2024-25 MRIC Region 18 Benefit Guide by Higginbotham Public Sector

Benefit Contact Information

Higginbotham Public Sector (833) 453-1680

www.txescbenefits.com

BCBSTX (972) 766-6900 www.bcbstx.com

MDLIVE (888) 365-1663

www.mdlive.com/fbs

SAVINGS ACCOUNT (HSA) FLEXIBLE SPENDING ACCOUNT (FSA) HOSPITAL INDEMNITY

Find HSA vendor contact details at www.txescbenefits.com

National Benefit Services (800) 274-0503

www.nbsbenefits.com

Cigna Group #3309408 (800) 244-6224

www.mycigna.com

CHUBB (888) 499-0425

Superior Vision Group #27244-01/17 (800) 507-3800 www.superiorvision.com

CHUBB (888) 499-0425

Aetna Group #802613 (855) 513-9865

www.aetna.com

Unum (800) 583-6908 www.unum.com

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

CHUBB (888) 499-0425

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

Cigna Group #3309408 (800) 244-6224

www.mycigna.com

MASA (800) 423-3226 www.masamts.com

ID Watchdog (800) 774-3772

www.idwatchdog.com

1 www.txescbenefits.com

CLICK LOGIN

Enter your Information

• Last Name

• Date of Birth

• Last Four (4) of Social Security Number

NOTE: THEbenefitsHUB uses this information to check behind the scenes to confirm your employment status.

Once confirmed, the Additional Security Verification page will list the contact options from your profile. Select either Text, Email, Call, or Ask Admin options to receive a code to complete the final verification step.

Enter the code that you receive and click Verify. You can now complete your benefits enrollment!

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 Office or you can call Higginbotham Public Sector at 866-914-5202 for assistance.

Where can I find forms?

For benefit summaries and claim forms, go to your benefit website: www.txescbenefits.com. 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 MRIC benefit website: www.txescbenefits.com. 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 log in 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

Section 125 Cafeteria Plan Guidelines

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

CHANGES IN STATUS (CIS):

Marital Status

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

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 Benefits Office to complete and sign the necessary paperwork in order to make a benefit election change. Benefit changes must be consistent with the qualifying event.

QUALIFYING EVENTS

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

A change in number of dependents includes the following: birth, adoption and placement for adoption. You can add existing dependents not previously enrolled whenever a dependent gains eligibility as a result of a valid change in status event.

Change in employment status of the employee, or a spouse or dependent of the employee, that affects the individual’s eligibility under an employer’s plan includes commencement or termination of employment.

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

If a judgment, decree, or order from a divorce, annulment or change in legal custody requires that you provide accident or health coverage for your dependent child (including a foster child who is your dependent), you may change your election to provide coverage for the dependent child. If the order requires that another individual (including your spouse and former spouse) covers the dependent child and provides coverage under that individual’s plan, you may change your election to revoke coverage only for that dependent child and only if the other individual actually provides the coverage.

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

Annual Benefit Enrollment

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 2024 benefits become effective on September 1, 2024, you must be actively-at-work on September 1, 2024 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 Higginbotham Public Sector, 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 Higginbotham Public Sector, 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 Higginbotham Public Sector 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

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 Benefits Office to request a continuation of coverage.

Description

Health Savings Account (HSA)

(IRC Sec. 223)

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

Employer Eligibility A qualified high deductible health plan

Contribution Source Employee and/or employer

Account Owner Individual

Underlying Insurance

Requirement High deductible health plan

Minimum Deductible

Maximum Contribution

Permissible Use Of Funds

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

Year-to-year rollover of account balance?

Does the account earn interest?

Portable?

$1,600 single (2024)

$3,200 family (2024)

$4,150 single (2024)

$8,300 family (2024) 55+ catch up +$1,000

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

Flexible

Spending Account (FSA)

(IRC Sec. 125)

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

All employers

Employee and/or employer

Employer

None

N/A

$3,200 (2024)

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

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

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

Yes

No. Access to some funds may be extended if your employer’s plan contains a 2 1/2 –month grace period or $550 rollover provision.

Yes, portable year-to-year and between jobs. No

The 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, visit www.bcbstx.com/member/policy-forms/2023 or by calling 1-800-521-2227. 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/sbc-glossary/ or call 1-855-756-4448 to request a copy.

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.

Yes. Network office visits with a copayment, prescription drugs and preventive care services and services with a copayment are covered before you meet your 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/preventive-care-benefits/ .

Are there services covered before you meet your deductible?

Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services.

The out-of-pocket 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 out-of-pocket limits until the overall family out-of-pocket limit has been met.

Network: $7,350

Individual/$14,700 Family Out-of-Network: Unlimite d

What is the out-of-pocket limit for this plan?

Even though you pay these expenses, they don't count toward the out-of-pocket limit.

Individual/Unlimited Family

Premiums, balance-billing charges, and health care this plan doesn't cover.

What is not included in the out-of-pocket 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 out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work).

Check with your provider before you get services.

Yes. See www.bcbstx.com/go/bcppo or call 1-800-810-2583 for a list of network provide rs.

Will you pay less if you use a network provider?

Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral.

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Limitations, Exceptions, & Other

Virtual visits are available. See your benefit booklet* for details.

What You Will Pay

(You will pay the most)

(You will pay the least) Out-of-Network

Services You May Need

Information Primary care visit to treat an injury o r illness

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.

$50/visit; deductible does not apply

visit $100/visit; deductible does not apply

None If you visit a health care provider’s office or clinic Preventive care/screening/ immunization No Charge; deductible does not apply

Inpatient: Certain services may require Preauthorization for out-of-network; failure to preauthorize may result in $250 reduction in benefits. Outpatient: Certain services may require Preauthorization for out-of-network; failure to preauthorize may result in 50% reduction in benefits not to exceed $500; see your benefit booklet* for details.

Retail$10/prescription; deductible does not apply plus 50% additional charge

RetailPreferredNo Charge Non-Preferred - $10/prescription MailNo Charge; deductible does not apply

Preferred generic drugs

Cost sharing for insulin included in the drug list will not exceed $25 per prescription for a 30-

Retail$20/prescription; deductible does not apply plus 50% additional charge

RetailPreferred$10/prescription Non-Preferred - $20/prescription Mail$30/prescription; deductible does not apply

If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.bcbstx.com/rxdrugs/drug-lists/drug-lists Non-preferred generic drugs

more information about limitations and exceptions, see the plan or

You May Need Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most)

$250/prescription; deductible does not apply plus 50% additional charge day supply, regardless of the amount or type of insulin needed to fill the prescription.

Certain services may require preauthorization for out-of-network; failure to preauthorize may result in 50% reduction in benefits not to exceed $500. For Outpatient Infusion Therapy, see your benefit booklet* for details.

