2016 benefit guide esc region 20 - cigna version 1

ESC REGION 20 BENEFITS COOPERATIVE

EFFECTIVE:

09/01/2016 - 8/31/2017

BENEFIT GUIDE

www.esc20bc.net

1

Benefit Contact Information 3 How to Enroll 4-5 Annual Benefit Enrollment 6-11 1. Benefit Updates 6 2. Section 125 Cafeteria Plan Guidelines 7 3. Annual Enrollment 8 4. Eligibility Requirements 9 5. Helpful Definitions 10 6. Health Savings Account (HSA) vs. Flexible

Spending Account (FSA) 11

MDLIVE Telehealth 12-13 APL MEDlink® Medical Supplement 14-17 APL Accident 18-21 Cigna Dental 22-27 Superior Vision 28-29 Cigna Short Term Disability 30-33 Cigna Long Term Disability 34-37 APL Cancer 38-41 Texas Life Individual Life 42-45 Cigna Life and AD&D 46-51 HSA Bank Health Savings Account (HSA) 52-55 NBS Flexible Spending Account (FSA) 56-59 ID Watchdog Identity Theft 60-61

Table of Contents

HOW TO ENROLL

PG. 4

BENEFIT UPDATE—WHAT’S NEW

PG. 6

YOUR BENEFITS PACKAGE

PG. 12

FLIP TO...

2

Benefit Contact Information

ESC REGION 20 BC BENEFITS VISION LIFE AND AD&D

Financial Benefit Services (800) 583-6908 www.esc20bc.net

Group #28888 Superior Vision (800) 507-3800 www.superiorvision.com

Life Group #FLX 965377 AD&D Group #OK 966961 Cigna (800) 583-6908 www.cigna.com

TELEHEALTH SHORT TERM DISABILITY HEALTH SAVINGS ACCOUNT MDLIVE (888) 365-1663 www.consultmdlive.com

Group #VDT-961363 Cigna (800) 583-6908 www.cigna.com

HSA Bank (800) 357-6246 www.hsabank.com

MEDICAL SUPPLEMENT—MEDLINK ® LONG TERM DISABILITY FLEXIBLE SPENDING ACCOUNT Group #15304 American Public Life (800) 256-8606 www.ampublic.com

Group #VDT-961364 Cigna (800) 583-6908 www.cigna.com

National Benefit Services (800) 274-0503 www.nbsbenefits.com

ACCIDENT CANCER IDENTITY THEFT

Group #13309 American Public Life (800) 256-8606 www.ampublic.com

Group #13309 American Public Life (800) 256-8606 www.ampublic.com

ID Watchdog (800) 237-1521 www.idwatchdog.com

DENTAL INDIVIDUAL LIFE MEDICAL Group #3336975 Cigna (800) 244-6224 www.mycigna.com

Texas Life (866) 283-9233 www.texaslife.com

Aetna (800) 222-9205 www.trsactivecareaetna.com

Benefit Contact Information

3

!

How to Enroll

On Your Computer Access the ESC Region 20 BC

benefits website from your

computer, tablet or smartphone!

Our online benefit enrollment

platform provides a simple and

easy to navigate process. Enroll

at your own pace, whether at

home or at work.

www.esc20bc.net delivers

important benefit information

with 24/7 access, as well as

detailed plan information, rates

and product videos.

On Your Device

Enrollment has just become

easier!

Avoid typing long URLs and scan

directly to your benefits websites,

videos, and benefit guides.

Try it yourself! Scan the following

code in the picture.

SCAN:

4

GO www.esc20bc.net 1

2

Login Steps

3

Go to:

Click Login

Enter Username & Password

OR SCAN

All login credentials have been RESET to the default

described below:

Username:

The first six (6) characters of your last name, followed

by the first letter of your first name, followed by the

last four (4) digits of your Social Security Number.

If you have six (6) or less characters in your last name,

use your full last name, followed by the first letter of

your first name, followed by the last four (4) digits of

your Social Security Number.

Default Password:

Last Name* (lowercase, excluding punctuation)

followed by the last four (4) digits of your Social

Security Number.

Sample Password

l incola1234

l incoln1234

If you have trouble

logging in, click on the

“Login Help Video”

for assistance.

Click on “Enrollment Instructions” for more information about how to enroll.

Sample Username

LOGIN

Open Enrollment Tip

For your User ID: If you have less than six (6) characters in your last

name, use your full last name, followed by the first letter of your first

name, followed by the last four (4) digits of your Social Security Number.

5

Login and complete your benefit enrollment from 07/18/2016 - 08/22/2016

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

to speak to a representative Monday—Friday between 8am – 5pm CST

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

Update dependent social security numbers and student status for college aged children

Benefit Updates - What’s New:

Don’t Forget!

Benefit elections will become effective 9/1/2016. Elections requiring evidence of insurability, such as Life Insurance, may have a later effective date, if approved. After annual enrollment, benefit changes can only be made if you experience a qualifying event. Changes must be made within 30 days of event.

If you currently participate in a Healthcare or

Dependent Care Flexible Spending Account, you MUST re-elect a new contribution amount in the summer enrollment to continue to participate.

Your current monthly HSA contribution will rollover to

next plan year unless you make a change to your election during the summer enrollment window.

IMPORTANT: Reminder, the LOW PPO Dental Plan pays

differently when you go to an out-of-network dentist. If

you choose to go out-of-network, CIGNA will only reimburse what your dentist charges up to the negotiated in-network level fee. What this could mean to you: high out-of-pocket costs since you will be balance-billed the difference between what your dentist charges and what CIGNA pays. If you use an out-of-network dentist, you may want to consider changing to the High PPO Dental plan (gives you flexibility to use an out-of-network dentist). If you want to stay on the Low PPO dental plan, go to an in-network dentist. The Low PPO dental plan provides lower premiums and cost-savings due to utilizing in-network dentists since CIGNA negotiates lower fees with in-network providers, making your benefits go further.

Effective 9/1/2016, MDLIVE Telehealth premium will

Increase.

Annual Benefit Enrollment

SUMMARY PAGES

6

CHANGES IN STATUS (CIS):

QUALIFYING EVENTS

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

Change in Number of Tax Dependents

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 Status of Employment Affecting

Coverage Eligibility

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.

Gain/Loss of Dependents' Eligibility Status

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

Judgment/Decree/Order

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.

Eligibility for Government Programs

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

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

Changes in benefit elections can occur only if you experience a qualifying event. You must present proof of a qualifying event to your Benefit Office within 30 days of your qualifying event and meet with your Benefit/HR Office to complete and sign the necessary paperwork in order to make a benefit election change. Benefit changes must be consistent with the qualifying event.

Section 125 Cafeteria Plan Guidelines

SUMMARY PAGES

7

Annual Enrollment

During your annual enrollment period, you have the opportunity

to review, change or continue benefit elections each year.

Changes are not permitted during the plan year (outside of

annual enrollment) unless a Section 125 qualifying event occurs.

Changes, additions or drops may be made only during the

annual enrollment period without a qualifying event.

Employees must review their personal information and verify

that dependents they wish to provide coverage for are

included in the dependent profile. Additionally, you must

notify your employer of any discrepancy in personal and/or

benefit information.

Employees must confirm on each benefit screen (medical,

dental, vision, etc.) that each dependent to be covered is

selected in order to be included in the coverage for that

particular benefit.

New Hire Enrollment

All new hire enrollment elections must be completed in the

online enrollment system within the first 31 days of benefit

eligibility employment. Failure to complete elections during this

timeframe will result in the forfeiture of coverage.

Q&A

Who do I contact with Questions?

For supplemental benefit questions, you can contact your

Benefits/HR department or you can call Financial Benefit Services

at 866-914-5202 for assistance.

Where can I find forms?

For benefit summaries and claim forms, go to the ESC Region

20 BC benefit website: www.esc20bc.net. Click on your school

district, then click on 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 ESC Region

20 BC benefit website: www.esc20bc.net. Click on your school

district, then click on the benefit plan you need information

on (i.e., Dental) and you can find provider search links under

the Quick Links section.

When will I receive ID cards?

If the insurance carrier provides ID cards, you can expect to

receive those 3-4 weeks after your effective date. For most

dental and vision plans, you can login to the carrier website

and print a temporary ID card or simply give your provider the

insurance company’s phone number and they can call and

verify your coverage if you do not have an ID card at that

time. If you do not receive your ID card, you can call the

carrier’s customer service number to request another card.

If the insurance carrier provides ID cards, but there are no

changes to the plan, you typically will not receive a new ID

card each year.

SUMMARY PAGES

8

PLAN CARRIER MAXIMUM AGE

Accident American Public Life Through 25

Cancer American Public Life Through 25

Dental Cigna Through 25

Dependent Flex

National Benefit Services

12 or younger or qualified individual unable to care for themselves & claimed

as a dependent on your taxes

Healthcare FSA National Benefit Services Through 25 or IRS Tax Dependent

Health Savings Account HSA Bank IRS Tax Dependent

Identity Theft ID Watchdog Through 25

Medical Supplement Plan American Public Life Through 25

Permanent Life Texas Life Through 21

Telehealth MDLIVE Through 25

Vision Superior Vision Through 25

Voluntary Life Cigna Through 25

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 2016 benefits become effective on September 1, 2016, you

must be actively-at-work on September 1, 2016 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 ESC Region 20 BC or as

both employees and dependents.

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

SUMMARY PAGES

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Actively at Work You are performing your regular occupation for the employer

on a full-time basis, either at one of the employer’s usual

places of business or at some location to which the employer’s

business requires you to travel. If you will not be actively at

work beginning 9/1/2016 please notify your benefits

administrator.

Annual Enrollment The period during which existing employees are given the

opportunity to enroll in or change their current elections.

Annual Deductible The amount you pay each plan year before the plan begins to

pay covered expenses.

Calendar Year January 1st through December 31st

Co-insurance After any applicable deductible, your share of the cost of a

covered health care service, calculated as a percentage (for

example, 20%) of the allowed amount for the service.

Guaranteed Coverage The amount of coverage you can elect without answering any

medical questions or taking a health exam. Guaranteed

coverage is only available during initial eligibility period.

Actively-at-work and/or pre-existing condition exclusion

provisions do apply, as applicable by carrier.

In-Network Doctors, hospitals, optometrists, dentists and other providers

who have contracted with the plan as a network provider.

Out of Pocket Maximum The most an eligible or insured person can pay in co-insurance

for covered expenses.

Plan Year September 1st through August 31st

Pre-Existing Conditions Applies to any illness, injury or condition for which the

participant has been under the care of a health care provider,

taken prescriptions drugs or is under a health care provider’s

orders to take drugs, or received medical care or services

(including diagnostic and/or consultation services).

Helpful Definitions SUMMARY PAGES

10

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

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

Description

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.

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

Employer Eligibility A qualified high deductible health plan. All employers

Contribution Source Employee and/or employer Employee and/or employer

Account Owner Individual Employer

Underlying Insurance Requirement

High deductible health plan None

Minimum Deductible $1,300 single (2016) $2,600 family (2016) N/A

Maximum Contribution $3,350 single (2016) $6,750 family (2016)

Varies per employer

Permissible Use Of Funds

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

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

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

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

Not permitted

Year-to-year rollover of account balance?

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

No. Access to some funds can may be extended if your employer’s plan contains a 2 1/2 –month grace period or $500 rollover provision.

Does the account earn interest?

Yes No

Portable? Yes, portable year-to-year and between jobs.

No

FOR HSA INFORMATION

FLIP TO… PG. 52

FOR FSA INFORMATION

FLIP TO… PG. 56

HSA vs. FSA SUMMARY PAGES

11

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

About this Benefit

Telehealth

DID YOU KNOW?

75%

of all doctor, urgent care, and ER visits could be handled safely and effectively via

telehealth.

MDLIVE YOUR BENEFITS PACKAGE

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan details on covered expenses, limitations and exclusions are included in the summary plan description located on the

ESC Region 20 BC Benefits Website: www.esc20bc.net 12

Telehealth

When should I use MDLIVE? If you’re considering the ER or urgent care for a non-

emergency medical issue

Your primary care physician is not available

At home, traveling, or at work

24/7/365, even holidays!

What can be treated? Allergies

Asthma

Bronchitis

Cold and Flu

Ear Infections

Joint Aches and Pain

Respiratory Infection

Sinus Problems

And More!

Pediatric Care related to: Cold & Flu

Constipation

Ear Infection

Fever

Nausea & Vomiting

Pink Eye

And More!

Who are our doctors? MDLIVE has the nation’s largest network of telehealth doctors. On average, our doctors have 15 years of experience practicing medicine and are licensed in the state where patients are located. Their specialties include primary care, pediatrics, emergency medicine and family medicine. Our doctors are committed to providing convenient, quality care and are always ready to take your call.

Are children eligible? Yes. MDLIVE has local pediatricians on-call 24/7/365. Please note, a parent or guardian must be present during any interactions involving minors. We ask parents to establish a child record under their account. Parents must be present on each call for children 18 or younger.

How much does it cost? $8 for Employee Only. $16 for Family.

Download the App Doctor visits are easier and more convenient with the MDLIVE App. Be prepared. Download today. www.mdlive.com/getapp

Access to a doctor anywhere: at home, at work, or on the go

Choose doctors from one of the nation's largest telehealth networks

Available 24/7 by video or phone

Private, secure and confidential visits

Connect instantly with MDLIVE Assist

Disclaimers: MDLIVE does not replace the primary care physician. MDLIVE operates subject to state regulation and may not be available in certain states. MDLIVE does not guarantee that a prescription will be written. MDLIVE does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. MDLIVE physicians reserve the right to deny care for potential misuse of services. For complete terms of use visit www.mdlive.com/pages/terms.html 010113

Call us at (888) 365-1663 or visit us at www.consultmdlive.com

Scan with your smartphone to get the app.

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Medical supplement is designed to help supplement your Employer's major medical plan. This plan provides supplemental coverage to help offset out-of-pocket costs that you may experience due to deductibles, co-payments and coinsurance of your medical plan.

About this Benefit

MEDlink®

DID YOU KNOW?

33%

of total healthcare costs are paid out-of-pocket.

AMERICAN PUBLIC LIFE YOUR BENEFITS PACKAGE



SUMMARY OF BENEFITS

Base Policy Option 1 Option 2

In-Hospital Benefit - Maximum In-Hospital Benefit $1,500 per confinement $2,500 per confinement

Outpatient Benefit up to $200 per treatment up to $200 per treatment

Physician Outpatient Treatment Benefit $25 per treatment; $125 max per family per Calendar Year

$25 per treatment; $125 max per family per Calendar Year

Option 1 Total Monthly Premiums by Plan*

Issue Ages 17-54 Issue Ages 55-59 Issue Ages 60-69

Employee Only $21.50 $32.00 $49.00

Employee + Spouse $39.50 $59.00 $88.00

Employee + Child(ren) $36.50 $47.00 $64.00

Family Coverage $54.50 $74.00 $103.00

Option 2 Total Monthly Premiums by Plan*

Issue Ages 17-54 Issue Ages 55-59 Issue Ages 60-69

Employee Only $28.00 $44.50 $68.50

Employee + Spouse $51.50 $81.50 $122.50

Employee + Child(ren) $45.50 $62.00 $86.00

Family Coverage $69.00 $99.00 $140.00

Plans available to employees age 70 and over if You work for an employer employing 20 or more employees on a typical workday in the preceding

Calendar Year.

*Total premium includes the Plan selected and any applicable rider premium. Premiums are subject to increase with notice.

