2016 Benefit Guide Jacksonville ISD

EFFECTIVE:

09/01/2016 - 8/31/2017

BENEFIT GUIDE

www.mybenefitshub.com/jacksonvilleisd

JACKSONVILLE ISD

1

Benefit Contact Information 3

How to Enroll 4-5

Annual Benefit Enrollment 6-11

1. Benefit Updates 6

2. Section 125 Cafeteria Plan Guidelines 7

3. Annual Enrollment 8

4. Eligibility Requirements 9

5. Helpful Definitions 10

6. HSA vs FSA Comparison 11

TRS-ActiveCare Aetna 12-13

HSA Bank Health Savings Account 14-17

Cigna Dental 18-21

Superior Vision 22-23

The Hartford Long Term Disability 24-27

APL Cancer 28-31 5Star Family Protection Plan Term Life Insurance with Quality of Life Rider 32-35

One America Life and AD&D 36-39

NBS Flexible Spending Account 40-43

Table of Contents

HOW TO ENROLL

PG. 4

YOUR BENEFIT UPDATES: WHAT’S NEW

PG. 6

YOUR MEDICAL BENEFITS

PG. 12

FLIP TO...

2

Benefit Contact Information

Benefit Contact Information

BENEFIT ADMINISTRATORS DENTAL FAMILY PROTECTION PLAN-

Financial Benefit Services (866) 914-5202 www.mybenefitshub.com/jacksonvilleisd

Group # 3338975 CIGNA (800) 244-6224 www.mycigna.com

5Star Life Insurance Company (866) 863-9753 http://5starlifeinsurance.com

JACKSONVILLE ISD BENFITS OFFICE VISION LIFE AND AD&D

(903) 586-6511 www.jisd.org

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

OneAmerica www.oneamerica.com

TRS ACTIVECARE MEDICAL DISABILITY FLEXIBLE SPENDING ACCOUNTS

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

Group # 873359 The Hartford (800) 523-2233 File a claim : (866) 278-2655 www.thehartford.com

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

HEALTH SAVINGS ACCOUNTS CANCER

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

American Public Life (APL) (800) 256-8606 www.ampublic.com

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/

jacksonvilleisd delivers

important benefit information

with 24/7 access, as well as

detailed plan information, rates

and product videos.

TEXT

“jcksnville”

TO

313131

On Your Device Enrolling in your benefits just got

a lot easier! Text “jcksnville” 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/jacksonvilleisd 1

2

Login Steps

3

Go to:

Click Login

Enter Username & Password

OR SCAN

All login credentials have been RESET to the default

described below:

Username:

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

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

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

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

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

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

your Social Security Number.

Default Password:

Last Name* (lowercase, excluding punctuation)

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

Security Number.

Sample Password

l incola1234

l incoln1234

If you have trouble

logging in, click on the

“Login Help Video”

for assistance.

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

Sample Username

LOGIN

Open Enrollment Tip

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

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

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

5

Due to the ACA, you MUST login to www.mybenefitshub.com/jacksonvilleisd in August 2016 & either waive or elect medical insurance by 8/21/16! NEW! 5Star Family Protection Plan with a Quality of

Life Rider. This is a new individual life policy UPDATE! The Hartford Long-Term Disability rates are

increasing. UPDATE! The family HSA max contribution is

increasing to $6,750. Even if you are declining insurance, you MUST login to www.mybenefitshub.com/jacksonvilleisd & elect/waive benefits. 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 (& changes must be made within 30 days of event). If you currently participate in a HealthCare or Dependent Care FSA, you MUST re-elect a new contribution amount every year to continue to participate. You cannot participate in the HealthCare FSA if you elect the HSA. HealthCare Reimbursement FSA funds can be rolled up to $500 from the following plan year.

Don’t Forget!

You MUST login & complete your benefit enrollment from 8/1/16-8/21/16. Any changes made after 8/21/16 must be completed through the benefits administration office.

Enrollment assistance is available by calling Financial Benefit Services at (866) 914-5202 to speak to a representative (bilingual assistance is available).

Your dependent Social Security numbers MUST be listed in THEbenefitsHUB. Update your profile information: (home address, phone numbers, email). Update your beneficiary designation for the free Basic Life coverage & any Voluntary Life,

Individual Life and/or AD&D coverage.

Benefit Updates - What’s New:

SUMMARY PAGES

Annual Benefit Enrollment

6

SUMMARY PAGES

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

7

Annual Enrollment

During your annual enrollment period, you have the opportunity

to review, change or continue benefit elections each year.

Changes are not permitted during the plan year (outside of

annual enrollment) unless a Section 125 qualifying event occurs.

Changes, additions or drops may be made only during the

annual enrollment period without a qualifying event.

Employees must review their personal information and verify

that dependents they wish to provide coverage for are

included in the dependent profile. Additionally, you must

notify your employer of any discrepancy in personal and/or

benefit information.

Employees must confirm on each benefit screen (medical,

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

selected in order to be included in the coverage for that

particular benefit.

New Hire Enrollment

All new hire enrollment elections must be completed in the

online enrollment system within the first 31 days of benefit

eligibility employment. Failure to complete elections during this

timeframe will result in the forfeiture of coverage.

Q&A

Who do I contact with Questions?

For supplemental benefit questions, you can contact your

Benefits/HR department or you can call Financial Benefit Services

at 866-914-5202 for assistance.

Where can I find forms?

For benefit summaries and claim forms, go to your benefit

website:

www.mybenefitshub.com/jacksonvilleisd. Click on the benefit

plan you need information on (i.e., Dental) and you can find

the forms you need under the Benefits and Forms section.

How can I find a Network Provider?

For benefit summaries and claim forms, go to the Jacksonville

ISD benefit website: www.mybenefitshub.com/jacksonvilleisd.

Click on the benefit plan you need information on (i.e.,

Dental) and you can find provider search links under the Quick

Links section.

When will I receive ID cards?

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

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

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

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

insurance company’s phone number and they can call and

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

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

carrier’s customer service number to request another card.

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

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

card each year.

SUMMARY PAGES

8

PLAN CARRIER MAXIMUM AGE

Medical Aetna To Age 26

Dental Cigna To Age 26

Vision Superior Vision To Age 26

Cancer APL To Age 26

Family Protection Plan w/ LTC 5Star Life Issue to 24; Keep to 100

Voluntary Life and AD&D One America 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 Jacksonville 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

9

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

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

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

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

work beginning 9/1/2016 please notify your benefits

administrator.