Copayment waived if admitted.

RetailPreferred -

Retail$70/prescription; deductible does not apply plus 50% additional charge

$50/prescription Non-Preferred - $70/prescription Mail$150/prescription; deductible does not apply

Preferred brand drugs

Retail$120/prescription; deductible does not apply plus 50% additional charge

RetailPreferred$100/prescription Non-Preferred - $120/prescription Mail$300/prescription; deductible does not apply

Non-preferred brand drugs

$150/prescription; deductible does not apply plus 50% additional charge

$150/prescription; deductible does not apply

Preferred specialty drugs

$250/prescription; deductible does not apply

Non-preferred specialty drugs

If you have outpatient surgery

Preauthorization required. Preauthorization penalty: $250 out-of-network. See your benefit booklet* for details.

$500/visit plus 30% coinsurance $500/visit plus 30% coinsurance

room care

deductible does not apply

If you need immediate medical attention

care

fee (e.g., hospital room) 30%

If you have a hospital stay

fees30% coinsurance

more information about limitations and exceptions, see the plan or policy

(You will pay the most)

(You will pay the least)

Certain services must be preauthorized, failure to preauthorize at least two business days prior to service will result in 50% reduction in benefits (not to exceed $500), refer to benefit booklet* for details.

Preauthorization required out-of-network; failure to preauthorize at least two business days prior to admission will result in $250 reduction in benefits.

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

60 visits/year. Preauthorization may be required for out-of-network. Failure to preauthorize may result in 50% reduction in benefits not to exceed $500. See your benefit booklet* for details.

For Outpatient, limited to combined 35 visits per year, including Chiropractic.

25-day maximum per calendar year. Preauthorization may be required for out-ofnetwork. Failure to preauthorize may result in $250 reduction in benefits. See your benefit booklet* for details.

Inpatient: Preauthorization may be required for out-of-network; failure to preauthorize may result in a $250 reduction in benefits.

or 30%

for

No Charge; deductible does not apply

more information about limitations and exceptions, see the plan or policy

You Will Pay

Limitations, Exceptions, &

Out-of-Network Provider (You will pay the most)

You May Need Network Provider (You will pay the least)

Outpatient: Preauthorization may be required for out-of-network; failure to preauthorize may result in 50% reduction in benefits not to exceed $500. See your benefit booklet* for details. Children’s eye exam

information about limitations and exceptions, see the plan or policy

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.)

 Private-duty nursing

 Routine eye care (Child)

 Weight loss programs

 Dental care (Adult and Child)

 Long-term care

 Non-emergency care when traveling outside the U.S.

(Except for a pregnancy that, as certified by a physician, places the woman in danger of death or a serious risk of substantial impairment of a major bodily function unless an abortion is performed)

 Abortion

 Acupuncture

 Bariatric surgery  Cosmetic surgery

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

 Routine foot care (Only covered in connection with diabetes, circulatory disorders of the lower extremities, peripheral vascular disease, peripheral neuropathy, or chronic arterial or venous insufficiency)

 Infertility treatment (Invitro and artificial insem ination are not covered unless shown in your plan document)

 Routine eye care (Adult)

 Chiropractic care (OutpatientMax.35 visits/year combined with habilitation and rehabilitation services)

 Hearing aids (Limited to one hearing aid per ear every 36 months)

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 1-800-521-2227 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 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform . For non-federal governmental group health plans, contact Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or www.cciio.cms.gov . Church plans are not covered by the Federal COBRA continuation coverage rules. If the coverage is insured, individuals should contact their State insurance regulator regarding their possible rights to continuation coverage under State law. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. 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 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 information about your rights, this notice, or assistance, contact: For group health coverage subject to ERISA: Blue Cross and Blue Shield of Texas at 1-800-521-2227 or visit www.bcbstx.com , the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform , and the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov . For non-federal governmental group health plans and church plans that are group health plans, Blue Cross and Blue Shield of Texas at 1-800-521-2227 or www.bcbstx.com or contact the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 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 1-800-252-3439 or visit www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/tx.html . 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 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 1-800-521-2227.

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-521-2227.

Chinese ( 中文 ): 如果需要中文的帮助，请拨打这个号码 1-800-521-2227.

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-521-2227.

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

About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

The 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, visit www.bcbstx.com/member/policy-forms/2023 or by calling 1-877-299-2377. 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/sbc-glossary/ or call 1-855-756-4448 to request a copy.

Yes. Network office visits, prescription drugs and preventive care services are covered before you meet your 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/preventive-care-benefits/ . Are there other deductibles for specific services?

Are there services covered before you meet your deductible?

Yes. ER $500. There are no other specific deductibles. 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.

$7,350 Individual/$14,700 Family The out-of-pocket 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 out-of-pocket limits until the overall family out-of-pocket limit has been met.

What is the out-of-pocket limit for this plan?

Premiums, balance-billing charges, and health care this plan doesn't cover. Even though you pay these expenses, they don't count toward the out-of-pocket limit.

What is not included in the out-of-pocket limit?

Will you pay less if you use a network provider? Yes. See www.bcbstx.com/go/bahmo or call 1-877-299-2377 for a list of Participating Providers.

Do you need a referral to see a specialist? Yes. This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist.

in this chart are after your deductible has been met, if a deductible applies. What You Will Pay

costs

visits are available. See your benefit booklet* for details.

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.

Limited to a 30-day supply at retail (or a 90day supply at a network of select retail pharmacies). Up to a 90-day supply at mail order. Specialty drugs limited to a 30-day supply. Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available. Cost Sharing 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.

pay the least)

$50/visit; deductible does not apply

visit $100/visit; deductible does not apply

does not apply

Preferred$50/prescription Non-Preferred - $70/prescription Mail$150/prescription; deductible does not apply

Copayment applies to first prenatal visit (per pregnancy). Cost sharing does not apply to certain preventive services. Depending on the type of services, coinsurance may apply.

You Will Pay

Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).

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.)

 Long-term care

 Non-emergency care when traveling outside the U.S.

 Weight loss programs

 Children's glasses

 Cosmetic surgery

 Dental care (Adult)

 Abortion (Except for a pregnancy that, as certified by a physician, places the woman in danger of death or a serious risk of substantial impairment of a major bodily function unless an abortion is performed)

 Acupuncture  Bariatric surgery  Children's dental check-up

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

 Routine eye care (AdultOne visit every two years for members ages 18 and older)

 Infertility treatment (Invitro not covered)

 Private-duty nursing (Only when ordered or authorized by the Primary Care Physician)

 Chiropractic care (Preauthorization required)

 Hearing aids (Limited to one hearing aid per ear every 36 months)

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 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 information about your rights, this notice, or assistance, contact: For group health coverage subject to ERISA: Blue Cross and Blue Shield of Texas at 1-877-299-2377 or visit www.bcbstx.com , the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform , and the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov . For non-federal governmental group health plans and church plans that are group health plans, Blue Cross and Blue Shield of Texas at 1-877-299-2377 or www.bcbstx.com or contact the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 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 1-800-252-3439 or visit www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/tx.html .

