Table of Contents. Pre-Tax Benefits. Anthem Health Insurance Plans Anthem Health Insurance Plans Comparison 5

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1 Table of Contents Pre-Tax Benefits Anthem Health Insurance Plans Anthem Health Insurance Plans Comparison 5 Anthem Lumenos HSA Health Insurance Plan 7 Anthem HMO Health Insurance Plan 14 Anthem PPO Health Insurance Plan 21 Flexible Benefits Administrators Flexible Spending and Dependent Care Accounts 29 Ameritas Dental 40 Ameritas Vision 42 Aflac Accident 44 Aflac Critical Illness Plan (Without Cancer) 51 Aflac Critical Illness Plan (With Cancer) 56 Aflac Value Added Services 61 Humana Cancer 63 After-Tax Benefits AUL Short-Term Disability Plan 68 Texas Life PureLife-plus 71 Texas Life Whole Life 77 Legal Resources 82 For Your Reference Continuation of Benefits 85 Contact Information for Questions and Claims 86 If you wish to add or make changes to your insurance coverage(s), please consult a Benefits Representative during your scheduled enrollment period. You will not be able to make any changes once the enrollment period is over unless you experience a qualified event outlined by the IRS (i.e., marriage, divorce, birth of a child, etc.) If you should experience a qualified event, you have 30 days from the date of the event to make any changes. All information in this booklet is a brief description of your coverage and is not a contract. Please refer to your policy or certificate for each product for the exact terms and conditions. Page 1

2 * * * * * * * * NOTICE * * * * * * * * Montgomery County Public Schools offers a comprehensive benefits package specifically designed to protect your income and assets. The benefit plans are arranged and enrolled by Mark III Brokerage, a benefits firm that has worked in the public sector for many years. During annual enrollment, you may purchase coverage through pre-tax and aftertax payroll deductions. To learn more about your benefit package, please plan to meet with a Mark III Benefits Counselor during the 2018 enrollment period. Once you enroll, your coverage will be effective on October 1, The plan year will run from October 1, 2018 through September 30, 2019 All products described in this booklet are deducted on a pre-tax basis except: L egal Resources AUL Short-Term Disability Texas Life Purelife-Plus Texas Life Whole LIfe Employees can choose pre- or post-tax for Anthem, and must complete our pre-tax conversion form to indicate which. Please note that in order to be eligible for a Health Care Flexible Spending Account, you cannot have an HSA or be listed as a dependent on your spouse s HDHP. Even if you are not eligible for a Health Care FSA, you can elect a Dependent Care Flexible Spending Account. You will not be able to make any changes once the enrollment period is over unless you experience a qualified event as outlined by the IRS (i.e., marriage, divorce, birth of a child, etc.). If you should experience a qualified event, you have 30 days from the date of the event to make any changes. This booklet highlights the benefits offered through your employer for the current plan year. This is not an Insurance Contract and only the actual policy provisions will prevail. All information in this booklet including premiums are subject to change. All policy descriptions are for informational purposes only. Please read your certificate for each product for the exact terms and conditions. Plan Design By: Page 2

3 ANTHEM HEALTH INSURANCE 12-MONTH RATES AVAILABLE TO ALL ELIGIBLE EMPLOYEES 1. (HSA - PPO) LUMENOS HIGH DEDUCTIBLE HEALTH PLAN ount deposited into an employee s employee s HSA account. The first deposit will be made in October 201 Total Employee Monthly Monthly Monthly Health Savings Premium Premium Account 2. (HMO) HEALTH MAINT ORG. HEALTHKEEPERS 15 Total Monthly Premium Employee Monthly Premium August 1, 2018 Page 3

4 AVAILABLE TO CURRENT PPO ENROLLEES (NO NEW ENROLLEES) 3. (PPO) PREFERRED PROVIDER ORG. KEYCARE 15 Total Employee Monthly Monthly Premium Premium Current PPO members can add or remove dependents or move to a different plan. IMPORTANT NOTES August 1, 2018 Page 4

5 Montgomery County Public Schools In-Network Benefit Comparison Overview October 1, 2018 September 30, 2019 In-Network Benefits Lumenos HSA Member Pays Page 5 HMO POS Open Access 15 Member Pays Key Care 15 (PPO) Member Pays Lifetime Maximum None None None Individual: $1,350 Individual: $500 Family: $2,700 Individual: $250 Family: $1,000 Calendar Year Deductible (Deductible applies to all Family: $500 (Only applies to certain services. services except Routine Vision Please see below.) Exam) Annual Out-of-Pocket Expense Limit* (Combined medical and prescription drug) Individual: $3,425 Family: $6,850 Individual: $2,500 Family: $5,000 PCP: 20% Coinsurance (after Office Visits deductible) PCP: $15 Copayment Specialist: 20% Coinsurance Specialist: $35 Copayment (after deductible) Primary Care Physician selection required? No Yes No Referral required for specialist services? No No No Preventive Care/Routine Wellness Service Well Baby Care Maternity Care Annual Routine Vision Exam through Blue View Vision Hospital Emergency Room Care Outpatient Surgery Outpatient Diagnostic X-rays & Lab Services Therapy Services Physical and Occupational: combines 30 visits limit per calendar year Speech Therapy: 30 visit limit per calendar year Home Health Care (100 visit limit) Spinal Manipulations/Manual Medical Interventions (30 visit limit per calendar year) Inpatient Hospital Services Skilled Nursing Facility Mental Health and Substance Abuse (Outpatient Care) Individual: $2,500 Family: $5,000 PCP: $15 Copayment Specialist: $30 Copayment Covered at 100% Covered at 100% Covered at 100% Facility: 20% coinsurance (after deductible) Professional: Pre-natal care, post-natal care, and delivery: 20% coinsurance (after deductible) $15 copayment (deductible does not apply) Facility: 20% coinsurance (after deductible) Professional: 20% coinsurance (after deductible) Facility: 20% coinsurance (after deductible) Professional: 20% coinsurance (after deductible) 20% coinsurance Advanced Diagnostic Imaging: 20% coinsurance (after deductible) Facility: 20% coinsurance (after deductible) Professional: 20% coinsurance (after deductible) 20% coinsurance (after deductible) 20% coinsurance (after deductible) Facility: 20% coinsurance (after deductible) Professional: 20% coinsurance (after deductible) 20% coinsurance (after deductible) Partial Day Facility: 20% coinsurance (after deductible) Office Visit: 20% coinsurance (after deductible) Facility: $200 copayment per day (not to exceed $1,000 per admission) Professional: Pre-natal care and post-natal care $150 copayment Delivery: No copayment $15 copayment $15 copayment Facility: $200 copayment Professional: No copayment Facility: $150 copayment Professional: $15 PCP/$35 Specialist Office Visit Copayment Advanced Diagnostic Imaging: 20% coinsurance Facility: $25 copayment per visit Professional: $25 copayment per visit 20% coinsurance Facility: $300 copayment + 20% coinsurance (after deductible) per admission Professional: Pre-natal care and post-natal care $150 copayment Delivery: 20% coinsurance (after deductible) Facility: $200 copayment + 20% coinsurance (after deductible) Professional: 20% coinsurance (after deductible) Facility: $150 copayment + 20% coinsurance Professional: $15 PCP/$30 Specialist 20% coinsurance Advanced Diagnostic Imaging: 20% coinsurance (after deductible) Facility: $30 copayment + 20% coinsurance Professional: $15 PCP/$30 Specialist 20% coinsurance (after deductible) $25 copayment $30 copayment Facility: $200 copayment per admission (not to exceed $1,000 per admission Professional: No copayment 20% coinsurance Partial Day Facility: No charge Office Visit: $20 group or individual therapy up to 30 minutes or medication management $30 copayment all other visits Facility: $200 copayment + 20% coinsurance per admission (after deductible Professional: 20% coinsurance (after deductible) 20% coinsurance (after deductible) Partial Day Facility: 20% coinsurance (after deductible) Office Visit: $15 copayment

