2016 benefit guide palacios isd

EFFECTIVE:

09/01/2016 - 8/31/2017

BENEFIT GUIDE

www.mybenefitshub.com/palaciosisd

PALACIOS ISD

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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. ACA Employee Responsibilities 11 TRS-ActiveCare 12-13 Symetra Medical Supplement 14-15 Cigna Dental 16-19 Superior Vision 20-21 Cigna Long Term Disability 22-25 APL Cancer 26-29 Cigna Life and AD&D 30-33 5Star Individual Life w/ Critical Illness 34-37 ID Watchdog Identity Theft 38-39 NBS Flexible Spending Account (FSA) 40-43

Table of Contents

HOW TO ENROLL

PG. 4

BENEFIT UPDATE—WHAT’S NEW

PG. 6

YOUR BENEFITS PACKAGE

PG. 12

FLIP TO...

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Benefit Contact Information

PALACIOS ISD BENEFITS VISION INDIVIDUAL LIFE W/ CRITICAL ILLNESS

Financial Benefit Services (800) 583-6908 www.mybenefitshub.com/palaciosisd

Group # 325530 Superior Vision (800) 507-3800 www.superiorvision.com

5Star Life Insurance Company (800) 776-2322 www.5starlifeinsurance.com

MEDICAL LONG TERM DISABILITY IDENTITY THEFT

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

Group # VDT600930 Cigna (800) 583-6908 www.cigna.com

ID Watchdog (800) 774-3772 www.idwatchdog.com

MEDICAL SUPPLEMENT CANCER FLEXIBLE SPENDING ACCOUNT

Group # 89155 Symetra (800) 796-3872 www.symetra.com

Group # 14184 American Public Life (800) 256-8606 www.ampublic.com

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

DENTAL LIFE AND AD&D

Group # 3337069 Cigna (800) 244-6224 www.cigna.com

Life Group # SGM604163 AD&D Group # SGD604160 Cigna (800) 583-6908 www.cigna.com

Benefit Contact Information

3

!

How to Enroll

On Your Computer Access THEbenefitsHUB 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.mybenefitshub.com/

palaciosisd delivers important

benefit information with 24/7

access, as well as detailed plan

information, rates and product

videos.

TEXT

“palaciosisd”

TO

313131

On Your Device Enrolling in your benefits just got

a lot easier! Text “palaciosisd” to

313131 to receive everything you

need to complete your

enrollment.

Avoid typing long URLs and scan

directly to your benefits website,

to access plan information,

benefit guide, benefit videos, and

more!

SCAN: TRY ME

4

GO www.mybenefitshub.com/palaciosisd 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.

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Due to the Affordable Care Act (ACA), every employee is required to login & complete the enrollment process, even if you are declining benefits.

Social Security Numbers for your dependents are

required regardless if they are enrolled in coverage or not. Please make sure you have these items on hand when going through your open enrollment.

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 closes, benefit changes can only be made if you experience a qualifying event (and changes must be made within 30 days of event).

If you are electing Identity Theft protection from ID

Watchdog, please make sure you have an active email address listed in our system, as well as social security numbers for all dependents listed in the Benefits HUB.

Medical, HSA, & FSA elections will NOT rollover meaning, if you do not login & elect coverage, you will not have these benefits in the 2016 -2017 plan year. New enrollees will automatically receive the new debit card after the start of the new plan year. If you are already enrolled please do not throw away your current card they are good for 3 years.

Palacios ISD pays for Employee Tier Dental, Vision, Basic

Life and Long-Term Disability benefits. Please remember, in order to maximize insurance

coverage and reduce out of pocket expenses you should utilize In-Network providers whenever possible.

Login and complete your benefit enrollment from August 1- August 22, 2016

Enrollment assistance is available by calling Financial Benefit Services at (800) 583-6908

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

Please be sure to update your profile information: home address, phone numbers, email,

beneficiaries

Benefit Updates - What’s New:

Don’t Forget!

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

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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 your school

district’s benefit website:

www.mybenefitshub.com/palaciosisd. 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 your school

district’s benefit website:

www.mybenefitshub.com/palaciosisd. 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

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PLAN CARRIER MAXIMUM AGE

Medical Aetna To age 26

Dental Cigna To age 26

Vision Superior Vision To age 26

Cancer American Public Life To age 26

Voluntary Child(ren) Life Cigna To age 26

Identity Theft ID Watchdog To age 26

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 the Palacios ISD 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

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Mandatory Medical Enrollment After becoming eligible, you must elect or

decline medical coverage offered through

your employer.

