2016 Benefit Guide TIPS - General Version

Region VIII TIPS Employee Benefits Cooperative

EFFECTIVE:

09/01/2016 - 8/31/2017

BENEFIT GUIDE

www.tipsebc.com

1

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

Spending Account (FSA) 11

MDLIVE Telehealth 12-13 APL MEDlink® Medical Supplement 14-17 APL Accident Plan 18-21 Cigna Dental 22-25 Superior Vision 26-27 The Hartford Long Term Disability 28-31 APL Cancer 32-39 5Star Family Protection Plan Term Life Insurance with Quality of Life Rider 40-43

UNUM Life and AD&D 44-45 UNUM Critical Illness 46-49 HSA Bank Health Savings Account (HSA) 50-53 NBS Flexible Spending Account (FSA) 54-57 ID Watchdog Identity Theft 58-59

Table of Contents

HOW TO ENROLL

PG. 4

BENEFIT UPDATES: WHAT’S NEW

PG. 6

YOUR BENEFITS PACKAGE

PG. 12

FLIP TO...

2

Benefit Contact Information

TIPS BENEFITS VISION CRITICAL ILLNESS

Financial Benefit Services (800) 583-6908 www.tipsebc.com

Group # 320560 Superior Vision (800) 507-3800 www.superiorvision.com

UNUM (866) 679-3054 www.unum.com

TELEHEALTH DISABILITY HEALTH SAVINGS ACCOUNT

MDLIVE (888) 365-1663 www.consultmdlive.com

Group # 395317 The Hartford (866) 278-2655 www.thehartford.com

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

MEDICAL SUPPLEMENT—MEDLINK ® CANCER FLEXIBLE SPENDING ACCOUNT

Group # 13041 American Public Life (800) 256-8606 www.ampublic.com


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

ACCIDENT FAMILY PROTECTION PLAN– TERM LIFE WITH QUALITY OF LIFE RIDER

IDENTITY THEFT


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

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

DENTAL LIFE AND AD&D MEDICAL

Group # 3338828 Cigna (800) 244-6224 www.mycigna.com

UNUM (866) 679-3054 www.unum.com

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

Benefit Contact Information

3

!

How to Enroll

On Your Computer Access the TIPSEBC benefits website

from your computer, tablet or

smartphone!

Our online benefit enrollment

platform provides a simple and

easy to navigate process. Enroll

at your own pace, whether at

home or at work.

www.tipsebc.com delivers

important benefit information

with 24/7 access, as well as

detailed plan information, rates

and product videos.

On Your Device

Enrollment has just become

easier!

Avoid typing long URLs and scan

directly to your benefits websites,

videos, and benefit guides.

Try it yourself! Scan the following

code in the picture.

SCAN:

4

GO www.tipsebc.com 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

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

Aetna is the current carrier for TRS ActiveCare Medical coverage. You MUST log on during the annual enrollment to either elect or waive your medical elections.

HSA Bank is the plan administrator for Health Savings Accounts. Your current monthly contribution will roll to next year. If you want to change your monthly contribution, you can only do so during the annual enrollment. If you are currently participating, and will participate again in 2016-2017, please keep your HSA card.

MEDlink® with APL. If you would like to add the MEDlink® Plan for 2016-2017, you can only do so during the annual enrollment.

FSA with NBS. If you currently participate in a Healthcare or Dependent Care FSA, you MUST re-elect a new contribution amount every year to continue to participate. The Medical FSA plan year maximum remains at $2,550. If you are currently participating and will participate in 2016-2017, please keep your FSA card.

UPDATE! Hartford Disability will continue to be the disability carrier, there will be a 10% rate increase in premium effective 9/1/2016. The pre-existing benefit that provides coverage up to a maximum of 4 weeks will remain in place. The Hartford Plan has a first day hospital benefit if you elect a 0/7, 14/14 or 30/30 plan.

UPDATE! Telehealth with MDLIVE. This plan gives you access to telephone consultations with a licensed physician for evaluation, diagnosis and prescriptions, as appropriate, for minor illnesses. This covers you, your spouse and dependent children to age 26. Effective 9/1/2016,

Employee only coverage premium will be $8.00 and Family coverage will be $16.00. If you have Employer Paid MDLIVE, there are no changes for 2016-2017.

Cigna is the Dental Carrier. You have a choice between a High and a Low Plan. There are different premiums and Calendar Year Maximums for the High Plan and the Low Plan. If you want to go to an out of Network dentist, the High Plan maybe a better choice. If you go to an out of network dentist, the High plan may be the best choice because the Low plan only reimburses at negotiated in-network fee schedule out-of-network and you will be billed for the difference in cost, which could be significant.

Superior Vision. Your current card will continue to work and the benefits have remained the same effective 9/1/2016.

UNUM is the Life and AD&D provider. UNUM allows employees that are currently enrolled in the life insurance and are below the Guaranteed Issue (GI) amount to increase the coverage to the GI without evidence of insurability. If you are not currently enrolled, you can enroll subject to evidence of insurability for the lesser of $230,000 or 7x salary for self, up to $50,000 for spouse and up to $10,000 for children. For increases in coverage to take effect, employees must be actively at work and spouse/child cannot be disabled.

NEW! 5 Star Term Life to 100 with Quality of Life Employees may elect up to $100,000 and may elect $30,000 on their spouse. You may elect up to $20,000 for eligible children up to age 23. This plan includes a Quality of Life component which will pay up to 18 months of long term care if the insured is unable to perform at least 2 of the 6 Activities of Daily Living (ADLs) without substantial assistance or if the insured suffers an impairment such as dementia, Alzheimer’s or other forms of senility requiring substantial supervision. Quality of Life is not available for children. Premiums are locked and do not increase.

Login and complete your supplemental benefit enrollment from 08/01/2016 - 08/22/2016 Enrollment assistance is available by calling Financial Benefit Services at 866-914-5202 to

speak to an enrollment representative Monday—Friday, 8 AM—5 PM from 08/01/2016—08/22/2016. Bilingual assistance is available.

Update your profile information: home address, phone numbers, email. IMPORTANT!! Due to the Affordable Care Act (ACA) reporting requirements, please add

your dependent’s social security numbers in the online enrollment system. If you have questions, please contact your Benefits Administrator.

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 school

district’s benefit website: www.tipsebc.com. Click on your

district, then click the benefit plan you need information on

(i.e., Dental) and you can find the forms you need under the

Benefits and Forms section.

How can I find a Network Provider?

For benefit summaries and claim forms, go to the TIPSEBC

benefit website: www.tipsebc.com. Click on your district, then

click on the benefit plan you need information on (i.e., Dental)

and you can find provider search links under the Quick Links

section.

When will I receive ID cards?

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

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

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

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

insurance company’s phone number and they can call and

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

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

carrier’s customer service number to request another card.

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

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

card each year.

SUMMARY PAGES

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PLAN CARRIER MAXIMUM AGE

Accident American Public Life Through 25

Cancer American Public Life Through 25

Critical Illness UNUM Through 23

Dental Cigna Through 25

Dependent Flex

National Benefit Services

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

as a dependent on your taxes

Flexible Spending Account (FSA) National Benefit Services Through 25 or IRS Tax Dependent

Health Savings Account (HSA) HSA Bank IRS Tax Dependent

Individual Life 5Star Life Through 23

Life and AD&D UNUM Through 25

Medical Supplement Plan American Public Life Through 25

Telehealth MDLIVE Through 25

Vision Superior Vision Through 25

Employee Eligibility Requirements

Supplemental Benefits: Eligible employees must work 15 or more

regularly scheduled hours each work week.

Eligible employees must be actively at work on the plan effective

date for new benefits to be effective, meaning you are physically

capable of performing the functions of your job on the first day of

work concurrent with the plan effective date. For example, if

your 2016 benefits become effective on September 1, 2016, you

must be actively-at-work on September 1, 2016 to be eligible for

your new benefits.

Dependent Eligibility Requirements

Dependent Eligibility: You can cover eligible dependent

children under a benefit that offers dependent coverage,

provided you participate in the same benefit, through the

maximum age listed below. Dependents cannot be double

covered by married spouses within the TIPSEBC or as both

employees and dependents.

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

SUMMARY PAGES

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

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

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

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

work beginning 9/1/2016 please notify your benefits

administrator.

Annual Enrollment The period during which existing employees are given the

opportunity to enroll in or change their current elections.

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

pay covered expenses.

Calendar Year January 1st through December 31st

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

covered health care service, calculated as a percentage (for

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

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

medical questions or taking a health exam. Guaranteed

coverage is only available during initial eligibility period.

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

provisions do apply, as applicable by carrier.

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

who have contracted with the plan as a network provider.

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

for covered expenses.

Plan Year September 1st through August 31st

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

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

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

orders to take drugs, or received medical care or services

(including diagnostic and/or consultation services).

Helpful Definitions SUMMARY PAGES

10

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 10% 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. 50

FOR FSA INFORMATION

FLIP TO… PG. 54

11

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

About this Benefit

Telehealth YOUR BENEFITS PACKAGE

DID YOU KNOW?

75%

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

telehealth.

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

TIPSEBC Benefits Website: www.tipsebc.com

MDLIVE

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Telehealth

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

non-emergency medical issue

Your primary care physician is not available

At home, traveling, or at work

24/7/365, even holidays!

What can be treated? Allergies

Asthma

Bronchitis

Cold and Flu

Ear Infections

Joint Aches and Pain

Respiratory Infection

Sinus Problems

And More!

Pediatric Care related to: Cold & Flu

Constipation

Ear Infection

Fever

Nausea & Vomiting

Pink Eye

And More!

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

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

How much does it cost? $8 for Employee Only. $16 for Family. If your district offers an employer paid benefit, there is no premium cost to you.