Limitations Eligibility This policy will be issued to those persons who meet American Public Life Insurance Company’s insurability requirements. Evidence of insurability acceptable to us may be required. If our underwriting rules are met, you are on active service, you are covered under your Employer’s Medical Plan and premium has been paid, your insurance will take effect on the requested Effective Date or the Effective Date assigned by us upon approval of your written application, whichever is later.

Covered Charges mean those charges that are incurred by a Covered Person because of an Accident or Sickness; are for necessary treatment, services and medical supplies and recommended by a Physician; are not more than any dollar limit set forth in the Schedule; are incurred while insured under the Policy, subject to any Extension of Benefits; and are not excluded under the Policy.

A Hospital is not any institution used as a place for rehabilitation; a place for rest, or for the aged; a nursing or convalescent home; a long term nursing unit or geriatrics ward; or an extended care facility for the care of convalescent, rehabilitative or ambulatory patients.

In-Hospital Benefit Benefits payable are limited to any out-of-pocket deductible amount; any out-of-pocket co-payment or coinsurance amounts the Covered Person actually incurs after the Employer’s Medical Plan has paid; any out-of-pocket amount the Covered Person actually incurs for surgery performed by a Physician after the Employer’s Medical Plan has paid; and the Maximum In-Hospital Benefit shown in the Policy Schedule. The Covered Person must be an Inpatient and covered by your Employer’s Medical Plan when the Covered Charges are incurred.

Outpatient Benefits Treatment is for the same or related conditions, unless separated by a period of 90 consecutive days. After 90 consecutive days, a new Outpatient Benefit will be payable. The Covered Person must be covered by your Employer’s Medical Plan when the Covered Charges are incurred.

Physician Outpatient Treatment Benefit Benefit maximum of $125 per family per Calendar Year. The Covered Person must be covered by your Employer’s Medical Plan when the Covered Charges are incurred. The Covered Person must not be an Inpatient when the Covered Charges are incurred.

APSB-22330(TX)-0116 MGM/FBS ESC Region 20 Benefits Co-op

MEDlink® Limited Benefit Medical Expense Supplemental Insurance

THE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A

SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM BY PURCHASING THE POLICY AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE EMPLOYEE LOSES

THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS’ COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKERS’

COMPENSATION LAW AS IT PERTAINS TO NON-SUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED.

ESC Region 20 Benefits Co-op

15

Premiums The premium rates may be changed by Us. If the rates are changed, We will give You at least 31 days advance written notice. If a change in benefits increases Our liability, premium rates may be changed on the date Our liability is increased. This plan may be continued in accordance with the Consolidated Omnibus Reconciliation Act of 1986.

Exclusions We will pay no benefits for any expenses incurred during any period the Covered Person does not have coverage under your Employer’s Medical Plan, except as provided in the Absence of your Employer’s Medical Plan provision or which result from: (a) suicide or any attempt, thereof, while sane or insane; (b) any intentionally self-inflicted injury or Sickness; (c) rest care or rehabilitative care and treatment; (d) outpatient routine newborn care; (e) voluntary abortion except, with respect to You or Your covered

Dependent spouse: (1) where Your or Your Dependent spouse’s life would be endangered if the fetus were carried to term; or (2) where medical complications have arisen from abortion; (f) pregnancy of a Dependent child; (g) participation in a riot, civil commotion, civil disobedience, or unlawful assembly. This does not include a loss which occurs while acting in a lawful manner within the scope of authority; (h) commission of a felony; (i) participation in a contest of speed in power driven vehicles, parachuting, or hang gliding; (j) air travel, except: (1) as a fare-paying passenger on a commercial airline on a regularly scheduled route; or (2) as a passenger for transportation only and not as a pilot or crew member; (k) intoxication; (Whether or not a person is intoxicated is determined

and defined by the laws and jurisdiction of the geographical area in which the loss occurred.)

(l) alcoholism or drug use, unless such drugs were taken on the advice of a Physician and taken as prescribed; (m) sex changes; (n) experimental treatment, drugs, or surgery; (o) an act of war, whether declared or undeclared, or while

performing police duty as a member of any military or naval organization; (This exclusion includes Accident sustained or Sickness contracted while in the service of any military, naval, or air force of any country engaged in war. We will refund the pro rata unearned premium for any such period the Covered Person is not covered.)

(p) Accident or Sickness arising out of and in the course of any occupation for compensation, wage or profit; (This does not apply to those sole proprietors or partners not covered by Workers’ Compensation.)

(q) mental illness or functional or organic nervous disorders, regardless of the cause; (r) dental or vision services, including treatment, surgery, extractions,

or x-rays, unless: (1) resulting from an Accident occurring while the Covered Person’s coverage is in force and if performed within 12 months of the date of such Accident; or (2) due to congenital disease or anomaly of a covered newborn child. (s) routine examinations, such as health exams, periodic check-ups, or routine physicals, except when part of Inpatient routine newborn care; (t) any expense for which benefits are not payable under the Covered Person’s Employer’s Medical Plan; or (u) air or ground ambulance.

Termination of Coverage Your Insurance coverage will end on the earliest of these dates: the date You no longer qualify as an Insured; the end of the last period for which premium has been paid; the date the Policy is discontinued; the date You retire; if You work for an employer employing less than 20 employees on a typical work day in the preceding Calendar Year, the date You attain age 70; the date You cease to be on Active Service; the date Your coverage under Another Medical Plan ends; or the date You cease employment with the employer through whom You originally became insured under the Policy. Insurance coverage on a Dependent will end on the earliest of these dates: the date Your coverage terminates; the end of the last period for which premium has been paid; the date the Dependent no longer meets the definition of Dependent; the date the Dependent’s coverage under Another Medical Plan ends; or the date the Policy is modified so as to exclude Dependent coverage. We may end the coverage of any Covered Person who submits a fraudulent claim. We may end the coverage of a Subscribing Unit if fewer persons are insured than the Policyholder’s application requires.


Underwritten by American Public Life Insurance Company. This is a brief description of the coverage. For complete benefits, limitations, exclusions and other provisions, please refer to the policy and riders. This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. | This policy is considered an employee welfare benefit plan established and/or maintained by an association or employer intended to be covered by ERISA, and will be administered and enforced under ERISA. Group policies issued to governmental entities and municipalities may be exempt from ERISA guidelines. | Policy Form MEDlink® Series | Texas | Limited Benefit Medical Expense Supplemental Insurance | (10/14) | ESC Region 20 Benefits Co-op

APSB-22330(TX)-0116 MGM/FBS ESC Region 20 Benefits Co-op

2305 Lakeland Drive | Flowood, MS 39232

ampublic.com | 800.256.8606

16


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Accident insurance is designed to supplement your medical insurance coverage by covering indirect costs that can arise with a serious, or a not-so-serious, injury. Accident coverage is low cost protection available to you and your family without evidence of insurability.

About this Benefit

Accident

of disabling injuries suffered by American workers are not work related.

DID YOU KNOW?

36% of American workers report they always or usually live paycheck to paycheck.

2/3




Accident insurance is designed to supplement your medical insurance coverage by covering indirect costs that can arise with a serious, or a not-so-serious,injury. Accident coverage is low cost protectionavailable to you and your family without evidence of insurability.

About this Benefit

AccidentYOUR

BENEFITS

A-3 Supplemental Limited Benefit Accident Expense Insurance

THE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A

SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM BY PURCHASING THE POLICY AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE EMPLOYEE LOSES

THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS’ COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKERS’

COMPENSATION LAW AS IT PERTAINS TO NON-SUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED.

Summary of Benefits*

Benefit Description Level 1 - 1 Unit

Accidental Death - per unit $5,000

Medical Expense Accidental Injury Benefit - per unit actual charges up to $500

Daily Hospital Confinement Benefit $75 per day

Air and Ground Ambulance Benefit actual charges up to $1,250

Accidental Dismemberment BenefitSingle finger or toe Multiple fingers or toes Single hand, arm, foot or leg Multiple hands, arms, feet or legs

$500 $500

$2,500 $5,000

Accidental Loss of Sight Benefit - per unit Loss of Sight in one eye

Loss of Sight in both eyes $2,500 $5,000

Individual Individual & Spouse

1 Parent Family

2 Parent Family

Level 1 - 1 Unit $10.80 $19.40 $21.20 $29.80

*The premium and amount of benefits vary dependent upon the Plan selected at time of application. Premiums are subject to

increase with notice.

of disabling injuries

suffered by American

workers are not work

related.

DID YOU KNOW?

36% of American workers

report they always or

usually live paycheck

to paycheck.

2/3


ESC Region 20 benefits Co-op Benefits Website: www.mybenefitshub.com/region20

AMERICAN PUBLIC LIFE

APSB-22329(TX)-MGM/FBS ESC Region 20 Benefits Co-op

ESC Region 20 Benefits Co-op

19

A-3 Supplemental Limited Benefit Accident Expense Insurance A-3 Supplemental Limited Benefit Accident Expense Insurance

Underwritten by American Life Insurance Company. This is a brief description of the coverage. For actual benefits, limitations, exclusions and other provisions, please refer to the policy and riders. This coverage does not replace Workers’ Compensation Insurance. | This product is inappropriate for people who are eligible for Medicaid coverage. | Policy Form A3 Series | Texas | Supplemental Limited Benefit Accident Expense Insurance Policy | (10/14) | ESC Region 20 Benefits Co-op

Limitations and Exclusions Eligibility This policy will be issued to only those persons who meet American Public Life Insurance Company’s insurability requirements. Persons not meeting APL’s insurability requirements will be excluded from coverage by an endorsement attached to the policy.

Base Policy No benefits are payable for a pre-existing condition. Pre-existing condition means an Injury that pertains solely to an Accidental Bodily Injury which resulted from an accident sustained before the Effective Date of coverage. Pre-Existing Conditions specifically named or described as permanently excluded in any part of this contract are never covered. A Hospital is not an institution which is primarily a place for alcoholics or drug addicts; the aged; a nursing, rest or convalescent nursing home; a mental institution or sanitarium; a facility contracted for or operated by the United States Government for treatment of members or ex-members of the armed forces (unless You are legally required to pay for services rendered in the absence of insurance); or, a long-term nursing unit or geriatrics ward.

Medical Expense Accidental Injury Benefit Expenses must commence within 60 days of the covered accident. The maximum benefit amount payable for any one accident for the Insured Person shall not exceed the Medical Expense Benefit.

Air and Ground Ambulance Benefit Emergency transportation must occur within 21 calendar days of the accident causing such Injury.

Daily Hospital Confinement Benefit The maximum benefit period for this benefit is 30 days per covered accident.

Accidental Death Accidental Death must result within 90 days of the covered accident causing the injury.

Accidental Dismemberment Benefit The total amount payable for all Losses resulting from the same accident will not exceed the Maximum Dismemberment Benefit of $5,000 cumulative per unit, per Accident. Loss must be within 90 days of the accident causing such Injury.

Exclusions Benefits otherwise provided by this Policy will not be payable for services or expenses or any such Loss resulting from or in connection with:

(1) sickness, illness or bodily infirmity; (2) suicide, attempted suicide or intentional self-inflicted Injury, whether sane or insane; (3) dental care or treatment unless due to accidental Injury to natural teeth; (4) war or any act of war (whether declared or undeclared) or participating in a riot or felony; (5) alcoholism or drug addiction; (6) travel or flight in or descent from any aircraft or device which can fly above the earth’s surface in any capacity other than as a fare paying passenger on a regularly scheduled airline; (7) Injury originating prior to the effective date of the Policy; (8) Injury occurring while intoxicated (Intoxication means that which is determined and defined by the laws and jurisdiction of the geographical area in which the loss or cause of loss is incurred.); (9) Voluntary inhalation of gas or fumes or taking of poison or asphyxiation; (10) Voluntary ingestion or injection of any drug, narcotic or sedative, unless administered on the advice and taken in such doses as prescribed by a Physician; (11) Injury sustained or sickness which first manifests itself while on full-time duty in the armed forces; (Upon notice, We will refund the proportion of unearned premium while in such forces.) (12) Injury incurred while engaging in an illegal occupation; (13) Injury incurred while attempting to commit a felony or an assault; (14) Injury to a covered person while practicing for or being a part of organized or competitive rodeo, sky diving, hang gliding, parachuting or scuba diving;

(15) driving in any race or speed test or while testing an automobile or any vehicle on any racetrack or speedway;

(16) hernia, carpal tunnel syndrome or any complication therefrom;

If You are entitled to benefits under this Policy as a result of sprained or lame back, or any intervertebral disk conditions, such benefits shall be payable for a maximum period of time, not exceeding in the aggregate three (3) months for any Injury.

Guaranteed Renewable You have the right to renew this Policy until the first premium due date on or after Your 69th birthday, if you pay the correct premium when due or within the Grace Period. When an Insured’s coverage terminates at age 70, coverage for other Insured Persons, if any, shall continue under this Policy. We have the right to change premium rates by class.

APSB-22329(TX)-MGM/FBS ESC Region 20 Benefits Co-op APSB-22329(TX)-MGM/FBS ESC Region 20 Benefits Co-op



20

A-3 Supplemental Limited Benefit Accident Expense Insurance A-3 Supplemental Limited Benefit Accident Expense Insurance

Underwritten by American Life Insurance Company. This is a brief description of the coverage. For actual benefits, limitations, exclusions and other provisions, please refer to the policy and riders. This coverage does not replace Workers’ Compensation Insurance. | This product is inappropriate for people who are eligible for Medicaid coverage. | Policy Form A3 Series | Texas | Supplemental Limited Benefit Accident Expense Insurance Policy | (10/14) | ESC Region 20 Benefits Co-op

Limitations and Exclusions Eligibility This policy will be issued to only those persons who meet American Public Life Insurance Company’s insurability requirements. Persons not meeting APL’s insurability requirements will be excluded from coverage by an endorsement attached to the policy.

Base Policy No benefits are payable for a pre-existing condition. Pre-existing condition means an Injury that pertains solely to an Accidental Bodily Injury which resulted from an accident sustained before the Effective Date of coverage. Pre-Existing Conditions specifically named or described as permanently excluded in any part of this contract are never covered. A Hospital is not an institution which is primarily a place for alcoholics or drug addicts; the aged; a nursing, rest or convalescent nursing home; a mental institution or sanitarium; a facility contracted for or operated by the United States Government for treatment of members or ex-members of the armed forces (unless You are legally required to pay for services rendered in the absence of insurance); or, a long-term nursing unit or geriatrics ward.

Medical Expense Accidental Injury Benefit Expenses must commence within 60 days of the covered accident. The maximum benefit amount payable for any one accident for the Insured Person shall not exceed the Medical Expense Benefit.

Air and Ground Ambulance Benefit Emergency transportation must occur within 21 calendar days of the accident causing such Injury.

Daily Hospital Confinement Benefit The maximum benefit period for this benefit is 30 days per covered accident.

Accidental Death Accidental Death must result within 90 days of the covered accident causing the injury.

Accidental Dismemberment Benefit The total amount payable for all Losses resulting from the same accident will not exceed the Maximum Dismemberment Benefit of $5,000 cumulative per unit, per Accident. Loss must be within 90 days of the accident causing such Injury.