Medical Election Employee chooses to elect on the Medical

Plans offered.

Play or Pay Rules If you elect a medical plan offered through

your employer, you will receive the IRS Tax

Form 1095 -C. You will use this document to

file your 1040 Tax Return.

However, if you choose to decline medical

coverage, you will be subject to the Individual

Mandate Penalties, unless you have a

minimum essential health plan.

2016 & Beyond

Penalty is $695 per adult and

$347.50 per child ( up to $2,085 for a

family) OR 2.5% of family income,

whichever is greater.

RECEIVE 1095 -C NO PENALTIES

Are you electing to enroll in the

medical plan?

Are you receiving medical coverage

elsewhere? *See examples below

YES

NO

NO

YES RECEIVE 1095 -C NO PENALTIES

PENALTIES ASSESSED

*Examples of other coverage:

-Military

-Medicare

-Medicaid

-Through a spouse

-Marketplace exchange

ACA 101

ACA Employee Responsibilities SUMMARY PAGES

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2015-2016 TRS-ActiveCare Plan Highlights Effective September 1, 2015 through August 31, 2016 | Network Level of Benefits*

Type of Service ActiveCare 1-HD ActiveCare Select or ActiveCare Select Whole Health

(Baptist Health System and HealthTexas Medical Group; Baylor Scott & White Quality Alliance; Memorial Hermann

Accountable Care Network; Seton Health Alliance)

ActiveCare 2

Deductible (per plan year)

$2,500 employee only $5,000 family

$1,200 individual $3,600 family


Out-of-Pocket Maximum (per plan year; does include medical deductible/ any medical copays/coinsurance/any prescription drug deductible and applicable copays/coinsurance)

$6,550 individual $13,100 family (the individual out-of-pocket maximum only includes covered expenses incurred by that individual)



Coinsurance Plan pays (up to allowable amount) Participant pays (after deductible)

80% 20%

80% 20%

80% 20%

Office Visit Copay Participant pays

20% after deductible $30 copay for primary $60 copay for specialist

$30 copay for primary $50 copay for specialist

Diagnostic Lab Participant pays

20% after deductible Plan pays 100% (deductible waived) if performed at a Quest facility; 20% after deductible at other facility

Plan pays 100% (deductible waived) if performed at a Quest facility; 20% after deductible at other facility

Preventive Care See next page for a list of services

Plan pays 100% Plan pays 100% Plan pays 100%

Teladoc® Physician Services $40 consultation fee (applies to deductible and out-of-pocket maximum)

Plan pays 100% Plan pays 100%

High-Tech Radiology (CT scan, MRI, nuclear medicine) Participant pays

20% after deductible $100 copay plus 20% after deductible $100 copay plus 20% after deductible

Inpatient Hospital (preauthorization required) (facility charges) Participant pays

20% after deductible $150 copay per day plus 20% after deductible ($750 maximum copay per admission)

$150 copay per day plus 20% after deductible($750 maximum copay per admission; $2,250 maximum copay per plan year)

Emergency Room (true emergency use) Participant pays

20% after deductible $150 copay plus 20% after deductible (copay waived if admitted)

$150 copay plus 20% after deductible (copay waived if admitted)

Outpatient Surgery Participant pays

20% after deductible $150 copay per visit plus 20% after deductible

$150 copay per visit plus 20% after deductible

Bariatric Surgery Physician charges (only covered if performed at an IOQ facility) Participant pays

$5,000 copay plus 20% after deductible

Not covered $5,000 copay (does not apply to out-of-pocket maximum) plus 20% after deductible

Prescription Drugs Drug deductible (per plan year)

Subject to plan year deductible $0 for generic drugs $200 per person for brand-name drugs

$0 for generic drugs $200 per person for brand-name drugs

Retail Short-Term (up to a 31-day supply) Participant pays • Generic copay • Brand copay (preferred list) • Brand copay (non-preferred list)