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 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 1-877-299-2377. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-877-299-2377.

Chinese ( 中文 ) : 如果需要中文的帮助，请拨打这个号码 1-877-299-2377 . Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-877-299-2377. To see examples of how this plan might cover costs for a sample medical situation, see the next section.

Are there services covered before you meet your deductible? Yes. In-Network preventive care services are covered before you meet you r 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/preventive-care-benefits/ .

No. You don’t have to meet deductibles for specific services.

Are there other deductibles for specific services?

Network: $5,000

Individual/$10,000 Family

Out-of-Network: Unlimite d Individual/Unlimited Family

What is the out-of-pocket limit for this plan?

Even though you pay these expenses, they don't count toward the out-of-pocket limit.

Premiums, balance-billing charges, and health care this plan doesn't cover.

What is not included in the out-of-pocket limit?

Check with your provider before you get services.

Will you pay less if you use a network provider? Yes. See www.bcbstx.com/go/bcppo or call 1-800-810-2583 for a list of network provide rs.

Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral.

after your deductible has been met, if a deductible applies. What

this

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.

Limited to a 30-day supply at retail (or a 90-day supply at a network of select retail pharmacies). Up to a 90-day supply at mail order. Specialty drugs limited to a 30-day supply. Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available. Additional charge will not apply to any deductible or out-of-pocket amounts. Cost sharing 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.

after deductible plus 50% additional charge

plus 50% additional charge

No Charge after deductible plus 50% additional charge

plus 50% additional charge

Preauthorization required. Preauthorization penalty: $250 out-of-network. See your benefit booklet* for details.

Preauthorization required out-of-network; failure to preauthorize at least two business days prior to admission will result in $250 reduction in benefits.

60 visits/year. Preauthorization may be required for out-of-network. Failure to preauthorize may result in 50% reduction in

You Will Pay

Limitations, Exceptions, & Other

Information benefits not to exceed $500. See your benefit booklet* for details.

Provider (You will pay the least) Out-of-Network Provider (You will pay the most)

For Outpatient, limited to combined 35 visits per year, including Chiropractic.

25-day maximum per calendar year. Preauthorization may be required for out-ofnetwork. Failure to preauthorize may result in $250 reduction in benefits. See your benefit booklet* for details.

Inpatient: Preauthorization may be required for out-of-network; failure to preauthorize may result in a $250 reduction in benefits. Outpatient: Preauthorization may be required for out-of-network; failure to preauthorize may result in 50% reduction in benefits not to exceed $500. See your benefit booklet* for details.

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.)

 Private-duty nursing

 Routine eye care (Child)

 Weight loss programs

 Dental care (Adult and Child)

 Long-term care

 Non-emergency care when traveling outside the U.S.

(Except for a pregnancy that, as certified by a physician, places the woman in danger of death or a serious risk of substantial impairment of a major bodily function unless an abortion is performed)

 Abortion

 Acupuncture

 Bariatric surgery  Cosmetic surgery

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

 Infertility treatment (Invitro and artificial insem ination are not covered unless shown in your plan document)

 Routine eye care (Adult)

 Chiropractic care (OutpatientMax.35 visits/year combined with habilitation and rehabilitation services)

 Hearing aids (Limited to one hearing aid per ear every 36 months)

Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-800-521-2227.

Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-800-521-2227.

Chinese ( 中文 ): 如果需要中文的帮助，请拨打这个号码 1-800-521-2227.

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-800-521-2227.

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

The 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, visit www.bcbstx.com/member/policy-forms/2023 or by calling 1-877-299-2377. 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/sbc-glossary/ or call 1-855-756-4448 to request a copy.

Generally, you must pay all of the costs from providers up to the deductible amount before this

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/preventive-care-benefits/ .

Yes. In-Network preventive care services are covered before you meet you r deductible.

Important Questions

Are there services covered before you meet your deductible?

Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services.

$5,000 Individual/$10,000 Family The out-of-pocket 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 out-of-pocket limits until the overall family out-of-pocket limit has been met.

What is the out-of-pocket limit for this plan?

Premiums, balance-billing charges, and health care this plan doesn't cover. Even though you pay these expenses, they don't count toward the out-of-pocket limit.

What is not included in the out-of-pocket limit?

Will you pay less if you use a network provider? Yes. See www.bcbstx.com/go/bahmo or call 1-877-299-2377 for a list of Participating Providers.

Do you need a referral to see a specialist? Yes. This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist.

Information

in this chart are after your deductible has been met, if a deductible applies. What You Will Pay

visits are available. See your benefit booklet* for details.

(You will pay the most)

(You will pay the least)

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.

For Outpatient Infusion Therapy, see your benefit booklet* for details.

deductible does not apply

brand drugs No Charge after deductible Not Covered Preferred specialty drugs No Charge after deductible Not Covered

Charge after deductible Not Covered

If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.bcbstx.com/rxdrugs/drug-lists/drug-lists Non-preferred specialty drugs No

Charge after deductible Not Covered

Facility fee (e.g., ambulatory surgery center) No

If you have outpatient surgery

Charge after deductible Not Covered

Physician/surgeon fees No

Charge after deductible None

Charge after deductible No

Emergency room care No

None

Charge after deductible

Charge after deductible No

Emergency medical transportation No

If you need immediate medical attention

None

Charge after deductible Not Covered

Urgent care No

Charge after deductible Not Covered

Facility fee (e.g., hospital room) No

If you have a hospital stay

sharing does not apply to certain preventive services. Depending on the type of services, deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).

only. Does not include refractions. One

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.)

 Long-term care

 Non-emergency care when traveling outside the U.S.

 Weight loss programs

 Children's glasses

 Cosmetic surgery

 Dental care (Adult)

 Acupuncture  Bariatric surgery  Children's dental check-up

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

 Routine eye care (AdultOne visit every two years for members ages 18 and older)

 Infertility treatment (Invitro not covered)

 Private-duty nursing (Only when ordered or authorized by the Primary Care Physician)

 Chiropractic care (Preauthorization required)

 Hearing aids (Limited to one hearing aid per ear every 36 months)

Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al 1-877-299-2377. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-877-299-2377.

The 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, visit www.bcbstx.com/member/policy-forms/2024 or by calling 1-877-299-2377. 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/sbc-glossary/ or call 1-855-756-4448 to request a copy.

Important Questions Answers

What is the overall deductible?

Are there services covered before you meet your deductible?