Exclusions Benefits otherwise provided by this Policy will not be payable for services or expenses or any such Loss resulting from or in connection with:

(1) sickness, illness or bodily infirmity; (2) suicide, attempted suicide or intentional self-inflicted Injury, whether sane or insane; (3) dental care or treatment unless due to accidental Injury to natural teeth; (4) war or any act of war (whether declared or undeclared) or participating in a riot or felony; (5) alcoholism or drug addiction; (6) travel or flight in or descent from any aircraft or device which can fly above the earth’s surface in any capacity other than as a fare paying passenger on a regularly scheduled airline; (7) Injury originating prior to the effective date of the Policy; (8) Injury occurring while intoxicated (Intoxication means that which is determined and defined by the laws and jurisdiction of the geographical area in which the loss or cause of loss is incurred.); (9) Voluntary inhalation of gas or fumes or taking of poison or asphyxiation; (10) Voluntary ingestion or injection of any drug, narcotic or sedative, unless administered on the advice and taken in such doses as prescribed by a Physician; (11) Injury sustained or sickness which first manifests itself while on full-time duty in the armed forces; (Upon notice, We will refund the proportion of unearned premium while in such forces.) (12) Injury incurred while engaging in an illegal occupation; (13) Injury incurred while attempting to commit a felony or an assault; (14) Injury to a covered person while practicing for or being a part of organized or competitive rodeo, sky diving, hang gliding, parachuting or scuba diving;

(15) driving in any race or speed test or while testing an automobile or any vehicle on any racetrack or speedway;

(16) hernia, carpal tunnel syndrome or any complication therefrom;

If You are entitled to benefits under this Policy as a result of sprained or lame back, or any intervertebral disk conditions, such benefits shall be payable for a maximum period of time, not exceeding in the aggregate three (3) months for any Injury.

Guaranteed Renewable You have the right to renew this Policy until the first premium due date on or after Your 69th birthday, if you pay the correct premium when due or within the Grace Period. When an Insured’s coverage terminates at age 70, coverage for other Insured Persons, if any, shall continue under this Policy. We have the right to change premium rates by class.

APSB-22329(TX)-MGM/FBS ESC Region 20 Benefits Co-op APSB-22329(TX)-MGM/FBS ESC Region 20 Benefits Co-op



21

Dental insurance is a coverage that helps defray the costs of dental care. It insures against the expense of routine care, treatment and dental disease.

About this Benefit

Dental

Good dental care may improve your overall health.

Also Women with gum disease may be at greater risk of giving birth to a preterm or low birth weight baby.

DID YOU KNOW?

CIGNA YOUR BENEFITS PACKAGE



Dental PPO - High Option

Benefits Cigna Dental PPO - High Option

In-Network Out-of-Network

Network Total Cigna DPPO

Plan Year Maximum (Class I, II, and III expenses)

$1,500 $1,500

Annual Deductible Individual Family

$50 per person $150 per family


Reimbursement Levels** Based on Reduced Contracted Fees

90th percentile of Reasonable and

Customary Allowances

Plan Pays You Pay Plan Pays You Pay

Class I - Preventive & Diagnostic Care Oral Exams Routine Cleanings Bitewing X-rays Full Mouth X-rays Panoramic X-ray Emergency Care to Relieve Pain Fluoride Application Sealants Histopathologic Exams Space Maintainers

100% No Charge 100% No Charge

Class II - Basic Restorative Care Fillings Surgical Extractions of Impacted Teeth Brush Biopsies Oral Surgery - all except simple extractions Anesthetics Oral Surgery – Simple Extractions

80%* 20%* 80%* 20%*

Class III - Major Restorative Care Crowns Root Canal Therapy/Endodontics Osseous Surgery Periodontal Scaling and Root Planing Denture Repairs Denture Relines, Rebases and Adjustments Repairs to Bridges, Crowns and Inlays Dentures Bridges Inlays/Onlays Prosthesis Over Implant

50%* 50%* 50%* 50%*

Class IV - Orthodontia Lifetime Maximum

50% $1,000

Dependent children to

age 19

50%

50% $1,000

Dependent children to

age 19

50%

Monthly PPO Premiums

Tier Rate

EE Only $26.50

EE + Spouse $65.28

EE + Child(ren) $71.58

Family Coverage $99.78

Missing Tooth Limitation – The amount payable is 50% of the amount otherwise payable until insured for 12 months; thereafter, considered a Class III expense. Pretreatment review is available on a voluntary basis when extensive dental work in excess of $200 is proposed. * Subject to annual deductible Dental Oral Health Integration Program (OHIP) - All dental customers = Clinical research shows an association between oral health and overall health. The Cigna Dental Oral Health Integration Program (OHIP)® is designed to provide enhanced dental coverage for customers with certain eligible medical conditions. Eligible conditions for the program include cardiovascular disease, cerebrovascular disease (stroke), diabetes, maternity, chronic kidney disease, organ transplants, and head and neck cancer radiation. The program provides:

100% coverage for certain dental procedures

guidance on behavioral issues related to oral health

discounts on prescription and non-prescription dental products For more information and to see the complete list of eligible conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24. **For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Contracted Fee Schedule. For services provided by an out-of-network dentist, Cigna Dental will reimburse according to Reasonable and Customary Allowances but the dentist may balance bill up to their usual fees. In Texas, the insured dental product offered by CGLIC and CHLIC is referred to as the Cigna Dental Choice Plan, and this plan utilizes the national Cigna Dental PPO network. Dependents/Students up to age 26.

23

Dental PPO - Low Option

Benefits Cigna Dental PPO - Low Option

In-Network Out-of-Network

Network Total Cigna DPPO Plan Year Maximum (Class I, II, and III expenses)

$750 $750

Annual Deductible Individual Family



Reimbursement Levels** Based on Reduced Contracted Fees

Based on Maximum Allowable Charge (In-

network fee level)

Plan Pays You Pay Plan Pays You Pay

Class I - Preventive & Diagnostic Care Oral Exams Routine Cleanings Bitewing X-rays Full Mouth X-rays Panoramic X-ray Emergency Care to Relieve Pain Fluoride Application Sealants Histopathologic Exams Space Maintainers

100% No Charge 100% No Charge

Class II - Basic Restorative Care Fillings Brush Biopsies Oral Surgery – Simple Extractions

60%* 40%* 60%* 40%*

Class III - Major Restorative Care Crowns Root Canal Therapy/Endodontics Osseous Surgery Periodontal Scaling and Root Planing Surgical Extractions of Impacted Teeth Oral Surgery - all except simple extractions Anesthetics Denture Repairs Denture Relines, Rebases and Adjustments Repairs to Bridges, Crowns and Inlays Dentures Bridges Inlays/Onlays Prosthesis Over Implant

40%* 60%* 40%* 60%*

Class IV - Orthodontia Not covered 100% of your

dentist’s usual fees

Not covered 100% of your

dentist’s usual fees

Monthly PPO Premiums

Tier Rate

EE Only $13.28

EE + Spouse $26.98



Missing Tooth Limitation – The amount payable is 50% of the amount otherwise payable until insured for 12 months; thereafter, considered a Class III expense. Pretreatment review is available on a voluntary basis when extensive dental work in excess of $200 is proposed. * Subject to annual deductible Dental Oral Health Integration Program (OHIP) - All dental customers = Clinical research shows an association between oral health and overall health. The Cigna Dental Oral Health Integration Program (OHIP)® is designed to provide enhanced dental coverage for customers with certain eligible medical conditions. Eligible conditions for the program include cardiovascular disease, cerebrovascular disease (stroke), diabetes, maternity, chronic kidney disease, organ transplants, and head and neck cancer radiation. The program provides:

100% coverage for certain dental procedures

guidance on behavioral issues related to oral health

discounts on prescription and non-prescription dental products For more information and to see the complete list of eligible conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24. **For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Contracted Fee Schedule. For services provided by an out-of-network dentist, Cigna Dental will reimburse according to Reasonable and Customary Allowances but the dentist may balance bill up to their usual fees. In Texas, the insured dental product offered by CGLIC and CHLIC is referred to as the Cigna Dental Choice Plan, and this plan utilizes the national Cigna Dental PPO network. Dependents/Students up to age 26.

24

Dental PPO - High and Low Options

Procedure Exclusions and Limitations Late Entrants Limit None Exams Two per Plan year Prophylaxis (Cleanings) Two per Plan year Fluoride 1 per Plan year for people under 19 Histopathologic Exams Various limits per Plan year depending on specific test X-Rays (routine) Bitewings: 2 per Plan year X-Rays (non-routine) Full mouth: 1 every 36 consecutive months, Panorex: 1 every 36 consecutive months Model Payable only when in conjunction with Ortho workup Minor Perio (non-surgical) Various limitations depending on the service Perio Surgery Various limitations depending on the service Crowns and Inlays Replacement every 5 years Bridges Replacement every 5 years Dentures and Partials Replacement every 5 years Relines, Rebases Covered if more than 6 months after installation Adjustments Covered if more than 6 months after installation Repairs - Bridges Reviewed if more than once Repairs - Dentures Reviewed if more than once Sealants Limited to posterior tooth. One treatment per tooth every three years up to age 14 Space Maintainers Limited to non-Orthodontic treatment Prosthesis Over Implant 1 per 60 consecutive months if unserviceable and cannot be repaired. Benefits are based on the amount payable for nonprecious metals. No porcelain or white/tooth colored material on molar crowns or bridges Alternate Benefit When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses

Benefit Exclusions Services performed primarily for cosmetic reasons Replacement of a lost or stolen appliance Replacement of a bridge or denture within five years following the date of its original installation Replacement of a bridge or denture which can be made useable according to accepted dental standards Procedures, appliances or restorations, other than full dentures, whose main purpose is to change vertical dimension, diagnose or treat

conditions of TMJ, stabilize periodontally involved teeth, or restore occlusion Veneers of porcelain or acrylic materials on crowns or pontics on or replacing the upper and lower first, second and third molars Bite registrations; precision or semi-precision attachments; splinting A surgical implant of any type Instruction for plaque control, oral hygiene and diet Dental services that do not meet common dental standards Services that are deemed to be medical services Services and supplies received from a hospital Charges which the person is not legally required to pay Charges made by a hospital which performs services for the U.S. Government if the charges are directly related to a condition

connected to a military service Experimental or investigational procedures and treatments Any injury resulting from, or in the course of, any employment for wage or profit Any sickness covered under any workers’ compensation or similar law Charges in excess of the reasonable and customary allowances To the extent that payment is unlawful where the person resides when the expenses are incurred; Procedures performed by a Dentist who is a member of the covered person’s family (covered person’s family is limited to a spouse,

siblings, parents, children, grandparents, and the spouse’s siblings and parents); For charges which would not have been made if the person had no insurance; For charges for unnecessary care, treatment or surgery; To the extent that you or any of your Dependents is in any way paid or entitled to payment for those expenses by or through a public

program, other than Medicaid; To the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to

comply with a “no-fault” insurance law or an uninsured motorist insurance law. Cigna HealthCare will take into account any adjustment option chosen under such part by you or any one of your Dependents.

In addition, these benefits will be reduced so that the total payment will not be more than 100% of the charge made for the Dental Service if benefits are provided for that service under this plan and any medical expense plan or prepaid treatment program sponsored or made available by your Employer.

This benefit summary highlights some of the benefits available under the proposed plan. A complete description regarding the terms of coverage, exclusions and limitations, including legislated benefits, will be provided in your insurance certificate or plan description. Benefits are insured and/or administered by Connecticut General Life Insurance Company. "Cigna HealthCare" refers to various operating subsidiaries of Cigna Corporation. Products and services are provided by these subsidiaries and not by Cigna Corporation. These subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. DPPO insurance coverage is set forth on the following policy form numbers: AR: HP-POL77; CA: HP-POL57; CO: HP-POL78; CT: HP-POL58; DE: HP-POL79; FL: HP-POL60; ID: HPPOL82; IL: HP-POL62; KS: HP-POL84; LA: HP-POL86: MA: HP-POL 63; MI: HP-POL88; MO: HP- POL65; MS: HP-POL90; NC: HP-POL96; NE: HP-POL92; NH: HP-POL94; NM: HP-POL95; NV: HP-POL93; NY: HP-POL67; OH: HP-POL98; OK: HP-POL99; OR: HP-POL68; PA: HP-POL100; RI: HP-POL101; SC: HP-POL102; SD: HP-POL103; TN: HP-POL69; TX: HP-POL70; UT: HP-POL104; VA: HP-POL72; VT: HP-POL71; WA: POL-07/08; WI: HP-POL107; WV: HP-POL106; and WY: HP-POL108. “Cigna,” the “Tree of Life” logo and “Cigna Dental Care” are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company (CGLIC), Cigna Health and Life Insurance Company (CHLIC), Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. and its subsidiaries. Cigna Dental PPO plans are underwritten or administered by CGLIC or CHLIC, with network management services provided by Cigna Dental Health, Inc. and certain of its subsidiaries. In Arizona and Louisiana, the insured Dental PPO plan offered by CGLIC is known as the “CG Dental PPO”. In Texas, the insured dental product offered by CGLIC and CHLIC is referred to as the Cigna Dental Choice Plan, and this plan utilizes the national Cigna Dental PPO network. Cigna Dental Care (DHMO) plans are underwritten or administered by Cigna Dental Health Plan of Arizona, Inc., Cigna Dental Health of California, Inc., Cigna Dental Health of Colorado, Inc., Cigna Dental Health of Delaware, Inc., Cigna Dental Health of Florida, Inc., a Prepaid Limited Health Services Organization licensed under Chapter 636, Florida Statutes, Cigna Dental Health of Kansas, Inc. (Kansas and Nebraska), Cigna Dental Health of Kentucky, Inc. (Kentucky and Illinois), Cigna Dental Health of Maryland, Inc., Cigna Dental Health of Missouri, Inc., Cigna Dental Health of New Jersey, Inc., Cigna Dental Health of North Carolina, Inc., Cigna Dental Health of Ohio, Inc., Cigna Dental Health of Pennsylvania, Inc., Cigna Dental Health of Texas, Inc., and Cigna Dental Health of Virginia, Inc. In other states, Cigna Dental Care plans are underwritten by CGLIC, CHLIC, or Cigna HealthCare of Connecticut, Inc. and administered by Cigna Dental Health, Inc. BSD46380 © 2015 Cigna

25

Dental DHMO

Monthly DHMO Premiums

Tier Rate

EE Only $8.99

EE + Spouse $16.99



What You’ll Pay

Sampling of covered procedures Cost with Cigna Dental Care

Estimated cost without dental coverage

Adult cleaning (two per calendar year each at $0) (additional cleanings available at $45 each)

$0 $70–$136 each

Child cleaning (two per calendar year each at $0) (additional cleanings available at $30 each)

$0 $53–$102 each

Periodic oral evaluation $0 $40–$76

Comprehensive oral evaluation $0 $62–$118

Topical fluoride (two per calendar year each at $0) (additional topical fluoride available at $15 each)

$0 $28–$53

X–rays – (bitewings) 2 films $0 $33–$63

X–rays – panoramic film $0 $84–$161

Sealant – per tooth $17 $42–$80

Amalgam filling (silver colored) – 2 surfaces $28 $118–$226

Composite filling (tooth–colored) – 1 surface, Anterior $33 $120–$231

Molar root canal (excluding final restoration) $595 $852–$1,640

Comprehensive orthodontics – child (up to 19th birthday) – Banding

$515 $1,042–$2,005

Periodontal (gum) scaling & root planing – 1 quadrant $135 $179–$344

Periodontal (gum) maintenance $93 $109–$209

Removal/extraction of erupted tooth $64 $120–$231

Removal/extraction of impacted tooth $300 $370–$712

Crown – porcelain fused to high noble metal $480 $849–$1,634

Implant supported retainer for porcelain fused to metal fixed partial denture

$780 $1,097–$2,112

Occlusal appliance, by report (for treatment of TMJ) $575 $640–$1,233

Procedure Limit

Exams Two per calendar year

X-rays (routine) Bitewings: 2 per calendar year

X-rays (non-routine) Full mouth: 1 every 3 calendar years. Panorex: 1 every 3 calendar years

Crowns and inlays Replacement every 5 years

Bridges Replacement every 5 years

Dentures and partials Replacement every 5 years

Relines, rebases One every 36 months

Adjustments Four within the first 6 months after installation

Prosthesis over implant Replacement every 5 years if unserviceable and can-not be repaired

Temporomandibular

Joint (TMJ) treatment One occlusal orthotic device per 24 months

Athletic mouth guard One athletic mouth guard per 12 months when listed on your PCS

Finding a network dentist is easy. There are several ways to chooseyour network general dentist: Find a dentist at Cigna.com. Our

online dental directory is updated weekly.