20% after deductible

$20 $40** 50% coinsurance**

$20 $40** $65**

Retail Maintenance (after first fill; up to a 31-day supply) Participant pays • Generic copay • Brand copay (preferred list) • Brand copay (non-preferred list)

20% after deductible

$35 $60** 50% coinsurance**

$35 $60** $90**

Mail Order and Retail-Plus (up to a 90-day supply) Participant pays • Generic copay • Brand copay (preferred list) • Brand copay (non-preferred list)

20% after deductible $45 $105*** 50% coinsurance

$45 $105*** $180***

Specialty Drugs Participant pays

20% after deductible 20% coinsurance per fill $200 per fill (up to 31-day supply) $450 per fill (32- to 90-day supply)

A specialist is any physician other than family practitioner, internist, OB/GYN or pediatrician. *Illustrates benefits when in-network providers are used. For some plans non-network benefits are also available; there is no coverage for non-network benefits under the ActiveCare Select or ActiveCare Select Whole Health Plan; see Enrollment Guide for more information. Non-contracting providers may bill for amounts exceeding the allowable amount for covered services. Participants will be responsible for this balance bill amount, which maybe considerable. **If the patient obtains a brand-name drug when a generic equivalent is available, the patient will be responsible for the generic copayment plus the cost difference between the brand-name drug and the generic drug.

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TRS-ActiveCare Plans—Preventive Care

Preventive Care Services

Network Benefits When Using In-Network Providers

(Provider must bill services as “preventive care”)

ActiveCare 1-HD ActiveCare Select or ActiveCare Select

Whole Health (Baptist Health System and

HealthTexas Medical Group; Baylor Scott & White Quality Alliance;

Memorial Hermann Accountable Care Network; Seton Health

Alliance)

ActiveCare 2 Network

Evidence−based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force (USPSTF www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations

Immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC) with respect to the individual involved.

Evidence−informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA) for infants, children and adolescents. Additional preventive care and screenings for women, not described above, as provided for in comprehensive guidelines supported by the HRSA www.hhs.gov/healthcare/facts-and-features/fact-sheets/preventive-services-covered-under-aca/#CoveredPreventiveServicesforAdults

For purposes of this benefit, the current recommendations of the USPSTF regarding breast cancer screening and mammography and prevention will be considered the most current (other than those issued in or around November 2009).

The preventive care services described above may change as USPSTF, CDC and HRSA guidelines are modified.

Plan pays 100% (deductible waived; no copay required) Some examples of preventive care frequency and services: Routine physicals – annually age

12 and over Well-child care – unlimited up to

age 12 Well woman exam & pap smear

– annually age 18 and over Mammograms – 1 every year age

35 and over Colonoscopy – 1 every 10 years

age 50 and over Prostate cancer screening – 1 per

year age 50 and over Smoking cessation counseling – 8

visits per 12 months Healthy diet/obesity counseling –

unlimited to age 22; age 22 and over-26 visits per 12 months

Breastfeeding support – 6 lactation counseling visits per 12 months

Plan pays 100% (deductible waived; no copay required) Some examples of preventive care frequency and services: Routine physicals –

annually age 12 and over Well-child care – unlimited

up to age 12 Well woman exam & pap

smear – annually age 18 and over

Mammograms – 1 every year age 35 and over

Colonoscopy – 1 every 10 years age 50 and over

Prostate cancer screening –1 per year age 50 and over

Smoking cessation counseling –8 visits per 12 months

Healthy diet/obesity counseling – unlimited to age 22; age 22 and over-26 visits per 12 months

Breastfeeding support –6 lactation counseling visits per 12 months

Plan pays 100% (deductible waived) Some examples of preventive care frequency and services: Routine physicals – annually

age 12 and over Well-child care – unlimited

up to age 12 Well woman exam & pap

smear – annually age 18 and over

Mammograms – 1 every year age 35 and over

Colonoscopy – 1 every 10 years age 50 and over

Prostate cancer screening – 1 per year age 50 and over

Smoking cessation counseling – 8 visits per 12 months

Healthy diet/obesity counseling – unlimited to age 22; age 22 and over-26 visits per 12 months

Breastfeeding support – 6 lactation counseling visits per 12 months

(Examples of covered services included are: Routine annual physicals (one per year); immunizations; well-child care; breastfeeding support, services and supplies; cancer screening mammograms; bone density test; screening for prostate cancer and colorectal cancer (including routine colonoscopies); smoking cessation counseling services and healthy diet counseling; and obesity screening/counseling.

