central texas employee benefits cooperative

Central Texas

Employee Benefits Cooperative

Employee Benefit Guide EFFECTIVE 09/01/2020 - 08/31/2020

( www.ctxebc.com )

Benefit Contact Informa on

Program Vendor Phone Number Website/Email

(Customer Service) 66.513.1518

www.voya.com

5

800.583 6908

Refer to this list when you need to contact one of your benefit providers. For general information please contact your Benefits Department, Combined Benefits Group, Financial Benefit Services or log on to www.ctxebc.com.

1

During your annual enrollment period, you have the opportunity to review, change or con nue benefit elec ons each year. Changes are not permi ed during the plan year unless a Sec on 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 providecoverage 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 isselected in order to be included in the coverage for that particular benefit.

All new hire enrollment elec ons must be completed in the online enrollment system within the first 31 days of benefit eligibility employment. Failure to complete elec ons during this meframe will result in the forfeiture of coverage.

Who do I contact with Ques ons? For supplemental benefit ques ons, you can contact your Benefits/HR department or you can call Combined Benefits Group at 800.749.6458 or Financial Benefit Services at 800.583.6908 for assistance.

Where can I find forms? For benefit summaries and claim forms, www.ctxebc.com Click on the benefit plan you need informa on on (i.e., Dental) and you can find the forms you need under the Benefits and Forms sec on.

How can I find a Network Provider? For benefit summaries and claim forms, www.ctxebc.com 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 a er your effec ve 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 me. If you do not receive your ID card, you can call the carrier’s customer service number to request another card.

Annual Enrollment

New Hire Enrollment

Q&A

2

Plan Carrier Child Maximum Age Continuation Hospital Indemnity To 26 Portable

Dental First Continental Life Unmarried to 26 COBRA

Telehealth MDLIVE Unmarried to 26 Contact for individual plan

Vision Superior Vision Unmarried to 26 COBRA

Cancer American Public Life To 26 Portable if covered 12 mos.

Within 30 days of termination

Accident and Critical Illness

Voya To 26 Portable

Voluntary Life & AD&D

OneAmerica Unmarried to 26 Portable or Convertible

Within 30 days of termination

ID Theft Protection

ID Watchdog Unmarried to 26 Contact for individual plan

Legal Protection LegalShield To 26 Contact for individual plan

Medical Flex National Benefit Services To 26 COBRA, restrictions apply

Dependent Flex National Benefit Services 12 or younger or qualified individual

unable to care for themselves & claimed as a dependent on your taxes

Not applicable

Emergency Transportation

MASA To 26 Contact for individual plan

Health Savings Account

HSA Bank 26 (benefits terminate at the end of the plan year following the birthday)

Contact for individual plan

Dependent Eligibility: You can cover eligible dependent children under a benefit that offers dependent coverage, provided you par cipate in the same benefit, up to the maximum age listed below. Dependents cannot be double covered by married spouses within the CTXEBC Coop or as employees and dependents.

If your dependent is disabled, coverage can con nue 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 .

Dependent Eligibility Requirements

Supplemental Benefits: Eligible employees must work 20 or more regularly scheduled hours each work week.

Eligible employees must be ac vely at work on the plan effec ve date for new benefits to be effec ve, meaning you are physically capable of performing the func ons of your job on the first day of work concurrent with the plan effective date. For example, if your 2020 benefits become effective on September 1, 2020, you must be actively-at-work on September 1, 2020 to be eligible for your new benefits.

Employee Eligibility Requirements

! 3

Changes In Status (CIS): Qualifying Events

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

Change in Number of Tax Dependents

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

Change in Status of Employment Affec ng

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 termina on of employment.

Gain/Loss of Dependents' Eligibility Status

An event that causes an employee's dependent to sa sfy or cease to sa sfy 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 elec on 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 elec on 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 permi ed elec on 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 automa c unless you decline this benefit. Elec ons made during annual enrollment will become effec ve on the plan effec ve date and will remain in effect during the en re plan year.

Changes in pre-tax benefit elec ons 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/Administrator to complete and sign the necessary paperwork in order to make a benefit elec on change. Benefit changes must be consistent with the qualifying event.

Section 125 Cafeteria Plan Guidelines

4

iHelpful Definitions www.ctxebc.com

Actively at Work

This is only a generic list of defini ons, the defini ons in the cer ficate of coverage or policy will govern.

The most an eligible or insured person can pay in coinsurance for covered expenses.

Out-of-Pocket Maximum

Pre-Existing Condition

Applies to any illness, injury or condi on for which the par cipant has been under the care of a health care provider, taken prescrip ons drugs or is under a health care provider’s orders to take drugs, or received medical care or services (including diagnos c and/or consulta on services within the designated period immediately preceding the effec ve date of change).

Plan Year

September 1st through August 31st.

You are performing your regular occupa on for the employer on a full- me 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 9/1/2020 please notify your Benefits Administrator.

Annual Enrollment The period during which exis ng employees and their dependents are given the opportunity to enroll in or change their current elec ons.

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 The percent of eligible charges that the plan pays.

Guaranteed Coverage

The amount of coverage you can elect without answering any medical ques ons or taking a health exam. Guaranteed coverage is only available during Ini al Enrollment and other mes as approved.

In-Network

Doctors, hospitals, optometrists, den sts and other providers who have contracted with the plan.

5

Extra coverage to help pay for the unexpected!

Aetna Hospital Indemnity Plan

For medical costs or everyday living expenses Medical plans help you pay for covered out-of-pocket costs when you’re in the hospital. But they don’t cover all expenses.

For a little help paying these other costs, there’s the Aetna Hospital Indemnity Plan. You can use it to cover your deductible and coinsurance costs. Or for things like a mortgage, child care or utility bills.

More features you’ll like •It's affordable and you won't be turned down for health

reasons.•Covered benefits include payments for planned and

unplanned events.• Payments are made directly to you.•Your premium payments can be made through payroll

deductions at work.

Why is a Hospital Indemnity plan important?

At least 35 million Americans are hospitalized each year.1

2 outof

covered 4

workers …

deductible of $1,000or more for single coverage.2

63% Of Americans Don't Have EnoughSavings To Cover A $500 Emergency3

¹American Hospital Association. Fast Facts on US Hospitals 2017. Article online. Available at: http://www.aha.org/research/rc/stat-studies/fast-facts.shtml. Accessed March 16, 2017.

2The Kaiser Family Foundation, Health Research & Educational Trust. 2014 Employer Health Benefits Survey. September 10, 2014. 3Americans Don't Have Enough Savings To Cover A $500 Emergency. Article online. January 6, 2016. Available at: https://www.forbes.com/sites/maggiemcgrath/2016/01/06/63-of-americans-dont-have-enough-savings-to-cover-a-500-emergency/#3d59d4cd4e0d. Accessed March 2017.

Submitting claims is easy

Aetna’s simplified online claims process If you are an Aetna medical plan member, we can retrieve your medical information to process your Hospital Indemnity claim. Here’s how it works.

Covered benefits

Submit your Hospital Indemnity claim using the online claim form

Our system matches this claim to your medical claim and

retrieves the necessary medical information

Your Hospital Indemnity claim is

processed

Payments are sent directly to

you

Not an Aetna medical plan member? Just upload your medical paperwork when submitting your claim.

Here's How: 1. Go to myaetnasupplemental.com.2. Click the "Create a new claim" button, answer a few quick questions, and submit.Your payment for covered services will be on the way.That’s all there is to it!Claims can be completed online at myaetnasupplemental.com or printed and mailed to: Aetna Voluntary Plans, PO Box 14079, Lexington, KY 40512-4079.

THIS PLAN DOES NOT COUNT AS MINIMUM ESSENTIAL COVERAGE UNDER THE AFFORDABLE CARE ACT. THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE. LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL TAX PAYMENT BY EMPLOYEES. This plan provides limited benefits. The benefit payments are not intended to cover the full cost of medical care. Members are responsible for making sure the providers’ bills get paid. These benefits are paid in addition to any other health coverage members may have. Health insurance plans are offered and/or underwritten by Aetna Life Insurance Company (Aetna). This material is for information only. Health insurance plans contain exclusions and limitations. Not all health services are covered, and coverage is subject to applicable laws and regulations, including economic and trade sanctions. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features, rates, eligibility and availability may vary by location and are subject to change. Aetna does not provide care or guarantee access to health services. Information is believed to be accurate as of the production date; however, it is subject to change. For more information about Aetna plans, refer to www.aetna.com. Policy form numbers issued in Oklahoma and Missouri include: AL VOL HPOL-Hosp 01 and AL VOL HCOC-Hosp 01.

www.aetna.com ©2018 Aetna Inc. 57.02.408.1 (0 /18)

¡Cobertura adicional paraayudar a pagar lo inesperado!

Plan de Indemnización hospitalaria de Aetna

Para gastos médicos o gastos de la vida cotidianaLos planes médicos le ayudan a pagar los gastos de bolsillo cubiertos cuando está en el hospital. Pero no cubren todos los gastos.

Por un poco de ayuda para pagar estos otros gastos, está el Plan de Indemnización hospitalaria de Aetna. Se puede utilizar paracubrir sus costos de deducible y coseguro. O para cosas como pagos de hipoteca, guardería infantil o facturas de servicios públicos.

Más características que le gustarán •Es económico y no será rechazado por razones de salud.•Los beneficios cubiertos incluyen pagos por eventos planeados

y no planeados.• Los pagos se envían directamente a usted.•Sus pagos de prima pueden hacerse a través de deducciones

de nómina en el trabajo.

¿Por qué es importante un Plan de Indemnización hospitalaria?

al menos 35 millones de estadounidenses son hospitalizados cada año.1

2 detrabajadores

4 cubiertos …

deducible de $1,000 o más de cobertura por persona.2

63% de los estadounidenses no tienen ahorros suficientes para cubrir una emergencia3 de $500

¹American Hospital Association. (Hechos rápidos sobre los hospitales de los EE.UU.) 2017.Artículo en Internet. Disponible en: www.aha.org/research/rc/stat-studies/fast-facts.shtml. Consultado el 16 de marzo de 2017.

2The Kaiser Family Foundation, Health Research & Educational Trust. Encuesta anual 2014 de los beneficios de empleadores.10 de septiembre de 2014.

3Americans Don't Have Enough Savings To Cover A $500 Emergency. Artículo en Internet. Enero de 2016. Disponible en:https://www.forbes.com/sites/maggiemcgrath/2016/01/06/63-of-americans-dont-have-enough-savings-to-cover-a-500-emergency/#3d59d4cd4e0d. Consultado en marzo de 2017.

Presentar reclamos es fácil

Proceso simplificado de reclamos en Internet de Aetna Si usted es miembro del plan médico de Aetna, podemos recuperar su información médica para procesar su reclamo de indemnización hospitalaria. Así es cómo funciona.

Beneficios cubiertos

Envíe su reclamo de Indemnización

hospitalaria usando el formulario de

reclamos en Internet

Nuestro sistema combina este reclamo con el reclamo médico

para recuperar la información médica

necesaria

Se procesa su reclamo de Indemnización

hospitalaria

Los pagos se envían

directamente a usted

¿No es miembro del plan médico Aetna? Simplemente suba su documentación médica cuando presente su reclamo.

Así es cómo: 1. Vaya a myaetnasupplemental.com.2. Haga clic en el botón "Crear un nuevo reclamo", responda algunas preguntas rápidas y envíe el reclamo.Su pago por los servicios cubiertos estará en camino.¡Eso es todo lo que necesita hacer!Los reclamos se pueden completar en Internet en myaetnasupplemental.com o se pueden imprimir e enviar por correo a: Aetna Voluntary Plans, PO Box 14079, Lexington, KY 40512-4079.

ESTE PLAN NO CUENTA COMO COBERTURA ESENCIAL MÍNIMA SEGÚN LA LEY DE CUIDADO DE SALUD A BAJO PRECIO. ESTE ES UN COMPLEMENTO DEL SEGURO MÉDICO Y NO SUSTITUYE LA COBERTURA MÉDICA PRINCIPAL. LA FALTA DE COBERTURA MÉDICA PRINCIPAL (U OTRACOBERTURA ESENCIAL MÍNIMA) PUEDE RESULTAR EN UN PAGO ADICIONAL DE IMPUESTOS POR PARTE DE LOS EMPLEADOS. Este plan proporciona beneficios limitados. Los pagos de los beneficios no están destinados a cubrir el costo total de la atención médica. Los miembros son responsables de asegurar que se paguen las facturas del proveedor. Estos beneficios se pagan además de cualquier otra cobertura médica que los miembros puedan tener. Los planes de seguro médico son ofrecidos y/o suscritos por Aetna Life Insurance Company (Aetna). Este material es sólo para fines informativos. Los planes de seguro médico tienen exclusiones y limitaciones. No todos los servicios médicos están cubiertos, y la cobertura está sujeta a las leyes y reglamentos aplicables, incluidas las sanciones económicas y comerciales. Consulte los documentos del plan para obtener una descripción completa de los beneficios, exclusiones, limitaciones y condiciones de la cobertura. Las características, tarifas, elegibilidad y disponibilidad del plan pueden variar según la ubicación y están sujetas a cambios. Aetna no brinda atención médica ni garantiza el acceso a servicios médicos. Si bien se cree que la información dada en el presente documento es precisa a la fecha de producción, está sujeta a cambios. Para más información sobre los planes de Aetna, consulte www.aetna.com. Los formularios de póliza emitidos en Oklahoma y Missouri incluyen: AL VOL HPOL-Hosp 01 y AL VOL HCOC-Hosp 01.

www.aetna.com ©2018 Aetna Inc. 57.02.408.2 (0 /18)

Health Savings AccountsAnnual IRS Contribution Limits

Contributions made by all parties to a Health Savings Account (HSA) cannot exceed the annual HSA limit set by the Internal Revenue Service. Anyone can contribute to your HSA, but only the accountholder and employer can receive tax deductions on those contributions.

Combined annual contributions from the accountholder, employer, and third parties (i.e., parent, spouse, or anyone else) must not exceed these limits*.

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.

Catch-Up Contributions

Accountholders who meet the qualifications noted below 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)

Spouses who are 55 or older and covered under the accountholder’s medical insurance can also make a catch-up

contribution into a separate HSA in their own name.

*HSA funds contributed in excess of these limits are subject to penalty and tax unless the excess and earnings are withdrawn priorto the due date, including any extensions for filing Federal Tax returns. Accountholders should consult with a qualified tax advisorin connection with excess contribution removal. The Internal Revenue Service requires HSA Bank to report withdrawals that areconsidered refunds of excess contributions. In order for the withdrawal to be accurately reported, accountholders may not withdrawthe excess directly. Instead, an excess contribution refund must be requested from HSA Bank and an Excess Contribution RemovalForm completed.

