2016 benefit guide boerne isd

EFFECTIVE:

09/01/2016 - 8/31/2017

BENEFIT GUIDE

www.mybenefitshub.com/boerneisd

BOERNE ISD

1

Benefit Contact Information 3 How to Enroll 4-5 Annual Benefit Enrollment 6-11 1. Benefit Updates 6 2. Section 125 Cafeteria Plan Guidelines 7 3. Annual Enrollment 8 4. Eligibility Requirements 9 5. Helpful Definitions 10 6. HSA vs FSA Comparison 11 Cigna Dental 12-15 Eyetopia Vision 16-19 The Hartford Disability 20-23 Guardian Cancer 24-27

Lincoln Financial Accident 28-31

APL MEDlink® 32-35

Sun Life Voluntary Life and AD&D 36-39

Texas Life Permanent Life 40-41 MDLIVE Telehealth 42-43 NBS Flexible Spending Account 44-47 NBS Health Savings Account 48-51

Table of Contents

HOW TO ENROLL

PG. 4

YOUR BENEFIT UPDATES: WHAT’S NEW

PG. 6

YOUR BENEFITS PACKAGE

PG. 12

FLIP TO...

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Benefit Contact Information

BENEFIT ADMINISTRATORS CANCER PERMANENT LIFE

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

Group #487531 Guardian (888) 600-1600 www.guardianlife.com

Texas Life (800) 283-9233 www.texaslife.com

DENTAL ACCIDENT TELEHEALTH

Group #3337083 CIGNA (800) 244-6224 www.mycigna.com

Group #404002706 Lincoln Financial (800) 583-6908 www.lincolnfinancial.com

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

VISION MEDICAL SUPPLEMENT—MEDLINK ® FLEXIBLE SPENDING ACCOUNT (FSA)

Eyetopia (800) 507-3800 www.eyetopiaplans.com

Group #15719 American Public Life (800) 256-8606 www.ampublic.com

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

DISABILITY LIFE AND AD&D HEALTH SAVINGS ACCOUNT (HSA)

Group #873389 The Hartford (800) 583-6908 File a claim: (866) 278-2655 www.thehartford.com

Group #228827 Sun Life (800) 583-6908 www.sunlife.com/us

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

Benefit Contact Information

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How to Enroll

On Your Computer Access THEbenefitsHUB from your

computer, tablet or smartphone!

Our online benefit enrollment

platform provides a simple and

easy to navigate process. Enroll

at your own pace, whether at

home or at work.

www.mybenefitshub.com/

boerneisd delivers important

benefit information with 24/7

access, as well as detailed plan

information, rates and product

videos.

TEXT

“boerneisd”

TO

313131

On Your Device Enrolling in your benefits just got

a lot easier! Text “boerneisd” 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/boerneisd 1

2

Login Steps

3

Go to:

Click Login

Enter Username & Password

OR SCAN

All login credentials have been RESET to the default

described below:

Username:

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

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

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

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

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

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

your Social Security Number.

Default Password:

Last Name* (lowercase, excluding punctuation)

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

Security Number.

Sample Password

l incola1234

l incoln1234

If you have trouble

logging in, click on the

“Login Help Video”

for assistance.

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

Sample Username

LOGIN

Open Enrollment Tip

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

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

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

5

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

For information on new health insurance premiums and

plan changes, please contact your benefit administrator or go to www.trsactivecareaetna.com.

Reminder, If you currently participate in a Healthcare or

Dependent Care FSA, you MUST re-elect a new contribution amount every year to continue to participate.

Effective 9/1/2016, Hartford Disability premiums will

increase by 10%. All dependents should be added in the system with

social security numbers regardless if you enrolling coverage for those dependents.

Telehealth with MDLive gives you access to telephone

consultations with a licensed physician for minor illnesses. This is offered to you and your dependents paid by Boerne ISD.

Don’t Forget!

Login and complete your benefit enrollment from 7/11/2016—8/22/2016. Enrollment assistance is available by calling Financial Benefit Services at (800) 583-6908 to speak to

a representative. Update your profile information: home address, phone numbers, email. Update dependent social security numbers and student status for college aged children.

Benefit Updates - What’s New:

SUMMARY PAGES

Annual Benefit Enrollment

6

SUMMARY PAGES

CHANGES IN STATUS (CIS):

QUALIFYING EVENTS

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

Change in Number of Tax Dependents

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

Change in Status of Employment Affecting

Coverage Eligibility

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

Gain/Loss of Dependents' Eligibility Status

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

Judgment/Decree/Order

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

Eligibility for Government Programs

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

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

Changes in benefit elections can occur only if you experience a qualifying event. You must present proof of a qualifying event to your Benefit Office within 31 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

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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 benefit

website:

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

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

forms you need under the Benefits and Forms section.

How can I find a Network Provider?

For benefit summaries and claim forms, go to the Boerne ISD

benefit website: www.mybenefitshub.com/boerneisd. Click on

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

you can find provider search links under the Quick Links

section.

When will I receive ID cards?

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

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

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

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

insurance company’s phone number and they can call and

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

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

carrier’s customer service number to request another card.

SUMMARY PAGES

8

PLAN CARRIER MAXIMUM AGE

Dental Cigna 25

Vision Eyetopia 25

Cancer Guardian 25

Accident Lincoln Financial 25

Voluntary Life SunLife 25

Telehealth MDLIVE 25

MEDlink American Public Life 25

Permanent Life Texas Life 22

Employee Eligibility Requirements

Supplemental Benefits: Eligible employees must work 20 or more

regularly scheduled hours each work week.

Eligible employees must be actively at work on the plan effective

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

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

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

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

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

your new benefits.

Dependent Eligibility Requirements

Dependent Eligibility: You can cover eligible dependent

children under a benefit that offers dependent coverage,

provided you participate in the same benefit, through the

maximum age listed below. Dependents cannot be double

covered by married spouses within the Boerne ISD as both

employees and dependents.

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

SUMMARY PAGES

9

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

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

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

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

work beginning 9/1/2016 please notify your benefits

administrator.

Annual Enrollment The period during which existing employees are given the

opportunity to enroll in or change their current elections.

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

pay covered expenses.

Calendar Year January 1st through December 31st

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

covered health care service, calculated as a percentage (for

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

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

medical questions or taking a health exam. Guaranteed

coverage is only available during initial eligibility period.

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

provisions do apply, as applicable by carrier.

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

who have contracted with the plan as a network provider.

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

for covered expenses.

Plan Year September 1st through August 31st

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

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

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

orders to take drugs, or received medical care or services

(including diagnostic and/or consultation services).

Helpful Definitions SUMMARY PAGES

10

SUMMARY PAGES HSA vs. FSA

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

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

Description

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

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

Employer Eligibility A qualified high deductible health plan. All employers

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

Account Owner Individual Employer

Underlying Insurance Requirement

High deductible health plan None

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

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

Varies per employer

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

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

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

Permitted, but subject to current tax rate plus 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. 48

FOR FSA INFORMATION

FLIP TO… PG. 44

11

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

About this Benefit

Dental YOUR BENEFITS PACKAGE

Good dental care may improve your overall health.

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

DID YOU KNOW?