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

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

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

Available 24/7 by video or phone

Private, secure and confidential visits Connect instantly with MDLIVE Assist

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

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

Scan with your smartphone to get the app.

13

MEDlink® Limited Benefit Medical Expense Supplemental Insurance

SUMMARY OF BENEFITS

Base Policy Option 1

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

Outpatient Benefit up to $200 per treatment

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

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® YOUR

BENEFITS

DID YOU KNOW?

33%

of total healthcare costs are paid

out-of-pocket.



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

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

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

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

Plans available to employees age 70 and over if You work for an employer employing 20 or more employees on a typical workday in the preceding Calendar Year. *Total premium includes the Plan selected and any applicable rider premium. Premiums are subject to increase with notice. Thepremium and amount of benefits vary dependent upon the Plan selected at time of application.

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

Covered Charges mean those charges that are incurred by a Covered Person because of an Accident or Sickness; are for necessary treatment, services and medical supplies and recommended by a Physician; are incurred in a covered facility as defined in the Policy or any attached rider; are not more than any dollar limit set forth in the Schedule; areincurred while insured under the Policy, subject to any Extension of Benefits; and are not excluded under the Policy. Covered charges also include Inpatient routine newborn care and are subject to above.

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

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

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

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

APSB-22330(TX)-0116 MGM/FBS Region VIII ESC

Region VIII ESC

Option 1 Total Monthly Premiums by Plan*

Issue Ages Issue Ages Issue Ages

Employee Only $28.00 $44.50 $68.50

Employee + Spouse $51.50 $81.50 $122.50

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

Family Coverage $69.00 $99.00 $140.00

14


SUMMARY OF BENEFITS

Base Policy Option 1

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

Outpatient Benefit up to $200 per treatment

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

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® YOUR

BENEFITS

DID YOU KNOW?

33%

of total healthcare costs are paid

out-of-pocket.


Region VIII ESC Benefits Website: www.mybenefitshub.com/regionviii

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




Plans available to employees age 70 and over if You work for an employer employing 20 or more employees on a typical workday in the preceding Calendar Year. *Total premium includes the Plan selected and any applicable rider premium. Premiums are subject to increase with notice. The premium and amount of benefits vary dependent upon the Plan selected at time of application.

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

Covered Charges mean those charges that are incurred by a Covered Person because of an Accident or Sickness; are for necessary treatment, services and medical supplies and recommended by a Physician; are incurred in a covered facility as defined in the Policy or any attached rider; are not more than any dollar limit set forth in the Schedule; are incurred while insured under the Policy, subject to any Extension of Benefits; and are not excluded under the Policy. Covered charges also include Inpatient routine newborn care and are subject to above.

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

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

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

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

APSB-22330(TX)-0116 MGM/FBS TIPSEBC

TIPSEBC

Option 1 Total Monthly Premiums by Plan*

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

Employee Only $28.00 $44.50 $68.50

Employee + Spouse $51.50 $81.50 $122.50

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

Family Coverage $69.00 $99.00 $140.00

15

Premiums The premium rates may be changed by Us. If the rates are changed, We will give You at least 31 days advance written notice. If a change in benefits increases Our liability, premium rates may be changed on the date Our liability is increased.

This plan may be continued in accordance with the Consolidated Omnibus Reconciliation Act of 1986.

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

Dependent spouse:(1) where Your or Your Dependent spouse’s life would be

endangered if the fetus were carried to term; or(2) where medical complications have arisen from abortion;

(f) pregnancy of a Dependent child;(g) participation in a riot, civil commotion, civil disobedience, or

unlawful assembly. This does not include a loss which occurs while acting in a lawful manner within the scope of authority;

(h) commission of a felony;(i) participation in a contest of speed in power driven vehicles,

parachuting, or hang gliding;(j) air travel, except:

(1) as a fare-paying passenger on a commercial airline on a regularly scheduled route; or

(2) as a passenger for transportation only and not as a pilot orcrew member;

(k) intoxication; (Whether or not a person is intoxicated is determinedand defined by the laws and jurisdiction of the geographical area in which the loss occurred.)

(l) alcoholism or drug use, unless such drugs were taken on theadvice of a Physician and taken as prescribed;

(m) sex changes;(n) experimental treatment, drugs, or surgery;(o) an act of war, whether declared or undeclared, or while

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

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

(q) mental illness or functional or organic nervous disorders, regardless of the cause;

(r) dental or vision services, including treatment, surgery, extractions, or x-rays, unless:(1) resulting from an Accident occurring while the Covered

Person’s coverage is in force and if performed within 12months of the date of such Accident; or

(2) due to congenital disease or anomaly of a covered newborn child.

(s) routine examinations, such as health exams, periodic check-ups, or routine physicals, except when part of Inpatient routine newborncare;

(t) any expense for which benefits are not payable under the Covered Person’s Employer’s Medical Plan; or

(u) air or ground ambulance.

Termination of Coverage Your Insurance coverage will end on the earliest of these dates: the date You no longer qualify as an Insured; the end of the last period for which premium has been paid; the date the Policy is discontinued; the date You retire; if You work for an employer employing less than 20 employees on a typical work day in the preceding Calendar Year, the date You attain age 70; the date You cease to be on Active Service; the date Your coverage under your Employer’s Medical Plan ends; or the date You cease employment with the employer through whom You originally became insured under the Policy.

Insurance coverage on a Dependent will end on the earliest of these dates: the date Your coverage terminates; the end of the last period for which premium has been paid; the date the Dependent no longer meets the definition of Dependent; the date the Dependent’s coverage under your Employer’s Medical Plan ends; or the date the Policy is modified so as to exclude Dependent coverage.

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

We may end the coverage of a Subscribing Unit if fewer persons are insured than the Policyholder’s application requires.


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

APSB-22330(TX)-0116 MGM/FBS TIPSEBC

2305 Lakeland Drive | Flowood, MS 39232

ampublic.com | 800.256.8606

16


17

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

About this Benefit

Accident YOUR

BENEFITS

A-3 Supplemental Limited Benefit Accident Expense Insurance

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




Summary of Benefits*

Benefit Description Level 1 - 1 Unit Level 2 - 2 Units Level 3 - 3 Units Level 4 - 4 Units

Accidental Death - per unit $5,000 $10,000 $15,000 $20,000

Medical Expense Accidental Injury Benefit - per unit

actual charges up to $500

actual charges up to $1,000



Daily Hospital Confinement Benefit $75 per day $150 per day $225 per day $300 per day

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




Accidental Dismemberment BenefitSingle finger or toe Multiple fingers or toesSingle hand, arm, foot or legMultiple hands, arms, feet or legs

$500 $500

$2,500 $5,000

$1,000 $1,000 $5,000

$10,000

$1,500 $1,500 $7,500

$15,000

$2,000 $2,000

$10,000 $20,000

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

$2,500 $5,000

$5,000 $10,000

$7,500 $15,000

$10,000 $20,000

Individual Individual & Spouse

1 Parent Family

2 Parent Family

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

Level 3 - 3 Units $21.50 $38.90 $45.20 $62.60

*Total premium includes the Plan selected and any applicable rider premium. The premium and amount of benefits vary

dependent upon the Plan selected at time of application. Premiums are subject to increase with notice.

of disabling injuries

suffered by American

workers are not work

related.

DID YOU KNOW?

36% of American workers

report they always or

usually live paycheck

to paycheck.

2/3



AMERICAN PUBLIC LIFE

APSB-22329(TX)-MGM/FBS Region VIII ESC

Region VIII ESC

18

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

About this Benefit

AccidentYOUR

BENEFITS

A-3 Supplemental Limited Benefit Accident Expense Insurance

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




Summary of Benefits*

Benefit Description Level 1 - 1 Unit Level 2 - 2 Units Level 3 - 3 Units Level 4 - 4 Units

Accidental Death - per unit $5,000 $10,000 $15,000 $20,000

Medical Expense Accidental Injury Benefit - per unit

actual charges up to $500




Daily Hospital Confinement Benefit $75 per day $150 per day $225 per day $300 per day

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




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

$500 $500

$2,500 $5,000

$1,000 $1,000 $5,000

$10,000

$1,500 $1,500 $7,500

$15,000

$2,000 $2,000

$10,000 $20,000

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

$2,500 $5,000

$5,000 $10,000

$7,500 $15,000

$10,000 $20,000

Individual Individual & Spouse

1 Parent Family

2 Parent Family

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

Level 3 - 3 Units $21.50 $38.90 $45.20 $62.60

*Total premium includes the Plan selected and any applicable rider premium. The premium and amount of benefits vary

dependent upon the Plan selected at time of application. Premiums are subject to increase with notice.

of disabling injuries

suffered by American

workers are not work

related.

DID YOU KNOW?

36% of American workers

report they always or

usually live paycheck

to paycheck.

2/3


Region VIII ESC Benefits Website: www.mybenefitshub.com/regionviiiesc


APSB-22329(TX)-MGM/FBS TIPSEBC

TIPSEBC

19

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

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

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

Base Policy and Optional Benefits No benefits are payable for a pre-existing condition. Pre-existing condition means an Injury that pertains solely to an Accidental Bodily Injury which resulted from an accident sustained before the Effective Date of coverage. Pre-Existing Conditions specifically named or described as permanently excluded in any part of this contract are never covered.

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

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

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

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

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

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

Hospital Admission Benefit The maximum benefit is 4 units.