6 Montgomery County Public Schools In-Network Benefit Comparison Overview October 1, 2018 September 30, 2019 Applies to all benefit plans: Mandatory Generic Prescription Contraceptive Medications and Services Diabetic Supplies Prescription drug calendar year deductible Prescription Drugs Tier 1, Tier 2 and Tier 3 medications subject to combined medical and prescription calendar year deductible Tier 2 and Tier 3 medications subject to $100 calendar year deductible Tier 2 and Tier 3 medications subject to $100 calendar year deductible Retail (30 day supply) Tier 1 20% coinsurance (after $10 $10 deductible) Tier 2 20% coinsurance (after deductible) $25 (after $100 deductible) $25 (after $100 deductible) Tier 3 20% coinsurance (after deductible) $50 (after $100 deductible) $50 (after $100 deductible) Mail Order (90 day supply) Tier 1 20% coinsurance (after deductible) $10 $10 Tier 2 20% coinsurance (after deductible) $50 (after $100 deductible) $50 (after $100 deductible) Tier 3 20% coinsurance (after deductible) $150 (after $100 deductible) $150 (after $100 deductible) *The HMO Plan has an Embedded Out-of-Pocket Maximum. The PPO has an Embedded Deductible and Out-of-Pocket Maximum. The Lumenos HSA plan has a Non-Embedded Deductible and Out-of-Pocket Maximum. Page 6

7 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 10/01/ /30/2019 Montgomery County Public Schools: HSA Coverage for: Individual + Family Plan Type: CDHP The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at or call (833) to request a copy. Important Questions Answers Why This Matters: What is the overall $1,350/individual or Generally, you must pay all of the costs from providers up to the deductible amount before deductible? $2,700/family for In-Network this plan begins to pay. If you have other family members on the policy, the overall family Providers and for Out-of- deductible must be met before the plan begins to pay. Network Providers. Are there services covered before you meet your deductible? Yes. Preventive care for In- Network Providers. Vision exam. This plan covers some items and services even if you haven t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at Are there other deductibles for specific services? What is the out-ofpocket limit for this plan? What is not included in the out-of-pocket limit? Will you pay less if you use a network provider? No. You don't have to meet deductibles for specific services. $3,425/individual or $6,850/family for In-Network Providers. $5,000/individual or $10,000/family for Out-of- Network Providers. Premiums, Balance-Billing charges, and Health Care this plan doesn't cover. Yes, KeyCare. See or call (833) for a list of network providers. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, the overall family out-of-pocket limit must be met. Even though you pay these expenses, they don t count toward the out-of-pocket limit. This plan uses a provider network. You will pay less if you use a provider in the plan s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. VA/L/A/MontgomeryCounty: LHSA-CDHP/NA/VC9ZL/NA/ of 10 Page 7

8 Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event If you visit a health care provider s office or clinic If you have a test If you need drugs to treat your illness or condition More information about prescription drug coverage is available at m.com/pharmacyin formation/ National If you have outpatient surgery If you need immediate medical attention Services You May Need Network Provider (You will pay the least) What You Will Pay Out-of-Network Provider (You will pay the most) Primary care visit to treat an injury or illness 20% coinsurance 40% coinsurance none Specialist visit 20% coinsurance 40% coinsurance none Preventive care/screening/ immunization No charge 40% coinsurance Diagnostic test (x-ray, blood work) 20% coinsurance 40% coinsurance none Imaging (CT/PET scans, MRIs) 20% coinsurance 40% coinsurance none Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty Drugs Facility fee (e.g., ambulatory surgery center) 20% coinsurance (retail) and 20% coinsurance (home delivery) 20% coinsurance (retail) and 20% coinsurance (home delivery) 20% coinsurance (retail) and 20% coinsurance (home delivery) 20% coinsurance (retail) and 20% coinsurance (home delivery) 40% coinsurance (retail) and 40% coinsurance (home delivery) 40% coinsurance (retail) and 40% coinsurance (home delivery) 40% coinsurance (retail) and 40% coinsurance (home delivery) 40% coinsurance (retail) and 40% coinsurance (home delivery) Limitations, Exceptions, & Other Important Information You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. *See Prescription Drug section 20% coinsurance 40% coinsurance none Physician/surgeon fees 20% coinsurance 40% coinsurance none Emergency room care 20% coinsurance 40% coinsurance none Emergency medical transportation 20% coinsurance 40% coinsurance none Urgent care 20% coinsurance 40% coinsurance none * For more information about limitations and exceptions, see plan or policy document at 2 of 10 Page 8

9 Common Medical Event If you have a hospital stay If you need mental health, behavioral health, or substance abuse services If you are pregnant If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Network Provider (You will pay the least) What You Will Pay Out-of-Network Provider (You will pay the most) Facility fee (e.g., hospital room) 20% coinsurance 40% coinsurance none Physician/surgeon fees 20% coinsurance 40% coinsurance none Outpatient services Office Visit 20% coinsurance Other Outpatient 20% coinsurance Office Visit 40% coinsurance Other Outpatient 40% coinsurance Limitations, Exceptions, & Other Important Information Office Visit none Other Outpatient none Inpatient services 20% coinsurance 40% coinsurance none Office visits 20% coinsurance 40% coinsurance Childbirth/delivery professional Maternity care may include tests and 20% coinsurance 40% coinsurance services services described elsewhere in the Childbirth/delivery facility SBC (i.e. ultrasound.) 20% coinsurance 40% coinsurance services Home health care 20% coinsurance 40% coinsurance 90 visits/calendar year. Rehabilitation services 20% coinsurance 40% coinsurance Habilitation services 20% coinsurance 40% coinsurance *See Therapy Services section Skilled nursing care 20% coinsurance 40% coinsurance 100 days limit/calendar year. Durable medical equipment 20% coinsurance 40% coinsurance none Hospice services 20% coinsurance 40% coinsurance none Children s eye exam $15/visit $30 allowance deductible does not apply *See Vision Services section Children s glasses Not covered Not covered Children s dental check-up Not covered Not covered none * For more information about limitations and exceptions, see plan or policy document at 3 of 10 Page 9

10 Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Acupuncture Bariatric surgery Cosmetic surgery Dental care (adult) Hearing aids Infertility treatment Long- term care Routine foot care unless you have been diagnosed with diabetes. Weight loss programs Other Covered Services (Limitations may apply to these services. This isn t a complete list. Please see your plan document.) Chiropractic care 30 visits/calendar year. Most coverage provided outside the United Private-duty nursing States. See Routine eye care (adult) Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at x61565 or Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit or call Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: ATTN: Grievances and Appeals, P.O. Box 27401, Richmond, VA Does this plan provide Minimum Essential Coverage? Yes If you don t have Minimum Essential Coverage for a month, you ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet the Minimum Value Standards? Yes If your plan doesn t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. To see examples of how this plan might cover costs for a sample medical situation, see the next section. * For more information about limitations and exceptions, see plan or policy document at 4 of 10 Page 10