© 2019 HSA Bank. HSA Bank is a division of Webster Bank, N.A., Member FDIC.Contribution_Limits_060419

2019 Annual HSA Contribution Limits

Individual = $3,500 Family = $7,000

2020 Annual HSA Contribution Limits

Individual = $3,550 Family = $7,100

Please call the number on the back ofyour HSA Bank debit card or visit us atwww.hsabank.com

Cuentas de ahorros médicosLímites de contribución anual del IRS

Las contribuciones realizadas por todas las partes a una cuenta de ahorros médicos (Health Savings Account, HSA) no pueden exceder el límite anual de la HSA establecido por el Servicio de Impuestos Internos (Internal Revenue Service, IRS). Cualquier persona puede hacer contribuciones a su HSA, pero sólo el dueño de la cuenta y el empleador pueden recibir las deducciones fiscales sobre dichas contribuciones.

Las contribuciones anuales combinadas del dueño de la cuenta, el empleador y terceras personas o negocios (p. ej., padre o madre, cónyuge u otra persona) no deben exceder estos límites.*

De acuerdo con las pautas del IRS, cada año usted tiene hasta la fecha límite de la declaración de impuestos para realizar las contribuciones a su HSA (por lo general, el 15 de abril del siguiente año). Las contribuciones en línea deben realizarse antes de las 2:00 p.m., Hora del Centro, el día hábil anterior a la fecha límite para la declaración de impuestos. Las contribuciones electrónicas deben recibirse antes del mediodía, Hora del Centro, en la fecha límite para presentar la declaración de impuestos, y los formularios de contribución con cheques deben recibirse antes de la fecha límite para presentar la declaración de impuestos.

Contribuciones Extras HSA

Los dueños de la cuenta que cumplan las especificaciones que se mencionan a continuación pueden realizar una contribución de extra a la HSA de $1,000.

• Dueño de la cuenta de ahorros médicos• Después de los 55 años de edad o mayores (sin importar la fecha en la que el dueño de la cuenta cumple 55

años)• No está inscrito en Medicare (si el dueño de la cuenta se inscribe en Medicare a medio año, el dueño de la

cuenta debe hacer un promedio de las contribuciones extras)

Los cónyuges que tienen 55 años de edad o más y están cubiertos por el seguro de salud del titular de la cuenta también pueden hacer una contribución para ponerse al día en una HSA separada que está a su nombre.

*Los fondos de la HSA que se hayan pagado y excedan estos límites están sujetos a una penalización y a impuestos, a menos que elexceso y los rendimientos se retiren antes de la fecha de vencimiento, incluida cualquier ampliación para presentar la declaración deimpuestos federales. Los dueños de la cuenta deben consultar a un asesor fiscal calificado con respecto al retiro del exceso de lascontribuciones. El Servicio de Impuestos Internos requiere que HSA Bank informe sobre los retiros que se consideran reembolsos delexceso de las contribuciones. Con el fin de que el retiro se informe de manera precisa, los dueños de la cuenta no pueden realizar elretiro del exceso directamente. En vez de eso, se debe solicitar el reembolso del retiro de las contribuciones a HSA Bank y debellenarse un Formulario de retiro del exceso de las contribuciones.

©2019 HSA Bank. HSA Bank is a division of Webster Bank, N.A., Member FDIC.Contribution_Limits_Spanish_060319

Llame al número que figura en el reverso desu tarjeta de débito de HSA Bank o visítenos enwww.hsabank.com

Límites de contribución anual de unaHSA para 2019

Individual = $3,500 Familiar = $7,000

Límites de contribución anual de unaHSA para 2020

Individual = $3,550 Familiar = $7,100

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• Insect Bites• Nausea / Vomiting• Pink Eye• Rash• Respiratory Problems• Sore Throats• And More

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• Consults by mobile app, video or phone

• Prescriptions can be sent to your nearestpharmacy if medically necessary

Copyright © 2019 MDLIVE Inc. All Rights Reserved. MDLIVE may not be available in certain states and is subject to state regulations. MDLIVE does not replace the primary care physician, is not an insurance product and may not be able to substitute for traditional in person care in every case or for every condition. MDLIVE does not prescribe DEA controlled substances and may not prescribe non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. MDLIVE does not guarantee patients will receive a prescription. Healthcare professionals using the platform have the right to deny care if based on professional judgment a case is inappropriate for telehealth or for misuse of services. MDLIVE and the MDLIVE logo are registered trademarks of MDLIVE, Inc. and may not be used without written permission. For complete terms of use visit https://www.MDLIVE.com/terms-of-use/.

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Texas- DenteMax

Passive PPO Dental Plan (100/80/50)

Annual Benefit - Per Person . . . . . . . . . . . . . . . . $1,000 Percentage of Covered Benefits Per Policy Year

TYPE I TYPE II TYPE III* DURING THE 1ST YEAR 100% 80% 0% 2ND YEAR AND THEREAFTER 100% 80% 50%

* 12-month waiting periodCalendar Year Deductible, Per Person $50/150

This deductible applies to Type II and III services Dependent Children Covered to Age 26

Payment is based upon allowable charges in the area in which service is rendered. Services provided at a non-contracting provider are paid at the 90th percentile.

TYPE I (PREVENTIVE SERVICES) Including: • No waiting period • Routine Exams ( one per 6 months) • Prophylaxis (cleanings-one per 6 months) • Emergency exams for dental pain (minor

procedures) • Fluoride treatments for dependent children under

age 19 (one per 12 months) • Bitewing X-rays (once per 6 months)

TYPE III (MAJOR SERVICES) Including: • 12 month waiting period • Major restorative services (crowns and inlays) • Prosthetics (bridges, dentures) • Replacement of prosthodontics, dentures, crowns

and inlays • Denture relines • General anesthesia (for services dentally necessary) • Space Maintainers

ORTHODONTIC SERVICES• 12 month waiting period • 50% coverage – children under 19 • $1,000 lifetime maximum benefit

Renewal Date: September 1, 2019

Employee $24.84 Employee + Spouse $51.75 Employee +Child(ren) $57.36 Employee + Family $88.51

Marketed, Administered and Underwritten By: ——————————————————————————————

FIRST CONTINENTAL LIFE & ACCIDENT INSURANCE CO. 101 Parklane Blvd, Suite 301

Sugar Land, TX 77478 (281) 313-7150 - (877) 493-6282

Fax (281) 313-7155

TYPE II (BASIC SERVICES) Including: • No waiting period • Periapical X-rays • Simple restorative services (fillings) • Simple extractions • Palliative treatment for dental pain, local anesthesia • Endodontics/root canal therapy • Periodontics • Oral Surgery • Sealants for children ages 6-15 (one per tooth) • Periapical X-rays • Full mouth or panorex X-rays (one per 36 months)

ODP 185 TX (MKTG) VOLFCL (01/05)

Limitations and Exclusions Covered Expenses Will Not Include and No Benefits Will be Payable:

1. For any treatment which is for cosmetic purposes or to correctcongenital malformations, except for medically necessary care andtreatment of congenital cleft lip and palate.

2. To replace any prosthetic appliance, crown, inlay or onlayrestoration, or fixed bridge within five years of the date of the lastplacement of these items, unless required because of an accidentalbodily injury sustained while the Insured is covered. Replacementis not covered if the item can be repaired.

3. For initial placement of any prosthetic appliance or fixed bridgeunless such placement is needed because of the extraction ofnatural teeth during the same period of continuous coverage. Butthe extraction of a third molar (wisdom tooth) will not qualify theitem for payment. Any such appliance or fixed bridge mustinclude the replacement of the extracted tooth or teeth. Coveragedoes not include the part of the cost that aplies specifically toreplacement of teeth extracted prior to the period of coverage.

4. For addition of teeth to an existing prosthetic appliance or fixedbridge unless for replacement of natural teeth extracted during thesame period of continuous coverage.

5. For any expense incurred or procedure begun before the Insured’scurrent period of continuous coverage.

6. For any expense incurred or procedure begun after the Insured’sinsurance under this section terminates, except for a prosthetic appliance, fixed bridge, crown, or inlay or onlay restoration forwhich both (a) the procedure begins before insurance ends and (b)the item’s final placement is within 90 days after insurance ends.

7. To duplicate appliances or replace lost or stolen appliances.8. For appliances, restorations or procedures to:

a. alter vertical dimension;b. restore or maintain occlusion;c. splint or replace tooth structure lost as a result of

abrasion or attrition; ord. treat jaw fractures or disturbances of the

temporomandibular joint.9. For education or training in, and supplies used for, dietary or

nutritional counseling, personal oral hygiene or dental plaquecontrol.

10. For broken appointments or the completion of claim forms.11. For orthodontia service or for any services associated with

orthodontic therapy when this optional coverage is not elected andthe premium is not paid.

12. For sealants which are:a. not applied to a permanent molar;b. applied before age 6 or after attaining age 16; orc. reapplied to a molar within three years from the date

of a previous sealant application.13. For subgingival curettage or root planing (procedure numbers

4220 and 4341) unless the presence of periodontal disease isconfirmed by both x-rays and pocket depth summaries of eachtooth involved.

14. Because of an Insured’s injury arising out of, or in the course of,work for wage or profit.

15. For an Insured’s sickness, injury or condition for which he or sheis eligible for benefits under any Workers Compensation Act orsimilar laws.

16. For charges for which the Insured is not liable or whichwould not have been made had no insurance been in force.

17. For services which are not recommended by a dentist, notrequired for necessary care and treatment, or do not have areasonably favorable prognosis.

18. Because of war or any act of war, declared or not, or while onfull-time active duty in the armed forces of any country.

19. To an Insured if payment is not legal where the Insured isliving when expenses are incurred.

20. For any services related to: equilibration, bite registration orbite analysis.

21. For crowns for the purpose of periodontal splinting.22. For charges for: any implants; overdentures; precision or

semi-precision attachments and associated endodontictreatment; other customized attachments; or specializedprosthodontic techniques or characterizations.

23. For charges for myofunctional therapy, orthognathic surgeryor athletic mouthguards.

24. For procedures for which benefits are payable under theemployer’s medical expense benefits plan for employees andtheir dependents.

25. Services or supplies provided by a family member or amember of the Insured’s household.

Note: This is a general outline of covered benefits and does not include all the benefits, limitations and exclusions of the policy. See your certificate for details.

Predetermination of Benefits: As a service to protect the Insured, First Continental Life & Accident Insurance Co. will provide predetermination of benefits for recommended treatment plans that exceed $300. This predetermination of benefits explains which of the recommended procedures will be covered and at what amount. This benefit helps Insured's better understand their coverage. The Insured should submit the treatment plan to First Continental Life & Accident Insurance Co. for review and predetermination of benefits before the service begins.

TAKEOVER BENEFITS Takeover means that you are given credit for waiting periods for like coverage's accumulated under your existing plan. No credit is given for deductibles satisfied under your existing plan. 1. In order to provide Takeover Benefits your employer’s current

dental plan must have been in effect continuously for at least 12months prior to the effective date of this plan.

2. All employees insured on the effective date with continuouscoverage from the prior group dental contract are eligible forTakeover Benefits. Waiting periods will be reduced by theamount of time insured under the prior plan.

3. A minimum of three (3) enrolled members are needed for anemployer to be eligible for Takeover Benefits.

4. Takeover Benefits must be requested and are subject to theapproval of First Continental Life & Accident Insurance Co.

Submission of Claims: First Continental Life & Accident Insurance Co. ATTN: Claims Department 101 Parklane Blvd, Suite 301 Sugar Land, TX. 77478

Superior Vision of Texas P.O. Box 967 Rancho Cordova, CA 95741 (800) 507-3800 superiorvision.com 0119-BSv2/TX

superiorvision.com

(800) 507-3800

Vision plan benefits for Central Texas Employee Benefits

Copays Monthly premiums Services/frequency Exam1 $10 Emp. only $6.65 Exam 12 months Eyewear2 $25 Emp. + spouse $11.36 Frame 24 months Emp. + children $12.01 Lenses 12 months Emp. + family $18.01 Contact lenses 12 months

(Based on date of service) Benefits through Superior Select Southwest network

In-network Out-of-network Exam Covered in full Up to $35 retail Frames $125 retail allowance Up to $70 retail Lenses (standard) per pair Single vision Covered in full Up to $25 retail Bifocal Covered in full Up to $40 retail Trifocal Covered in full Up to $45 retail Progressive See description3 Up to $45 retail Contact lenses4 $150 retail allowance Up to $80 retail Medically necessary contact lenses Covered in full Up to $150 retail LASIK vision correction5 $200 allowance

Co-pays apply to in-network benefits; co-pays for out-of-network visits are deducted from reimbursements 1 Eye exam copay is a single payment due to the provider at the time of service. 2 Eyewear copay applies to eyeglass lenses / frame and contact lenses. Eyewear copay is a single payment that applies to the entire purchase of eyeglasses (frame and lenses) 3Covered to provider’s in-office standard retail lined trifocal amount; member pays difference between progressive and standard retail lined trifocal, plus applicable co-pay 4 Contact lenses and related professional services (fitting, evaluation and follow-up) are covered in lieu of eyeglass lenses and frames benefit 5 Lasik Vision Correction is in lieu of eyewear benefit, subject to routine regulatory filings and certain exclusions and limitations

Discount features Non-covered eyewear discount: members may also receive a discount of 20% from a participating provider’s usual and customary fees for eyewear purchases which exceed the benefit coverage (except disposable contact lenses, for which no discount applies). This includes eyeglass frames which exceed the selected benefit coverage, specialty lenses (i.e. progressives) and lens “extras” such as tints and coatings. Eyewear purchased from a Walmart Vision Center does not qualify for this additional discount because of Walmart’s “Always Low Prices” policy. The national LASIK network of laser vision correction providers, featuring LasikPlus, offers members special program pricing on services. The program pricing should be verified prior to service.

.

The Plan discount features are not insurance. All allowances are retail; the member is responsible for paying the provider directly for all non-covered items and/or any amount over the allowances, minus available discounts. These are not covered by the plan. Discounts are subject to change without notice. Disclaimer: All final determinations of benefits, administrative duties, and definitions are governed by the Certificate of Insurance for your vision plan. Please check with your Human Resources department if you have any questions.

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Full-time Employee Requirement An eligible employee is a full-time permanent employee authorized to work and reside in the United States. Eligible employees must work 20 or more hours per week and cannot be considered a part-time, temporary or seasonal employee. If any eligible employee is not actively at work on the individual effective date, group insurance coverage for that employee will not exist until he/she returns to full-time active work.

Life Amount $10,000

Guaranteed Issue Amount $10,000

Accelerated Life Benefit The Employee may request payment of 25%, 50%, or 75% of the Life Amount if the Employee is diagnosed with a terminal condition, as defined in the Certificate.

Waiver of Premium AUL may waive further premium payments for the Employee's Life Amount if the Employee becomes Totally Disabled before age 60 while insured under the Policy, and remains continuously Totally Disabled for 6 months, and submits proof of Total Disability.

