2016 Benefit Guide Lake Worth ISD

EFFECTIVE:

09/01/2016 - 8/31/2017

BENEFIT GUIDE

www.mybenefitshub.com/lakeworthisd

LAKE WORTH 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 Medical 12-15

TRS Baylor Scott & White Medical 16-17

NBS Flexible Spending Account 18-21

MEDLink® Medical Supplement 22-25

Aetna Dental 26-29 VSP Vision 30-31

Reliance Standard Disability 32-35

Loyal American Cancer 36-39 Allstate Critical Illness 40-41

AUL a OneAmerica Company Life & AD&D 42-45

ID Watchdog Identity Theft Protection 46-47

HSA Bank Health Savings Account (HSA) 48-51

Table of Contents

HOW TO ENROLL

PG. 4

YOUR BENEFIT UPDATES: WHAT’S NEW

PG. 6

YOUR MEDICAL BENEFITS

PG. 12

FLIP TO...

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Benefit Contact Information

Benefit Contact Information

LAKE WORTH ISD BENEFITS FLEXIBLE SPENDING ACCOUNTS

DISABILITY LIFE AND AD&D

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

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

Group #VPL683271 Reliance Standard (800) 351-7500 www.reliancestandard.com

Group #GFZ02331 AUL a OneAmerica Company (800) 583-6908 www.oneamerica.com

LAKE WORTH ISD BENFITS OFFICE MEDICAL SUPPLEMENT—MEDLINK ®

CANCER ID THEFT PROTECTION

Maria Castillo or Leslie Reyes (817) 306-4200 ext 1048 or 1049 [email protected] or [email protected]

Group #15302 American Public Life (800) 256-8606 www.ampublic.com

Loyal American (800) 366-8354 www.loyalamerican.com

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

TRS ACTIVECARE MEDICAL DENTAL CRITICAL ILLNESS HEALTH SAVINGS ACCOUNT (HSA)

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

Aetna (877) 238-6200 www.aetna.com

Allstate (800) 348-4489 www.allstateatwork.com

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

TRS HMO MEDICAL VISION

Scott and White Health (800) 321-7947 www.trs.swhp.org

Group #12243999 VSP (800) 877- 7195 www.vsp.com

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!

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/

lakeworthisd delivers

important benefit information

with 24/7 access, as well as

detailed plan information, rates

and product videos.

TEXT

“lakeworth”

TO

313131

On Your Device Enrolling in your benefits just got

a lot easier! Text “lakeworth” 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/lakeworthisd 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

NEW! All plans offered by Lake Worth ISD become effective on 9/1/16 and remain in effect until 8/31/17. For 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 31 days of event.

Aetna remains the carrier for TRS ActiveCare Medical

Plans: ActiveCare 1 HD, ActiveCare 2 and ActiveCare Select. Scott and White HMO Plan is available for all employees working or residing in Dallas, Ellis, Denton, Collin, Rockwall and Tarrant counties. All eligible employees, including active, contributing TRS members and employees regularly working 10 hours per week MUST either enroll for coverage or decline coverage in the Benefits HUB. For comprehensive TRS medical information, please visit www.trs.state.tx.us.

LWISD provides $50,000 of Basic Term Life and AD&D

insurance to all eligible employees through One America. Voluntary Life for employees, spouses, and children is also available. New hire Guarantee Issue (GI) is up to 7 times salary or $200,000; $50,000 for spouse and $10,000 for children. All current employees and spouse coverage amounts can increase by $10,000 up to the GI amount with no health questions asked.

NEW! Lake Worth now offers enrollment in a Health Savings Account which are administered by HSA Bank. An HSA allows you to contribute funds pre-taxed into your account that can be used for medical, dental, vision, and prescription expenses. The IRS annual maximums are determined by the participants enrolled in the High Deductible Health Plan, Active Care 1 HD: $3350 for an individual or $6750 for your family. When you enroll in an HSA, you will receive a welcome packet and verification instructions to receive your new debit card no earlier than mid-September. Fund balances rollover from year to year but annual enrollment is required during open enrollment. If you elect the MEDLink® plan, Active Care Select or ActiveCare 2, you are not eligible to participate in an HSA.

NEW! Lake Worth now offers group Cancer though Loyal

American and Group Critical Illness through Allstate. Enrollment is guaranteed issue and requires no paper applications. You may enroll in coverage for yourself, your spouse and your children.

National Benefit Services remains the administrator of

your Flexible Spending and Childcare Reimbursement Accounts. You MUST re-elect a new contribution amount every year to participate. This benefit does NOT rollover. Your entire annual contribution amount will be available to use 9/1/16. Claim forms are available on the benefits website at www.mybenefitshub.com/lakeworthisd.

Don’t Forget!

Lake Worth will conduct Open Enrollment from July 18th though August 22. Per ACA requirements and LWISD protocol, all LWISD employees are required to either elect or decline medical and supplemental benefits during the open enrollment period.

Enrollment assistance is available by using the “Contact Us” link on the website or by calling Financial Benefit Services Call Center at (866) 914-5202 Monday-Friday, July 18th through August 22th from 8am - 5pm to speak to a representative. Spanish speaking representatives will be available.

Please have spouse and dependent's Social Security numbers and dates of birth available when completing your enrollment.

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/lakeworthisd. 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 Lake Worth

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

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.

SUMMARY PAGES

8

PLAN CARRIER MAXIMUM AGE

TRS Medical Aetna 26

Dental Aetna 26

Vision VSP 26

Cancer Loyal American 25

Critical Illness Allstate 26

MEDLink IV* APL 26

Life and AD&D AUL a OneAmerica Company 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 Lake Worth ISD or as both

employees and dependents.

If your dependent is disabled, coverage can 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

*Contact carrier within 30 days of termination to be eligible for continuation

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. 48

FOR FSA INFORMATION

FLIP TO… PG. 18

11

Major medical insurance is a type of health care coverage that provides benefits for a broad range of medical expenses that may be incurred either on an inpatient or outpatient basis.

About this Benefit

Medical

YOUR BENEFITS PACKAGE

DID YOU KNOW?

TRS Aetna

More than 70% of adults across the United States are already being diagnosed with

a chronic disease.

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

Lake Worth ISD Benefits Website: www.mybenefitshub.com/lakeworthisd 12

TRS-ActiveCare Plan 1- HD

TRS Monthly Premium

Lake Worth ISD Contribution

2016-2017 TRS Employee Premium

Employee Only $341.00 $225.00 $116.00

Employee & Spouse $914.00 $225.00 $689.00

Employee & Child(ren) $615.00 $225.00 $390.00

Employee & Family $1,231.00 $225.00 $1,006.00

Deductible: Employee Only $2500 & Employee Family $5000 Max Out of Pocket: Employee Only $6550 & Employee Family $13,100

TRS-ActiveCare Select- Exclusive Provider

Organization

TRS Monthly Premium

Lake Worth ISD Contribution

2016-2017 TRS Employee Premium

Employee Only $484.00 $225.00 $259.00

Employee & Spouse $1,147.00 $225.00 $922.00


Employee & Family $1,361.00 $225.00 $1,136.00

Deductible: Employee Only $1200 Ded & Employee Family $3600 Ded Max Out of Pocket: Employee Only $6850 & Employee Family $13,700

TRS-ActiveCare 2 TRS

Monthly Premium Lake Worth ISD

Contribution 2016-2017 TRS

Employee Premium

Employee Only $645.00 $225.00 $420.00

Employee & Spouse $1,552.00 $225.00 $1,327.00

Employee & Child(ren) $1,042.00 $225.00 $817.00

Employee & Family $1,597.00 $225.00 $1,372.00

Deductible: Employee Only $1200 & Employee Family $3000 Max Out of Pocket: Employee Only $6850 & Employee Family $13,700

Scott and White HMO TRS

Monthly Premium Lake Worth ISD

Contribution 2016-2017 TRS

Employee Premium

Employee Only $503.60 $225.00 $278.60

Employee & Spouse $1,135.62 $225.00 $910.62


Employee & Family $1,259.76 $225.00 $1,034.76

Deductible: Employee Only $1000 Ded & Employee Family $3000 Max Out of Pocket: Employee Only $5000 & Employee Family $10,000

Lake Worth ISD 2016 - 2017 TRS Medical Rates

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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.