11 About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing Joe s type 2 Diabetes (a year of routine in-network care of a wellcontrolled condition) Mia s Simple Fracture (in-network emergency room visit and follow up care) The plan s overall deductible $1,300 The plan s overall deductible $1,300 The plan s overall deductible $1,300 Specialist coinsurance 20% Specialist coinsurance 20% Specialist coinsurance 20% Hospital (facility) coinsurance 20% Hospital (facility) coinsurance 20% Hospital (facility) coinsurance 20% Other coinsurance 20% Other coinsurance 20% Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $12,840 Total Example Cost $7,460 Total Example Cost $1,970 In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay: Cost Sharing Cost Sharing Cost Sharing Deductibles $1,300 Deductibles $1,300 Deductibles $1,300 Copayments $0 Copayments $0 Copayments $0 Coinsurance $2,527 Coinsurance $1,437 Coinsurance $385 What isn t covered What isn t covered What isn t covered Limits or exclusions $60 Limits or exclusions $55 Limits or exclusions $0 The total Peg would pay is $3,887 The total Joe would pay is $2,792 The total Mia would pay is $1,685 The plan would be responsible for the other costs of these EXAMPLE covered services. 5 of 10 Page 11

12 Language Access Services: It s important we treat you fairly That s why we follow federal civil rights laws in our health programs and activities. We don t discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C or by calling (TDD: ) or online at Complaint forms are available at 10 of 10 Page 12

13 Anthem Lumenos High Deductible Health Plan: Health Savings Account (HSA) contributions MCPS contributes to your HSA account: Employee only: $112.50/month or $ /plan year Employee plus dependent(s): $225.00/month or $2,700.00/plan year Contributions are made in 2 installments: October: $ April: $ Contributions are made in 2 installments: October: $1, April: $1, Note: Employer and Employee contributions count towards your total annual HSA contribution limit (per IRS regulation): Total for 2018: Employee only: $3,450 Employee plus dependent(s): $6,900 Total for 2019: $3,500 $7, Deduction may be stopped or changed any time. Other (post-tax) contributions to your account decrease the amount you may contribute through pre-tax payroll deduction. Page 13

14 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 10/01/ /30/2019 Montgomery County Public Schools: HMO Coverage for: Individual + Family Plan Type: POS The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at or call (833) to request a copy. Important Questions Answers Why This Matters: What is the overall $250/individual or $500/family Generally, you must pay all of the costs from providers up to the deductible amount before deductible? for In-Network Providers. this plan begins to pay. If you have other family members on the plan, each family member $500/individual or must meet their own individual deductible until the total amount of deductible expenses paid $1,000/family for Out-of- by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Are there other deductibles for specific services? What is the out-ofpocket limit for this plan? What is not included in the out-of-pocket limit? Network Providers. Yes. Preventive care, Office visits, Emergency room, Inpatient stay, and Outpatient stay for In-Network Providers. Vision exam and Prescription Drugs. Yes. $100/individual or $100/family for Prescription Drug Tier 2 and 3. There are no other specific deductibles. $2,500/individual or $5,000/family for In-Network Providers. $3,500/individual or $7,000/family for Out-of- Network Providers. Costs associated with routine vision care, the cost of care when the benefit limits have been reached, Premiums, Balance-Billing charges, and Health Care this plan doesn't cover. This plan covers some items and services even if you haven t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. Even though you pay these expenses, they don t count toward the out-of-pocket limit. VA/L/A/HMO/NA/LEHFX/NA/ of 11 Page 14

15 Will you pay less if you use a network provider? Yes, HealthKeepers HMO. See or call (833) for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event If you visit a health care provider s office or clinic If you have a test If you need drugs to treat your illness or condition Services You May Need Primary care visit to treat an injury or illness Specialist visit Preventive care/screening/ immunization HMO Provider (You will pay the least) $15/visit deductible does not apply $35/visit deductible does not apply What You Will Pay Non- HMO Provider (You will pay the most) No charge 30% coinsurance 30% coinsurance none % coinsurance none Limitations, Exceptions, & Other Important Information You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. A copay does not apply when these Diagnostic test (x-ray, blood $15 or $35/visit deductible services are provided by the same 30% coinsurance work) does not apply provider on the same day as the office visit. Imaging (CT/PET scans, MRIs) 20% coinsurance 30% coinsurance none Tier 1 - Typically Generic $10/prescription, Prescription Drug deductible does not apply (retail) and $10/prescription, Prescription Drug deductible does not apply (home delivery) $10/prescription, Prescription Drug deductible does not apply (retail) and $10/prescription, Prescription Drug deductible does not apply (home delivery) *See Prescription Drug section * For more information about limitations and exceptions, see plan or policy document at 2 of 11 Page 15

16 Common Medical Event More information about prescription drug coverage is available at m.com/pharmacyin formation/ National If you have outpatient surgery If you need immediate medical attention If you have a hospital stay If you need mental health, behavioral health, or substance abuse services Services You May Need Tier 2 - Typically Preferred / Brand Tier 3 - Typically Non-Preferred / Specialty Drugs Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Emergency room care Emergency medical transportation Urgent care Facility fee (e.g., hospital room) HMO Provider (You will pay the least) $25/prescription, Prescription Drug deductible applies (retail) and $50/prescription, Prescription Drug deductible applies (home delivery) $50/prescription, Prescription Drug deductible applies (retail) and $150/prescription, Prescription Drug deductible applies (home delivery) $150/visit deductible does not apply $15 or $35/visit deductible does not apply $200/visit deductible does not apply $150/transport deductible does not apply $15 or $35/visit deductible does not apply $200/day up to $1,000/admission deductible does not apply What You Will Pay Non- HMO Provider (You will pay the most) $25/prescription, Prescription Drug deductible applies (retail) and $50/prescription, Prescription Drug deductible applies (home delivery) $50/prescription, Prescription Drug deductible applies (retail) and $150/prescription, Prescription Drug deductible applies (home delivery) 30% coinsurance none % coinsurance none % coinsurance 30% coinsurance none % coinsurance none % coinsurance none Physician/surgeon fees No charge after facility fee 30% coinsurance none Outpatient services Inpatient services Office Visit $15/visit deductible does not apply Other Outpatient No charge $200/day up to $1,000/admission deductible does not apply Office Visit 30% coinsurance Other Outpatient 30% coinsurance Limitations, Exceptions, & Other Important Information If admitted to the hospital, ER copay is waived. Office Visit none Other Outpatient none % coinsurance none * For more information about limitations and exceptions, see plan or policy document at 3 of 11 Page 16

17 Common Medical Event If you are pregnant If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need HMO Provider (You will pay the least) Office visits $150/pregnancy deductible does not apply Childbirth/delivery professional services Childbirth/delivery facility services What You Will Pay Non- HMO Provider (You will pay the most) No charge after facility fee 30% coinsurance $200/day up to $1,000/admission deductible does not apply Limitations, Exceptions, & Other Important Information 30% coinsurance Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.) 30% coinsurance Home health care 20% coinsurance 30% coinsurance 100 visits/calendar year. Rehabilitation services Habilitation services $25/visit deductible does not apply $25/visit deductible does not apply 30% coinsurance 30% coinsurance *See Therapy Services section Skilled nursing care 20% coinsurance 30% coinsurance 100 days limit/stay. Durable medical equipment 20% coinsurance 30% coinsurance none Hospice services Children s eye exam No charge deductible does not apply $15/visit deductible does not apply 30% coinsurance none $30 allowance/visit medical deductible does not apply *See Vision Services section Children s glasses Not covered Not covered Children s dental check-up Not covered Not covered none Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Acupuncture Bariatric surgery Cosmetic surgery Dental care (adult) Hearing aids Infertility treatment Long- term care Routine foot care unless you have been diagnosed with diabetes. Weight loss programs * For more information about limitations and exceptions, see plan or policy document at 4 of 11 Page 17