Accidental Death & Dismemberment

(AD&D) Principal Sum Amount

$10,000

For additional benefit information, please contact your HR Representative or call OneAmerica at 800-553-5318. 6/27/2014Page 1 of 2

Central Texas Employee Benefits CooperativeBasic Life Benefit Summary

Class 1 - All Eligible Full Time Employees

Reduction Schedule The Life Amount and AD&D Principal Sum will reduce to 65% of the amount shown above when the Employee reaches age 65. See Certificate for further benefit reductions due to age.

Loss Schedule LossLife [AD&D Principal Sum]Both hands or both feet or sight of both eyes [AD&D Principal Sum]Speech and hearing [AD&D Principal Sum]One hand and one foot [AD&D Principal Sum]One hand and sight of one eye [AD&D Principal Sum]One foot and sight of one eye [AD&D Principal Sum]Sight of one eye [Half of AD&D Principal Sum]One hand or one foot [Half of AD&D Principal Sum]Speech or hearing [Half of AD&D Principal Sum]Thumb and index finger [Quarter of AD&D Principal Sum]

ConditionsQuadriplegia or Loss of Use of Upper and Lower Limbs of the Body [AD&D Principal Sum]Paraplegia or Loss of Use of Both Lower Limbs of the Body [Half of AD&D Principal Sum]Hemiplegia or Loss of Use of Upper and Lower Limbs on the Same Side of the Body [Half of AD&D Principal]Monoplegia or Loss of Use of One Limb of the Body [Quarter of AD&D Principal]Severe Burns [AD&D Principal Sum]The total amount payable will never exceed the AD&D Principal Sum for all losses or conditions sustained by the Employee.

Conversion If the Employee's Life Insurance or a portion of it ceases, the Employee may be entitled to convert his / her life amount. The Employee can refer to his or her Certificate for specific details of this provision.

Accidental Death & Dismemberment While insured under the Policy, if the Employee has an accident which results in a loss or condition specified in the chart below, AUL will pay the amount shown. The loss or condition must occur within 365 days from the date of the accident and AUL must receive acceptable proof of loss or condition.

Benefit Features Offered for Basic

Term Life and AD&D

Seat BeltAir BagExposureDisappearanceRepatriationChild Higher EducationChild Care

Exclusions This plan will not cover any disability resulting from war, declared or undeclared or any act of war; active participation in a riot; intentionally self-inflicted injuries; commission of an assault or felony.

This information is provided as a Benefit Outline. It is not a part of the insurance policy and does not change or extend American United Life Insurance Company’s® liability under the group Policy. Employers may receive either a group Policy or a Certificate of Insurance containing a detailed description of the insurance coverage under the group Policy. If there are any discrepancies between this information and the group Policy, the Policy will prevail.

For additional benefit information, please contact your HR Representative or call OneAmerica at 800-553-5318. 6/27/2014Page 2 of 2

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

About this Benefit

Cancer YOUR BENEFITS

Breast Cancer is the most commonly diagnosed cancer in women.

DID YOU KNOW?

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

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

Central Texas EBC Benefits Website: www.ctxebc.com

AMERICAN PUBLIC LIFE

(03/16)

20

GC3 Limited Benefit Group Cancer Indemnity Insurance

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

Level 1 Plan Level 2 Plan

$50 per treatment, up to 12 per calendar year $50 per treatment, up to 12 per calendar year

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




$150 per day, up to $7,500 per calendar year $200 per day, up to $10,000 per calendar year

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

Autologous - $1,000 per calendar year Non-Autologous - $3,000 per calendar year

$200 per ground trip $200 per ground trip

$100 per day $200 per day

$100 per day $200 per day

required required

21


Level 1 Level 2

$16.30 $19.60 $24.50 $27.80

One-Parent Family $22.80 $27.30 $34.00 $38.50

Two-Parent Family $29.00 $35.90 $43.20 $50.10

22

-

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


23

Compass Accident InsuranceEnrollment at a glance

For the employees of: Central Texas Employee Benefits Cooperative #70097-5

What is Accident Insurance?Accident Insurance pays you benefits for specific injuries and events resulting from a covered accident that occurs while you are not at work, on or after your coverage effective date. The benefit amount depends on the type of injury and care received. Your employer provides Accident Insurance to meet your needs. Accident Insurance is a limited benefit policy. It is not health insurance and does not satisfy the requirement of minimum essential coverage under the Affordable Care Act.

Features of Accident Insurance include:• Guaranteed issue: No medical questions or tests are required for coverage.• Flexible: You can use the benefit payments for any purpose you like. • Portable: If you leave your current employer or retire, you can take your coverage with you.

How can Accident Insurance help?Below are a few examples of how your Accident Insurance benefits could be used:

• Medical expenses, such as deductibles and copays• Home healthcare costs• Lost income due to lost time at work • Everyday expenses like utilities and groceries

What accident benefits are available?The following list is a summary of the benefits provided by Accident Insurance. You may be required to seek care for your injury within a set amount of time. Note that there may be some variations by state. For a list of standard exclusions and limitations, go to the end of this document. For a complete description of your available benefits, exclusions and limitations, see your certificate of insurance and any benefits.

Event BenefitAccident hospital care

Surgery open abdominal, thoracic $1,200Surgery exploratory or without repair $175Blood, plasma, platelets $600Hospital admission $1,250Hospital confinement per day, up to 365 days $375Critical care unit confinement per day, up to 15 days $600Rehabilitation facility confinement per day, up to 90 days $200Coma duration of 14 or more days $17,000Transportation per trip, up to three per accident $750Lodging per day, up to 30 days $180Family care per child per day, up to 45 days $25

Accident careInitial doctor visit $90Urgent care facility treatment $225Emergency room treatment $225Ground ambulance $360Air ambulance $1,500

ReliaStar Life Insurance Company, a member of the Voya® family of companies.

Follow-up doctor treatment $90Chiropractic treatment up to six per accident $45Medical equipment $120Physical or occupational therapy up to six per accident $45Speech therapy up to 6 per accident $45Prosthetic device (one) $750Prosthetic device (two or more) $1,200Major diagnostic exam $240Outpatient surgery (one per accident) $225X-ray $45Common injuriesBurns second degree, at least 36% of the body $1,250Burns third degree, at least nine but less than 35 square inches of the body $7,500

Burns third degree, 35 or more square inches of the body $15,000Skin grafts 25% of the burn benefitEmergency dental work $350 crown, $90 extractionEye injury removal of foreign object $100Eye injury surgery $350Torn knee cartilage surgery with no repair or if cartilage is shaved $225

Torn knee cartilage surgical repair $800Laceration1 treated no sutures $30Laceration1 sutures up to 2” $60Laceration1 sutures 2” – 6” $240Laceration1 sutures over 6” $480Ruptured disk surgical repair $800Tendon/ligament/rotator cuff exploratory arthroscopic surgery with no repair $425

Tendon/ligament/rotator cuff one, surgical repair $825Tendon/ligament/rotator cuff two or more, surgical repair $1,225Concussion $225Paralysis - paraplegia $16,000Paralysis - quadriplegia $24,000Dislocations Closed/open reduction2

Hip joint $3,850/$7,700Knee $2,400/$4,800Ankle or foot bone(s) other than toes $1,500/$3,000Shoulder $1,600/$3,200Elbow $1,100/$2,200Wrist $1,100/$2,200Finger/toe $275/$550Hand bone(s) other than fingers $1,100/$2,200Lower jaw $1,100/$2,200Collarbone $1,100/$2,200Partial dislocations 25% of the closed reduction amount


Fractures Closed/open reduction3

Hip $3,000/$6,000Leg $2,500/$5,000Ankle $1,800/$3,600Kneecap $1,800/$3,600Foot excluding toes, heel $1,800/$3,600Upper arm $2,100/$4,200Forearm, hand, wrist except fingers $1,800/$3,600Finger, toe $240/$480Vertebral body $3,360/$6,720Vertebral processes $1,440/$2,880Pelvis except coccyx $3,200/$6,400Coccyx $400/$800Bones of face except nose $1,200/$2,400Nose $600/$1,200Upper jaw $1,500/$3,000Lower jaw $1,440/$2,880Collarbone $1,440/$2,880Rib or ribs $400/$800Skull – simple except bones of face $1,400/$2,800Skull – depressed except bones of face $3,000/$6,000Sternum $360/$720Shoulder blade $1,800/$3,600Chip fractures 25% of the closed reduction

1 Laceration benefits are a total of all lacerations per accident.2 Closed reduction of dislocation = Non-surgical reduction of a completely separated joint. Open reduction of dislocation = Surgical reduction of a completely separated joint.3 Closed reduction of fracture = Non-surgical. Open reduction of fracture = Surgical.

Who is eligible for Accident Insurance?• You—All active employees working 20+ hours per week.• Your spouse*— Coverage is available only if employee coverage is elected.• Your children**— to age 26. Coverage is available only if employee coverage is elected.*The use of “spouse” in this document means a person insured as a spouse as described in the certificate of insurance or rider. This may include domestic partners or civil union partners as defined by the group policy. Please contact your employer for more information.

What does my Accident Insurance include?The benefits listed below are included with your Accident Insurance coverage. For a list of standard exclusions and limitations, please refer to the end of this document. For a complete description of your available benefits, exclusions and limitations, see your certificate of insurance and any benefits.

• Sports Accident Benefit: If your accident occurs while participating in an organized sporting activity as defined in the certificate, the Accident Hospital Care, Accident Care or Common Injuries benefit will be increased by 25%, to a maximum additional benefit of $1000.

o If your spouse and/or children are covered for Accident Insurance, their coverage includes this benefit.o This benefit only applies to the events in the table above. It does not apply to any of the additional

benefits/coverage outlined in this section.• Accidental Death and Dismemberment (AD&D) coverage: If you are severely injured or die as a result of a

covered accident, an AD&D benefit may be payable to you or your beneficiary. o If your spouse and/or children are covered for Accident Insurance, their coverage includes AD&D.


AAccidental Death Benefits Benefit Employee $100,000 Spouse $50,000 Children $25,000Other accident Employee $50,000 Spouse $20,000 Children $10,000

Accidental Dismemberment BenefitsLoss of both hand or both feet or sight in both eyes $28,000Loss of one hand or one foot AND the sight of one eye $22,000Loss of one hand AND one foot $22,000Loss of one hand OR one foot $12,500Loss of two or more fingers or toes $1,800Loss of one finger or one toe $1,250

How much does Accident Insurance cost?All employees within the same class pay the same rate, no matter their age. See the chart below for the premium amounts.

Rates shown are guaranteed until September, 2020.

Monthly Rates

Employee Employee and Spouse

Employee and Children Family

$12.20 $19.00 $19.90 $26.70


Exclusions and limitationsExclusions for the Certificate, Spouse Accident Insurance, and Children’s Accident Insurance and AD&D are listed below.(These may vary by state.) Benefits are not payable for any loss caused in whole or directly by any of the following*:

• Participation or attempt to participate in a felony or illegal activity.• An accident while the covered person is operating a motorized vehicle while intoxicated. Intoxication means the

covered person’s blood alcohol content meets or exceeds the legal presumption of intoxication under the laws of the state where the accident occurred.

• Suicide, attempted suicide or any intentionally self-inflicted injury, while sane or insane.• War or any act of war, whether declared or undeclared, other than acts of terrorism.• Loss sustained while on active duty as a member of the armed forces of any nation. We will refund, upon written

notice of such service, any premium which has been accepted for any period not covered as a result of this exclusion.

• Alcoholism, drug abuse, or misuse of alcohol or taking of drugs, other than under the direction of a doctor.• Riding in or driving any motor-driven vehicle in a race, stunt show or speed test.• Operating, or training to operate, or service as a crew member of, or jumping, parachuting or falling from, any

aircraft or hot air balloon, including those which are not motor-driven. Flying as a fare-paying passenger is not excluded.

• Engaging in hang-gliding, bungee jumping, parachuting, sail gliding, parasailing, parakiting, kite surfing or any similar activities.

• Practicing for, or participating in, any semi-professional or professional competitive athletic contests for which any type of compensation or remuneration is received.

• Any sickness or declining process caused by a sickness.

*See the certificate of insurance and riders for a complete list of available benefits, exclusions and limitations.*Definition and limitation/exclusion may vary by state.

Questions?Where do I get more information?

For more information or to access the certificate of insurance, please call the Voya Employee Benefits Customer Service Team at (877) 236-7564

This offer is contingent upon participation requirements being met.

This is a summary of benefits only. A complete description of benefits, limitations, exclusions and termination of coverage will be provided in the certificate of insurance and riders. All coverage is subject to the terms and conditions of the group policy. If there is any discrepancy between this document and the group policy documents, the policy documents will govern. To keep coverage in force, premiums are payable up to the date of coverage termination. Accident Insurance is underwritten by ReliaStar Life Insurance Company, a member of the Voya® family of companies. Policy Form #RL-ACC3-POL-16; Certificate Form #RL-ACC3-CERT-16; and Rider Forms: Spouse Accident Rider Form #RL-ACC3-SPR-16, Children's Accident Rider Form #RL-ACC3-CHR-16, Accidental Death & Dismemberment (AD&D) Rider Form #RL-ACC3-ADR-16. Form numbers, provisions and availability may vary by state.

CN0221-31181-0218

Central Texas Employee Benefits Cooperative, Group #70097-5, Date Prepared: 05/08/2017

177546-04/01/2017

Seguro contra accidentes de Compass Datos para la Inscripción

Para los empleados de: Central Texas Employee Benefits Cooperative

#70097-5 ¿Qué es el seguro contra accidentes? El seguro contra accidentes le paga beneficios por lesiones e incidentes específicos que surgen de un accidente con cobertura que ocurra mientras no está en el trabajo, en o después de la fecha de entrada en vigencia de la cobertura. El monto del beneficio depende del tipo de lesión y la atención recibida. Su empleador provee seguro contra accidentes para satisfacer sus necesidades. El Seguro contra accidentes es una póliza de beneficios limitados. Éste no es un seguro de salud y no satisface el requisito de cobertura mínima esencial bajo la Ley de Atención de Salud a Bajo Costo. Las características del seguro contra accidentes son:

Emisión garantizada: No se requieren preguntas médicas o exámenes para la cobertura. Flexible: Usted puede utilizar los pagos del beneficio para cualquier propósito que desee. Transferible: Si deja su empleo actual o se jubila, usted puede llevarse la cobertura consigo.

¿Cómo puede ayudar un seguro contra accidentes? A continuación presentamos algunos ejemplos de cómo pueden usarse sus beneficios de seguro contra accidentes:

Gastos médicos, tales como deducibles y copagos Costos de atención de la salud en el hogar Pérdida de ingresos debido al tiempo perdido del trabajo Gastos cotidianos como servicios públicos y comestibles

¿Qué beneficios por accidente están disponibles? La lista que aparece a continuación es un resumen de los beneficios proporcionados por el seguro contra accidentes. Se le puede exigir buscar atención para su lesión dentro de una cantidad de tiempo establecida. Tenga en cuenta que puede haber variaciones por estado. Para una lista de exclusiones y limitaciones estándar, vaya al final de este documento. Para una descripción completa de sus beneficios disponibles, exclusiones y limitaciones, consulte su certificado de seguro y cualquier beneficio del mismo.