Annual Enrollment The period during which existing employees are given the

opportunity to enroll in or change their current elections.

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

pay covered expenses.

Calendar Year January 1st through December 31st

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

covered health care service, calculated as a percentage (for

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

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

medical questions or taking a health exam. Guaranteed

coverage is only available during initial eligibility period.

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

provisions do apply, as applicable by carrier.

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

who have contracted with the plan as a network provider.

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

for covered expenses.

Plan Year September 1st through August 31st.

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

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

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

orders to take drugs, or received medical care or services

(including diagnostic and/or consultation services).

Helpful Definitions SUMMARY PAGES

10

SUMMARY PAGES HSA vs. FSA

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

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

Description

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

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

Employer Eligibility A qualified high deductible health plan. All employers

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

Account Owner Individual Employer

Underlying Insurance Requirement

High deductible health plan None

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

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

Varies per employer

Permissible Use Of Funds If used for non-qualified medical expenses, subject to current tax rate plus 20% penalty.

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

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

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

Not permitted

Year-to-year rollover of account balance?

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

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

Does the account earn interest?

Yes No

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

No

FOR HSA INFORMATION

FLIP TO… PG. 14

FOR FSA INFORMATION

FLIP TO… PG. 40

11

2016-2017 TRS-ActiveCare Plan Highlights Effective September 1, 2016 through August 31, 2017 | In-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.

12

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-andb- 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/factsand- features/fact-sheets/preventive-services-covered-underaca/ index.html#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

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

About this Benefit

HSA (Health Savings Account)

YOUR BENEFITS PACKAGE

The interest earned in an HSA is tax free.

DID YOU KNOW?

Money withdrawn for medical spending never falls under taxable income.

HSA BANK

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

Jacksonville ISD Benefits Website: www.mybenefitshub.com/jacksonvilleisd 14

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

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

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

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

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

Using Funds Debit Card

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

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

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

Health Savings accountholder

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

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

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

Examples of Qualified Medical Expenses Surgery

Braces

Contact lenses

Dentures

Eyeglasses

Vaccines For a list of sample expenses, please refer to the Jacksonville ISD website at www.mybenefitshub.com/jacksonvilleisd

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

HSA (Health Savings Account)

15

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

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

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

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

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

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

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

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

You cannot be covered by TriCare.

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

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

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

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

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

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

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

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

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

HSA funds earn interest and investment earnings are tax free.

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

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

How the HSA Plan Works

16

How the HSA Plan Works

Examples of IRS-Qualified Medical Expenses4:

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

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

Gynecologist Hearing aids and batteries Hospital bills Insurance premiums5

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

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

17

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 YOUR BENEFITS PACKAGE

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



Dental PPO - Low Option

Benefits Cigna Dental PPO - Low Option

In-Network Out-of-Network

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

$750 $750

Contract Deductible Individual Family

$100 per person $300 per family


Reimbursement Levels** Based on Reduced Contracted Fees

Based on Maximum Allowable Charge

(In-network fee level)

Plan Pays You Pay Plan Pays You Pay

Class I - Preventive & Diagnostic Care Oral Exams Routine Cleanings Bitewing X-rays Fluoride Application Sealants Space Maintainers

100% No Charge 100% No Charge

Class II - Basic Restorative Care Fillings Full Mouth X-rays Panoramic X-ray Periapical X-rays Emergency Care to Relieve Pain Oral Surgery – Simple Extractions

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

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

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

Class IV - Orthodontia Lifetime Maximum

Not covered 100% of your

dentist’s usual fees

Not covered 100% of your

dentist’s usual fees

Monthly PPO Premiums

Tier Rate

EE Only $20.10

EE + Spouse $43.84

EE + 1 Child(ren) $48.70

EE+ Family $72.44

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 the Contracted Fee Schedule but the dentist may balance bill up to their usual fees. In Texas, the insured dental product offered by CGLIC and CHLIC is referred to as the Cigna Dental Choice Plan, and this plan utilizes the national Cigna Dental PPO network. Dependents/Students up to age 26.

19

Dental PPO - High Option

Monthly PPO Premiums

Tier Rate

EE Only $29.98

EE + Spouse $65.56

EE + 1 Child(ren) $72.82

EE + Family $108.34

Missing Tooth Limitation – Teeth missing prior to coverage under the Cigna Dental PPO plan are not covered until insured for 12 months; thereafter, considered a Class III expense. Pretreatment review is available on a voluntary basis when extensive dental work in excess of $200 is proposed. * Subject to annual deductible. Dental Oral Health Integration Program (OHIP) - All dental customers = Clinical research shows an association between oral health and overall health. The Cigna Dental Oral Health Integration Program (OHIP)® is designed to provide enhanced dental coverage for customers with certain eligible medical conditions. Eligible conditions for the program include cardiovascular disease, cerebrovascular disease (stroke), diabetes, maternity, chronic kidney disease, organ transplants, and head and neck cancer radiation. The program provides: ·100% coverage for certain dental procedures · guidance on behavioral issues related to oral health ·discounts on prescription and non-prescription dental products. For more information and to see the complete list of eligible conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24. **For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Contracted Fee Schedule. For services provided by an out-of-network dentist, Cigna Dental will reimburse according to Reasonable and Customary Allowances but the dentist may balance bill up to their usual fees. In Texas, the insured dental product offered by CGLIC and CHLIC is referred to as the Cigna Dental Choice Plan, and this plan utilizes the national Cigna Dental PPO network. Dependents/Students up to age 26.

Benefits Cigna Dental PPO - High Option

In-Network Out-of-Network

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

$1,000 $1,000

Contract Deductible Individual Family



Reimbursement Levels** Based on Reduced Contracted Fees

90th percentile of Reasonable and Customary Allowances

Plan Pays You Pay Plan Pays You Pay

Class I - Preventive & Diagnostic Care Oral Exams Routine Cleanings Bitewing X-rays Full Mouth X-rays Panoramic X-ray 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 Surgical Extractions of Impacted Teeth Brush Biopsies Oral Surgery - all except simple extractions Anesthetics Denture Repairs Denture Relines, Rebases and Adjustments Repairs to Bridges, Crowns and Inlays Oral Surgery – Simple Extractions

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

Class III - Major Restorative Care Crowns 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%