18 Other Covered Services (Limitations may apply to these services. This isn t a complete list. Please see your plan document.) Chiropractic care 30 visits/calendar year. Most coverage provided outside the United Private-duty nursing States. See Routine eye care (adult) one eye exam/ calendar year. Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at x61565 or Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit or call Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: ATTN: Grievances and Appeals, P.O. Box 27401, Richmond, VA Does this plan provide Minimum Essential Coverage? Yes If you don t have Minimum Essential Coverage for a month, you ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet the Minimum Value Standards? Yes If your plan doesn t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. To see examples of how this plan might cover costs for a sample medical situation, see the next section. * For more information about limitations and exceptions, see plan or policy document at 5 of 11 Page 18

19 About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing Joe s type 2 Diabetes (a year of routine in-network care of a wellcontrolled condition) Mia s Simple Fracture (in-network emergency room visit and follow up care) The plan s overall deductible $0 The plan s overall deductible $0 The plan s overall deductible $0 Specialist copayment $35 Specialist copayment $35 Specialist copayment $35 Hospital (facility) copayment $200 Hospital (facility) copayment $200 Hospital (facility) copayment $200 Other copayment $15 Other copayment $15 Other copayment $15 This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $12,840 Total Example Cost $7,460 Total Example Cost $1,970 In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay: Cost Sharing Cost Sharing Cost Sharing Deductibles $0 Deductibles $100 Deductibles $0 Copayments $540 Copayments $1,915 Copayments $1,120 Coinsurance $0 Coinsurance $0 Coinsurance $47 What isn t covered What isn t covered What isn t covered Limits or exclusions $60 Limits or exclusions $55 Limits or exclusions $0 The total Peg would pay is $600 The total Joe would pay is $2,070 The total Mia would pay is $1,167 The plan would be responsible for the other costs of these EXAMPLE covered services. 6 of 11 Page 19

20 Language Access Services: It s important we treat you fairly That s why we follow federal civil rights laws in our health programs and activities. We don t discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C or by calling (TDD: ) or online at Complaint forms are available at 11 of 11 Page 20

21 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 10/01/ /30/2019 Montgomery County Public Schools: PPO Coverage for: Individual + Family Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at or call (833) to request a copy. Important Questions Answers Why This Matters: What is the overall deductible? Are there services covered before you meet your deductible? $500/individual or $1,000/family for In-Network Providers. $800/individual or $1,600/family for Out-of- Network Providers. Yes. Preventive care, Office visits and Outpatient stay for In-Network Providers. Vision exam and Prescription Drugs. Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. This plan covers some items and services even if you haven t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at Are there other deductibles for specific services? What is the out-ofpocket limit for this plan? What is not included in the out-of-pocket limit? Yes. $100/individual or $100/family for Prescription Drugs Tier 2 and 3. There are no other specific deductibles. $2,500/individual or $5,000/family for In-Network Providers. $3,750/individual or $7,500/family for Out-of- Network Providers. Costs associated with routine vision care, the cost of care when the benefit limits have been reached, Premiums, Balance-Billing charges, and Health Care this plan doesn't cover. You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. Even though you pay these expenses, they don t count toward the out-of-pocket limit. VA/L/A/MontgomeryCountyPublicSchools-PPO/NA/CXBBQ/NA/ of 12 Page 21

22 Will you pay less if you use a network provider? Yes, KeyCare. See or call (833) for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider s charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event If you visit a health care provider s office or clinic If you have a test If you need drugs to treat your illness or condition Services You May Need Primary care visit to treat an injury or illness Specialist visit Preventive care/screening/ immunization Network Provider (You will pay the least) $15/visit deductible does not apply $30/visit deductible does not apply What You Will Pay Non-Network Provider (You will pay the most) No charge 30% coinsurance 30% coinsurance none % coinsurance none Diagnostic test (x-ray, blood work) 20% coinsurance 30% coinsurance none Imaging (CT/PET scans, MRIs) 20% coinsurance 30% coinsurance none Tier 1 - Typically Generic $10/prescription, Prescription Drug deductible does not apply (retail) and $10/prescription, Prescription Drug deductible does not apply (home delivery) $10/prescription, Prescription Drug deductible does not apply (retail) and $10/prescription, Prescription Drug, deductible does not apply (home delivery) Limitations, Exceptions, & Other Important Information You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. *See Prescription Drug section * For more information about limitations and exceptions, see plan or policy document at 2 of 12 Page 22

23 Common Medical Event More information about prescription drug coverage is available at m.com/pharmacyin formation/ National If you have outpatient surgery If you need immediate medical attention If you have a hospital stay If you need mental health, behavioral health, or substance abuse services Services You May Need Tier 2 - Typically Preferred / Brand Tier 3 - Typically Non-Preferred / Specialty Drugs Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Emergency room care Emergency medical transportation Urgent care Network Provider (You will pay the least) $25/prescription, Prescription Drug deductible applies (retail) and $50/prescription, Prescription Drug deductible applies (home delivery) $50/prescription, Prescription Drug deductible applies (retail) and $150/prescription, Prescription Drug deductible applies (home delivery) $150/visit then 20% coinsurance deductible does not apply $15 or $30/visit deductible does not apply $200/visit then 20% coinsurance deductible does not apply $150/transport deductible does not apply $15 or $30/visit deductible does not apply What You Will Pay Non-Network Provider (You will pay the most) $25/prescription, Prescription Drug deductible applies (retail) and $50/prescription, Prescription Drug deductible applies (home delivery) $50/prescription, Prescription Drug deductible applies (retail) and $150/prescription, Prescription Drug deductible applies (home delivery) 30% coinsurance none % coinsurance none % coinsurance none % coinsurance none % coinsurance none $300/admission then 20% Facility fee (e.g., hospital room) coinsurance deductible 30% coinsurance none does not apply Physician/surgeon fees 20% coinsurance 30% coinsurance none Outpatient services Office Visit $15/visit deductible does not apply Other Outpatient 20% coinsurance Office Visit 30% coinsurance Other Outpatient 30% coinsurance Limitations, Exceptions, & Other Important Information Office Visit none Other Outpatient none * For more information about limitations and exceptions, see plan or policy document at 3 of 12 Page 23

24 Common Medical Event If you are pregnant Services You May Need Inpatient services Office visits Childbirth/delivery professional services Childbirth/delivery facility services Network Provider (You will pay the least) $300/admission then 20% coinsurance deductible does not apply $150/pregnancy deductible does not apply What You Will Pay Non-Network Provider (You will pay the most) 30% coinsurance none % coinsurance 20% coinsurance 30% coinsurance $300/admission then 20% coinsurance deductible does not apply 30% coinsurance Limitations, Exceptions, & Other Important Information Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.) If you need help recovering or have other special health needs If your child needs dental or eye care Home health care 20% coinsurance 30% coinsurance 100 visits/benefit period. Rehabilitation services Habilitation services $30/visit then 20% coinsurance deductible does not apply $30/visit then 20% coinsurance deductible does not apply 30% coinsurance 30% coinsurance *See Therapy Services section Skilled nursing care 20% coinsurance 30% coinsurance 100 days limit/stay. Durable medical equipment 20% coinsurance 30% coinsurance none Hospice services No charge 30% coinsurance none Children s eye exam $15/visit deductible does not apply $30 allowance/visit *See Vision Services section Children s glasses Not covered Not covered Children s dental check-up Not covered Not covered none * For more information about limitations and exceptions, see plan or policy document at 4 of 12 Page 24

25 Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Acupuncture Bariatric surgery Cosmetic surgery Dental care Hearing aids Infertility treatment Long- term care Routine foot care unless you have been diagnosed with diabetes. Weight loss programs Other Covered Services (Limitations may apply to these services. This isn t a complete list. Please see your plan document.) Chiropractic care 30 visits/benefit period. Most coverage provided outside the United Private-duty nursing States. See Routine eye care (adult) One eye exam/benefit period. * For more information about limitations and exceptions, see plan or policy document at 5 of 12 Page 25

