2016 Benefit Guide - Victoria ISD

EFFECTIVE:

09/01/2016 - 8/31/2017

BENEFIT GUIDE

www.mybenefitshub.com/victoriaisd

VICTORIA ISD

1

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

Spending Account (FSA) 11

TRS-ActiveCare Plans 12-13 HSA Bank Health Savings Account (HSA) 14-17 Cigna Dental 18-21 UnitedHealthcare Vision 22-23 UNUM Long Term Disability 24-27 APL Cancer 28-33 UNUM Life and AD&D 34-37 Texas Life Individual Life 38-39 UNUM Critical Illness 40-41 LifeWorks Employee Assistance Program (EAP) 42-43 Higginbotham Flexible Spending Account (FSA) 44-51

Table of Contents

HOW TO ENROLL

PG. 4

BENEFIT UPDATE—WHAT’S NEW

PG. 6

YOUR BENEFITS PACKAGE

PG. 12

FLIP TO...

2

Benefit Contact Information

VICTORIA ISD BENEFITS VISION INDIVIDUAL LIFE

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

UnitedHealthcare (800) 638-3120 www.myuhcvision.com

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

TRS ACTIVECARE MEDICAL DISABILITY CRITICAL ILLNESS

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

Policy # 469176 UNUM (800) 583-6908 www.unum.com

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

HEALTH SAVINGS ACCOUNT CANCER EMPLOYEE ASSISTANCE PROGRAM

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

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

LifeWorks (888) 739-9020 www.lifeworks.com

DENTAL LIFE AND AD&D FLEXIBLE SPENDING ACCOUNT

Cigna (800) 244-6224 www.mycigna.com

UNUM (800) 583-6908 www.unum.com

Higginbotham (866) 419-3519 www.higginbotham.net

Benefit Contact Information

3

!

How to Enroll

On Your Computer Access the Victoria ISD 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.mybenefitshub.com/

victoriaisd delivers important

benefit information with 24/7

access, as well as detailed plan

information, rates and product

videos.

TEXT

“victoriaisd”

TO

313131

On Your Device Enrolling in your benefits just got

a lot easier! Text “victoriaisd” to

313131 to receive everything you

need to complete your

enrollment.

Avoid typing long URLs and scan

directly to your benefits website,

to access plan information,

benefit guide, benefit videos, and

more!

SCAN: TRY ME

4

GO www.mybenefitshub.com/victoriaisd 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

Employees who elect to waive participation in the TRS ActiveCare coverage are provided an alternate health package that includes a hospital indemnity plan, dental and vision for the employee only at no cost.

If you currently participate in a Healthcare or

Dependent Care Flexible Spending Account, you must re-elect a new contribution amount in the summer enrollment to continue to participate. Please keep your current cards through 8/31/16.

All NEW Benefit elections will become effective 9/1/16 (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).

IMPORTANT NOTICE: Federal mandate regulations

require all dependent information, including social security numbers, even if coverage is declined.

Meet with a benefit counselor during open enrollment to complete your benefit

enrollment from 7/11/16-8/22/16

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

to speak to a representative. Bilingual assistance is available at this number.

Representatives will be on various campuses 7/11/16-8/22/16

Verify your profile information: home address, phone numbers, email

Benefit Updates - What’s New:

Don’t Forget!

Annual Benefit Enrollment

SUMMARY PAGES

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CHANGES IN STATUS (CIS):

QUALIFYING EVENTS

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

Change in Number of Tax Dependents

A change in number of dependents includes the following: birth, adoption and placement for adoption. You can add existing dependents not previously enrolled whenever a dependent gains eligibility as a result of a valid change in status event.

Change in Status of Employment Affecting

Coverage Eligibility

Change in employment status of the employee, or a spouse or dependent of the employee, that affects the individual's eligibility under an employer's plan includes commencement or termination of employment.

Gain/Loss of Dependents' Eligibility Status

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

Judgment/Decree/Order

If a judgment, decree, or order from a divorce, annulment or change in legal custody requires that you provide accident or health coverage for your dependent child (including a foster child who is your dependent), you may change your election to provide coverage for the dependent child. If the order requires that another individual (including your spouse and former spouse) covers the dependent child and provides coverage under that individual's plan, you may change your election to revoke coverage only for that dependent child and only if the other individual actually provides the coverage.

Eligibility for Government Programs

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

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

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

Section 125 Cafeteria Plan Guidelines

SUMMARY PAGES

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Annual Enrollment

During your annual enrollment period, you have the opportunity

to review, change or continue benefit elections each year.

Changes are not permitted during the plan year (outside of

annual enrollment) unless a Section 125 qualifying event occurs.

Changes, additions or drops may be made only during the

annual enrollment period without a qualifying event.

Employees must review their personal information and verify

that dependents they wish to provide coverage for are

included in the dependent profile. Additionally, you must

notify your employer of any discrepancy in personal and/or

benefit information.

Employees must confirm on each benefit screen (medical,

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

selected in order to be included in the coverage for that

particular benefit.

New Hire Enrollment

All new hire enrollment elections must be completed in the

online enrollment system within the first 31 days of benefit

eligibility employment. Failure to complete elections during this

timeframe will result in the forfeiture of coverage.

Q&A

Who do I contact with Questions?

For supplemental benefit questions, you can contact your

Benefits/HR department or you can call Financial Benefit Services

at 866-914-5202 for assistance.

Where can I find forms?

For benefit summaries and claim forms, go to your school

district’s benefit website:

www.mybenefitshub.com/victoriaisd. Click on the benefit plan

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

forms you need under the Benefits and Forms section.

How can I find a Network Provider?

For benefit summaries and claim forms, go to your school

district’s benefit website: www.mybenefitshub.com/

victoriaisd. Click on the benefit plan you need information on

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

Quick Links section.

When will I receive ID cards?

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

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

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

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

insurance company’s phone number and they can call and

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

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

carrier’s customer service number to request another card.

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

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

card each year.

SUMMARY PAGES

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PLAN CARRIER MAXIMUM AGE

Medical Aetna To age 26

Dental Cigna To age 26

Vision UHC To age 26

Cancer APL To age 26

Critical Illness UNUM To age 25

Voluntary Life UNUM To age 26

EAP Ceridian To age 26

Individual Life TX Life To age 26 for children

To age 18 for grandchildren

Employee Eligibility Requirements

Supplemental Benefits: Eligible employees must work 20 or more

regularly scheduled hours each work week.

Eligible employees must be actively at work on the plan effective

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

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

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

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

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

your new benefits.

Dependent Eligibility Requirements

Dependent Eligibility: You can cover eligible dependent

children under a benefit that offers dependent coverage,

provided you participate in the same benefit, through the

maximum age listed below. Dependents cannot be double

covered by married spouses within Victoria ISD or as both

employees and dependents.

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

SUMMARY PAGES

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

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

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

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

work beginning 9/1/2016 please notify your benefits

administrator.

Annual Enrollment The period during which existing employees are given the

opportunity to enroll in or change their current elections.

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

pay covered expenses.

Calendar Year January 1st through December 31st

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

covered health care service, calculated as a percentage (for

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

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

medical questions or taking a health exam. Guaranteed

coverage is only available during initial eligibility period.

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

provisions do apply, as applicable by carrier.

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

who have contracted with the plan as a network provider.

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

for covered expenses.

Plan Year September 1st through August 31st

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

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

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

orders to take drugs, or received medical care or services

(including diagnostic and/or consultation services).