Incidente Beneficio Atención hospitalaria por accidente

Cirugía abierta abdominal o torácica $1,200 Cirugía exploratoria o sin reparación $175 Sangre, plasma, plaquetas $600 Admisión en el hospital $1,250 Ingreso en hospital por día hasta 365 días $375 Ingreso en unidad de cuidados intensivos por día hasta 15 días $600 Ingreso en centro de rehabilitación por día, hasta 90 días $200 Coma duración de 14 días o más $17,000 Transporte por viaje, hasta tres por accidente $750 Hospedaje por día, hasta 30 días $180 Cuidado familiar por hijo por día, hasta 45 días $25

Atención por accidente Visita inicial al médico $90 Tratamiento en centro de atención de urgencia $225 Tratamiento en sala de emergencia $225 Ambulancia terrestre $360 Ambulancia aérea $1,500

ReliaStar Life Insurance Company, un miembro de la familia de compañías de Voya®.

Tratamiento médico de seguimiento $90 Tratamiento quiropráctico hasta seis por accidente $45 Equipo médico $120 Terapia física u ocupacional hasta seis por accidente $45 Terapia del habla hasta 6 por accidente $45 Prótesis (una) $750 Prótesis (dos o más) $1,200 Examen de diagnóstico principal $240 Cirugía de paciente ambulatoria (una por accidente) $225 Radiografía $45 Lesiones comunes Quemaduras de segundo grado, al menos 36% del cuerpo $1,250 Quemaduras de tercer grado, al menos nueve pero menos de 35 pulgadas cuadradas del cuerpo $7,500

Quemaduras de tercer grado, 35 o más pulgadas cuadradas del cuerpo $15,000 Injertos de piel 25% del beneficio por quemaduras Trabajo dental de emergencia corona $350, extracción $90 Lesión del ojo extracción de objeto extraño $100 Lesión del ojo cirugía $350 Cartílago de la rodilla desgarrado cirugía sin reparación o si el cartílago es raspado $225

Cartílago de la rodilla desgarrado reparación quirúrgica $800 Laceración1 tratada sin suturas $30 Laceración1 suturas, hasta 2” $60 Laceración1 suturas de 2” a 6” $240 Laceración1 suturas, más de 6” $480 Discos rotos reparación quirúrgica $800 Tendón, ligamento, manguito rotador cirugía artroscópica exploratoria sin reparación $425

Tendón, ligamento, manguito rotador uno, reparación quirúrgica $825 Tendón, ligamento, manguito rotador dos o más, reparación quirúrgica $1,225

Traumatismo craneano $225 Parálisis – paraplejia $16,000 Parálisis – cuadriplejia $24,000 Luxaciones Reducción abierta/cerrada2

Articulación de la cadera $3,850/$7,700 Rodilla $2,400/$4,800 Hueso(s) del tobillo o pie que no sean los de los dedos $1,500/$3,000 Hombro $1,600/$3,200 Codo $1,100/$2,200 Muñeca $1,100/$2,200 Dedo de la mano/del pie $275/$550 Hueso(s) de la mano que no sean los de los dedos $1,100/$2,200 Mandíbula inferior $1,100/$2,200 Clavícula $1,100/$2,200 Luxaciones parciales 25% del monto de la reducción cerrada


Fracturas Reducción abierta/cerrada3 Cadera $3,000/$6,000 Pierna $2,500/$5,000 Tobillo $1,800/$3,600 Rótula $1,800/$3,600 Pie excluye dedos, talón $1,800/$3,600 Parte superior del brazo $2,100/$4,200 Antebrazo, mano, muñeca excepto dedos $1,800/$3,600 Dedo de la mano, del pie $240/$480 Cuerpo vertebral $3,360/$6,720 Procesos vertebrales $1,440/$2,880 Pelvis excepto Coxis $3,200/$6,400 Coxis $400/$800 Huesos de la cara excepto la nariz $1,200/$2,400 Nariz $600/$1,200 Mandíbula superior $1,500/$3,000 Mandíbula inferior $1,440/$2,880 Clavícula $1,440/$2,880 Costilla o costillas $400/$800 Cráneo – simple excepto los huesos de la cara $1,400/$2,800 Cráneo – deprimida excepto huesos de la cara $3,000/$6,000 Esternón $360/$720 Omóplato $1,800/$3,600 Fracturas con minutas 25% del monto de la reducción

1 Los beneficios por laceración son un total de todas las laceraciones por accidente. 2 Reducción cerrada de una luxación = Reducción no quirúrgica de una articulación completamente separada. Reducción abierta de una luxación = Reducción quirúrgica de una articulación completamente separada. 3 Reducción cerrada de fractura = No quirúrgica. Reducción abierta de fractura = Quirúrgica.

¿Quién es elegible para el seguro contra accidentes? Usted: todos los empleados activos que trabajan 20 horas o más por semana. Su cónyuge*: La cobertura está disponible solamente si se elige la cobertura del empleado. Sus hijos**: hasta la edad de 26 años. La cobertura está disponible solamente si se elige la cobertura del empleado.*El uso del término “cónyuge” en este documento significa una persona asegurada como un cónyuge, según se describe en el certificado o anexo deseguro. [Esto puede incluir pareja de hecho o pareja de unión civil según lo define la póliza grupal.] Contacte a su empleador para obtener másinformación.

¿Qué incluye mi seguro contra accidentes? Los beneficios detallados a continuación están incluidos en su cobertura de seguro contra accidente. Para una lista de exclusiones y limitaciones estándar, consulte el final de este documento. Para una descripción completa de sus beneficios disponibles, exclusiones y limitaciones, consulte su certificado de seguro y cualquier beneficio del mismo.

Beneficio de accidente deportivo: Si su accidente ocurre mientras participa en una actividad deportivaorganizada tal y como se define en el certificado, el beneficio por atención hospitalaria por accidente, poratención por accidente o por lesiones comunes será aumentado en 25%; hasta un beneficio adicional máximo de$1000.

o Si su cónyuge y/o hijos están cubiertos por el seguro contra accidentes, su cobertura incluye estebeneficio.

o Este beneficio solo se aplica a los eventos en la tabla que aparece arriba. No se aplica a ninguno de losbeneficios/cobertura adicionales que se describen en esta sección.


Cobertura por Muerte Accidental y Desmembramiento (AD&D, por sus siglas en inglés): Si usted tiene una lesión grave o fallece como resultado de un accidente cubierto, se le puede pagar un beneficio por AD&D a usted o a su beneficiario.

o Si su cónyuge y/o hijos están cubiertos por el seguro contra accidentes, su cobertura incluye el Seguro por AD&D.

Beneficios por fallecimiento accidental Beneficio Empleado $100,000 Cónyuge $50,000 Hijos $25,000 Otro accidente Empleado $50,000 Cónyuge $20,000 Hijos $10,000

Beneficios por desmembramiento accidental Pérdida de ambas manos o ambos pies o de la vista en ambos ojos $28,000

Pérdida de una mano o de un pie Y de la vista en un ojo $22,000 Pérdida de una mano Y un pie $22,000 Pérdida de una mano O un pie $12,500 Pérdida de dos o más dedos de la mano o del pie $1,800 Pérdida de un dedo de la mano o de un pie $1,250

¿Cuánto cuesta el seguro contra accidentes? Todos los empleados dentro de la misma clase pagan la misma tarifa, sin importar su edad. Consulte la tabla a continuación para ver los montos de prima.

Tarifas mensuales

Empleado Empleado y cónyuge Empleado e hijos Familia

$12.20 $19.00 $19.90 $26.70 Las tarifas mostradas están garantizadas hasta el 1 de septiembre 2022.


Exclusiones y limitaciones Las exclusiones para el Certificado, el Seguro contra accidente para cónyuge, el Seguro contra accidente para hijos y el Seguro por AD&D se muestran a continuación. (Puede variar de un estado a otro). No se pagan beneficios por ninguna pérdida causada en su totalidad o directamente por ninguna de las siguientes razones*:

Participación o intento de participación en un crimen o actividad ilegal. Accidente mientras la persona cubierta opera un vehículo motorizado estando intoxicado. Intoxicación significa

que el contenido de alcohol en sangre de la persona asegurada alcanza o excede la presunción legal de intoxicación conforme las leyes del estado donde ocurrió el accidente.

Suicidio, intento de suicidio o lesión autoprovocada de manera intencional, ya sea en su sano juicio o no. Guerra o cualquier acto de guerra, ya sea declarada o no declarada, aparte de los actos de terrorismo. Pérdida sufrida en el servicio activo como miembro de las fuerzas armadas de cualquier nación. Nosotros

reembolsaremos, al recibir aviso por escrito de dicho servicio, cualquier prima recibida correspondiente a cualquier período no cubierto como resultado de esta exclusión.

Alcoholismo, abuso de drogas, uso indebido de alcohol o consumo de drogas no supervisado por un médico. Ser pasajero de o conducir cualquier vehículo automotor durante una carrera, un espectáculo acrobático o

pruebas de velocidad. Operar o capacitación para operar o prestación de servicio como miembro de la tripulación de, o saltar, usar

paracaídas o hacer caída libre de, cualquier aparato aéreo o globo aerostático, incluyendo los que no son propulsados por motor. Volar como pasajero que paga boleto no está excluido.

Involucrarse en parapentismo, lanzarse amarrado a una cuerda elástica, paracaidismo, planear, planear a vela, parakiting, surfear en el aire o cualquier actividad similar.

Practicar para, o participar en cualquier concurso competitivo atlético profesional o semiprofesional por los cuales se reciba cualquier tipo de compensación o remuneración.

Cualquier enfermedad o proceso degenerativo causado por una enfermedad. *Revise el certificado de seguro y los anexos para ver una lista completa de los beneficios, exclusiones y limitaciones disponibles. *La definición y exclusión/limitación puede variar según el estado.

¿Tiene alguna pregunta? ¿Dónde puedo obtener más información? Para obtener más información o acceso al certificado de seguro, llame al Equipo de servicio al cliente de Voya Employee Benefits al (877) 236-7564

Esta oferta depende de que sean cumplidos los requisitos de participación.

La póliza de seguros que se ofrece está disponible solo en inglés, y constituye el documento oficial. Cualquier información en español se proporciona solamente con fines informativos, y no se deberá interpretar como una modificación o un cambio a la póliza de seguros.

The insurance policy being advertised is available only in English. The policy is the official, controlling document. Any information provided in Spanish is for informational purposes only, and shall not be construed to modify or change the insurance policy.

Esto es sólo un resumen de los beneficios. Se suministrará una descripción completa de los beneficios, las limitaciones, las exclusiones y la rescisión de la cobertura en el certificado de seguro y los anexos. Toda la cobertura está sujeta a los términos y condiciones de la póliza grupal. Si existe alguna discrepancia entre este documento y los documentos de la póliza grupal, regirán los documentos de la póliza. Para mantener la cobertura en vigencia, las primas son pagaderas hasta la fecha de rescisión de la cobertura. El seguro contra accidente es suscrito por ReliaStar Life Insurance Company, miembro de la familia de compañías de Voya®. Formulario de Póliza #RL-ACC3-POL-16; Formulario de Certificado #RL-ACC3-CERT-16; y Formularios de Anexos: Formulario de Anexo de Seguro contra accidentes para cónyuge #RL-ACC3-SPR-16, Formulario de Anexo de Seguro contra accidentes para hijos #RL-ACC3-CHR-16 y Formulario de Anexo de Seguro por muerte y desmembramiento accidental (AD&D) #RL-ACC3-ADR-16. Los números de formulario, las cláusulas y la disponibilidad pueden variar por estado.

CN0221-31181-0218

Central Texas Employee Benefits Cooperative, Grupo #70097-5, Fecha de preparación: 05/08/2017

177546-04/01/2017

Compass Critical Illness Insurance Enrollment at a glance

For the employees of: Central Texas Employee Benefits Cooperative #70097-5

What is Critical Illness Insurance?Critical Illness Insurance pays a lump-sum benefit if you are diagnosed with a covered illness or condition on or after your coverage effective date. Critical Illness Insurance is a limited benefit policy. It is not health insurance and does not satisfy the requirement of minimum essential coverage under the Affordable Care Act.

Features of Critical Illness Insurance include:• Guaranteed Issue: No medical questions or tests are required for coverage.• Flexible: You can use the benefit payments for any purpose you like.• Portable: If you leave your current employer or retire, you can take your coverage with you.

What benefits are available?Critical Illness Insurance provides a benefit payment for the following illnesses and conditions. Covered illnesses/conditions are broken out into groups called “modules”. Benefits are paid at 100% of the Maximum Critical Illness Benefit amount unless otherwise stated. For a complete description of your benefits, along with applicable provisions, conditions on benefit determination, exclusions and limitations, see your certificate of insurance and any riders.

Base Module• Heart attack* • Major organ failure• Stroke • Permanent paralysis• Coronary artery bypass Coronary obstruction

(25%)• End stage renal (kidney) failure

• Coma

*Cardiac arrest is not a heart attack.

Module A• Benign brain tumor • Occupational HIV• Deafness • Blindness

Module B• Multiple sclerosis • Alzheimer’s disease• Amyotrophic lateral sclerosis (ALS) • Infectious disease• Parkinson’s disease

Cancer Module• Cancer • Carcinoma in situ (25%)• Skin cancer (10%)


Who is eligible for Critical Illness Insurance?• You—all active employees working 20+ hours per week.• Your spouse*— Coverage is available only if employee coverage is elected. • Your children**— to age 26. Coverage is available only if employee coverage is elected.

*The use of “spouse” in this document means a person insured as a spouse as described in the certificate of insurance or rider. This may include domestic partners or civil union partners as defined by the group policy. Please contact your employer for more information.**The definition of “child” may vary by state. Please contact your employer for more information.

How many times can I receive the Maximum Critical Illness Benefit?Usually you are only able to receive the Maximum Specified Disease Benefit once for each covered condition. Your plan includes the Recurrence Benefit, which allows you to receive a benefit for the same condition a second time. In order for the second occurrence of the illness to be covered, it must occur after 12 consecutive months without the occurrence of any covered critical illness named in your certificate, including the illness from the first benefit payment.

If you have reached the benefit limit by receiving the maximum benefit for each covered condition, you may choose to end your coverage; however, if you have coverage for your spouse and/or children, you must continue your coverage in order to keep their coverage active. Please see your certificate of coverage for details.

What additional benefits does my Critical Illness Insurance include?The benefits listed below are included with your Critical Illness coverage. There may be some variation by state. For a list of standard exclusions and limitations, please refer to the end of this document. For a complete description of your available benefits, exclusions and limitations, see your certificate of insurance and any riders.