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

(1) sickness, illness or bodily infirmity; (2) suicide, attempted suicide or intentional self-inflicted

Injury, whether sane or insane; (3) dental care or treatment unless due to accidental

Injury to natural teeth; (4) war or any act of war (whether declared or

undeclared) or participating in a riot or felony; (5) alcoholism or drug addiction; (6) travel or flight in or descent from any aircraft or

device which can fly above the earth’s surface in any capacity other than as a fare paying passenger on a regularly scheduled airline;

(7) Injury originating prior to the effective date of the Policy;

(8) Injury occurring while intoxicated (Intoxication means that which is determined and defined by the laws and jurisdiction of the geographical area in which the loss or cause of loss is incurred.);

(9) Voluntary inhalation of gas or fumes or taking of poison or asphyxiation;

(10) Voluntary ingestion or injection of any drug, narcotic or sedative, unless administered on the advice and taken in such doses as prescribed by a Physician;

(11) Injury sustained or sickness which first manifests itself while on full-time duty in the armed forces; (Upon notice, We will refund the proportion of unearned premium while in such forces.)

(12) Injury incurred while engaging in an illegal occupation; (13) Injury incurred while attempting to commit a felony or

an assault; (14) Injury to a covered person while practicing for or being

a part of organized or competitive rodeo, sky diving, hang gliding, parachuting or scuba diving;

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

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

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

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

APSB-22329(TX)-MGM/FBS TIPSEBC APSB-22329(TX)-MGM/FBS Region VIII ESC



20

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

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

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

Base Policy and Optional Benefits No benefits are payable for a pre-existing condition. Pre-existing condition means an Injury that pertains solely to an Accidental Bodily Injury which resulted from an accidentsustained before the Effective Date of coverage. Pre-Existing Conditions specifically named or described as permanently excluded in any part of this contract are never covered.

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

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

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

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

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

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

Hospital Admission Benefit The maximum benefit is 4 units.

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

(1) sickness, illness or bodily infirmity; (2) suicide, attempted suicide or intentional self-inflicted

Injury, whether sane or insane; (3) dental care or treatment unless due to accidental

Injury to natural teeth;(4) war or any act of war (whether declared or

undeclared) or participating in a riot or felony; (5) alcoholism or drug addiction;(6) travel or flight in or descent from any aircraft or

device which can fly above the earth’s surface in any capacity other than as a fare paying passenger on a regularly scheduled airline;

(7) Injury originating prior to the effective date of the Policy;

(8) Injury occurring while intoxicated (Intoxication means that which is determined and defined by the laws and jurisdiction of the geographical area in which the loss or cause of loss is incurred.);

(9) Voluntary inhalation of gas or fumes or taking of poison or asphyxiation;

(10) Voluntary ingestion or injection of any drug, narcotic or sedative, unless administered on the advice and taken in such doses as prescribed by a Physician;

(11) Injury sustained or sickness which first manifests itself while on full-time duty in the armed forces; (Upon notice, We will refund the proportion of unearned premium while in such forces.)

(12) Injury incurred while engaging in an illegal occupation; (13) Injury incurred while attempting to commit a felony or

an assault; (14) Injury to a covered person while practicing for or being

a part of organized or competitive rodeo, sky diving, hang gliding, parachuting or scuba diving;

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

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

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

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

APSB-22329(TX)-MGM/FBS Region VIII ESC APSB-22329(TX)-MGM/FBS TIPSEBC



21

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

About this Benefit

Dental YOUR BENEFITS PACKAGE

Good dental care may improve your overall health.

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

DID YOU KNOW?

CIGNA


TIPSEBC Benefits Website: www.tipsebc.com 22

Dental PPO - High Option

Benefits Cigna Dental PPO - High Option In-Network Out-of-Network Network Total Cigna DPPO

Calendar Year Maximum (Class I, II, III, V, IX expenses)

$1,500 $1,500

Annual Deductible Individual Family

$50 per person $150 per family


Reimbursement Levels** Based on Reduced Contracted Fees

90th percentile of Reasonable and

Customary Allowances

Plan Pays You Pay Plan Pays You Pay Class I - Preventive & Diagnostic Care Oral Exams Cleanings Routine X-Rays Fluoride Application Sealants Space Maintainers (limited to non-orthodontic treatment) Non-Routine X-Rays Emergency Care to Relieve Pain

100% No Charge 100% No Charge

Class II - Basic Restorative Care Fillings Oral Surgery-Simple Extractions Anesthetics Relines, Rebases, and Adjustments Repairs-Bridges, Crowns, and Inlays Repairs-Dentures Brush Biopsy Stainless Steel Crowns

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

Class III - Major Restorative Care Oral Surgery-All Except Simple Extraction Surgical Extraction of Impacted Teeth Major Periodontics Minor Periodontics Root Canal Therapy / Endodontics Crowns / Inlays / Onlays Dentures Bridges Resin Crowns

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

Class IV - Orthodontia Coverage for Eligible Children Only to age 19 Lifetime Maximum

50% $1,000

50% 50%

$1,000 50%

Class V - TMJ 50%* 50%* 50%* 50%*

Class IX - Implants 50%* 50%* 50%* 50%*

Monthly PPO Premiums

Tier Rate

EE Only $30.88

EE + Spouse $76.82

EE + Child(ren) $74.84

Family Coverage $118.96

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

100% coverage for certain dental procedures

guidance on behavioral issues related to oral health

discounts on prescription and non-prescription dental products For more information and to see the complete list of eligible conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24. **For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Contracted Fee Schedule. For services provided by an out-of-network dentist, Cigna Dental will reimburse according to Reasonable and Customary Allowances but the dentist may balance bill up to their usual fees.

23

Dental PPO - Low Option

Benefits Cigna Dental PPO - Low Option In-Network Out-of-Network1

Network Total Cigna DPPO

Calendar Year Maximum (Class I, II, III, V, IX expenses)

$1,000 $1,000

Annual Deductible Individual Family



Reimbursement Levels** Based on Reduced Contracted Fees

Based on Maximum Allowable Charge

(In-network fee level)

Plan Pays You Pay Plan Pays You Pay Class I - Preventive & Diagnostic Care Oral Exams Cleanings Routine X-Rays Fluoride Application Sealants Space Maintainers (limited to non-orthodontic treatment) Non-Routine X-Rays Emergency Care to Relieve Pain

100% No Charge 100%

Any amount over

maximum allowable

charge

Class II - Basic Restorative Care Fillings Oral Surgery – Simple Extractions Anesthetics Relines, Rebases, and Adjustments Repairs – Bridges, Crowns and Inlays Repairs – Dentures Brush Biopsy

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

Class III - Major Restorative Care Oral Surgery – All Except Simple Extraction Surgical Extraction of Impacted Teeth Major Periodontics Minor Periodontics Root Canal Therapy / Endodontics Crowns / Inlays / Onlays Dentures Bridges Stainless Steel/Resin Crowns

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

Class IV - Orthodontia Coverage for Eligible Children Only to age 19 Lifetime Maximum

50% $1,000

50% 50%

$1,000 50%

Class V - TMJ 50%* 50%* 50%* 50%*

Class IX - Implants 50%* 50%* 50%* 50%*

Monthly PPO Premiums

Tier Rate

EE Only $22.65

EE + Spouse $56.34

EE + Child(ren) $54.90

Family Coverage $87.25

1Benefits are based on the discounted fee schedules agreed upon by our network dentists. Any amount that is charged over the fee schedule is the responsibility of the patient. Missing Tooth Limitation – The amount payable is 50% of the amount otherwise payable until insured for 12 months; thereafter, considered a Class III expense. Pretreatment review is available on a voluntary basis when extensive dental work in excess of $200 is proposed. * Subject to annual deductible Dental Oral Health Integration Program (OHIP) - All dental customers = Clinical research shows an association between oral health and overall health. The Cigna Dental Oral Health Integration Program (OHIP)® is designed to provide enhanced dental coverage for customers with certain eligible medical conditions. Eligible conditions for the program include cardiovascular disease, cerebrovascular disease (stroke), diabetes, maternity, chronic kidney disease, organ transplants, and head and neck cancer radiation. The program provides:

100% coverage for certain dental procedures

guidance on behavioral issues related to oral health

discounts on prescription and non-prescription dental products For more information and to see the complete list of eligible conditions, go to www.mycigna.com or call customer service 24/7 at 1.800.CIGNA24. **For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Contracted Fee Schedule. For services provided by an out-of-network dentist, Cigna Dental will reimburse according to the Contracted Fee Schedule but the dentist may balance bill up to their usual fees.

24

Dental PPO - High and Low Options

Procedure Exclusions and Limitations Late Entrants Limit 50% coverage on Class III and IV for 12 months Exams Two per Calendar year Prophylaxis (Cleanings) Two per Calendar year Fluoride 1 per Calendar year for people under 19 Histopathologic Exams Various limits per Calendar year depending on specific test X-Rays (routine) Bitewings: 2 per Calendar year X-Rays (non-routine) Full mouth: 1 every 36 consecutive months., Panorex: 1 every 36 consecutive months Model Payable only when in conjunction with Ortho workup Minor Perio (non-surgical) Various limitations depending on the service Perio Surgery Various limitations depending on the service Crowns and Inlays Replacement every 5 years Bridges Replacement every 5 years Dentures and Partials Replacement every 5 years Relines, Rebases Covered if more than 6 months after installation Adjustments Covered if more than 6 months after installation Repairs - Bridges Reviewed if more than once Repairs - Dentures Reviewed if more than once Sealants Limited to posterior tooth. One treatment per tooth every three years up to age 14 Space Maintainers Limited to non-Orthodontic treatment Prosthesis Over Implant 1 per 60 consecutive months if unserviceable and cannot be repaired. Benefits are based on the amount payable for nonprecious metals. No porcelain or white/tooth colored material on molar crowns or bridges Alternate Benefit When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna HealthCare will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses

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

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

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

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

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

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

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

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

25

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

About this Benefit

Vision YOUR BENEFITS PACKAGE

75%

DID YOU KNOW?

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

correction.