Are there other deductibles for specific services?

What is the out-of-pocket limit for this plan?

What is not included in the out-of-pocket limit?

Will you pay less if you use a network provider?

$3,000 Individual/$9,000 Family

Yes. Network office visits, prescription drugs, preventive care services, and Urgent care services are covered before you meet your deductible.

Yes. ER $500. There are no other specific deductibles.

$7,350 Individual/$14,700 Family

Premiums, balance billing charges, and health care this plan doesn't cover.

Yes. See www.bcbstx.com/go/be or call 1-877-299-2377 for a list of Participating Providers.

Do you need a referral to see a specialist? Yes.

Why This Matters:

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 out-of-pocket limit.

This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist.

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 Page 1 of 7

What You Will Pay

Common Medical Event Services You May Need Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most)

Primary care visit to treat an injury or illness

$50 copayment/visit; deductible does not apply Not Covered

If you visit a health care provider’s office or clinic

Specialist visit

Limitations, Exceptions, & Other Important Information

Virtual visits are available. See your benefit booklet* for details.

$100 copayment/visit; deductible does not apply Not Covered Referral required.

Preventive care/screening/ immunization No Charge; deductible does not apply Not Covered

Diagnostic test (x-ray, blood work)

If you have a test

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.

Not

Imaging (CT/PET scans, MRIs)

Generic drugs (Preferred)

If you need drugs to treat your illness or condition

More information about prescription drug coverage is available at www.bcbstx.com/rxdrugs/drug-lists/drug-lists

Generic drugs (Nonpreferred)

Brand drugs (Preferred)

Retail - Preferred - No Charge

Non-Preferred - $10 copayment/prescription Mail - No Charge; deductible does not apply Not Covered

Retail - Preferred – $10 copayment/prescription Non-Preferred – $20 copayment/prescription Mail – $30 copayment/prescription; deductible does not apply Not Covered

Retail - Preferred – $50 copayment/prescription Non-Preferred - $70 copayment/prescription Mail - $150 copayment/prescription; deductible does not apply Not Covered

Limited to a 30-day supply at retail (or a 90-day supply at a network of select retail pharmacies). Up to a 90-day supply at mail order. Specialty drugs limited to a 30-day supply except for certain FDA-designated dosing regimens. Payment of the difference between the cost of a brand name drug and a generic may also be required if a generic drug is available.

Cost sharing 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 more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2024

Page 2 of 7

If you have outpatient surgery

If you need immediate medical attention

Brand drugs (Non-preferred)

What You Will Pay

Provider (You will pay the most)

Retail - Preferred - $100 copayment/prescription Non-Preferred - $120 copayment/prescription Mail - $300 copayment/prescription; deductible does not apply Not Covered

If you have a hospital stay

If you need mental health, behavioral health, or substance abuse services

Specialty drugs (Preferred)

Specialty drugs (Nonpreferred)

(e.g., ambulatory surgery center)

Emergency room care

$150 copayment/prescription; deductible does not apply Not Covered

$250 copayment/prescription; deductible does not apply Not Covered

Not Covered For Outpatient Infusion Therapy, see your benefit booklet* for details.

$500 copayment/visit plus 30% coinsurance $500 copayment/visit plus 30% coinsurance Per Occurrence Deductible waived if admitted.

Urgent care $75 copayment/visit; deductible does not apply Not Covered None Facility fee (e.g., hospital room) 30% coinsurance Not Covered

Physician/surgeon fees 30% coinsurance Not Covered None

Outpatient services

$50 copayment/office visit; deductible does not apply or 30% coinsurance for other outpatient services Not Covered

None

Inpatient services 30% coinsurance Not Covered None

*For more information about limitations and exceptions, see the plan or policy document at www.bcbstx.com/member/policy-forms/2024

Office visits

If you are pregnant

What You Will Pay

Primary Care: $50 copayment/initial visit Specialist: $100 copayment/initial visit; deductible does not apply

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

If your child needs

Primary

Eye screenings only. Does not include refractions. One visit per year for members ages 17 and younger. Children’s

Specialist:

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.)

 Acupuncture

 Bariatric surgery

 Children's dental check-up

 Children's glasses

 Cosmetic surgery

 Dental care (Adult)

 Long-term care

 Non-emergency care when traveling outside the U.S.

 Weight loss programs

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

 Chiropractic care (Preauthorization required)

 Hearing aids (Limited to one hearing aid per ear every 36 months)

 Infertility treatment (Invitro not covered)

 Private-duty nursing (Only when ordered or authorized by the Primary Care Physician)

 Routine eye care (Adult - One visit every two years for members ages 18 and older)

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 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 information about your rights, this notice, or assistance, contact: For group health coverage subject to ERISA: Blue Cross and Blue Shield of Texas at 1-877-299-2377 or visit www.bcbstx.com, the U.S. Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or www.dol.gov/ebsa/healthreform, and the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 or www.tdi.texas.gov. For non-federal governmental group health plans and church plans that are group health plans, Blue Cross and Blue Shield of Texas at 1-877-299-2377 or www.bcbstx.com or contact the Texas Department of Insurance, Consumer Protection at 1-800-252-3439 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 1-800-252-3439 or visit www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/tx.html

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 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 1-877-299-2377. Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-877-299-2377.

Chinese (中文): 如果需要中文的帮助，请拨打这个号码1-877-299-2377

Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-877-299-2377.

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

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery)

Managing Joe’s Type 2 Diabetes

(a year of routine in-network care of a wellcontrolled condition)

Mia’s Simple Fracture

(in-network emergency room visit and follow up care)

This EXAMPLE event includes services like:

Specialist office visits (prenatal care)

Childbirth/Delivery Professional Services

Childbirth/Delivery Facility Services

Diagnostic tests (ultrasounds and blood work)

Specialist visit (anesthesia)

Total Example Cost $12,700

In this example, Peg would pay: Cost

This EXAMPLE event includes services like:

Primary care physician office visits (including disease education)

Diagnostic tests (blood work)

Prescription drugs

Durable medical equipment (glucose meter)

Total Example Cost $5,600

This EXAMPLE event includes services like: Emergency room care (including medical supplies)

Diagnostic test (x-ray)

Durable medical equipment (crutches)

Rehabilitation

The plan would be responsible for the other costs of these EXAMPLE covered services.

bcbstx.com

ABOUT TELEHEALTH

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

For full plan details, please visit your benefit website: www.txescbenefits.com

Alongside your medical coverage is access to quality telehealth services through MDLIVE. Connect anytime day or night with a board-certified doctor via your mobile device or computer. While MDLIVE does not replace your primary care physician, it is a convenient and cost-effective option when you need care and:

• Have a non-emergency issue and are considering a convenience care clinic, urgent care clinic or emergency room for treatment

• Are on a business trip, vacation or away from home

• Are unable to see your primary care physician

When to Use MDLIVE:

At a cost that is the same or less than a visit to your physician, use telehealth services for minor conditions such as:

• Sore throat

• Headache

• Stomachache

• Cold

• Flu

• Allergies

• Fever

• Urinary tract infections

Do not use telemedicine for serious or life-threatening emergencies.