CIGNA

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

Boerne ISD Benefits Website: www.mybenefitshub.com/boerneisd 12

Dental PPO - Low Option

Benefits Cigna Dental PPO - Low Option

In-Network Out-of-Network

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

$750 $750

Contract Deductible Individual Family

$50 per person Unlimited


Reimbursement Levels** Based on Reduced Contracted Fees

90th percentile of Reasonable and Customary

Allowances

Plan Pays You Pay Plan Pays You Pay

Class I - Preventive & Diagnostic Care Oral Exams Routine Cleanings Full Mouth X-rays Bitewing X-rays Panoramic X-ray Periapical X-rays Fluoride Application Sealants Space Maintainers Histopathologic Exams

100% No Charge 100% No Charge

Class II - Basic Restorative Care Fillings Emergency Care to Relieve Pain Brush Biopsies Oral Surgery – Simple Extractions

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

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

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

Class IV - Orthodontia Not covered 100% of your

dentist’s usual fees

Not covered 100% of your

dentist’s usual fees

Monthly PPO Premiums

Tier Rate

EE Only $20.09

EE + Spouse $50.21

EE + 1 Child(ren) $53.24

EE+ Family $80.34

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 more information and to see the complete list of eligible conditions, go to www.mycigna.comor 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.

13

Dental PPO - High Option

Monthly PPO Premiums

Tier Rate

EE Only $27.14

EE + Spouse $67.85

EE + 1 Child(ren) $71.93

EE + Family $108.56

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.comor 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.

Benefits Cigna Dental PPO - High Option

In-Network Out-of-Network

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

$1,000 $1,000

Contract Deductible Individual Family



Reimbursement Levels** Based on Reduced Contracted Fees

90th percentile of Reasonable and Customary Allowances

Plan Pays You Pay Plan Pays You Pay

Class I - Preventive & Diagnostic Care Oral Exams Routine Cleanings Full Mouth X-rays Bitewing X-rays Panoramic X-ray Periapical X-rays Fluoride Application Sealants Space Maintainers Histopathologic Exams

100% No Charge 100% No Charge

Class II - Basic Restorative Care Fillings Brush Biopsies Emergency Care to Relieve Pain Oral Surgery – Simple Extractions

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

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

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

Class IV - Orthodontia Yearly deductible Lifetime Maximum

50% $50

$1,000 Dependent

children to age 19

50% 50% $50

$1,000 Dependent

children to age 19

50%

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Dental PPO - High and Low Options

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

This benefit summary highlights some of the benefits available under the proposed plan. A complete description regarding the terms of coverage, exclusions and limitations, including legislated benefits, will be provided in your insurance certificate or plan description. Benefits are insured and/or administered by Connecticut General Life Insurance Company. "Cigna HealthCare" refers to various operating subsidiaries of Cigna Corporation. Products and services are provided by these subsidiaries and not by Cigna Corporation. These subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. DPPO insurance coverage is set forth on the following policy form numbers: AR: HP-POL77; CA: HP-POL57; CO: HP-POL78; CT: HP-POL58; DE: HP-POL79; FL: HP-POL60; ID: HP- POL82; IL: HP-POL62; KS: HP-POL84; LA: HP-POL86: MA: HP-POL 63; MI: HP-POL88; MO: HP- POL65; MS: HP-POL90; NC: HP-POL96; NE: HP-POL92; NH: HP-POL94; NM: HP-POL95; NV: HP-POL93; NY: HP-POL67; OH: HP-POL98; OK: HP-POL99; OR: HP-POL68; PA: HP-POL100; RI: HP-POL101; SC: HP-POL102; SD: HP-POL103; TN: HP-POL69; TX: HP-POL70; UT: HP-POL104; VA: HP-POL72; VT: HP-POL71; WA: POL-07/08; WI: HP-POL107; WV: HP-POL106; and WY: HP-POL108. “Cigna,” the “Tree of Life” logo and “Cigna Dental Care” are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company (CGLIC), Cigna Health and Life Insurance Company (CHLIC), Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. and its subsidiaries. Cigna Dental PPO plans are underwritten or administered by CGLIC or CHLIC, with network management services provided by Cigna Dental Health, Inc. and certain of its subsidiaries. In Arizona and Louisiana, the insured Dental PPO plan offered by CGLIC is known as the “CG Dental PPO”. In Texas, the insured dental product offered by CGLIC and CHLIC is referred to as the Cigna Dental Choice Plan, and this plan utilizes the national Cigna Dental PPO network. Cigna Dental Care (DHMO) plans are underwritten or administered by Cigna Dental Health Plan of Arizona, Inc., Cigna Dental Health of California, Inc., Cigna Dental Health of Colorado, Inc., Cigna Dental Health of Delaware, Inc., Cigna Dental Health of Florida, Inc., a Prepaid Limited Health Services Organization licensed under Chapter 636, Florida Statutes, Cigna Dental Health of Kansas, Inc. (Kansas and Nebraska), Cigna Dental Health of Kentucky, Inc. (Kentucky and Illinois), Cigna Dental Health of Maryland, Inc., Cigna Dental Health of Missouri, Inc., Cigna Dental Health of New Jersey, Inc., Cigna Dental Health of North Carolina, Inc., Cigna Dental Health of Ohio, Inc., Cigna Dental Health of Pennsylvania, Inc., Cigna Dental Health of Texas, Inc., and Cigna Dental Health of Virginia, Inc. In other states, Cigna Dental Care plans are underwritten by CGLIC, CHLIC, or Cigna HealthCare of Connecticut, Inc. and administered by Cigna Dental Health, Inc.

15

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

About this Benefit

Vision YOUR BENEFITS PACKAGE

75%

DID YOU KNOW?

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

correction.

EYETOPIA



Eyetopia Gold (150/250)

1 The co-pay must be paid to the Participating Provider at the time of service. 2 Special Lens Materials: The member may select special lens materials (transition, ultra light, premium PALs, etc.) provided they pay any amount exceeding the participating provider’s U&C fees for the covered lenses. 3 Non-covered items: Any items not specifically mentioned above, including but not exclusive to rush service, service agreements, special lens materials, oversize and other extras are paid for by the patient at the time of service. 4 If the contact lens exam or “fitting” is performed and the patient decides against getting contact lenses, the patient is responsible for the cost of the contact lens fitting fee. 5 Safigel® daily wear contact lenses are the most advanced contact lenses on the market, they release a wetting agent throughout the day that is proven to provide maximum comfort. Your Eyetopia Gold plan benefit is $300 when you order a one-year supply. 6 The Participating Provider must pre-authorize medical necessity. 7 Non-covered Items and Exclusions – Facility fees, medications and enhancements or treatments related to complications. 8 Access to surgeons must come by referral from a Primary Eye Care Provider who provides pre and post-op care and counseling.

Eyetopia Vision Care Benefits Co-pay1 Eyetopia provides two vision benefits each eligibility period. By coordinating your coverage with your health insurance wellness eye exam you have the opportunity to maximize your Eyetopia benefits.

BENEFIT ONE (choose either one of the following 2 options every 12 months):

1. Refractive Exam-One refraction (CPT Code 92015) or one Routine Vision Exam 2. Warranted Anti-Reflective Coating or any other, tint, treatment, coating, or service of an equal or lesser

value.

$5.00

BENEFIT TWO (choose only one of the following Vision Correction Options): Eyetopia Vision Care Provides you with three (3) options for cor-recting your vision. You may select one of the following every 12 months:

Prescription Eye Wear (lenses and/or frame)2,3 Prescription High Index or Polycarbonate single vision, bifocal or trifocal lenses that also include basic UV and Scratch Resistance coatings – covered 100%. Members can get PFOGlobal Acuity® PALs or upgrade® single vision lenses that come with a premium anti-reflective coating and is cov-ered 100%.