SUPERIOR VISION



Co-Pays

Exam $10

Materials $10

Services/Frequency (Based on date of service)

Exam 12 months

Frame 24 months

Lenses 12 months

Contact Lenses 12 months

Benefits In-Network Out-of-Network

Exam Covered in full Up to $35 retail

Frames $125 retail allowance Up to $70 retail

Contact Lens2 $150 retail allowance Up to $80 retail

Medically Necessary Contact Lens

Covered in full Up to $150 retail

Lenses (standard) per pair

Single Vision Covered in full Up to $25 retail

Bifocal Covered in full Up to $40 retail

Trifocal Covered in full Up to $45 retail

Progressive See description1 Up to $45 retail

Lenticular Covered in full Up to $80 retail

Monthly Premiums

EE Only $7.82

EE + spouse $13.32

EE+ child(ren) $14.11

EE + family $21.14

Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements. ₁ Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay ₂Contact lenses and related professional services (fitting, evaluation and follow-up) are covered in lieu of eyeglass lenses and frames benefit

Vision

Discount Features

Non-Covered Eyewear Discount: Members may also receive a discount of 20% from a participating provider’s usual and customary fees for eyewear purchases which exceed the benefit coverage (except disposable contact lenses, for which no discount applies). This includes eyeglass frames which exceed the selected benefit coverage, specialty lenses (i.e. progressives) and lens “extras” such as tints and coatings. Eyewear purchased from a Walmart Vision Center does not qualify for this additional discount because of Walmart’s “Always Low Prices” policy. The Plan discount features are not insurance. All allowances are retail; the member is responsible for paying the provider directly for all non-covered items and/or any amount over the allowances, minus available discounts. These are not covered by the plan. Discounts are subject to change without notice. Disclaimer: All final determinations of benefits, administrative duties, and definitions are governed by the Certificate of Insurance for your vision plan. Please check with your Human Resources department if you have any questions

www.SuperiorVision.com Customer Service 800.507.3800

27

About this Benefit

Disability YOUR BENEFITS PACKAGE

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

they retire.

DID YOU KNOW?

34.6 months is the duration of the

average disability claim.

THE HARTFORD

Disability insurance protects one of your most valuable assets, your paycheck. This insurance will replace a portion of your income in the event that you become physically unable to work due to sickness or injury for an extended period of time.



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

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

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

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

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

before you became disabled Retirement benefits that are funded by your after-tax

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

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

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

armed conflict The commission of, or attempt to commit a felony An intentionally self-inflicted injury

Any case where your being engaged in an illegal occupation was a contributing cause to your disability

You must be under the regular care of a physician to receive benefits

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

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

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

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

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

Survivor Benefit - If you die while receiving disability benefits, a benefit will be paid to your spouse or in equal shares to your surviving children under the age of 25, equal to three times the last monthly gross benefit.