26 Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at x61565 or Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit or call Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: ATTN: Grievances and Appeals, P.O. Box 27401, Richmond, VA Does this plan provide Minimum Essential Coverage? Yes If you don t have Minimum Essential Coverage for a month, you ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet the Minimum Value Standards? Yes If your plan doesn t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. To see examples of how this plan might cover costs for a sample medical situation, see the next section. * For more information about limitations and exceptions, see plan or policy document at 6 of 12 Page 26

27 About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing Joe s type 2 Diabetes (a year of routine in-network care of a wellcontrolled condition) Mia s Simple Fracture (in-network emergency room visit and follow up care) The plan s overall deductible $500 The plan s overall deductible $500 The plan s overall deductible $500 Specialist copayment $30 Specialist copayment $30 Specialist copayment $30 Hospital (facility) copayment $300 Hospital (facility) copayment $300 Hospital (facility) copayment $300 Other coinsurance 20% Other coinsurance 20% Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $12,840 Total Example Cost $7,460 Total Example Cost $2,010 In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay: Cost Sharing Cost Sharing Cost Sharing Deductibles $500 Deductibles $500 Deductibles $500 Copayments $0 Copayments $180 Copayments $390 Coinsurance $2,250 Coinsurance $27 Coinsurance $208 What isn t covered What isn t covered What isn t covered Limits or exclusions $60 Limits or exclusions $21 Limits or exclusions $0 The total Peg would pay is $2,810 The total Joe would pay is $728 The total Mia would pay is $1,098 The plan would be responsible for the other costs of these EXAMPLE covered services. 7 of 12 Page 27

28 Language Access Services: It s important we treat you fairly That s why we follow federal civil rights laws in our health programs and activities. We don t discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C or by calling (TDD: ) or online at Complaint forms are available at 12 of 12 Page 28

29 Montgomery County Public Schools Get reimbursed for out-of-pocket health care and dependent care expenses with tax free dollars! MAXIMIZE YOUR INCOME! Flexible Spending Accounts (FSAs) allow you to pay certain health care and dependent care expenses with pre-tax money. (The key to the Flexible Benefit Plan is that your eligible expenses are paid for with Tax Free Dollars!) You will not pay any Federal, State or Social Security taxes on funds placed in the plan. You will save, approximately, $27.65 to $37.65 on every $100 you place in the plan. The amount of your savings will depend on your federal tax bracket. ELIGIBILITY Participation in the plan begins on October 1, 2018 and ends on September 30, All employees regularly scheduled to work 30 or more hours a week will be eligible to participate in the plan. Those employees having a qualifying event are eligible to enroll within 30 days of the qualifying event. Deductions will begin on the first pay period following your plan start date. You must complete an enrollment to participate in the Flexible Spending Accounts each year during the open enrollment period. If an enrollment is not completed during open enrollment, you will not be enrolled in the plan and you will not be able to join until the next Plan Year or if you have a qualifying event. ELECTION CHANGES Election changes are only allowed if you experience one of the following qualifying events: Marriage or divorce Birth or adoption Involuntary loss of spouse s medical or dental coverage REIMBURSEMENT SCHEDULE ONLINE ACCESS Death of dependent (child or spouse) Unpaid FMLA or Non-FMLA leave Change in Dependent Care Providers All manual or paper claims received in the office of Flexible Benefit Administrators, Inc. will be processed twice a week via check or direct deposit. You may also use your Benefits Card to pay for expenses. Please refer to the Benefits Card section for details. Flexible Benefit Administrators, Inc. provides online account access for all FSA participants. Please visit their website at: to view the following features: FSA Login View account transactions, create account alerts, and download participation forms. FSA Educational Tools FSA calculator: Estimate how much you can save by utilizing an FSA. THE HEALTH CARE ACCOUNT IS A PRE-FUNDED ACCOUNT This means that you can submit a claim for medical expenses in excess of your account balance. You will be reimbursed your total eligible expense up to your annual election. The funds that you are pre-funded will be recovered as deductions are deposited into your account throughout the Plan Year. Contribution Limits: The maximum you may place in this account for the Plan Year is $2,650. HEALTH CARE REIMBURSEMENT With this account, you can pay for your out-of-pocket health care expenses for yourself, your spouse and all of your tax dependents for health care services that are incurred during your Plan Year and while an active participant. Eligible expenses are those incurred for the diagnosis, cure, mitigation, treatment, or prevention of disease, or for the purpose of affecting any structure or function of the body. This is a broad definition that lends itself to creativity. EXAMPLES OF ELIGIBLE HEALTH CARE EXPENSES Fees/Co-Pays/Deductibles For: Acupuncture Prescription Eyeglasses/ Reading glasses/ Contact lens and supplies/ Eye Exams/ Laser Eye Surgery Physician Ambulance Psychiatrist Psychologist Anesthetist Hospital Chiropractor Laboratory/ Diagnostic Fertility Treatments OVER-THE-COUNTER EXPENSES Examples of medications and drugs that may be purchased in reasonable quantities with a prescription: Antacids Pain relievers/aspirin Ointments & creams for joint pain Allergy & sinus medication Surgery Dental/ Orthodontic Fees Obstetrician X-Rays Eye Exams Prescription Drugs Artificial limbs & teeth Birth control pills, patches Orthopedic shoes/ inserts Therapeutic care for drug and alcohol addiction Vaccinations & Immunizations Mileage Take-home screening kits Diabetic supplies Routine Physicals Oxygen Physical Therapy Hearing aids and batteries Medical equipment First aid creams Cough & cold medications Laxatives Anti-diarrhea medicine Page 29