Specific to PFOGloba® Premium Lenses Only: Premium Anti-glare, anti-smudge, anti-scratch with UV Protection Optimized Manufacturing Technology

None

Tint (Solid and Gradient) Standard Anti-Reflective Coating Warranted Anti-Reflective Coating

$12.00 $45.00 $65.00

Frame: The member may select any frame on display. Eyetopia Vision Care provides an allowance of $150.00 to be applied toward the frame selected. The member pays any amount exceeding the $150.00 allowance.

None

1. Contact Lens Option 3,4 Eyetopia Vision provides a $250.00 allowance to be applied toward the Participating Pro-vider’s usual and customary (U&C) fees toward prescription contact lenses. This allowance can be applied toward the contact lens fitting fee and all other charges including follow-up visits and contact lenses.

None

The Eyetopia allowance for Safigel® Daily wear lenses is $300 - must get a one year supply5

Medically necessary spectacle or contact lenses - $400 total allowance6

2. Refractive Surgery Option.7,8 You may select refractive surgery instead of spectacles or contact lenses during each plan period. Eyetopia Vision Care provides a $500.00 per eye allowance toward the fees for refractive surgery, for the following procedures: PRK, LASIK, PIOL, TIOL, RLE or ICL. The member pays any amount exceeding the $500.00 per eye allowance.

None

Employee Only $20.00

EE + Spouse $39.00

EE + Child(ren) $44.00

EE + Family $54.00

17

Eyetopia (120/145)

Eyetopia Vision Care Benefits Co-pay1

Eyetopia provides two vision benefits each eligibility period. By coordinating your coverage with your health insurance wellness eye exam you have the opportunity to maximize your Eyetopia benefits.

BENEFIT ONE (choose either one of the following 2 options every 12 months):

1. Refractive Exam. One refraction (CPT code 92015) or one routine Vision Exam. 2. Standard Anti-Reflective Coating or any other material or service of an equal or lesser value.

$10.00

BENEFIT TWO (choose only one of the following Vision Correction Options): Eyetopia Vision Care provides you with three (3) options for correcting your vision. If your prescription has changed at least ½ diopter or your eye doctor recommends a change of lenses, you may select one of the following every 12 months:

1. Prescription Eye Wear (lenses and/or frame)2,3 Specific to PFOGloba® Premium Lenses Only: Standard Prescription Lenses – covered 100% Non-coated CR-39 plastic single vision, bifocal, trifocal or standard Progressive lenses.

$20.00

Standard Ultra Violet Protection Coating Standard Tints (Gradient and Solid) Standard Scratch Resistance Coating Standard Polycarbonate upgrade Standard Anti-Reflective Coating Warranted Anti-Reflective Coating PFOGlobal Acuity® PAL or upgrade® SV in CR-39 with a premium anti-reflective coating.4

$12.00 $12.00 $15.00 $35.00 $45.00 $65.00 $65.00

Frame: The member may select any frame on display. Eyetopia Vision Care provides an allow-ance of $120.00 to be applied toward the frame selected. The member pays any amount ex-ceeding the $120.00 allowance.

1. Contact Lens Option 3,4 Eyetopia Vision provides a $145.00 allowance to be applied toward the Partici-pating Provider’s usual and customary (U&C) fees toward prescription contact lenses.

This allowance can be applied toward the contact lens fitting fee and all other charges including follow-up visits and contact lenses.

$20.00

The Eyetopia allowance for Safigel® Daily wear lenses is $200 – must get a one year supply5

Medically necessary spectacle or contact lenses - $400 total allowance 6

2. Refractive Surgery Option.7,8 Eyetopia Vision Care provides a $350.00 per eye allowance toward the 3. fees for refractive surgery, for the following procedures: PRK, LASIK, PIOL, TIOL, RLE or ICL. The member

pays any amount exceeding the $350.00 per eye allowance.

None

Employee Only $10.00

EE + Spouse $19.00

EE + Child(ren) $22.00

EE + Family $27.00

18

1 The co-pay must be paid to the Participating Provider at the time of service. 2 When Health Insurance Carriers offer an annual wellness eye exam it creates an overlap in benefits for Eyetopia Members. If this occurs, the Member may choose another option under Benefit One as described, a $10.00 co-pay is still required to exercise these other options. 3 Special Lens Materials and Non-covered Items: Transition, ultra light, premium PALs, rush service, service agreements, other special lens materials, oversize, other extras and any items not specifically mentioned above may be substituted provided the Member pays any amount exceeding the price of the covered benefit and the Participating Provider’s usual and customary fees for the upgrade at the time of service. 4 Members can upgrade from the standard lens to the PFOGlobal Acuity® PAL or upgrade® single vision in CR-39 plastic for an additional $65.00. 5 Safigel® daily wear contact lenses are the most advanced contact lenses on the market, they release a wetting agent throughout the day that is proven to provide maximum comfort. Your Eyetopia plan benefit is $200.00 when you order a one-year supply. 6 The Participating Provider must pre-authorize medical necessity. 7 Non-covered Items and Exclusions – Facility fees, medications and enhancements or treatments related to complications. 8 Access to surgeons must come by referral from a Primary Eye Care Provider who provides pre and post-op care and counseling.

Eyetopia (120/145)

19

About this Benefit

Disability YOUR BENEFITS PACKAGE

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

they retire.

DID YOU KNOW?

34.6 months is the duration of the

average disability claim.

THE HARTFORD

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



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

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

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

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

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

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

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

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

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

armed conflict

The commission of, or attempt to commit a felony An intentionally self-inflicted injury Any case where your being engaged in an illegal

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

receive benefits

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

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

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

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

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

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

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

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

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

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

Long Term Disability

21


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

Age Disabled Benefits Payable

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

Age 63 To Normal Retirement Age or 42 months if greater

Age 64 36 months

Age 65 30 months

Age 66 27 months

Age 67 24 months

Age 68 21 months

Age 69 and older 18 months

MONTHLY PREMIUM COST (based on 12 payments per year)

Accident / Sickness Elimination Period in Days

Annual Earnings Monthly Earnings Monthly Benefit 0 / 3 14 / 14 30 / 30 60 / 60 90 / 90 180 / 180