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

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

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

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

Long Term Disability

29


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

Age Disabled Benefits Payable

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

Age 63 To Normal Retirement Age or 42 months if greater

Age 64 36 months

Age 65 30 months

Age 66 27 months

Age 67 24 months

Age 68 21 months

Age 69 and older 18 months

MONTHLY PREMIUMS

Accident / Sickness Elimination Period in Days

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

$3,600 $300 $200 $7.04 $5.96 $5.18 $4.22 $2.44 $1.74

$5,400 $450 $300 $10.56 $8.94 $7.77 $6.33 $3.66 $2.61

$7,200 $600 $400 $14.08 $11.92 $10.36 $8.44 $4.88 $3.48

$9,000 $750 $500 $17.60 $14.90 $12.95 $10.55 $6.10 $4.35

$10,800 $900 $600 $21.12 $17.88 $15.54 $12.66 $7.32 $5.22

$12,600 $1,050 $700 $24.64 $20.86 $18.13 $14.77 $8.54 $6.09

$14,400 $1,200 $800 $28.16 $23.84 $20.72 $16.88 $9.76 $6.96

$16,200 $1,350 $900 $31.68 $26.82 $23.31 $18.99 $10.98 $7.83

$18,000 $1,500 $1,000 $35.20 $29.80 $25.90 $21.10 $12.20 $8.70

$19,800 $1,650 $1,100 $38.72 $32.78 $28.49 $23.21 $13.42 $9.57

$21,600 $1,800 $1,200 $42.24 $35.76 $31.08 $25.32 $14.64 $10.44

$23,400 $1,950 $1,300 $45.76 $38.74 $33.67 $27.43 $15.86 $11.31

$25,200 $2,100 $1,400 $49.28 $41.72 $36.26 $29.54 $17.08 $12.18

$27,000 $2,250 $1,500 $52.80 $44.70 $38.85 $31.65 $18.30 $13.05

$28,800 $2,400 $1,600 $56.32 $47.68 $41.44 $33.76 $19.52 $13.92

$30,600 $2,550 $1,700 $59.84 $50.66 $44.03 $35.87 $20.74 $14.79

$32,400 $2,700 $1,800 $63.36 $53.64 $46.62 $37.98 $21.96 $15.66

$34,200 $2,850 $1,900 $66.88 $56.62 $49.21 $40.09 $23.18 $16.53

$36,000 $3,000 $2,000 $70.40 $59.60 $51.80 $42.20 $24.40 $17.40

$37,800 $3,150 $2,100 $73.92 $62.58 $54.39 $44.31 $25.62 $18.27

$39,600 $3,300 $2,200 $77.44 $65.56 $56.98 $46.42 $26.84 $19.14

$41,400 $3,450 $2,300 $80.96 $68.54 $59.57 $48.53 $28.06 $20.01

$43,200 $3,600 $2,400 $84.48 $71.52 $62.16 $50.64 $29.28 $20.88

$45,000 $3,750 $2,500 $88.00 $74.50 $64.75 $52.75 $30.50 $21.75

$46,800 $3,900 $2,600 $91.52 $77.48 $67.34 $54.86 $31.72 $22.62

$48,600 $4,050 $2,700 $95.04 $80.46 $69.93 $56.97 $32.94 $23.49

$50,400 $4,200 $2,800 $98.56 $83.44 $72.52 $59.08 $34.16 $24.36

$52,200 $4,350 $2,900 $102.08 $86.42 $75.11 $61.19 $35.38 $25.23

$54,000 $4,500 $3,000 $105.60 $89.40 $77.70 $63.30 $36.60 $26.10

$55,800 $4,650 $3,100 $109.12 $92.38 $80.29 $65.41 $37.82 $26.97

$57,600 $4,800 $3,200 $112.64 $95.36 $82.88 $67.52 $39.04 $27.84

$59,400 $4,950 $3,300 $116.16 $98.34 $85.47 $69.63 $40.26 $28.71

30


MONTHLY PREMIUMS

Accident / Sickness Elimination Period in Days

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

$61,200 $5,100 $3,400 $119.68 $101.32 $88.06 $71.74 $41.48 $29.58

$63,000 $5,250 $3,500 $123.20 $104.30 $90.65 $73.85 $42.70 $30.45

$64,800 $5,400 $3,600 $126.72 $107.28 $93.24 $75.96 $43.92 $31.32

$66,600 $5,550 $3,700 $130.24 $110.26 $95.83 $78.07 $45.14 $32.19

$68,400 $5,700 $3,800 $133.76 $113.24 $98.42 $80.18 $46.36 $33.06

$70,200 $5,850 $3,900 $137.28 $116.22 $101.01 $82.29 $47.58 $33.93

$72,000 $6,000 $4,000 $140.80 $119.20 $103.60 $84.40 $48.80 $34.80

$73,800 $6,150 $4,100 $144.32 $122.18 $106.19 $86.51 $50.02 $35.67

$75,600 $6,300 $4,200 $147.84 $125.16 $108.78 $88.62 $51.24 $36.54

$77,400 $6,450 $4,300 $151.36 $128.14 $111.37 $90.73 $52.46 $37.41

$79,200 $6,600 $4,400 $154.88 $131.12 $113.96 $92.84 $53.68 $38.28

$81,000 $6,750 $4,500 $158.40 $134.10 $116.55 $94.95 $54.90 $39.15

$82,800 $6,900 $4,600 $161.92 $137.08 $119.14 $97.06 $56.12 $40.02

$84,600 $7,050 $4,700 $165.44 $140.06 $121.73 $99.17 $57.34 $40.89

$86,400 $7,200 $4,800 $168.96 $143.04 $124.32 $101.28 $58.56 $41.76

$88,200 $7,350 $4,900 $172.48 $146.02 $126.91 $103.39 $59.78 $42.63

$90,000 $7,500 $5,000 $176.00 $149.00 $129.50 $105.50 $61.00 $43.50

$91,800 $7,650 $5,100 $179.52 $151.98 $132.09 $107.61 $62.22 $44.37

$93,600 $7,800 $5,200 $183.04 $154.96 $134.68 $109.72 $63.44 $45.24

$95,400 $7,950 $5,300 $186.56 $157.94 $137.27 $111.83 $64.66 $46.11

$97,200 $8,100 $5,400 $190.08 $160.92 $139.86 $113.94 $65.88 $46.98

$99,000 $8,250 $5,500 $193.60 $163.90 $142.45 $116.05 $67.10 $47.85

$100,800 $8,400 $5,600 $197.12 $166.88 $145.04 $118.16 $68.32 $48.72

$102,600 $8,550 $5,700 $200.64 $169.86 $147.63 $120.27 $69.54 $49.59

$104,400 $8,700 $5,800 $204.16 $172.84 $150.22 $122.38 $70.76 $50.46

$106,200 $8,850 $5,900 $207.68 $175.82 $152.81 $124.49 $71.98 $51.33

$108,000 $9,000 $6,000 $211.20 $178.80 $155.40 $126.60 $73.20 $52.20

$109,800 $9,150 $6,100 $214.72 $181.78 $157.99 $128.71 $74.42 $53.07

$111,600 $9,300 $6,200 $218.24 $184.76 $160.58 $130.82 $75.64 $53.94

$113,400 $9,450 $6,300 $221.76 $187.74 $163.17 $132.93 $76.86 $54.81

$115,200 $9,600 $6,400 $225.28 $190.72 $165.76 $135.04 $78.08 $55.68

$117,000 $9,750 $6,500 $228.80 $193.70 $168.35 $137.15 $79.30 $56.55

$118,800 $9,900 $6,600 $232.32 $196.68 $170.94 $139.26 $80.52 $57.42

$120,600 $10,050 $6,700 $235.84 $199.66 $173.53 $141.37 $81.74 $58.29

$122,400 $10,200 $6,800 $239.36 $202.64 $176.12 $143.48 $82.96 $59.16

$124,200 $10,350 $6,900 $242.88 $205.62 $178.71 $145.59 $84.18 $60.03

$126,000 $10,500 $7,000 $246.40 $208.60 $181.30 $147.70 $85.40 $60.90

$127,800 $10,650 $7,100 $249.92 $211.58 $183.89 $149.81 $86.62 $61.77

$129,600 $10,800 $7,200 $253.44 $214.56 $186.48 $151.92 $87.84 $62.64

$131,400 $10,950 $7,300 $256.96 $217.54 $189.07 $154.03 $89.06 $63.51

$133,200 $11,100 $7,400 $260.48 $220.52 $191.66 $156.14 $90.28 $64.38

$135,000 $11,250 $7,500 $264.00 $223.50 $194.25 $158.25 $91.50 $65.25

31

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

About this Benefit

Cancer YOUR

BENEFITS

Breast Cancer is

the most commonly

diagnosed cancer

in women.

DID YOU KNOW?

If caught early,

prostate cancer is one

of the most treatable

malignancies.

This is a general overview of your plan benefits. If the terms of this outline differ from your policy, the policy will govern. Additional plan

details on covered expenses, limitations and exclusions are included in the summary plan description located on the



32

GC12 Limited Benefit Group Cancer Indemnity Insurance TIPSEBC

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

Summary of BenefitsBenefits Option 1 Base Plan Option 2 Base Plan

Cancer Screening Benefits Level 1 Level 1

Diagnostic Testing - 1 test per Calendar Year $50 per test $50 per test

Follow-Up Diagnostic Testing - 1 test per Calendar Year $100 per test $100 per test

Medical Imaging – 1 per Calendar Year $500 per test $500 per test

Cancer Treatment Benefits Level 1 Level 4

Radiation Therapy, Chemotherapy or ImmunotherapyMaximum per 12-month period $10,000 $20,000

Hormone Therapy - Maximum of 12 treatments per Calendar Year $50 per treatment $50 per treatmentSurgical Benefits Level 1 Level 1

Surgical $30 Unit Dollar Amount Maximum

$3,000 per operation

[$30 Unit Dollar Amount Maximum

$3,000 per operation Anesthesia 25% of amount paid for

covered surgery25% of amount paid for

covered surgeryBone Marrow Transplant - Maximum per lifetime $6,000 $6,000Stem Cell Transplant - Maximum per lifetime $600 $600Prosthesis Surgical Implantation – 1 device per site, per lifetime Non-Surgical (not hair piece) – 1 device per site, per lifetime

$1,000$100

$1,000$100

Patient Care Benefits Level 1 Level 1Hospital Confinement Per day of Hospital Confinement (1-30 days) Per day for Eligible Dependent children Per day of Hospital Confinement (31+ days) Per day for Eligible Dependent children

$100$200$100$200

$100$200$100$200

Outpatient Facility - Per day surgery is performed $200 $200Attending Physician - Per day of Hospital Confinement $30 $30

Dread Disease Per day of Hospital Confinement (1-30 days) Per day of Hospital Confinement (31+ days)

$100$100

$100$100

Extended Care Facility Up to the same number of Hospital Confinement Days $100 per day $100 per day

Donor $100 per day $100 per day

Home Health Care Up to the same number of Hospital Confinement Days $100 per day $100 per day

Hospice Care Up to maximum of 365 days per lifetime $100 per day $100 per day

US Government, Charity Hospital or HMO Per day of Hospital Confinement (1-30 days) Per day of Hospital Confinement (31+ days)

$100$100

$100$100

APSB-22338(TX) MGM/FBS TIPSEBC33

Miscellaneous Benefits Level 1 Level 1

Cancer Treatment Center Evaluation or Consultation - 1 per lifetime N/A N/AEvaluation or Consultation Travel and Lodging - 1 per lifetime N/A N/ASecond and Third Surgical Opinion Second Surgical Opinion Third Surgical Opinion

$300 per Diagnosis of Cancer$300 per Diagnosis of Cancer

$300 per Diagnosis of Cancer$300 per Diagnosis of Cancer

Drugs and Medicine Inpatient Outpatient - Maximum $150 per month

$150 per Confinement$50 per Prescription

$150 per Confinement$50 per Prescription

Hair Piece (Wig) - 1 per lifetime $150 $150

Transportation Travel by bus, plane or train

Travel by car Maximum of 12 trips per Calendar year for all modes of transportation

combined

Lodging - up to a maximum of 100 days per Calendar Year

Actual coach fare or $.40 per mile

$.40 per mile

$50 per day


$.40 per mile

$50 per day

Family Transportation Travel by bus, plane or train

Travel by car Maximum of 12 trips per Calendar year for all modes of transportation combined

Family Lodging - up to a maximum of 100 days per Calendar Year


$.40 per mile

$50 per day


$.40 per mile

$50 per day

Blood, Plasma and Platelets $300 per day $300 per dayExperimental Treatment Paid in the same manner and under the same

maximums as any other benefit

Ambulance Ground Air Maximum of 2 trips per Hospital Confinement for all modes of

transportation combined

$200 per trip

$2,000 per trip

$200 per trip

$2,000 per trip

Inpatient Special Nursing Services - Per day of Hospital Confinement $150 per day $150 per day

Outpatient Special Nursing Services Up to same number of Hospital Confinement days $150 per day $150 per day

Medical Equipment - Maximum of 1 benefit per Calendar Year N/A N/A

Physical, Occupational, Speech, Audio Therapy & Psychotherapy Maximum per Calendar Year

$25 per visit$1,000

$25 per visit$1,000

Waiver of Premium Waive Premium Waive Premium

APSB-22338(TX) MGM/FBS TIPSEBC

GC12 Limited Benefit Group Cancer Indemnity Insurance

34

Benefit Riders Internal Cancer First Occurrence Benefit Rider Level 1 Level 2

Lump Sum Benefit Maximum 1 per Covered Person per lifetime

$2,500 $2,500

Lump Sum for Eligible Dependent Children Maximum 1 per Covered Person per lifetime

$3,750 $3,750

Heart Attack/Stroke First Occurrence Benefit Rider Level 1 Level 1Lump Sum Benefit Maximum 1 per Covered Person per lifetime $2,500 $2,500

Lump Sum for Eligible Dependent Children Maximum 1 per Covered Person per lifetime

$3,750 $3,750

Hospital Intensive Care Unit Rider

Intensive Care Unit $600 per day $600 per day

Step Down Unit Maximum of 45 days per Confinement for any combination of Intensive Care Unit or Step Down Unit

$300 per day $300 per day


*The premium and amount of benefits vary dependent upon Plan selected at time of application.**Total premium includes the Plan selected and any applicable rider premium.

Issue Ages Individual Individual & Spouse 1 Parent Family 2 Parent Family18+ $20.64 $43.80 $26.70 $49.80

OPTION 1 TOTAL MONTHLY PREMIMS BY PLAN**

Monthly Premiums*

Issue Ages Individual Individual & Spouse 1 Parent Family 2 Parent Family18+ $26.90 $56.62 $34.14 $63.86

OPTION 2 TOTAL MONTHLY PREMIUMS BY PLAN**


35

Plan Benefit HighlightsCancer Screening BenefitsDiagnostic TestingPays the indemnity amount for one test per Calendar Year when a Covered Person receives a screening test that is generally medically recognized to detect internal cancer. The test must be performed after the 30-day period following the Covered Person’s effective date for this benefit to be paid. This benefit is payable without a diagnosis of Cancer. This benefit ONLY pays for a screening test and does not include any test payable under the Medical Imaging benefit.

Follow-Up Diagnostic TestingPays the indemnity amount for one follow-up invasive screening test per Calendar Year when a Covered Person receives abnormal results from a covered screening test. For tests involving an incision or surgery, this benefit will only be paid for a test that results in a negative diagnosis of Cancer. Diagnostic surgeries that result in a positive diagnosis of Cancer will be paid under the Surgical benefit.

Medical ImagingPays the indemnity amount, up to the maximum number of tests per Calendar Year, when a Covered Person has been diagnosed with Cancer and receives a MRI, CT scan, CAT scan or PET scan. These tests must be at the request of a Physician.

Cancer Treatment BenefitsRadiation Therapy, Chemotherapy or ImmunotherapyPays actual charges, up to the maximum benefit per 12-month period, when a Covered Person receives treatment and incurs a charge for covered Radiation Therapy, Chemotherapy or Immunotherapy. The 12-month period begins on the first day the Covered Person receives covered Radiation Therapy, Chemotherapy or Immunotherapy. Chemotherapy or Immunotherapy coverage will be limited to drugs only. This benefit does not cover other procedures related to Radiation Therapy, Chemotherapy, Immunotherapy, anti-nausea drugs or any drugs or medicines covered under the Drugs and Medicine benefit or Hormone Therapy benefit.

Hormone TherapyPays an indemnity amount, up to 12 treatments per calendar year, when hormone therapy treatment is prescribed by a Physician for a Covered Person. This benefit covers drugs and medicine only. This benefit does not cover associated administrative processes or any drugs or medicines covered under the Drugs and Medicine benefit or Radiation Therapy, Chemotherapy or Immunotherapy benefit.