14

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. 15

2016-2017 Scott & White Health Plan Highlights Summary of Benefits for TRS-ActiveCare

Fully Covered Health Care Services Copay

Preventive Services No Charge

Standard Lab and X-ray No Charge

Disease Management and Complex Case Management No Charge

Well Child Care Annual Exams No Charge

Immunizations (age appropriate) No Charge

Plan Provisions Copay

Annual Deductible $1,000 Individual/ $3,000 Family

Annual out-of-pocket maximum (including medical and prescription co-pays and coinsurance)

$5,000 Individual/ $10,000 Family (includes combined Medical and RX copays, deductibles and

coinsurance)

Lifetime Paid Benefit Maximum None

Outpatient Services Copay

Primary Care1 $20 co-pay

(First Primary Care Visit for Illness $0 Copay2)

Specialty Care $50 co-pay

Other Outpatient Services 20% after deductible3

Diagnostic/Radiology Procedures 20% after deductible

Eye Exam (one annually) No Charge

Allergy Serum & Injections 20% after deductible

Outpatient Surgery $150 co-pay and 20% of charges after deductible

Maternity Care Copay

Prenatal Care No Charge

Inpatient Delivery $150 per day4 and 20% of charges after deductible

Inpatient Services Copay

Overnight hospital stay: includes all medical services including semi-private room or intensive care

$150 per day4 and 20% of charges after deductible

Diagnostic & Therapeutic Services Copay

Physical and Speech Therapy $50 copay

Manipulative Therapy5 20% without office visit $40 plus 20% with office visit

Equipment and Supplies Copay

Preferred Diabetic Supplies and Equipment $3 copay; no deductible

Non-Preferred Diabetic Supplies and Equipment 30% after Rx deductible

Durable Medical Equipment/ Prosthetics 20% after deductible

16

2016-2017 Scott & White Health Plan Highlights Summary of Benefits for TRS-ActiveCare

Home Health Services Copay

Home Health Care Visit $50 co-pay

Worldwide Emergency Care Copay

Nurse Advice Line 1-877-505-7947

Online Services No Charge — go to www.trs.swhp.org

After Hours Primary Care Clinics $20 co-pay

Ambulance and Helicopter $40 copay and 20% of charges after deductible

Emergency Room6 $150 copay and 20% of charges after deductible

Urgent Care Facility $55 copay

Prescription Drugs Copay

Annual Benefit Maximum Unlimited

Rx Deductible Does not apply to preferred generic drugs

$100

Ask an SWHP Pharmacy representative how to save money on your prescriptions.

Retail Quantity (Up to a 30-day supply)

Maintenance Quantity BSWH Pharmacies Only (Up to a 90-day supply)

Preferred Generic7 $3 copay $6 copay

Preferred Brand 30% after Rx deductible 30% after Rx deductible

Non-preferred 50% after Rx deductible 50% after Rx deductible

Non-formulary Greater of $50 or 50% after deductible Not available

Mail Order 1-800-707-3477

1Including all services billed with office visit 2Does not apply to wellness or preventive visits 3Includes other services, treatments, or procedures received at time of office visit 4$750 maximum copay per admission and 20% after deductible 55 visits max per month, 35 max visit per year 6Copay waived if admitted within 24 hours 7If a brand name drug is dispensed when a generic is available, 50% copay applies

Specialty Medications (Up to a 30-day supply)

Copay

20% after Rx deductible

17

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

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

About this Benefit

FSA (Flexible Spending Account)


NBS


Lake Worth ISD Benefits Website: www.mybenefitshub.com/lakeworthisd

FOR HSA VS. FSA COMPARISON

FLIP TO… PG. 11

18

Available Benefits Health flexible spending account: The health flexible spending account (FSA) enables you to pay for expenses allowed under Section 105 and 213(d) of the Internal Revenue Code which are not covered by our insured medical plan. The most that you can contribute to your Health FSA each plan year is set by the IRS. This amount can be adjusted for increases in cost-of-living in accordance with Code Section 125(i)(2).

Current plan participants: A premium expense portion of the plan allows you to use pre- tax dollars to pay for specific premiums under various insurance programs we offer you.

Dependent care flexible spending account: The dependent care flexible spending account (DCFSA) enables you to pay for out-of-pocket, work-related dependent daycare costs. Please see the Summary Plan Description for the definition of an eligible dependent. The law places limits on the amount of money that can be paid to you in a calendar year. Generally, your reimbursement may not exceed the lesser of: (a) $5,000 (if you are married filing a joint return or you are head of a household) or $2,500 (if you are married filing separate returns); (b) your taxable compensation; (c) your spouse’s actual or deemed earned income. Also, in order to have the reimbursements made to you and be excluded from your income, you must provide a statement from the service provider including the name, address and, in most cases, the taxpayer identification number of the service provider as well as the amount of such expense and proof that the expense has been incurred.

Determining contributions Before each plan year begins, you will select the benefits you want and how much contributions should go toward each benefit. It is very important that you make these choices carefully based on what you expect to spend on each covered benefit or expense during the plan year. Generally, you cannot change the elections you have made after the beginning of the plan year. However, there are certain limited situations when you can change your elections if you have a “change in status”. Please refer to your Summary Plan Description for a change in status listing

How do I receive reimbursements? During the course of the plan year, you may submit requests for reimbursement of expenses you have incurred. Expenses are

considered “incurred” when the service is performed, not necessarily when it is paid for. You can get submit a claim online at: my.nbsbenefits.com Please note: Policies other than company sponsored policies (i.e. spouse’s or dependents’ individual policies) may not be paid through the flexible benefits plan. Furthermore, qualified long-term care insurance plans may not be paid through the flexible benefits plan.

Account Information A Participants may call NBS and talk to a representative during our regular buisiness hours, Monday-Friday, 7 a.m. to 6 p.m. 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 at (888) 353-9125. For immediate access to your account information at any time, log on to our website at my.nbsbenefits.com or download the NBS Mobile App.

FSA (Flexible Spending Account)

FSA No FSA

Annual taxable income

$24,000 $24,000

Health FSA $1,500 $0

Dependent care FSA $1,500 $0

Total pre-tax contributions

-$3,000 $0

Taxable income after FSA

$21,000 $24,000

Income taxes -$6,300 -$7,200

After-tax income $14,700 $16,800

After-tax health and welfare expenses

$0 -$3,000

Take-home pay $14,700 $13,800

You saved $900 $0

What Can I Save with an FSA?

19

Easy and Convenient Designed to work just as other iOS and Android apps which

makes it easy to learn and use. Shares user authentication with the NBS portal. Registered

useres can download the app and log in immediately to gain access to their benefit accounts, with no need to register their phone or your account.

It’s secure No sensitive account information is ever stored on your mobile device and secure encryption is used to protect all transmissions.

NBS Mobile App

Mobile App Features

The NBS mobile app supports a wide variety of features, empowering you to proactively manage your account.

View account balances

View claims

View reimbursement history

Submit claims

Submit documentation using your device’s camera

Pay providers

Setup a variety of SMS alerts

Edit your personal information

View contribution details

View plan information

View calendar deadlines

Contact a service representative

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

20

Sample Expenses

Dental Expenses

Acupuncture

Addiction programs

Adoption (medical expenses for baby birth)

Alternative healer fees

Ambulance

Body scans

Breast pumps

Care for mentally handicapped

Chiropractor

Copayments

Crutches Diabetes (insulin, glucose monitor)

Eye patches

Fertility treatment

First aid (i.e. bandages, gauze)

Hearing aids & batteries

Hypnosis (for treatment of illness)

Incontinence products (i.e. Depends, Serene)

Joint support bandages and hosiery

Lab fees

Monitoring device (blood pressure, cholesterol)

Physical exams

Pregnancy tests

Prescription drugs

Psychiatrist/psychologist (for mental illness)

Physical therapy

Speech therapy

Vaccinations

Vaporizers or humidifiers

Weight loss program fees (if pre-scribed by physician)

Wheelchair

Vision Expenses

Artificial teeth

Copayments

Deductible

Dental work

Dentures

Orthodontia expenses

Preventative care at dentist office

Bridges, crowns, etc.

Vision Expenses

Braille - books & magazines

Contact lenses

Contact lens solutions

Eye exams

Eye glasses

Laser surgery

Office fees

Guide dog and upkeep/other animal aid

Items that generally do not qualify for reimbursement

Personal hygiene (deodorant, soap, body powder, sanitary products)

Addiction products

Allergy relief (oral meds, nasal spray)

Antacids and heartburn relief

Anti-itch and hydrocortisone creams

Athlete’s foot treatment

Arthritis pain relieving creams

Cold medicines (i.e. syrups, drops, tablets)

Cosmetic surgery

Cosmetics (i.e. makeup, lipstick, cotton swabs, cotton balls, baby oil)

Counseling (i.e. marriage/family)

Dental care - routine (i.e. toothpaste, toothbrushes, dental floss, anti-bacterial mouthwashes, fluoride rins-es, teeth whitening/bleaching)

Exercise equipment

Fever & pain reducers (i.e. Aspirin, Tylenol)

Hair care (i.e. hair color, shampoo, conditioner, brushes, hair loss prod-ucts)

Health club or fitness program fees

Homeopathic supplement or herbs

Household or domestic help

Laser hair removal

Laxatives

Massage therapy

Motion sickness medication

Nutritional and dietary supplements (i.e. bars, milkshakes, power drinks, Pedialyte)

Skin care (i.e. sun block, moisturizing lotion, lip balm)

Sleep aids (ie.e oral meds, snoring strips)

Smoking cessation relief (i.e. patches, gum)

Stomach & digestive relief (i.e. Pepto- Bismol, Imodium)

Tooth and mouth pain relief (Orajel, Anbesol)

Vitamins

Wart removal medication

Weight reduction aids (i.e. Slimfast, appetite suppresant

These expenses may be eligible if they are prescribed by a physician (if medically necessary for a specific condition).

21

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

About this Benefit

MEDlink®IV YOUR

BENEFITS

DID YOU KNOW?

33%

of total healthcare costs are paid

out-of-pocket.



AMERICAN PUBLIC LIFE

(03/16) 22

APSB-22354(TX) MGM/FBS Lake Worth ISD

*Total premium includes the Plan selected and any applicable rider premium. Premiums are subject to increase with notice.The premium and amount of benefits vary dependent upon the Plan selected at time of application.