20

Dental PPO - High and Low Options

Procedure Exclusions and Limitations Late Entrants Limit 50% coverage on Class III and IV for 12 months 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., or Panorex: 1 every 36 consecutive months Model Payable only when in conjunction with Ortho workup Minor Perio (non-surgical) Various limitations depending on the service Perio Surgery Various limitations depending on the service Crowns and Inlays Replacement every 5 years Bridges Replacement every 5 years Dentures and Partials Replacement every 5 years Relines, Rebases Covered if more than 6 months after installation Adjustments Covered if more than 6 months after installation Repairs - Bridges Reviewed if more than once Repairs - Dentures Reviewed if more than once Sealants Limited to posterior tooth. One treatment per tooth every three years up to age 14 Space Maintainers Limited to non-Orthodontic treatment Prosthesis Over Implant 1 per 60 consecutive months if unserviceable and cannot be repaired. Benefits are based on the amount payable for non- precious metals. No porcelain or white/tooth colored material on molar crowns or bridges Alternate Benefit When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses

Benefit Exclusions Services performed primarily for cosmetic reasons Replacement of a lost or stolen appliance Replacement of a bridge or denture within five years following the

date of its original installation Replacement of a bridge or denture which can be made useable

according to accepted dental standards Procedures, appliances or restorations, other than full dentures, whose

main purpose is to change vertical dimension, diagnose or treat conditions of TMJ, stabilize periodontally involved teeth, or restore occlusion

Veneers of porcelain or acrylic materials on crowns or pontics on or replacing the upper and lower first, second and third molars

Bite registrations; precision or semi-precision attachments; splinting Instruction for plaque control, oral hygiene and diet Dental services that do not meet common dental standards Services that are deemed to be medical services Services and supplies received from a hospital Charges which the person is not legally required to pay Charges made by a hospital which performs services for the U.S.

Government if the charges are directly related to a condition connected to a military service

Experimental or investigational procedures and treatments Any injury resulting from, or in the course of, any employment for

wage or profit Any sickness covered under any workers’ compensation or similar law Charges in excess of the reasonable and customary allowances To the extent that payment is unlawful where the person resides when

the expenses are incurred; Procedures performed by a Dentist who is a member of the covered

person’s family (covered person’s family is limited to a spouse, siblings, parents, children, grandparents, and the spouse’s siblings and parents);

For charges which would not have been made if the person had no insurance;

For charges for unnecessary care, treatment or surgery; To the extent that you or any of your Dependents is in any way paid or

entitled to payment for those expenses by or through a public program, other than Medicaid;

To the extent that benefits are paid or payable for those expenses under the mandatory part of any auto insurance policy written to comply with a “no-fault” insurance law or an uninsured motorist

insurance law. Cigna HealthCare will take into account any adjustment option chosen under such part by you or any one of your Dependents.

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

This benefit summary highlights some of the benefits available under the proposed plan. A complete description regarding the terms of coverage, exclusions and limitations, including legislated benefits, will be provided in your insurance certificate or plan description. Benefits are insured and/or administered by Connecticut General Life Insurance Company. "Cigna HealthCare" refers to various operating subsidiaries of Cigna Corporation. Products and services are provided by these subsidiaries and not by Cigna Corporation. These subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. DPPO insurance coverage is set forth on the following policy form numbers: AR: HP-POL77; CA: HP-POL57; CO: HP-POL78; CT: HP-POL58; DE: HP-POL79; FL: HP-POL60; ID: HP- POL82; 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.

21

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 YOUR BENEFITS PACKAGE

75%

DID YOU KNOW?

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

correction.

SUPERIOR VISION



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. 2Covered 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 $35 retail

Frames $125 retail allowance Up to $70 retail

Contact Lenses1 $150 retail allowance Up to $80 retail

Medically Necessary Contact Lenses Covered in full Up to $150 retail

Lenses (standard) per pair

Single Vision Covered in full Up to $25 retail

Bifocal Covered in full Up to $40 retail

Trifocal Covered in full Up to $45 retail

Progressive See description2 Up to $45 retail

Lenticular Covered in full Up to $80 retail

Monthly Premiums

EE Only $7.64

EE + Spouse $13.00

EE + Child(ren) $13.78

EE + Family $20.64

SuperiorVision.com Customer Service 800.507.3800

(Based on date of service)

23

About this Benefit

Disability YOUR BENEFITS PACKAGE

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.

THE HARTFORD

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.



Disability is designed to provide a monthly income to an individual that is disabled due to an accident or illness. There are different plans available with benefits becoming available from the 1st day of disability to as late as the 180th day. For specific details on how benefits are paid, refer to carrier brochure. Your disability coverage amount and premium can be accessed during your enrollment.

Pre-existing Conditions Your policy limits the benefits you can receive for a disability caused by a pre-existing condition. In general, if you were diagnosed or received care for a disabling condition within the 3 consecutive months just prior to the effective date of this policy, your benefit payment will be limited, unless: You have not received treatment for the disabling condition within 3 months, while insured under this policy, before the disability begins, or You have been insured under this policy for 12 months before your disability begins. You may also be covered if you have already satisfied the pre-existing condition requirement of your previous insurer. If your disability is a result of a pre-existing condition we will pay benefits for a maximum of 4 weeks.

Benefit Reductions Your benefit payments may be reduced by other income you receive or are eligible to receive due to your disability, such as: Social Security Disability Insurance (please see

www.mybenefitshub.com/jacksonvilleisd for exceptions) Workers' Compensation Other employer-based Insurance coverage you may have Unemployment benefits Settlements or judgments for income loss Retirement benefits that your employer fully or partially

pays for (such as a pension plan.) Your benefit payments will not be reduced by certain kinds of other income, such as: Retirement benefits if you were already receiving them

before you became disabled The portion of your Long -Term Disability payment that

you place in an IRS-approved account to fund your future retirement.

Your personal savings, investment, IRAs or Keoghs Profit-sharing Most personal disability policies Social Security increases

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

Exclusions You cannot receive Disability benefit payments for disabilities that are caused or contributed to by: War or act of war (declared or not) Military service for any country engaged in war or other

armed conflict The commission of, or attempt to commit a felony

An intentionally self-inflicted injury Any case where your being engaged in an illegal

occupation was a contributing cause to your disability You must be under the regular care of a physician to

receive benefits

Mental Illness, Alcoholism and Substance Abuse You can receive benefit payments for Long-Term

Disabilities resulting from mental illness, alcoholism and substance abuse for a total of 24 months for all disability periods during your lifetime.

Any period of time that you are confined in a hospital or other facility licensed to provide medical care for mental illness, alcoholism and substance abuse does not count toward the 24 month lifetime limit.

What other benefits are included in my disability coverage? Workplace Modification provides for reasonable

modifications made to a workplace to accommodate your disability and allow you to return to active full-time employment.