$3,600 $300 $200 $8.96 $6.38 $5.10 $4.34 $3.64 $2.76

$5,400 $450 $300 $13.44 $9.57 $7.65 $6.51 $5.46 $4.14

$7,200 $600 $400 $17.92 $12.76 $10.20 $8.68 $7.28 $5.52

$9,000 $750 $500 $22.40 $15.95 $12.75 $10.85 $9.10 $6.90

$10,800 $900 $600 $26.88 $19.14 $15.30 $13.02 $10.92 $8.28

$12,600 $1,050 $700 $31.36 $22.33 $17.85 $15.19 $12.74 $9.66

$14,400 $1,200 $800 $35.84 $25.52 $20.40 $17.36 $14.56 $11.04

$16,200 $1,350 $900 $40.32 $28.71 $22.95 $19.53 $16.38 $12.42

$18,000 $1,500 $1,000 $44.80 $31.90 $25.50 $21.70 $18.20 $13.80

$19,800 $1,650 $1,100 $49.28 $35.09 $28.05 $23.87 $20.02 $15.18

$21,600 $1,800 $1,200 $53.76 $38.28 $30.60 $26.04 $21.84 $16.56

$23,400 $1,950 $1,300 $58.24 $41.47 $33.15 $28.21 $23.66 $17.94

$25,200 $2,100 $1,400 $62.72 $44.66 $35.70 $30.38 $25.48 $19.32

$27,000 $2,250 $1,500 $67.20 $47.85 $38.25 $32.55 $27.30 $20.70

$28,800 $2,400 $1,600 $71.68 $51.04 $40.80 $34.72 $29.12 $22.08

$30,600 $2,550 $1,700 $76.16 $54.23 $43.35 $36.89 $30.94 $23.46

$32,400 $2,700 $1,800 $80.64 $57.42 $45.90 $39.06 $32.76 $24.84

$34,200 $2,850 $1,900 $85.12 $60.61 $48.45 $41.23 $34.58 $26.22

$36,000 $3,000 $2,000 $89.60 $63.80 $51.00 $43.40 $36.40 $27.60

$37,800 $3,150 $2,100 $94.08 $66.99 $53.55 $45.57 $38.22 $28.98

$39,600 $3,300 $2,200 $98.56 $70.18 $56.10 $47.74 $40.04 $30.36

$41,400 $3,450 $2,300 $103.04 $73.37 $58.65 $49.91 $41.86 $31.74

$43,200 $3,600 $2,400 $107.52 $76.56 $61.20 $52.08 $43.68 $33.12

$45,000 $3,750 $2,500 $112.00 $79.75 $63.75 $54.25 $45.50 $34.50

$46,800 $3,900 $2,600 $116.48 $82.94 $66.30 $56.42 $47.32 $35.88

$48,600 $4,050 $2,700 $120.96 $86.13 $68.85 $58.59 $49.14 $37.26

$50,400 $4,200 $2,800 $125.44 $89.32 $71.40 $60.76 $50.96 $38.64

$52,200 $4,350 $2,900 $129.92 $92.51 $73.95 $62.93 $52.78 $40.02

$54,000 $4,500 $3,000 $134.40 $95.70 $76.50 $65.10 $54.60 $41.40

$55,800 $4,650 $3,100 $138.88 $98.89 $79.05 $67.27 $56.42 $42.78

$57,600 $4,800 $3,200 $143.36 $102.08 $81.60 $69.44 $58.24 $44.16

$59,400 $4,950 $3,300 $147.84 $105.27 $84.15 $71.61 $60.06 $45.54

22


MONTHLY PREMIUM COST (based on 12 payments per year)

Accident / Sickness Elimination Period in Days

Annual Earnings Monthly Earnings Monthly Benefit 0 / 3 14 / 14 30 / 30 60 / 60 90 / 90 180 / 180

$61,200 $5,100 $3,400 $152.32 $108.46 $86.70 $73.78 $61.88 $46.92

$63,000 $5,250 $3,500 $156.80 $111.65 $89.25 $75.95 $63.70 $48.30

$64,800 $5,400 $3,600 $161.28 $114.84 $91.80 $78.12 $65.52 $49.68

$66,600 $5,550 $3,700 $165.76 $118.03 $94.35 $80.29 $67.34 $51.06

$68,400 $5,700 $3,800 $170.24 $121.22 $96.90 $82.46 $69.16 $52.44

$70,200 $5,850 $3,900 $174.72 $124.41 $99.45 $84.63 $70.98 $53.82

$72,000 $6,000 $4,000 $179.20 $127.60 $102.00 $86.80 $72.80 $55.20

$73,800 $6,150 $4,100 $183.68 $130.79 $104.55 $88.97 $74.62 $56.58

$75,600 $6,300 $4,200 $188.16 $133.98 $107.10 $91.14 $76.44 $57.96

$77,400 $6,450 $4,300 $192.64 $137.17 $109.65 $93.31 $78.26 $59.34

$79,200 $6,600 $4,400 $197.12 $140.36 $112.20 $95.48 $80.08 $60.72

$81,000 $6,750 $4,500 $201.60 $143.55 $114.75 $97.65 $81.90 $62.10

$82,800 $6,900 $4,600 $206.08 $146.74 $117.30 $99.82 $83.72 $63.48

$84,600 $7,050 $4,700 $210.56 $149.93 $119.85 $101.99 $85.54 $64.86

$86,400 $7,200 $4,800 $215.04 $153.12 $122.40 $104.16 $87.36 $66.24

$88,200 $7,350 $4,900 $219.52 $156.31 $124.95 $106.33 $89.18 $67.62

$90,000 $7,500 $5,000 $224.00 $159.50 $127.50 $108.50 $91.00 $69.00

$91,800 $7,650 $5,100 $228.48 $162.69 $130.05 $110.67 $92.82 $70.38

$93,600 $7,800 $5,200 $232.96 $165.88 $132.60 $112.84 $94.64 $71.76

$95,400 $7,950 $5,300 $237.44 $169.07 $135.15 $115.01 $96.46 $73.14

$97,200 $8,100 $5,400 $241.92 $172.26 $137.70 $117.18 $98.28 $74.52

$99,000 $8,250 $5,500 $246.40 $175.45 $140.25 $119.35 $100.10 $75.90

$100,800 $8,400 $5,600 $250.88 $178.64 $142.80 $121.52 $101.92 $77.28

$102,600 $8,550 $5,700 $255.36 $181.83 $145.35 $123.69 $103.74 $78.66

$104,400 $8,700 $5,800 $259.84 $185.02 $147.90 $125.86 $105.56 $80.04

$106,200 $8,850 $5,900 $264.32 $188.21 $150.45 $128.03 $107.38 $81.42

$108,000 $9,000 $6,000 $268.80 $191.40 $153.00 $130.20 $109.20 $82.80

$109,800 $9,150 $6,100 $273.28 $194.59 $155.55 $132.37 $111.02 $84.18

$111,600 $9,300 $6,200 $277.76 $197.78 $158.10 $134.54 $112.84 $85.56

$113,400 $9,450 $6,300 $282.24 $200.97 $160.65 $136.71 $114.66 $86.94

$115,200 $9,600 $6,400 $286.72 $204.16 $163.20 $138.88 $116.48 $88.32

$117,000 $9,750 $6,500 $291.20 $207.35 $165.75 $141.05 $118.30 $89.70

$118,800 $9,900 $6,600 $295.68 $210.54 $168.30 $143.22 $120.12 $91.08

$120,600 $10,050 $6,700 $300.16 $213.73 $170.85 $145.39 $121.94 $92.46

$122,400 $10,200 $6,800 $304.64 $216.92 $173.40 $147.56 $123.76 $93.84

$124,200 $10,350 $6,900 $309.12 $220.11 $175.95 $149.73 $125.58 $95.22

$126,000 $10,500 $7,000 $313.60 $223.30 $178.50 $151.90 $127.40 $96.60

$127,800 $10,650 $7,100 $318.08 $226.49 $181.05 $154.07 $129.22 $97.98

$129,600 $10,800 $7,200 $322.56 $229.68 $183.60 $156.24 $131.04 $99.36

$131,400 $10,950 $7,300 $327.04 $232.87 $186.15 $158.41 $132.86 $100.74

$133,200 $11,100 $7,400 $331.52 $236.06 $188.70 $160.58 $134.68 $102.12

$135,000 $11,250 $7,500 $336.00 $239.25 $191.25 $162.75 $136.50 $103.50

23

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

About this Benefit

Cancer YOUR BENEFITS PACKAGE

Breast Cancer is the most commonly diagnosed cancer in women.