Total Monthly Premiums by Plan*

Employee Employee & Spouse Employee & Child Employee & Family

Ages 18-54 $19.30 $44.38 $32.80 $57.89

Ages 55+ $28.94 $66.57 $49.20 $86.83

ENHANCED PLAN SUMMARY OF BENEFITS*

Base Policy Option 1

Maximum In-Hospital Benefits $1,500 per Covered Person per Confinement

In-Hospital Ambulance Benefit Up to $350 per trip for ground transportation or up to $1,000 per trip for air transportation where a Covered Person is Confined as an Inpatient. Limited to one trip per day.

In-Hospital Deductible $0 per Covered Person per Confinement

Outpatient Benefit Rider

Maximum Outpatient Benefits $250 per Covered Person per Occurrence for Covered Outpatient Services

Outpatient Ambulance Benefit Up to $350 per trip for ground transportation or up to $1,000 per trip for air transportation where a Covered Person resides less than 18 hours. Limited to one trip per day.

Outpatient Deductible $0 per Covered Person Per Occurrence

Covered Outpatient ServicesHospital Emergency Room Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.

Urgent Care Facility Maximum of three Urgent Care visits per Covered Person per Calendar Year. Maximum of six Urgent Care visits per Calendar Year for all Covered Persons combined. Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.

Outpatient Surgery Outpatient Surgery in Hospital Outpatient Facility or Freestanding Outpatient Surgery Center. Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.

Diagnostic Testing Diagnostic Testing in a Hospital Outpatient Facility or MRI Facility. Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.

Outpatient Treatment for a Serious Mental Illness in a Hospital Outpatient Facility

Maximum of 60 days of treatment per Covered Person per Calendar Year. Payable up to the Maximum Outpatient Benefit, subject to the Outpatient Benefit Deductible, as shown above.

MEDlink® IV EnhancedLimited Benefit Group Medical Expense Supplemental InsuranceLake Worth ISDTHE 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.

23

Important Policy Provisions EligibilityYou are eligible to be covered under this Policy/Certificate if you are Actively At Work, qualify for coverage as defined in the Master Application, are covered under your Employer’s Medical Plan and are under age 70 (if you work for an employer employing less than 20 employees). Your Eligible Dependents, as defined in the Policy/Certificate, are eligible for coverage if they are covered under the Employer’s Medical Plan. You must apply for insurance during the Initial Enrollment period or on the date the person first becomes eligible for coverage. If you do not apply during the Initial Enrollment period or on the date you become eligible for coverage, you may be subject to additional underwriting by APL. Evidence of coverage under your Employer’s Medical Plan is required.

When Coverage BeginsCoverage will begin on the requested Certificate Effective Date or the Certificate Effective Date assigned by us, upon approval of your application, if our underwriting rules are met, the premium has been paid and all persons to be insured are covered under your Employer’s Medical Plan and you are Actively At Work on the Certificate Effective Date. If you are not Actively At Work on the Certificate Effective Date due to disability, Injury, Sickness, temporary layoff, leave of absence or Family and Medical Leave of Absence, coverage begins on the date you return to Actively At Work.

Limitations & ExclusionsNo benefits will be payable for expenses incurred during any period the Covered Person does not have coverage under your Employer’s Medical Plan, except as provided in the Absence of the Insured’s Employer’s Medical Plan provision, described in the Policy.

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

Pre-Existing Condition LimitationNo benefits are payable during the Pre-Existing Condition Exclusion Period following the Covered Person’s Effective Date for any loss resulting from a Pre-Existing Condition. The Pre-Existing Condition Limitation will apply only if the Covered Person is subject to a Pre-Existing Condition Limitation under the Employer’s Medical Plan. Therefore, any Pre-Existing Condition Limitation applied to the Major Medical plan would, in effect, limit coverage under this plan.

ExclusionsNo benefits are payable for any loss resulting from or caused, whether directly or indirectly, by: s war or any act of war, whether declared or undeclared, or active service in the armed forces; (This exclusion includes Accident sustained or Sickness contracted while in the service of any military, naval or air force of any country engaged in war. If coverage is suspended for any Covered Person during a period of military service, APL will refund the pro-rata portion of any premium paid for any such Covered Person upon receipt of your written request) s an intentionally self-inflicted Injury or Sickness; s suicide or attempted suicide, while sane or insane; s rest care or rehabilitative care and treatment; s outpatient routine newborn care; s voluntary abortion except, with respect to you or your covered Eligible Dependent spouse: s where you or your Dependent spouse’s life would be endangered if the fetus were carried to term; or s where medical complications have arisen from abortion; s pregnancy of an Eligible Dependent child; s participating in a riot, insurrection, rebellion, civil commotion, civil disobedience or unlawful assembly; (This does not include a loss which occurs while acting in a lawful manner within the scope of authority.)

s committing, or attempting to commit, an illegal act that is defined as a felony; (Felony is as defined by the law of the jurisdiction in which the act takes place.) s participation in a contest of speed in power driven vehicles, parachuting or hang gliding; s air travel, except: s as a fare-paying passenger on a commercial airline on a regularly scheduled route; or s as a passenger for transportation only and not as a pilot or crew member; s being intoxicated or under the influence of any narcotic unless administered by a Physician or taken according to the Physician’s instructions; (Intoxication means that which is determined and defined by the laws and jurisdiction of the geographical area in which the event that caused the loss occurred.) s alcoholism or drug addiction; s sex changes; sexperimental treatment, drugs or surgery; s Accident or Sickness arising out of, and in the course of, any occupation for compensation, wage or profit; (This does not apply to those sole proprietors or partners not covered by Workers’ Compensation.) s dental or vision services, including treatment, surgery, extractions or x-rays, unless: s resulting from an Accident occurring while the Covered Person’s coverage is in force and if performed within 12 months of the date of such Accident; or s due to congenital disease or anomaly of a covered newborn child. s routine examinations, such as health exams, periodic check-ups or routine physicals, except when part of Inpatient routine newborn care; s elective cosmetic surgery; s drugs (prescription and non-prescription for use outside of a covered facility as defined in this Policy/Certificate or any attached rider); s sterilization and reversal of sterilization; s an expense that does not meet the definition of Covered Charges; s an expense or service that exceeds any of the Maximum Benefits, as shown in the Schedule of Benefits; or s any expense for which benefits are not payable under your Other Medical Plan.

Premium ChangesThe premium rates may be changed by APL at the first anniversary date of this Policy or any premium due date thereafter. No such increase in rates will be made unless 60 days prior notice is given to the Policyholder. Premiums will not increase during the initial 12 months of coverage.

Optionally RenewableThis Policy is renewable at the option of APL. The Policyholder or APL may terminate this Policy on any premium due date after the first anniversary following the Policy Effective Date, subject to 60 days written notice.

Termination of CertificateYour insurance coverage under this Certificate and any attached riders will end on the earliest of these dates: s the date the Policy terminates; s the end of the grace period if the premium remains unpaid; s the date you no longer qualify as an Insured; s the date you attain age 70 (if you work for an employer employing less than 20 employees); s the date your coverage under your Employer’s Medical Plan ends; or s the date of your death.


MEDlink® IV Enhanced Limited Benefit Group Medical Expense Supplemental Insurance

24

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


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

Termination of CoverageYour insurance coverage under this Certificate and any attached riders for a Covered Person will end as follows: s the date the Policy terminates; s the date the Certificate terminates; s the end of the Certificate Month in which APL receives a written request from you to terminate the Covered Person’s coverage; s the date a Covered Person no longer qualifies as an Insured or Eligible Dependent; or s the date of the Covered Person’s death.

APL may end the coverage of any Covered Person who submits a fraudulent claim.

Cobra Continuation of CoverageThis plan may be continued in accordance with the Consolidated Omnibus Reconciliation Act of 1986.

MEDlink® IV Enhanced Limited Benefit Group Medical Expense Supplemental Insurance

25

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?

AETNA



Dental Passive PDN and DMO Plans

DMO Passive PDN With PDNII Network

Participating Annual Deductible*

Individual None $75

Family None $225

Preventive Services 100% 80%

Basic Services 80% 80%

Major Services 60% 50%

Annual Benefit Maximum None $1,000

Office Visit Copay $10 N/A

Orthodontic Services** $1,500 copay 50%

Orthodontic Deductible None None

Orthodontic Lifetime Maximum *** $1,000

*The deductible applies to: Basic & Major services only **Orthodontia is covered only for children (appliance must be placed prior to age 20). PDN also includes coverage for adults. *** 24 months of comprehensive orthodontic treatment plus 24 months of retention

Partial List of Services DMO Passive PDN With PDNII Network

Participating Preventative Oral examinations (a) 100% 80%

Cleanings (a) Adult/Child 100% 80%

Fluoride (a) 100% 80%

Sealants (permanent molars only) (a) 100% 80%

Bitewing Images (a) 100% 80%

Full mouth series Images (a) 100% 80%

Space Maintainers 100% 80%

Basic Root canal therapy

Anterior teeth / Bicuspid teeth 80% 80%

Root canal therapy, molar teeth See Below 80%

Scaling and root planing (a) 80% 80%

Gingivectomy* 80% 80%

Amalgam (silver) fillings 80% 80%

Composite fillings (anterior teeth only) 80% 80%

Stainless steel crowns 80% 80%

Incision and drainage of abscess* 80% 80%

Uncomplicated extractions 80% 80%

Surgical removal of erupted tooth* 80% 80%

Surgical removal of impacted tooth (soft tissue)* See Below 80%

Osseous surgery (a)* See Below 80%

Surgical removal of impacted tooth (partial bony/ full bony)* See Below 80%

General anesthesia/intravenous sedation* See Below 80%

Crown Lengthening See Below 80%

Major Inlays 60% 50%

Onlays 60% 50%

Crowns 60% 50%

Full & partial dentures 60% 50%

Pontics 60% 50%

Root canal therapy, molar teeth 60% See Above

Osseous surgery (a)* 60% See Above

Surgical removal of impacted tooth (partial bony/ full bony)* 60% See Above

General anesthesia/intravenous sedation* 60% See Above

Denture repairs 60% 50%

Crown Lengthening 60% See Above

Crown Build-Ups 60% 50%

*Certain services may be covered under the Medical Plan. Contact Member Services for more details. (a) Frequency and/or age limitations may apply to these services. These limits are described in the booklet/certificate.