Helpful Definitions SUMMARY PAGES

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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 $1,000 single (2016) $2,600 family (2016) N/A

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

Varies per employer

Permissible Use Of Funds

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

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

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

Permitted, but subject to current tax rate plus 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. 14

FOR FSA INFORMATION

FLIP TO… PG. 44

HSA vs. FSA SUMMARY PAGES

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2016-2017 TRS-ActiveCare Plan Highlights Effective September 1, 2016 through August 31, 2017 | In-Network Level of Benefits*

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

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

Accountable Care Network; Seton Health Alliance)

ActiveCare 2

Deductible (per plan year)

$2,500 employee only $5,000 family

$1,200 individual $3,600 family


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

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



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

80% 20%

80% 20%

80% 20%

Office Visit Copay Participant pays

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

$30 copay for primary $50 copay for specialist

Diagnostic Lab Participant pays

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

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

Preventive Care See next page for a list of services

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

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

Plan pays 100% Plan pays 100%

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

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

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

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

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

Emergency Room (true emergency use) Participant pays

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

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

Outpatient Surgery Participant pays

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

$150 copay per visit plus 20% after deductible

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

$5,000 copay plus 20% after deductible

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

Prescription Drugs Drug deductible (per plan year)

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

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

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

20% after deductible

$20 $40** 50% coinsurance**

$20 $40** $65**

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

20% after deductible

$35 $60** 50% coinsurance**

$35 $60** $90**

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

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

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

Specialty Drugs Participant pays

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

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

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TRS-ActiveCare Plans—Preventive Care

Preventive Care Services

Network Benefits When Using In-Network Providers

(Provider must bill services as “preventive care”)

ActiveCare 1-HD ActiveCare Select or ActiveCare Select

Whole Health (Baptist Health System and

HealthTexas Medical Group; Baylor Scott & White Quality Alliance;

Memorial Hermann Accountable Care Network; Seton Health

Alliance)

ActiveCare 2 Network

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

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

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

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

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

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

12 and over Well-child care – unlimited up to

age 12 Well woman exam & pap smear

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

35 and over Colonoscopy – 1 every 10 years

age 50 and over Prostate cancer screening – 1 per

year age 50 and over Smoking cessation counseling – 8

visits per 12 months Healthy diet/obesity counseling –

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

Breastfeeding support – 6 lactation counseling visits per 12 months

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

annually age 12 and over Well-child care – unlimited

up to age 12 Well woman exam & pap

smear – annually age 18 and over

Mammograms – 1 every year age 35 and over

Colonoscopy – 1 every 10 years age 50 and over

Prostate cancer screening –1 per year age 50 and over

Smoking cessation counseling –8 visits per 12 months

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

Breastfeeding support –6 lactation counseling visits per 12 months

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

age 12 and over Well-child care – unlimited

up to age 12 Well woman exam & pap

smear – annually age 18 and over

Mammograms – 1 every year age 35 and over

Colonoscopy – 1 every 10 years age 50 and over

Prostate cancer screening – 1 per year age 50 and over

Smoking cessation counseling – 8 visits per 12 months

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

Breastfeeding support – 6 lactation counseling visits per 12 months

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

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

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

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

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

$60 copay for specialist $50 copay for specialist

Annual Hearing Examination Participant pays

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



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

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

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

About this Benefit

HSA (Health Savings Account)

The interest earned in an HSA is tax free.

DID YOU KNOW?

Money withdrawn for medical spending never falls under taxable income.

HSA BANK YOUR BENEFITS PACKAGE

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

Victoria ISD Benefits Website: www.mybenefitshub.com/victoriaisd 14

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

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

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

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

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

Using Funds Debit Card

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

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

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

Health Savings accountholder

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

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

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

Examples of Qualified Medical Expenses Surgery

Braces

Contact lenses

Dentures

Eyeglasses

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

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

HSA (Health Savings Account)

15

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

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

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

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

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

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

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

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

You cannot be covered by TriCare.

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

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

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

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

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

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

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

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

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

HSA funds earn interest and investment earnings are tax free.

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

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

How the HSA Plan Works

16

How the HSA Plan Works

Examples of IRS-Qualified Medical Expenses4:

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

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

Gynecologist Hearing aids and batteries Hospital bills Insurance premiums5

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

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

17

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

About this Benefit

Dental

Good dental care may improve your overall health.

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

DID YOU KNOW?

CIGNA YOUR BENEFITS PACKAGE



Dental PPO - High Option

Receiving regular dental care can not only catch minor problems before they become major and expensive to treat - it may even help improve your overall health. Gum disease is increasingly being linked to complications for pre-term birth, heart disease, stroke, diabetes, osteoporosis and other health issues. That’s why this dental plan includes Cigna Dental WellnessPlusSM features. When you or your family members receive any preventive care in one plan year, the annual dollar maximum will increase in the following plan year. When you or your family members remain enrolled in the plan and continue to receive preventive care, the annual dollar maximum will increase in the following plan year, until it reaches the level specified below. Please refer to your plan materials for additional information on this plan feature.

Benefits Cigna Dental PPO

In-Network Out-of-Network

Network Total Cigna DPPO

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

Year 1: $1,000 Year 2: $1,100#

Year 3: $1,200+

Year 4: $1,300^

Year 1: $1,000 Year 2: $1,100#

Year 3: $1,200+

Year 4: $1,300^

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

100% No Charge 100% No Charge

Class II - Basic Restorative Care Emergency Care to Relieve Pain Fillings Oral Surgery-Simple Extractions Oral Surgery-All Except Simple Extractions Surgical Extraction of Impacted Teeth Anesthetics Major Periodontics Minor Periodontics Root Canal Therapy / Endodontics Brush Biopsy

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

Class III - Major Restorative Care Relines, Rebases, and Adjustments Repairs-Bridges, Crowns, and Inlays Repairs-Dentures Crowns / Inlays / Onlays Dentures Bridges Stainless Steel/Resin Crowns

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

Class IV - Orthodontia Coverage for Eligible Adults and Dependents Lifetime Maximum

50% $1,500

50% 50%

$1,500 50%

Monthly PPO Premiums

Tier Rate

EE Only $20.46

EE + Spouse $40.93

EE + Child(ren) $47.13

Family Coverage $61.71

19

Dental PPO - Low Option

Receiving regular dental care can not only catch minor problems before they become major and expensive to treat - it may even help improve your overall health. Gum disease is increasingly being linked to complications for pre-term birth, heart disease, stroke, diabetes, osteoporosis and other health issues. That’s why this dental plan includes Cigna Dental WellnessPlusSM features. When you or your family members receive any preventive care in one plan year, the annual dollar maximum will increase in the following plan year. When you or your family members remain enrolled in the plan and continue to receive preventive care, the annual dollar maximum will increase in the following plan year, until it reaches the level specified below. Please refer to your plan materials for additional information on this plan feature.

Monthly PPO Premiums

Tier Rate

EE Only $17.04

EE + Spouse $34.10


Family Coverage $51.40

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

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

Year 1: $750 Year 2: $850#

Year 3: $950+

Year 4: $1,050^

Year 1: $750 Year 2: $850#

Year 3: $950+

Year 4: $1,050^

Annual Deductible Individual Family



Reimbursement Levels** Based on Reduced Contracted Fees 80th 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

100% No Charge 100% No Charge

Class II - Basic Restorative Care Emergency Care to Relieve Pain Fillings Oral Surgery-Simple Extractions Oral Surgery-All Except Simple Extractions Surgical Extraction of Impacted Teeth Anesthetics Major Periodontics Minor Periodontics Root Canal Therapy / Endodontics Brush Biopsy

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

Class III - Major Restorative Care Relines, Rebases, and Adjustments Repairs-Bridges, Crowns, and Inlays Repairs-Dentures Crowns / Inlays / Onlays Dentures Bridges Stainless Steel/Resin Crowns

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

Class IV - Orthodontia Not covered 100%

of your dentist’s usual fees

Not covered 100%

of your dentist’s usual fees

NOTE: Employees who waive the TRS Medical receive employee only low dental at no cost, but must enroll when completing open enrollment walkthrough.

20

Dental PPO - High and Low Options

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. # Increase contingent upon receiving Preventive Services in Plan Year 1 + Increase contingent upon receiving Preventive Services in Plan Years 1 and 2

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 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.

21

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

About this Benefit

Vision

75%

DID YOU KNOW?

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

correction.

UNITED HEALTHCARE VISION YOUR BENEFITS PACKAGE



Vision

Important to Remember

Benefit frequency based on last date of service.

Your $150.00 contact lens allowance is applied to the fitting/evaluation fees as well as the purchase of contact lenses. For example, if the fitting/evaluation fee is $30, you will have $120.00 toward the purchase of contact lenses. The allowance may be separated at some retail chain locations between the examining physician and the optical store.

You can log on to our website to print off your personalized ID card. An ID card is not required for service, but is available as a convenience to you should you wish to have an ID card to take to your appointment.

Out-of-Network Reimbursement, when applicable: Receipts for services and materials purchased on different dates must be submitted together at the same time to receive reimbursement. Receipts must be submitted within 12 months of date of service to the following address: UnitedHealthcare Vision Attn. Claims Department P.O. Box 30978 Salt Lake City, UT 84130 FAX: 248.733.6060.