Survivor Benefit - If you die while receiving disability benefits, a benefit will be paid to your spouse, child or estate equal to three times the last monthly gross benefit.

Travel Assistance Program – Available 24/7, this program provides assistance to employees and their dependents who travel 100 miles from their home for 90 days or less. Services include pre-trip information, emergency medical assistance and emergency personal services.

The Hartford's Ability Assist service is included as a part of your group Long Term Disability (LTD) insurance program. You have access to Ability Assist services both prior to a disability and after you’ve been approved for an LTD claim and are receiving LTD benefits. Once you are covered you are eligible for services to provide assistance with child/elder care, substance abuse, family relationships and more. In addition, LTD claimants and their immediate family members receive confidential services to assist them with the unique emotional, financial and legal issues that may result from a disability. Ability Assist services are provided through ComPsych®, a leading provider of employee assistance and work/life services.

Waiver of Premium – Once your disability claim is approved and you have satisfied your elimination period, your coverage premiums will be waived.

Identity Theft Protection – An array of identity fraud support services to help victims restore their identity. Benefits include 24/7 access to an 800 number; direct contact with a certified caseworker who follows the case until it’s resolved; and a personalized fraud resolution kit with instructions and resources for ID theft victims.

Long Term Disability

25


For the Premium benefit option – the table below applies to disabilities resulting from injury or sickness:

Age Disabled Benefits Payable

Prior to Age 63 To Normal Retirement Age or 48 months if greater

Age 63 To Normal Retirement Age or 42 months if greater

Age 64 36 months

Age 65 30 months

Age 66 27 months

Age 67 24 months

Age 68 21 months

Age 69 and older 18 months

MONTHLY PREMIUMS

Accident / Sickness Elimination Period in Days

Annual Earnings Monthly Earnings Monthly Benefit 0 / 7 14 / 14 30 / 30 60 / 60 90 / 90 180 / 180

$3,600 $300 $200 $7.62 $6.44 $5.58 $4.56 $2.62 $1.88

$5,400 $450 $300 $11.43 $9.66 $8.37 $6.84 $3.93 $2.82

$7,200 $600 $400 $15.24 $12.88 $11.16 $9.12 $5.24 $3.76

$9,000 $750 $500 $19.05 $16.10 $13.95 $11.40 $6.55 $4.70

$10,800 $900 $600 $22.86 $19.32 $16.74 $13.68 $7.86 $5.64

$12,600 $1,050 $700 $26.67 $22.54 $19.53 $15.96 $9.17 $6.58

$14,400 $1,200 $800 $30.48 $25.76 $22.32 $18.24 $10.48 $7.52

$16,200 $1,350 $900 $34.29 $28.98 $25.11 $20.52 $11.79 $8.46

$18,000 $1,500 $1,000 $38.10 $32.20 $27.90 $22.80 $13.10 $9.40

$19,800 $1,650 $1,100 $41.91 $35.42 $30.69 $25.08 $14.41 $10.34

$21,600 $1,800 $1,200 $45.72 $38.64 $33.48 $27.36 $15.72 $11.28

$23,400 $1,950 $1,300 $49.53 $41.86 $36.27 $29.64 $17.03 $12.22

$25,200 $2,100 $1,400 $53.34 $45.08 $39.06 $31.92 $18.34 $13.16

$27,000 $2,250 $1,500 $57.15 $48.30 $41.85 $34.20 $19.65 $14.10

$28,800 $2,400 $1,600 $60.96 $51.52 $44.64 $36.48 $20.96 $15.04

$30,600 $2,550 $1,700 $64.77 $54.74 $47.43 $38.76 $22.27 $15.98

$32,400 $2,700 $1,800 $68.58 $57.96 $50.22 $41.04 $23.58 $16.92

$34,200 $2,850 $1,900 $72.39 $61.18 $53.01 $43.32 $24.89 $17.86

$36,000 $3,000 $2,000 $76.20 $64.40 $55.80 $45.60 $26.20 $18.80

$37,800 $3,150 $2,100 $80.01 $67.62 $58.59 $47.88 $27.51 $19.74

$39,600 $3,300 $2,200 $83.82 $70.84 $61.38 $50.16 $28.82 $20.68

$41,400 $3,450 $2,300 $87.63 $74.06 $64.17 $52.44 $30.13 $21.62

$43,200 $3,600 $2,400 $91.44 $77.28 $66.96 $54.72 $31.44 $22.56

$45,000 $3,750 $2,500 $95.25 $80.50 $69.75 $57.00 $32.75 $23.50

$46,800 $3,900 $2,600 $99.06 $83.72 $72.54 $59.28 $34.06 $24.44

$48,600 $4,050 $2,700 $102.87 $86.94 $75.33 $61.56 $35.37 $25.38

$50,400 $4,200 $2,800 $106.68 $90.16 $78.12 $63.84 $36.68 $26.32

$52,200 $4,350 $2,900 $110.49 $93.38 $80.91 $66.12 $37.99 $27.26

$54,000 $4,500 $3,000 $114.30 $96.60 $83.70 $68.40 $39.30 $28.20

$55,800 $4,650 $3,100 $118.11 $99.82 $86.49 $70.68 $40.61 $29.14

$57,600 $4,800 $3,200 $121.92 $103.04 $89.28 $72.96 $41.92 $30.08

$59,400 $4,950 $3,300 $125.73 $106.26 $92.07 $75.24 $43.23 $31.02

26


MONTHLY PREMIUMS

Accident / Sickness Elimination Period in Days

Annual Earnings Monthly Earnings Monthly Benefit 0 / 7 14 / 14 30 / 30 60 / 60 90 / 90 180 / 180