27


Other Important Information This benefits summary of the Aetna Dental DMO® (Dental Maintenance Organization) provides information on benefits provided when services are rendered by a participating dentist. In order for a covered person to be eligible for benefits, dental services must be provided by a primary care dentist selected from the network of participating DMO dentists. Under the Dental® Participating Dental Network (PDN) plan, you may choose at the time of service either a PDN participating dentist or any nonparticipating dentist. With the PDN plan, savings are possible because the PDN participating dentists have agreed to provide care for covered services at negotiated rates. Non-participating benefits are subject to usual and prevailing charge limits, as determined by Aetna. Due to state law, limited (varying by state) DMO® benefits for non-emergency services rendered by non-participating providers are available for plan contracts written in: CT, IL, KY and OH and for members residing in MA and OK (regardless of contract situs state). Emergency Dental Care If you are covered under the DMO plan and need emergency dental care for the palliative treatment (pain relieving, stabilizing) of a dental emergency, you are covered 24 hours a day, 7 days a week. You should contact your Primary Care Dentist to receive treatment. If you are unable to contact your PCD, contact Member Services for assistance in locating a dentist. Refer to your plan documents for details. Subject to state requirements. Out-of-area emergency dental care may be reviewed by our dental consultants to verify appropriateness of treatment. When emergency services are provided by a participating PDN dentist, your co-payment/coinsurance amount will be based on a negotiated fee schedule. When emergency services are provided by a non-participating dentist, you will be responsible for the difference between the plan payment and the dentist’s usual charge. Refer to your plan documents for details. Subject to state requirements. Out-of-area emergency dental care may be reviewed by our dental consultants to verify appropriateness of treatment. Partial List of Exclusions and Limitations* - Coverage is not provided for the following: 1. Services or supplies that are covered in whole or in part:

a. under any other part of this Dental Care Plan; or b. under any other plan of group benefits provided by or

through your employer. 2. Services and supplies to diagnose or treat a disease or injury that is

not: a. a non-occupational disease; or b. a non-occupational injury.

3. Services not listed in the Dental Care Schedule that applies, unless otherwise specified in the Booklet-Certificate.

4. Those for replacement of a lost, missing or stolen appliance, and those for replacement of appliances that have been damaged due to abuse, misuse or neglect.

5. Those for plastic, reconstructive or cosmetic surgery, or other dental services or supplies, that are primarily intended to improve, alter or enhance appearance. This applies whether or not the services and supplies are for psychological or emotional reasons. Facings on molar crowns and pontics will always be considered cosmetic.

6. Those for or in connection with services, procedures, drugs or other supplies that are determined by Aetna to be experimental or still under clinical investigation by health professionals.

7. Those for dentures, crowns, inlays, onlays, bridgework, or other appliances or services used for the purpose of splinting, to alter vertical dimension, to restore occlusion, or to correct attrition, abrasion or erosion. (This item does not apply to California residents under the DMO plan)

8. Those for any of the following services (Does not apply to the DMO plan in TX):

a. an appliance or modification of one if an impression for it was made before the person became a covered person;

b. a crown, bridge, or cast or processed restoration if a tooth was prepared for it before the person became a covered person; or

c. root canal therapy if the pulp chamber for it was opened before the person became a covered person.

9. Services that Aetna defines as not necessary for the diagnosis, care or treatment of the condition involved. This applies even if they are prescribed, recommended or approved by the attending physician or dentist.

10. Those for services intended for treatment of any jaw joint disorder, unless otherwise specified in the Booklet-Certificate.

11. Those for space maintainers, except when needed to preserve space resulting from the premature loss of deciduous teeth.

12. Those for orthodontic treatment, unless otherwise specified in the Booklet-Certificate.

13. Those for general anesthesia and intravenous sedation, unless specifically covered. For plans that cover these services, they will not be eligible for benefits unless done in conjunction with another necessary covered service.

14. Those for treatment by other than a dentist, except that scaling or cleaning of teeth and topical application of fluoride may be done by a licensed dental hygienist. In this case, the treatment must be given under the supervision and guidance of a dentist.

15. Those in connection with a service given to a person age 5 or older if that person becomes a covered person other than:

a. during the first 31 days the person is eligible for this coverage, or

b. as prescribed for any period of open enrollment agreed to by the employer and Aetna. This does not apply to charges incurred:

i. after the end of the 12-month period starting on the date the person became a covered person; or

ii. as a result of accidental injuries sustained while the person was a covered person; or

iii. for a primary care service in the Dental Care Schedule that applies as shown under the headings Visits and Exams, and X-rays and Pathology.

16. Services given by a nonparticipating dental provider to the extent that the charges exceed the amount payable for the services shown in the Dental Care Schedule that applies.

17. Those for a crown, cast or processed restoration unless: a. it is treatment for decay or traumatic injury, and teeth

cannot be restored with a filling material; or b. the tooth is an abutment to a covered partial denture or

fixed bridge. 18. Those for pontics, crowns, cast or processed restorations made

with high-noble metals, unless otherwise specified in the Booklet-Certificate.

19. Those for surgical removal of impacted wisdom teeth only for orthodontic reasons, unless otherwise specified in the Booklet- Certificate.

20. Services needed solely in connection with non-covered services. 21. Services done where there is no evidence of pathology,

dysfunction or disease other than covered preventive services. (This item does not apply to California residents under the DMO plan)

Any exclusion above will not apply to the extent that coverage of the charges is required under any law that applies to the coverage. *This is a partial list of exclusions and limitations, others may apply. Please check your plan booklet for details.

28


Your Dental Care Plan Coverage Is Subject to the Following Rules: Replacement Rule The replacement of; addition to; or modification of: existing dentures; crowns; casts or processed restorations; removable denture; fixed bridgework; or other prosthetic services is covered only if one of the following terms is met: The replacement or addition of teeth is required to replace one or more teeth extracted after the existing denture or bridgework was installed. This coverage must have been in force for the covered person when the extraction took place. The existing denture, crown; cast or processed restoration, removable denture, bridgework, or other prosthetic service cannot be made serviceable, and was installed at least 5 years under the Dental DMO plan and 8 years under the Dental PDN plan before its replacement. The existing denture is an immediate temporary one to replace one or more natural teeth extracted while the person is covered, and cannot be made permanent, and replacement by a permanent denture is required. The replacement must take place within 12 months from the date of initial installation of the immediate temporary denture. The extraction of a third molar does not qualify. Any such appliance or fixed bridge must include the replacement of an extracted tooth or teeth. Tooth Missing But Not Replaced Rule - (This item does not apply to California or Texas residents under the DMO plan) Coverage for the first installation of removable dentures; fixed bridgework and other prosthetic services is subject to the requirements that such removable dentures; fixed bridgework and other prosthetic services are (i) needed to replace one or more natural teeth that were removed while this policy was in force for the covered person; and (ii) are not abutments to a partial denture; removable bridge; or fixed bridge installed during the prior 5 years under the Dental DMO plan and 8 years under the Dental PDN plan. Alternate Treatment Rule: If more than one service can be used to treat a covered person’s dental condition, Aetna may decide to authorize coverage only for a less costly covered service provided that all of the following terms are met:

a. the service must be listed on the Dental Care Schedule; b. the service selected must be deemed by the dental

profession to be an appropriate method of treatment; and

c. the service selected must meet broadly accepted national standards of dental practice.

If treatment is being given by a participating dental provider and the covered person asks for a more costly covered service than that for which coverage is approved, the specific copayment for such service will consist of:

a. the copayment for the approved less costly service; plus b. the difference in cost between the approved less costly

service and the more costly covered service.

Finding Participating Providers Consult Aetna Dental’s online provider directory, DocFind®, for the most current provider listings. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna Dental or its affiliates. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change without notice. Not every provider listed in the directory will be accepting new patients. Although Aetna Dental has identified providers who were not accepting patients in our DMO plan as known to Aetna Dental at the time the provider directory was created, the status of a provider’s practice may have changed. For the most current information, please contact the selected provider or Aetna Member Services at the toll-free number on your online ID card, or use our Internet-based provider directory (DocFind) available at www.aetna.com.