Surgical BenefitsSurgicalPays an indemnity amount when a surgical operation is performed on a Covered Person for a covered diagnosed Cancer, Skin Cancer or for reconstructive surgery due to Cancer. The indemnity amount is payable up to the maximum per operation amount chosen and will be calculated by multiplying the surgical unit value assigned to the procedure, as shown in the most current Physician’s Relative Value Table, by the Unit Dollar Amount. This benefit will be paid for surgery performed in or out of the Hospital.

Two or more surgical procedures performed through the same incision will be considered one operation and benefits will be limited to the most expensive procedure. Diagnostic surgeries that result in a negative diagnosis of Cancer are not covered under this benefit. Bone Marrow or Stem Cell Transplant surgeries are paid under the Bone Marrow or Stem Cell Transplant benefits. Surgeries required to implant a permanent prosthetic device are covered under the Prosthesis benefit.

This benefit is payable for reconstructive breast surgery performed on a non-diseased breast to establish symmetry with a diseased breast when the reconstructive surgery of the diseased breast is performed while covered under this policy. Reconstructive surgery to the non-diseased breast must occur within 24 months of the reconstructive surgery of the diseased breast.

AnesthesiaPays 25% of the paid Surgical benefit amount for services of an anesthesiologist as a result of a covered surgery. Services of an anesthesiologist for Bone Marrow or Stem Cell Transplants are covered under the Bone Marrow or Stem Cell Transplant benefits. Services of an anesthesiologist for Skin Cancer or surgical prosthesis implantation are not covered under this benefit.

Bone Marrow/Stem Cell TransplantPays an indemnity amount once per lifetime when a bone marrow or stem cell transplant is performed on a Covered Person as treatment for a diagnosed Cancer. This benefit is payable in or out of the Hospital and is payable in lieu of the Surgical and Anesthesia benefits. If a bone marrow and a stem cell transplant are performed on the same day, only the Bone Marrow Transplant benefit will be payable.

ProsthesisPays an indemnity amount once per lifetime for a non-surgical or a surgically implanted prosthetic device prescribed by a Physician as a direct result of surgery for Cancer. The Cancer must have manifested after the 30 days following the Effective Date. This benefit does not cover prosthetic related supplies. Artificial limbs will be paid under the surgical implantation portion of this benefit. Temporary prosthetic devices used as tissue expanders are covered under the Surgical benefit. Benefits for hair prosthesis will only be covered under the Hair Piece benefit.

Patient Care BenefitsHospital ConfinementPays an indemnity amount when a Covered Person is confined to a Hospital for the treatment of a covered Cancer or the treatment of a condition or disease directly caused by Cancer or the treatment of Cancer. Outpatient treatment or a stay of less than 18 hours in an observation unit or an Emergency Room is not covered. A Hospital is not an institution, or part thereof, used as: a hospice unit, including any bed designated as a hospice or a swing bed; a convalescent home; a rest or nursing facility; a rehabilitative facility; an extended-care facility; or a facility primarily affording custodial, educational care, or care of treatment for persons suffering from mental diseases or disorders, or care for the aged, or drug or alcohol addiction.

Outpatient FacilityPays an indemnity amount when a facility fee is charged for a surgical procedure performed on an outpatient basis in a Hospital or at an Ambulatory Surgical Center on a Covered Person for a diagnosed Cancer. Surgical procedures for Skin Cancer performed on an outpatient basis in a Hospital or Ambulatory Surgical Center are not covered under this benefit.

Attending PhysicianPays an indemnity amount for one Physician’s visit per day of Hospital confinement when a Covered Person requires the services of a Physician, other than a surgeon, while confined in a Hospital for the treatment of Cancer.

Extended Care FacilityPays the indemnity amount when a Covered Person is confined to an Extended Care Facility due to Cancer. Confinement must be at the direction of a Physician and begin within 14 days after a Hospital Confinement. This benefit is payable for the same number of days benefits were paid for the Covered Person’s preceding Hospital Confinement.

Home Health CarePays the indemnity amount when a Covered Person requires Home Health Care in lieu of Hospital Confinement due to Cancer. Home Health Care must be prescribed by a Physician and provided by a Nurse or by a home health Nurse’s aide under the supervision of a registered Nurse. Confinement must begin within 14 days after a covered Hospital Confinement and is payable up to the same number of days benefits were paid for the Covered Person’s preceding Hospital Confinement. The caregiver may not be a member of the Insured’s Immediate Family.

This benefit does not include physical, speech or audio therapy, or psychotherapy as these therapies are covered under the Physical, Occupational, Speech or Audio Therapy or Psychotherapy benefit. If the Covered Person qualifies for coverage under the Hospice Care benefit, the Hospice Care benefit will be paid in lieu of this benefit.



36

Hospice CarePays the indemnity amount, up to the maximum number of days per lifetime, when a Covered Person is diagnosed by a Physician as terminally ill and requires Hospice Care due to Cancer. Care must be directed by a licensed hospice organization in the patient’s home or on an outpatient or short-term Inpatient basis in a hospice facility. The Covered Person is considered terminally ill if expected to live six months or less.

US Government, Charity Hospital or H.M.O.Pays an indemnity amount if an itemized list of services is not available because a Covered Person is confined in a charity Hospital or U.S. Government owned Hospital or covered under a Health Maintenance Organization (H.M.O.) or a Diagnostic Related Group (D.R.G.) where no charges are made to the Covered Person. If this option is elected and the Covered Person is confined as an Inpatient in a Hospital as a result of Cancer or Dread Disease, benefits for each full day of confinement will be paid. If outpatient services are provided, we will pay the benefit for each day that outpatient surgery is performed or outpatient therapy is received for Cancer covered by the Policy. This benefit will be paid in lieu of most benefits under the Policy/Certificate.

Miscellaneous BenefitsCancer Treatment Cancer Evaluation or Consultation Pays the indemnity amount once per lifetime when a Covered Person obtains a treatment opinion at a National Cancer Institute designated Comprehensive Cancer Treatment Center. If the center is located more than 50 miles from the Covered Person’s place of residence, we will also pay a transportation and lodging indemnity amount in lieu of the Transportation and Lodging benefit and Family Member Transportation and Lodging benefit.

Second & Third Surgical OpinionPays the indemnity amount for a second surgical opinion when the attending Physician recommends surgery for a Covered Person as treatment of a diagnosed Cancer. The second surgical opinion must be obtained from the consulting Physician prior to surgery. If the second surgical opinion does not agree with the first surgical opinion and a third surgical opinion is required, we will pay an indemnity amount for a third surgical opinion. Each surgical opinion is payable once per diagnosis of Cancer. Surgical opinions for reconstructive, Skin Cancer or prosthesis surgeries are not covered under this benefit.

Drugs & MedicinePays the indemnity amount when anti-nausea and pain medication are prescribed by a Physician and administered to a Covered Person who is also receiving Radiation Therapy, Chemotherapy, Immunotherapy, a covered surgery, Bone Marrow Transplant or Stem Cell Transplant. This benefit does not cover associated administrative processes. This benefit does not include drugs or medicines covered under the Radiation Therapy, Chemotherapy or Immunotherapy benefit or the Hormone Therapy benefit.

Transportation & LodgingPays the actual coach fare for transportation for a Covered Person by bus, plane or train or the per mile amount for transportation by car, to receive covered Radiation Therapy, Chemotherapy, Immunotherapy, Bone Marrow Transplant, Stem Cell Transplant or surgery in a Hospital that is at least 50 miles away from the Covered Person’s residence, using the most direct route. The Hospital must be prescribed by a Physician and be the nearest Hospital which offers the specialized treatment. If the Covered Person travels by bus, plane or train, the Insured will have the option to receive the coach fare benefit or the per mile benefit. If the Insured is unable to provide proof of coach fare, the per mile benefit will be paid. Travel must be by scheduled bus, plane or train, or by car and be within the United States or its Territories. Travel by car will be paid at the stated rate per mile for up to 1,000 miles round trip. Benefits will be provided for only one mode of transportation per round trip, up to the maximum number of trips per Calendar year. If the Covered Person receives treatment while Hospital Confined, benefits for transportation will be paid once per Hospital Confinement.

Pays the indemnity amount for lodging, up to the maximum number of days, when treatment is received on an outpatient basis. The Covered Person’s lodging must be in a single room in a motel, hotel or other accommodation acceptable to us and will be paid only while the Covered Person is receiving the specialized treatment as an outpatient.

Family Transportation & LodgingPays the actual coach fare for transportation by bus, plane or train, or the per mile amount for transportation by car for one adult family member to be near a Covered Person who is receiving covered Radiation Therapy, Chemotherapy, Immunotherapy, Bone Marrow Transplant, Stem Cell Transplant or surgery due to Cancer in a Hospital that is at least 50 miles away from the Covered Person’s residence, using the most direct route. Travel must be by scheduled bus, plane or train, or by car and be within the United States or its Territories. If the family member travels by bus, plane or train, the Insured will have the option to receive the coach fare benefit or the per mile benefit. If the Insured is unable to provide proof of coach fare, the per mile benefit will be paid. Travel by car will be paid at the stated rate per mile for up to 1,000 miles round trip. Benefits will be provided for only one mode of transportation per round trip, up to the maximum number of trips per Calendar year. If the Covered Person receives treatment while Hospital Confined, benefits for travel and/or lodging will be paid once per Hospital Confinement.

If treatment for the Covered Person is received on an outpatient basis, we will pay the indemnity amount for lodging, subject to the maximum number of days, for the family member’s lodging in a single room in a motel, hotel or other accommodation acceptable to us. If treatment is received on an outpatient basis, benefits for travel and/or lodging will be paid only on those days the Covered Person received outpatient treatment.