30 DAY CARE/AGED ADULT CARE REIMBURSEMENT The Day Care/Aged Adult Care FSA allows you to pay for day care expenses for your qualified dependent/child with pre-tax dollars. Eligible Day Care/Aged Adult Care expenses are those you must pay for the care of an eligible dependent so that you and your spouse can work. Eligible dependents, as revised under Section 152 of the Code by the Working Families Tax Act of 2005, are defined as either dependent children or dependent relatives that you claim as dependents on your taxes. Refer to the Employee Guide for more details. Eligible dependents are further defined as: Under age 13 Physically or mentally unable to care for themselves such as: - Disabled spouse - Children who became disabled prior to age Elderly parents that live with you Contribution Limits: The annual maximum contribution may not exceed the lesser of the following: $5,000 ($2,500 if married filing separately) Your wages for the year or your spouse s if less than above Maximum is reduced by spouse s contribution to a Day Care/ Aged Adult Care FSA ELIGIBLE DAY CARE/AGED ADULT CARE EXPENSES Au Pair Nannies Before and After Care Day Camps Babysitters Ineligible Expenses Overnight Camps Babysitting for Social Events Daycare for an Elderly Dependent Daycare for a Disabled Dependent Tuition Expenses Including Kindergarten Food Expenses (if separate from dependent care expenses) Nursery School Private Pre School Sick Child Center Licensed Day Care Centers Care Provided By Children Under 19 (or by anyone you claim as a dependent) Days Your Spouse Doesn t Work (though you may still have to pay the provider) Kindergarten expenses are ineligible as an expense because it is primarily educational, regardless if it is half or full day, private, public, state mandated or voluntary. Transportation, books, clothing, food, entertainment and registration fees are ineligible if these expenses are shown separately on your bill. Expenses incurred while on a Leave of Absence or Vacation. HOW THE FLEXIBLE BENEFIT PLAN WORKS HOW TO RECEIVE REIMBURSEMENT Gross Monthly Income $ 2, $ 2, Eligible Pre-Tax employer medical insurance $ 0.00 $ Eligible Pre-Tax Medical Expenses $ 0.00 $ Eligible Pre-Tax Dependent Child Care Expenses $ 0.00 $ Taxable Income $ $ Federal Tax (15%) $ $ State Tax (5.75%) $ $ FICA Tax (7.65%) $ $ After-Tax employer medical insurance $ $ 0.00 After-Tax medical expenses $ $ 0.00 After-Tax dependent child care expenses $ $ 0.00 Monthly Spendable Income $ $ By taking advantage of the Flexible Benefit Plan this employee was able to increase his/her spendable income by $ every month! This means an annual tax savings of $1, Remember, with the FLEXIBLE BENEFIT PLAN, the better you plan the more you save! To obtain a reimbursement from your Flexible Spending Account, you must complete a Claim Form. This form is available to you in your Employee Guide or on our website. You must attach a receipt or bill from the service provider which includes all the pertinent information regarding the expense: Without With Flex Benefits Flex Benefits Date of service Patient s name Amount charged Provider s name Nature of the expense Amount covered by insurance (if applicable) Canceled checks, bankcard receipts, credit card receipts and credit card statements are NOT acceptable forms of documentation. You are responsible for paying your health care or dependent care provider directly. FORFEITING FUNDS Plan carefully! Unused funds will be forfeited back to your employer as governed by the IRS s use-it-or-lose-it rule. Your employer has elected to adopt the IRS offered 2 month 15-day grace period. Please see the Employee Guide for more information. HOW TO ENROLL IN OUR FSA PLAN Step 1 Carefully estimate your eligible Health care and Day Care/Aged Adult Care expenses for the upcoming Plan Year. Then use our online FSA Educational Tools located at to help you determine your total expenses for the Plan Year. Step 2 Complete your enrollment during the open enrollment period which instructs payroll to deduct a certain amount of money for your expenses. This amount will be contributed on a pre-tax basis from your paychecks to your FSA. Remember, the amount you elect will be set aside before any Federal, Social Security, and State taxes are calculated. BENEFITS CARD The Benefits Card can be used as a direct payment method for eligible expenses incurred at approved service providers and merchants. Using your card allows you instant access to your funds with no out-of-pocket expenses. Please keep all your itemized receipts. Flexible Benefit Administrators, Inc. may request documentation to substantiate Benefits Card transactions to determine eligibility of an expense. Benefits Cards are available upon request of the account holder for dependents over the age of 18. Please contact Flexible Benefit Administrators, Inc. to order additional cards. P.O. Drawer 8188 Virginia Beach, VA Toll Free (800) Phone (757) Fax (757) Page 30

31 Montgomery County Public Schools With the Limited Purpose FSA, get reimbursed for out-of-pocket dental and vision care expenses with tax free dollars! MAXIMIZE YOUR INCOME! THE LIMITED FSA ACCOUNT IS A PREFUNDED ACCOUNT Limited Purpose Flexible Spending Account (FSA) will allow you to pay certain dental and vision expenses with pre-tax money. (The key to the Limited Purpose Flexible Benefit Plan is that your eligible expenses are paid for with Tax Free Dollars.) You will not pay any Federal, State, or Social Security taxes on funds placed in the plan. You will save between approximately $27.65 and $37.65 on every $100 you place in the plan. The amount of your savings will depend on your Federal tax bracket. ELIGIBILITY Participation in the plan begins on October 1, 2018 and ends on September 30, All employees regularly scheduled to work 30 or more hours a week will be eligible to participate in the plan. You must also be enrolled in a High-Deductible Health Plan (HDHP). Those employees having a qualifying event are eligible to enroll within 30 days of the qualifying event. Deductions begin on the first pay period following your plan start date. You must complete an enrollment to participate in the Limited Purpose Flexible Spending Account each year during the open enrollment period. If an enrollment is not completed during open enrollment, you will not be enrolled in the plan and you will not be able to join until the next Plan Year or if you have a qualifying event. ELECTION CHANGES Once you have enrolled in an Limited Purpose FSA you may NOT make any changes to your election unless you have a change in status such as: Marriage or divorce Birth or adoption Involuntary loss of spouse s medical or dental coverage REIMBURSEMENT SCHEDULE Death of dependent (child or spouse) Unpaid FMLA or Non-FMLA leave All claims received in the office of Flexible Benefit Administrators, Inc. will be processed twice a week via check or direct deposit. You may also use your Benefits Card to pay for expenses. Please refer to the Benefits Card section for details. ONLINE ACCESS Flexible Benefit Administrators, Inc. provides online account access for all FSA participants. Please visit their website at: to view the following features: FSA Login View account transactions, create account alerts, and download participation forms. FSA Educational Tools FSA calculator: estimate how much you can save by utilizing an Limited Purpose FSA. This means that you can submit a claim for qualified expenses in excess of your account balance. You will be reimbursed your total eligible expenses up to your annual election. The funds that you are prefunded will be recovered as deductions are deposited into your account throughout the Plan Year. Contribution Limits: The maximum you may place in this account for the Plan Year is $2,650. Page 31 BENEFITS OF USING A LIMITED PURPOSE FSA WITH AN HSA With this account, you can pay for your out-of-pocket dental, vision, and preventative care expenses for yourself, your spouse and all of your dependents for services that are incurred during your Plan Year and while an active participant. Funds contributed to your Health Savings Account (HSA) can also cover these expenses, so why would someone choose to make a second contribution to a Limited FSA along with an HSA? Below are a few key reasons to contribute to both in order to get the most out of your HSA. You will likely have dental and/or vision expenses early in the Plan Year. The Limited Purpose FSA is prefunded at the beginning of the Plan Year while HSA funds are only available as they are deposited into your account. For this reason, if you are planning on incurring dental and/or vision expenses early in the Plan Year, a Limited Purpose FSA is a great way to pay for those expenses. With the Limited Purpose FSA, you can use your full election as soon as you need it in order to pay for expenses, since it acts like a tax-free interest free loan. This is particularly useful for those who have just opened their HSA or who haven t been able to build up a balance in their HSA account. You want to use your HSA contributions primarily for medical expenses. Since you are covered by a High-Deductible Health Plan, you know you may be required to pay higher amounts for medical expenses you incur. If you know you ll use most of your HSA contributions to pay for these medical expenses, it makes sense to set aside separate contributions to cover any vision and/or dental expenses. You wish to use your HSA as a retirement or investment account. HSAs offer a triple-tax advantage, meaning you get a tax advantage towards your contributions, distributions (if used for eligible expenses), and any interest you earn from your HSA. Medicare expenses for those 65 years and older can easily add up to $200,000 for a couple over the course of 20 years. This does not include dental, vision, hearing aids, and out-of-pocket drugs. By using funds from a Limited Purpose FSA, you can allow more money to remain in your HSA to gain interest while still getting the same tax advantage on your vision and/or dental expenses.