At a participating network provider you will receive a 20% discount on an additional pair of eyeglasses or contact lenses. This program is available after your vision benefits have been exhausted. Please note that this discount shall not be considered insurance, and that UnitedHealthcare Vision shall neither pay nor reimburse the provider or member for any funds owed or spent. Not all providers may offer this discount. Please contact your provider to see if they participate. Discounts on contact lenses may vary by provider. Additional materials do not have to be purchased at the time of initial material purchase. Additional materials can be purchased at a discount any time after the insured benefit has been used.

NOTE: Employees who waive the TRS Medical receive employee only low dental at no cost, but must enroll when completing open enrollment walkthrough.

Monthly Premiums EE Only $6.29

EE + Spouse $12.56


EE + Family $18.72

Co-Pays for In-Network Services Exam $10

Materials $20

Benefit Frequency Comprehensive Exam Once every 12 months

Spectacle Lenses Once every 12 months

Frames Once every 12 months

Contact Lenses in Lieu of Eye Glasses

Once every 12 months

Frame Benefit Private Practice Provider $130.00 retail frame allowance

Retail Chain Provider $130.00 retail frame allowance

Lens Options Standard scratch-resistant coating, Glass coating -- covered in full. Other optional lens upgrades may be offered at a discount. (Discount varies by provider.)

Contact Lens Benefit Covered-in-full elective contact lenses1

The fitting/evaluation fees, contact lenses, and up to two follow-up visits are covered in full (after copay). If you choose disposable contacts, up to 6 boxes are included when obtained from a network provider.

All other elective contact lenses A $150.00 allowance is applied toward the fitting/evaluation fees and purchase of contact lenses outside the covered selection (materials copay does not apply). Toric, gas permeable and bifocal contact lenses are examples of contact lenses that are outside of our covered contacts.

Necessary contact lenses2

Covered in full after applicable copay.

Laser Vision Benefit

UnitedHealthcare Vision has partnered with the Laser Vision Network of America (LVNA) to provide our members with access to discounted laser vision correction providers. Members receive 15% off usual and customary pricing, 5% off promotional pricing at over 500 network provider locations and even greater discounts through set pricing at LasikPlus locations. For more information, call 1-888-563-4497 or visit us at www.uhclasik.com.

Out-of-Network Reimbursements Up To: (copays do not apply)

Exams $40.00

Frames $45.00

Single Vision Lenses $40.00

Bifocal Lenses $60.00

Trifocal Lenses $80.00

Lenticular Lenses $80.00

Elective Contacts in Lieu of Eye Glasses3

$150.00

Necessary Contacts in Lieu of Eye Glasses2

$210.00

1Coverage for Covered Contact Lens Selection does not apply at Costco, Walmart or Sam’s Club locations. The allowance for non-selection contact lenses will be applied toward the fitting/evaluation fee and purchase of all contacts.

2Necessary contact lenses are determined at the provider’s discretion for one or more of the following conditions: Following post cataract surgery without intraocular lens implant; to correct extreme vision problems that cannot be corrected with spectacle lenses; with certain conditions such as keratoconus, anisometropia, irregular corneal/astigmatism, aphakia, facial deformity or corneal deformity. If your provider considers your contacts necessary, you should ask your provider to contact UnitedHealthcare Vision confirming reimbursement that UnitedHealthcare Vision will make before you purchase such contacts.

3The out-of-network reimbursement applies to materials only. The fitting/evaluation is not included.

23

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

About this Benefit

Long Term Disability

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

they retire.

DID YOU KNOW?

34.6 months is the duration of the

average disability claim.

UNUM YOUR BENEFITS PACKAGE




Please read carefully the following description of your Unum Educator Select Income Protection Plan insurance.

Eligibility You are eligible for disability coverage if you are an active employee in the United States working a minimum of 20 hours per week. The date you are eligible for coverage is the later of: the plan effective date; or the day after you complete the waiting period.

Guarantee Issue Current Employees: Coverage is available to you without answering any medical questions or providing evidence of insurability. You may enroll on or before the enrollment deadline. After the initial enrollment period, you can apply only during an annual enrollment period. New Hires: Coverage is available to you without answering any medical questions or providing evidence of insurability. You may apply for coverage within 60 days after your eligibility date. If you do not apply within 60 days after your eligibility date, you can apply only during an annual enrollment period. Benefits are subject to the pre-existing condition exclusion referenced later in this document. Please see your Plan Administrator for your eligibility date.

Benefit Amount You may purchase a monthly benefit in $100 units, starting at a minimum of $200, up to 66 2/3% of your monthly earnings rounded to the nearest $100, but not to exceed a monthly maximum benefit of $8,000. Please see your Plan Administrator for the definition of monthly earnings. The total benefit payable to you on a monthly basis (including all benefits provided under this plan) will not exceed 100% of your monthly earnings unless the excess amount is payable as a Cost of Living Adjustment. However, if you are participating in Unum’s Rehabilitation and Return to Work Assistance program, the total benefit payable to you on a monthly basis (including all benefits provided under this plan) will not exceed 110% of your monthly earnings (unless the excess amount is payable as a Cost of Living Adjustment).

Elimination Period The Elimination Period is the length of time of continuous disability, due to sickness or injury, which must be satisfied before you are eligible to receive benefits. You may choose an Elimination Period (injury/sickness) of 0/7, 14/14, 30/30, 60/60, 90/90 or 180/180 days. If, because of your disability, you are hospital confined as an inpatient, benefits begin on the first day of inpatient confinement. Inpatient means that you are confined to a hospital room due to your sickness or injury for 23 or more consecutive hours. (Applies to Elimination Periods of 30 days or less.)

Benefit Duration Your duration of benefits is based on your age when the disability occurs. Plan: SS ADEA: Your duration of benefits is based on the following table: Age at Disability Maximum Duration of Benefits Less than age 62 To Social Security Normal Retirement Age Age 62 60 months Age 63 48 months Age 64 42 months Age 65 36 months Age 66 30 months Age 67 24 months Age 68 18 months Age 69 or older 12 months Year of Birth Social Security Normal Retirement Age 1937 or before 65 years 1938 65 years 2 months 1939 65 years 4 months 1940 65 years 6 months 1941 65 years 8 months 1942 65 years 10 months 1943-1954 66 years 1955 66 years 2 months 1956 66 years 4 months 1957 66 years 6 months 1958 66 years 8 months 1959 66 years 10 months 1960 and after 67 years

Delayed Effective Date of Coverage If you are absent from work due to injury, sickness, temporary layoff or leave of absence, your coverage will not take effect until you return to active employment. Please contact your Plan Administrator after you return to active employment for when your coverage will begin.

Questions If you should have any questions about your coverage or how to enroll, please contact your Plan Administrator. This plan highlight is a summary provided to help you understand your insurance coverage from Unum. Some provisions may vary or not be available in all states. Please refer to your certificate booklet for your complete plan description. If the terms of this plan highlight summary or your certificate differ from your policy, the policy will govern. For complete details of coverage, please refer to policy form number C.FP-1, et al. Underwritten by: Unum Life Insurance Company of America 2211 Congress Street, Portland, Maine 04122, www.unum.com ©2007 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum Group and its insuring subsidiaries.