If the family member and the Covered Person who is receiving treatment travel in the same car or lodge in the same room, benefits for travel and lodging will only be paid under the Transportation and Lodging benefit.

Blood, Plasma & PlateletsPays the indemnity amount for blood, plasma and platelets. This benefit does not include coverage for any laboratory processes or colony stimulating factors. Benefits for Blood, Plasma and Platelets are ONLY provided under this benefit.

AmbulancePays the indemnity amount, up to two trips per confinement, for either licensed air or ground ambulance transportation of a Covered Person to a Hospital or from one medical facility to another where the Covered Person is admitted as an Inpatient and Hospital confined for at least 18 consecutive hours for the treatment of Cancer. If both air and ground ambulance is required on the same day, we will only pay the highest benefit amount.

Physical, Occupational, Speech, Audio Therapy or Psychotherapy Pays the indemnity amount, up to the maximum per Calendar Year, when a Covered Person is advised by a Physician to seek physical, occupational, speech, audio therapy or psychotherapy as a result of Cancer or the treatment of Cancer. These therapies must be performed by a caregiver licensed in physical, occupational, speech, audio therapy or psychotherapy. If two or more therapies occur on the same day, only one benefit will be paid.

Waiver of PremiumWhen the Certificate is in force and the Insured becomes Disabled, we will waive all premiums due including premiums for any riders attached to the Certificate. Disability must be due to Cancer and occur while receiving treatment for such Cancer for which benefits are payable under the Policy. The Insured must remain Disabled for 60 continuous days before this benefit will begin. The Waiver of Premium will begin on the next premium due date following the 60 consecutive days of Disability. This benefit will continue for as long as the Insured remains Disabled until the earliest of either the date the Insured is no longer Disabled or the date coverage ends according to the Termination provisions in the Certificate. Proof of Disability must be provided for each new period of Disability before a new Waiver of Premium benefit is payable.Other Benefits include:s Donors Dread DiseasesExperimental TreatmentsHair PiecesInpatient Special Nursing ServicessMedical EquipmentsOutpatient Special Nursing Services



See your Policy/Certificate for more information regarding the benefits listed above.37

Important Policy ProvisionsEligibilityYou and your Eligible Dependents are eligible to be insured under the Certificate if you and your Eligible Dependents meet APL’s underwriting rules and you are Actively at Work and qualify for coverage as defined in the Master Application.

Limitations & ExclusionsNo benefits will be paid for any of the following: s care or treatment received outside the territorial limits of the United States s treatment by any program engaged in research that does not meet the

definition of Experimental Treatment s losses or medical expenses incurred prior to the Covered Person’s

Effective Date regardless of when Cancer was diagnosed

Only Loss for Cancer or Dread DiseaseThe Policy/Certificate pays only for loss resulting from definitive Cancer treatment including direct extension, metastatic spread or recurrence. Proof must be submitted to support each claim. The Policy/Certificate also covers other conditions or diseases directly caused by Cancer or the treatment of Cancer. The Policy/Certificate does not cover any other disease, sickness or incapacity which existed prior to the diagnosis of Cancer, even though after contracting Cancer it may have been complicated, aggravated or affected by Cancer or the treatment of Cancer except for conditions specifically provided in the Dread Disease benefit.

Pre-Existing Condition ExclusionNo benefits are payable for any loss incurred during the Pre-Existing Condition Exclusion Period following the Covered Person’s Effective Date as the result of a Pre-Existing Condition. Pre-Existing Conditions specifically named or described as excluded in any part of the Policy/Certificate are never covered. If any change to coverage after the Certificate Effective Date results in an increase or addition to coverage, the Time Limit on Certain Defenses and Pre-Existing Condition Limitation for such increase will be based on the effective date of such increase.

Waiting PeriodThe Policy/Certificate contains a Waiting Period during which no benefits will be paid. If any Covered Person has a Specified Disease diagnosed before the end of the Waiting Period immediately following the Covered Person’s Effective Date, coverage for that person will apply only to loss that is incurred after one year from the Covered Person’s Effective Date. If any Covered Person is diagnosed as having a Specified Disease during the Waiting Period immediately following the Covered Person’s Effective Date, the Insured may elect to void the Certificate from the beginning and receive a full refund of premium.

If the Policy/Certificate replaced Specified Disease Cancer coverage from another company that terminated within 30 days of the Certificate Effective Date, the Waiting Period will be waived for those Covered Persons that were covered under the prior coverage. However, the Pre-Existing Condition Limitation will still apply.

Termination of CertificateInsurance coverage under the Certificate and any attached riders will end on the earliest of any of the following dates:s the date the Policy terminatessthe end of the grace period if the premium remains unpaids the date insurance has ceased on all persons covered under this Certificates the end of the Certificate Month in which the Policyholder requests to terminate this coveragesthe date you no longer qualify as an Insuredsthe date of your death

Termination of CoverageInsurance coverage for a Covered Person under the Certificate and any attached riders for a Covered Person will end as follows:s the date the Policy terminatessthe date the Certificate terminatessthe end of the grace period if the premium remains unpaidsthe end of the Certificate Month in which the Policyholder requests to terminate the coverage for an Eligible Dependentsthe date a Covered Person no longer qualifies as an Insured or Eligible

Dependentsthe date of the Covered Person’s death

Optionally RenewableThe policy is optionally renewable. The Policyholder has the right to terminate the policy on any premium due date after the first Anniversary following the Policy Effective Date. APL must give at least 60 days written notice prior to cancellation.

Portability (Voluntary Plans Only)When the Insured no longer meets the definition of Insured, he or she will have the option to continue this coverage, including any attached riders. No Evidence of Insurability will be required. Portability must meet all of the following conditions:sthe Certificate has been continuously in force for the last 12 monthss APL receives a request and payment of the first premium for the portability

coverage no later than 30 days after the date the Insured no longer qualifies as an eligible Insured. All future premiums due will be billed directly to the Insured. The Insured is responsible for payment of all premiums for the portability coverage

s the Policy, under which this Certificate was issued, continues to be in force on the date the Insured ceases to qualify for coverage

The benefits, terms and conditions of the portability coverage will be the same as those elected under the Certificate immediately prior to the date the Insured exercised portability. Portability coverage may include any Eligible Dependents who were covered under the Certificate at the time the Insured ceased to qualify as an eligible Insured. No new Eligible Dependents may be added to the portability coverage except as provided in the Newborn and Adopted Children provision. No increases in coverage will be allowed while the Insured is exercising his or her rights under this rider.If the Policy is no longer in force, then portability coverage is not available.



Underwritten by American Public Life Insurance Company. This is a brief description of the coverage. For complete benefits, limitations, exclusions and other provisions, please refer to the policy and riders. This coverage does not replace Workers’ Compensation Insurance. This product is inappropriate for people who are eligible for Medicaid coverage. | This policy is considered an employee welfare benefit plan established and/or maintained by an association or employer intended to be covered by ERISA, and will be administered and enforced under ERISA. Group policies issued to governmental entities and municipalities may be exempt from ERISA guidelines. | This product contains Limitations & Exclusions | Policy Form GC12APL Limited Benefit Group Cancer Indemnity Insurance Series | Texas | (04/13) | TIPSEBC

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

38

www.ampublic.com


39

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

About this Benefit

Individual Life YOUR BENEFITS PACKAGE

x 10

Experts recommend at least

your gross annual income in coverage when purchasing life insurance.

DID YOU KNOW?

5STAR



Term Life with Terminal Illness and Quality of Life Rider

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

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

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

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

Affordability—With several options to choose from, select the coverage that best meets the needs of your family. Terminal Illness—This plan pays the insured 30% (25% in Connecticut and Michigan) of the policy coverage amount in a lump sum upon the occurrence of a terminal condition that will result in a limited life span of less than 12 months. Portability—You and your family continue coverage with no loss of benefits or increase in cost should you terminate employment after the first premium is paid. If this happens, we can simply bill you directly. Coverage can never be cancelled by the insurance company or your employer unless you stop paying premiums. Family Protection—Individual policies can be purchased on the employee, their spouse, children and grandchildren. Children & Grandchildren Plan— Individual life policies can be purchased for children and grandchildren ages newborn through 23. They are not eligible for the Quality of Life Rider. Convenience—Premiums are taken care of simply and easily through payroll deductions. Protection You Can Count On—Within 24 hours after receiving notice of an insured’s death, an emergency death benefit of the lesser of 50% of the coverage amount, or $10,000, will be mailed to the insured’s beneficiary, unless the death is within the two-year contestability period and/or under investigation. This product also contains no war or terrorism exclusions.

Example Weekly

Premium Death

Benefit Accelerated

Benefit

Your age at issue: 35

$10.00

$89,655

4% $3,586.20 a month

41

Family Protection Plan - Terminal Illness

MONTHLY RATES WITH QUALITY OF LIFE RIDER DEFINED BENEFIT

Age on App. Date

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

42

Family Protection Plan - Terminal Illness

43

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

About this Benefit

Life and AD&D YOUR BENEFITS PACKAGE

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

drowning, and choking.

DID YOU KNOW?