DID YOU KNOW?

If caught early, prostate cancer is one of the most treatable malignancies.

GUARDIAN



Cancer

COVERAGE - DETAILS Option 1: Advantage Plan Option 2: Premier Plan

INITIAL DIAGNOSIS BENEFIT - Benefit is paid when you are diagnosed with Internal cancer for the first time while insured under this Plan.

Benefit Amount(s)

Employee $5,000 Spouse $5,000 Child $5,000

Employee $2,500 Spouse $2,500 Child $2,500

Benefit Waiting Period - A specified period of time after your effective date during which the Initial Diagnosis benefits will not be payable.

30 Days 30 Days

CANCER SCREENING

Benefit Amount $50; $50 for Follow-Up screening

$75; $75 for Follow-Up screening

Pre-Existing Conditions Limitation: Apre-existing condition includes any condition for which you, in the specified time period prior to coverage in this plan, consulted with a physician, received treatment, or took prescribed drugs.

3 months prior/ 6 months treatment free/ 12 months after.

3 months prior/ 6 months treatment free/ 12 months after.

Portability: Allows you to take your Cancer coverage with you if you terminate employment.

Included Included

Child(ren) Age Limits Children age birth to 26 years (26 if full time student)

Children age birth to 26 years (26 if full time student)

FEATURES

Air Ambulance $1,500/trip, limit 2 trips per

hospital confinement $2,000/trip, limit 2 trips per hospital

confinement

Alternative Care No Benefit $50/visit up to 20 visits

Ambulance $200/trip, limit 2 trips per

hospital confinement $250/trip, limit 2 trips per hospital

confinement

Anesthesia 25% of surgery benefit 25% of surgery benefit

Anti-Nausea $50/day up to $150 per month

$50/day up to $250 per month

Attending Physician $25/day while hospital

confined. Limit 75 visits. $25/day while hospital confined.

Limit 75 visits.

Blood/Plasma/Platelets $100/day up to $5,000 per year

$200/day up to $10,000 per year

Bone Marrow/Stem Cell Bone Marrow: $7,500 Stem Cell: $1,500

Bone Marrow: $10,000 Stem Cell: $2,500

Experimental Treatment $100/day up to $1,000/month

$200/day up to $2,400/month

Extended Care Facility/Skilled Nursing care $100/day up to 90 days per year

$150/day up to 90 days per year

25

Cancer

FEATURES (Cont.) Option 1: Advantage Plan Option 2: Premier Plan

Government or Charity Hospital $300 per day in lieu of all other

benefits $400 per day in lieu of all other

benefits Home Health Care $50/visit up to 30 visits per year $100/visit up to 30 visits per year

Hormone Therapy $25/treatment up to 12 treatments

per year $50/treatment up to 12 treatments

per year Hospice $50/day up to 100 days/lifetime $100/day up to 100 days/lifetime

Hospital Confinement

$300/day for first 30 days; $600/day for 31st day thereafter

per confinement


per confinement ICU Confinement


per confinement


per confinement

Immunotherapy $500 per month, $2,500 lifetime

max $500 per month, $2500 lifetime

max Inpatient Special Nursing $100/day up to 30 days per year $150/day up to 30 days per year

Medical Imaging $100/image up to 2 per year $200/image up to 2 per year

Outpatient and family member lodging - Lodging must be more

than 50 miles from your home. $100/day, up to 90 days per year $75/day, up to 90 days per year

Outpatient or Ambulatory Surgical Center $250/day, 3 days per procedure $350/day, 3 days per procedure

Physical or Speech Therapy $25/visit up to 4 visits per month, $400 lifetime max

$50/visit up to 4 visits per month, $1,000 lifetime max

Prosthetic

Surgically Implanted: $2,000/device, $4,000 lifetime max Non-Surgically: $200/device, $400

lifetime max

Surgically Implanted: $3,000/device, $6,000 lifetime max Non-Surgically: $300/device, $600

lifetime max

Radiation Therapy or Chemotherapy Schedule amounts up to a $4,000

benefit year maximum Schedule amounts up to a $12,000

benefit year maximum

Reconstructive Surgery

Breast TRAM Flap $2,000 Breast reconstruction $500 Breast Symmetry $250 Facial reconstruction $500

Breast TRAM $3,000 Breast reconstruction $700 Breast Symmetry $350 Facial reconstruction $700

Reproductive Benefit No Benefit $1,500 egg harvesting, $500 egg or

sperm storage, $2,000 lifetime max Second Surgical Opinion $200/surgery procedure $300/surgery procedure

Skin Cancer

Biopsy Only: $100 Reconstructive Surgery: $250 Excision of a skin cancer: $375 Excision of a skin cancer with flap or graft: $600

Biopsy Only: $100 Reconstructive Surgery: $250 Excision of a skin cancer: $375 Excision of a skin cancer with flap or graft: $600

Surgical Benefit Schedule amount up to $4,125 Schedule amount up to $5,500

Transportation/Companion Transportation - Benefit is paid if you have

to travel more than 50 miles one way to receive treatment for trip/

equal benefit for companion internal cancer.

$0.50/mile up to $1,500 per round trip/equal benefit for companion

$0.50/mile up to $1,000 per round trip/equal benefit for companion

Waiver of Premium - If you become disabled due to cancer that is

diagnosed after the employee's effective date, and you remain disabled

for 90 days, we will waive the premium due after such 90 days for as

long as you remain disabled.

Included Included

26

Cancer

You and Spouse

<30 $5.83 <30 $8.60

30-39 $11.24 30-39 $17.15

40-49 $24.41 40-49 $38.85

50-59 $45.04 50-59 $73.93 60-64 $72.39 60-64 $121.19

65+ $105.53 65+ $180.65

You and Child(ren)

<30 $5.89 <30 $8.91

30-39 $9.15 30-39 $14.11

40-49 $16.74 40-49 $26.72

50-59 $26.47 50-59 $43.38

60-64 $38.46 60-64 $64.28

65+ $52.53 65+ $89.73

You, Spouse and Child(ren)

<30 $8.52 <30 $12.81

30-39 $13.93 30-39 $21.35

40-49 $27.10 40-49 $43.06

50-59 $47.73 50-59 $78.14

60-64 $75.08 60-64 $125.40

65+ $108.22 65+ $184.86

Your Monthly premium (cntd.)

<30 $3.20 <30 $4.70

You

30-39 $6.46 30-39 $9.90

40-49 $14.05 40-49 $22.51

50-59 $23.78 50-59 $39.17

60-64 $35.78 60-64 $60.07

65+ $49.84 65+ $85.52

Understanding Your Benefits Alternative Care – Benefit is paid for palliative care (bio-feedback or hypnosis) or lifestyle benefits such as visits to an accredited practitioner for smoking cessation, yoga, meditation, relaxation techniques and nutritional counseling. Cancer – Cancer means you have been diagnosed with a disease manifested by the presence of a malignant tumor characterized by the uncontrolled growth and spread of malignant cells in any part of the body. This includes leukemia, Hodgkin's disease, lym-phoma, sarcoma, malignant tumors and melanoma. Cancer in-cludes carcinomas in-situ (in the natural or normal place, con-fined to the site of origin, without having invaded neighboring tissue). Pre-malignant conditions or conditions with malignant potential, such as myelodyplastic and myeloproliferative disor-ders, carcinoid, leukoplakia, hyperplasia, actinic keratosis, poly-cythemia, and nonmalignant melanoma, moles or similar diseas-es or lesions will not be considered cancer. Experimental Treatment – Benefits will be paid for experimental treatment prescribed by a doctor for the purpose of destroying or changing abnormal tissue. All treatment must be NCI listed as viable experimental treatment for Internal Cancer.