Specific products may not be available on both a self-funded and insured basis. The information in this document is subject to change without notice. In case of a conflict between your plan documents and this information, the plan documents will govern. In the event of a problem with coverage, members should contact Member Services at the toll-free number on their online ID cards for information on how to utilize the grievance procedure when appropriate. All member care and related decisions are the sole responsibility of participating providers. Aetna Dental does not provide health care services and, therefore, cannot guarantee any results or outcomes. Dental plans are provided or administered by Aetna Life Insurance Company, Aetna Dental Inc., Aetna Dental of California Inc. and/or Aetna Health Inc. In Arizona, DMO®, Advantage Dental, Basic Dental and Family Preventive Dental Plans are provided or administered by Aetna Health Inc. In Texas, the Dental Participating Dental Network (PDN) is known as the Participating Dental Network (PDN), and Indemnity Dental plans are provided or administered by Aetna Life Insurance Company. This material is for informational purposes only and is neither an offer of coverage nor dental advice. It contains only a partial, general description of plan or program benefits and does not constitute a contract. The availability of a plan or program may vary by geographic service area. Certain dental plans are available only for groups of a certain size in accordance with underwriting guidelines. Some benefits are subject to limitations or exclusions. Consult the plan documents (Schedule of Benefits, Certificate/Evidence of Coverage, Booklet, Booklet-Certificate, Group Agreement, Group Policy) to determine governing contractual provisions, including procedures, exclusions and limitations relating to your plan.

2016 -2017 PDN & DMO Rates

Employee Only $34.68

Employee + Spouse $72.91

Employee + Children $80.71

Employee Family $116.27

29

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.

VSP



Vision

Benefit Description Copay Frequency

Your Coverage with a VSP Doctor

WellVision Exam Focuses on your eyes and overall wellness $10 Every 12 months

Prescription Glasses $30 See frame and lenses

Frame

$120 allowance for a wide selection of frames

$140 allowance for featured frame brands

20% savings on the amount over your allowance

Included in Prescription Glasses Every 24 months

Lenses

Single vision, lined bifocal, and lined trifocal lenses

Polycarbonate lenses for dependent children

Included in Prescription Glasses Every 12 months

Lens Enhancements

Standard progressive lenses Premium progressive lenses Custom progressive lenses Average savings of 35-40% on

other lens enhancements

$50 $80 - $90

$120 - $160 Every 12 months

Contacts (instead of glasses)

$120 allowance for contacts; copay does not apply

Contact lens exam (fitting and evaluation)

Up to $60 Every 12 months

Extra Savings

Glasses and Sunglasses

Extra $20 to spend on featured frame brands. Go to vsp.com/specialoffers for details.

30% savings on additional glasses and sunglasses, including lens enhancements, from the same VSP provider on the same day as your WellVision Exam. Or get 20% from any VSP provider within 12 months of your last WellVision Exam.

Retinal Screening

No more than a $39 copay on routine retinal screening as an enhancement to a WellVision Exam

Laser Vision Correction

Average 15% off the regular price or 5% off the promotional price; discounts only available from contracted facilities

After surgery, use your frame allowance (if eligible) for sunglasses from any VSP doctor Your Coverage with Other Providers $9.41 Member only | $15.05 Member + 1 | $15.36 Member + children | $24.77 Member +family

Your Coverage with Out-of-Network Providers

Visit www.vsp.com for details, if you plan to see a provider other than a VSP doctor.

Exam..........................up to $50 Single Vision Lenses…….up to $50 Lined Trifocal Lenses......up to $100 Contacts.....................up to $105

Frame........................up to $70 Lined Bifocal Lenses......up to $75 Progressive Lenses.........up to $75

VSP guarantees coverage from VSP doctors only. Coverage information is subject to change. In the event of a conflict between this information and your organization’s contract with VSP, the terms of the contract will prevail. Based on applicable laws, benefits may vary by location.

VSP Provider Network: VSP Signature

Rates

Employee Only $9.41

Employee + Spouse $15.05

Employee + Children $15.36

Employee Family $24.77

31

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.

RELIANCE STANDARD

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

Coverage Disability income protection insurance provides a benefit for “long term” disability resulting from a covered injury or sickness. Benefits begin at the end of the elimination period and continue while you are disabled up to the maximum benefit duration.

Eligibility Each active full time employee working 20 or more hours per week.

Benefit Amount You may elect a monthly benefit in increments of $100, from a minimum of $200 up to a maximum benefit of $7,500 per month, not to exceed 60% of your covered earnings (rounded to the next lower increment).

Elimination Period Option of: 14 consecutive days of total disability 30 consecutive days of total disability 60 consecutive days of total disability 90 consecutive days of total disability 180 consecutive days of total disability *If you are hospital confined as an inpatient because of your disability and have selected an elimination period of 30 days or less, benefits begin immediately. Inpatient means an individual who is physically confined for an overnight stay, as a registered bed patient in a hospital or institution, as defined in the policy or plan.

Maximum Benefit Duration Benefits will not extend beyond the longer of: Social Security Normal Retirement Age or Duration of Benefits below: Age at Disablement Duration of Benefits

Contribution Requirements Coverage is 100% employee paid.

Rates See rates on the following pages.

Features Limited Benefit Period for Other Specific Conditions – 24

months Mental/Nervous Illness Limitation – 24 month out-patient Own Occupation Coverage – 24 months Pre-Existing Condition Limitation – 3/12 Residual and Partial Disability Specific Indemnity Benefit Substance Abuse Limitation – 24 months Survivor Benefit – 3 months Work Incentive & Child Care provisions

Value Added Services Employee Assistance Program

Exclusions Benefits will not be payable for any disability caused by: an intentionally self-inflicted injury; an act of war (declared or undeclared); commission of a felony; injury or sickness occurring while confined in any penal or correctional institution. For a comprehensive list of exclusions, limitations, and any applicable benefit offsets, please refer to the Certificate of Insurance. The Certificate also provides all requirements necessary to be eligible for coverage and benefits. This Plan Highlights is a brief description of the key features of the RSL insurance plan. The availability of the benefits and features described may vary by state. It is not a certificate of insurance or evidence of coverage. Insurance is provided under group policy form LRS-6564, et al.

61 or less To age 65

62 3 1/2 years

63 3 years

64 2 1/2 years

65 2 years

66 1 3/4 years

67 1 1/2 years

68 1 1/4 years

69 or more 1 year

33

Disability

Monthly Premiums

Min. Annual Earnings

Min. Monthly Earnings

Maximum Monthly Benefit

Option 1 14 day EP

Option 2 30 day EP

Option 3 60 day EP

Option 4 90 day EP

Option 5 180 day EP

$3,600.00 $300.00 $200.00 $5.30 $4.26 $3.62 $3.04 $2.28 $5,400.00 $450.00 $300.00 $7.95 $6.39 $5.43 $4.56 $3.42 $7,200.00 $600.00 $400.00 $10.60 $8.52 $7.24 $6.08 $4.56 $9,000.00 $750.00 $500.00 $13.25 $10.65 $9.05 $7.60 $5.70

$10,800.00 $900.00 $600.00 $15.90 $12.78 $10.86 $9.12 $6.84 $12,600.00 $1,050.00 $700.00 $18.55 $14.91 $12.67 $10.64 $7.98 $14,400.00 $1,200.00 $800.00 $21.20 $17.04 $14.48 $12.16 $9.12 $16,200.00 $1,350.00 $900.00 $23.85 $19.17 $16.29 $13.68 $10.26 $18,000.00 $1,500.00 $1,000.00 $26.50 $21.30 $18.10 $15.20 $11.40 $19,800.00 $1,650.00 $1,100.00 $29.15 $23.43 $19.91 $16.72 $12.54 $21,600.00 $1,800.00 $1,200.00 $31.80 $25.56 $21.72 $18.24 $13.68 $23,400.00 $1,950.00 $1,300.00 $34.45 $27.69 $23.53 $19.76 $14.82 $25,200.00 $2,100.00 $1,400.00 $37.10 $29.82 $25.34 $21.28 $15.96 $27,000.00 $2,250.00 $1,500.00 $39.75 $31.95 $27.15 $22.80 $17.10 $28,800.00 $2,400.00 $1,600.00 $42.40 $34.08 $28.96 $24.32 $18.24 $30,600.00 $2,550.00 $1,700.00 $45.05 $36.21 $30.77 $25.84 $19.38 $32,400.00 $2,700.00 $1,800.00 $47.70 $38.34 $32.58 $27.36 $20.52 $34,200.00 $2,850.00 $1,900.00 $50.35 $40.47 $34.39 $28.88 $21.66 $36,000.00 $3,000.00 $2,000.00 $53.00 $42.60 $36.20 $30.40 $22.80 $37,800.00 $3,150.00 $2,100.00 $55.65 $44.73 $38.01 $31.92 $23.94 $39,600.00 $3,300.00 $2,200.00 $58.30 $46.86 $39.82 $33.44 $25.08 $41,400.00 $3,450.00 $2,300.00 $60.95 $48.99 $41.63 $34.96 $26.22 $43,200.00 $3,600.00 $2,400.00 $63.60 $51.12 $43.44 $36.48 $27.36 $45,000.00 $3,750.00 $2,500.00 $66.25 $53.25 $45.25 $38.00 $28.50 $46,800.00 $3,900.00 $2,600.00 $68.90 $55.38 $47.06 $39.52 $29.64 $48,600.00 $4,050.00 $2,700.00 $71.55 $57.51 $48.87 $41.04 $30.78 $50,400.00 $4,200.00 $2,800.00 $74.20 $59.64 $50.68 $42.56 $31.92 $52,200.00 $4,350.00 $2,900.00 $76.85 $61.77 $52.49 $44.08 $33.06 $54,000.00 $4,500.00 $3,000.00 $79.50 $63.90 $54.30 $45.60 $34.20 $55,800.00 $4,650.00 $3,100.00 $82.15 $66.03 $56.11 $47.12 $35.34 $57,600.00 $4,800.00 $3,200.00 $84.80 $68.16 $57.92 $48.64 $36.48 $59,400.00 $4,950.00 $3,300.00 $87.45 $70.29 $59.73 $50.16 $37.62 $61,200.00 $5,100.00 $3,400.00 $90.10 $72.42 $61.54 $51.68 $38.76 $63,000.00 $5,250.00 $3,500.00 $92.75 $74.55 $63.35 $53.20 $39.90 $64,800.00 $5,400.00 $3,600.00 $95.40 $76.68 $65.16 $54.72 $41.04 $66,600.00 $5,550.00 $3,700.00 $98.05 $78.81 $66.97 $56.24 $42.18 $68,400.00 $5,700.00 $3,800.00 $100.70 $80.94 $68.78 $57.76 $43.32 $70,200.00 $5,850.00 $3,900.00 $103.35 $83.07 $70.59 $59.28 $44.46 $72,000.00 $6,000.00 $4,000.00 $106.00 $85.20 $72.40 $60.80 $45.60 $73,800.00 $6,150.00 $4,100.00 $108.65 $87.33 $74.21 $62.32 $46.74 $75,600.00 $6,300.00 $4,200.00 $111.30 $89.46 $76.02 $63.84 $47.88 $77,400.00 $6,450.00 $4,300.00 $113.95 $91.59 $77.83 $65.36 $49.02 $79,200.00 $6,600.00 $4,400.00 $116.60 $93.72 $79.64 $66.88 $50.16