32 ELIGIBLE VISION AND DENTAL EXPENSES The Limited Purpose FSA allows you to pay for dental and/or vision expenses for you and your eligible dependents with pre-tax dollars. Eligible dental expenses include dental procedures that are not for cosmetic purposed and not covered by your insurance such as those listed below. Examples of Eligible Dental Expenses: Orthodontia (Braces) Crowns Fillings Checkups For orthodontia expenses, you can use funds in you Limited Purpose FSA to either be reimbursed for a payment made in full on the first orthodontic visit (up to your annual election). If you pay for your orthodontia treatments over the span of multiple plan years, you can pay the monthly payment directly to your orthodontist, then send a claim form in each month to be reimbursed or you can pay your monthly payments with your Benefits Card and send FBA a copy of your orthodontic contract to keep on file so that we can setup a recurring expense on your account. Examples of Eligible Vision Expenses: Eyeglasses Prescription Sunglasses Routine Eye Exam ELIGIBLE PREVENTATIVE CARE EXPENSES HOW TO RECEIVE REIMBURSEMENT Gross Monthly Income $ 2, $ 2, Eligible Pre-Tax employer medical insurance $ 0.00 $ Eligible Pre-Tax Medical Expenses $ 0.00 $ Eligible Pre-Tax Dental and Vision Expenses $ 0.00 $ Taxable Income $ $ Federal Tax (15%) $ $ State Tax (5.75%) $ $ FICA Tax (7.65%) $ $ After-Tax employer medical insurance $ $ 0.00 After-Tax Medical expenses $ $ 0.00 After-Tax Dental and Vision expenses $ $ 0.00 Monthly Spendable Income $ $ By taking advantage of the Limited FSA to cover dental and vision expenses and the HSA to cover their Medical expenses, this employee was able to increase his/her spendable income by $ every month! This means an annual tax savings of $1, Remember, with the FLEXIBLE BENEFIT PLAN, the better you plan the more you save! Lasik Eye Surgery Contact Lenses Diagnostic Services In order for an expense to be considered preventative care you will need to acquire a prescription or letter of medical necessity from your medical provider that specifically states that the treatment is for the prevention of the onset of an illness. Once you are officially diagnosed with a condition, any expenses used towards treating the condition would not be eligible. Below are two examples of preventative care to prevent the onset of illnesses. Diabetes Your doctor may write you a letter of medical necessity stating that they recommend you get a gym membership and exercise in order to prevent the onset of Type II Diabetes. High Blood Pressure If you have a family history of high blood pressure, your doctor may write you a prescription for blood pressure medication preventing high blood pressure. Other eligible preventative care expenses include tobacco cessation programs, cancer screening, heart and vascular care screenings, substance abuse screenings, routine prenatal care, and child and adult immunizations. Please refer to IRS Notice for a more comprehensive list of preventative care expenses. HOW THE FLEXIBLE BENEFIT PLAN WORKS To obtain a reimbursement from your Limited Purpose Flexible Spending Account, you must complete a Claim Form. This form is available to you in your Employee Guide or on our website. You must attach a receipt or bill from the service provider which includes all the pertinent information Without With Flex Benefits Flex Benefits regarding the expense: FORFEITING FUNDS Date of service Patient s name Amount charged Provider s name Nature of the expense Amount covered by insurance (if applicable) Canceled checks, bank card receipts, credit card receipts and credit card statements are NOT acceptable forms of documentation. You are responsible for paying your service providers directly. Plan carefully! Unused funds will be forfeited as governed by the IRS s use-it-or-lose-it rule. Your employer has elected to continue the 2 month 15-day grace period for the Limited FSA. Please see the Employee Guide for more information. HOW TO ENROLL IN OUR LIMITED PURPOSE FSA PLAN Step 1 Carefully estimate your eligible vision and/or expenses for the upcoming Plan Year. Then use our online FSA Educational Tools located at to help you determine your total expenses for the Plan Year. Step 2 Complete your enrollment during the open enrollment period which instructs payroll to deduct a certain amount of money for your expenses. This amount will be contributed on a pre-tax basis from your paychecks to your Limited Purpose FSA. Remember, the amount you elect will be set aside before any Federal, Social Security, and State taxes are calculated. BENEFITS CARD The Benefits Card can be used as a direct payment method for eligible expenses incurred at approved service providers and merchants. Using your card allows you instant access to your funds with no out-of-pocket expenses. Please keep all your itemized receipts. Flexible Benefit Administrators, Inc. may request documentation to substantiate Benefits Card transactions to determine eligibility of an expense. Benefits Cards are available upon request of the account holder for dependents over the age of 18. Please contact Flexible Benefit Administrators, Inc. to order additional cards. P.O. Drawer 8188 Virginia Beach, VA Toll Free (800) Phone (757) Fax (757) Page 32

33 Employee FAQ: Dependent Care FSA What is a dependent care FSA (DCA)? A DCA is a flexible spending account that allows you to contribute a portion of your paycheck before taxes are taken out to pay for qualified dependent care expenses so that you can work or look for work. Why should I participate? Since contributions to the account are deducted from your paycheck before income taxes are assessed, your taxable income is reduced. Participants enjoy a 30% average tax savings on the total amount they contribute to the account. How do I contribute money to my DCA? Once you make your annual election during open enrollment, your employer will deduct this amount from your paycheck before taxes are assessed in equal amounts throughout the year. How much can I contribute? The IRS limits annual contributions to $5,000 on income tax returns for single or married filing jointly, and $2,500 for married filing separately. Who qualifies as a dependent? You can use your DCA to pay for care for children under age 13 that you claim as dependents, as well as adults or other relatives that are incapable of caring for themselves (if you provide more than 50% of their support). What type of care is eligible? Eligible expenses must be for the purpose of allowing you to work or look for work. Services may be provided at a child or adult care center, nursery, preschool, after-school, summer day camp, or a nanny in your home. What type of care is not eligible? Care expenses that are not eligible to be paid with DCA funds include care for a child over age 13, overnight camp, babysitting that is not work related, school fees for kindergarten and higher grades, and long-term care services. Do I have access to my entire DCA election amount at the beginning of the year? No, you will only have access to DCA funds that have already been deducted from your paycheck. Are there any rules about who can care for my dependents? Yes. You can not use funds to pay for care provided by a spouse, a person you list as a dependent for income tax purposes, or one of your children under the age of 19. How do I use the funds in my account? If you have a benefits debit card and your care provider accepts MasterCard, you may pay directly from your account. Otherwise, pay out-of-pocket and then file a reimbursement claim with your expense documentation. What happens if I don t spend all of my DCA funds by the end of the plan year? It is essential to estimate conservatively during elections. Any unused funds at the end of the plan year are forfeited, also called the use-it-or-lose-it rule. Can I change my election amount mid-year? Typically, you cannot change your contribution midyear. However, if you experience a qualifying event, such as the birth of a new child, or if your child care provider significantly increases their rates, you may be eligible to adjust your contribution. What happens to my account if my employment is terminated? Participation in the plan is also terminated. This means that only expenses that were incurred prior to your termination date are eligible for reimbursement. Can I still deduct dependent care expenses on my tax return? Yes, but not the same expenses for which you have already been reimbursed. If your total expenses were $7,000 and you were reimbursed $5,000 from your DCA, you may only claim the $2,000 difference. For more information, please call Page 33