Examples of covered services for women with reproductive capacity are: Female sterilization procedures and specified FDA-approved contraception methods with a written prescription by a health care practitioner, including cervical caps, diaphragms, implantable contraceptives, intra-uterine devices, injectables, transdermal contraceptives and vaginal contraceptive devices. Prescription contraceptives for women are covered under the pharmacy benefits administered by Caremark.

To determine if a specific contraceptive drug or device is included in this benefit, contact Customer Service at 1-800-222-9205. The list may change as FDA guidelines are modified.

Annual Vision Examination (one per plan year; performed by an opthalmologist or optometrist using calibrated instruments) Participant pays

After deductible, plan pays 80%; participant pays 20%

$60 copay for specialist $50 copay for specialist

Annual Hearing Examination Participant pays

After deductible, plan pays 80%; participant pays 20%



Note: Covered services under this benefit must be billed by the provider as “preventive care.” If you receive preventive services from a non-network provider, you will be responsible for any applicable deductible and coinsurance under the ActiveCare 1-HD and ActiveCare 2. Non-network preventive care is not paid at 100%. There is no coverage for non-network services under the ActiveCare Select plan or ActiveCare Select Whole Health.

TRS-ActiveCare is administered by Aetna Life Insurance Company. Aetna provides claims payment services only and does not assume any financial risk or obligation with respect to claims. Prescription drug benefits are administered by Caremark. 13

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

Medical Supplement

DID YOU KNOW?

33%

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

SYMETRA 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

Palacios ISD Benefits Website: www.mybenefitshub.com/palaciosisd 14

Medical Supplement

Select Benefits Coverages Option 1 Option 2 Option 3

Doctor's Office Visit Indemnity Benefit

$35 per visit $300 pp/pcy1

max. $40 per visit

$300 pp/pcy1 max.

$45 per visit $300 pp/pcy1

max.

Outpatient Diagnostic X-Ray & Lab Indemnity Benefit

$35 per visit $300 pp/pcy max.



Preventive Care Indemnity Benefit -- -- $50 per visit

$150 pp/pcy max.

Hospital Indemnity Benefit 500 days lifetime maximum

$100 daily hospital $200 daily ICU2

30 days pp/pcy max.


30 days pp/pcy max.


30 days pp/pcy max.

Additional Accident Benefit -- $300 pp/pcy max. $300 pp/pcy max.

Employee Life/AD&D3 Insurance Benefit $5,000 / $5,000 $5,000 / $5,000 $5,000 / $5,000

Dependent Life Insurance Benefit Spouse Child Infant

$2,500 $1,250 $200

$2,500 $1,250 $200

$2,500 $1,250 $200

Pharmacy Discount Program Included Included Included

Survivor Benefit Included Included Included

Monthly Premium

Employee and Eligible Dependents $47.72 $64.11 $82.39

1pp/pcy=per person, per calendar year 2ICU=Intensive Care Unit 3AD&D=Accidental Death & Dismemberment Insurance benefits are provided under the Select Benefits limited benefit medical insurance policy, form number LGC-3000 2/99. It is insured by Symetra Life Insurance Company. The coverage is not a substitute for major medical or other comprehensive coverage. Benefits are paid based on a preselected fixed amount. It may be subject to exclusions, limitations, reductions and terminations of benefits provisions. Please review the description of benefits for additional details. For more information, contact your agent.

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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

Benefits Cigna Dental PPO In-Network Out-of-Network Network Total Cigna DPPO Calendar Year Maximum (Class I, II, and III expenses)

$1,500 $1,500

Annual Deductible Individual Family

$50 per person $150 per family

$50 per person $150 per family

Reimbursement Levels** Based on Reduced Contracted Fees

95th 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 Fluoride Application Sealants Space Maintainers

100% No Charge 100% No Charge

Class II - Basic Restorative Care Fillings Emergency Care to Relieve Pain Root Canal Therapy/Endodontics Osseous Surgery Periodontal Scaling and Root Planing Oral Surgery – Simple Extractions

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

Class III - Major Restorative Care Crowns Surgical Extractions of Impacted Teeth Oral Surgery - all except simple extractions Brush Biopsies Anesthetics Histopathologic Exams 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% $1,500

Dependent children to age 19

50%

50% $1,500

Dependent children to age 19

50%

Class IX - Implants Deductible Annual Maximum

50%

Subject to plan deductible

Subject to plan annual maximum

50%

50%

Subject to plan deductible

Subject to plan annual maximum

50%

Monthly PPO Premiums

Tier Rate

EE Only $0.00

Family Coverage $80.08

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.