25


VICTORIA ISD Costs below are based on a Monthly payroll deduction (Employer billing mode is based on 12 Payments per year)

Product: Educator Select Income Protection Plan

Plan A

SS ADEA Duration of Benefits

Elimination Period (Days)

Injury (Days) 0* 14* 30* 60 90 180

Sickness (Days) 7* 14* 30* 60 90 180

Annual Earnings

Monthly Earnings

Maximum Monthly Benefit

3600 300 200 5.44 4.34 3.58 2.46 2.12 1.64

5400 450 300 8.16 6.51 5.37 3.69 3.18 2.46

7200 600 400 10.88 8.68 7.16 4.92 4.24 3.28

9000 750 500 13.60 10.85 8.95 6.15 5.30 4.10

10800 900 600 16.32 13.02 10.74 7.38 6.36 4.92

12600 1050 700 19.04 15.19 12.53 8.61 7.42 5.74

14400 1200 800 21.76 17.36 14.32 9.84 8.48 6.56

16200 1350 900 24.48 19.53 16.11 11.07 9.54 7.38

18000 1500 1000 27.20 21.70 17.90 12.30 10.60 8.20

19800 1650 1100 29.92 23.87 19.69 13.53 11.66 9.02

21600 1800 1200 32.64 26.04 21.48 14.76 12.72 9.84

23400 1950 1300 35.36 28.21 23.27 15.99 13.78 10.66

25200 2100 1400 38.08 30.38 25.06 17.22 14.84 11.48

27000 2250 1500 40.80 32.55 26.85 18.45 15.90 12.30

28800 2400 1600 43.52 34.72 28.64 19.68 16.96 13.12

30600 2550 1700 46.24 36.89 30.43 20.91 18.02 13.94

32400 2700 1800 48.96 39.06 32.22 22.14 19.08 14.76

34200 2850 1900 51.68 41.23 34.01 23.37 20.14 15.58

36000 3000 2000 54.40 43.40 35.80 24.60 21.20 16.40

37800 3150 2100 57.12 45.57 37.59 25.83 22.26 17.22

39600 3300 2200 59.84 47.74 39.38 27.06 23.32 18.04

41400 3450 2300 62.56 49.91 41.17 28.29 24.38 18.86

43200 3600 2400 65.28 52.08 42.96 29.52 25.44 19.68

45000 3750 2500 68.00 54.25 44.75 30.75 26.50 20.50

46800 3900 2600 70.72 56.42 46.54 31.98 27.56 21.32

48600 4050 2700 73.44 58.59 48.33 33.21 28.62 22.14

50400 4200 2800 76.16 60.76 50.12 34.44 29.68 22.96

52200 4350 2900 78.88 62.93 51.91 35.67 30.74 23.78

54000 4500 3000 81.60 65.10 53.70 36.90 31.80 24.60

55800 4650 3100 84.32 67.27 55.49 38.13 32.86 25.42

57600 4800 3200 87.04 69.44 57.28 39.36 33.92 26.24

59400 4950 3300 89.76 71.61 59.07 40.59 34.98 27.06

61200 5100 3400 92.48 73.78 60.86 41.82 36.04 27.88

63000 5250 3500 95.20 75.95 62.65 43.05 37.10 28.70

64800 5400 3600 97.92 78.12 64.44 44.28 38.16 29.52

66600 5550 3700 100.64 80.29 66.23 45.51 39.22 30.34

68400 5700 3800 103.36 82.46 68.02 46.74 40.28 31.16

70200 5850 3900 106.08 84.63 69.81 47.97 41.34 31.98

72000 6000 4000 108.80 86.80 71.60 49.20 42.40 32.80

73800 6150 4100 111.52 88.97 73.39 50.43 43.46 33.62

75600 6300 4200 114.24 91.14 75.18 51.66 44.52 34.44

77400 6450 4300 116.96 93.31 76.97 52.89 45.58 35.26

79200 6600 4400 119.68 95.48 78.76 54.12 46.64 36.08

81000 6750 4500 122.40 97.65 80.55 55.35 47.70 36.90

82800 6900 4600 125.12 99.82 82.34 56.58 48.76 37.72

84600 7050 4700 127.84 101.99 84.13 57.81 49.82 38.54

86400 7200 4800 130.56 104.16 85.92 59.04 50.88 39.36

88200 7350 4900 133.28 106.33 87.71 60.27 51.94 40.18

90000 7500 5000 136.00 108.50 89.50 61.50 53.00 41.00

91800 7650 5100 138.72 110.67 91.29 62.73 54.06 41.82

93600 7800 5200 141.44 112.84 93.08 63.96 55.12 42.64

26


VICTORIA ISD

AnnualEarnings

MonthlyEarnings

MonthlyBenefit

95400 7950 5300 144.16 115.01 94.87 65.19 56.18 43.46

97200 8100 5400 146.88 117.18 96.66 66.42 57.24 44.28

99000 8250 5500 149.60 119.35 98.45 67.65 58.30 45.10

100800 8400 5600 152.32 121.52 100.24 68.88 59.36 45.92

102600 8550 5700 155.04 123.69 102.03 70.11 60.42 46.74

104400 8700 5800 157.76 125.86 103.82 71.34 61.48 47.56

106200 8850 5900 160.48 128.03 105.61 72.57 62.54 48.38

108000 9000 6000 163.20 130.20 107.40 73.80 63.60 49.20

109800 9150 6100 165.92 132.37 109.19 75.03 64.66 50.02

111600 9300 6200 168.64 134.54 110.98 76.26 65.72 50.84

113400 9450 6300 171.36 136.71 112.77 77.49 66.78 51.66

115200 9600 6400 174.08 138.88 114.56 78.72 67.84 52.48

117000 9750 6500 176.80 141.05 116.35 79.95 68.90 53.30

118800 9900 6600 179.52 143.22 118.14 81.18 69.96 54.12

120600 10050 6700 182.24 145.39 119.93 82.41 71.02 54.94

122400 10200 6800 184.96 147.56 121.72 83.64 72.08 55.76

124200 10350 6900 187.68 149.73 123.51 84.87 73.14 56.58

126000 10500 7000 190.40 151.90 125.30 86.10 74.20 57.40

127800 10650 7100 193.12 154.07 127.09 87.33 75.26 58.22

129600 10800 7200 195.84 156.24 128.88 88.56 76.32 59.04

131400 10950 7300 198.56 158.41 130.67 89.79 77.38 59.86

133200 11100 7400 201.28 160.58 132.46 91.02 78.44 60.68

135000 11250 7500 204.00 162.75 134.25 92.25 79.50 61.50

136800 11400 7600 206.72 164.92 136.04 93.48 80.56 62.32

138600 11550 7700 209.44 167.09 137.83 94.71 81.62 63.14

140400 11700 7800 212.16 169.26 139.62 95.94 82.68 63.96

142200 11850 7900 214.88 171.43 141.41 97.17 83.74 64.78

144000 12000 8000 217.60 173.60 143.20 98.40 84.80 65.60

27

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

About this Benefit

Cancer

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.

AMERICAN PUBLIC LIFE YOUR BENEFITS PACKAGE



GC12 Limited Benefit Group Cancer Indemnity InsuranceVictoria ISD

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

Summary of Benefits

Benefits Option 1 Base Plan Option 2 Base PlanCancer 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 treatment

Surgical 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 surgery

25% of amount paid for covered surgery

Bone Marrow Transplant - Maximum per lifetime $6,000 $6,000

Stem Cell Transplant - Maximum per lifetime $600 $600

Prosthesis 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 1

Hospital 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 $200

Attending 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 Victoria ISD

Miscellaneous Benefits Level 1 Level 1

Cancer Treatment Center Evaluation or Consultation - 1 per lifetime N/A N/A

Evaluation or Consultation Travel and Lodging - 1 per lifetime N/A N/A

Second 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

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Miscellaneous Benefits Continued Level 1 Level 1

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 transpor-tation 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 day

Experimental 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 Confine-ment

$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


GC12 Limited Benefit Group Cancer Indemnity Insurance

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

Lump Sum Benefit Maximum 1 per Covered Person per lifetime

$2,500 $5,000

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

$3,750 $7,500

Heart Attack/Stroke First Occurrence Benefit Rider Level 1 Level 1

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

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

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*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**

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**

GC12 Limited Benefit Group Cancer Indemnity Insurance

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.

See your Policy/Certificate for more information regarding the benefits listed above.31


GC12 Limited Benefit Group Cancer Indemnity InsuranceHome 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.

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 Donor s Dread DiseasesExperimental TreatmentsHair PiecesInpatient Special Nursing Services sMedical Equipment sOutpatient Special Nursing Services

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GC12 Limited Benefit Group Cancer Indemnity InsuranceImportant 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 Certificate s the end of the Certificate Month in which the Policyholder requests to terminate this coveragesthe date you no longer qualify as an Insured sthe 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 Dependent sthe 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 months s 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) | Victoria ISD

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

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

About this Benefit

Life and AD&D

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

drowning, and choking.

DID YOU KNOW?

#1

Motor vehicle crashes are the




Term Life Insurance and AD&D

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 26. *Note: Disabled children over the maximum child age may be eligible for benefits, please see your plan administer for more details.