Scheduled Benefit: Each eligible employee may elect an amount of insurance, in increments of $100 from a minimum of $200 to a maximum of $7,500 per month up to 67% of covered earnings. You may select any benefit amount from $200 up to your maximum monthly benefit. Locate your monthly earnings to determine your maximum monthly benefit amount. If your covered month earnings fall between ranges, the lesser benefit amount will apply.

34

Disability

Monthly Premiums

Min. Annual Earnings

Min. Monthly Earnings

Maximum Monthly Benefit

Option 1 14 day EP

Option 2 30 day EP

Option 3 60 day EP

Option 4 90 day EP

Option 5 180 day EP

$81,000.00 $6,750.00 $4,500.00 $119.25 $95.85 $81.45 $68.40 $51.30

$82,800.00 $6,900.00 $4,600.00 $121.90 $97.98 $83.26 $69.92 $52.44

$84,600.00 $7,050.00 $4,700.00 $124.55 $100.11 $85.07 $71.44 $53.58

$86,400.00 $7,200.00 $4,800.00 $127.20 $102.24 $86.88 $72.96 $54.72

$88,200.00 $7,350.00 $4,900.00 $129.85 $104.37 $88.69 $74.48 $55.86

$90,000.00 $7,500.00 $5,000.00 $132.50 $106.50 $90.50 $76.00 $57.00

$91,800.00 $7,650.00 $5,100.00 $135.15 $108.63 $92.31 $77.52 $58.14

$93,600.00 $7,800.00 $5,200.00 $137.80 $110.76 $94.12 $79.04 $59.28

$95,400.00 $7,950.00 $5,300.00 $140.45 $112.89 $95.93 $80.56 $60.42

$97,200.00 $8,100.00 $5,400.00 $143.10 $115.02 $97.74 $82.08 $61.56

$99,000.00 $8,250.00 $5,500.00 $145.75 $117.15 $99.55 $83.60 $62.70

$100,800.00 $8,400.00 $5,600.00 $148.40 $119.28 $101.36 $85.12 $63.84

$102,600.00 $8,550.00 $5,700.00 $151.05 $121.41 $103.17 $86.64 $64.98

$104,400.00 $8,700.00 $5,800.00 $153.70 $123.54 $104.98 $88.16 $66.12

$106,200.00 $8,850.00 $5,900.00 $156.35 $125.67 $106.79 $89.68 $67.26

$108,000.00 $9,000.00 $6,000.00 $159.00 $127.80 $108.60 $91.20 $68.40

$109,800.00 $9,150.00 $6,100.00 $161.65 $129.93 $110.41 $92.72 $69.54

$111,600.00 $9,300.00 $6,200.00 $164.30 $132.06 $112.22 $94.24 $70.68

$113,400.00 $9,450.00 $6,300.00 $166.95 $134.19 $114.03 $95.76 $71.82

$115,200.00 $9,600.00 $6,400.00 $169.60 $136.32 $115.84 $97.28 $72.96

$117,000.00 $9,750.00 $6,500.00 $172.25 $138.45 $117.65 $98.80 $74.10

$118,800.00 $9,900.00 $6,600.00 $174.90 $140.58 $119.46 $100.32 $75.24

$120,600.00 $10,050.00 $6,700.00 $177.55 $142.71 $121.27 $101.84 $76.38

$122,400.00 $10,200.00 $6,800.00 $180.20 $144.84 $123.08 $103.36 $77.52

$124,200.00 $10,350.00 $6,900.00 $182.85 $146.97 $124.89 $104.88 $78.66

$126,000.00 $10,500.00 $7,000.00 $185.50 $149.10 $126.70 $106.40 $79.80

$127,800.00 $10,650.00 $7,100.00 $188.15 $151.23 $128.51 $107.92 $80.94

$129,600.00 $10,800.00 $7,200.00 $190.80 $153.36 $130.32 $109.44 $82.08

$131,400.00 $10,950.00 $7,300.00 $193.45 $155.49 $132.13 $110.96 $83.22

$133,200.00 $11,100.00 $7,400.00 $196.10 $157.62 $133.94 $112.48 $84.36

$135,000.00 $11,250.00 $7,500.00 $198.75 $159.75 $135.75 $114.00 $85.50

35

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 PACKAGE

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.

LOYAL AMERICAN



Cancer

ADDITIONAL BENEFIT AMOUNTS LEVEL A

Maximum LEVEL B

Maximum ANNUAL CANCER SCREENING BENEFIT RIDER (form LG-6041) A. Basic Benefit We will pay the expense incurred, but not to exceed the maximum benefit amount shown on the Certificate Schedule, once per calendar year per Insured Person for screening tests performed to determine whether Cancer exists in an Insured Person. Covered annual Cancer screening tests include but are not limited to: mammogram, pap smear, breast ultrasound, ThinPrep, biopsy, chest x-ray, thermography, colonoscopy, flexible sigmoidoscopy, hemocult stool specimen, PSA (blood test for prostate cancer), CEA (blood tests for colon cancer), CA125 (blood test for ovarian cancer), CA15-3 (blood test for breast cancer), serum protein electrophesis (blood test for myeloma).

B. Additional Benefit We will pay the expense incurred, but not to exceed two times the maximum benefit amount per calendar year as shown on the Certificate Schedule, for one additional invasive diagnostic procedure required as the result of an abnormal cancer screening test for which benefits are payable under the Basic Benefit above for an Insured Person. This additional benefit is payable regardless of the results of the additional diagnostic procedure. However, the amount payable will be reduced dollar for dollar for any amount payable under the Positive Diagnosis Benefit contained in the base Certificate.

$50 Per Calendar

Year

$100 Per Calendar

Year

$50 Per Calendar

Year

$100 Per Calendar

Year

FIRST OCCURRENCE BENEFIT RIDER (form LG-6043) If an Insured Person receives a positive diagnosis of Internal Cancer, We will pay the First Occurrence benefit amount shown on the Certificate Schedule. If the Insured Person receiving the positive diagnosis of Internal Cancer is a child under the age of 21, we will pay one and one-half times the First Occurrence benefit amount shown on the Certificate Schedule.

$2,000 Once per Lifetime $3,000

Once per Lifetime

$2,000 Once per Lifetime $3,000

Once per Lifetime

ANNUAL RADIATION, CHEMOTHERAPY, IMMUNOTHERAPY and EXPERIMENTAL TREATMENT BENEFIT RIDER (form LG-6045) We will pay the expense incurred, but not to exceed the maximum benefit amount shown on the Certificate Schedule, per calendar year per Insured Person for Radiation Treatment, Chemotherapy, Hormonal Therapy, Immunotherapy or Experimental Treatment. The Radiation Treatment, Chemotherapy, Hormonal Therapy, Immunotherapy or Experimental Treatment must be for the treatment of an Insured Person’s Cancer. The benefit amount shown on the Certificate Schedule is the maximum calendar year benefit available per Insured Person regardless of the number or types of Cancer treatments received in the same year.

$7,500 Per Calendar

Year

$10,000 Per Calendar

Year

SURGICAL BENEFIT RIDER (form LG-6048) Surgical Expense We will pay the Surgical Expense benefit for a surgical procedure for the treatment of an Insured Person’s Cancer (except Skin Cancer) according to the Surgical Schedule shown in this rider. However, in no event will the amount payable exceed the maximum Surgical Expense benefit shown on the Certificate Schedule, nor will it exceed the expense incurred.

$5,000

Procedure Maximum

$5,000

Procedure Maximum

Anesthesia Expense We will pay the anesthesia expense incurred, not to exceed 25% of the covered Surgical Expense benefit for the operation performed. This includes the services of an anesthesiologist or of an anesthetist under supervision of a physician for the purpose of administering anesthesia.