Limitations and Exclusions A SUMMARY OF CANCER LIMITATIONS AND EXCLUSIONS: Conditional Issue is one medical question as a part of the enroll-ment form. This plan will not pay benefits for: Services or treatment not in-cluded in the Features. Services or treatment provided by a fam-ily member. Services or treatment rendered for hospital confine-ment outside the United States. Any cancer diagnosed solely outside of the United States. Services or treatment provided primarily for cosmetic purposes. Services or treatment for premalignant conditions. Services or treatment for conditions with malignant potential. Services or treatment for non-cancer sicknesses. Cancer caused by, contributed to by, or resulting from: partici-pating in a felony, riot or insurrection; intentionally causing a self-inflicted injury; committing or attempting to commit suicide while sane or insane; a covered person’s mental or emotional disorder, alcoholism or drug addiction; engaging in any illegal activity; or serving in the armed forces or any auxiliary unit of the armed forces of any country.

27

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

About this Benefit

Accident YOUR BENEFITS PACKAGE

of disabling injuries suffered by American workers are not work related.

DID YOU KNOW?

36% of American workers report they always or usually live paycheck to paycheck.

2/3


Boerne ISD Benefits Website: www.mybenefitshub.com/boerneisd

LINCOLN FINANCIAL

28

Accident

Eligibility: All employees working 20 or more hours per week in an eligible class. Issue Ages 17-80

Emergency care Choice Plan

Ambulance/Air Ambulance $150/$600

Initial physician office visit/ER visit $50/$150

Major diagnostic care $100

Treatment care

Hospital admission $1,000

Hospital confinement daily benefit $200

Intensive care daily benefit $400

Alternate care and rehabilitative facility daily benefit $100

Follow-up doctor/patient care up to 6 sessions $50

Transportation for care (up to 3 times per accident) $175

Companion lodging (up to 30 days per accident) $100

Family care per child (up to 30 days) $20

Fractures Nonsurg/Surg

Per fracture $125-$3,000/$250-$6,000

Chip fractures 25% benefit

Dislocations Nonsurg/Surg

Per injury $125-$1,500/$250-$3,000

Partial dislocation 25% benefit

Specific injuries or treatments Choice Plan

Transfusions $150

Burns $100 - $6,400

Skin Grafts Additional 25%

Joint replacement $1,500-$2,000

Coma $2,000

Concussion $100

Dental crown once per accident $150

Dental extraction once per accident $50

Eye (removal of foreign body) once per eye/accident $100

Eye (surgical repair) once per eye/accident $300

Laceration $50-$400

Surgery $250-$1,000

Treatment of ligaments/tendons, knee cartilage, rotator cuff, ruptured disc

$300-$400

Transitional care benefits

Crutches, wheelchair, walker $25-$350

Prosthesis per limb/device $500

Reasonable modifications to home or vehicle $2,500

29

Accidental Death & Dismemberment (AD&D) Choice Plan

Accidental death

Employee $30,000

Spouse $10,000

Child $5,000

Loss of or loss of use of one: hand, foot, arm, leg, eye $7,000

Loss of or loss of use of any one finger, thumb, or toe $300

Common carrier enhanced death benefit 2x benefit amt

Transportation of remains $5,000

Seat belt/helmet AD&D benefit 10% of AD&D

Common disaster enhanced death benefit 2x benefit amt

Catastrophic loss $50,000

Additional benefits

Accident EAP services Included

TravelConnectSM Included

Health assessment (wellness) benefit: If an insured under-goes a defined health assessment, a benefit will be paid.

$50, one time per year per insured

Sickness Hospital Confinement Benefit: If an insured is con-fined to a hospital due to an illness unrelated to an acci-dent, a daily benefit will be paid up to a maximum of 30 days.

$100 per day

Choice Plan

Accident base coverage Monthly Cost

Employee only $13.69

Employee + spouse $19.15

Employee + child(ren) $23.23

Employee + family $30.72

Employee level benefit options Additional benefits selected by the employee for an additional cost

Health Assessment (wellness) Monthly Cost

Employee only $2.21




Sickness Hospital Confinement Benefit

Employee only $4.09




Accident

30

Accident

Exclusions This accident policy will not cover losses caused by or as a result of: Injury occurring prior to the effective date of coverage or

after termination of the coverage Duty as a member of any military, including Reserves or

National Guard Travel or flight in or on any Aircraft, except as a fare paying

passenger on a regularly scheduled commercial flight Participating in high risk or extreme sports Having cosmetic or elective surgery Participating in or attempting to commit a felony Being incarcerated in any type of penal or detention facility Having a blood alcohol level of .08 grams of alcohol or more

per 100 milliliters of blood Deliberately using poison, gas, fumes, or drugs (except

when prescribed by a Physician and administered

appropriately) Committing or attempting to commit suicide or any other

self-inflicted injury Any sickness, disease (physical or mental), or medical or

surgical treatment of these Participating in, practicing for, or officiating a semi-

professional or professional sport Riding in or driving any motor-driven vehicle for race, stunt

show, or speed test War, act of war, or participation in a riot, insurrection or

rebellion An injury sustained while residing outside the U.S., U.S.

territories, Canada or Mexico for more than 12 months Injury arising out of or in the course of any employment for

wage or profit for Off-the-Job Coverage only

31

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

About this Benefit

MEDlink®IV YOUR

BENEFITS

DID YOU KNOW?

33%

of total healthcare costs are paid

out-of-pocket.



AMERICAN PUBLIC LIFE

(03/16) 32

APSB-22354(TX) MGM/FBS Boerne ISD

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

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

Total Monthly Premiums by Plan*

Employee Employee & Spouse Employee & Child Employee & Family

Ages 18-54 $34.73 $80.30 $62.57 $108.05

Ages 55+ $50.06 $115.58 $88.64 $154.06

ENHANCED PLAN SUMMARY OF BENEFITS*

Base Policy Option 1

Maximum In-Hospital Benefits $2,500 per Covered Person per Confinement

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

In-Hospital Deductible $0 per Covered Person per Confinement

Outpatient Benefit Rider

Maximum Outpatient Benefits $500 per Covered Person per Occurrence for Covered Outpatient Services

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

Outpatient Deductible $0 per Covered Person Per Occurrence

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

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

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

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

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

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

Benefit RiderPhysician Outpatient Treatment Benefit Rider

$25 per visit; Maximum of four visits per Covered Person per Calendar Year and eight visits per Calendar Year for all Covered Persons combined for treatment in a:s Hospital Outpatient Facilitys Freestanding Emergency Care Clinics Urgent Care Facility/Clinics Physician Office

33

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

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

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

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

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

ExclusionsNo benefits are payable for any loss resulting from or caused, whether directly or indirectly, by: s war or any act of war, whether declared or undeclared, or active service in the armed forces; (This exclusion includes Accident sustained or Sickness contracted while in the service of any military, naval or air force of any country engaged in war. If coverage is suspended for any Covered Person during a period of military service, APL will refund the pro-rata portion of any premium paid for any such Covered Person upon receipt of your written request) s an intentionally self-inflicted Injury or Sickness; s suicide or attempted suicide, while sane or insane; s rest care or rehabilitative care and treatment; s outpatient routine newborn care; s voluntary abortion except, with respect to you or your covered Eligible Dependent spouse: s where you or your Dependent spouse’s life would be endangered if the fetus were carried to term; or s where medical complications have arisen from abortion; s pregnancy of an Eligible Dependent child;

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

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

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

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

MEDlink® IV Enhanced Limited Benefit Group Medical Expense Supplemental Insurance

APSB-22354(TX) MGM/FBS Boerne ISD34

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

APSB-22354(TX) MGM/FBS Boerne ISD

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

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

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

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

MEDlink® IV Enhanced Limited Benefit Group Medical Expense Supplemental Insurance

35

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

About this Benefit

Life and AD&D YOUR BENEFITS PACKAGE

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

drowning, and choking.