Call 1.800.Cigna24 (1.800.244.6224) to speak with a customer service representative.Our representatives can send youa customized dental directorylisting via email.

26

Dental DHMO

Under your plan, you have coverage for hundreds of dental procedures. This overview shows you a small sampling of covered services and what you will pay compared to your estimated cost without coverage. See savings below! Review your plan materials to understand how your plan works. For questions on the plan before enrollment, call 1.800.Cigna24 (1.800.244.6224) and select the “Enrollment Information” prompt. Key plan features

There is a $5 office visit fee associated with your plan.

No deductibles – you don’t have to reach a certain level of out-of-pocket expenses before your insurance kicks in.

No dollar maximums – you don’t have to worry about your coverage running out after your covered expenses reach a certain dollar amount.

Easy to understand plan – the fees you pay your dentist are clearly listed on your Patient Charge Schedule (PCS).

There are no claim forms to fill and no waiting periods for coverage.

The network general dentist you choose will manage your overall dental care.

Covered family members can choose their own network general dentists – near home, work or school.

You don’t need a referral for children under seven to visit a network pediatric dentist. And you don’t need a referral to see a network orthodontist.

There’s no age limit on sealants, which help prevent tooth decay.

Your plan covers certain procedures to help detect oral cancer in its early stages.

24/7 access to the Dental Information Line—this line is staffed by trained professionals who can help you if you have questions about dental treatment and clinical symptoms.

Referrals are required for specialty care services. Specialty treatment plans require payment authorization for services to be covered under your plan, except for Pediatrics, Orthodontics and Endodontics. You should verify with your Network Specialty Dentist that your treatment plan has been authorized for payment by Cigna before treatment begins. Listed below are the services or expenses which are NOT covered under your Dental Plan and which are your responsibility at the dentist’s usual fees. There is no coverage for: Or in connection with an injury arising out of, or in the course of,

any employment for wage or profit Charges which would not have been made in any facility, other

than a hospital or a correctional institution owned or operated by the United States government or by a state or municipal government if the person had no insurance

To the extent that payment is unlawful where the person resides when the expenses are incurred or the services are received

The charges which the person is not legally required to pay Charges which would not have been made if the person had

no insurance Due to injuries which are intentionally self-inflicted Services not listed on the PCS Services provided by a non-network dentist without Cigna

Dental’s prior approval (except emergencies, as described in your plan documents)

Services related to an injury or illness paid under workers’ compensation, occupational disease or similar laws

Services provided or paid by or through a federal or state governmental agency or authority, political subdivision or a public program, other than Medicaid

Services required while serving in the armed forces of any country or international authority or relating to a declared or undeclared war or acts of war

Services performed primarily for cosmetic reasons unless specifically listed on your PCS

General anesthesia, sedation and nitrous oxide, unless specifically listed on your PCS

Prescription medications Replacement of filled and/or removable appliances (including

filled and removable orthodontic appliances) that have been lost, stolen, or damaged due to patient abuse, misuse or neglect

Surgical implant of any type unless specifically listed on your PCS

Services considered to be unnecessary or experimental in nature or do not meet commonly accepted dental standards

Procedures or appliances for minor tooth guidance or to control harmful habits

Services and supplies received from a hospital The completion of crowns, bridges, dentures, or root canal

treatment already in progress on the effective date of your Cigna Dental coverage

The completion of implant supported prosthesis (including crowns, bridges and dentures) already in progress on the effective date of your Cigna Dental coverage, unless specifically listed on your PCS4

Consultations and/or evaluations associated with services that are not covered

Endodontic treatment and/or periodontal (gum tissue and supporting bone) surgery of teeth exhibiting a poor or hopeless periodontal prognosis

Bone grafting and/or guided tissue regeneration when performed at the site of a tooth extraction unless specifically listed on your PCS

Bone grafting and/or guided tissue regeneration when performed in conjunction with an apicoectomy or periradicular surgery

Intentional root canal treatment in the absence of injury or disease to solely facilitate a restorative procedure

Services performed by a prosthodontist Localized delivery of antimicrobial agents when performed

alone or in the absence of traditional periodontal therapy Any localized delivery of antimicrobial agent procedures when

more than eight (8) of these procedures are reported on the same date of service.

Infection control and/or sterilization The recementation of any inlay, onlay, crown, post and core

or filled bridge within 180 days of initial placement The recementation of any implant supported prosthesis

(including crowns, bridges and dentures) within 180 days of initial placement

Services to correct congenital malformations, including the replacement of congenitally missing teeth

The replacement of an occlusal guard (night guard) beyond one per any 24 consecutive month period, when this limitation is noted on the PCS

Crowns, bridges and/or implant supported prosthesis used solely for splinting

Resin bonded retainers and associated pontics

27

Vision insurance provides coverage for routine eye examinations and may cover all or part of the costs associated with contact lenses, eyeglasses and vision correction, depending on the plan.

About this Benefit

Vision

75%

DID YOU KNOW?

of U.S. residents between age 25 and 64 require some sort of vision

correction.

SUPERIOR VISION YOUR BENEFITS PACKAGE



Co-Pays

Exam $10

Materials₁ $25

Contact Lens Fitting (standard & specialty)

$25

Services/Frequency

Exam 12 months

Frame 12 months

Contact Lens Fitting 12 months

Lenses 12 months

Contact Lenses 12 months

Benefits In-Network Out-of-Network

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

Exam (optometrist) Covered in full Up to $37 retail

Frames $125 retail allowance Up to $68 retail

Contact Lens Fitting (standard₂) Covered in full Not Covered

Contact Lens Fitting (specialty₂) $50 retail allowance Not Covered

Contact Lenses4 $120 retail allowance Up to $100 retail

Lenses (standard) per pair

Single Vision Covered in full Up to $32 retail

Bifocal Covered in full Up to $46 retail

Trifocal Covered in full Up to $61 retail

Progressive lens upgrade See description3 Up to $61 retail

Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements. ₁ Materials co-pay applies to lenses & frames only, not contact lenses. ₂Visit FAQs on www.superiorvision.com for definitions of standard and specialty CLF. ₃Covered to the provider's retail amount for a standard lined trifocal lens; member pays the difference between the retail price of the progressive lens they have chose and their provider's standard lined trifocal lens, plus applicable co-pay. 4Contact lenses are in lieu of eyeglass lenses and frames benefit.

Vision

Discounts on Covered Materials5

Frames: 20% off amount over allowance Lens options: 20% off retail Progressives: 20% off amount over retail lined trifocal lens, including lens options The following options have out-of-pocket maximums on standard (not premium, brand, or progressive) plastic lenses. 5Discounts and maximums may vary by lens type. Please check with your

provider.

Maximum Member Out-of-Pocket

Single Vision Bifocal & Trifocal

Scratch coat $13 $13

Ultraviolet coat $15 $15

Tints, solid or gradients $25 $25

Anti-reflective coat $50 $50

Polycarbonate $40 20% off retail

High index 1.6 $55 20% off retail

Photochromics $80 20% off retail

Discounts on Non-Covered Exam and Materials5 Exams, frames, and prescription lenses: 30% off retail Lens options, contacts, other prescription materials: 20% off retail Disposable contact lenses: 10% off retail

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

provider.

Refractive Surgery Superior Vision has a nationwide network of refractive surgeons and leading LASIK networks who offer members a discount. These discounts range from 5%-50%, and are the best possible discounts available to Superior Vision. The Plan discount features are not insurance. All allowances are retail; member is responsible for any amount over the allowance, minus available discounts.

Discounts are subject to change without notice.

Disclaimer: All final determinations of benefits, administrative duties, and definitions are governed by the Certificate of Insurance for your vision plan. Please check with your Human Resources department if you have any questions.

Monthly Premiums

EE Only $6.88

EE + Spouse $13.66


EE + Family $20.36

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Disability insurance protects one of your most valuable assets, your ability to earn a living. This insurance will replace a portion of your income in the event that you become physically unable to work. Short term disability coverage provides benefits when you are unable to work for a short period of time due to a covered sickness or injury.

About this Benefit

Short Term Disability CIGNA

DID YOU KNOW?

60% of Americans do not have a “rainy day” fund to cover three

months of unanticipated financial emergencies.




Short Term Disability

Important Definitions and Features Definition of Disability Disability means that, solely because of a covered injury or sickness, you are unable to perform the material duties of your regular occupation and/or you are unable to earn 80% or more of your covered earnings from working in your regular occupation. We will require proof of earnings and continued disability.

Covered Earnings Covered earnings means your annual wages or salary, not including bonuses, commissions, other extra compensation and overtime.

Termination of Disability Benefits Your benefits will terminate on the earliest of any of the following dates: the date the insurance company determines you are no longer disabled; the date you earn from any occupation more than the percentage of covered earnings as defined in your definition of disability; the date the maximum benefit period ends; the date you cease to get appropriate care; the date you die; the date you refuse to participate without good cause in all required phases of the rehabilitation plan; the date you fail to cooperate with us in the administration of the claim. Benefits may be resumed if you begin to cooperate in the rehabilitation plan within 30 days of the date benefits terminated.

Cost The cost of this insurance program is paid by you. The cost of this coverage per $100 of monthly Benefit is: Option 1 Option 2 Under age 30: $0.26 Under age 30: $0.34 Age 30 – 34: $0.26 Age 30 – 34: $0.34 Age 35 – 39: $0.26 Age 35 – 39: $0.34 Age 40 – 44: $0.38 Age 40 – 44: $0.51 Age 45 – 49: $0.51 Age 45 – 49: $0.69 Age 50 – 54: $0.76 Age 50 – 54: $0.76 Age 55 – 59: $1.01 Age 55 – 59: $1.01 Age 60+: $1.17 Age 60+: $1.17 Costs are subject to change.

Short Term Disability (STD) Insurance Coverage

Eligibility All active, full-time U.S. Employees of the Employer regularly working a minimum of 18.75 hours per week.

Eligibility Waiting Period

No waiting period.

Weekly Benefit Benefit Amount Up to 60% of your weekly covered earnings

Maximum $1,385 per week

Elimination Period

Option 1—You must be disabled for 30 days from either accident or sickness. This time period ends automatically on the date you are admitted as an inpatient to a hospital if that occurs before the 30 days are completed. Option 2—You must be disabled for 14 days from either accident or sickness. This time period ends automatically on the date you are admitted as an inpatient to a hospital if that occurs before the 14 days are completed.

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Effects of Other Income Benefits The disability benefit provided by this plan is a total benefit; that is, it will be reduced by any disability benefits payable on behalf of you or your dependents, or a qualified third party on behalf of you or your dependents, whether or not you are actually receiving them. Your disability benefits will not be reduced by any Social Security disability benefits you are not receiving as long as you cooperate fully in efforts to obtain them and agree to repay any overpayment when and if you do receive them. Other income sources that may reduce your benefits under this plan include:

Any Social Security disability or retirement benefits you or any third party receive (or are assumed to receive) on your own behalf; or which your dependents receive (or are assumed to receive) because of your entitlement to such benefits.

Benefits payable by a Canadian and/or Quebec provincial pension plan.

Amounts payable under the Railroad Retirement Act.

Amounts payable under any local, state, provincial or federal government disability or retirement plan or law as it pertains to the employer.

Employer-paid portion of company retirement plan benefits.

Amounts payable by company sponsored sick leave or salary continuation plan.

Amounts payable by any franchise or group insurance or similar plan.

Benefits payable under work-loss provisions of any mandatory “no fault” auto insurance.

Any amounts paid on account of loss of earnings or earning capacity through settlement, judgment, arbitration or otherwise, where a third party may be liable, regardless of whether liability is determined.

Income sources that WILL NOT reduce your benefits under this plan are:

Benefits paid by personal, individual disability income policies.

Individual deferred compensation agreements.

Employee savings plans, including thrift plans, stock options or stock bonuses.

Individual retirement funds, such as IRA or 401(k) plans.

Profit-sharing, investment or other retirement or savings plans maintained in addition to an employer-sponsored pension plan.

Additional Plan Details & Features

Earnings While Disabled Benefits will be reduced for any week that benefits plus income from employment exceeds 100% of weekly covered earnings.

Benefit Duration Option 1- Once you qualify for benefits under this plan, you continue to receive them until the end of the 22 benefit period, or until you no longer qualify for benefits, whichever occurs first. Option 2- Once you qualify for benefits under this plan, you continue to receive them until the end of the 24 benefit period, or until you no longer qualify for benefits, whichever occurs first.

Pre-existing Conditions Benefits are not payable for medical conditions for which you incurred expenses, took prescription drugs, received medical treatment, care or services (including diagnostic measures,) or for which a reasonable person would have consulted a physician during the 3 months just prior to the most recent effective date of insurance. Benefits are not payable for any disability resulting from a pre-existing condition unless the disability occurs after you have been in active service for a time of 3 consecutive months when you received no medical treatment, care, or services after you have been under this plan for at least 12 months after your most recent effective date of insurance.

Termination of Disability Benefits Your benefits will terminate on the earliest of any of the following dates: the date the insurance company determines you are no longer disabled; the date you earn from any occupation more than the percentage of indexed earnings as defined in your definition of disability; the date the maximum benefit period ends; the date you cease to get appropriate care; the date you die; the date you refuse to participate without good cause in all required phases of the rehabilitation plan; the date you fail to cooperate with us in the administration of the claim. Benefits may be resumed if you begin to cooperate in the rehabilitation plan within 30 days of the date benefits terminated.

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Exclusions This plan does not pay benefits for a disability which results, directly or indirectly, from any of the following: Suicide, attempted suicide, or whenever you injure yourself on purpose; war or any act of war, whether or not declared; active participation in a riot; commission of a felony; cosmetic surgery or medically unnecessary surgical procedures; an injury or sickness for which you are entitled to benefits from Workers’ Compensation or occupational disease law; an injury or sickness that is work-related; the revocation, restriction or non-renewal of your license, permit or certification necessary for you to perform the duties of your occupation, unless solely due to injury or sickness otherwise covered by the policy. In addition, we will not pay disability benefits for any period of disability during which you are incarcerated in a penal or corrections institution for any reason.

Plan Termination Coverage terminates if the group policy is terminated, if you cease to be in active service, if you are no longer a member of an eligible class of employees, the day after the last date for which premium has been paid by you or the employer, or the date you become eligible for a plan of benefits intended to replace this coverage. If you are disabled and receiving benefits under this plan, your benefits and coverage will continue until the expiration of your benefit period, or until you no longer qualify for benefits under the plan, whichever comes first.

When Coverage Takes Effect Your coverage takes effect on the later of the program’s effective date, the date you become eligible, the date we receive your completed enrollment form, or the date you authorize any necessary payroll deductions. If you have to submit evidence of good health, your coverage takes effect on the date we agree, in writing, to cover you. If you’re not actively at work on the date your coverage would otherwise take effect, you’ll be covered on the date you return to work.