• Wellness Benefit: This provides an annual benefit payment if you complete a health screening test. You may only receive a benefit payment once per year, even if you complete multiple health screening tests.

o Examples of health screening tests include but are not limited to: Pap test, serum cholesterol test for HDL and LDL levels, mammography, colonoscopy, and stress test on bicycle or treadmill.

o The annual benefit amount is $50 for completing a health screening test. o If your spouse and/or children are covered for Critical Illness Insurance, they are also covered by the

Wellness Benefit. Your spouse’s benefit amount is also $50. The benefit for child coverage is 50% of your benefit amount per child with an annual maximum of $100 for all children.


How much does Critical Illness Insurance cost?See the chart below for the premium amounts.

Employee CoverageMonthly Rates

Includes Wellness Benefit RiderUni-Tobacco

Attained Age $5,000 $10,000 $15,000 $20,000 $25,000 $30,000

Under 30 $2.65 $5.30 $7.95 $10.60 $13.25 $15.90 30-39 $3.05 $6.10 $9.15 $12.20 $15.25 $18.30 40-49 $5.60 $11.20 $16.80 $22.40 $28.00 $33.60 50-59 $11.60 $23.20 $34.80 $46.40 $58.00 $69.60 60-64 $18.15 $36.30 $54.45 $72.60 $90.75 $108.90 65-69 $23.50 $47.00 $70.50 $94.00 $117.50 $141.00 70+ $32.85 $65.70 $98.55 $131.40 $164.25 $197.10

Spouse Coverage* Children Coverage Monthly Rates Monthly Rates

Includes Wellness Benefit Rider Includes Wellness Benefit RiderUni-Tobacco

Coverage Amount RateAttained Age $5,000 $10,000 $15,000

Under 30 $3.15 $6.30 $9.45 $1,000 $0.3130-39 $3.55 $7.10 $10.65 $2,500 $0.7840-49 $6.55 $13.10 $19.65 $5,000 $1.5550-59 $14.75 $29.50 $44.25 $10,000 $3.1060-64 $23.20 $46.40 $69.60 65-69 $29.15 $58.30 $87.45 70+ $39.50 $79.00 $118.50

*Spouse rates are based on the age of the employee.

Rates shown are guaranteed until September 2020.


Exclusions and LimitationsBenefits are not payable for any critical illness caused in whole or directly by any of the following*:

• Participation or attempt to participate in a felony or illegal activity.• Suicide, attempted suicide or any intentionally self-inflicted injury, while sane or insane.• War or any act of war, whether declared or undeclared, other than acts of terrorism.• Loss that occurs while on full-time active duty as a member of the armed forces of any nation. We will refund,

upon written notice of such service, any premium which has been accepted for any period not covered as a result of this exclusion.

• Alcoholism, drug abuse, or misuse of alcohol or taking of drugs, other than under the direction of a doctor.

Benefits reduce 50% for the employee and/or covered spouse on the policy anniversary following the 70th birthday, however, premiums do not reduce as a result of this benefit change.

*See the certificate of insurance and any riders for a complete list of available benefits, along with applicable provisions, exclusions and limitations.

Questions? Where do I get more information?

For more information please call Voya Employee Benefits Customer Service Team at (877) 236-7564

This offer is contingent upon participation requirements being met.

This is a summary of benefits only. A complete description of benefits, limitations, exclusions and termination of coverage will be provided in the certificate of insurance and riders. All coverage is subject to the terms and conditions of the group policy. If there is any discrepancy between this document and the group policy documents, the policy documents will govern. To keep coverage in force, premiums are payable up to the date of coverage termination. Critical Illness Insurance is underwritten by ReliaStar Life Insurance Company, a member of the Voya® family of companies. Policy Form #RL-CI3-POL-12; Certificate Form #RL-CI3-CERT-12; and Rider Forms: Spouse Critical Illness Rider Form #RL-CI3-SPR-12, Children's Critical Illness Rider Form #RL- CI3-CHR-12,Wellness Benefit Rider Form #RL- CI3-WELL-12 Form numbers, provisions and availability may vary by state.

CN0223-31343-0218

Central Texas Employee Benefits Cooperative, Group #70097-5, Date Prepared: 05/08/2017

177620-03/27/2017

Seguro contra enfermedades críticas de Compass Datos para la Inscripción

Para los empleados de: Central Texas Employee Benefits Cooperative

#70097-5

¿Qué es el seguro contra enfermedades críticas? El seguro contra enfermedades críticas paga un beneficio de suma única si se le diagnostica una enfermedad o afección cubierta en o después de la fecha de entrada en vigencia de la cobertura. El seguro contra enfermedades críticas es una póliza de beneficios limitados. Éste no es un seguro de salud y no satisface el requisito de cobertura mínima esencial bajo la Ley de Atención de Salud a Bajo Costo. Las características del seguro contra enfermedades críticas incluyen:

Emisión garantizada: No son requeridas preguntas médicas o exámenes para la cobertura. Flexible: Usted puede utilizar los pagos del beneficio para cualquier propósito que desee. Transferible: Si deja su empleo actual o se jubila, usted puede llevarse la cobertura consigo.

¿Qué beneficios están disponibles? El seguro contra enfermedades críticas provee un pago de beneficio para las siguientes enfermedades y afecciones. Las enfermedades/afecciones cubiertas se dividen en dos grupos llamados “módulos”. Los beneficios se pagan al 100% del monto de Beneficio máximo por enfermedad crítica, a menos que se declare lo contrario. Para una descripción completa de sus beneficios, junto con las cláusulas, condiciones de determinación de beneficios, exclusiones y limitaciones correspondientes, consulte su certificado de seguro y cualquier anexo del mismo.

Módulo básico Ataque cardíaco* Insuficiencia orgánica mayor Accidente cerebrovascular Parálisis permanente Derivación de arterias coronarias Obstrucción

coronaria (25%) Enfermedad renal (del riñón) en etapa terminal

Coma *El paro cardíaco no es un ataque cardíaco.

Módulo A Tumor cerebral benigno VIH adquirido en el trabajo Sordera Ceguera

Módulo B Esclerosis múltiple Enfermedad de Alzheimer Esclerosis lateral amiotrófica (ALS, por sus siglas

en inglés) Enfermedad infecciosa

Enfermedad de Parkinson

Módulo de cáncer Cáncer Carcinoma in situ (25%) Cáncer de la piel (10%)


¿Quién es elegible para el seguro contra enfermedades críticas? Usted: todos los empleados activos que trabajan 20 horas o más por semana. Su cónyuge*: La cobertura está disponible solamente si se elige la cobertura del empleado. Sus hijos**: hasta la edad de 26 años. La cobertura está disponible solamente si se elige la cobertura del

empleado. *El uso del término “cónyuge” en este documento significa una persona asegurada como un cónyuge, según se describe en el certificado o anexo de seguro. Esto puede incluir pareja de hecho o pareja de unión civil según lo define la póliza grupal. Contacte a su empleador para obtener más información. **La definición de “hijo” puede variar de un estado a otro. Contacte a su empleador para obtener más información. ¿Cuántas veces puedo recibir el beneficio máximo por enfermedades críticas? Por lo general, usted solo puede recibir el Beneficio máximo por enfermedades específicas una vez por cada afección cubierta. Su plan incluye el Beneficio de recurrencia, el cual le permite recibir un beneficio por la misma afección una segunda vez. Para que la segunda existencia de la enfermedad esté cubierta, debe ocurrir después de 12 meses consecutivos sin la existencia de cualquier enfermedad crítica cubierta mencionada en su certificado, incluyendo la enfermedad del primer pago de beneficio. Si usted ha llegado al límite del beneficio al recibir el beneficio máximo para cada afección cubierta, usted puede elegir terminar su cobertura; sin embargo, si usted tiene cobertura para su cónyuge y/o hijos, debe continuar su cobertura para mantener las coberturas de ellos activas. Consulte su certificado de cobertura para obtener detalles. ¿Qué beneficios adicionales incluye mi seguro contra enfermedades críticas? Los beneficios detallados a continuación están incluidos en su cobertura de seguro contra enfermedades críticas. Puede haber algunas variaciones por estado. Para una lista de exclusiones y limitaciones estándar, consulte el final de este documento. Para una descripción completa de sus beneficios disponibles, exclusiones y limitaciones, consulte su certificado de seguro y cualquier anexo del mismo.

Beneficio de bienestar: Esto provee un pago de beneficio anual, si usted completa un examen preventivo de salud. Usted solo puede recibir un pago de beneficio una vez al año, aun cuando se le realicen varios exámenes preventivos de salud.

o Los ejemplos de exámenes preventivos de salud incluyen pero no se limitan a: Prueba de Papanicolaou, prueba de colesterol sérico para detectar los niveles de HDL y LDL, mamografía, colonoscopía y prueba de estrés en bicicleta o caminadora.

o El monto del beneficio anual es de $50 por completar un examen preventivo de salud. o Si su cónyuge y/o hijos están cubiertos por el seguro contra enfermedades críticas, ellos también están

cubiertos por el Beneficio de bienestar. El monto del beneficio para su cónyuge también es de $50. El beneficio por cobertura de hijo es 50% de su monto de beneficio por hijo con un máximo anual de $100 para todos los hijos.


¿Cuánto cuesta el Seguro contra enfermedades críticas? Consulte la tabla a continuación para ver los montos de prima.

Cobertura del empleado Tarifas mensuales

Incluye Anexo de beneficio de bienestar Consume tabaco

Edad cumplida $5,000 $10,000 $15,000 $20,000 $25,000 $30,000

Menor de 30 $2.65 $5.30 $7.95 $10.60 $13.25 $15.90 30-39 $3.05 $6.10 $9.15 $12.20 $15.25 $18.30 40-49 $5.60 $11.20 $16.80 $22.40 $28.00 $33.60 50-59 $11.60 $23.20 $34.80 $46.40 $58.00 $69.60 60-64 $18.15 $36.30 $54.45 $72.60 $90.75 $108.90 65-69 $23.50 $47.00 $70.50 $94.00 $117.50 $141.00 70 + $32.85 $65.70 $98.55 $131.40 $164.25 $197.10

Cobertura para el cónyuge* Cobertura para hijos

Tarifas mensuales Tarifas mensuales

Incluye Anexo de beneficio de bienestar Incluye Anexo de beneficio de bienestar

Consume tabaco Monto de la cobertura Tarifa Edad

cumplida $5,000 $10,000 $15,000

Menor de 30 $3.15 $6.30 $9.45 $1,000 $0.31 30-39 $3.55 $7.10 $10.65 $2,500 $0.78 40-49 $6.55 $13.10 $19.65 $5,000 $1.55 50-59 $14.75 $29.50 $44.25 $10,000 $3.10 60-64 $23.20 $46.40 $69.60 65-69 $29.15 $58.30 $87.45 70 + $39.50 $79.00 $118.50

*Las tarifas para cónyuges se basan en la edad del empleado. Las tarifas mostradas están garantizadas hasta el 1 de septiembre 2022.


Exclusiones y limitaciones No se pagan beneficios por ninguna enfermedad crítica causada en su totalidad o directamente por alguna de las siguientes razones*:

Participación o intento de participación en un crimen o actividad ilegal. Suicidio, intento de suicidio o lesión autoprovocada de manera intencional, ya sea en su sano juicio o no. Guerra o cualquier acto de guerra, ya sea declarada o no declarada, aparte de los actos de terrorismo. Pérdida que ocurre mientras en servicio activo a tiempo completo como miembro de las fuerzas armadas de

cualquier nación. Nosotros reembolsaremos, al recibir aviso por escrito de dicho servicio, cualquier prima recibida correspondiente a cualquier período no cubierto como resultado de esta exclusión.

Alcoholismo, abuso de drogas, uso indebido de alcohol o consumo de drogas que no esté supervisado por un médico.

Los beneficios se reducen en un 50% para el empleado y/o el cónyuge cubierto en el aniversario de la póliza que siga el cumpleaños número 70; sin embargo, las primas no se reducen como resultado de este cambio de beneficio. *Revise el certificado de seguro y los anexos para ver una lista completa de beneficios disponibles, junto con las cláusulas, exclusiones y limitaciones correspondientes.

¿Tiene alguna pregunta? ¿Dónde puedo obtener más información? Para obtener más información o acceso al certificado de seguro, llame al Equipo de servicio al cliente de Voya Employee Benefits al (877) 236-7564. Esta oferta depende de que sean cumplidos los requisitos de participación. La póliza de seguros que se ofrece está disponible solo en inglés, y constituye el documento oficial. Cualquier información en español se proporciona solamente con fines informativos, y no se deberá interpretar como una modificación o un cambio a la póliza de seguros.

The insurance policy being advertised is available only in English. The policy is the official, controlling document. Any information provided in Spanish is for informational purposes only, and shall not be construed to modify or change the insurance policy.

Esto es sólo un resumen de los beneficios. Se suministrará una descripción completa de los beneficios, las limitaciones, las exclusiones y la rescisión de la cobertura en el certificado de seguro y los anexos. Toda la cobertura está sujeta a los términos y condiciones de la póliza grupal. Si existe alguna discrepancia entre este documento y los documentos de la póliza grupal, regirán los documentos de la póliza. Para mantener la cobertura en vigencia, las primas son pagaderas hasta la fecha de rescisión de la cobertura. El seguro contra enfermedades críticas es suscrito por ReliaStar Life Insurance Company, miembro de la familia de compañías de Voya®. Formulario de Póliza #RL-CI3-POL-12; Formulario de Certificado #RL-CI3-CERT-12; y Formularios de Anexos: Formulario de Anexo de Seguro contra enfermedades críticas para cónyuge #RL-CI3-SPR-12, Formulario de Anexo de Seguro contra enfermedades críticas para hijos #RL-CI3-CHR-12, Formulario de Anexo de Beneficio de bienestar #RL- CI3-WELL-12. Los números de formulario, las cláusulas y la disponibilidad pueden variar por estado.

CN0223-31343-0218 Central Texas Employee Benefits Cooperative, Grupo #70097-5, Fecha de preparación: 05/08/2017 177620-03/27/2017

12019 Identity Fraud Study, Javelin Research, March 2019 2 Locking your Equifax credit report will prevent access to it by certain third parties. Locking your Equifax credit report will not prevent access to your credit report at any other credit reporting agency. Entities that may still have access to your Equifax credit report include: companies like ID Watchdog, which provide you with access to your credit report or credit score, or monitor your credit report as part of a subscription or similar service; companies that provide you with a copy of your credit report or credit score, upon your request; federal, state and local government agencies and courts in certain circumstances; companies using the information in connection with the underwriting of insurance, or for employment, tenant or background screening purposes; companies that have a current account or relationship with you, and collection agencies acting on behalf of those whom you owe; companies that authenticate a consumer’s identity for purposes other than granting credit, or for investigating or preventing actual or potential fraud; and companies that wish to make pre-approved offers of credit or insurance to you. To opt out of such pre-approved offers, visit www.optoutprescreen.com

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What You Need to Know The credit scores provided are based on the VantageScore® 3.0 model. For three-bureau VantageScore credit scores, data from Equifax, Experian, and TransUnion are used respectively. Any one-bureau VantageScore uses Equifax data. Third parties use many different types of credit scores and are likely to use a different type of credit score to assess your creditworthiness.