Registration is Easy

• Register with MDLIVE so you are ready to use this valuable service when and where you need it.

• Online – www.mdlive.com/fbs

• Phone – 888-365-1663

• Mobile – download the MDLIVE mobile app to your smartphone or mobile device

• Select –“MDLIVE as a benefit” and “FBS” as your Employer/Organization when registering your account.

Check with your employer to see if this benefit is available at no cost to you

Health Savings Account (HSA)

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.txescbenefits.com

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 taxfree 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 (TSHBP HD & Aetna HD)

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

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

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

• Not enrolled in Medicare or TRICARE Not receiving Veterans Administration benefits

You can use the money in your HSA to pay for qualified medical expenses now or in the future. You can also use HSA funds to pay health care expenses for your dependents, even if they are not covered under your HDHP.

Maximum Contributions

Your HSA contributions may not exceed the annual maximum amount established by the Internal Revenue Service. The annual contribution maximum for 2024 is based on the coverage option you elect:

• Individual – $4,150

• Family (filing jointly) – $8,300 You decide whether to use the money in your account to pay for qualified expenses or let it grow for future use. If you are 55 or older, you may make a yearly catch-up contribution of up to $1,000 to your HSA. If you turn 55 at any time during the plan year, you are eligible to make the catch-up contribution for the entire plan year.

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.

“ ” ’

returns); (b) your taxable compensation; (c) your spouse’s actual or deemed earned income.

“Register” in the top right corner, and follow the

Hospital Indemnity Aetna

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.txescbenefits.com

The Hospital Indemnity Plan provided through Aetna helps with the high cost of medical care by paying you a set amount when you have an inpatient hospital stay. Unlike traditional insurance, which pays a benefit to the hospital or doctor, this plan pays you directly based on the care or treatment you receive. These costs may include meals and transportation, childcare or time away from work due to a medical issue that requires hospitalization.

If you need to submit a claim you do so on the Aetna portal at myaetnasupplemental.com

Rehabilitation unit stay- Daily- Pays a benefit each day of your stay in a rehabilitation unit immediately after your hospital stay due to an illness or accidental injury. Maximum 30 days per plan year.

Important Note: All daily inpatient stay benefits begin on day two and count toward the plan year maximum.

Dental PPO 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.txescbenefits.com

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.

DPPO Plan

Two levels of benefits are available with the DPPO plan: innetwork and out-of-network. You may select the dental provider of your choice, but your level of coverage may vary based on the provider you see for services. You could pay more if you use an out-of-network provider.

How to Find a Dentist

Visit https://hcpdirectory.cigna.com/ or call 800-244-6224 to find an in-network dentist.

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.

Dental PPO Insurance

Class III Benefit Waiting Period applies for 12 months. Applies to New Hires Only

Class III: Major Restorative Inlays and Onlays, Prosthesis Over Implant, Crowns: prefabricated stainless steel / resin, Crowns: permanent cast and porcelain, Bridges and Dentures, Oral Surgery: major, Endodontics: minor and major, Periodontics: minor and major

Class III Benefit Waiting Period applies for 12 months. Applies to New Hires Only

Class IV: Orthodontia

for Dependent Children to age 19 Class IV

$50,

In-Network Reimbursement

Non-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.

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.

Vision Insurance

Superior Vision

ABOUT VISION

Vision insurance helps cover the cost of care for maintaining healthy vision. Similar to an annual checkup at your family doctor, routine eyecare is necessary to ensure that your eyes are healthy and to check for any signs of eye conditions or diseases . Most plans cover your routine eye exam with a copay and provide an allowance for Frames or Contact Lenses.

www.txescbenefits.com

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

Superior Vision Customer Service 1-800-507-3800

An overview of your vision benefits

• In-network benefits available through network eye care professionals.

• Find an in-network eye care professional at superiorvision.com. Call your eye doctor to verify network participation.

• Obtain a vision exam with either an MD or OD.

• Flexibility to use different eye care professionals for exam and for eyewear.

• Access your benefits through our mobile app – Display member ID card – view your member ID card in full screen or save to wallet .

Our network is built to support you.

• We manage one of the largest eye care professional networks in the country .

• The network includes 50 of the top 50 national retailers. Examples include:

• In-network online retail Providers :

Additional discounts

Members may also receive additional discounts, including 20% off lens upgrades and 30% off additional pairs of glasses.*

Access to LASIK discounts

A LASIK discount is available to all covered members. Our Discounted LASIK services are administered by QualSight. Visit lasik.sv.qualsight.com to learn more.

Access to hearing aid discounts

Members save up to 40% on brand name hearing aids and have access to a nationwide network of licensed hearing professionals through Your Hearing Network. *Discounts are provided by participating

Disability Insurance

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.txescbenefits.com

Disability insurance provides partial income protection if you are unable to work due to a covered accident or illness. We offer Short Term Disability (STD) and Long Term Disability (LTD) insurance for you to purchase through UNUM.

Long Term Disability

Elimination Period 90 days

Percentage of Earnings You Receive 60% of your monthly salary, limited to $5000 per month Your payment may be reduced by deductible sources of income and disability earnings. Some disabilities may not be covered or may have limited coverage under this plan.

Pre-existing Condition Exclusion 12/12/24

Who pays for this coverage Your Employer pays the cost of your coverage.

Maximum Period of Benefit Payout

than Age

Age 65

Age 67

Age 69 or older

or before

and after

Total Benefit Cap

The total benefit payable to you on a monthly basis (including all benefits provided under this plan) will not exceed 100% of your monthly earnings. However, if you are participating in Unum’s Rehabilitation and Return to Work Assistance program, the total benefit payable to you on a monthly basis (including all benefits provided under this plan) will not exceed 110% of your monthly earnings.

Disability Insurance

Short Term Disability Insurance (STD)

STD coverage pays a percentage of your weekly salary for up to 11 weeks if you are temporarily disabled and unable to work due to an illness, non-work related injury or pregnancy. STD benefits are not payable if the disability is due to a job-related injury or illness.

Short Term Disability

Sickness Elimination Period 14 Days

Percentage of Earnings You Receive 60% of your weekly salary, limited to $2,500 per week.