DID YOU KNOW?

#1

Motor vehicle crashes are the



SUN LIFE

36

Group Life & Option Life Insurance Benefits

Group Life Insurance Benefits For Employees of Boerne ISD

Benefits $10,000 of coverage for all Full-Time United States

Employees working in the United States who are scheduled to work a minimum of 30 hours per week.

Accidental Death and Dismemberment (AD&D) insurance which would pay an additional benefit, up to the amount of your Life benefit, if you suffer a covered loss due to an accident.

Benefits are reduced to 67% at age 70 and to 50% at age 75. Coverage is discontinued at termination of employment or retirement.

Accelerated Benefits that help offset expenses at a critical time. You may collect a portion of your benefits during your lifetime if you become terminally ill.

If you leave Boerne ISD, you may be able to convert or port your Group Life coverage to an Individual Life insurance policy.

No Cost to You Your employer pays your Group Life and AD&D premium.

How to Enroll Basic group term life coverage begins automatically when

you meet the eligibility requirements. You’ll need to designate beneficiaries for your basic life benefits using our Beneficiary Designation form or Group Enrollment form. Check with your

employer for the necessary forms and for additional coverage options that may be available, or find the forms you need online at www.sunlife.com/us.

For Complete Plan Details This highlight flyer is intended to provide an overview of the

benefits available from your employer, and is not a complete description of plan provisions. Receipt of this flyer does not certify eligibility for benefits under this plan.

Your employer will provide you with the Sun Life Financial Group booklet containing complete plan details.

Optional Life Insurance Benefits For Employees of Boerne ISD

Benefits

For you: An amount between $10,000 and $500,000, in increments of $10,000, not to exceed 5x basic annual earnings. Guaranteed Issue Amount is $150,000. Benefits cease at retirement.

For your spouse: An amount between $5,000 and $100,000, in increments of $5,000. Guaranteed Issue Amount is $25,000. Spouse Optional Life coverage may not exceed 50% of the employee’s coverage. Coverage ends when your spouse turns 70.

For your dependent child(ren): An amount between $1,000 and $10,000, in increments of $1,000 for each eligible child who is 6 months to 19 years old (or 25 if a full-time student); $100 for a child who is 14 days to under 6 months. Child coverage cannot exceed 50% of the employee’s coverage. You must elect Optional Life coverage for yourself in order to cover your spouse and/or children.

Features of the Plan Your employer’s plan includes optional Accidental Death

and Dismemberment (AD&D) Insurance which would pay an additional benefit, up to the amount of your Optional Life benefit, if you suffer a covered loss due to accident.

The plan also includes many special features including Waiver of Premium and Accelerated Benefits. For more information, ask your employer for a copy of the flyer entitled “Optional Life Means Added Financial Security.”

How to Enroll Once you have selected the amount of coverage that’s right

for you, your spouse and your children, simply fill out the Optional Life enrollment form provided by your employer. Be sure to sign, date, and return the form to your employer. Please submit the form to your employer along with any Evidence of Insurability forms that may be required.

About Evidence of Insurability Evidence of Insurability – also called “proof of good health”

– is required if: You decline coverage during your initial eligibility

period and then want coverage at a later date; or You apply for Optional Life in excess of the

Guaranteed Issue Amount. All late entrants and increases require Evidence of

Insurability. Your employer will advise you if you need to submit an Evidence of Insurability application. If so, Sun Life Financial may arrange for you to take a medical exam (at our expense) and/or complete a questionnaire. Coverage will not go into effect until Sun Life Financial approves the application.

37

Example amount

of insurance

Divided by 1000

Multiplied by rate

$25000 / 1000 = 25 x $0.05

Your volume of insurance

Divided by 1000

Multiplied by rate

$ [ ] / 1000 = [ ] x $[ ]

Optional Life Insurance Benefits

Employee

Monthly cost per Age $1,000 of coverage

Spouse

Monthly cost per Age $1,000 of coverage

Child(ren)

Monthly cost per $1,000 of

coverage

Under 25 $ 0.045 Under 25 $ 0.045 All eligible $ 0.20 25 – 29 $ 0.045 25 – 29 $ 0.045 children 30 – 34 $ 0.045 30 – 34 $ 0.045

35 – 39 $ 0.065 35 – 39 $ 0.065 40 – 44 $ 0.075 40 – 44 $ 0.075 45 – 49 $ 0.105 45 – 49 $ 0.105

50 – 54 $ 0.155 50 – 54 $ 0.155

55 – 59 $ 0.275 55 – 59 $ 0.275

60 – 64 $ 0.475 60 – 64 $ 0.475

65 – 69 $ 0.705 65 – 69 $ 0.705

70 - 74 $ 0.975

75 + $ 1.735

Optional Life Insurance Rates

Cost to You You are responsible for paying the cost of voluntary Life

coverage through payroll deduction. Calculate your cost by dividing your amount of optional life insurance by 1000 and multiplying the result by the appropriate rate above. Follow the example below to determine your monthly cost.

Example cost*

$ 1.25

Your cost*

Cost per pay period

$ [ ] $ [ ] *Contact your employer to confirm the portion of the cost for which you will be responsible.

Age Reductions Amounts of Life Insurance are reduced at the following

ages:

Age Percentage

70 67%

75 50%

For Complete Plan Details This highlight flyer is intended to provide an overview of the benefits available from your employer, and is not a complete

description of plan provisions. Receipt of this flyer does not certify eligibility for benefits under this plan. Your employer will provide you with the Sun Life Financial Group booklet containing complete plan details.

Exclusions Where allowed by law, if the Employee’s cause of death is suicide: No amount of contributory Life or contributory Dependent Life Insurance is payable if the suicide occurs within 24 months

after the Employee’s Insurance is effective. If there was prior coverage in place, any period of time the Employee was insured for the same amount of Life Insurance under the previous insurer’s group Life policy will count towards completion of the 24 months.

No increased or additional amount of Life Insurance is payable if the suicide occurs within 24 months after the increased or additional amount of Basic Life Insurance is effective.

No amount of Life Insurance in excess of the Guaranteed Issue Amount is payable if the suicide occurs within 24 months after the amount in excess of the Guaranteed Issue Amount is effective.

This summary represents a general overview. Limitations and exclusions may vary depending on your specific benefit plan. Please review your Life booklet for complete information.