$1,250 Procedure Maximum

$1,250 Procedure Maximum

Breast Reconstruction With transverse rectus adominis myocutaneous flap (TRAM), single pedicle, including closure of donor site, with microvascular anastomosis (supercharging) is one of the surgical procedures listed in the Surgical Schedule. If this procedure is performed on an Insured Person as the result of a mastectomy for which We paid a Surgical Expense benefit for the treatment of Breast Cancer, We will pay the expense incurred not to exceed $900 per $1,000 of the Surgical Benefit issued.

Skin Cancer Surgery Expense We will pay the expense incurred, not to exceed the procedure amount listed in this rider ($125 to $750 depending on the procedure) when a surgical operation is performed on an Insured Person for treatment of a diagnosed Skin Cancer. This benefit is payable in lieu of any benefits for Surgical Expense and Anesthesia Expense which are not applicable to Skin Cancer.

$4,500

Procedure Maximum

Per Procedure

$4,500

Procedure Maximum

Per Procedure

DAILY HOSPITAL CONFINEMENT BENEFIT RIDER (form LG-6042) Confinements of 30 Days or Less We will pay the Daily Hospital Confinement benefit amount shown on the Certificate Schedule for each of the first 30 days in each period of hospital confinement during which an Insured Person is confined to a hospital, including a government or charity hospital, for the treatment of Cancer.

Confinements of 31 Days or More If an Insured Person is continuously confined to a hospital, including a government or charity hospital, for longer than 30 consecutive days for the treatment of Cancer, We will pay two times the Daily Hospital Confinement benefit amount shown on the Certificate Schedule. This benefit payment will begin on the 31st continuous day of such confinement and continue for each day of confinement until the Insured Person is discharged from the Hospital.

Benefits for an Insured Dependent Child under Age 21 The amount payable under this benefit will be double the Daily Hospital Confinement benefit shown on the Certificate Schedule if the Insured Person so confined is a dependent child under the age of 21.

$200

Per Day

$400 Per Day

$400/ $800

Per Day

$200

Per Day

$400 Per Day

$400/ $800

Per Day

37

Cancer

Additional Benefits Amounts SPECIFIED DISEASE BENEFIT RIDER (form LG-6052) If an Insured Person is first diagnosed with one or more covered Specified Diseases and is hospitalized for the definitive treatment of any covered Specified Disease, We will pay benefits according to the provisions of this rider.

Covers These 38 Specified Diseases

Addison’s Disease Lupus Erythematosus Rocky Mountain Spotted Fever

Amyotrophic Lateral Sclerosis Malaria Sickle Cell Anemia

Botulism Meningitis Tay-Sachs Disease

Bovine Spongiform Encephalopathy Multiple Sclerosis Tetanus

Budd-Chiari Syndrome Muscular Dystrophy Toxic Epidermal Necrolysis

Cystic Fibrosis Myasthenia Gravis Tuberculosis

Diptheria Neimann-Pick Disease Tularemia

Encephalitis Osteomyelitis Typhoid Fever

Epilepsy Poliomyelitis Undulant Fever

Hansen’s Disease Q Fever West Nile Virus

Histoplasmosis Rabies Whipple’s Disease

Legionnaire’s Disease Reye’s Syndrome Whooping Cough

Lyme Disease Rheumatic Fever

Benefits If an Insured Person is first diagnosed with one or more covered Specified Diseases and is hospitalized for the definitive treatment of any covered Specified Disease, We will pay benefits according to the provisions of this rider. An applicant may select 1, 2 or 3 units of coverage. Initial Hospitalization Benefit We will pay a benefit of $1,500 per unit of coverage selected when an Insured Person is confined to a hospital (for 12 or more hours, not applicable in SD) as a result of receiving treatment for a Specified Disease. This benefit is payable only once per period of confinement and once per calendar year for each Insured Person. Hospital Confinement Benefit We will pay a benefit of $300 per day per unit of coverage selected when an Insured Person is hospitalized during any continuous period of 30 days or less for the treatment of a covered Specified Disease. Benefits will double per day beginning with the 31st day of continuous confinement. If the hospital confinement follows a previously covered confinement, it will be deemed a continuation of the first confinement unless it is the result of an entirely different Specified Disease, or unless the confinements are separated by 30 days or more.

Monthly Rates Employee Single Parent Family

Base Plan A $21.26 $25.97 $35.84

Base Plan B $23.17 $28.20 $38.99

38

Cancer

OPTIONAL BENEFITS YOU MAY SELECT FOR ADDITIONAL PREMIUM

HOSPITAL INTENSIVE CARE UNIT BENEFIT RIDER (form LG-6047) Intensive Care Unit Benefit We will pay the daily Hospital Intensive Care Unit Benefit shown on the Certificate Schedule for an Insured Person’s confinement in an ICU for sickness or injury.

$1,000 Per Day

Double Intensive Care Unit Benefit We will pay double the daily Hospital Intensive Care Unit benefit amount shown on the Certificate Schedule for an Insured Person’s confinement in an ICU as a result of Cancer. We will also double this ICU benefit for only the initial ICU confinement resulting from an Insured Person’s travel related injury, provided that the ICU confinement begins within 24 hours of the accident causing the travel related injury. A travel related injury includes being struck by an automobile, bus, truck, van, motorcycle, train or airplane; or being involved in an accident where the Insured Person was the operator or passenger in or on such vehicle.

$2,000 Per Day

Step Down Unit Benefit We will pay one-half of the daily Hospital Intensive Care Unit benefit amount shown on the Certificate Schedule for an Insured Person’s confinement in a Step Down Unit for a sickness or injury.

$500

Per Day

*Additional Limitations and Exclusions for the Hospital Intensive Care Unit Benefit Rider If the rider is issued and coverage is in force, it will provide benefits if an Insured Person goes into a hospital Intensive Care Unit (including a Cardiac Intensive Care Unit or Neonatal Intensive Care Unit). Benefits start the first day of confinement in an ICU for sickness or injury. Any combination of benefits payable under this rider is limited to a maximum of 45 days per each period of confinement. ALL BENEFITS CONTAINED IN THIS HOSPITAL INTENSIVE CARE UNIT BENEFIT RIDER REDUCE BY ONE-HALF AT AGE 75. Benefits are not payable for any ICU or Step Down Unit confinement that results from intentional self-inflicted injury; or the Insured Person’s being intoxicated or under the influence of alcohol, drugs or any narcotics, unless administered on and according to the advice of a medical practitioner. THIS IS A LIMITED RIDER.

Monthly Rates Employee Single Parent Family

Base Plan A $25.90 $32.36 $44.64

Base Plan B $27.82 $34.59 $47.79

39

Critical illness insurance is designed to supplement your medical and disability coverage easing the financial impacts by covering some of your additional expenses. It provides a benefit payable directly to the insured upon diagnosis of a covered condition or event, like a heart attack or stroke.

About this Benefit

YOUR BENEFITS PACKAGE Critical Illness

Is the aggregate cost of a hospital stay for a heart

attack.

DID YOU KNOW?

$16,500



ALLSTATE

40

Critical Illness

Base Policy Initial Critical Illness Benefits

Heart Attack Major Organ Transplant Waiver of Premium

Stroke End Stage Renal Failure Coronary Artery Bypass Surgery

Second Event Benefit Initial Critical Illness

Supplemental Critical Illness Benefits II Benign Brain Tumor Complete Loss of Hearing

Paralysis $154.50

Coma $222.50

Complete Blindness

Wellness (Pays annually when one of 23 screening exams is performed) Biopsy for skin cancer Hemoccult stool analysis

Blood test for triglycerides HPV Vaccination (Human Papillomavirus)

Bone Marrow Testing Lipid panel (Total cholesterol count)

CA15-3, CA125, CEA and PSA (Blood tests)1 Mammography (Including Breast Ultrasound)

Chest X-ray Pap Smear (ThinPrep Pap Test included)

Colonoscopy Serum Protein Electrophoresis (Myeloma test)

Doppler screenings or carotids and peripheral vascular disease Stress test on bike or treadmill

Echocardiogram Thermography

EKG (Electrocardiogram) Ultrasound screening (abdominal aortic aneurysms)

Flexible Sigmoidoscopy

Benefits

1Breast, ovarian, colon and prostate cancer. *Employee only.