$61,200 $5,100 $3,400 $129.54 $109.48 $94.86 $77.52 $44.54 $31.96 $63,000 $5,250 $3,500 $133.35 $112.70 $97.65 $79.80 $45.85 $32.90 $64,800 $5,400 $3,600 $137.16 $115.92 $100.44 $82.08 $47.16 $33.84 $66,600 $5,550 $3,700 $140.97 $119.14 $103.23 $84.36 $48.47 $34.78 $68,400 $5,700 $3,800 $144.78 $122.36 $106.02 $86.64 $49.78 $35.72 $70,200 $5,850 $3,900 $148.59 $125.58 $108.81 $88.92 $51.09 $36.66 $72,000 $6,000 $4,000 $152.40 $128.80 $111.60 $91.20 $52.40 $37.60 $73,800 $6,150 $4,100 $156.21 $132.02 $114.39 $93.48 $53.71 $38.54 $75,600 $6,300 $4,200 $160.02 $135.24 $117.18 $95.76 $55.02 $39.48 $77,400 $6,450 $4,300 $163.83 $138.46 $119.97 $98.04 $56.33 $40.42 $79,200 $6,600 $4,400 $167.64 $141.68 $122.76 $100.32 $57.64 $41.36 $81,000 $6,750 $4,500 $171.45 $144.90 $125.55 $102.60 $58.95 $42.30 $82,800 $6,900 $4,600 $175.26 $148.12 $128.34 $104.88 $60.26 $43.24 $84,600 $7,050 $4,700 $179.07 $151.34 $131.13 $107.16 $61.57 $44.18 $86,400 $7,200 $4,800 $182.88 $154.56 $133.92 $109.44 $62.88 $45.12 $88,200 $7,350 $4,900 $186.69 $157.78 $136.71 $111.72 $64.19 $46.06 $90,000 $7,500 $5,000 $190.50 $161.00 $139.50 $114.00 $65.50 $47.00 $91,800 $7,650 $5,100 $194.31 $164.22 $142.29 $116.28 $66.81 $47.94 $93,600 $7,800 $5,200 $198.12 $167.44 $145.08 $118.56 $68.12 $48.88 $95,400 $7,950 $5,300 $201.93 $170.66 $147.87 $120.84 $69.43 $49.82 $97,200 $8,100 $5,400 $205.74 $173.88 $150.66 $123.12 $70.74 $50.76 $99,000 $8,250 $5,500 $209.55 $177.10 $153.45 $125.40 $72.05 $51.70

$100,800 $8,400 $5,600 $213.36 $180.32 $156.24 $127.68 $73.36 $52.64 $102,600 $8,550 $5,700 $217.17 $183.54 $159.03 $129.96 $74.67 $53.58 $104,400 $8,700 $5,800 $220.98 $186.76 $161.82 $132.24 $75.98 $54.52 $106,200 $8,850 $5,900 $224.79 $189.98 $164.61 $134.52 $77.29 $55.46 $108,000 $9,000 $6,000 $228.60 $193.20 $167.40 $136.80 $78.60 $56.40 $109,800 $9,150 $6,100 $232.41 $196.42 $170.19 $139.08 $79.91 $57.34 $111,600 $9,300 $6,200 $236.22 $199.64 $172.98 $141.36 $81.22 $58.28 $113,400 $9,450 $6,300 $240.03 $202.86 $175.77 $143.64 $82.53 $59.22 $115,200 $9,600 $6,400 $243.84 $206.08 $178.56 $145.92 $83.84 $60.16 $117,000 $9,750 $6,500 $247.65 $209.30 $181.35 $148.20 $85.15 $61.10 $118,800 $9,900 $6,600 $251.46 $212.52 $184.14 $150.48 $86.46 $62.04 $120,600 $10,050 $6,700 $255.27 $215.74 $186.93 $152.76 $87.77 $62.98 $122,400 $10,200 $6,800 $259.08 $218.96 $189.72 $155.04 $89.08 $63.92 $124,200 $10,350 $6,900 $262.89 $222.18 $192.51 $157.32 $90.39 $64.86 $126,000 $10,500 $7,000 $266.70 $225.40 $195.30 $159.60 $91.70 $65.80 $127,800 $10,650 $7,100 $270.51 $228.62 $198.09 $161.88 $93.01 $66.74 $129,600 $10,800 $7,200 $274.32 $231.84 $200.88 $164.16 $94.32 $67.68 $131,400 $10,950 $7,300 $278.13 $235.06 $203.67 $166.44 $95.63 $68.62 $133,200 $11,100 $7,400 $281.94 $238.28 $206.46 $168.72 $96.94 $69.56 $135,000 $11,250 $7,500 $285.75 $241.50 $209.25 $171.00 $98.25 $70.50

27

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

Jacksonville ISD Benefits Website: www.mybenefitshub.com/jacksonvilleisd

AMERICAN PUBLIC LIFE

(03/16) 28

Summary of Benefits*Benefits Level 1 Base Plan Level 2 Base Plan

Radiation Therapy/Chemotherapy/ Immunotherapy Benefit

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

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

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

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

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

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

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

Outpatient Hospital or Ambulatory Surgical Center Benefit

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

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

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

Transportation & Outpatient Lodging Benefit

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


Family Member Transportation & Lodging Benefit



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

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

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

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

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

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

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

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

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

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

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

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

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

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

Extended Care Benefit $100 per day $300 per day

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

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

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

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

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

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

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

Riders

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

Critical Illness Rider: Cancer/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 Jacksonville ISD-0315

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

Individual $14.80 $17.80 $29.40 $32.40

One Parent $20.60 $24.80 $40.40 $44.60

Two Parent $26.40 $32.70 $51.50 $57.80

*Premium and amount of benefits provided vary dependent upon the level selected at time of application. **Total premium includes the policy and riders of the option selected.

GC3 Limited Benefit Group Cancer Indemnity InsuranceJacksonville 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.

29

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, or part thereof, used as: a hospice unit, including any bed designated as a hospice or a swing bed; a convalescent home; a rest or nursing facility; a rehabilitative facility; an extended-care facility; a skilled nursing facility; or a facility primarily affording custodial, educational care, or care or treatment for persons suffering from mental diseases or disorders, or care for the aged, or drug or alcohol addiction.

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. Pre-Existing Condition, as used in this rider means any sickness or condition for which prior to the 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.

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.


GC3 Limited Benefit Group Cancer Indemnity Insurance

30

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


GC3 Limited Benefit Group Cancer Indemnity Insurance

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

31

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

Individual Life YOUR BENEFITS PACKAGE

DID YOU KNOW?



5STAR

x 10

Experts recommend at least

your gross annual income in coverage when purchasing life insurance.