Coverage Amounts

Your Term Life coverage options are: Employee: Up to 5 times salary 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. Benefits will be paid to the employee. Child: Up to 100% of employee coverage amount in increments of $2,000. Not to exceed $10,000. The maximum death benefit for a child between the ages of live birth and 6 months is $1,000. Benefits will be paid to the employee. In order to purchase Life coverage for your spouse and/or child, you must purchase Life coverage for yourself. Your AD&D coverage options are: Employee: Up to 5 times salary in increments of $10,000. Not to exceed $500,000. You may purchase AD&D coverage for yourself regardless of whether you purchase Life coverage. Spouse: Up to 100% of employee amount in increments of $5,000. Not to exceed $500,000. Benefits will be paid to the employee. Child: Up to 100% of employee amount in increments of $2,000. Not to exceed $10,000. The maximum death benefit for a child between the ages of live birth and 6 months is $1,000. Benefits will be paid to the employee. In order to purchase AD&D coverage for your spouse and/or child, you must purchase AD&D coverage for yourself. AD&D Benefit Schedule: The full benefit amount is paid for loss of: Life Both hands or both feet or sight of both eyes One hand and one foot One hand and the sight of one eye One foot and the sight of one eye Speech and hearing

Other losses may be covered as well. Please see your Plan Administrator. Coverage amount(s) will reduce according to the following schedule: Age: Insurance Amount Reduces to: 70 65% of original amount 75 50% of original amount Coverage may not be increased after a reduction.

Guarantee Issue Current Employees: If you and your eligible dependents enroll on or before 09/01/2016, you may apply for any amount of Life insurance coverage up to $200,000 for yourself and any amount of coverage up to $50,000 for your spouse. Any Life insurance coverage over the Guarantee Issue amount(s) will be subject to evidence of insurability. If you and your eligible dependents do not enroll on or before 09/01/2016, you can apply for coverage only during an annual enrollment period and will be required to furnish evidence of insurability for the entire amount of Life insurance coverage. AD&D coverage does not require evidence of insurability. If you and your eligible dependents enroll on or before 09/01/2016 and later wish to increase your Life insurance coverage, you may increase your coverage with evidence of insurability at anytime during the year. However, you may wait until the next annual enrollment and only coverage over one benefit unit increase will be subject to evidence of insurability. Employees hired on or after 09/01/2016: If you and your eligible dependents enroll within 31 days of your eligibility date, you may apply for any amount of Life insurance coverage up to $200,000 for yourself and any amount of coverage up to $50,000 for your spouse. Any Life insurance coverage over the Guarantee Issue amount(s) will be subject to evidence of insurability. If you and your eligible dependents do not enroll within 31 days of your eligibility date, you can apply for coverage only during an annual enrollment period and will be required to furnish evidence of insurability for the entire amount of coverage. AD&D coverage does not require evidence of insurability. If you and your eligible dependents enroll within 31 days of your eligibility date, and later, wish to increase your coverage, you may increase your Life insurance coverage, with evidence of insurability, at anytime during the year. However, you may wait until the next annual enrollment and only coverage over one benefit unit increase will be subject to evidence of insurability. Please see your Plan Administrator for your eligibility date.

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Term Life Coverage Rates Rates shown are your Monthly deduction:

NOTE: Your rate will increase as you age and move to the next age band.

AD&D Coverage Rates

Insurance Age Your rate is based on your insurance age, which is your age immediately prior to and including the anniversary/effective date.

Additional Benefits Life Planning Financial & Legal Resources

This personalized financial counseling service provides expert, objective financial counseling to survivors and terminally ill employees at no cost to you. This service is also extended to you upon the death or terminal illness of your covered spouse. The financial consultants are master level consultants. They will help develop strategies needed to protect resources, preserve current lifestyles, and build future security. At no time will the consultants offer or sell any product or service.

Portability/Conversion If you retire, reduce your hours or leave your employer, you can take this coverage with you according to the terms outlined in the contract. However, if you have a medical condition which has a material effect on life expectancy, you will be ineligible to port your coverage. You may also have the option to convert your Term life coverage to an individual life insurance policy.

Accelerated Benefit If you become terminally ill and are not expected to live beyond a certain time period as stated in your certificate booklet, you may request up to 50% of your life insurance amount up to $750,000, without fees or present value adjustments. A doctor must certify your condition in order to qualify for this benefit. Upon your death, the remaining benefit will be paid to your designated beneficiary(ies). This feature also applies to your covered dependents.

Waiver of Premium If you become disabled (as defined by your plan) and are no longer able to work, your premium payments will be waived during the period of disability.

Retained Asset Account Benefits of $10,000 or more are paid through the Unum Retained Asset Account. This interest bearing account will be established in the beneficiary's name. He or she can then write a check for the full amount or for $250 or more, as needed.

Additional AD&D Benefits

Education Benefit: If you or your insured spouse die within 365 days of an accident, an additional benefit is paid to your dependent child(ren). Your child(ren) must be a full-time student beyond grade 12. (Not available in Illinois or New York.) Seat Belt/Air Bag Benefit: If you or your insured dependent(s) die in a car accident and are wearing a properly fastened seat belt and/or are in a seat with an air bag, an amount will be paid in addition to the AD&D benefit.

Limitations/Exclusions/Termination of Coverage Suicide Exclusion Life benefits will not be paid for deaths caused by suicide in the first twenty-four months after your effective date of coverage. No increased or additional benefits will be payable for deaths caused by suicide occurring within 24 months after the day such increased or additional insurance is effective.

Age Band

Employee per $1,000

Spouse per $1,000

Child per $1,000

$0.20

24 and under

$0.031 $0.031

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 $0.041 $0.041

30-34 $0.060 $0.060

35-39 $0.094 $0.094

40-44 $0.141 $0.141

45-49 $0.216 $0.216

50-54 $0.316 $0.316

55-59 $0.440 $0.440

60-64 $0.549 $0.549

65-69 $0.791 $0.791

70-74 $1.495 $1.495

75+ $4.622 $4.622

AD&D Cost Per: Monthly Rate

Employee $1,000 $0.02

Spouse $1,000 $0.02

Child $1,000 $0.02

36

AD&D Benefit Exclusions AD&D benefits will not be paid for losses caused by, contributed to by, or resulting from:

Disease of the body or diagnostic, medical or surgical treatment or mental disorder as set forth in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders;

Suicide, self-destruction while sane, intentionally self-inflicted injury while sane, or self-inflicted injury while insane;

War, declared or undeclared, or any act of war;

Active participation in a riot;

Attempt to commit or commission of a crime;

The voluntary use of any prescription or non-prescription drug, poison, fume, or other chemical substance unless used according to the prescription or direction of your or your dependent’s doctor. This exclusion does not apply to you or your dependent if the chemical substance is ethanol;

Intoxication. (“Intoxicated” means that the individual’s blood alcohol level equals or exceeds the legal limit for operating a motor vehicle in the state or jurisdiction where the accident occurred.)

Termination of Coverage Your coverage and your dependents’ coverage under the Summary of Benefits ends on the earliest of: The date the policy or plan is cancelled;

The date you no longer are in an eligible group;

The date your eligible group is no longer covered;

The last day of the period for which you made any required contributions;

The last day you are in active employment unless continued due to a covered layoff or leave of absence or due to an injury or sickness, as described in the certificate of coverage;

For dependent’s coverage, the date of your death. In addition, coverage for any one dependent will end on the earliest of:

The date your coverage under a plan ends;

The date your dependent ceases to be an eligible dependent;

For a spouse, the date of divorce or annulment. Unum will provide coverage for a payable claim which occurs while you and your dependents are covered under the policy or plan.

Next Steps How to Apply Current employees: To apply for coverage, complete your enrollment by the enrollment deadline

For employees hired on or after 09/01/2016: To apply for coverage, complete your enrollment form within 31 days of your eligibility date. All employees: If you apply for coverage after your effective date, or if you choose coverage over the guarantee issue amount, you will need to complete a medical questionnaire which you can get from your Plan Administrator. You may also be required to take certain medical tests at Unum’s expense.

Effective Date of Coverage

Your coverage will become effective on 09/01/2016. For employees who become eligible after this date, please see your Plan Administrator for your effective date.