PLAN OPTIONS ID WATCHDOG® 1B ID WATCHDOG® PLATINUM

Credit Report(s)4 & VantageScore Credit Score(s) 1 Bureau Monthly 1 Bureau Daily & 3 Bureau Annually

Credit Score Tracker 1 Bureau Monthly 1 Bureau Daily

Credit Report Monitoring5 1 Bureau 3 Bureau

Credit Report Lock6 1 Bureau Multi-Bureau

Identity Theft Insurance7 Up to $1M Up to $1M

401K/HSA Stolen Funds Reimbursement7

SPECIAL EMPLOYEE PRICING PER MONTH

Employee (Includes 1 child <18)

-

ID WATCHDOG® 1B

$7.95

$14.95Employee + Family

Up to $500k

ID WATCHDOG® PLATINUM

$11.95

$22.95

Enroll in this valuable benefit today.Take steps to help better protect your identity.

FPPduoQOL_MKT_FLYER_1119

Underwritten by 5Star Life Insurance Company (a Lincoln, Nebraska company); Administered by NTT Data at 777 Research Drive, Lincoln, NE 68521FPPi product available in all states and some U.S. Territories except: CA, DE, FL, NY, ND. SD. Quality of Life rider not available in CA.FPPg product available in all states and some U.S. Territories except: CA, DE, FL, NY, ND. SD, VI

FPPi/gQOLFlyerR1119

5Star Life Insurance CompanyIndividual and Group Term Life Insurance with Terminal Illness coverage to age 121

FamilyProtectionPlan

CUSTOMIZABLEWith several options to choose from, employees select the coverage that best meets the needs of their families.

TERMINAL ILLNESS ACCELERATION OF BENEFITSCoverage that pays 30% (25% in CT and MI) of the coverage amount in a lump sum upon the occurrence of a terminal condition that will result in a limited life span of less than 12 months (24 months in IL).

PORTABLECoverage continues with no loss of benefits or increase in cost if employment terminates after the first premium is paid. We simply bill the employee directly.

CONVENIENCEEasy payments through payroll deduction.

FAMILY PROTECTIONCoverage is available for spouses and financially dependent children, even if the employee doesn’t elect coverage on themselves.

* Financially dependent children 14 days to 23 years old.

Enhanced coverage options for employees. Easy and flexibile enrollment for employers. The 5Star Life Insurance Company’s Family Protection Plan offers both Individual and Group products with Terminal Illness coverage to age 121, making it easy to provide the right benefit for you and your employees.

PROTECTION TO COUNT ONWithin one business day of notification, payment of 50% of coverage or $10,000 whichever is less is mailed to the beneficiary, unless the death is within the two-year contestability period and/or under investigation. This coverage has no war or terrorism exclusions.

QUALITY OF LIFEOptional benefit that accelerates a portion of the death benefit on a monthly basis, up to 75% of your benefit, and is payable directly to you on a tax favored basis for the following:

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

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

including Quality of Life benefit

FPPi Rate Sheet Monthly Rates with Quality of Life Rider

Defined Benefit

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

18-25 $9.90 $13.28 $16.68 $20.07 $23.46 $31.94 $40.42 $48.89 $57.3826 $9.91 $13.34 $16.75 $20.16 $23.59 $32.13 $40.66 $49.21 $57.7527 $9.98 $13.46 $16.96 $20.44 $23.92 $32.62 $41.34 $50.04 $58.7628 $10.08 $13.66 $17.26 $20.84 $24.42 $33.37 $42.34 $51.29 $60.2629 $10.23 $13.95 $17.68 $21.40 $25.13 $34.44 $43.75 $53.07 $62.3830 $10.43 $14.35 $18.28 $22.20 $26.12 $35.94 $45.75 $55.56 $65.3831 $10.64 $14.76 $18.90 $23.04 $27.16 $37.50 $47.84 $58.16 $68.5032 $10.87 $15.23 $19.61 $23.97 $28.34 $39.25 $50.17 $61.09 $72.0133 $11.11 $15.72 $20.33 $24.93 $29.55 $41.06 $52.58 $64.11 $75.6334 $11.40 $16.30 $21.20 $26.10 $31.00 $43.26 $55.50 $67.75 $80.0035 $11.72 $16.93 $22.16 $27.37 $32.59 $45.63 $58.67 $71.71 $84.7636 $12.08 $17.65 $23.23 $28.80 $34.37 $48.31 $62.25 $76.18 $90.1337 $12.46 $18.44 $24.40 $30.36 $36.34 $51.25 $66.16 $81.09 $96.0038 $12.88 $19.25 $25.63 $32.00 $38.38 $54.32 $70.25 $86.19 $102.1339 $13.33 $20.17 $27.00 $33.83 $40.67 $57.76 $74.83 $91.92 $109.0040 $13.83 $21.15 $28.48 $35.80 $43.13 $61.44 $79.75 $98.06 $116.3841 $14.38 $22.25 $30.13 $38.00 $45.87 $65.57 $85.25 $104.94 $124.6342 $14.98 $23.46 $31.96 $40.44 $48.92 $70.12 $91.34 $112.54 $133.7643 $15.60 $24.70 $33.81 $42.90 $52.00 $74.75 $97.50 $120.25 $143.0144 $16.26 $26.02 $35.78 $45.53 $55.30 $79.69 $104.08 $128.48 $152.8845 $16.93 $27.37 $37.80 $48.23 $58.67 $84.75 $110.83 $136.92 $163.0046 $17.67 $28.83 $40.00 $51.17 $62.33 $90.26 $118.17 $146.09 $174.0047 $18.43 $30.35 $42.28 $54.20 $66.13 $95.94 $125.75 $155.56 $185.3848 $19.19 $31.88 $44.58 $57.27 $69.96 $101.69 $133.42 $165.15 $196.8849 $20.02 $33.55 $47.08 $60.60 $74.13 $107.94 $141.75 $175.57 $209.3850 $20.93 $35.36 $49.81 $64.24 $78.67 $114.75 $150.84 $186.92 $223.0151 $21.94 $37.39 $52.83 $68.26 $83.71 $122.32 $160.91 $199.52 $238.1352 $23.11 $39.74 $56.35 $72.96 $89.59 $131.13 $172.66 $214.21 $255.7553 $24.42 $42.33 $60.26 $78.17 $96.09 $140.87 $185.67 $230.46 $275.2654 $25.88 $45.27 $64.65 $84.03 $103.42 $151.88 $200.33 $248.80 $297.2555 $27.44 $48.37 $69.31 $90.23 $111.17 $163.50 $215.83 $268.17 $320.5156 $29.19 $51.87 $74.56 $97.23 $119.92 $176.63 $233.33 $290.04 $346.7657 $30.99 $55.49 $79.98 $104.46 $128.96 $190.19 $251.41 $312.64 $373.8858 $32.84 $59.19 $85.53 $111.86 $138.21 $204.06 $269.91 $335.77 $401.6359 $34.74 $62.97 $91.21 $119.43 $147.67 $218.25 $288.83 $359.42 $430.0160 $36.71 $66.94 $97.15 $127.36 $157.59 $233.13 $308.66 $384.21 $459.7561 $38.77 $71.05 $103.33 $135.60 $167.88 $248.57 $329.25 $409.94 $490.6362 $40.93 $75.37 $109.80 $144.23 $178.67 $264.75 $350.83 $436.92 $523.0063 $43.22 $79.95 $116.68 $153.40 $190.13 $281.94 $373.75 $465.56 $557.3864 $45.72 $84.93 $124.16 $163.37 $202.59 $300.62 $398.67 $496.71 $594.7665 $48.50 $90.50 $132.51 $174.50 $216.50 $321.50 $426.50 $531.50 $636.5166* $49.13 $91.75 $134.38 $177.00 $219.63 $326.19 $432.75 $539.31 $645.8867* $52.62 $98.73 $144.85 $190.97 $237.08 $352.38 $467.67 $582.96 $698.2568* $56.58 $106.67 $156.75 $206.83 $256.92 $382.13 $507.33 $632.54 $757.7569* $61.09 $115.68 $170.28 $224.87 $279.46 $415.94 $552.42 $688.90 $825.3870* $66.18 $125.85 $185.53 $245.20 $304.88 $454.06 $603.25 $752.44 $901.63

*Quality of Life not available ages 66-70. Quality of Life benefits not available for children.

FPPiDBQOLMonthlyRates 9/18

Child life coverage available only on children and grandchildren of employee (age on application date: 14 days through 23 years).$7.15 monthly for $10,000 coverage per child.

Employee Coverage

Legal protection is just a tap away.Follow these steps to create your LegalShield account.

1. CREATE your account at https: //accounts.legalshield.com/.

2. ENTER in your member number and create a username and password.

3. DOWNLOAD the LegalShield mobile app and use your account username and password to login. ��ÞÞ�üËêÚ�×ÚËõ¬��Ú�½�ö�ĈÚÃǲ�s¬½½�preparation steps and more!

SHEET_LS_ActivationSteps_080519

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If you have questions about setting up your account or forgot your member number, please call LegalShield Member Services at 1-800-654-7757 from

7 a.m. - 7 p.m. CT, Monday - Friday.

Create YourAccount

The LegalShield apps are available for download at no cost. Some services require an active LegalShield Membership to be accessed.

If you have membership questions or to get your member number: 1-800-654-7757

Contact your law firm - Ross and Matthews: 1-800-458-6982

Document PreparationStandard Will Preparation• Will preparation and annual reviews and updates for covered members• Other documents available: Living Will,��+��½æ©��Ú��VËö�Ú�Ë£��ææËÚÄ�ü��Ä�� %¬Ä�Ä�¬�½�VËö�Ú�Ë£��ææËÚÄ�ü

Residential Loan DocumentAssistance Mortgage documents (as required of theborrower by the lending institution)prepared by your Provider Law Firm forthe purchase of your primary residence

AutoMotor Vehicle Servicesǰ�DËÄȗ�Ú¬Ã¬Ä�½�ÃËõ¬Ä¤�æÚ�Ć��õ¬Ë½�æ¬ËÄ assistanceǰ�CËæËÚ�õ�©¬�½�ȗÚ�½�æ��Ú¬Ã¬Ä�½��©�Ú¤� assistance for manslaughter, involuntary manslaughter, negligent homicide or vehicular homicide• Up to 2.5 hours of help with driver’s license reinstatement and property damage collection assistance of��ȯƬǲƧƧƧ�ËÚ�½�ÞÞ�×�Ú��½�¬Ãǰ��õ�¬½��½��ËÄ½ü�¬£�Ã�Ã��Ú�©�Þ��õ�½¬� driver’s license and is driving a noncommercial motor vehicle

IRSIRS Audit Legal Services• One hour of consultation, advice or��ÞÞ¬Þæ�Ä��ö©�Ä�üËê��Ú��ÄËæ¬Ĉ��Ë£��Ä audit by the IRSǰ��Ä��¬æ¬ËÄ�½�ƩǷƬ�©ËêÚÞ�¬£��Þ�ææ½�Ã�Äæ��¬Þ�ÄËæ��©¬�õ��ö¬æ©¬Ä�ƪƧ��üÞ• If your case goes to trial, you’ll receive 46.5 hours of your Provider Law Firm’s servicesǰ��Ëõ�Ú�¤��£ËÚ�æ©¬Þ�Þ�Úõ¬��¤¬ÄÞ�ö¬æ©��æ©��æ�û�Ú�æêÚÄ��ê��×Ú¬½�ƨƬ�Ë£�æ©��ü��Ú you enroll

��¬æ¬ËÄ�½��Ä�ĈæÞ25% Preferred Member DiscountYou may continue to use your ProviderLaw Firm for legal situations that extendbeyond plan coverage. The additionalÞ�Úõ¬��Þ��Ú��ƩƬɅ�Ëą�æ©��½�ö�ĈÚÃȣÞstandard hourly rates. Your ProviderLaw Firm will let you know when the 25%discount applies, and go over these fees

Your Plan Cover:

LEGAL PLAN

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%�Ã¬½ü�C�ææ�ÚÞ�Uncontested Name ChangeAssistance*Uncontested name changeprepared by Provider Law Firm

Uncontested AdoptionRepresentation*Representation by your Provider LawFirm for uncontested adoptionproceedings

Uncontested Separation/DivorceRepresentation*Representation by your Provider LawFirm for uncontested legal separation,uncontested civil annulment anduncontested divorce proceedings �ÞÞ¬Þæ�Ä��¬£�üËê�ËÚ�üËêÚ�Þ×ËêÞ��Ú�named defendant or respondent in a�Ëõ�Ú��¬õ¬½��æ¬ËÄ�Ĉ½��¬Ä��ËêÚæ

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Access LegalShield on the go!

Access LegalShield on the go!c©��=�¤�½]©¬�½��××�×êæÞ�üËêÚ�½�ö�ĈÚÃ�¬Ä�æ©��×�½Ã�Ë£�üËêÚ�©�Ä�Ƿ�c�×�æË��½½�üËêÚ�½�ö�ĈÚÃ�directly, access free legal forms, and send ¬Ä£Ë��¬Ú��æ½ü�æË�üËêÚ�½�ö�ĈÚÃ�ö¬æ©�£��æêÚ�Þ�like Prepare Your Will and Snap (for speeding tickets). The LegalShield app makes it easy to access legal guidance you can trust.

Download the free app from the App Store or Google Play.Apple and the Apple logo are trademarks of Apple Inc., regis-tered in the U.S. and other countries. App Store is a service mark of Apple Inc., registered in the U.S. and other countries. Android is a trademark of Google Inc.

]×��¬Ĉ��û�½êÞ¬ËÄÞ��××½ü. See plan contract for complete terms, coverage, amounts, conditions and exclusions.

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ǭc©�Þ��Þ�Úõ¬��Þ��Ú��õ�¬½��½��ưƧ��ËÄÞ��êæ¬õ��üÞ�£ÚËÃ�æ©��ą��æ¬õ� date of your membership. For detailed information about the legal services provided by the LegalShield contract, go to http://www.legalshield.com/info/legalplan. Business issues are not included; however, plans providing those services are available.

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Family Plan Rate $15.95/mo

Text

Your LegalShield and IDShield memberships are simply amazing. And in addition to the privileges that are

already yours, we have added these MEMBERPERKS with hundreds of merchants and thousands of discounts.

Members can access savings at both national and local companies on everyday purchases such as tickets,

electronics, apparel, travel and more. Members have the opportunity to save, on average, over $2,000 per year.

MEMBERPERKS can save you enough to pay for your membership for years to come!

RECEIVE EXCLUSIVE DISCOUNTS Access your members-only discounts in categories such as:

Getting Started To sign up, simply login at legalshield.com, click on the Resources tab, then click on MEMBERPERKS. If you don’t already have an account, follow the simple on-screen instructions to make an account with your personal or work email and LegalShield membership number.