32

Individual Life with Terminal Illness and Quality of Life Rider

The Family Protection Plan: Individual Life Insurance with Terminal Illness Coverage to Age 100 With the Family Protection Plan (FPP), you can provide financial stability for your loved ones should something happen to you. You have peace of mind that you are covered up to age 100.* No matter what the future brings, you and your family will be protected. If faced with a chronic medical condition that required continuous care, would you be able to protect yourself? Traditionally, expenses associated with treatment and care necessitated by a chronic injury or illness have accounted for 86% of all health care spending and can place strain on your assets when you need them most. To provide protection during this time of need, 5Star Life Insurance Company (5Star Life) is pleased to offer the Quality of Life Rider, which is included with your FPP life insurance coverage. This rider accelerates a portion of the death benefit on a monthly basis—4% each month as scheduled by your employer at the group level, and payable directly to you on a tax favored basis. You can receive up to 75% of the current face amount of the life benefit, following a diagnosis of either a chronic illness or cognitive impairment that requires substantial assistance. Benefits are paid for the following:

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

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

For example, in case of chronic illness, you would receive $3,586 each month up to $67,241.25. The remainder death benefit of $22,413.75 would be made payable to your beneficiary. * Life insurance product underwritten by 5Star Life Insurance Company (a Baton Rouge, Louisiana company). Product may not be available in all states or territories. Request FPP insurance from Dell Perot, Post Office Box 83043, Lincoln, Nebraska 68501, (866) 863-9753.

Affordability—With several options to choose from, select the coverage that best meets the needs of your family. Terminal Illness—This plan pays the insured 30% (25% in Connecticut and Michigan) of the policy coverage amount in a lump sum upon the occurrence of a terminal condition that will result in a limited life span of less than 12 months. 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. If this happens, we can simply bill you directly. Coverage can never be cancelled by the insurance company or your employer unless you stop paying premiums. Family Protection—Individual policies can be purchased on the employee, their spouse, children and grandchildren. Children & Grandchildren Plan—Policies can be purchased for children and grandchildren ages 15 days to age 24. Convenience—Premiums are taken care of simply and easily through payroll deductions. Protection You Can Count On—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 $10,000, will be mailed to the insured’s beneficiary, unless the death is within the two-year contestability period and/or under investigation. This product also contains no war or terrorism exclusions.

Example Weekly

Premium Death

Benefit Accelerated

Benefit

Your age at issue: 35

$10.00 $89,655 4%

$3,586.20 a month

33

Family Protection Plan - Terminal Illness

Age on Eff.

Date

Employee Coverage Amounts Spouse Coverage Amounts

$10,000 $25,000 $50,000 $75,000 $100,000 $125,000 $150,000 $10,000 $20,000 $30,000 $40,000 $50,000

18-25 $7.56 $12.40 $20.46 $28.52 $36.58 $44.65 $52.71 $7.56 $10.78 $14.01 17.23 20.46

26 $7.58 $12.46 $20.58 $28.71 $36.83 $44.96 $53.08 $7.58 $10.83 $14.08 17.33 20.58

27 $7.65 $12.63 $20.92 $29.21 $37.50 $45.79 $54.08 $7.65 $10.97 $14.28 17.60 20.92

28 $7.74 $12.85 $21.38 $29.90 $38.42 $46.94 $55.46 $7.74 $11.15 $14.56 17.97 21.38

29 $7.88 $13.21 $22.08 $30.96 $39.83 $48.71 $57.58 $7.88 $11.43 $14.98 18.53 22.08

30 $8.07 $13.67 $23.00 $32.33 $41.67 $51.00 $60.33 $8.07 $11.80 $15.53 19.27 23.00

31 $8.27 $14.17 $24.00 $33.83 $43.67 $53.50 $63.33 $8.27 $12.20 $16.13 20.07 24.00

32 $8.49 $14.73 $25.13 $35.52 $45.92 $56.31 $66.71 $8.49 $12.65 $16.81 20.97 25.13

33 $8.73 $15.31 $26.29 $37.27 $48.25 $59.23 $70.21 $8.73 $13.12 $17.51 21.90 26.29

34 $9.00 $16.00 $27.67 $39.33 $51.00 $62.67 $74.33 $9.00 $13.67 $18.33 23.00 27.67

35 $9.30 $16.75 $29.17 $41.58 $54.00 $66.42 $78.83 $9.30 $14.27 $19.23 24.20 29.17

36 $9.64 $17.60 $30.88 $44.15 $57.42 $70.69 $83.96 $9.64 $14.95 $20.26 25.57 30.88

37 $10.02 $18.54 $32.75 $46.96 $61.17 $75.38 $89.58 $10.02 $15.70 $21.38 27.07 32.75

38 $10.41 $19.52 $34.71 $49.90 $65.08 $80.27 $95.46 $10.41 $16.48 $22.56 28.63 34.71

39 $10.84 $20.60 $36.88 $53.15 $69.42 $85.69 $101.96 $10.84 $17.35 $23.86 30.37 36.88

40 $11.31 $21.77 $39.21 $56.65 $74.08 $91.52 $108.96 $11.31 $18.28 $25.26 32.23 39.21

41 $11.83 $23.08 $41.83 $60.58 $79.33 $98.08 $116.83 $11.83 $19.33 $26.83 34.33 41.83

42 $12.41 $24.52 $44.71 $64.90 $85.08 $105.27 $125.46 $12.41 $20.48 $28.56 36.63 44.71

43 $13.00 $26.00 $47.67 $69.33 $91.00 $112.67 $134.33 $13.00 $21.67 $30.33 39.00 47.67

44 $13.63 $27.56 $50.79 $74.02 $97.25 $120.48 $143.71 $13.63 $22.92 $32.21 41.50 50.79

45 $14.28 $29.19 $54.04 $78.90 $103.75 $128.60 $153.46 $14.28 $24.22 $34.16 44.10 54.04

46 $14.97 $30.92 $57.50 $84.08 $110.67 $137.25 $163.83 $14.97 $25.60 $36.23 46.87 57.50

47 $15.69 $32.73 $61.13 $89.52 $117.92 $146.31 $174.71 $15.69 $27.05 $38.41 49.77 61.13

48 $16.43 $34.56 $64.79 $95.02 $125.25 $155.48 $185.71 $16.43 $28.52 $40.61 52.70 64.79

49 $17.22 $36.54 $68.75 $100.96 $133.17 $165.38 $197.58 $17.22 $30.10 $42.98 55.87 68.75

50 $18.08 $38.69 $73.04 $107.40 $141.75 $176.10 $210.46 $18.08 $31.82 $45.56 59.30 73.04

51 $19.04 $41.10 $77.88 $114.65 $151.42 $188.19 $224.96 $19.04 $33.75 $48.46 63.17 77.88

52 $20.16 $43.90 $83.46 $123.02 $162.58 $202.15 $241.71 $20.16 $35.98 $51.81 67.63 83.46

53 $21.40 $47.00 $89.67 $132.33 $175.00 $217.67 $260.33 $21.40 $38.47 $55.53 72.60 89.67