Delayed Effective Date of Coverage Employee: Insurance coverage will be delayed if you are not in active employment because of an injury, sickness, temporary layoff, or leave of absence on the date that insurance would otherwise become effective. Dependent: Insurance coverage will be delayed if that dependent is totally disabled on the date that insurance would otherwise be effective. Exception: infants are insured from live birth. “Totally disabled” means that, as a result of an injury, a sickness or a disorder, your dependent is confined in a hospital or similar institution; is unable to perform two or more activities of daily living (ADLs) because of a physical or mental incapacity resulting from an injury or a sickness; is cognitively impaired; or has a life threatening condition.

Changes to Coverage Each year you and your spouse will be given the opportunity to change your Life coverage and AD&D coverage. You and your spouse may purchase additional Life coverage up to one benefit unit increase without evidence of insurability if you are already enrolled in the plan. Elected Life coverage over the one benefit unit increase will be medically underwritten and will require evidence of insurability and approval by Unum’s Medical Underwriters. The suicide exclusion will apply to any increase in coverage. AD&D coverage does not require evidence of insurability for increase amounts.

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


37

TEXAS LIFE

Individual Life YOUR BENEFITS PACKAGE

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

About this Benefit

x 10

Experts recommend at least

your gross annual income in coverage when purchasing life insurance.

DID YOU KNOW?



Life Insurance Highlights

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

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

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

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

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

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

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

Individual Life

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

39

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

About this Benefit

Critical Illness

Is the aggregate cost of a hospital stay for a heart

attack.

DID YOU KNOW?

$16,500




Critical Illness

Without Cancer Monthly Rates per $1,000

Issue Age Non-Tobacco Tobacco

Under 25 $0.29 $0.29

25-29 $0.31 $0.31

30-34 $0.46 $0.46

35-39 $0.63 $0.63

40-44 $0.93 $0.93

45-49 $1.25 $1.25

50-54 $1.64 $1.64

55-59 $2.14 $2.14

60-64 $2.78 $2.78

65-69 $3.20 $3.20

70+ $5.99 $5.99

Wellness Benefit - Additional Monthly Cost per $50

Employee and Children $1.60

Spouse $1.60

How can critical illness insurance help? Critical illness insurance can pay a lump sum benefit at the diagnosis of a critical illness. You can choose the level of coverage from $10,000 to $30,000 - and you can use the money any way you see fit.

Covered Conditions Heart attack

Major organ failure

Occupational HIV

Benign brain tumor

Blindness

End-stage renal (kidney) failure

Coronary artery bypass surgery; pays 25% of lump sum benefit

Covered Conditions With Time Limitations Stroke—Evidence of persistent neurological deficits

confirmed by a neurologist at least 30 days after the event

Coma—Coma resulting from severe traumatic brain injury lasting for a period of 14 or more consecutive days

Permanent paralysis—Complete and permanent loss of the use of two or more limbs for continuous 90 days as a result of a covered accident

Available Family Coverage

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.

Benefit Overview

Critical illness insurance is designed to help employees offset the financial effects of a catastrophic illness with a lump sum benefit if an insured is diagnosed with a covered critical illness. The Critical Illness benefit is based on the amount of coverage in effect on the date of diagnosis of a critical illness or the date treatment is received according to the terms and provisions of the policy. Coverage Amounts Employee - $10,000 to $30,000 in increments of $5,000 Spouse - $5,000 to $15,000 in increments of $5,000 Child - 25% of Employee Coverage Amount Guarantee Issue Employee - $30,000 Spouse - $15,000 Pre-Existing Condition 12/12 exclusion Benefit Waiting Period 30 days Portability Included Wellness Benefit $50 per insured per calendar year Recurrence Benefit Included - 50% of the coverage amount for an additional payout for a subsequent occurrence of benign brain tumor, coma, heart attack or stroke. Premium Paid by the Employee Rate Information Wellness benefit premium is in addition to the base premium.

Who can have it? Benefit

Employees who are actively at work

$10,000 to $30,000 in $5,000

increments

Dependent children

newborn until their 26th

birthday, regardless of

marital or student status

All eligible children are

automatically covered

at 25% of the employee

benefit amount (no

additional cost)

Eligible children are covered

for the same conditions as

employee and the following

specific childhood conditions:

cerebral palsy, cleft lip or palate, cystic fibrosis, Down syndrome and spina bifida.

Diagnosis must occur after the child’s coverage effective date.

Spouse ages 17 through

64 with purchase of

employee coverage

From $5,000 to $15,000 in $5,000 increments

41

An Employee Assistance Plan (EAP) is an employee benefit program offered to help employees manage personal and professional problems that might adversely impact their work performance, health, and well-being. Employee Assistance Plans generally include short-term counseling and referral services for employees and their household members. Your Employee Assistance Program benefit is provided to you by your employer.

About this Benefit

EAP (Employee Assistance Program)

DID YOU KNOW?

LIFEWORKS

38% of employees have missed life events because of bad work-life balance.


Victoria ISD Benefits Website: www.mybenefitshub.com/victoriaisd

YOUR BENEFITS PACKAGE

42

Employee Assistance Program (EAP)

LifeWorks—fast, confidential help with family, work, money, health and life, whenever you need it. Life brings new ups and downs every day. From finding child or elder care or managing your personal finances, to getting help with a relationship or taking care of your health, LifeWorks offers fast, free, confidential help, 24/7. Call anytime to speak with a caring, professional consultant or visit LifeWorks.com to find help and resources with almost any issue, including:

Life

Stress and overload

Addiction and

recovery

Relationships

Depression

Grief and loss

Divorce and

separation

Finding time for you

Moving

Home improvement

Legal issues

Family

Parenting

Finding child care

Adoption

Discipline and safety

Teenagers

Single parenting

Blended families

Education

Planning for college

Financial aid

Caring for older

relatives

Caregiver resources

Money

Budgeting

Debt management

Credit and collections

Saving and investing

Basic tax planning

Buying a car

Home buying and

renting

Saving for college

Bankruptcy

Estate planning

Work

Time management

Career development

Getting along at work

Communication

Job stress and burnout

Relocation

Networking

Retirement planning

Managing people

Handling change at work

Health

Exercise

Healthy eating

Managing stress

Sleep

Quitting tobacco

Heart health

Navigating the health

care system

Living with a disability

Aging well

Call LifeWorks at 888-456-1324 anytime.

En español: 888-732-9020, TTY: 800-999-3004.

You can also visit www.lifeworks.com

(username: visd; password: lifeworks)

43

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)

HIGGINBOTHAM YOUR BENEFITS PACKAGE

FOR HSA VS. FSA COMPARISON

FLIP TO… PG. 11



What is a Flexible Spending Account? A Flexible Spending Account is a benefit provided by your employer that lets you set aside a certain amount of your paycheck into an account before paying income taxes. Then, during the year, you can use the funds in the account to pay for qualified expenses with untaxed dollars.

Why should I participate in the plan? Your biggest benefit is savings on payroll withholding taxes. You will save $25 to $40 on every $100 you budget to pay for qualified expenses.

What expenses qualify for payment? Most qualified expenses are for goods or services that you’ll buy anyway. They include health care costs such as co-pays, doctors’ fees, over-the-counter items and prescriptions, dental and eye care expenses and daycare expenses for dependents so you can work.

How do I know how much is available for me to spend and how do I file a claim? Your balance and claim forms are available 24/7 online at www.myRSC.com and all other details are always available online or by calling the Flex Hotline at 866-419-3519. Filing claims is easy. Just complete a claim form and attach a copy of the bill. Then, send it to us. Within a short time (usually less than 72 hours), you’ll receive your TAX-FREE reimbursement.

Must money be deposited in my account before I pay expenses or file a claim? NO. The entire annual amount you elect for the Health Care Spending Account (Health FSA) is available on the first day. However, only amounts contributed to date are available for the Dependent Care Spending Account (Dependent Care FSA).

I already have health insurance. Why should I participate in the Health FSA? The Health FSA is used to pay for expenses not covered by insurance. These include co-pays, over-the-counter medications, glasses, contacts, orthodontics and prescription drugs, just to name a few.

I don’t use my employer’s health insurance. Can I still save? YES. You can still set aside money (before taxes are taken out) to budget and pay for qualified expenses. Remember, a qualified expense paid from this plan cannot be eligible for reimbursement from another plan.