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Save with these incredible MEMBERPERKS

AND MANY MORE!

APPAREL

AUTOMOTIVE

BOOKS, MOVIES & MUSIC

CELL PHONES

ELECTRONICS

FINANCE

FLOWERS & GIFTS

FOOD

HEALTH & WELLNESS

HOME SERVICES

INSURANCE & PROTECTION SERVICES

OFFICE & BUSINESS

REAL ESTATE & MOVING SERVICES

SPORTS & OUTDOORS

TICKETS & ENTERTAINMENT

TRAVEL

WHAT MEMBERS ARE SAYING:

“MEMBERPerks pays for my membership!”

— Martha S.

“I saved 20% at Advance Auto and I also saved 30% on movie tickets on date night with my wife. This membership is it!”

— Andre E.

Ƞ.��Ã�Ú��¬õ¬Ä¤�ƯɅ�Ëą�Ãü�r�Ú¬āËÄ�cell phone monthly charge!”

— Paulette M.

SHEET_MEMBERPerks_051818

Enjoy preferred member pricing on some of your favorite brands and services.

Any Ground. Any Air. Anywhere.

Member Services AgreementEmergent Ground

A Division of MASA Global

Important Instructions� Always have your membership card with you

� Emergency Ground and Air services are activated by calling 911

YOU DO NOT NEED TO CONTACT MASA MTS IN A MEDICAL EMERGENCY

� National toll free number 1-800-643-9023

MEMBER SERVICES AGREEMENTEMERGENT GROUND

This Member Services Agreement (“Agreement”) is made and entered into by and between MASA Medical Transport Solutions (hereinafter, “MASA MTS”), a division of Medical Air Services Association, Inc., and the subscribing Member (hereinafter, the “Member”). In consideration of payment of the membership and other related fees, MASA MTS agrees to provide the services described herein to the Member, during the term hereof, subject to the conditions and limitations set forth below.

ARTICLE IDefinitions

“Emergent Ground Transportation” shall be defined as transport, necessitated by a Serious Emergency, by a medically-equipped ground vehicle from (i) the site of the Serious Emergency, (ii) a Suitable Airport, following arrival from an Emergent Air Transportation, or (iii) a hospital where Member is receiving treatment resulting from the Serious Emergency to the nearest and most appropriate Medical Facility readily capable of receiving Member and providing the necessary level of care, as may be required due to the Serious Emergency, or to a Suitable Airport for the purposes of Emergent Air Transportation, as may be required by the Serious Emergency.

“Medical Facility” shall be defined as a hospital, licensed and operated according to all applicable laws, which possesses the facilities necessary to provide for the diagnosis and treatment, including major surgical intervention, of injury and sickness by or under the supervision of physicians on an inpatient basis with continuous, twenty-four (24) hour nursing services. Medical Facility does not include physical rehabilitation centers, skilled nursing centers, hospice settings, psychiatric centers and/or other related long-term recovery centers, even if they are otherwise contained within a Medical Facility.

“Member” shall be defined as the person who makes, either directly or through a third-party, the application for membership with MASA MTS and whose application and applicable fees have been received by MASA MTS, and thereby becomes a Member in good standing. For the purposes of this Agreement, Member shall also mean Member’s spouse or domestic partner and/or any legal dependents, up to age twenty-six (26), of the Member(s).

“Physician” shall be defined as a duly licensed Doctor of Medicine (MD) or Doctor of Osteopathy (DO).

“Serious Emergency” shall be defined as a medical emergency, wherein the delay in immediate treatment(s) and/or procedure(s) may likely result in permanent and/or irreversible harm to Member, such as, but not limited to, paralysis, loss of limb, visual impairment, organ damage, and/or death. Any transportation between Medical Facilities, for a heightened level of care not readily available at the transferring Medical Facility, does not constitute a Serious Emergency, unless the immediate lack of such heighten level of care would result in permanent and/or irreversible harm to Member, such as, but not limited to, paralysis, loss of limb, visual impairment, organ damage, and/or death.

ARTICLE IIServices

Emergent Ground Transportation. Member is hereby entitled to Emergent Ground Transportation services, if necessitated by a Serious Emergency, to be rendered by a duly-licensed emergency transportation provider, at no additional expense to the Member. Such transportation shall be to the nearest and most appropriate Medical Facility, readily capable of receiving Member and providing the necessary level of care, as may be required by the Serious Emergency. Transport must result from the request or recommendation by a first-responder or transferring physician who deems Emergent Ground Transportation medically necessary. Emergent Ground Transportation shall also include any ground transportation associated with Emergent Air Transportation. Transports covered under this Agreement must originate and end within the United States or Canada.

ARTICLE IIIGeneral Provisions

Effective Date. This Agreement, and the Services provided herein, shall become in force and effective following thirty (30) days from the date of enrollment, unless otherwise mutually agreed to, in writing, by the parties (“Effective Date”). MASA MTS shall not be obligated to perform any Services to Member prior to the Effective Date of this Agreement. In the event of a revision to the terms and conditions of this Agreement, such revisions shall become effective as of the renewal date of the Agreement.

Identification. MASA MTS shall provide Member with an identification card bearing a Membership Number. Such card and other forms of identification should be carried by the Member at all times, as to provide proof of membership and the right to Services under this Agreement. Any authentic digital form of membership identification will be accepted by MASA MTS.

Supplemental Protection. Member acknowledges and agrees that MASA MTS is not an insurer and/or insurance provider, and the MASA MTS membership should not be construed as an insurance product, unless otherwise required by law. Further, Member acknowledges and agrees that the Services provided hereunder are meant exclusively to supplement Member’s health and/or other insurance coverage(s). In the event that Member possess health and/or other insurance coverage(s) and/or participates in a provider-specific membership or other related program, such coverages and/or programs shall take priority over MASA MTS’ obligations under this Agreement.

Service Contract. Member shall not contract, authorize or engage any service or expense in the name of or on behalf of MASA MTS. The obligations of MASA MTS in this Agreement are limited to providing Services, as described herein.

Authorization. To facilitate the provision of services, the Member does hereby authorize any physician, hospital, medical attendant or others to furnish to MASA MTS any and all information regarding the Member’s physical condition including medical records acquired in the course of examinations and treatment.

Cancellation & Reimbursement. In the event Member desires to terminate this Agreement, written notice of cancellation must be sent by (i) certified mail, return receipt requested, to PO Box 14130, Fort Lauderdale, Florida 33302; (ii) electronic mail, including delivery confirmation, to [email protected]; or (iii) facsimile, including confirmation of delivery, to (817) 416-2326. Member acknowledges and agrees that failure to provide

proof of notice of cancellation delivery may result in the delayed termination of this Agreement. In the event that Member terminates this Agreement within thirty (30) days of the Effective Date and provided that Member has not received any of the Services subject to this Agreement, Member may receive reimbursement of membership fees.

ARTICLE IVExclusions

All Services, subject to this Agreement, shall be provided contingent upon (i) receipt a completed Membership application, or related documentation, (ii) all applicable fees (iii) and upon the Effective Date. MASA MTS reserves the right to deny claims reported to MASA MTS one-hundred and eighty (180) days or more from the date that the claim originated. This Agreement does not provide for transport arising out of or caused by the following: (i) elective and/or cosmetic surgery; (ii) occurrences related to military personnel during active duty hours; (iii) air travel, other than as a passenger in an aircraft operated by a common-carrier airline, maintaining regular published schedules; or (iv) treatment for mental illness or disease.

State laws may prevent a Medicaid recipient from participating in a medical transport membership and/or association. In the event that Member is a Medicaid recipient, Member shall immediately notify MASA MTS, whereupon MASA MTS will cancel the membership and provide a pro-rata refund for the Membership fees. MASA MTS shall deny any claims for a Medicaid recipient.

ARTICLE VLimitations on Liability

Liability. MASA MTS shall not be liable for any negligence and/or tortuous acts or omissions, resulting from Services provided by emergency transportation and/or other providers. MASA MTS is not liable for delayed and/or canceled departures or arrivals due to unsafe conditions, as determined by airport authorities and/or pilots, Acts of God or mechanical failure.

Death, Disability and Injury. MASA MTS shall not be liable to any person for the death, disability or injury of the Member, the patient, or any other person accompanying the Member/patient. Member acknowledges and agrees that MASA MTS may enter into contracts with emergency transportation and/or other providers, and that such providers shall be solely responsible in the event of any injury or death to the Member which might occur during the course of transport by such contracted carrier.

Impossibility of Performance. MASA MTS shall not be liable for failure to perform under this Agreement in the event that such failure is caused by Act of God, fire, flood, strike, labor dispute, riot, insurrection, war or any other cause beyond the control of MASAMTS. Nothing herein contained shall require MASA MTS to take any action contrary to law, any order or regulation of any governmental agency or officer, or contrary to any permit or authorization granted to MASA MTS by any governmental agency.

ARTICLE VIGeneral Provisions

Alternative Dispute Resolution (“ADR”) & Legal Action. The Parties agree that all disputes arising hereunder shall be resolved by arbitration in accordance with the Commercial Rules of the American Arbitration Association. In the event of any legal action, the prevailing party shall be reimbursed all legal costs and reasonable attorney’s fees by the losing party. This Agreement is issued in the State of Texas, and the venue of any action to enforce this Agreement shall be Tarrant County, Texas, and shall be constructed in accordance with the laws of the State of Texas.

Entire Agreement and Severability. All provisions of this Agreement, the Member’s membership application, the Member’s identification card and/or other related documentation provided related to the membership, constitute the entire agreement between MASA MTS and Member. If any provision is declared null and void under the law, that provision is severable and the remainder of this Agreement shall remain in full force and effect.

Effective Term. Payment of membership fees is required no later than thirty (30) days following the end of the membership term, whether monthly, annual or multi-year (“Grace Period”). If payment is not made within the Grace Period, then MASA MTS shall not be responsible for any Services to Member. Member is solely responsible for the payment of all membership fees, even if payment is submitted to MASA MTS by a designated third-party.

Assignment. Member may not assign this Agreement or any of Member’s rights and/or responsibilities herein without the prior written approval of MASA MTS.

Legal Services & Power of Attorney. Member hereby grants to MASA MTS the authority to retain, at MASA MTS’ sole expense, legal counsel on behalf of Member for the purposes of negotiating and/or resolving any third-party claims related to the Services. Furthermore, Member grants to MASA MTS an irrevocable right to settle and/or resolve Member’s outstanding obligations related to the Services without further approval and/or consent by Member. Member acknowledges and agrees that failure to reasonably cooperate or assist the retained legal counsel may result in a limitation of MASA obligations to perform Services.

Subrogation. Member hereby irrevocably assigns to MASA MTS all of Member’s rights, entitlements and interests in any and all insurance policy and/or plan benefits to which Member may be entitled to receive monies for any of the same services provided herein by MASA MTS. Member warrants that MASA MTS may pursue any claims for payment of any insurance benefits directly to itself from any insurance source from which Member is entitled to payment of monies for any of the same services provided herein by MASA MTS.

MASA Medical Transport SolutionsA division of Medical Air Services Association, Inc.

Executive Office & Member Services: (800) 423-3226 Emergency Access: (800) 643-9023

E-Mail: [email protected]

www.masamts.com

© MASA 1985, Revised 2018

A division of MASA Global.

Coverage against unplanned medical emergencies is surprisingly affordable.

Be prepared for the unexpected with a MASA membership. No matter where you live, you could have access to vital emergency medical transportation for a minimal monthly fee. That member-ship could one day save your life, and, every day, it will give you peace of mind like nothing else.

MASA MTS protects you whenyour insurance falls short.

• One low fee for peace of mind for emergent transport costs

• No deductibles

• Easy claim process

• No health questions

• Anyone can join

MASA MTS providespeace of mind.

Facts You Should Know

Emergent Ground Ambulance transports can easily surpass $2,000 and can reach as high as $5,000.

Emergent Air Ambulance transports frequently cost more than $40,000, reaching as high as $70,000.

If you are in need of specialized care and can be transported on an non-emergent basis, it is common for a medically equipped plane to cost more than $20,000.

Most people assume that their health insurance will cover most, if not all, of the costs for these transports. Usually, the opposite is true, leaving you with financially crippling bills.

•

•

•

• When is your next medical emergency planned?

Are you prepared?

BENEFIT EMERGENT GROUND$9/mo

Emergent Ground Transportation U.S./Canada

Coverage available for spouses/domestic partnersand dependents up to age 26.

Any Ground. Any Air. Anywhere.

ANY GROUND. ANY AIR. ANYWHERE.

MASA MTS CLAIMS INSTRUCTIONS

SUBMITTING A NEW CLAIM

1. Go to www.masamts.com.

2. Click on “Member Login” located top right-hand corner and login. If you have not

registered ID number already, you will need to do that.

3. Click on the Claims Tab and then click on “Submit New Claim”.

4. Upload Bill/Invoice and other documentation received.

WHAT’S NEXT?

MASA MTS will need to obtain the following items:

□ Bill/Health Insurance Claim Form (a.k.a. HICFA)

□ Run notes / trip notes

□ Current Explanation of Benefits (EOB)

After receiving all documents and assurance of accurate billing of all responsible

insurance policies and completion of all available claims, MASA MTS will work with the

provider to settle the claim per the Member Services Agreement.

□ The length of time to settle the claim may vary dependent on many factors including

but not limited to the appeals process and responsiveness of the provider to submit.

CONTACT INFORMATION

For alternative method of submission, the claim may also be faxed to 877-681-2399.

For help submitting a claim or to discuss a claim, please contact the claims department at:

Email: [email protected]

Phone: 954-334-8261

Who is eligible? You are eligible for disability coverage if you are an active employee in the United

States working a minimum of 20 hours per week.

What is my monthly

benefit amount?

You can elect to purchase a benefit of 45%, 55% or 65% of your monthly

earnings.

How long do I have to

wait to receive

benefits?

The elimination period is the length of time you must be continuously disabled

before you can receive benefits.

Elimination Period Options:

Option 1: 0 days/7 days first day hospital



Option 4: 90 days/90 days

Option 5: 180 days/180 days

During your elimination period, you will be considered disabled if you are limited

from performing the material and substantial duties of your regular occupation

due to your sickness or injury, you are under the regular care of a physician and

you are unable to perform any of the material and substantial duties of your

regular occupation due to the same sickness or injury.

If, because of your disability, you are hospital confined as an inpatient, benefits

begin on the first day of inpatient confinement. Inpatient means that you are

confined to a hospital room due to your sickness or injury for 23 or more

consecutive hours. (Applies to Elimination Periods of 30 days or less.)

How long will my

benefits last?

Age at Disability Maximum Period of Payment

Less than age 62 To Social Security Normal Retirement Age*

(see table below)

Age 62 60 months

Age 63 48 months

Age 64 42 months

Age 65 36 months

Age 66 30 months

Age 67 24 months

Age 68 18 months

Age 69 or older 12 months

Year of Birth *Social Security Normal Retirement Age (SSNRA)

On or before 1937 65 years

1938 65 years, 2 months





1943 – 1954 66 years






On or after 1960 67 years

Central Texas Employee Benefits Cooperative Voluntary Disability Insurance

Plan Highlights

When is my coverage

effective?