This information is a brief description of the important features of the plan. It is not a contract. Terms and conditions of insurance are set forth in Group Policy No. vdt0961364. Please refer to your Certificate of Insurance or Summary Plan Description for more detailed information. Coverage is underwritten by Life Insurance Company of North America, a Cigna company. “Cigna” and the Tree of Life logo are registered service marks of Cigna Intellectual Property, Inc. © Cigna 2015

33

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.

About this Benefit

Long Term Disability

Just over 1 in 4 of today's 20 year-olds will become disabled before

they retire.

DID YOU KNOW?

34.6 months is the duration of the

average disability claim.





Important Definitions and Features Definition of Disability Disability means that, solely because of a covered injury or sickness, you are unable to perform the material duties of your regular occupation and you are unable to earn 80% or more of your indexed earnings from working in your regular occupation. After benefits have been payable for 24 months, you are considered disabled if solely due to your injury or sickness, you are unable to perform the material duties of any occupation for which you are (or may reasonably become) qualified by education, training or experience, and you are unable to earn 60% or more of your indexed earnings. We will require proof of earnings and continued disability.

Covered Earnings Covered earnings means your annual wages or salary, not including bonuses, commissions, other extra compensation and overtime.

Termination of Disability Benefits Your benefits will terminate on the earliest of any of the following dates: the date the insurance company determines you are no longer disabled; the date you earn from any occupation more than the percentage of indexed earnings as defined in your definition of disability; the date the maximum benefit period ends; the date you cease to get appropriate care; the date you die; the date you refuse to participate without good cause in all required phases of the rehabilitation plan; the date you fail to cooperate with us in the administration of the claim. Benefits may be resumed if you begin to cooperate in the rehabilitation plan within 30 days of the date benefits terminated.

Cost The cost of this insurance program is paid by you. The cost per $100 of monthly covered earnings are shown below. Costs are subject to change. Option 1 Option 2 Under age 30: $0.126 Under age 30: $0.081 Age 30 – 34: $0.180 Age 30 – 34: $0.117 Age 35 – 39: $0.270 Age 35 – 39: $0.171 Age 40 – 44: $0.432 Age 40 – 44: $0.342 Age 45 – 49: $0.612 Age 45 – 49: $0.450 Age 50 – 54: $0.900 Age 50 – 54: $0.666 Age 55 – 59: $1.206 Age 55 – 59: $0.882 Age 60+: $1.431 Age 60+: $1.035 Costs are subject to change.

Long Term Disability (LTD) Insurance Coverage

Eligibility All active, full-time U.S. Employees of the Employer regularly working a minimum of 18.75 hours per week.

Eligibility Waiting Period

No waiting period.

Benefit Amount Up to 60% of your monthly covered earnings Monthly Benefit

Maximum $6,000 per month

Elimination Period Option 1—You must be disabled for 90 days before benefits may be payable. Option 2—You must be disabled for 180 days before benefits may be payable.

Benefit Duration

Once you qualify for benefits under this plan, you continue to receive them until the end of the benefit period shown below, or until you no longer qualify for benefits, whichever occurs first. Your benefit period begins on the first day after you complete your elimination period. And, should you remain disabled, your benefits continue according to the following schedule, depending on your age at the time you become disabled.

Age at Disability

Age 62 or younger 63 64 65 66 67 68 69+

Duration of Payments (months)

To age 65 or the date the 42nd monthly benefit is payable, if later

36 30 24 21 18 15 12

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Effects of Other Income Benefits The disability benefit provided by this plan is a total benefit; that is, it will be reduced by any disability benefits payable on behalf of you or your dependents, or a qualified third party on behalf of you or your dependents, whether or not you are actually receiving them. Other income sources that may reduce your benefits under this plan include:

Any Social Security disability or retirement benefits you or any third party receive (or are assumed to receive) on your own behalf; or which your dependents receive (or are assumed to receive) because of your entitlement to such benefits.

Benefits payable by a Canadian and/or Quebec provincial pension plan.

Amounts payable under the Railroad Retirement Act.

Amounts payable under local, state, provincial or federal government disability or retirement plan or law as it pertains to the employer.

Employer-paid portion of company retirement plan benefits.

Amounts payable by company sponsored sick leave or salary continuation plan.

Amounts payable by any franchise or group insurance or similar plan.

Benefits payable under work-loss provisions of any mandatory “no fault” auto insurance.

Any amounts paid on account of loss of earnings or earning capacity through settlement, judgment, arbitration or otherwise, where a third party may be liable, regardless of whether liability is determined.

Amounts payable under any workers’ compensation (including temporary or permanent disability benefits), occupational disease, and unemployment compensation. This includes damages, compromises or settlements paid in place of such benefits, whether or not liability is admitted.

Income sources that WILL NOT reduce your benefits under this plan are:

Benefits paid by personal, individual disability income policies.

Individual deferred compensation agreements.

Employee savings plans, including thrift plans, stock options or stock bonuses.

Individual retirement funds, such as IRA or 401(k) plans.

Profit-sharing, investment or other retirement or savings plans maintained in addition to an employer-sponsored pension plan.

Additional Plan Details & Features

Earnings While Disabled During the first 24 months that benefits are payable, benefits will be reduced if benefits plus income from employment exceeds 100% of pre-disability covered earnings. After that, benefits will be reduced by 50% of earnings from employment.

Pre-existing Conditions Benefits are not payable for medical conditions for which you incurred expenses, took prescription drugs, received medical treatment, care or services (including diagnostic measures,) during the 3 months just prior to the most recent effective date of insurance. Benefits are not payable for any disability resulting from a pre-existing condition unless the disability occurs after you have been insured under this plan for at least 12 months after your most recent effective date of insurance.

Limited Benefit Period Disabilities caused by or contributed to by any one or more of the following conditions are subject to a lifetime limit of 24 months: Anxiety-disorders, delusional (paranoid) or depressive disorders, eating disorders, mental illness, somatoform disorders (including psychosomatic illnesses). Benefits are payable during periods of hospital confinement for these conditions for hospitalizations lasting more than 14 consecutive days that occur before the 24-month lifetime limit is exhausted. Once the 24-month benefits are exhausted, the plan pays no further benefits. Disabilities caused by or contributed to by any one or more of the following conditions are subject to a lifetime limit of 24 months: Alcoholism, drug addiction or abuse. Benefits are payable during periods of hospital confinement for these conditions for hospitalizations lasting more than 14 consecutive days that occur before the 24-month lifetime limit is exhausted. Once the 24-month benefits are exhausted, the plan pays no further benefits.

Exclusions This plan does not pay benefits for a disability which results, directly or indirectly, from any of the following: Suicide, attempted suicide, or whenever you injure yourself on

36


purpose; war or any act of war, whether or not declared; active participation in a riot; commission of a felony; the revocation, restriction or non-renewal of your license, permit or certification necessary for you to perform the duties of your occupation, unless solely due to injury or sickness otherwise covered by the policy. In addition, we will not pay disability benefits for any period of disability during which you are incarcerated in a penal or corrections institution for any reason.

Plan Termination Coverage terminates if the group policy is terminated, if you cease to be in active service, if you are no longer a member of an eligible class of employees, the day after the last date for which premium has been paid by you or the employer, or the date you become eligible for a plan of benefits intended to replace this coverage. If you are disabled and receiving benefits under this plan, your benefits and coverage will continue until the expiration of your benefit period, or until you no longer qualify for benefits under the plan, whichever comes first.

When Coverage Takes Effect Your coverage takes effect on the later of the program’s effective date, the date you become eligible, the date we receive your completed enrollment form, or the date you authorize any necessary payroll deductions. If you have to submit evidence of good health, your coverage takes effect on the date we agree, in writing, to cover you. If you’re not actively at work on the date your coverage would otherwise take effect, you’ll be covered on the date you return to work.

Family Survivor Benefit If you die while receiving disability benefits, we will pay a survivor benefit based on 100% of the total of your last month’s benefit plus the amount of any disability earnings by which this benefit had been reduced for that month. This plan pays a single lump sum equal to 3 months of benefits. We pay this benefit directly to your lawful spouse, or to your children in equal shares, if there is no lawful spouse. If you have no lawful spouse or children, we pay this benefit to your estate.

This information is a brief description of the important features of the plan. It is not a contract. Terms and conditions of insurance are set forth in Group Policy No. vdt0961364. Please refer to your Certificate of Insurance or Summary Plan Description for more detailed information. Coverage is underwritten by Life Insurance Company of North America, a Cigna company. “Cigna” and the Tree of Life logo are registered service marks of Cigna Intellectual Property, Inc. © Cigna 2015

37

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.

About this Benefit

Cancer

Breast Cancer is the most commonly diagnosed cancer in women.

DID YOU KNOW?

If caught early, prostate cancer is one of the most treatable malignancies.




GC3 Limited Benefit Group Cancer Indemnity InsuranceESC Region 20 Benefits Co-op Group

THE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKERS’ COMPENSATION INSURANCE. THE EMPLOYER DOES NOT BECOME A SUBSCRIBER TO THE WORKERS’ COMPENSATION SYSTEM BY PURCHASING THE POLICY AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE EMPLOYEE LOSES THOSE BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS’ COMPENSATION LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKERS’ COMPENSATION LAW AS IT PERTAINS TO NON-SUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED AND POSTED.

SUMMARY OF BENEFITSBenefits Level 1 Plan Level 2 Plan

Radiation Therapy/Chemotherapy/ Immunotherapy Benefit

$500 per calendar month of treatment $1,500 per calendar month of treatment

Hormone Therapy Benefit $50 per treatment, up to 12 per calendar year $50 per treatment, up to 12 per calendar year

Surgical Schedule Benefit $1,600 max per operation; $15 per surgical unit $4,800 max per operation; $45 per surgical unit

Anesthesia Benefit 25% of the amount paid for covered surgery 25% of the amount paid for covered surgery

Hospital Confinement Benefit $100 per day 1-90 days; $100 per day, 91+ days in lieu of other benefits

$300 per day 1-90 days; $300 per day, 91+ days in lieu of other benefits

US Government/Charity Hospital/HMO $100 per day in lieu of most other benefits $300 per day in lieu of most other benefits

Outpatient Hospital or Ambulatory Surgical Center Benefit

$200 per day of surgery $600 per day of surgery

Drugs & Medicine Benefit - Inpatient $150 per confinement $150 per confinement

Drugs & Medicine Benefit - Outpatient $50 per prescription, up to $50 per cal month $50 per prescription, up to $150 per cal month

Transportation & Outpatient Lodging Benefit

$0.50 per mile per round trip $100 per day, up to 100 days per calendar year


Family Member Transportation & Lodging Benefit



Blood, Plasma & Platelets Benefit $150 per day, up to $7,500 per calendar year $250 per day, up to $12,500 per calendar year

Bone Marrow/Stem Cell Transplant Autologous - $500 per calendar year Non-Autologous - $1,500 per calendar year

Autologous - $1,500 per calendar year Non-Autologous - $4,500 per calendar year

Experimental Treatment Benefit Pays as any non-experimental benefit Pays as any non-experimental benefit

Attending Physician Benefit $30 per day of confinement $50 per day of confinement

Surgical Prosthesis Benefit $1,000 per device (includes surgical fee); max 1 device per site, 2 lifetime max

$3,000 per device (includes surgical fee); max 1 device per site, 2 lifetime max

Hair Prosthesis Benefit $50 per hair prosthetic, 2 lifetime max $50 per hair prosthetic, 2 lifetime max

Dread Disease Benefit $100 per day, 1-90 days of hospital confinement $300 per day, 1-90 days of hospital confinement

Hospice Care Benefit $50 per day, $9,000 lifetime max $100 per day, $18,000 lifetime max

Inpatient Special Nursing Services $150 per day of confinement $150 per day of confinement

Ambulance Ground Benefit $200 per ground trip $200 per ground trip

Ambulance Air Benefit $2,000 per air trip; up to 2 trips per hospital confinement (any combination of ground/air)

$2,000 per air trip; up to 2 trips per hospital confinement (any combination of ground/air)

Extended Care Benefit $100 per day $300 per day

Home Health Care Benefit $100 per day $300 per day

Second & Third Surgical Opinions $300 per diagnosis; additional $300 if third opinion required

$300 per diagnosis; additional $300 if third opinion required

Waiver of Premium Premium waived after 90 days of primary insured continuous total disability due to cancer

Premium waived after 90 days of primary insured continuous total disability due to cancer

Physical/Speech Therapy Benefit $25 per visit, up to 4 visits per calendar month, $1,000 lifetime max

$25 per visit, up to 4 visits per calendar month, $1,000 lifetime max

RidersDiagnostic Testing Benefit Rider $50; 1 person, per calendar year $50; 1 person, per calendar year

Critical Illness Rider: Heart Attack/Stroke $2,500 lump sum benefit $2,500 lump sum benefit

Optional Benefit Rider

Intensive Care Unit Rider $600 up to a max of 30 days per confinement $600 up to a max of 30 days per confinement

APSB-22356(TX) MGM/FBS ESC Region 20 Benefits Co-op 39

EligibilityThis policy/certificate will be issued only to those persons who meet American Public Life Insurance Company’s insurability requirements. The policy/certificate and the Internal Cancer coverage under the Critical Illness Rider will not be issued to anyone who has been diagnosed or treated for Cancer in the previous ten years. The Heart Attack or Stroke coverage under the Critical Illness Rider will not be issued to anyone who has been diagnosed or treated for any heart or stroke related conditions. The Hospital Intensive Care Unit Rider will not cover heart conditions for a period of two years following the Effective Date of coverage for anyone who has been diagnosed or treated for any heart related condition prior to the 30th day following the Covered Person’s Effective Date of coverage.

If You are working either under contract to or as a Full-Time Employee for the Policyholder, or You are a member in or employed by the association, You are eligible for insurance provided You qualify for coverage as defined in the Master Application. You must apply for insurance within thirty (30) days of the Policy Effective Date or the date that You become eligible for coverage. If You do not apply within thirty (30) days of the Policy Effective Date or the date You become eligible for coverage, You may be subject to additional underwriting by Us.

Base PolicyAll diagnosis of cancer must be positively diagnosed by a legally licensed doctor of medicine certified by the American Board of Pathology or American Board of Osteopathic Pathology. This policy/certificate pays only for loss resulting from definitive cancer treatment including direct extension, metastatic spread or recurrence. Proof must be submitted to support each claim. This policy/certificate also covers other conditions or diseases directly caused by cancer or the treatment of cancer.

No benefits are payable for any covered person for any loss incurred during the first year of this policy/certificate as a result of a Pre-Existing Condition. A Pre-Existing Condition is a specified disease for which, within 12 months prior to the covered person’s effective date of coverage, medical advice, consultation or treatment, including prescribed medications, was recommended by or received from a member of the medical profession, or for which symptoms manifested in such a manner as would cause an ordinarily prudent person to seek diagnosis, medical advice or treatment. Pre-Existing Conditions specifically named or described as excluded in any part of this contract are never covered. This policy/certificate contains a 30-day waiting period during which no benefits will be paid under this policy/certificate. If any covered person has a specified disease diagnosed before the end of the 30-day period immediately following the covered person’s effective date, coverage for that person will apply only to loss that is incurred after one year from the effective date of such person’s coverage. If any covered person is diagnosed as having a specified disease during the 30-day period immediately following the effective date, you may elect to void the policy/certificate from the beginning and receive a full refund of premium. All benefits payable only up to the maximum amount listed in the schedule of benefits in the policy/certificate.