If I set aside part of my pay, won’t I make less money? NO. For every dollar you set aside to pay qualified expenses, you save FICA and federal income tax withholding. Your net take-home pay will increase by the tax you save. Plus, when you pay a qualified expense or receive a cash reimbursement, it’s TAX FREE.

Can I change my contribution during the year? YES, but only in certain situations. For the Health FSA and Dependent Care FSA, you can change your election if you have a change in status or a change in your employment or the employment of your spouse or a dependent.

What if I don’t use all the money in my account? Generally, contributions that are not used during the plan year are forfeited back to your employer, but changes to IRS may allow extra time to spend your money or to carryover up to $500. Check with your employer to learn your options.

What happens to my accounts if I terminate employment? You may request reimbursement for qualified expenses incurred prior to your termination date.


AS OF JANUARY 1, 2011: All over-the-counter items require a one-time physician’s prescription per plan year.

45

How Flexible Spending Accounts Work When you pay for these expenses with pre-tax dollars, you pay no social security or federal income tax on your contributions. Your taxable income and your taxes are reduced. Here’s how it works: Let’s say you earn $25,000 per year. And you are paid semi-monthly, so each paycheck is for gross compensation of $1,041.67. You have insurance premiums and other expenses eligible for payment through the Health FSA of $62.50 per pay period. Here is a comparison of what your paycheck looks like both with and without the Flexible Spending Account.

When you incur a medical, dental or vision expense, you will be reimbursed the “full” amount of the expense at that time, up to your yearly contribution election.

Your account balance and claim forms are available 24/7 online at www.myRSC.com All other general details are always available online or by calling the Flex Hotline at 866-419–3519


Without FSA With FSA

Gross Earnings Plan Contributions

Taxable Earnings Less Taxes FICA Federal

$1,041.67 -0-

$1,041.67

$79.69 $105.42

$1,041.67 $62.50

$979.17

$74.91 $93.41

Eligible Expenses

$856.56 $62.50

$810.85

$794.06 $810.85

****GAIN**** $33.58 Monthly $402.96 Annually

EXAMPLE: You are going to contribute $500 for the plan year ($41.67 per month). On January 15, you visit your eye doctor and receive your exam and contact lenses for a total charge of $200.

Fax that receipt to Higginbotham and receive your full $200 back within 24-72 hours, even though you do not have the $200 in your account at that time.

You are entitled to the entire $500 from day one of your plan year.

As you can see, when you pay for your expenses with pre-tax dollars,

your net income is increased!

Orthodontia Expenses If you are currently paying on an orthodontia contract for yourself, your spouse or your children, you can put that payment aside in your Health FSA and use the mySourceCard to make the payment each month to your orthodontist. All we need is a copy of your current contract and the first payment receipt made with the mySourceCard. Your monthly orthodontic payments will be substantiated automatically for the current plan year.

46


Health Care Expenses That Qualify for Reimbursement NOTE: Only health care expenses NOT reimbursed by insurance can be claimed on a Flexible Spending Account plan.

Acupuncture (excluding remedies and treatments prescribed by acupuncturist)

Alcoholism treatment Ambulance Artificial limbs/teeth Chiropractors Christian Science Practitioner’s fees Contact lenses and solutions Co-payments (doctor, dental, vision,

pharmacy) Costs of physical or mental illness

confinement Crutches Deductibles Dental fees (cosmetic procedures not

eligible) Dentures Diagnostic fees

Drug and medical supplies (syringes, needles, etc.)

Endodontist fees Eye examination fees Eyeglasses prescribed by your doctor Eye surgery (cataracts, LASIK, etc.) Hearing devices and batteries Home health care Hospital bills Insulin Laboratory fees Laser eye surgery Obstetrics and fertility Office visits Oral surgery Orthodontic fees Orthopedic devices Osteopath fees

Oxygen Periodontist fees Physician fees (cosmetic procedures

not eligible) Podiatrist fees Prescribed medicines Psychiatric care Psychologist and psychiatrist fees Radiology Routine physicals and other non-

diagnostic services or treatments Smoking cessation over-the-counter

drugs Smoking cessation programs Surgical fees Wheelchair Vitamins with doctor’s letter X-rays and MRI

Health Care Expenses That Require a Physician’s Letter Listing a Medical Condition Making the Item Necessary

Bedpans Ring Cushions Boost/Pediasure Foot spa Massagers Massages Reconstructive surgery in connection with birth defect,

disease or accident Special school for disabled child Therapeutic support gloves Weight loss program fees and over-the-counter drugs

pertaining to a specific disease Wigs for hair loss caused by disease

FSAStore for Eligible Products The thousands of products that are available at FSAStore are all FSA/HSA eligible or FSA/HSA eligible with a prescription and can be purchased with your FSA/HSA debit card or any major credit card. FSAStore offers free shipping on orders of at least $50, and its prices on brand products are very competitive. When you take into account that you are using pre-tax dollars, you generally save up to 40%.

Health Care Expenses That Do Not Qualify for Reimbursement Cosmetic surgery, procedures and/or medications Dental bleaching and electronic toothbrushes Hair restoration (procedures, drugs or medications) Health club or gym memberships for general health Marriage and family counseling Weight loss program food supplements Weight loss programs for general health or appearance Mail order prescriptions from another country Premiums you or your spouse pay for insurance coverage

(payroll-deducted premiums sponsored by your employer are eligible under the Premium Only Plan)

For additional information on Over-the-Counter items that do or do not qualify for reimbursement please visit the benefit site, www.mybenefitshub.com/victoriaisd for detailed information.

Reimbursements are as simple as 1, 2, 3! Complete a claim form

Provide required documentation

Submit by email or mail

47

Health Care Spending Account Worksheet Accurate budgeting of out-of-pocket medical expenses not reimbursed or covered by insurance is necessary to gain maximum

benefit from the Health Care Spending Account. Only expenses that you know you or your family will incur during the plan year can be included in the program. You should consider your cost of deductibles and coinsurance features of any medical and dental

insurance policies as well as those costs not covered by insurance.

INCLUDE EXPENSES FOR ALL MEMBERS OF YOUR IMMEDIATE FAMILY!!

This is only a worksheet and is just for your use.

Visit our website at www.myRSC.com for more information.


PLANNED MEDICAL EXPENSES Known Annual Medical Expenses (those expenses not covered by insurance that your entire family will incur during the plan year for the following services):

Deductibles — Coinsurance

Prescriptions and Doctor Visits (CO-PAYS)

Over-the-Counter Medications (with RX)

Massage Therapy (Dr.’s RX Needed)

Lasik Eye Surgery

Medical Supplies and Equipment

Therapist, Psychologist, Chiropractor

Hearing Aids and Supplies

Laboratory and X-ray Expenses

PLANNED DENTAL CARE (Your portion of these expenses)

Deductibles

Fillings and Crowns

Extractions, Dentures and Bridgework

Oral Surgery

Orthodontic Expenses

PLANNED VISION CARE

Examination

Glasses/RX Sunglasses

Contact Lenses, Solution and Materials

TOTAL $

Total Expenses / # of pay periods = $

48

Reasons to Take Advantage of the Tax Savings Now

Taking advantage of the Health FSA and Dependent Care FSA doesn’t change what you do at tax time. You actually get a “tax refund” on every paycheck after electing the benefits because you pay no tax on the money you set aside each pay period. You decide how much money to put into the plan and where and when to spend the money in your account. This is a great way to budget. A regular amount is deducted from your paycheck, but the entire annual election is always available for you to spend on eligible expenses from day one of the plan year. Starting January 1, 2015, Health Care Reform limits the annual election for Health FSAs to $2,550. Once you have enrolled in the plan, everything you need can be found at the website www.myRSC.com. You can even enter your claim online. Then you just print the claim form and submit it along with your detailed receipts. It only takes a few moments to go to the website and familiarize yourself with the reimbursement plan. Turning in a reimbursement claim is quick and easy. Don’t worry about it making your social security benefits smaller because social security benefits are based on your lifetime earnings history. Your social security benefits may be slightly reduced by participating in the plan. However, tax advisors will tell you that the tax savings you earn today will far outweigh any reduction in social security benefits. The Flexible Spending Accounts are not just for people who need prescription drugs and have children — everyone has medical expenses, not just families. And with the new IRS Revenue ruling, anyone who buys over-the-counter (OTC) drugs may be reimbursed through the plan. The plan is not just for prescription drugs. Things like cough syrup, pain relievers, allergy medicine, etc. are included with an OTC prescription. It is OK if both you and your spouse enroll in a similar plan at work. There is no IRS limit on the amount of medical expenses that can be reimbursed per household. Each employer sets the annual limits for the Health FSA plan.

