60 69 $26.50 $53.00 $79.50 70 79 $51.00 $102.00 $153.00 80+ $72.10 $144.20 $216.30

Spouse $10,000.00 $20,000.00 $30,000.00

> 29 $2.30 $4.60 $6.90 30 39 $3.80 $7.60 $11.40 40 49 $7.50 $15.00 $22.50 50 59 $13.50 $27.00 $40.50 60 69 $26.50 $53.00 $79.50 70 79 $51.00 $102.00 $153.00 80+ $72.10 $144.20 $216.30 Child

Child dependent coverage is offered at no additional cost

Emergency Medical Transport

ABOUT MEDICAL TRANSPORT

Medical Transport covers emergency transportation to and from appropriate medical facilities by covering the out of pocket costs that are not covered by insurance. It can include emergency transportation via ground ambulance, air ambulance and helicopter, depending on the plan.

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

A MASA MTS Membership provides the ultimate peace of mind at an affordable rate for emergency ground and air transportation service within the United States and Canada, regardless of whether the provider is in or out of a given group healthcare benefits network. After the group health plan pays its portion, MASA MTS works with providers to deliver our members’ $0 in out of pocket costs for emergency transport.

If a member has a high deductible health plan that is compatible with a health savings account, benefits will become available under the MASA membership for expenses incurred for medical care (as defined under Internal Revenue Code (“IRC”) section 213 (d)) once a member satisfies the applicable statutory minimum deductible under IRC section 223(c) for high deductible health plan coverage that is compatible with a health savings account.

Emergent Air Transportation

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

Emergent Ground Transportation

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

Non Emergency Inter Facility Transportation

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

Repatriation/Recuperation

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

Emergency Air Transportation

Emergent Ground Transportation

Non Emergency Inter Facility Transportation

Repatriation/Recuperation

Escort Transportation

Visitor Transportation

Return Transportation

Mortal Remains Transportation

Minor Return

Organ Retrieval/Organ Recipient Transportation

Vehicle Return

Pet Return

Worldwide Coverage

Emergency Medical

Employee & Family $14.00

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

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 Socorro 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 Socorro 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.