A Hospital is not an institution which is primarily a place for alcoholics or drug addicts; the aged; a nursing, rest or convalescent nursing home; a mental institution or sanitarium; a facility contracted for or operated by the United States Government for treatment of members or ex-members of the armed forces (unless You are legally required to pay for services rendered in the absence of insurance); or, a long-term nursing unit or geriatrics ward.

Diagnostic Testing Benefit RiderWe will pay the indemnity amount for one generally medically recognized internal cancer screening test per covered person per calendar year. Screening test include, but limited to: mammogram; breast ultrasound; breast thermography; breast cancer blood test (CA15-3); colon cancer blood test (CEA); prostate-specific antigen blood test (PSA); flexible sigmoidoscopy; colonoscopy; virtual colonoscopy; ovarian cancer blood test (CA-125); pap smear (lab test required); chest x-ray; hemocult stool specimen; serum protein electrophoresis (blood test for myeloma); thin prep pap test. Screening tests payable under this benefit will only be paid under this benefit. Benefits will only be paid for tests performed after the 30-day period following the covered person’s effective date of coverage.

Critical Illness RiderBenefits will only be paid for a covered critical illness as shown on the policy/certificate schedule page in the policy. No benefits will be provided for any loss caused by or resulting from: intentionally self-inflicted bodily injury, suicide or attempted suicide, whether sane or insane; or alcoholism or drug addiction; or any act of war, declared or undeclared , or any act related to war; or military service for any country at war; or a pre-existing condition; or a covered critical illness when the date of diagnosis occurs during the waiting period; or participation in any activity or event while intoxicated or under the influence of any narcotic unless administered by a physician or taken according to the physician’s instructions; or participation in, or attempting to participate in a felony, riot or insurrection (a felony is as defined by the law of the jurisdiction in which the activity takes place). Internal cancer does not include: other conditions that may be considered pre-cancerous or having malignant potential such as: acquired immune deficiency syndrome (AIDS); or actinic keratosis; or myelodysplastic and non-malignant myeloproliferative disorders; or aplastic anemia; or atypia; or non-malignant monoclonal gamopathy; or Leukoplakia; or Hyperplasia; or Carcinold; or Polycythemia; or carcinoma in situ or any skin cancer other than invasive malignant melanoma into the dermis or deeper. For a pre-existing condition no benefits are payable.

Hospital Intensive Care Unit RiderNo benefits will be provided during the first two years of this rider for hospital intensive care unit confinement caused by any heart condition when any heart condition was diagnosed or treated prior to the 30th day following the covered person’s effective date of this rider. The heart condition causing the confinement need not be the same condition diagnosed or treated prior to the effective date. No benefits will be provided if the loss results from: attempted suicide, whether sane or insane; or intentional self-injury; or alcoholism or drug addiction; or any act of war, declared or undeclared, or any act related to war; or military service for a country at war. No benefits will be paid for confinements in units such as surgical recovery rooms, progressive care, burn units, intermediate care, private monitored rooms, observation units, telemetry units or psychiatric units not involving intensive medical care; or other facilities which do not meet the standards for intensive care unit as defined in the rider. For a newborn child born within the ten-month period following the effective date of this rider, no benefits will be provided for hospital intensive care unit confinement that begins within the first 30 days following the birth of such child.

APSB-22356(TX) MGM/FBS ESC Region 20 Benefits Co-op

GC3 Limited Benefit Group Cancer Indemnity Insurance

Monthly Premium Level 1 Level 1 + ICU Rider Level 2 Level 2 + ICU RiderIndividual $14.80 $17.80 $29.40 $32.40One-Parent Family $20.60 $24.80 $40.40 $44.60Two-Parent Family $26.40 $32.70 $51.50 $57.80

*Premium and amount of benefits provided vary dependent upon the level selected at time of application.

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Underwritten by American Public Life Insurance Company. This is a brief description of the coverage. For complete benefits, limitations, exclusions and other provisions, please refer to the policy and riders. This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. | This policy is considered an employee welfare ben-efit plan established and/or maintained by an association or employer intended to be covered by ERISA, and will be administered and enforced under ERISA. Group policies issued to governmental entities and municipalities may be exempt from ERISA guidelines. | Policy Form GC-3 Series | Texas | Limited Benefit Group Cancer Indemnity Insurance Policy | (11/14) | ESC Region 20 Benefits Co-op

Conditionally RenewableThis policy/certificate is conditionally renewable. This means that We have the right to terminate your policy/certificate on any premium due date after the first Policyholder’s Anniversary Date. We must give the Policyholder at least 60 days written notice prior to cancellation. We cannot cancel Your coverage because of a change in Your age or health. We can change Your premiums if We change premiums for all similar Certificates issued to the Policyholder. We must give the Policyholder at least 60 days written notice before We change Your premiums.

Continuation RiderContinuation Coverage is continued when the Insured (You) cease employment with the employer through whom You originally became insured under the Policy. You will have the option to continue this Certificate (including any Riders, if applicable) by paying the premiums directly to Us at Our home office. Premiums must be paid within thirty-one (31) days after employment with your employer terminates. Premium rates required under this Continuation provision will be the same rates as those charged under the Employer’s Policy as if You had continued employment. We will bill You for these premiums after You notify Us to continue this coverage. Coverage will continue until the earlier of: (1) the Policy under which You originally became insured ends; or (2) You stop paying premiums under this option (subject to the terms of the Grace Period).

ConversionIf the Employer’s Policy is terminated, this Certificate will terminate. Upon termination of the Employer’s Policy, the employee (You) will be entitled to convert to an individual policy of insurance issued by Us without evidence of insurability provided the required premiums have been paid on your behalf and You notified Us in writing within thirty-one (31) days of the Employer’s Policy termination. Premiums for the individual policy of insurance will be figured from the premium rate table in effect on the date of conversion.

Subject to the terms of this provision, a covered child who ceases to be eligible may convert to an individual policy of insurance and a covered spouse who ceases to be eligible for coverage because of divorce or annulment may convert to an individual policy.

Terms of this provision include: (1) Application for the individual policy and payment of the first premium must be made within 60 days after coverage ceases under the Policy/Certificate. Premiums will be figured from the premium rate table in effect on the date of conversion. (2) The individual policy will be issued without proof of insurability. It will provide benefits that most nearly approximates those of the Policy/Certificate. (3) The individual policy will take effect the day after coverage ceases under the Policy/Certificate. However, no benefits will be payable under the individual policy for any loss for which benefits are payable under the Policy/Certificate. (4) The Pre-Existing Condition Limitation and Time Limit on Certain Defenses provisions for the individual policy will be figured from the Covered Person’s Effective Date of coverage under the Policy/Certificate. (5) Any benefit maximums will be figured from the Effective Date of the Policy/Certificate.

This rider is subject to all the provisions of the Policy and Certificate to which it is attached that are not in conflict with this rider.

Termination of CoverageYour Insurance coverage will end on the earliest of these dates: (a) the date You no longer qualify as an Insured; (b) the last day of the period for which a premium has been paid, subject to the Grace Period; (c) the date the Policy terminates (See Conversion provision); (d) the date You retire; (e) the date You cease employment, or terminate Your contract with the employer through whom You originally became insured under the Policy (See Conversion provision); or (f) the date We receive Your written request for termination. Termination of Dependent(s) Insurance coverage on Your Dependent(s) will end on the earliest of these dates: (a) the date the coverage under the Certificate terminates; (b) the date the Dependent no longer meets the definition of Dependent, as defined in the Policy/Certificate (See Conversion provision); (c) the date We receive Your written request for termination. Termination of Rider Coverage This rider terminates: (a) when Your coverage terminates under the Policy/Certificate to which this Rider is attached; or, (b) when any premium for this rider is not paid before the end of the Grace Period; or, (c) when You give Us a written request to do so. Coverage on a Dependent terminates under this rider when such person ceases to meet the definition of Dependent, as defined in the Policy.

APSB-22356(TX) MGM/FBS ESC Region 20 Benefits Co-op

2305 Lakeland Drive | Flowood, MS 39232ampublic.com | 800.256.8606

GC3 Limited Benefit Group Cancer Indemnity Insurance

41

TEXAS LIFE

Individual Life YOUR BENEFITS PACKAGE

Individual life is a policy that provides a specified death benefit to your beneficiary at the time of death. The advantage of having an individual life insurance plan as opposed to a group supplemental term life plan is that this plan is guaranteed renewable, portable and typically premiums remain the same over the life of the policy.

About this Benefit

x 10

Experts recommend at least

your gross annual income in coverage when purchasing life insurance.

DID YOU KNOW?



Individual Life

Life Insurance Highlights

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

High Death Benefit. With one of the highest death benefit available at the worksite,1 PureLife-plus gives your loved ones peace of mind, knowing there will be significant life insurance in force should you die prematurely.

Minimal Cash Value. Designed to provide high death benefit, PureLife-plus does not compete with the cash accumulation in your employer-sponsored retirement plans.

Long Guarantees. Enjoy the assurance of a policy that has a guaranteed death benefit to age 121 and level premium that guarantees coverage for a significant period of time (after the guaranteed period, premiums may go down, stay the same, or go up).

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

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

You may apply for this permanent, portable coverage, not only for yourself, but also for your spouse, minor children and grandchildren. Like most life insurance policies, Texas Life policies contain certain exclusions, limitations, exceptions, reductions of benefits, waiting periods and terms for keeping them in force. Please contact a Texas Life representative for costs and complete details. 1Voluntary and Universal Whole Life Products, Eastbridge Consulting Group, October 2008

DID YOU KNOW? Those with no life insurance think it’s 3 times more expensive than it actually is.

43

Individual Life

Issue

PureLife-plus—Standard Risk Table Premiums—Non-Tobacco—Express Issue

Monthly Premiums for Life Insurance Face Amounts Shown

PERIOD Age to Which Coverage

is Guaranteed at Table Premium

$10,000 $15,000 $25,000 $40,000 $50,000 $75,000 $100,000 $125,000 $150,000 15D-10

7.75

11.90

14.50

21.00

27.50

34.00

40.50

75 11-16 8.00 70 17-20 8.00 66

21

8.25 12.30 15.00 21.75 28.50 35.25 42.00 66 22 8.25 12.30 15.00 21.75 28.50 35.25 42.00 65

23-25 8.50 12.70 15.50 22.50 29.50 36.50 43.50 63 26

8.75 13.10 16.00 23.25 30.50 37.75 45.00 63 27 9.00 13.50 16.50 24.00 31.50 39.00 46.50 63 28 9.00 13.50 16.50 24.00 31.50 39.00 46.50 62 29

9.25 13.90 17.00 24.75 32.50 40.25 48.00 62 30-31 9.50 14.30 17.50 25.50 33.50 41.50 49.50 60

32 10.00 15.10 18.50 27.00 35.50 44.00 52.50 61 33

10.50 15.90 19.50 28.50 37.50 46.50 55.50 62 34 11.00 16.70 20.50 30.00 39.50 49.00 58.50 62 35 11.75 17.90 22.00 32.25 42.50 52.75 63.00 64 36

12.25 18.70 23.00 33.75 44.50 55.25 66.00 64 37 12.75 19.50 24.00 35.25 46.50 57.75 69.00 64 38 13.50 20.70 25.50 37.50 49.50 61.50 73.50 65 39

14.50 22.30 27.50 40.50 53.50 66.50 79.50 66 40 15.50 23.90 29.50 43.50 57.50 71.50 85.50 67 41 16.75 25.90 32.00 47.25 62.50 77.75 93.00 68 42

18.50 28.70 35.50 52.50 69.50 86.50 103.50 70 43 20.25 31.50 39.00 57.75 76.50 95.25 114.00 72 44 22.00 34.30 42.50 63.00 83.50 104.00 124.50 73 45

24.00 37.50 46.50 69.00 91.50 114.00 136.50 74 46 26.00 40.70 50.50 75.00 99.50 124.00 148.50 75 47 27.75 43.50 54.00 80.25 106.50 132.75 159.00 76 48

14.80

21.45

29.75 46.70 58.00 86.25 114.50 142.75 171.00 77 49 32.00 50.30 62.50 93.00 123.50 154.00 184.50 78 50 34.75 54.70 68.00 101.25 79 51 16.10 23.40 38.00 59.90 74.50 111.00

80 52 17.70 25.80 42.00 66.30 82.50 123.00 82 53 19.30 28.20 46.00 72.70 90.50 135.00 83 54 20.90 30.60 50.00 79.10 98.50 147.00

85 55 22.30 32.70 53.50 84.70 105.50 157.50 86 56 23.30 34.20 56.00 88.70 110.50 165.00 85 57 24.00 35.25 57.75 91.50 114.00 170.25

84 58 24.80 36.45 59.75 94.70 118.00 176.25 84 59 25.80 37.95 62.25 98.70 123.00 183.75 84 60 27.30 40.20 66.00 104.70 130.50 195.00

84 61 29.60 43.65 71.75 113.90 142.00 212.25 85 62 32.40 47.85 78.75 125.10 156.00 233.25 87 63 35.50 52.50 86.50 137.50 171.50 256.50

89 64 39.60 58.65 96.75 153.90 192.00 287.25 93 65 42.50 63.00 104.00 165.50 206.50 309.00 94 66 45.30

95 67 47.80 96 68 50.40 96 69 53.20

96

70 56.20 95

PureLife-plus is permanent life insurance to Attained Age 121 that can never be cancelled as long as you pay the necessary premiums. After the Guaranteed Period, the premiums can be lower, the same, or higher than the Table Premium. See the brochure under ”Permanent Coverage”.

44

Individual Life

Issue Age (ALB)

PureLife-plus—Standard Risk Table Premiums—Tobacco—Express Issue

Monthly Premiums for Life Insurance Face Amounts Shown

GUARANTEED PERIOD Age to Which Coverage

is Guaranteed at Table Premium

$10,000 $15,000 $25,000 $40,000 $50,000 $75,000 $100,000 $125,000 $150,000 15D-10 11-16 17-20

12.25

18.70

23.00

33.75

44.50

55.25

66.00

66 21

12.75 19.50 24.00 35.25 46.50 57.75 69.00 66 22 12.75 19.50 24.00 35.25 46.50 57.75 69.00 65

23-25 13.50 20.70 25.50 37.50 49.50 61.50 73.50 63 26

13.75 21.10 26.00 38.25 50.50 62.75 75.00 63 27 14.00 21.50 26.50 39.00 51.50 64.00 76.50 63 28 14.25 21.90 27.00 39.75 52.50 65.25 78.00 62 29

14.50 22.30 27.50 40.50 53.50 66.50 79.50 62 30-31 16.50 25.50 31.50 46.50 61.50 76.50 91.50 60

32 17.00 26.30 32.50 48.00 63.50 79.00 94.50 61 33

11.85

17.25 26.70 33.00 48.75 64.50 80.25 96.00 62 34 17.50 27.10 33.50 49.50 65.50 81.50 97.50 62 35 18.75 29.10 36.00 53.25 70.50 87.75 105.00 64 36

12.30 19.50 30.30 37.50 55.50 73.50 91.50 109.50 64 37 13.05 20.75 32.30 40.00 59.25 78.50 97.75 117.00 64 38 13.50 21.50 33.50 41.50 61.50 81.50 101.50 121.50 65 39

11.00 14.40 23.00 35.90 44.50 66.00 87.50 109.00 130.50 66

40 15.75 25.25 39.50 49.00 72.75 96.50 120.25 144.00 67 41 11.70 16.80 27.00 42.30 52.50 78.00 103.50 129.00 154.50 68 42 12.60 18.15 29.25 45.90 57.00 84.75 112.50 140.25 168.00 70 43 14.00 20.25 32.75 51.50 64.00 95.25 126.50 157.75 189.00 72 44 14.80 21.45 34.75 54.70 68.00 101.25 134.50 167.75 201.00 73 45 15.90 23.10 37.50 59.10 73.50 109.50 145.50 181.50 217.50 74 46 16.90 24.60 40.00 63.10 78.50 117.00 155.50 194.00 232.50 75 47 17.90 26.10 42.50 67.10 83.50 124.50 165.50 206.50 247.50 76 48 18.90 27.60 45.00 71.10 88.50 132.00 175.50 219.00 262.50 77 49 20.50 30.00 49.00 77.50 96.50 144.00 191.50 239.00 286.50 78 50 21.60 31.65 51.75 81.90 102.00 152.25 79 51 23.30 34.20 56.00 88.70 110.50 165.00

80 52 25.40 37.35 61.25 97.10 121.00 180.75 82 53 27.10 39.90 65.50 103.90 129.50 193.50 83 54 29.20 43.05 70.75 112.30 140.00 209.25

85 55 30.70 45.30 74.50 118.30 147.50 220.50 86 56 32.00 47.25 77.75 123.50 154.00 230.25 85 57 33.00 48.75 80.25 127.50 159.00 237.75

84 58 34.80 51.45 84.75 134.70 168.00 251.25 84 59 36.30 53.70 88.50 140.70 175.50 262.50 84 60 38.10 56.40 93.00 147.90 184.50 276.00

84 61 40.70 60.30 99.50 158.30 197.50 295.50 85 62 44.00 65.25 107.75 171.50 214.00 320.25 87 63 47.40 70.35 116.25 185.10 231.00 345.75

89 64 51.10 75.90 125.50 199.90 249.50 373.50 93 65 53.60 79.65 131.75 209.90 262.00 392.25 94 66 56.40

95 67 59.20 96 68 62.30 96 69 65.50

96

70 69.00 95

PureLife-plus is permanent life insurance to Attained Age 121 that can never be cancelled as long as you pay the necessary premiums. After the Guaranteed Peri-od, the premiums can be lower, the same, or higher than the Table Premium. See the brochure under ”Permanent Coverage”.