54 $22.79 $50.48 $96.63 $142.77 $188.92 $235.06 $281.21 $22.79 $41.25 $59.71 78.17 96.63

55 $24.27 $54.17 $104.00 $153.83 $203.67 $253.50 $303.33 $24.27 $44.20 $64.13 84.07 104.00

56 $25.93 $58.33 $112.33 $166.33 $220.33 $274.33 $328.33 $25.93 $47.53 $69.13 90.73 112.33

57 $27.66 $62.65 $120.96 $179.27 $237.58 $295.90 $354.21 $27.66 $50.98 $74.31 97.63 120.96

58 $29.42 $67.04 $129.75 $192.46 $255.17 $317.88 $380.58 $29.42 $54.50 $79.58 104.67 129.75

59 $31.23 $71.56 $138.79 $206.02 $273.25 $340.48 $407.71 $31.23 $58.12 $85.01 111.90 138.79

60 $33.12 $76.29 $148.25 $220.21 $292.17 $364.13 $436.08 $33.12 $61.90 $90.68 119.47 148.25

61 $35.08 $81.19 $158.04 $234.90 $311.75 $388.60 $465.46 $35.08 $65.82 $96.56 127.30 158.04

62 $37.13 $86.31 $168.29 $250.27 $332.25 $414.23 $496.21 $37.13 $69.92 $102.71 135.50 168.29

63 $39.31 $91.77 $179.21 $266.65 $354.08 $441.52 $528.96 $39.31 $74.28 $109.26 144.23 179.21

64 $41.68 $97.71 $191.08 $284.46 $377.83 $471.21 $564.58 $41.68 $79.03 $116.38 153.73 191.08

65 $44.33 $104.33 $204.33 $304.33 $404.33 $504.33 $604.33 $44.33 $84.33 $124.33 164.33 204.33

66* $44.93 $105.81 $207.29 $308.77 $410.25 $511.73 $613.21 $44.93 $85.52 $126.11 166.70 207.29

67* $48.25 $114.13 $223.92 $333.71 $443.50 $553.29 $663.08 $48.25 $92.17 $136.08 180.00 223.92

68* $52.03 $123.58 $242.83 $362.08 $481.33 $600.58 $719.83 $52.03 $99.73 $147.43 195.13 242.83

69* $56.33 $134.31 $264.29 $394.27 $524.25 $654.23 $784.21 $56.33 $108.32 $160.31 212.30 264.29

70* $61.17 $146.42 $288.50 $430.58 $572.67 $714.75 $856.83 $61.17 $118.00 $174.83 231.67 288.50 34

Family Protection Plan - Terminal Illness

*Qualify of Life not available ages 66-70. Quality of Life benefits not available for children. Child life coverage available only on children and grandchildren of employee (age on application date: 15 days to age 24). $4.98 monthly for $10,000 coverage and $9.97 monthly for $20,000 coverage.

35

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 & AD&D YOUR BENEFITS PACKAGE

DID YOU KNOW?

One America



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

drowning, and choking.

#1

Motor vehicle crashes are the

36

AUL's Group Voluntary Term Life Insurance Terms and Definitions

Eligible Employees: This benefit is available for employees who are actively at work on the effective date and working a minimum of 20 hours per week.

Flexible Choices: Since everyone's needs are different, this plan offers flexibility for you to choose a benefit amount that fits your needs and budget.

Guaranteed Issue Amounts: This is the most coverage you can purchase without having to answer any health questions. If you decline insurance coverage now and decide to enroll later, you will need to provide Evidence of Insurability.

Timely Enrollment: Enrolling timely means you have enrolled during the initial enrollment period when benefits were first offered by AUL, or as a newly hired employee within 31 days following completion of any applicable waiting period.

Evidence of Insurability: If you elect a benefit amount over the Guaranteed Issue Amount shown above for you or your eligible dependents, or you do not enroll timely, you will need to submit a Statement of Insurability form for review. Based on health history, you and / or your dependents will be approved or declined for insurance coverage by AUL.

Guaranteed Increase in Benefit: If eligible, this benefit allows you to increase your coverage every year as your life insurance needs change. You may be able to increase your benefit amount by $10,000 every year until you reach the guaranteed issue amount, without providing Evidence of Insurability. NOTE: If Evidence of Insurability is applied for and denied, please be aware Guaranteed Increase in Benefits will not be made available to you in the future.

Continuation of Coverage Options: Portability Should your coverage terminate for any reason, you may be eligible to take this term life insurance with you without providing Evidence of Insurability. You must apply within 31 days from the last day you are eligible. The Portability option is available until you reach age 70.

OR

Conversion Should your life insurance coverage, or a portion of it, cease for any reason, you may be eligible to convert your Group Term Coverage to Individual Coverage without providing Evidence of Insurability. You must apply within 31 days from the last day you are eligible. Accelerated Life Benefit: If diagnosed with a terminal illness and have less than 12 months to live, you may apply to receive 25%, 50% or 75% of your life insurance benefit to use for whatever you choose. Waiver of Premium: If approved, this benefit waives your and your dependents' insurance premium in case you become totally disabled and are unable to collect a paycheck. Reductions: Upon reaching certain ages, your original benefit amount will reduce to a percentage as shown in the following schedule.

This invitation to inquire allows eligible employees an opportunity to inquire further about AUL's group insurance and is limited to a brief description of any losses for which benefits are payable. The contract has exclusions, limitations reduction of benefits, and terms under which the contract may be continued in force or discontinued.

Life and AD&D

Employee Guaranteed Issue Amount $250,000

Spouse Guaranteed Issue Amount $60,000

Child Guaranteed Issue Amount $10,000

Age: 65 70

Reduces To: 65% 50%

37

Life and AD&D

Monthly Payroll Deduction Illustration

About your benefit options:

You may select a minimum benefit of $10,000 up to a maximum amount of $500,000, in increments of $10,000, not to exceed 7 times your annual base salary only, rounded to the next higher $10,000.

Amounts requested above $250,000 for an Employee, $60,000 for a Spouse, or any amount not requested timely will require Evidence of Insurability.

Employee must select coverage to select any Dependent coverage.

Dependent coverage cannot exceed 100% of the Voluntary Term Life amount selected by the Employee.