Maximum Benefit Period 11 weeks

Pre-existing Condition Exclusion 3/12*

Pre-existing Condition Exclusion

Benefits will not be paid for disabilities caused by, contributed to by, or resulting from a pre-existing condition. You have a pre-existing condition if:

• you received medical treatment, consultation, care or services including diagnostic measures, or took prescribed drugs or medicines in the 3 months just prior to your effective date of coverage; and

• the disability begins in the first 12 months after your effective date of coverage.

Definition of Disability

You are disabled when Unum determines that:

• you are limited from performing the material and substantial duties of your regular occupation due to your sickness or injury; and

• you have a 20% or more loss in weekly earnings due to the same sickness or injury.

You must be under the regular care of a physician in order to be considered disabled.

If you do not enroll during the initial enrollment period, you may apply only during an annual enrollment.

Educator Group Term Life Insurance Benefit Summary

Life insurance is an important part of your employee benefits package. Chubb Term Life and Accidental Death and Dismemberment (AD&D) insurance provides the protection your family needs if something were to happen to you. Your family can receive cash benefits paid directly to them that they can use to help cover expenses like mortgage payments, credit card debt, childcare, college tuition, and other household expenses.

Voluntary Term Life and AD&D Insurance is made available for purchase by you and your family. Employees must be actively at work for at least 20 hours per week.

For You

Life and AD&D: Up to 7 times your annual earnings to a maximum of $500,000 in $10,000 increments

For Your Spouse

Life: $5,000 increments up to a maximum of $500,000 not to exceed 100% of employee amount

AD&D: 50% of employee amount to a maximum of $250,000

For Your Dependent Children

Life: Live birth to 6 months: $1,000

6 months to age 26: Up to $10,000 in $5,000 increments

AD&D: Live birth to 6 months: $1,000

6 months to age 26: 10% of employee’s amount to a maximum of $50,000

Reduction Schedule

65% at age 70

Additional Plan Benefits

Guaranteed Issue

Employee: $300,000 Spouse: $50,000 Child: $10,000

Newly eligible employees and dependents: You and your eligible dependents may elect coverage up to the guaranteed issue amounts without answering health questions. Elections over the guaranteed issue amounts will require medical underwriting.

Current employees: At subsequent annual enrollments if you or your eligible dependents are currently enrolled in the plan, you may increase your coverage up to the guaranteed issue amounts without answering health questions. All amounts over the guaranteed issue will require medical underwriting.

*Please note that if you or your dependents did not elect coverage when first eligible, then you are considered a late entrant. Late entrants will be medically underwritten and will have to answer health questions for any amount of coverage elected.

The AD&D plan provides additional protection for you and your dependents in the event of an accidental bodily injury resulting in death or dismemberment. In addition to standard dismemberment coverage, the following benefit provisions are included:

• Air Bag Benefit – The lesser of 5% of AD&D benefit or $5,000

• Child Care Expense Benefit – 5% of employee’s AD&D benefit up to $12,000 per year for 4 years

• Child Education Expense Benefit – 6% of employee’s AD&D benefit up to $6,000 for 6 years; maximum benefit $24,000

• Common Carrier Benefit – Included

• Elder Care Expense Benefit – The lesser of 1% of AD&D benefit or $500

• Exposure and Disappearance Benefit– Included

• Repatriation Expense Benefit – The lesser of $1,000 or the actual expense incurred

• Seatbelt Benefit – The lesser of 10% of AD&D benefit or $25,000

• Spouse Education Benefit – The lesser of 1% of AD&D benefit, $1,000, or the actual tuition expenses incurred

• Workplace Felonious Assault Benefit – 5% of AD&D benefit up to $10,000

Portability

You can elect portable coverage, at group rates, if you terminate employment, reduce hours or retire from the employer.

Conversion When your group coverage ends, you may convert your coverage to an individual life policy without providing evidence of insurability.

Monthly Costs for Voluntary Term Life/AD&D Insurance

You have the option to purchase Supplemental Term life Insurance. Listed below are the monthly rates.

Child Life monthly rate is $1.00 for $5,000 and $2.00 for $10,000. One premium covers all children.

Employee AD&D rate per $1,000 is $0.028 Family AD&D rate per $1,000 is $0.028

Term Life Exclusions*

No benefits will be paid for losses that are caused by, contributed to, or result from: 1) suicide, while sane or insane, occurring within 24 months after a Covered Person’s initial effective date of coverage; and 2) suicide, while sane or insane, occurring within two years after the date any increases in or additional coverage applied for becomes effective for a Covered Person.

Accidental Death And Dismemberment Benefit Exclusions*

The Policy does not cover: 1) an infection not occurring as a direct result or consequence of Accidental Bodily Injury; 2) loss caused or contributed to by attempted suicide, while sane or insane; 3) loss caused or contributed to by intentionally self-inflicted harm, while sane or insane; 4) loss caused or contributed to by war or act of war; 5) loss caused or contributed to by active participation in a riot, insurrection; or terrorist activity; 6) loss caused or contributed to by committing or attempting to commit a felony; 7) loss caused or materially contributed to by voluntary intake or use by any means of any drug, unless: a. prescribed or administered by a Physician and taken in accordance with the Physician’s instructions; or b. an over-the-counter drug, taken in accordance with the instructions; 8) loss caused or contributed to being intoxicated as defined by the jurisdiction where the Accident occurred; and 9) loss caused or materially contributed to by participation in an illegal occupation or activity.

Questions?

Contact the FBS Benefits CareLine via the QR code or (833) 453-1680

*Please refer to your Certificate of Insurance at https://www.mybenefitshub.com/region2 for a complete listing of available benefits, limitations and exclusions. Underwritten by ACE Property & Casualty Company, a Chubb company.

Optional Term Life Insurance

Benefit Summary

Life insurance is an important part of your employee benefits package. Chubb Optional Term Life insurance provides the protection your family needs if something were to happen to you. Your family can receive cash benefits paid directly to them that they can use to help cover expenses like mortgage payments, credit card debt, childcare, college tuition and other household expenses.

Optional Term Life Insurance is made available for purchase by you and your family. Employees must be actively at work for at least 20 hours per week.

Life Insurance

For You

Up to 7 times your annual earnings to a maximum of $75,000 in $15,000 increments

For Your Spouse/Dependent Children

Option 1: $5,000/$1,000

Option 2: $10,000/$2,000

Dependent life coverage can be purchased without purchasing employee life coverage.

Reduction Schedule

None

Guaranteed Issue

Employee: $75,000 Spouse: $10,000 Child: $2,000

Newly eligible employees and dependents: You and your eligible dependents may elect coverage up to the guaranteed issue amounts without answering health questions.

Additional Plan Benefits

Definitions and Provisions

Portability You can elect portable coverage, at group rates, if you terminate employment, reduce hours or retire from the employer.

Conversion When your group coverage ends, you may convert your coverage to an individual life policy without providing evidence of insurability.