#1

Motor vehicle crashes are the

UNUM



Life and AD&D

UNUM Basic Term Life and AD&D Your district provides full-time employees with Basic Life coverage. You benefit amount is viewable during your enrollment or on your Consolidated Enrollment Form. Basic Life and AD&D Eligibility Full Time Employee working 15+ hours per week. Life Benefit Amount Varies by employer AD&D Benefit Amount Varies by employer Portability & Conversion Included Survivor Support Included Benefit Reduction Scheduled 65% at age 65; 50% at age 70

UNUM Supplemental Term Life Voluntary Life Eligibility Full Time Employee working 15+ hours per week. Life Benefit Amount Employee - Up to 7 times annual earnings in increments of $10,000. Not to exceed $500,000. Spouse - Up to 100% of employee amount in increments of $5,000. Not to exceed $500,000. Child(ren) - Up to 100% of employee coverage amount in increments of $5,000. Not to exceed $10,000. Guarantee Issue* Employee - $230,000 Spouse - $50,000 Child - $10,000 Portability and Conversion Included Survivor Support Included Benefit Reduction Schedule 65% at age 65; 50% at age 70 *UNUM allows employees that are currently enrolled in the life insurance and are below the Guaranteed Issue (GI) amount to increase the coverage to the GI without evidence of insurability. If you are not currently enrolled, you can enroll subject to evidence of insurability for the lesser of $230,000 or 7x salary for self, up to $50,000 for spouse and up to $10,000 for children. For increases in coverage to take effect, employees must be actively at work and spouse/child cannot be disabled.

NOTE: Your rate will increase as you age and move to the next age band. **Spouse rates are determined using the Employee’s age.

Age Employee

per $10,000 Spouse**

per $10,000 Child

per $5,000

Under 25 $0.400 $0.400

$0.65

NOTE: The premium paid for child coverage is based on the cost of coverage for

one child, regardless of how many children you have.

25-29 $0.400 $0.400

30-34 $0.600 $0.600

35-39 $0.700 $0.700

40-44 $1.000 $1.000

45-49 $1.400 $1.400

50-54 $2.500 $2.500

55-59 $4.000 $4.000

60-64 $6.000 $6.000

65-69 $10.000 $10.000

70-74 $20.000 $20.000

75+ $26.000 $26.000

45

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

UNUM



Critical Illness

Your Plan

Eligibility All employees working at least 20 hours each week in active employment in the U.S. with the employer, and their eligible spouses and children to age 23.

Benefit Advantages Lump sum benefit payable for each covered condition. Automatic coverage for dependent children at 25% of employee benefit. Children are covered for the same conditions as the employee, plus specific childhood conditions.

Covered Conditions Heart Attack, Coronary Artery Bypass Surgery*, Stroke, End Stage Renal (Kidney) Failure, Major Organ Failure, Permanent Paralysis as the result of a Covered Accident, Coma as the result of Severe Traumatic Brain Injury, Blindness, Benign Brain Tumor, Occupational HIV. Additional Covered Conditions for Dependent Children Cerebral Palsy

Cleft Lip or Palate

Cystic Fibrosis

Down Syndrome

Spina Bifida

Benefit Amount Employee: $5,000, 10,000 or $15,000 Spouse: $5,000 or $10,000 Child: 25% of Employee Benefit Amount Benefit reduces to 50% on the policy anniversary date following the insured’s 70th birthday. Premiums will not be reduced. Evidence of insurability is required as enrollment. *100% of the benefit payable for each covered condition, with the exception of coronary bypass which are paid at 25% of the purchased benefit amount.

Additional Benefits

Recurrence Benefit The employee and all family members covered by a Critical Illness certificate will automatically receive this benefit. The Benefit provides an additional payout for subsequent occurrence of benign brain tumor, coma, heart attack and stroke. The date of diagnosis between occurrences of the same conditions must be separated by 12 months. 50% of the original benefit amount.

Wellness Benefit Employee and children covered by a Critical Illness certificate will automatically be eligible to receive this benefit. A $75 benefit per calendar year, per insured, for covered health screening tests performed.

Portability Employees may take the coverage with them at the same rate, should they terminate employment. The ported coverage will remain in effect regardless of the group status.

Other Important Provisions

Pre-existing Condition Limitation Benefits will not be paid for a claim caused by, contributed to by, or occurs as a result of, a Pre-Existing Condition, or any medical or surgical treatment for that condition for which the date of diagnosis is in the first 12 months after the insured’s coverage effective date. You have a pre-existing condition if:

You have a sickness or injury or symptoms of a sickness or injury, whether diagnosed or not, for which the insured received medical treatment, consultation, care or services, including diagnostic measures, took prescribed drugs or medicine or had been prescribed drugs or medicine to be taken during the 12 months just prior to the insured’s coverage effective date; or

the insured had a sickness or injury or symptoms of a sickness or injury, whether diagnosed or not, for which an ordinarily prudent person would have consulted a health care provider during the 12 months just prior to the insured’s coverage effective date.

47

Instances When Benefits Would Not Be Paid Benefits will not be paid for a claim caused by, contributed to by, or resulting from:

participating or attempting to participate in a felony or being engaged in an illegal occupation; or

committing or trying to commit suicide or injuring oneself intentionally

participating in a war, act of war or committing acts of terrorism

being under the influence of or addicted to intoxicants or narcotics

having a diagnosis during the benefit waiting period

Reduction of Benefits The benefit amount for the employee and spouse reduces

by 50% on the first policy anniversary date after the insured individual’s 70th birthday.

Premiums will not be reduced.

For coverage purchased after age 70, benefit amounts will not be reduced.

Exclusions Unum will not pay benefits for a claim that is caused by, contributed to by or occurs as a result of:

participating or attempting to participate in a felony or being engaged in an illegal occupation; or

committing or trying to commit suicide or injuring oneself intentionally, whether sane or not; or

participating in war or any act of war, whether declared or undeclared; or

committing acts of terrorism; or

being under the influence of or addicted to intoxicants or narcotics. This would not include physician-prescribed medication, taken in the prescribed dosage; or

having a date of diagnosis during the benefit waiting period.

Questions If you should have any questions about your coverage or how to enroll, please contact your Plan Administrator.

Critical Illness

48

Age Band $5,000 $10,000 $15,000

25 $2.20 $4.40 $6.60

25-29 $2.25 $4.50 $6.75

30-34 $3.00 $6.00 $9.00

35-39 $4.10 $8.20 $12.30

40-44 $5.85 $11.70 $17.55

45-49 $7.75 $15.50 $23.25

50-54 $10.00 $20.00 $30.00

55-59 $12.80 $25.60 $38.40

60-64 $16.30 $32.60 $48.90

65-69 $18.40 $36.80 $55.20

70+ $34.30 $68.60 $102.90

Monthly Wellness Premium

Employee Only $2.40

Employee and Spouse $4.80

Employee and Children $2.40

Employee, Spouse, and Children/Family $4.80

Critical Illness

To Calculate Your Total Monthly Cost:

1. Choose a $5,000, $10,000 or $15,000 benefit for yourself. Locate the monthly cost that corresponds with your age on 9/1. 2. Choose a $5,000 or $10,000 benefit for your spouse. Locate the monthly cost that corresponds with your spouse’s age on

9/1. 3. Add the cost of the wellness benefit. If you chose coverage just for yourself, the wellness benefit cost is $2.40. If you chose

coverage for you and your spouse, the wellness benefit cost is $4.80. 4. Add the cost of 1, 2 and 3 for the total monthly cost. During your enrollment, you will see the total premium of the benefit,

including the wellness rider.

Region VIII TIPS Employee Benefits Cooperative Group Critical Illness Rate Sheet

49

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 TIPS website at www.tipsebc.com.

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

52

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

53

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

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

About this Benefit

FSA (Flexible Spending Account)


FOR HSA VS. FSA COMPARISON

FLIP TO… PG. 11

NBS



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

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

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

FSA Annual Contribution Max: $2,550

Dependent Care Annual Max: $5,000

Account Information: Participant Account Web Access: www.participant.nbsbenefits.com Participants may call NBS and talk to a representative during regular business hours, Monday-Friday, 8 am to 7 pm Central Time. Participants can also obtain account information using the Automated Voice Response Unit, 24 hours a day, 7 days a week at (801) 838-7324 or toll free (800) 274-0503. For immediate access to your account information at any time, log on to the NBS website: www.NBSbenefits.com Detailed claim history and processing status Health Care and Dependent Care account balances Health Care and Dependent Care account balances Claim forms, Direct Deposit form, worksheets, etc. Online claim FAQs

For a list of sample expenses, please refer to the TIPSEBC benefit website: www.tipsebc.com

NBS Contact Information:

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

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

FSA (Flexible Spending Account)

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

NBS Prepaid MasterCard® Debit Card

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

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

Health Care Expense Account Example Expenses:

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

The actual care of the dependent in your home.

Preschool tuition.

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

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

What Happens If I Don’t Use All of My Funds by The End of the Plan Year (August 31st)? Eligible expenses must be incurred within the plan year +75 day grace period. Contributions are use-it-or- lose-it. Remember to retain all your receipts (including receipts for card swipes). Please contact your benefits admin to determine if your district has the grace period or the $500 Roll-Over option. If your district does not have the roll-over, your plan contributions are use-it-or-lose-it.

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

Hearing aids & batteries

Lab fees

Laser Surgery

Orthodontia Expenses

Physical exams

Pregnancy tests

Prescription drugs

Vaccinations

Vaporizers or humidifiers

Acupuncture

Body scans

Breast pumps

Chiropractor

Co-payments

Deductible

Diabetes Maintenance

Eye Exam & Glasses

Fertility treatment

First aid

FSA Frequently Asked Questions

How To Receive Your Dependent Care Reimbursement Faster.

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

56

How the FSA Plan Works

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

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

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

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

Detailed claim history and processing status

Health Care and Dependent Care account balances

Claim forms, worksheets, etc.

Online Claim Submission

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

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

About this Benefit

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?



Identity Theft

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

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

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

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

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

ID Watchdog Dual Monthly Pricing

Plus Platinum

Individual Plan $7.95 $11.95

Family Plan $14.95 $22.95

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

ID Watchdog Services

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NOTES

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NOTES

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www.tipsebc.com

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2016 Benefit Guide TIPS - General Version

Documents

Transcript of 2016 Benefit Guide TIPS - General Version