INITIAL CRITICAL ILLNESS BENEFITS* PLAN 1 PLAN2

Heart Attack (100%) $10,000 $20,000

Stroke (100%) $10,000 $20,000

Coronary Artery Bypass Surgery (25%) $2,500 $5,000

Major Organ Transplant (100%) $10,000 $20,000

End Stage Renal Failure (100%) $10,000 $20,000

Waiver of Premium (employee only) Yes Yes

Benefit Amounts *Covered Dependents Receive 50% of Your Benefit Amount

SECOND EVENT BENEFIT* PLAN 1 PLAN2

Second Event Initial Critical Illness Benefit (same amount as Initial Critical Illness)

Yes Yes

SUPPLEMENTAL CRITICAL ILLNESS BENEFITS II* PLAN 1 PLAN 2

Advanced Alzheimer's Disease (25%) $2,500 $5,000

Advanced Parkinson’s Disease (25%) $2,500 $20,000

Benign Brain Tumor (100%) $10,000 $20,000

Coma (100%) $10,000 $20,000

Complete Blindness (100%) $10,000 $20,000

Paralysis (100%) $10,000 $20,000

ADDITIONAL BENEFIT PLAN 1 PLAN 2

Wellness Benefit (per year) $50 $50

Monthly Premiums

PLAN 1 $10,000 Basic Benefit Amount Non-tobacco

AGES EE, EE + CH EE +SP, F

18-29 $2.74 $4.73

30-39 $4.83 $7.87

40-49 $8.13 $12.81

50-59 $14.46 $22.32

60-63 $24.42 $37.26

64+ $34.22 $51.95

PLAN 1 $10,000 Basic Benefit Amount Tobacco


18-29 $3.54 $5.93

30-39 $6.84 $10.88

40-49 $13.27 $20.53

50-59 $22.97 $35.08

60-63 $39.87 $60.44

64+ $56.74 $85.74

PLAN 2 $10,000 Basic Benefit Amount Non-tobacco


18-29 $4.23 $6.97

30-39 $8.42 $13.25

40-49 $15.02 $23.15

50-59 $27.69 $42.15

60-63 $47.60 $72.02

64+ $67.18 $101.40

PLAN 2 $10,000 Basic Benefit Amount Tobacco


18-29 $2.74 $9.38

30-39 $4.83 $19.27

40-49 $8.13 $38.57

50-59 $14.46 $67.65

60-63 $24.42 $118.37

64+ $34.22 $168.97

EE+ Employee; EE+SP + Employee + Spouse; EE+CH + Employee + Child(ren); F = Family

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Life insurance provides a cash death benefit to your beneficiary upon your death. 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. If you are covered, you may apply for coverage on your spouse and eligible dependent children.

About this Benefit

Life and AD&D YOUR BENEFITS PACKAGE

x 10

Experts recommend at least

your gross annual income in coverage when purchasing life insurance.

DID YOU KNOW?

AUL A ONEAMERICA COMPANY



Life and AD&D

Basic Life a with AD&D Lake Worth provides $50,000 of Life with AD&D coverage to all full-time employees at no cost.

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.

Accidental Death & Dismemberment (AD&D): If approved for this benefit, additional life insurance benefits may be payable in the event of an accident which results in death or dismemberment as defined in the contract.

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.

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.

Employee Guaranteed Issue Amount $200,000

Spouse Guaranteed Issue Amount $50,000

Age: 65 70

Reduces To: 65% 50%

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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.

Amounts requested above $100,000 for an Employee, $50,000 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 $.70 $.70 $.70 $.80 $.90 $1.50 $2.20 $3.80 $6.40 $8.60 $14.80 $14.80 $14.80

$20,000 $1.40 $1.40 $1.40 $1.60 $1.80 $3.00 $4.40 $7.60 $12.80 $17.20 $29.60 $29.60 $29.60

$30,000 $2.10 $2.10 $2.10 $2.40 $2.70 $4.50 $6.60 $11.40 $19.20 $25.80 $44.40 $44.40 $44.40

$40,000 $2.80 $2.80 $2.80 $3.20 $3.60 $6.00 $8.80 $15.20 $25.60 $34.40 $59.20 $59.20 $59.20

$50,000 $3.50 $3.50 $3.50 $4.00 $4.50 $7.50 $11.00 $19.00 $32.00 $43.00 $74.00 $74.00 $74.00

$70,000 $4.90 $4.90 $4.90 $5.60 $6.30 $10.50 $15.40 $26.60 $44.80 $60.20 $103.60 $103.60 $103.60

$90,000 $6.30 $6.30 $6.30 $7.20 $8.10 $13.50 $19.80 $34.20 $57.60 $77.40 $133.20 $133.20 $133.20

$100,000 $7.00 $7.00 $7.00 $8.00 $9.00 $15.00 $22.00 $38.00 $64.00 $86.00 $148.00 $148.00 $148.00

$150,000 $10.50 $10.50 $10.50 $12.00 $13.50 $22.50 $33.00 $57.00 $96.00 $129.00 $222.00 $222.00 $222.00

$200,000 $14.00 $14.00 $14.00 $16.00 $18.00 $30.00 $44.00 $76.00 $128.00 $172.00 $296.00 $296.00 $296.00

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 $.70 $.70 $.70 $.80 $.90 $1.50 $2.20 $3.80 $6.40 $8.60 $14.80 $14.80 $14.80

$20,000 $1.40 $1.40 $1.40 $1.60 $1.80 $3.00 $4.40 $7.60 $12.80 $17.20 $29.60 $29.60 $29.60

$30,000 $2.10 $2.10 $2.10 $2.40 $2.70 $4.50 $6.60 $11.40 $19.20 $25.80 $44.40 $44.40 $44.40

$40,000 $2.80 $2.80 $2.80 $3.20 $3.60 $6.00 $8.80 $15.20 $25.60 $34.40 $59.20 $59.20 $59.20

$50,000 $3.50 $3.50 $3.50 $4.00 $4.50 $7.50 $11.00 $19.00 $32.00 $43.00 $74.00 $74.00 $74.00

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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: $10,000 $1,000 $1.50

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.

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

About this Benefit

YOUR BENEFITS PACKAGE Identity Theft



ID WATCHDOG

An identity is stolen every

2 seconds,

and takes over

300 hours to resolve, causing an

average loss of $9,650.

DID YOU KNOW?

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Identity Theft

LIFELOCK BASIC LIFELOCK

ULITMATE IDENTITY GUARD INFO ARMOUR IDW PLUS IDW PLATINUM

Basic Identity Monitoring

Advanced Identity Monitoring

Alternative Monitoring

Zero Hour Identity Monitoring

Cyber Monitoring

Credit Report Monitoring

Credit Reports & Scores

Lost Wallet

Full-Service Identity Restoration

NPI Monitoring

INDIVIDUAL PLAN $7.95/mo $11.95/mo

$14,95/mo $22.95/mo FAMILY PLAN

True Identity Protection Basic Identity Monitoring: Standard monthly scans of public records databases searching for new information associated with your Social Security Number. Advanced Identity Monitoring: Advanced scans of the National Change of Address (NCOA) database identifies new addresses associated with your personal information.

Alternative Monitoring: Identity thieves actions are not always imme-diately detected through mainstream credit and identity monitoring. Today we scan Non-Credit Payday loan databases which provide high-interest, quick cash transactions and require minimal personal information to obtain. We are expanding our fraud detection network to include monitoring Auto Pawn, Buy-Here- Pay Here auto dealers and Rent-To-Own store transactions. This is the most comprehensive alternative credit monitoring in the ID theft protection industry.

Proactive Zero Hour Identity Monitoring: Continuous monitoring from daily scanning of billions of transactions and data points will pro-vide an early warning alerting customers of high risk transactions. Be-cause this system is monitoring in real time you will be able to detect potential fraud as it is happening or immediately after it has happened- at the source- so that our dedicated team can help you stop it in its tracks and prevent the damage that can occur with identity theft. Cyber Monitoring: Scans social networking sites, hacker forums, under-ground websites and other illicit online sources that buy, sell, and trade personal information including (but not limited to) credit card numbers, password, and SSN. Credit Report Monitoring: Monitors your credit and notifies you when changes such as new accounts, delinquent accounts and other credit-related information is recorded. Plus plan is single-bureau credit moni-toring and Platinum plan is tri-bureau monitoring.

Credit Reports & Scores (Platinum Plan Only): Access to your credit

reports and scores from the three primary credit reporting agencies; Equifax, Experian and TransUnion.

Extended Identity Protection Lost Wallet: Online safe box securely stores credit card, driver license info and more. Includes cancellation and request for new credit cards in the event your wallet or purse is stolen.

Full-Service Identity Restoration: A dedicated team of trained in-house Certified Identity Theft Resolution Specialists (CITRS) who work on your behalf to restore your identity by addressing record- keeping and reporting agencies, removing erroneous and fraudulent records that appear in your name. ID Watchdog has a flawless record in restoring victim’s identities- and to date we have never failed to completely restore an identity. A benefit of our concierge level service is few costs associated with identity restora-tion. However, we know peace of mind is important. All our ID Protec-tion Plans include a $1,000,000 expense reimbursement insurance* to cover those rare instances when expenses may arise during a restora-tion. NPI Monitoring: Monitors National Provider Identifiers (NPI) for healthcare professionals. * Maximum $1 Million reimbursement insurance under a Master Insurance Policy underwritten by American International Group Inc. Please reference ID Watchdog benefits website for claim submission instructions and policy 43 details regarding applicable terms, conditions, and exclusions.

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

About this Benefit

HSA (Health Savings Account)


The interest earned in an HSA is tax free.

DID YOU KNOW?

Money withdrawn for medical spending never falls under taxable income.

HSA BANK



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

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

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

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

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

Using Funds Debit Card

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

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

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

Health Savings accountholder

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

Not enrolled in Medicare (if an accountholder enrolls in Medicare mid-year, catch 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 Lake Worth ISD website at www.mybenefitshub.com/lakeworthisd

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

HSA (Health Savings Account)

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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

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How the HSA Plan Works

Examples of IRS-Qualified Medical Expenses4:

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

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

Gynecologist Hearing aids and batteries Hospital bills Insurance premiums5

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

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

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www.mybenefitshub.com/lakeworthisd

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2016 Benefit Guide Lake Worth ISD

Documents

Transcript of 2016 Benefit Guide Lake Worth ISD