Monthly Costs for Optional Term Life

You may purchase Optional Term life Insurance. Listed below are the monthly rates. Dependent life coverage can be purchased without purchasing employee life coverage.

Term Life Exclusions*

Questions?

Contact the FBS Benefits CareLine via the QR code or (833) 453-1680

Family Protection Plan

Group Term Life Insurance to age 121 with Quality of Life

Make a smart choice to help protect your loved ones and your future.

Life doesn’t come with a lesson plan

Help protect your family with the Family Protection Plan Group Level Term Life Insurance to age 121. You can get coverage for your spouse even if you don’t elect coverage on yourself. And you can cover your ﬁnancially dependent children and grandchildren (14 days to 26 years old). The coverage lasts until age 121 for all insured,* so no matter what the future brings, your family is protected.

Why buy life insurance when you’re young?

Buying life insurance when you’re younger allows you to take advantage of lower premium rates while you’re generally healthy, which allows you to purchase more insurance coverage for the future. This is especially important if you have dependents who rely on your income, or you have debt that would need to be paid off.

Portable

Coverage continues with no loss of beneﬁts or increase in cost if you terminate employment after the ﬁrst premium is paid. We simply bill you directly.

Why is portability important?

Life moves fast so having a portable life insurance allows you to keep your coverage if you leave your school district. Keeping the coverage helps you ensure your family is protected even into your retirement years.

44% of American households would encounter significant financial difficulties within six months if they lost the primary family wage earner. 28% would reach this point in one month or less.

Family Protection Plan

Group Term

Terminal illness acceleration of beneﬁts

Coverage pays 30% (25% in CT and MI) of the coverage amount in a lump sum upon the occurrence of a terminal condition that will result in a limited life span of less than 12 months (24 months in IL).

Protection you can count on

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

Convenient

Easy payment through payroll deduction.

Quality of Life beneﬁt

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

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

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

How does Quality of Life help?

Many individuals who can’t take care of themselves require special accommodations to perform ADLs and would need to make modifications to continue to live at home with physical limitation. The proceeds from the Quality of Life benefit can be used for any purpose, including costs for infacility care, home healthcare professionals, home modifications, and more.

2024 Enrollment Plan Year

Guaranteed Issue is offered to all eligible applicants regardless of health status. No Doctor exams or physicals.

Employee: $100,000 | Spouse: $30,000 | Child: $10,000

Enroll to provide peace of mind for your family

To do an initial enrollment or if you have questions please call our customer service at 866-914-5202. Monday - Friday | 8:00 am-6:00 pm CST

About the coverage

The Family Protection Plan offers a lump-sum cash benefit if you die before age 121. The initial death benefit is guaranteed to be level for at least the first ten policy years. Afterward, the company intends to provide a nonguaranteed death benefit enhancement which will maintain the initial death benefit level until age 121. The company has the right to discontinue this enhancement. The death benefit enhancement cannot be discontinued on a particular insured due to a change in age, health, or employment status.

Cancer Insurance CHUBB

ABOUT CANCER

Cancer insurance offers you and your family supplemental insurance protection in the event you or a covered family member is diagnosed with cancer. It pays a benefit directly to you to help with expenses associated with cancer treatment.

For full plan details, please visit your benefit website: www.txescbenefits.com

Cash benefits when you need them most — Cancer Insurance from Chubb

A cancer diagnosis and treatment can be an emotionally and physically difficult time. Chubb is there to help support you by providing cash benefits paid directly to you. Benefits are paid if you are diagnosed with cancer, but also help cover many other cancer-related services such as doctor’s visits, treatments, specialty care, and recovery. However, there are no restrictions on how to use these cash benefits—so you can use them as you see fit.

Choose the right level of coverage during the enrollment period to better protect your family.

Cash benefits for every step of the way

$100

First

Diagnosis of cancer

Hospital confinement

Hospital confinement ICU

$5,000 employee or spouse

$7,500 child(ren)

Waiting period: 0 days

Benefit reduction: none

$100 per day – days 1 through 30

Additional days: $100

Maximum days per confinement: 31

$600 per day – days 1 through 30

Additional days: $600

Maximum days per confinement: 31

Maximum per covered person per calendar year per 12-month period: $10,000

$10,000 employee or spouse

$15,000 child(ren)

Waiting period: 0 days

Benefit reduction: none

$200 per day – days 1 through 30

Additional days: $200

Maximum days per confinement: 31

$600 per day – days 1 through 30

Additional days: $600

Maximum days per confinement: 31 Radiation therapy, chemotherapy, immunotherapy

Alternative care

Medical imaging

Skin cancer initial diagnosis

$75 per visit

Maximum visits per calendar year: 4

$500 per imaging study

Maximum studies per calendar year: 2

$100 per diagnosis

Lifetime maximum: 1

Maximum per covered person per calendar year per 12-month period: $20,000

$75 per visit

Maximum visits per calendar year: 4

$500 per imaging study

Maximum studies per calendar year: 2

$100 per diagnosis

Lifetime maximum: 1

Cancer Insurance CHUBB

Additional plan benefits

Renewability

Portability

Conditionally Renewable Coverage is automatically renewed as long as the insured is an eligible employee, premiums are paid as due, and the policy is in force.

Portability Employees can keep their coverage if they change jobs or retire while the policy is in-force. Continuity of coverage Included

Pre-existing conditions limitation

A condition for which a covered person received medical advice or treatment within the 12 months preceding the certificate effective date.

Waiver of premium Included

Definitions and provisions

Cancer means carcinoma in situ, leukemia, or a malignant tumor characterized by uncontrolled cell growth and invasion or spread of malignant cells to distant tissue. Cancer is also defined as cancer which meets the diagnosis criteria of malignancy established by the American Board of Pathology after a study of the histocytologic architecture or pattern of the suspect tumor, tissue, or specimen.

Definition of cancer

Carcinoma in situ means a malignant tumor which is typically classified as Stage 0 cancer, where the tumor cells still lie within the tissue of the site of origin without having invaded neighboring tissue.

The following are not considered cancer: Pre-malignant conditions or conditions with malignant potential; non-invasive basal cell carcinoma of the skin; non-invasive squamous cell carcinoma of the skin; or melanoma diagnosed as Clark’s Level I or II or Breslow less than .75mm.

Plan descriptions Refer to the Certificate of Coverage for details specific to each plan.

No benefits will be paid for a date of diagnosis or treatment of cancer prior to the coverage effective date, except where continuity of coverage applies.

No benefits will be paid for services rendered by a member of the immediate family of a covered person.

We will not pay benefits for other conditions or diseases, except losses due directly from cancer or skin cancer.