38

Voluntary Accidental Death & Dismemberment Insurance

Voluntary Accidental Death & Dismemberment Insurance For Employees of Boerne ISD

Benefits

For you: An amount between $10,000 and $500,000, in increments of $10,000. Maximum employee coverage is 5 times your basic annual earnings. Basic annual earnings do not include bonuses, commissions, or overtime pay.

For your spouse: An amount between $10,000 and $250,000, in increments of $10,000.

For your eligible children: An amount between $2,000 and $10,000, in increments of $2,000.

Employees may not elect a Spouse or Child amount greater than the amount elected for them.

Features of the Plan Accidental Death and Dismemberment (AD&D) insurance

pays a benefit – in addition to your Basic/Optional Life benefit – in case you die in a covered accident or suffer loss of a limb or paralysis. Also, AD&D pays a benefit for covered accidents resulting in loss of sight, speech, hearing and thumb/index finger.

Easy enrollment at work. Affordable group rates conveniently deducted from your paycheck.

Guaranteed coverage up to a predetermined amount. No medical exam required.

24-hour protection at home or work.

How to Enroll Once you have selected the amount of coverage that’s right

for you, your spouse and your children, simply fill out the Voluntary AD&D enrollment form.

Coverage for your spouse and child(ren) is only available if you elect coverage. Please submit the form to your employer. until Sun Life Financial approves the application.

AD&D Rates*

Cost to You You are responsible for paying the cost of Voluntary AD&D

coverage through payroll deduction. Calculate your cost by dividing your amount of optional Voluntary AD&D insurance by 1000 and multiplying the result by the appropriate rate above. Follow the example below to determine your monthly cost.

For Complete Plan Details This highlight flyer is intended to provide an overview of the

benefits available from your employer, and is not a complete description of plan provisions. Receipt of this flyer does not certify eligibility for benefits under this plan.

Your employer will provide you with the Sun Life Financial Group booklet containing complete plan details.

Exclusions (subject to state variations) No Voluntary Accidental Death or Accidental

Dismemberment payment will be made for a loss which is due to or results from:

Suicide while sane or insane, or intentionally self-inflicted injuries.

Bodily or mental infirmity or disease of any kind, or infection unless due to an accidental cut or wound.

Committing or attempting to commit an assault, felony or other illegal act.

Active participation in a war (declared or undeclared) or active duty in any armed service during a time of war.

Active participation in a riot, rebellion, or insurrection. Injury sustained from any aviation activities, other than

riding as a fare-paying passenger, if the pilot exclusion applies to the plan.

The Insured Person’s voluntary use of any controlled substance as defined in Title II of the Comprehensive Drug Abuse Prevention and Control Act of 1970, as now or hereafter amended, unless administered on the advice of a Physician.

The Insured Person’s operation of any motorized vehicle while intoxicated. Intoxicated means the minimum blood level alcohol required to be considered operating an automobile under the influence of alcohol in the jurisdiction where the accident occurred. For the purpose of this Exclusion, "Motorized Vehicle" includes, but is not limited to, automobiles, motorcycles, boats and snowmobiles

Your Coverage Monthly Cost Per $1,000

Coverage Employee coverage $ 0.020

Spouse coverage $ 0.020

Child(ren) coverage $ 0.080

Example amount

of insurance

Divided by 1000

Multiplied by rate

$20000 / 1000 = 20 x $0.02

Your volume of insurance

Divided by 1000

Multiplied by rate

$ [ ] / 1000 = [ ] x $[ ]

Example cost*

$.40

Your Monthly Cost*

$ [ ]

*Contact your employer to confirm the portion of the cost for which you will be responsible.

39

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

About this Benefit

Individual Life YOUR BENEFITS PACKAGE

DID YOU KNOW?

TEXAS LIFE

1/3 of Americans would be financially impacted by the loss of the primary wage earner in just one month.



Individual Life

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

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

41

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

About this Benefit

Telehealth YOUR BENEFITS PACKAGE

DID YOU KNOW?

75%

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

telehealth.

MDLIVE



Telehealth

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

non-emergency medical issue

Your primary care physician is not available

At home, traveling, or at work

24/7/365, even holidays!

What can be treated? Allergies

Asthma

Bronchitis

Cold and Flu

Ear Infections

Joint Aches and Pain

Respiratory Infection

Sinus Problems

And More!

Pediatric Care related to: Cold & Flu

Constipation

Ear Infection

Fever

Nausea & Vomiting

Pink Eye

And More!

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

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

How much does it cost?

Family coverages covers you, your spouse, and children up to age 26, with unlimited phone consultations.

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

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

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

Available 24/7 by video or phone

Private, secure and confidential visits

Connect instantly with MDLIVE Assist

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

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

Scan with your smartphone to get the app.

$0

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)


NBS



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

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

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

FSA Annual Contribution Max: $2,550

Dependent Care Annual Max: $5,000

Account Information: Participant Account Web Access: www.participant.nbsbenefits.com Participants may call NBS and talk to a representative during regular business hours, Monday-Friday, 8 am to 7 pm Central Time. Participants can also obtain account information using the Automated Voice Response Unit, 24 hours a day, 7 days a week at (801) 838-7324 or toll free (800) 274-0503. For immediate access to your account information at any time, log on to the NBS website: www.NBSbenefits.com

Detailed claim history and processing status

Health Care and Dependent Care Account balances

Claim forms, direct deposit form, worksheets, etc.

Online claim FAQs

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

NBS Contact Information:

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

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

FSA (Flexible Spending Account)

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

NBS Prepaid MasterCard® Debit Card

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

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

Health Care Expense Account Example Expenses:

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

The actual care of the dependent in your home.

Preschool tuition.

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

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

What Happens If I Don’t Use All of My Funds by The End of the Plan Year (August 31st)? Eligible expenses must be incurred within the plan year +75 day grace period. Contributions are use-it-or- lose-it. Remember to retain all your receipts (including receipts for card swipes).

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

Hearing aids & batteries

Lab fees

Laser Surgery

Orthodontia Expenses

Physical exams

Pregnancy tests

Prescription drugs

Vaccinations

Vaporizers or humidifiers

Acupuncture

Body scans

Breast pumps

Chiropractor

Co-payments

Deductible

Diabetes Maintenance

Eye Exam & Glasses

Fertility treatment

First aid

FSA Frequently Asked Questions

How To Receive Your Dependent Care Reimbursement Faster.

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

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How the FSA Plan Works

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

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

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

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

Detailed claim history and processing status

Health Care and Dependent Care account balances

Claim forms, worksheets, etc.

Online Claim Submission

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

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

About this Benefit

HSA (Health Savings Account)


The interest earned in an HSA is tax free.

DID YOU KNOW?

Money withdrawn for medical spending never falls under taxable income.

HSA BANK



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

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

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

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

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

Using Funds Debit Card

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

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

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

Health Savings accountholder

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

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

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

Examples of Qualified Medical Expenses Surgery

Braces

Contact lenses

Dentures

Eyeglasses

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

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

HSA (Health Savings Account)

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

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

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

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

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

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

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

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

You cannot be covered by TriCare.

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

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

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

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

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

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

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

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

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

HSA funds earn interest and investment earnings are tax free.

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

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

How the HSA Plan Works

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How the HSA Plan Works

Examples of IRS-Qualified Medical Expenses4:

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

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

Gynecologist Hearing aids and batteries Hospital bills Insurance premiums5

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

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

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www.mybenefitshub.com/boerneisd

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2016 benefit guide boerne isd

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