17

Dental PPO

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.

18

Dental PPO

Procedure Exclusions and Limitations Late Entrants Limit No coverage Exams Two per Calendar year Prophylaxis (Cleanings) Two per Calendar year Fluoride 1 per Calendar year for people under 19 Histopathologic Exams Various limits per Calendar year depending on specific test X-Rays (routine) Bitewings: 2 per Calendar 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 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 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

19

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 apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements. 1Contact lenses and related professional services (fitting, evaluation and follow-up) are covered in lieu of eyeglass lenses and frames benefit. 2Lasik Vision Correction is in lieu of eyewear benefit, subject to routine regulatory filings and certain exclusions and limitations 3Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay.

Vision

Discount Features

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

The Plan discount features are not insurance. All allowances are retail; the member is responsible for paying the provider directly for all non-covered items and/or any amount over the allowances, minus available discounts. These are not covered by the plan. 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

Co-Pays

Exam $10

Materials $25

Services/Frequency

Exam 12 months

Frame 24 months

Lenses 12 months

Contact Lenses 12 months

Benefits In-Network Out-of-Network

Exam Covered in full Up to $45 retail

Frames $125 retail allowance Up to $50 retail

Contact Lenses1 $125 retail allowance Up to $105 retail

Medically Necessary Contact Lenses Covered in full Up to $210 retail

Lasik Vision Correction $200 allowance2

Lenses (standard) per pair

Single Vision Covered in full Up to $45 retail

Bifocal Covered in full Up to $60 retail

Trifocal Covered in full Up to $80 retail

Progressive See description3 Up to $80 retail

Lenticular Covered in full Up to $80 retail

Monthly Premiums

EE Only $0.00

EE + Family $7.49

SuperiorVision.com Customer Service 800.507.3800

(Based on date of service)

21

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, excluding extra compensation, bonus, commission, and overtime.

Cost The cost of this insurance program is paid by your employer.

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.

Long Term Disability (LTD) Insurance Coverage

Eligibility All active, full-time U.S. Employees of the Employer regularly working a minimum of 20 hours per week.

Eligibility Waiting Period

No waiting period.

Benefit Amount Up to 66.67% of your monthly covered earnings Monthly Benefit

Maximum $5,000 per month

Elimination Period 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

24


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

25

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

YOUR

BENEFITS

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.

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

Palacios ISD Benefits Website: www.mybenefitshub.com/palaciosisd

AMERICAN PUBLIC LIFE

26

GC3 Limited Benefit Group Cancer Indemnity InsurancePalacios ISD

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 $1,000 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 $3,200 max per operation; $30 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

$200 per day 1-90 days; $200 per day, 91+ days in lieu of other benefits

US Government/Charity Hospital/HMO $100 per day in lieu of most other benefits $200 per day in lieu of most other benefits

Outpatient Hospital or Ambulatory Surgical Center Benefit

$200 per day of surgery $400 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 calendar month $50 per prescription, up to $100 per calendar 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 $200 per day, up to $10,000 per calendar year

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

Autologous - $1,000 per calendar year Non-Autologous - $3,000 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 $40 per day of confinement

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

$2,000 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 $200 per day, 1-90 days of hospital confinement

Hospice Care Benefit $50 per day, $9,000 lifetime max $75 per day, $13,500 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 $200 per day

Home Health Care Benefit $100 per day $200 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

Riders

Diagnostic 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 Up to $600 max of 30 days per ICU confinement;$100 ambulance per ICU admission