We will not pay benefits for cancer or skin cancer if the diagnosis or treatment of cancer is received outside of the territorial limits of the United States and its possessions. Benefits will be payable if the covered person returns to the territorial limits of the United States and its possessions, and a physician confirms the diagnosis or receives treatment.

Rates

Critical Illness Insurance Lincoln Financial Group

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.txescbenefits.com

The

Lincoln Critical Illness Insurance Plan:

• Provides cash benefits if you or a covered family member is diagnosed with a critical illness or event

• Benefits are paid in addition to what is covered under your health insurance

• Features group rates for employees

• Includes access to a personal health advocate who can assist you in managing healthcare services for you and your entire family

• There are no waiting periods or overall plan maximums

for you

• You

Coverage for your spouse

You can secure Critical Illness Insurance for your spouse when you choose coverage for yourself.

• You can choose from the coverage amount(s) for your spouse without completing evidence of insurability.

Coverage for your dependent children

You can elect Critical Illness Insurance for your dependent children when you choose coverage for yourself.

Critical Illness Insurance | Children

Guaranteed coverage amounts

$10,000, $20,000 or $30,000 (up to 100% of the employee coverage amount)

• You can choose from the coverage amounts above for your dependent children

Critical Illness Insurance

Lincoln Financial Group

Note: See the policy for details and specific requirements for each of these benefits.

Accident Insurance Cigna

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.txescbenefits.com

SUMMARY OF BENEFITS

Accidental Injury coverage provides a fixed cash benefit according to the schedule below when a Covered Person suffers certain Injuries or undergoes a broad range of medical treatments or care resulting from an injury.

Who Can Elect Coverage:

Eligibility for You, Your Spouse and Your Children will be considered by Your employer.

• You: All active, Full-time and Part-time Employees of the Employer who are regularly working in the United States a minimum of 15 hours per week and regularly residing in the United States and who are United States citizens or permanent resident aliens or non-United States citizens legally working and living in the United States (Inpats) and their Spouse, and Dependent Children who are United States citizens or permanent resident aliens or Spouse, or Dependent Child Inpats and who are legally residing in the United States who are not members of an employer paid plan. You will be eligible for coverage on the first of the month after 30 days from date of hire or Active Service.

• Your Spouse*: Up to age 100, as long as you apply for and are approved for coverage yourself.

• Your Child(ren): Birth to age 26; 26+ if disabled, as long as you apply for and are approved for coverage yourself.

Available Coverage: This Accidental Injury plan provides 24 hour coverage. The benefit amounts shown in this summary will be paid regardless of the actual expenses incurred and are paid on a per day basis unless otherwise specified. Benefits are only payable when all policy terms and conditions are met. Please read all the information in this summary to understand terms, conditions, state variations, exclusions and limitations applicable to these benefits. See your Certificate of Insurance for more information.

Benefit Percentage Amount (unless otherwise indicated)

• Employee: 100% of benefits shown

• Spouse: 100% of benefits shown

• Children: 100% of benefits shown

Accident Insurance Cigna

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

Concussion

Coma (lasting 7 days with no response)

Additional Accidental Injury benefits included - See certificate for details, including limitations & exclusions. Virtual Care accepted for Initial Physician Office Visit and Follow-Up Care. Accidental Death and Dismemberment Benefit Plan

Examples of benefits include (but are not limited to) payment for death from Automobile accident; total and permanent loss of speech or hearing in both ears. Actual benefit amount paid depends on the type of Covered Loss. The Spouse and Child benefit is 100% and 100% respective of the benefit shown.

Wellness Treatment, Health Screening Test and Preventive Care Benefit:* Benefit paid for all covered persons is 100% of the benefit shown. Also includes COVID-19 Immunization, Tests, and Screenings. Virtual Care accepted.

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

Important Definitions and Policy Provisions:

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

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

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

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

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

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

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

When your coverage ends: Coverage ends on the earliest of the date you and your dependents are no longer eligible, the date the group policy is no longer in force, or the date for the last period for which required premiums are paid. For your dependent, coverage also ends when your coverage ends, when their premiums are not paid or when they are no longer eligible. (Under certain circumstances, your coverage may be continued. Be sure to read the provisions in your Certificate.)

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

Costs are

Benefit Conditions and Limitations: This document provides only the highlights. All claims for a covered loss must meet specific Benefit Conditions and Limitations and are otherwise subject to all other terms set forth in the group policy.

Stay prepared with MASA® AccessSM

Comprehensive coverage and care for emergency transport.

Our Emergent Plus membership plan includes:

Emergency Ground Ambulance Coverage1

Your out-of-pocket expenses for your emergency ground transportation to a medical facility are covered with MASA.

Emergency Air Ambulance Coverage1

Your out-of-pocket expenses for your emergency air transportation to a medical facility are covered with MASA.

Hospital to Hospital Ambulance Coverage1

When specialized care is required but not available at the initial emergency facility, your out-of-pocket expenses for the ground or air ambulance transfer to the nearest appropriate medical facility are covered with MASA.

Repatriation Near Home Coverage1

Should you need continued care and your care provider has approved moving you to a hospital nearer to your home, MASA coordinates and covers the expense for ambulance transportation to the approved medical facility.

Did you know?

51.3 million emergency responses occur each year

MASA protects families against uncovered costs for emergency transportation and provides connections with care services.

Source: NEMSIS, National EMS Data Report, 2023

About MASA

MASA is coverage and care you can count on to protect you from the unexpected. With us, there is no “out-of-network” ambulance. Just send us the bill when it arrives and we’ll work to ensure charges are covered. Plus, we’ll be there for you beyond your initial ride, with expert coordination services on call to manage complex transport needs during or after your emergency — such as transferring you and your loved ones home safely.

Protect yourself, your family, and your family’s financial future with MASA.

Stay prepared with MASA®

protects families against out-of-pocket costs for emergency transportation and provides connections with care. Gain peace of mind and shield your finances knowing there’s a MASA plan best suited for your needs.

Identity Theft ID Watchdog

ABOUT IDENTITY THEFT PROTECTION

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

For full plan details, please visit your benefit website: www.txescbenefits.com

Identity theft is one of the fastest-growing crimes in the country. Millions of people have their identity stolen each year. Protect yourself and restore your identity with coverage from ID Watchdog. Benefits include:

• Identity consultation and advice

• Licensed private investigators

• Identity and credit monitoring

• Social media monitoring

• Identity restoration

• Threat and credit alerts

• 24/7 emergency ID protection access

• Mobile app

2024 - 2025 Plan Year

Enrollment Guide General Disclaimer: This summary of benefits for employees is meant only as a brief description of some of the programs for which employees may be eligible. This summary does not include specific plan details. You must refer to the specific plan documentation for specific plan details such as coverage expenses, limitations, exclusions, and other plan terms, which can be found at the MRIC 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 MRIC 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.