EMPLOYEE ONLY OPTIONS (based on Employee's age as of 09/01)

Life Options

0-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+

$10,000 $.45 $.45 $.45 $.55 $.65 $1.00 $1.55 $2.40 $3.67 $5.89 $9.79 $14.61 $26.72

$20,000 $.90 $.90 $.90 $1.10 $1.30 $2.00 $3.10 $4.80 $7.34 $11.78 $19.58 $29.22 $53.44

$30,000 $1.35 $1.35 $1.35 $1.65 $1.95 $3.00 $4.65 $7.20 $11.01 $17.67 $29.37 $43.83 $80.16

$40,000 $1.80 $1.80 $1.80 $2.20 $2.60 $4.00 $6.20 $9.60 $14.68 $23.56 $39.16 $58.44 $106.88

$50,000 $2.25 $2.25 $2.25 $2.75 $3.25 $5.00 $7.75 $12.00 $18.35 $29.45 $48.95 $73.05 $133.60

$80,000 $3.60 $3.60 $3.60 $4.40 $5.20 $8.00 $12.40 $19.20 $29.36 $47.12 $78.32 $116.88 $213.76

$100,000 $4.50 $4.50 $4.50 $5.50 $6.50 $10.00 $15.50 $24.00 $36.70 $58.90 $97.90 $146.10 $267.20

$150,000 $6.75 $6.75 $6.75 $8.25 $9.75 $15.00 $23.25 $36.00 $55.05 $88.35 $146.85 $219.15 $400.80

$200,000 $9.00 $9.00 $9.00 $11.00 $13.00 $20.00 $31.00 $48.00 $73.40 $117.80 $195.80 $292.20 $534.40

$250,000 $11.25 $11.25 $11.25 $13.75 $16.25 $25.00 $38.75 $60.00 $91.75 $147.25 $244.75 $365.25 $668.00

SPOUSE ONLY OPTIONS (based on Employee's Age as of 09/01)

Life Options

0-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75+

$10,000 $.45 $.45 $.45 $.55 $.65 $1.00 $1.55 $2.40 $3.67 $5.89 $9.79 $14.61 $26.72

$20,000 $.90 $.90 $.90 $1.10 $1.30 $2.00 $3.10 $4.80 $7.34 $11.78 $19.58 $29.22 $53.44

$30,000 $1.35 $1.35 $1.35 $1.65 $1.95 $3.00 $4.65 $7.20 $11.01 $17.67 $29.37 $43.83 $80.16

$40,000 $1.80 $1.80 $1.80 $2.20 $2.60 $4.00 $6.20 $9.60 $14.68 $23.56 $39.16 $58.44 $106.88

$50,000 $2.25 $2.25 $2.25 $2.75 $3.25 $5.00 $7.75 $12.00 $18.35 $29.45 $48.95 $73.05 $133.60

$60,000 $2.70 $2.70 $2.70 $3.30 $3.90 $6.00 $9.30 $14.40 $22.02 $35.34 $58.74 $87.66 $160.32

38

Life and AD&D

CHILD(REN) OPTIONS (Premium shown for Child(ren) reflects the cost for all eligible dependent children)

Child(ren) 6 months to age 26 Child(ren) live birth to 6 months Monthly Payroll Deduction Life

Amount

Option 1: $2,500 $1,000 $.50

Option 2: $5,000 $1,000 $1.00

Option 3: $7,500 $1,000 $1.50

Option 4: $10,000 $1,000 $2.00

About Premiums: The premiums shown above may vary slightly due to rounding; actual premiums will be calculated by American United Life Insurance Company® (AUL), and may increase upon reaching certain age brackets, according to contract terms, and are subject to change.

Employee Only AD&D Family AD&D

Volume

Monthly Deduction

Employee Volume

Spouse Volume

Child Volume

Monthly Deduction

$ 10,000 $ 0.176 $ 10,000 $ 5,000 $ 1,000 $ 0.318

$ 20,000 $ 0.352 $ 20,000 $ 10,000 $ 2,000 $ 0.636

$ 30,000 $ 0.528 $ 30,000 $ 15,000 $ 3,000 $ 0.954

$ 40,000 $ 0.704 $ 40,000 $ 20,000 $ 4,000 $ 1.272

$ 50,000 $ 0.880 $ 50,000 $ 25,000 $ 5,000 $ 1.590

$ 60,000 $ 1.056 $ 60,000 $ 30,000 $ 6,000 $ 1.908

$ 70,000 $ 1.232 $ 70,000 $ 35,000 $ 7,000 $ 2.226

$ 80,000 $ 1.408 $ 80,000 $ 40,000 $ 8,000 $ 2.544

$ 90,000 $ 1.584 $ 90,000 $ 45,000 $ 9,000 $ 2.862

$ 100,000 $ 1.760 $ 100,000 $ 50,000 $ 10,000 $ 3.180

$ 150,000 $ 2.640 $ 150,000 $ 75,000 $ 15,000 $ 4.770

$ 200,000 $ 3.520 $ 200,000 $ 100,000 $ 20,000 $ 6.360

$ 250,000 $ 4.400 $ 250,000 $ 125,000 $ 25,000 $ 7.950

$ 300,000 $ 5.280 $ 300,000 $ 150,000 $ 30,000 $ 9.540

$ 350,000 $ 6.160 $ 350,000 $ 175,000 $ 35,000 $ 11.130

$ 400,000 $ 7.040 $ 400,000 $ 200,000 $ 40,000 $ 12.720

$ 450,000 $ 7.920 $ 450,000 $ 225,000 $ 45,000 $ 14.310

$ 500,000 $ 8.800 $ 500,000 $ 250,000 $ 50,000 $ 15.900

Monthly Payroll Deduction Illustration About your benefit options:

You may select a minimum benefit of $10,000 up to a maximum amount of $500,000, in increments of $10,000.

Employee must select coverage to select any Dependent coverage.

The Spouse benefit is equal to 50% of the amount elected by the Employee, the Child benefit is equal to 10% of the amount elected by the Employee.

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)

YOUR BENEFITS PACKAGE

NBS



FOR HSA VS. FSA COMPARISON

FLIP TO… PG. 11

40

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 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 Jacksonville ISD benefit website: www.mybenefitshub.com/jacksonvilleisd

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 May. 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- lose-it. Remember to retain all your receipts.

Health Care Expense Account Example Expenses:

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

The actual care of the dependent in your home.

Preschool tuition.

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

What Can I Use My Flexible Spending Account On? For a full list of eligible expenses, please refer to www.mybenefitshub.com/jacksonvilleisd

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 up to $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/jacksonvilleisd 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!

42

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.

43

www.mybenefitshub.com/jacksonvilleisd

44

2016 Benefit Guide Jacksonville ISD

Documents

Transcript of 2016 Benefit Guide Jacksonville ISD