Up to $600 max of 30 days per ICU confinement;$100 ambulance per ICU admission

APSB-22356(TX) MGM/FBS Palacios ISD-0316 27

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 Palacios ISD-0316

GC3 Limited Benefit Group Cancer Indemnity Insurance

Monthly Premium Level 1 Level 1 + ICU Rider Level 2 Level 2 + ICU Rider

Individual $13.80 $17.10 $22.00 $25.30

One-Parent Family $19.10 $23.60 $30.30 $34.80

Two-Parent Family $24.30 $31.20 $38.50 $45.40

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

28

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) | Palacios ISD

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 Palacios ISD-0316

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

GC3 Limited Benefit Group Cancer Indemnity Insurance

29

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




Life and AD&D

Basic Term Life Insurance Coverage

(paid by your employer) Employee - If you are an active, full-time employee and work at least 20 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 – The lesser of 2X annual

compensation rounded to the nearest $1,000 to a maximum of $100,000

Benefit Reduction Schedule – Benefits will reduce to 67% at age 70, 45% at age 75, 45% at age 80, 45% at age 85, 45% at age 90 and 45% at age 95.

Voluntary Term Life Insurance Coverage (paid by you) Employee – If you are an active, full-time employee and work at least 20 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 Guaranteed Coverage Amount – $130,000 Maximum – $500,000 Benefit Reduction Schedule –Providing you are still

employed, your benefits will reduce to 67% at age 70, 45% at age 75, 45% at age 80, 45% at age 85, 45% at age 90 and 45% at age 95.

Your Spouse* — Up to age 70 is eligible provided that you apply for and are approved for coverage for yourself. Benefit Amount – Units of $5,000 Guaranteed Coverage Amount – $50,000 Maximum – $250,000, not to exceed 50% 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 -Birth to 6 months: $500 -6 months to 19 years: Units of $1,000 to $10,000 -26 years 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 80% of the Term Life Insurance coverage amount inforce or $400,000, 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 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.

31

Life and AD&D

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.

Basic Personal Accident Insurance Coverage (paid by your employer) Employee - If you are an active, full-time employee and work at least 20 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 – 2X Base Annual

Earnings rounded to the next higher $1 subject to a maximum of $100,000

Benefit Reduction Schedule – Benefits will reduce to 67% at age 70, 45% at age 75, 45% at age 80, 45% at age 85, 45% at age 90 and 45% at age 95.

Voluntary Personal Accident Insurance Coverage (paid by you)

Employee - If you are an active, full-time employee and work at least 20 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 to $500,000 Maximum – $500,000 Benefit Reduction Schedule – Providing you are still

employed, your benefits will reduce to 67% at age 70, 45% at age 75, 45% at age 80, 45% at age 85, 45% at age 90 and 45% at age 95.

Your Spouse* — Up to age 70 is eligible provided that you apply for and are approved for coverage for yourself. Benefit Amount – Units of $5,000 Maximum – $250,000, not to exceed 50% 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 – Units of $1,000 Maximum – $10,000 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 $0.021 for Employee, $0.037 for Spouse and $0.036 for Children. Costs are subject to change.

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

Age Employee Cost Per $1,000

Spouse Cost Per $1,000

Age Employee Cost Per $1,000

Spouse Cost Per $1,000

Benefit Premium Cost

<20

$0.026

$0.026

50-54

$0.364

$0.364

Voluntary Child per $1,000 of Coverage Elected

$0.18

20-24 $0.031 $0.031 55-59 $0.671 $0.671

25-29 $0.057 $0.057 60-64 $0.988 $0.988

30-34 $0.057 $0.057 65-69 $1.602 $1.602

35-39 $0.083 $0.083 70-74 $2.865 $2.865

40-44 $0.135 $0.135 75-79 $10.452 $10.452

45-49 $0.198 $0.198 80+ $10.452 $10.452

Cost Calculation Example

Age Monthly Cost

per $1,000 Benefit

Monthly Cost

Example 33 .057 X 100,000 / 1,000 = $5.70

Yours X / 1,000 =

32

Life and AD&D

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. Only one benefit (the largest) will be paid for losses from the same accident.

Additional Benefits of Personal Accident Insurance For Wearing a Seatbelt & Protection by an Airbag Additional 10% benefit but not more than $10,000 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 $10,000 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. We will increase your benefit by $3,000 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. 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.

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%

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5STAR

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 with Critical Illness

The Family Protection Plan Term life insurance with Critical Illness coverage to age 100 This insurance is a voluntary benefit that is being provided through your employer to complement your overall benefit package. Most people are not prepared for the financial devastation that frequently accompanies death or the survival of a critical illness. The Family Protection Plan was developed to provide term life insurance protection and an instant emergency fund if an unexpected critical illness occurs, to age 100*.