Your effective date of coverage is 9/1/2018. If you become eligible after this

date, please see your plan administrator for your effective date.

How much does the

coverage cost? Elimination Period Benefit Amount Rate per $100 of

Monthly Benefit

0 days/7 days first day hospital

45% Benefit $2.84

55% Benefit $3.10

65% Benefit $3.81


45% Benefit $2.58

55% Benefit $2.82

65% Benefit $3.48


45% Benefit $2.03

55% Benefit $2.22

65% Benefit $2.67

90 days/90 days

45% Benefit $1.15

55% Benefit $1.27

65% Benefit $1.64

180 days/180 days

45% Benefit $0.87

55% Benefit $0.99

65% Benefit $1.34

Do I have to take a

health exam to get

coverage?

You may receive coverage without answering any medical questions or providing

evidence of insurability if you apply for coverage within 31 days after your

eligibility date. If you apply more than 31 days after your eligibility date, your

coverage will be subject to a 3/12 pre-existing condition exclusion.

Please see your plan administrator for your eligibility date.

What if I am out of

work when the

coverage goes into

effect?

Insurance will be delayed if you are not in active employment because of an

injury, sickness, temporary layoff, or leave of absence on the date that insurance

would otherwise become effective.

What is my maximum

monthly benefit

amount?

Your total monthly benefit (including all benefits provided under this plan) will

not exceed 100% of your monthly earnings, unless the excess amount is payable

as a Cost of Living Adjustment.

What else is included

with this policy?

Worldwide emergency travel assistance is included with this long term disability

plan. Emergency travel assistance is available to you, your spouse* and your

dependent children when you travel to any foreign country, including Canada or

Mexico. It is also available anywhere in the United States when you travel just

100 or more miles from home.

* A spouse traveling on business for his or her employer is not covered by the

program.

Does this plan include

help with work-life

balance?

Yes. Our work-life balance employee assistance program (EAP) provides

professional advice for a wide range of personal and work-related issues. The

service is available to you and your family members 24 hours a day, 365 days a

year. It provides resources to help you find solutions to everyday issues — such

as financing a car or selecting child care — as well as more serious problems,

such as alcohol or drug addiction, divorce or relationship problems. There is no

additional charge for using the program, and you do not have to have filed a

disability claim or be receiving benefits to use the program.

What is not covered? Benefits would not be paid for disabilities caused by, contributed to by, or

resulting from:

• Intentionally self-inflicted injuries;

• Active participation in a riot;

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

• Commission of a crime for which you have been convicted;

• Loss of professional license, occupational license or certification;

• Pre-existing conditions (see pre-existing condition section); or

• Any occupational injury or sickness for Short Term Disability coverage.

The loss of a professional or occupational license does not, in itself, constitute

disability.

Unum will not pay a benefit for any period of disability during which you are

incarcerated.

What is considered a

pre-existing condition?

You have a pre-existing condition if:

• You received medical treatment, consultation, care or services including

diagnostic measures, or took prescribed drugs or medicines in the 3 months just

prior to your effective date of coverage; and

• The disability begins in the first 12 months after your effective date of

coverage.

Benefits under this provision are payable for no more than 90 days of benefit

from the date of disability. After 90 days, benefits are subject to a 3/12 pre-

existing condition exclusion. In no event will benefits be paid beyond the

applicable benefit duration. This applies to the 9/1/18 enrollment only and new

hires. Late entrants will be subject to a 3/12 pre-ex.

When does my

coverage end?

Your coverage under the policy ends on the earliest of the following:

• The date the policy or plan is cancelled;

• The date you no longer are in an eligible group;

• The date your eligible group is no longer covered;

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

contributions;

• The last day you are in active employment except as provided under the

covered layoff or leave of absence provision.

Please see your plan administrator for further information on these provisions.

Unum will provide coverage for a payable claim which occurs while you are

covered under the policy or plan.

How can I apply for

coverage?

To apply for coverage, complete your enrollment online by the enrollment

deadline.

If you were hired after 9/1/2018, check with your plan administrator for your

eligibility date, and complete your enrollment online within 31 days of that date.

You are considered in active employment, if on the day you apply for coverage, you are being paid regularly

by your employer for the required minimum hours each week and you are performing the material and

substantial duties of your regular occupation.

The work-life balance employee assistance program, provided by LifeWorks, is available with select Unum

insurance offerings. Terms and availability of service are subject to change. Service provider does not

provide legal advice; please consult your attorney for guidance. Services are not valid after coverage

terminates. Please contact your Unum representative for details.

Worldwide emergency travel assistance services, provided by Assist America, Inc., are available with select

Unum insurance offerings. Terms and availability of service are subject to change and prior notification

requirements. Services are not valid after coverage terminates. Please contact your Unum representative

for details.

This information is not intended to be a complete description of the insurance coverage available. The policy

or its provisions may vary or be unavailable in some states. The policy has exclusions and limitations which

may affect any benefits payable. For complete details of coverage and availability, please refer to Policy

Form C.FP-1 et al or contact your Unum representative.

Underwritten by Unum Life Insurance Company of America, Portland, Maine

© 2017 Unum Group. All rights reserved. Unum is a registered trademark and marketing brand of Unum

Group and its insuring subsidiaries.

EN-1776 (1-17) FOR EMPLOYEES

Flexible Spending Plans

45

Plan Highlights

Flexible Spending Plans

46

Policies other than company sponsored policies (i.e. spouse’s or dependents’ individual policies) may not be paid through

C

What Can I Save with an FSA?

FSA No FSAAnnual taxable income $24,000 $24,000

Health FSA $1,500 $0

Dependent care FSA $1,500 $0

Total pre-tax contributions -$3,000 $0

Taxable income after FSA $21,000 $24,000

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

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

$900 $0

47

What is a Dependent Care Assistance Program (DCAP)?

The Dependent Care Assistance Program (DCAP) allows you to use tax-free dollars to pay for child day care or elder day care expenses that you incur because you and your spouse are both gainfully employed.

To participate, determine the annual amount that you want to deduct from your paycheck before taxes.

Your annual amount will be divided by the number of pay periods in the plan year and that amount will be deducted from each paycheck.

Who is an eligible dependent?

You can use the DCAP for expenses incurred for:

• Your qualifying child who is age twelve or younger for whom you claim a dependency exemption on your income tax return.

• Your qualifying relative (e.g. a child over twelve, your parent, a spouse’s parent) who is physically or mentally incapable of caring for himself or herself and has the same principal place of abode as you for more than half of the year.

• Your spouse who is physically or mentally incapable of caring for himself or herself ans has the same principalplace of abode as you for more than half of the year.

What are eligible expenses for the DCAP?

The expenses which are eligible for reimbursement must have been incurred during the plan year and in connection with you and your spouse to remain gainfully employed.

Examples of eligible expenses:

• Before and After School and/or Extended Day Programs

• Daycare in your home or elsewhere so long as the dependent regularly spends at least 8 hours a day in your home.

• Base cost of day camps or similar programs.

Examples of ineligible expenses:

• Schooling for a child in kindergarten or above

• Babysitter while you go to the movies or out to eat

• Cost of overnight camps

Special Rule for Parents Who Are Divorced, Separated, or Living Apart

Generally, only the custodial parent (who has custody for the majority of the calendar year) can claim expenses from the DCAP. However, if the custodial parent signs a written declaration that the custodial parent will not claim the child as a dependent for the year and other conditions are met the noncustodial parent can make claims expenses for reimbursement from the DCAP.

48

What are some other important IRS regulations?

What does it mean to be “gainfully employed”?

This means that you are working and earning an income (i.e. not doing volunteer work). You are not considered gainfully employed during paid vacation time or sick days. Gainful employment is determined on a daily basis.

If you are married, then your spouse would also need to be gainfully employed for your day care expenses to be eligible for reimbursement.

You are also considered gainfully employed if you are unemployed but actively looking for work, you are self-employed, you are physically or mentally not capable of self-care, or you are a full-time student (must attend for the number of hours that the school considers full-time, must have been a

• You cannot be reimbursed for dependent care expenses that were paid to (1) one of your

• In the event that you use a day care center that cares for more than six children, the center mustbe licensed.

•

Can I still take the Federal Income Tax Credit for dependent care expenses?

The IRS allowsyou to take a tax credit for your dependent care expenses. The tax credit may provide

the tax credit or the DCAP is best for you, you will need to review your individual tax circumstances. You cannot use the same expenses for both the tax credit and the DCAP, however, you may be able to coordinate the federal dependent care tax credit with participation in the DCAP for expenses not reimbursed the the DCAP.

8523 South Redwood RoadWest Jordan, Utah 84088

1-800-274-0503

1(800) 274-0503

49

Cuentas de Gastos FlexiblesMaximice sus beneficios y dese un aumento.

Planes de gastos flexiblesUn Plan de Cafetería le permite ahorrar dinero en seguro de grupo, gastos relativos a la salud y gastos de cuidado de dependientes. Sus contribuciones se deducen de su paga antes de la retención de impuestos. Debido a que es gravado sobre un monto inferior de paga, paga menos en impuestos y tiene más para gastar. ¡Puede ahorrar tanto como un 35% en el costo de cada opción de beneficio!

Ahorros FSA

FSA No FSA

Ingreso Anual Imponible $24,000 $24,000

Gastos de Atención Médica $1,500 $0

Gastos de cuidado diaria de dependientes $1,500 $0

Total de Contribuciones Antes de Impuestos -$3,000 $0

Ingresos imponibles después de FSA $21,000 $24,000

Impuestos Federales, estatales & SS (30+%) -$6,300 -$7,200

Ingresos después de impuestos $14,700 $16,800

Dólares después de impuestos invertidos en gastos de cuidado de dependientes y salud

$0 -$3,000

Salario neto $14,700 $13,800

Salario neto aumentado $900 $0

Lista Parcial de Gastos Elegibles:

Consulte la lista completa en www.nbsbenefits.com

*Los ahorros federales y estatales pueden variar. Puede encontrar un calculador de ahorros en nues-tro sitio en Internet: NBSbenefits.com para averiguar cuánto podría ahorrar.

Opciones de Inscripción

• Cuenta de Gastos de Atención de la Salud

Su cuenta de gastos de atención de la salud le permite ahorrar dinero al pagar gastos relativos a la salud del propio bolsillo con dólares antes de impuestos. Durante su inscripción de beneficio anual, debe decidir si participa en esta cuenta y cuánto desea contribuir.

• Cuenta de Cuidado de Dependiente (Gastos de Cuidado por día)

Este plan opcional le permite usar los dólares antes de impuestos para pagar por los gastos de cuidado de dependientes mientras usted y su cónyuge (si está casado) están en el trabajo. Durante su inscripción de beneficio anual, debe decidir si participa en esta cuenta y cuánto desea contribuir. La cuenta de cuidado de dependiente no está financiada previamente. Usted es elegible para el reembolso una vez que haya incurrido en un reclamo y se haya deducido dinero de su nómina de pago.

• Copagos y deducibles médicos, dentales y de visión

• Medicamentos recetados• Terapia Física• Quiropráctico• Suministros de Primeros

Auxilios• Tarifas de Laboratorio• Psiquiatra/psicólogo

• Vacunas• Trabajo dental, incluso

ortodoncia• Exámenes oculares• Cirugía láser de ojos• Anteojos, lentes de

contacto, soluciones para lentes

• Medicamentos recetados de venta libre

Salt Lake City, UT - Sede | Dallas, TX | San Diego, CA | Honolulu, HI(800) 274-0503 | [email protected] | www.nbsbenefits.com

Cómo funciona el Plan FSAUsted nombra una elección anual de dólares antes de impuestos a ser depositados en sus cuentas de gasto de salud y cuidado de dependientes. Su elección total se divide por el número de períodos de pago en el año del Plan y se deduce de igual manera de cada nómina de pago antes de calcular los impuestos. Al final del año del Plan, su elección total se depositará por completo.

No obstante, puede hacer un reclamo por gastos elegibles tan pronto como los incurra durante el año del Plan. Los reclamos elegibles se pagarán hasta el total de su elección anual, incluso si aún no ha con-tribuido esa cantidad a su cuenta.

Obtenga su dinero1. Complete y firme un formulario de reclamo (disponible en su sitio en Internet) o en un reclamo en Inter-

net en línea.2. Adjunte la documentación; como una factura desglosada o una Explicación de los Beneficios (EOB)

declaración de un proveedor de seguro de salud.3. Envíe por fax o por correo el formulario firmado y la documentación a NBS.4. Reciba su reembolso no tributable después de que su reclamo se procesa, ya sea por cheque o depósito

directo.

NBS Smart Card—FSA MasterCard prepagaSu empleador puede patrocinar el uso de la NBS Flexcard, al re-alizar el acceso a sus dólares es más fácil que nunca. Puede usar esta tarjeta para pagar a comerciantes o proveedores de servicio que aceptan tarjetas de crédito, por lo que no hay necesidad de pagar en efectivo por anticipado y luego esperar el reembolso.

Información de CuentaLos participantes pueden llamar a NBS y hablar con unrepresentante durante nuestros horas comerciales habit-uales, de lunes a viernes, de 8 a.m. a 5 p.m. Hora de la Montaña. Los participantes también pueden obtener la información de la cuenta al usar la Unidad de Respuesta de Voz Automática, las 24 horas del día, los 7 días de la semana al (801) 838-7324 o en forma gratuita (888) 353-9125. Para el acceso inmediato a la infor-mación de su cuenta en cualquier momento, inicie sesión en nuestro sitio en Internet NBSbenefits.com. La información incluye:• Historial de reclamo detallado y estado de

procesamiento• Saldos de la cuenta de cuidado de Dependientes y

Atención de Salud• Formularios de reclamo, hojas de trabajo, etc.• Preguntas frecuentes

Consideraciones de Inscripción

Después de finalizado el período de inscripción, puede aumentar, disminuir o detener su contribución solo cuando experimente un “cambio de estado” calificador (estado de matrimonio, cambio de empleo, cambio de dependiente). Sea conservador en la suma total que elija para evitar la confiscación de su dinero que pueda quedar en su cuenta al final del año. Su empleador puede permitir un breve período de gracia después de finalizar el año del Plan para que pueda presentar reclamos calificados por cualquier fondo no usado.

i Notes n

This is a general overview of your plan benefits. Additional details on covered expenses, limitations and exclusions are included in the summary plan description located on the CTXEBC Benefits Website: www.ctxebc.com

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i Notes n

This is a general overview of your plan benefits. Additional details on covered expenses, limitations and exclusions are included in the summary plan description located on the CTXEBC Benefits Website: www.ctxebc.com

51

21 N. Glenville Drive | Richardson, Texas 75082 | ( | www.fbsbenefits.com

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central texas employee benefits cooperative

Documents