Don’t worry that you cannot afford to have any more money taken out of your paycheck… Did you know you can get money out of the plan before you put it in? By joining the plan, you can have the plan pay your health care expenses in full at the time of service, even before you make your contribution. Do you take a deduction for medical expenses on a Form 1040? If so, you can only do so after you spend in excess of 7.5%-10% of your adjusted gross income for them. The first dollar you pay for unreimbursed medical expenses is not deductible on your Form 1040. But through the Health FSA, the very first dollar you spend will earn you 25%-40% in tax savings.

Dependent Care Spending Account You and your spouse must be employed in order to

participate, or one of you can be a full-time student actively looking for work, or disabled.

Kindergarten is not reimbursable, unless it can be determined that the educational part is incidental and cannot be separated from the cost of care.

Overnight camps are not eligible — only day camps can be considered.

Household service is eligible if part of the service is for the care of a qualifying person.

Before and after school care is eligible.

Your care provider cannot be your dependent.

The debit card cannot be used for dependent child care.

The maximum flex deduction per family per year is $5,000 when filing jointly or head of household; and $2,500 when married filing separately. HOWEVER, the IRS maximum limit for income tax purposes is $6,000 and $3,000 — whatever amount you do not deduct from your Flexible Spending Account, you can deduct the difference (up to $3,000 or $6,000) on your income tax return.

Any care for your children whom you claim as tax dependents under the age of 13 is eligible. A person may qualify for only part of the year if he/she turns 13 mid-year.

Care for spouse or dependents of any age who spend at least eight hours a day in your home, who are mentally or physically incapable of self-care is eligible.


49

Answers to Common Questions

Q: I take a dependent care credit on Form 1040. Will the Dependent Care Spending Account save more? A: The more you earn, the more you’ll save. In addition, you’ll also save social security tax (FICA) with a Dependent Care Spending Account. So, don’t wait until April 15 to take the credit. Now, you can save taxes on every paycheck. Which is best for you? Visit www.myRSC.com and use the easy calculator under the Employees tab to determine your savings. Q: Are there any negatives I should know about? A: Because you will not pay social security tax on the amount of gross pay you set aside to pay for qualified expenses, your social security benefits at retirement may be slightly reduced. However, most tax advisors recommend taking advantage of current tax-savings opportunities like the Health FSA and Dependent Care FSA. Also, if disability insurance is paid on a pre-tax basis, any future benefits you receive will be taxable.

Quick Tips on Submitting Your Claims to Avoid Denial We need to know the date of service in order to pay the claim when you submit a dental or doctor bill. Please DO NOT submit “balance forward” or “previous balance” statements. On your doctor visit co-pays, we need the actual statement from the doctor if the charge is anything other than a co-pay amount. They will print a statement for you. We need date of service, service rendered, patient’s name, insurance payments, etc. If the statement is pink or yellow, please make a dark copy before faxing. The pink and yellow copies are not legible when faxed. An OTC RX Checklist is located at the back of this booklet. Please have your physician complete this form and return it to us, and any over-the-counter items you submit will be reimbursable back to you. When submitting a statement for a coinsurance, deductible or hospital expense, please make sure the Explanation of Benefits (EOB) states very clearly the date of service, patient name and procedure. The best document to submit is the EOB from your health insurance provider, as all these details will be included once insurance has been processed. For any forms, worksheets, or informational flyers referenced in this document, please visit: www.mybenefitshub.com/victoriaisd

Thank You for Your Help in the Above Submitting a complete claim request helps us pay all eligible claims in full and will also eliminate the letters coming back to you requesting more information regarding the reimbursement!

Mobile myRSC Benefits at Your Fingertips You can access your employee account information on your smartphone with the Mobile myRSC app for iPhone and Android. Locating and Loading the Mobile myRSC App Simply search for “myRSC” on the App StoreSM for Apple products or on the Google Play™ Store for Android products, and then load as you would any other app.

What You Can Do with Mobile myRSC View Accounts: Detailed account and balance information.

Card Activity: Account information.

SnapClaim: File a claim and upload receipt photos directly from your smartphone.

Manage Subscriptions: Set up e-mail notifications to keep you up-to-date on all account and health debit card activity.


How to Use Mobile myRSC

Logging In Use the same username and password you use to log in to the full myRSC website. After logging in, you will be on the home page, which will list your options. Getting Help Click the Help button at the bottom right of all pages to access contact information for your administrator, who will be able to provide assistance. Going Home Press the Home button on the bottom left corner of any page to return to the home page and start over.

50


mySourceCard™ The debit card is a quick and easy way to pay for qualified expenses from your Flexible Spending Account. You have no out-of-pocket expense — the money is taken directly out of your account. Plus, you don’t have to wait on reimbursement. Go to www.myRSC.com and request your mySourceCard debit card. Employee

24/7 access to plan documents, letters and notices, forms, account balances, contributions, investments and other plan information or cafeteria plans, health reimbursement arrangements and transit plans

Change personal information/census data online

Access to contact information or the administrator

Access to 125 tax calculators

Debit Card Procedure Use your debit card at the time of service (doctor’s office,

hospital, pharmacy, etc.).

The debit card cannot be used for child care.

Make sure you get a statement for the service rendered.

Hospital: Statement from the doctor with the procedure code and diagnosis code, date of service, name of patient and name and address of the provider.

Dental/Vision: Statement with the procedure code, date of service, name of patient and name and address of the provider.

Fax in the statement the next time you come to work: 817-882-9267 or toll-free 866-419-3516.

You can either fax the documents after you have received your services OR you can wait until you receive an e-mail from the plan requesting that you send in the statements. You will NOT get an e-mail for all of your swipes — the co-pays for your doctor visits and prescription co-pays will automatically substantiate. However, any time you swipe the card for any amount other than a copay amount, you will need to submit the itemized statement or an Explanation of Benefits.

Very Important: If you do not fax the documentation within 60 days from the date you receive the e-mail, your debit card will be suspended until proper substantiation is received.

Debit Card FAQs Q: Can I use my debit card to pay for over-the-counter drugs? A: No. You must provide a physician-signed over-the-counter prescription, and you must submit a paper claim for these items and then be reimbursed.

Q: The following items are auto substantiated: A: (1) Certain transactions involving dollar amounts that are consistent with predetermined co-pay under the plan. (2) Certain recurring previously approved expenses. (3) Certain charges that are substantiated at the time of the sale or if the vendors that participate are in the inventory information system (IIAS). Q: Purchases at pharmacies and medical providers that do not subscribe to the IIAS are treated as conditionally approved and paid at the time of service; statements must be faxed after the purchase to substantiate the purchase was for a qualified expense, i.e.: A: (1) A dentist office could charge you $200 for teeth bleaching. The $200 would be approved at the time of sale, but the member must submit the statement with the required information. Since teeth bleaching is not a covered expense, the claim would be denied, and the member would pay the plan $200. (2) A physician could charge $150 for a consult for cosmetic surgery. The $150 would be approved at the time of purchase, but cosmetic surgery is not a covered item and the claim is not eligible for reimbursement under IRS guidelines. The claim would be denied, and the member would owe the plan $150. (3) A member pays $125 for a qualified medical expense. He/she uses the debit card, sends in the form with the required information, and it is marked as eligible in the system.

Renewing Your Debit Card Your debit card will work for three years initially. Check the

expiration date on front of the card.

If your company has the “grace extension” added to the end of the plan year and you have a “balance” from the old year, that balance will “transfer” to the new debit card.

To receive a replacement card, you will be charged a $2.00 fee.

If your card is “suspended” as of the last day of your plan year, your new card will not work until the old plan year expenses are paid back.

New Plan Year Debit Card Use with an Old Plan Year Balance The main thing to keep in mind is that if your company has the “grace extension” or "rollover provision" on the prior plan year, the balance in your “prior” plan year will be loaded to your debit card — the system will automatically do a “look back” at the old plan year and apply these expenses to that plan year first.

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www.mybenefitshub.com/victoriaisd

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2016 Benefit Guide - Victoria ISD

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