45

Group term life is the most inexpensive way to purchase life insurance. You have the freedom to select an amount of life insurance coverage you need to help protect the well-being of your family. Accidental Death & Dismemberment is life insurance coverage that pays a death benefit to the beneficiary, should death occur due to a covered accident. Dismemberment benefits are paid to you, according to the benefit level you select, if accidentally dismembered.

About this Benefit

Life and AD&D

cause of accidental deaths in the US, followed by poisoning, falls,

drowning, and choking.

DID YOU KNOW?

#1

Motor vehicle crashes are the


ESC Region 20 BC Benefits Website: www.esc20bc.net


46

Basic & Voluntary Term Life

Basic Term Life Insurance Coverage

(paid by your employer) Eligibility - Active, full-time Employees of the Employer regularly working a minimum of 20 hours per week. El Benefit Amount and Maximum based on the option chosen by your employer:

Option I: $5,000

Option II: $10,000

Option III: $15,000

Option IV: $20,000

Option V: $50,000 Benefit Reduction Schedule – Benefits will reduce to 65% at age 65, 50% at age 70, 25% at age 75.

Voluntary Term Life Insurance Coverage (paid by you)

Employee – If you are an active, full-time employee and work at least 18.75 hours per week for your employer, you are eligible for coverage on the first of the month after 30 days of active service.

Benefit Amount –1 to 7 X Annual Compensation

Guaranteed Coverage Amount – $200,000

Maximum – The lesser of 7 times Annual Compensation rounded to the next higher $10,000 or $500,000

Benefit Reduction Schedule –Providing you are still employed, your benefits will reduce to 65% at age 65, 50% at age 70, 25% at age 75.

Your Spouse* — terms at age 70 - is eligible provided that you apply for and are approved for coverage for yourself.

Benefit Amount – Units of $10,000

Guaranteed Coverage Amount - $50,000

Maximum – $500,000, not to exceed 100% of the employee’s coverage amount

Your Unmarried, Dependent Children — Under age 26 , as long as you apply for and are approved for coverage for yourself.

Benefit Amount – $10,000

Maximum – $10,000 No one may be covered more than once under this plan.

Guaranteed Coverage for Voluntary Term Life Insurance Coverage Guaranteed Coverage Amount is the amount of coverage you can elect without answering any medical questions or taking a health exam. Guaranteed Coverage is only available during Initial Enrollment and other times as approved. If you apply for coverage that is above the Guaranteed Coverage Amount, or if you are applying for coverage after 31 days after you become eligible, you must fill out a Medical Evidence of Insurability form. All dependent child benefits are guaranteed issue.

Other Coverage Features Accelerated Death Benefit — Terminal Illness If you or your spouse is diagnosed by two unaffiliated physicians as terminally ill with a life expectancy of 12 months or less, the benefit for terminal illness provides for up to 75% of the Term Life Insurance coverage amount inforce or $250,000, whichever is less, to be paid to the insured. This benefit is payable only once in the insured's lifetime, and will reduce the life insurance death benefit. Continuation for Disability for Employees Age 60 or over If your active service ends due to disability, at age 60 or over, your coverage will continue while you are disabled. Benefits will remain in force until the earliest of: the date you are no longer disabled, the date the policy terminates, the date you are Disabled for 12 consecutive months, or the day after the last period for which premiums are paid. You are considered disabled if, because of injury or sickness, you are unable to perform all the material duties of your Regular Occupation, or you are receiving disability benefits under your Employer’s plan. Extended Death Benefit The extended death benefit ensures that if you become disabled prior to age 60, and die before it is determined if you qualify for Waiver of Premium, we will pay the life insurance benefit if you remain disabled during that period. If you qualify for this benefit and have insured your spouse or children, their coverage is also extended. No additional premium payment is required for the extended coverage. Waiver of Premium If you are totally disabled prior to age 60 and can't work for at least 9 months, you won't need to pay premiums for your coverage while you are disabled, provided the insurance

47

Basic & Voluntary Term Life

company approves you for this benefit. You are considered totally disabled when you are completely unable to engage in any occupation for wage or profit because of injury or sickness. This benefit will remain in force until age 65, subject to proof of continuing disability each year. If you qualify and have insured your spouse or children, their premium is also waived. Conversion If group life insurance coverage is reduced or ends for any reason except nonpayment of premiums, you can convert to an individual policy. To convert, you must apply for the conversion policy and pay the first premium payment within 31 days after your group coverage ends. Family members may convert their coverage as well. Converted policies are subject to certain benefits and limits as outlined in the conversion

brochure which may be requested as needed. Premiums may change at this time. Portability This plan allows you to continue all of your voluntary coverage if you leave your employer. Premiums may change at this time. Just pay your premiums directly to the insurance company. Coverage may be continued for you and your spouse until age 70. Coverage may also be continued for your children. Exclusions Voluntary life insurance will not be paid if loss of life is the result of suicide that occurs within the first two years of coverage.

How Much Your Coverage Will Cost Per Month (costs are subject to change)

Age Employee Cost Per $10,000

Spouse Cost Per $10,000

Age Employee Cost

Per $10,000

Spouse Cost Per $10,000

Benefit Premium Cost

<29

$0.50

$0.50

60-64

$5.90

$5.90

Voluntary Child per $10,000 of Coverage Elected

$1.80

30-34 $0.70 $0.70 65-69 $8.26 $8.26

35-39 $0.80 $0.80 70-74 $10.30

40-44 $1.00 $1.00 75-79 $14.70

45-49 $1.40 $1.40 80+ $14.70

50-54 $2.40 $2.40

55-59 $3.90 $3.90

Cost Calculation Example

Age Monthly Cost per $10,000

Benefit Monthly

Cost Example 33 .70 X 100,000 / 10,000 = $7.00

Yours X / 10,000 =

48

Voluntary Personal Accident

Basic Personal Accident Insurance Coverage (paid by your employer)

Employee - If you are an active, full-time employee and work at least 18.75 hours per week for your employer, you are eligible for coverage on the first of the month after 30 days of active service Benefit Amount and Maximum based on the option chosen by your employer:

Option I: $5,000

Option II: $10,000

Option III: $15,000

Option IV: $20,000

Option V: $50,000 Benefit Reduction Schedule – Benefits will reduce to 65% at age 65, 50% at age 70, 25% at age 75.

Voluntary Personal Accident Insurance Coverage (paid by you)

Employee - If you are an active, full-time employee and work at least 18.75 hours per week for your employer, you are eligible for coverage on the first of the month after 30 days of active service

Benefit Amount – Units of $10,000

Maximum – $500,000

Benefit Reduction Schedule – Providing you are still employed, your benefits will reduce to 65% at age 70, 45% at age 75, 30% at age 80, 15% at age 85+.

Family Plan Benefit Based on Family members at time of accident:

50% for spouse if no children

50% for spouse if eligible children

10% for children if eligible spouse

10% for children if no spouse Spouse maximum principle sum: - $250,000 Child maximum principle sum: - $50,000 No one may be covered more than once under this plan. You may need to request changes to your existing coverage if, in the future, you no longer have dependents who qualify for

coverage. We will refund premium if you do not notify us of this and it is determined at the time of a claim that premium has been overpaid.

How Much Your Coverage Will Cost Per Month The cost of the voluntary insurance is paid by you. Indicate your choice, or your decision not to elect coverage, on your enrollment form. The monthly cost per $1,000 of coverage is $0.025 for Employee, $0.04 for Family. Costs are subject to change.

A Valuable Combination of Benefits To help survivors of severe accidents adjust to new living circumstances, we will pay benefits according to the chart below.

If, within 365 days of a covered accident, bodily injuries result in:

We will pay this % of the benefit

amount: Loss of life 100%

Total paralysis of upper and lower limbs, or

Loss of any combination of two: hands, feet or eyesight, or

Loss of speech and hearing in both ears

100%

Total paralysis of both lower or upper limbs

75%

Total paralysis of upper and lower limbs on one side of the body, or Loss of hand, foot or sight in one eye, or

Loss of speech or loss of hearing in both ears, or

Severance and Reattachment of one hand or foot

50%

Total paralysis of one upper or lower limb, or

Loss of all four fingers of the same hand, or

Loss of thumb and index finger of the same hand

25%

Loss of all toes of the same foot 20%

49


What is Not Covered Self-inflicted injuries or suicide while sane or insane; commission or attempt to commit a felony or an assault; any act of war, declared or undeclared; any active participation in a riot, insurrection or terrorist act; bungee jumping; parachuting; skydiving; parasailing; hang-gliding; sickness, disease, physical or mental impairment, or surgical or medical treatment thereof, or bacterial or viral infection; voluntarily using any drug, narcotic, poison, gas or fumes except one prescribed by a licensed physician and taken as prescribed; while operating any type of vehicle while under the influence of alcohol or any drug, narcotic or other intoxicant including any prescribed drug for which the covered person has been provided a written warning against operating a vehicle while taking it; while the covered person is engaged in the activities of active duty service in the military, navy or air force of any country or international organization (this does not include Reserve or National Guard training, unless it extends beyond 31 days); traveling in an aircraft that is owned, leased or controlled by the sponsoring organization or any of its subsidiaries or affiliates; air travel, except as a passenger on a regularly scheduled commercial airline or in an aircraft being used by the Air Mobility Command or its foreign equivalent; being flown by the covered person or in which the covered person is a member of the crew.

When Your Coverage Begins and Ends Coverage becomes effective on the later of the program’s effective date, the date you become eligible, the date we receive your completed enrollment form, or the date you authorize any necessary payroll deductions. Your coverage will not begin unless you are actively at work on the effective date. Dependent coverage will not begin for any dependent who on the effective date is hospital or home confined; receiving chemotherapy or radiation treatment; or disabled and under the care of a physician. Coverage will continue while you and your dependents remain eligible, the group policy is in force, and required premiums are paid.

Additional Benefits of Personal Accident Insurance For Wearing a Seatbelt & Protection by an Airbag Additional 10% benefit but not more than $25,000 if the covered person dies in an automobile accident while wearing a seatbelt or approved child restraint. We will increase the benefit by an additional 5% but not more than $5,000 if the insured person was also positioned in a seat protected by a properly-functioning and properly deployed Supplemental Restraint System (Airbag).

For Comas 1% of full benefit amount, for up to 11 months, if you, your spouse, or your children are in a coma for 30 days or more as a result of a covered accident. If the covered person is still in a coma after 11 months, or dies, the full benefit amount will be paid.

For Exposure & Disappearance Benefits are payable if you or an insured family member suffer a covered loss due to unavoidable exposure to the elements as a result of a covered accident. If your or an insured family member's body is not found within one year of the disappearance, wrecking or sinking of the conveyance in which you or an insured family member were riding, on a trip otherwise covered, it will be presumed that you sustained loss of life as a result of a covered accident.

For Furthering Education If you die in a covered accident, we will pay an extra benefit for each insured child under age 25 who enrolls in a school of higher learning within one year of your death.

50


We will increase your benefit by 3% or $3,000, whichever is less, for each qualifying child, each year for 4 consecutive years as long as your child continues his/her education. If there is no qualifying child, we will pay an additional $1,000 to your beneficiary.

For Child Care Expenses If you die as a result of a covered accident, we will pay a benefit for a surviving child under 13 who is enrolled in a licensed child care center at the time of the accident or within 90 days afterwards. This benefit is 3% of your benefit amount per year, but not more than $3,000 per year for 5 years or until the child turns 13, whichever occurs first, for each covered child

For Training for Your Spouse If you die from a covered accident, your spouse will receive educational reimbursement if he or she enrolls, within 3 years of your death, in an accredited school to gain skills needed for employment. We will pay the actual cost of the education or training program to 3% of your benefit amount, not exceeding $5,000.

51

A Health Savings Account is a tax-advantaged medical savings account available to employees who are enrolled in a high-deductible health plan. The funds contributed to the account are not subject to federal income tax at the time of deposit. Unlike a flexible spending account (FSA), funds roll over and accumulate year to year if not spent.

About this Benefit

HSA (Health Savings Account)

The interest earned in an HSA is tax free.

DID YOU KNOW?

Money withdrawn for medical spending never falls under taxable income.



HSA BANK YOUR BENEFITS PACKAGE

52

HSA (Health Savings Account)

HSA Bank has teamed up with your employer to create an affordable health coverage option that helps you save on healthcare expenses. This plan is only available for those who are participating in the Active Care 1-HD medical plan. You may not enroll in the MEDlink® plan if you participate in the HSA. Depending on your district, you may or may not be able to participate in the FSA plan if you participate in HSA. Medicare, Medicaid, and Tricare participants are not eligible to participate in an HSA. You can use your Health Savings Account (HSA) to pay for a wide range of IRS-qualified medical expenses for yourself, your spouse or tax dependents. An IRS-qualified medical expense is defined as an expense that pays for healthcare services, equipment, or medications. Funds used to pay for IRS-qualified medical expenses are always tax-free.

What is an HSA? A tax-advantaged savings account that you use to pay for

eligible medical expenses as well as deductible, co-insurance, prescriptions, vision and dental care. Allows you to save while reducing your taxable income.

Unused funds that will roll over year to year. There’s no “use it or lose it” penalty.

A way to accumulate additional retirement savings. After age 65, funds can be withdrawn for any purpose without penalty.

Using Funds Debit Card

You may use the card to pay merchants or service providers that accept VISA credit cards, so there is no need to pay cash up front and wait for reimbursements.

You can make a withdrawal at any time. Reimbursements for qualified medical expenses are tax free. If you are disabled or reach age 65, you can receive non-medical distributions without penalty, but you must report the distributions as taxable income. You may also use your funds for a spouse or tax dependent not covered by your HDHP.