Term Insurance to Age 100. Offers a guaranteed level premium to age 100 and a guaranteed level death benefit for the first 10 years. After 10 years the death benefit is projected to remain level to age 100 and we do not anticipate a reduction in the future. The coverage amount cannot be individually decreased on a particular insured due to a change in age, health, or employment status.

Critical Illness Benefit pays the insured 30% of the policy coverage amount in a lump sum upon the occurrence of heart attack, life threatening cancer, stroke, cardiac bypass or heart transplant surgery or a terminal condition.

Portability. You and your family continue coverage with no loss of benefits or increase in cost should you terminate employment after the first premium is paid.

Family Protection. Individual policies can be purchased on the employee, spouse, children and grandchildren.

Children and Grandchildren Plan. Policies can also be purchased for children and grandchildren ages newborn through 23 for $4.33/month for a $10,000 policy or $8.67/month for a $20,000 policy.

Convenience. Premiums are taken care of simply and easily through payroll deductions.

Easy Application Process. This insurance does not require a medical exam or blood profile. Eligibility for coverage is based on a few simple health questions on the application.

Emergency Burial Benefit. Within 24 hours after receiving notice of an insured's death, an emergency death benefit of the lesser of 50% of the coverage amount, or $15,000 will be mailed to the insured's beneficiary, unless the death is within the two-year contestability period and/or under investigation.

The Benefits of Critical Illness Coverage More people are suffering from a critical illness than ever before. Chances are you have seen first hand the financial hardship that either a relative, close friend, or co-worker has had to endure during the recovery process of a critical illness. Most employee benefits plans are designed to cover specific expenses. But, The Family Protection Plan pays a one-time lump sum of 30% (25% in Michigan) of the policy benefit in cash directly to the owner-in addition to any other insurance plan the insured may have! There are no restrictions on how this benefit is used. *Age 95 in Maryland and Utah. Not available in all states.

The Family Protection Plan Covered Critical Illnesses Covered critical illnesses include:

Heart Attack

Life-Threatening Cancer

Stroke

Cardiac Bypass Surgery

Heart Transplant Surgery This benefit is also paid for terminal conditions

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

35


MONTHLY PREMIUMS & INITIAL COVERAGE AMOUNTS

Age on App. Date

Coverage Amount $10,000

Critical Illness Benefit $3,000













18 $8.25 $14.13 $23.92 $33.71 $43.50 $53.29 $63.08

19 $8.25 $14.13 $23.92 $33.71 $43.50 $53.29 $63.08

20 $8.25 $14.13 $23.92 $33.71 $43.50 $53.29 $63.08

21 $8.25 $14.13 $23.92 $33.71 $43.50 $53.29 $63.08

22 $8.25 $14.13 $23.92 $33.71 $43.50 $53.29 $63.08

23 $8.25 $14.13 $23.92 $33.71 $43.50 $53.29 $63.08

24 $8.25 $14.13 $23.92 $33.71 $43.50 $53.29 $63.08

25 $8.25 $14.13 $23.92 $33.71 $43.50 $53.29 $63.08

26 $8.28 $14.19 $24.04 $33.90 $43.75 $53.60 $63.46

27 $8.33 $14.33 $24.33 $34.33 $44.33 $54.33 $64.33

28 $8.43 $14.56 $24.79 $35.02 $45.25 $55.48 $65.71

29 $8.54 $14.85 $25.38 $35.90 $46.42 $56.94 $67.46

30 $8.68 $15.21 $26.08 $36.96 $47.83 $58.71 $69.58

31 $8.83 $15.56 $26.79 $38.02 $49.25 $60.48 $71.71

32 $8.97 $15.92 $27.50 $39.08 $50.67 $62.25 $73.83

33 $9.13 $16.31 $28.29 $40.27 $52.25 $64.23 $76.21

34 $9.32 $16.79 $29.25 $41.71 $54.17 $66.63 $79.08

35 $9.55 $17.38 $30.42 $43.46 $56.50 $69.54 $82.58

36 $9.87 $18.17 $32.00 $45.83 $59.67 $73.50 $87.33

37 $10.27 $19.17 $34.00 $48.83 $63.67 $78.50 $93.33

38 $10.75 $20.38 $36.42 $52.46 $68.50 $84.54 $100.58

39 $11.32 $21.79 $39.25 $56.71 $74.17 $91.63 $109.08

40 $11.93 $23.33 $42.33 $61.33 $80.33 $99.33 $118.33

41 $12.55 $24.88 $45.42 $65.96 $86.50 $107.04 $127.58

42 $13.18 $26.44 $48.54 $70.65 $92.75 $114.85 $136.96

43 $13.82 $28.04 $51.75 $75.46 $99.17 $122.88 $146.58

44 $14.48 $29.71 $55.08 $80.46 $105.83 $131.21 $156.58

45 $15.19 $31.48 $58.63 $85.77 $112.92 $140.06 $167.21

46 $15.96 $33.40 $62.46 $91.52 $120.58 $149.65 $178.71

47 $16.79 $35.48 $66.63 $97.77 $128.92 $160.06 $191.21

48 $17.68 $37.69 $71.04 $104.40 $137.75 $171.10 $204.46

49 $18.59 $39.98 $75.63 $111.27 $146.92 $182.56 $218.21

50 $19.53 $42.33 $80.33 $118.33 $156.33 $194.33 $232.33

51 $20.50 $44.75 $85.17 $125.58 $166.00 $206.42 $246.83

52 $21.50 $47.25 $90.17 $133.08 $176.00 $218.92 $261.83

53 $22.56 $49.90 $95.46 $141.02 $186.58 $232.15 $277.71

54 $23.70 $52.75 $101.17 $149.58 $198.00 $246.42 $294.83

55 $24.96 $55.90 $107.46 $159.02 $210.58 $262.15 $313.71

36


Available only on children and grandchildren of employee:

$4.98 monthly Age on application date: Full-term newborn to 23 years

Coverage amount—$10,000 Critical Illness benefits—$3,000

$9.97 monthly Age on application date: Full-term newborn to 23 years

Coverage amount—$20,000 Critical Illness benefits—$6,000

MONTHLY PREMIUMS & INITIAL COVERAGE AMOUNTS

Age on App. Date















56 $26.36 $59.40 $114.46 $169.52 $224.58 $279.65 $334.71

57 $27.90 $63.25 $122.17 $181.08 $240.00 $298.92 $357.83

58 $29.57 $67.42 $130.50 $193.58 $256.67 $319.75 $382.83

59 $31.34 $71.85 $139.38 $206.90 $274.42 $341.94 $409.46

60 $33.20 $76.50 $148.67 $220.83 $293.00 $365.17 $437.33

61 $35.10 $81.25 $158.17 $235.08 $312.00 $388.92 $465.83

62 $37.04 $86.10 $167.88 $249.65 $331.42 $413.19 $494.96

63 $39.04 $91.10 $177.88 $264.65 $351.42 $438.19 $524.96

64 $41.13 $96.31 $188.29 $280.27 $372.25 $464.23 $556.21

65 $43.40 $102.00 $199.67 $297.33 $395.00 $492.67 $590.33

66 $46.01 $108.52 $212.71 $316.90 $421.08 $525.27 $629.46

67 $49.16 $116.40 $228.46 $340.52 $452.58 $564.65 $676.71

68 $53.10 $126.25 $248.17 $370.08 $492.00 $613.92 $735.83

69 $58.04 $138.60 $272.88 $407.15 $541.42 $675.69 $809.96

70 $64.23 $154.08 $303.83 $453.58 $603.33 $753.08 $902.83

37

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


Palacios ISD Benefits Website: www.mybenefitshub.com/palaciosisd

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?

YOUR BENEFITS PACKAGE

38

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

Plus Platinum

Individual Plan $7.95 $11.95

Family Plan $14.95 $22.95

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

39

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)

NBS YOUR BENEFITS PACKAGE



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 claim FAQs

For a list of sample expenses, please refer to the Palacios ISD benefit website: www.mybenefitshub.com/palaciosisd

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

41

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- roll $500. 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.mybenefitshub.com/palaciosisd

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- roll $500. 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.mybenefitshub.com/palaciosisd 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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www.mybenefitshub.com/palaciosisd

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2016 benefit guide palacios isd

Documents