2016 Annual HSA Contribution Limits Individual: $3,350 Family: $6,750 Catch-Up Contributions: Accountholders who meet the qualifications noted below are eligible to make an HSA catch-up contribution of an additional $1,000.

Health Savings accountholder

Age 55 or older (regardless of when in the year an accountholder turns 55)

Not enrolled in Medicare (if an accountholder enrolls in Medicare mid-year, catch-up contributions should be prorated)

Authorized Signers who are 55 or older must have their own HSA in order to make the catch-up contribution Monthly Fee: Your account will be charged a monthly fee of $1.75, waived with an average daily balance at or above $3,000.

Examples of Qualified Medical Expenses Surgery

Braces

Contact lenses

Dentures

Eyeglasses

Vaccines For a list of sample expenses, please refer to the ESC Region 20 BC website at www.esc20bc.net

HSA Bank Contact Information 605 N. 8th Street, Ste 320 Sheboygan, WI 53081 Phone: 800-357-6246 www.hsabank.com

53

A Health Savings Account (HSA) is an individually-owned, tax-advantaged account that you can use to pay for current or future IRS-qualified medical expenses. With an HSA, you’ll have the potential to build more savings for healthcare expenses or additional retirement savings through self-directed investment options1.

How an HSA works: You can contribute to your HSA via payroll deduction,

online banking transfer, or by sending a personal check to HSA Bank. Your employer or third parties, such as a spouse or parent, may contribute to your account as well.

You can pay for qualified medical expenses with your HSA Bank Debit Card directly to your medical provider or pay out-of-pocket. You can either choose to reimburse yourself or keep the funds in your HSA to grow your savings.

Unused funds will roll over year to year. After age 65, funds can be withdrawn for any purpose without penalty (subject to ordinary income taxes).

Check balances and account information via HSA Bank’s Internet Banking 24/7.

Are you eligible for an HSA? If you have a qualified High Deductible Health Plan (HDHP) - either through your employer, through your spouse, or one you’ve purchased on your own - chances are you can open an HSA. Additionally:

You cannot be covered by any other non-HSA-compatible health plan, including Medicare Parts A and B.

You cannot be covered by TriCare.

You cannot have accessed your VA medical benefits in the past 90 days (to contribute to an HSA).

You cannot be claimed as a dependent on another person’s tax return (unless it’s your spouse).

You must be covered by the qualified HDHP on the first day of the month.

When you open an account, HSA Bank will request certain information to verify your identity and to process your application.

What are the annual IRS contribution limits? Contributions made by all parties to an HSA cannot exceed the annual HSA limit set by the Internal Revenue Service (IRS). Anyone can contribute to your HSA, but only the accountholder and employer can receive tax deductions on those contributions. Combined annual contributions for the accountholder, employer, and third parties (i.e., parent, spouse, or anyone else) must not exceed these limits2.

2016 Annual HSA Contribution Limits Individual = $3,350 Family = $6,750

Catch-up Contributions Accountholders who meet these qualifications are eligible to make an HSA catch-up contribution of $1,000: Health Savings accountholder; age 55 or older (regardless of when in the year an accountholder turns 55); not enrolled in Medicare (if an accountholder enrolls in Medicare mid-year, catch-up contributions should be prorated). Authorized signers who are 55 or older must have their own HSA in order to make the catch-up contribution. According to IRS guidelines, each year you have until the tax filing deadline to contribute to your HSA (typically April 15 of the following year). Online contributions must be submitted by 2:00 p.m., Central Time, the business day before the tax filing deadline. Wire contributions must be received by noon, Central Time, on the tax filing deadline, and contribution forms with checks must be received by the tax filing deadline.

How can you benefit from tax savings? An HSA provides triple tax savings3. Here’s how:

Contributions to your HSA can be made with pre-tax dollars and any after-tax contributions that you make to your HSA are tax deductible.

HSA funds earn interest and investment earnings are tax free.

When used for IRS-qualified medical expenses, distributions are free from tax.

IRS-Qualified Medical Expenses You can use your HSA to pay for a wide range of IRS-qualified medical expenses for yourself, your spouse, or tax dependents. An IRS-qualified medical expense is defined as an expense that pays for healthcare services, equipment, or medications. Funds used to pay for IRS-qualified medical expenses are always tax-free. HSA funds can be used to reimburse yourself for past medical expenses if the expense was incurred after your HSA was established. While you do not need to submit any receipts to HSA Bank, you must save your bills and receipts for tax purposes.

How the HSA Plan Works

54

How the HSA Plan Works

Examples of IRS-Qualified Medical Expenses4:

For assistance, please contact the Client Assistance Center 800-357-6246 Monday – Friday, 7 a.m. – 9 p.m., and Saturday, 9 a.m. - 1 p.m., CT www.hsabank.com | 605 N. 8th Street, Ste. 320, Sheboygan, WI 53081 1 Investment accounts are not FDIC insured, may lose value and are not a deposit or other obligation of, or guarantee by the bank. Investment losses which are replaced are subject to the annual contribution limits of the HSA. 2 HSA funds contributed in excess of these limits are subject to penalty and tax unless the excess and earnings are withdrawn prior to the due date, including any extensions for filing Federal Tax returns. Accountholders should consult with a qualified tax advisor in connection with excess contribution removal. The Internal Revenue Service requires HSA Bank to report withdrawals that are considered refunds of excess contributions. In order for the withdrawal to be accurately reported, accountholders may not withdraw the excess directly. Instead, an excess contribution refund must be requested from HSA Bank and an Excess Contribution Removal Form completed. 3 Federal Tax savings are available no matter where you live and HSAs are taxable in AL, CA, and NJ. HSA Bank does not provide tax advice. Consult your tax professional for tax‐related questions. 4 This list is not comprehensive. It is provided to you with the understanding that HSA Bank is not engaged in rendering tax advice. The information provided is not intended to be used to avoid Federal tax penalties. For more detailed information, please refer to IRS Publication 502 titled, “Medical and Dental Expenses”. Publications can be ordered directly from the IRS by calling 1-800-TAXFORM. If tax advice is required, you should seek the services of a professional. 5 Insurance premiums only qualify as an IRS-qualified medical expense: while continuing coverage under COBRA; for qualified long-term care coverage; coverage while receiving unemployment compensation; for any healthcare coverage for those over age 65 including Medicare (except Medicare supplemental coverage).

Acupuncture Alcoholism treatment Ambulance services Annual physical examination Artificial limb or prosthesis Birth control pills (by prescription) Chiropractor Childbirth/delivery Convalescent home (for medical treatment only) Crutches Doctor’s fees Dental treatments (including x-rays, braces, dentures, fillings, oral surgery) Dermatologist Diagnostic services Disabled dependent care Drug addiction therapy Fertility enhancement (including in-vitro fertilization) Guide dog (or other service animal)

Gynecologist Hearing aids and batteries Hospital bills Insurance premiums5

Laboratory fees Lactation expenses Lodging (away from home for outpatient care) Nursing home Nursing services Obstetrician Osteopath Oxygen Pregnancy test kit Podiatrist Prescription drugs and medicines (over-the-counter drugs are not IRS- qualified medical expenses unless prescribed by a doctor) Prenatal care & postnatal treatments Psychiatrist Psychologist Smoking cessation programs

Special education tutoring Surgery Telephone or TV equipment to assist the hearing or vision impaired Therapy or counseling Medical transportation expenses Transplants Vaccines Vasectomy Vision care (including eyeglasses, contact lenses, lasik surgery) Weight loss programs (for a specific disease diagnosed by a physician – such as obesity, hypertension, or heart disease) Wheelchairs X-rays

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A Cafeteria Plan is designed to take advantage of Section 125 of the Internal Revenue Code. It allows you to pay certain qualified expenses on a pre-tax basis, thereby reducing your taxable income. You can set aside a pre-established amount of money per plan year in a Healthcare Flexible Spending Account (FSA). Funds allocated to a healthcare FSA must be used during the plan year or are forfeited unless your plan contains a $500 rollover or grace period provision.

Unlimited FSA (Non HSA Compatible) The funds in the unlimited healthcare FSA can be used to pay for eligible medical expenses like deductibles, co-payments, orthodontics, glasses and contacts.

About this Benefit



FSA (Flexible Spending Account)

FOR HSA VS. FSA COMPARISON

FLIP TO… PG. 11

NBS YOUR BENEFITS PACKAGE

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NBS Flexcard You may use the card to pay merchants or service providers that accept MasterCard® credit cards, so there is no need to pay cash up front, then wait for reimbursement. If you are participating in the Dependent Care portion, the money isn’t loaded to the card. You must file web or paper claims or enroll in continual reimbursement.

Current plan participants: KEEP YOUR CARDS! NBS debit cards are good for 3 years. If you throw away your cards, there is a $5.00 fee to replace them.

New Plan Participants NBS will mail out your new benefit cards to the address listed in THEbenefitsHUB. They will be sent in unmarked envelopes so please watch for them as they should arrive within 21 business days of effective date. NBS debit cards are good for 3 years.

FSA Annual Contribution Max: $2,550

Dependent Care Annual Max: $5,000

Account Information: Participant Account Web Access: www.participant.nbsbenefits.com Participants may call NBS and talk to a representative during regular business hours, Monday-Friday, 8 am to 7 pm Central Time. Participants can also obtain account information using the Automated Voice Response Unit, 24 hours a day, 7 days a week at (801) 838-7324 or toll free (800) 274-0503. For immediate access to your account information at any time, log on to the NBS website: www.NBSbenefits.com

Detailed claim history and processing status

Health Care and Dependent Care account balances

Claim forms, Direct Deposit form, worksheets, etc.

Online claims

FAQs

For a list of sample expenses, please refer to the ESC Region 20 BC benefit website: www.esc20bc.net

NBS Contact Information:

8523 South Redwood Road West Jordan, UT 84088 Phone (800) 274‐0503 Fax (800) 478‐1528 Email: [email protected]

When Will I Receive My Flex Card? Expect Flex Cards to be delivered to the address listed in THEbenefitsHUB near the end of September. Don’t forget, Flex Cards Are Good For 3 Years!

FSA (Flexible Spending Account)

DID YOU KNOW? FSAs use tax-free funds to help pay for your Health Care Expenses.

NBS Prepaid MasterCard® Debit Card

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What is a Flexible Spending Account? A Flexible Spending Account allows you to save money by paying out-of-pocket health and/or dependent care related expenses with pre-tax dollars. Your contributions are deducted from your pay before taxes are withheld and your account is up fronted with an annual amount. Because you are taxed on a lower amount of pay, you pay less in taxes and you have more to spend.

How does a Flexible Spending Account Benefit Me? A Cafeteria plan enables you to save money on group insurance, health-related expenses, and dependent-care expenses. You may save as much as 35 percent on the cost of each benefit option! Eligible expenses must be incurred within the plan year and contributions are use-it-or- lose-it. Remember to retain all your receipts.

Health Care Expense Account Example Expenses:

Dependent Care Expense Account Example Expenses: Before and After School and/or Extended Day Programs

The actual care of the dependent in your home.

Preschool tuition.

The base costs for day camps or similar programs used as care for a qualifying individual.

What Can I Use My Flexible Spending Account On? For a full list of eligible expenses, please refer to www.esc20bc.net

What Happens If I Don’t Use All of My Funds by The End of the Plan Year (August 31st)? Eligible expenses must be incurred within the plan year +75 day grace period. Contributions are use-it-or- lose-it. Remember to retain all your receipts (including receipts for card swipes).

How Do I File A Claim? In most situations, you will be able to swipe your card however, in the event you lose your card or are waiting to receive one, you can visit www.esc20bc.net and complete the “Claim Form” to send to NBS or use the web or phone app to file online.

Hearing aids & batteries

Lab fees

Laser Surgery

Orthodontia Expenses

Physical exams

Pregnancy tests

Prescription drugs

Vaccinations

Vaporizers or humidifiers

Acupuncture

Body scans

Breast pumps

Chiropractor

Co-payments

Deductible

Diabetes Maintenance

Eye Exam & Glasses

Fertility treatment

First aid

FSA Frequently Asked Questions

How To Receive Your Dependent Care Reimbursement Faster.

A Direct Deposit form is available on the Benefits Website which will help you get reimbursed quicker!

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How the FSA Plan Works

You designate an annual election of pre-tax dollars to be deposited into your health and dependent-care spending accounts. Your total election is divided by the number of pay periods in the Plan year and deducted equally from each paycheck before taxes are calculated. By the end of the Plan year, your total election will be fully deposited. However, you may make a claim for eligible health FSA expenses as soon as they are incurred during the Plan year. Eligible claims will be paid up to your total annual election even if you have not yet contributed that amount to your account.

Get Your Money 1. Complete and sign a claim form (available on our website) or an online claim. 2. Attach documentation; such as an itemized bill or an Explanation of Benefits (EOB) statement from a health insurance provider. 3. Fax or mail signed form and documentation to NBS. 4. Receive your non-taxable reimbursement after your claim is processed either by check or direct deposit.

NBS Flexcard—FSA Pre-paid Benefit Card Your employer may sponsor the use of the NBS Flexcard, making access to your flex dollars easier than ever. You may use the card to pay merchants or service providers that accept credit cards, so there is no need to pay cash up front then wait for reimbursement.

Account Information Participants may call NBS and talk to a representative during our regular business hours, Monday–Friday, 7am to 6pm Mountain Time. Participants can also obtain account information using the Automated Voice Response Unit, 24 hours a day, 7 days a week at (801) 838-7324 or toll free (800) 274-0503. For immediate access to your account information at any time, log on to our website: www.NBSbenefits.com Information includes:

Detailed claim history and processing status

Health Care and Dependent Care account balances

Claim forms, worksheets, etc.

Online Claim Submission

Enrollment Considerations After the enrollment period ends, you may increase, decrease, or stop your contribution only when you experience a qualifying “change of status” (marriage status, employment change, dependent change). Be conservative in the total amount you elect to avoid forfeiting money that may be left in your account at the end of the year. Your employer may allow a short grace period after the Plan year ends for you to submit qualified claims for any unused funds.

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

About this Benefit

Identity Theft



ID WATCHDOG

An identity is stolen every

2 seconds, and takes over

300 hours to resolve, causing an

average loss of $9,650.

DID YOU KNOW?


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Identity Theft

Identity theft can strike anyone, at any time. More than 11 million Americans were victimized by identity theft in 2011, including more than 500,000 children.

Identity theft devastates its victims financially. The average victim will lose $4,841, and spend an additional $1,400 in out-of-pocket expenses resolving their case.

Repairing the damage caused by identity theft is frustrating and time consuming. The average victim spends 330 hours repairing the damage from identity theft—the equivalent of working a full-time job for more than 2 months.

The impact of identity theft follows victims for years. 50% of identity theft victims experience trouble getting loans or credit cards as a result of identity theft. 12% of identity theft victims end up having warrants issued by law enforcement in their name for crimes committed by the identity thief.

Who’s Evaluating your Credit Report? Potential Creditors, Potential Employers, Insurance Companies, Current Creditors, Government Agencies

ID Watchdog Monthly Rates

Individual Plan $7.95

Family Plan $14.95

Basic & Advanced Identity Monitoring Cyber Monitoring Full-Service Identity Restoration Non-Credit Loan Monitoring Address Monitoring Credit Report Monitoring 100% Resolution Guarantee

ID Watchdog Services

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NOTES

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NOTES

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www.esc20bc.net

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2016 benefit guide esc region 20 - cigna version 1

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