34 What is the benefit of participating in the DCA versus claiming a tax credit on my tax return? Generally speaking, those with less than a 15% tax bracket will be better served by the Dependent Care Tax Credit. IRS Publication 503 "Child and Dependent Care Expenses" provides full information about this tax credit and offers worksheets and aids for performing the calculations. If you are earning a moderate to high income, and particularly if you are filing taxes as "Married, Filing Jointly" (combining incomes with a spouse), the Dependent Care FSA is may be more advantageous. Reasons: Your tax bracket may be higher than 15%, the threshold generally regarded as the dividing point between the Dependent Care Tax Credit (best for those earning LESS) and the Dependent Care FSA (best for those earning MORE). Logically, if you have 1 child, the $5000 available through the Dependent Care FSA may be more generous than the credit arising from the $3000 limit imposed by the Dependent Care Tax Credit. Finally, the FSA saves not only income taxes (federal and state), but social security taxes as well. There are no social security tax savings offered by the Dependent Care Tax Credit. (Note: Your social security benefits could be slightly reduced by paying less social security taxes.) Based on the average US income and average US Child Care Costs, here is an example of why participating in the Dependent Care FSA is a smart option. Average US Salary is roughly $44,000. Average cost for Day Care in the US is roughly $10,000 per child. Average cost of After School Care (for older children) is roughly $7,700 in the US. Here is the breakdown for claiming a credit on your tax return: You can claim up to $3,000 on your tax return for child care costs if you have one child. If you have two or more children, you can claim up to $6,000. At the average salary of $44,000, 20% of those costs of child care you can be claimed in credit - meaning you can get a maximum of $600 in credit for one child and $1,200 in credit for two or more children. Here is how much you save by setting aside the maximum $5,000 in your Dependent Care Account pre-tax versus paying out of pocket after tax: Paying for Dependent Care After Tax Earning $44,00 per year Federal Tax (15%): -$6,600 FICA Tax (7.76%): -$3,366 State Tax (5.75%): -$2,530 After Tax Dependent Care Cost: -$5,000 Bring Home Salary Per Year: $26,504 Paying for Dependent Care Before Tax Earning $44,000, but taxed on $39,000 (since $5,000 is set aside before taxes are taken) Federal Tax (15%): -$5,850 FICA Tax (7.76%): -$2, State Tax (5.75%) -$2,530 Bring Home Salary Per Year: $27,924 The average person saves $1,420 for the year in taxes by setting aside the full $5,000 pre-tax! To top this off - the average person also has spends $10,000 per year in Day Care costs for one child, so they could still claim the maximum $3,000 on their tax return, since you can still claim any additional cost over what you set aside pre-tax. For someone who spends $20,000+ for Day Care costs for two or more children, they could still claim the maximum $6,000 on their tax return. Participating in the Dependent Care Flex Plan allows you to stretch your hard-earned dollars! For more information, call P.O. Box 8188 Virginia Beach, VA Page 34

35 Employee FAQ: 2 1/2 Month Grace Period What is it? The IRS amended the use-it-or-lose-it rule to allow employees to incur new expenses towards the plan year election for an additional 2 months and 15 days after the plan year ends. This is commonly referred to as the 2 1/2 Month Grace Period. The Grace Period is different than the run-out period. The run-out period only allows an employee to submit claims that were incurred during the applicable plan year. The Grace Period permits you to use the remaining balance to pay for claims during the following year. How much of my remaining funds can I use? You may use all of your remaining funds during the 2 1/2 Month Grace Period. Does the Grace Period rule apply to limited purpose or post-deductible FSAs? Yes. Under IRS guidance, the new rules applies to all health FSAs. Does the Grace Period rule apply to dependent care FSAs? Yes. Under IRS guidance, the grace period rules applies to dependent care FSAs. Does the Grace Period affect my eligibility to participate in a health savings account (HSA)? Participants in a traditional health FSA are not eligible to contribute to an HSA, therefore you are required to use all remaining funds from a traditional FSA prior to making payroll contributions to an HSA. If your employer offers a limited purpose FSA, they may allow you to transfer any remaining balance from the traditional health FSA to the limited purpose FSA. Check your plan documents to determine your employer s policy for participants enrolling in an HSA. How does the Grace Period apply to a short plan year? Use of a Grace Period for a short plan year is allowed. What happens if my employment is terminated during the Grace Period? If you leave the company during the Grace Period, you will no longer be eligible to incur new expenses. You can still submit expenses incurred prior to termination through the end of the termination run-out period. Check your plan document for the length of your run-out period after termination. Does the Grace Period option affect the runout period? No. You will still be able to file claims during the run-out period for expenses incurred during the plan year. The 2 1/2 Month Extension runs concurrently with your run-out period. Check your plan document for the length of your run-out period.. Do I have to elect a health FSA for the following plan year to use my remaining funds during the Grace Period? No, but you will be limited to the remaining funds left from your previous year s election. Although you may not be contributing in the Grace Period, you remain a participant until the end of the Grace Period or your employment is terminated. How long do I have to use my remaining funds? You may use your remaining funds for 2 Months and 15 days immediately following the end of the plan year. For a plan year running from January 1 - December 31, you may use funds towards new expenses until March 15. However, if you terminate employment, then you are only eligible for reimbursement for claims with dates of service on or before your termination date. In what order are funds utilized for new claims? According to the guidance examples, previous year funds will be used prior to funds being used from the new plan year. For more information, please call Page 35

36 Can I use my benefits debit card to access funds during the Grace Period? Yes. Card swipes during the Grace Period are recognized by our administrative software system. These wipes will be applied to your leftover balance from the previous plan year, if applicable, until those funds are exhasted. Once your prior year balance is depleted, any other card swipes within the plan year will be applied to your new plan year expenses. What happens to any unused funds after the end of the Grace Period? Any money you do not use from a reimbursement account for expenses incurred during the plan year and the Grace Period will be forfeited. The forfeited fund will be returned to your employer to offset the cost of the program. If you plan carefully, you can avoid being affected by this IRS restriction. For more information, please call P.O. Box 8188 Virginia Beach, VA Page 36

37 Get CONNECTED with your account... Wherever, whenever. Introducing... our convenient participant web site! With the online WealthCare Portal you can view your account status, submit claims and report your benefits card lost/stolen right from your computer. Once your account is established, you can use the same user name and password to access your account via our Mobile App! Follow the simple steps below to establish your secure user account. Get started by visiting and click the register button in the top-right corner of the homepage. You will be directed to the registration page. Follow the prompts to create your account. User Name Password Name Address Employee ID (Your SSN, no spaces/dashes) Registration ID Employer ID (FBAMCPS) Your Benefits Card Number Once completed, please proceed to your account. Getting Started is Easy! If you are having difficulty creating your user account or you have forgotten your password to an existing account, please contact us at or Page 37

38 The FBA Benefits Card The easy way to access all of your benefits The benefits debit card eliminates the hassles of claim submission and waiting for a reimbursement check. Start Saving Money by Participating in Benefit Accounts Are your out-of-pocket healthcare, dependent care and transportation costs rising? Tax-advantaged benefit accounts are a great way for you to save your hard-earned money. These accounts can include: Flexible spending accounts (FSAs) Health reimbursement arrangements (HRAs) Health savings accounts (HSAs) Dependent care flexible spending accounts (DCAs) Commuter accounts (transit/parking) Access to Funds Your benefits debit card gives you easy access to the funds in your tax-advantaged benefit accounts by swiping the card at the point of sale. The card can be used at any qualified service provider that accepts MasterCard. Funds are automatically transferred from the benefit account directly to qualified providers with no out-of-pocket cost and no need to file a claim for reimbursement. Your benefits debit card virtually eliminates: Out-of-pocket expenses Claim forms Reimbursement checks Multiple Benefit Accounts, One Card In the event that you have multiple benefit accounts, you need only one benefits debit card. Our technology understands which purchases should be applied to any one of your accounts. If your card is swiped at your child s daycare, the funds will be deducted from your dependent care FSA. Buy a train token automatically with funds from your transit account. It s one smart card! Your benefits debit card is as easy as Check your account balance You can view your transaction history, current balance, claim status, and more by logging in online, calling the phone number on the back of your card or via mobile application, if available. 2. Swipe your benefits debit card Swipe the card at the point-of-sale for eligible products and services. Most major retail chains utilize a system that will auto-substantiate the purchase, meaning it will approve eligible expenses without requiring submission of receipts. If a purchase is greater than your account balance, you can split the cost at the register or you may submit a manual claim. 3. Keep all your receipts Though the need for documentation is greatly reduced, it is a good practice to save your receipts in the rare instance documentation is requested by your administrator or in case of an IRS audit. How long is my card valid? As long as you do not have a break in participation, you can use your card for three years, until the expiration date printed on it. If you are still a participant when your card expires, a new card will be automatically mailed to you. For more information, please call P.O. Box 8188 Virginia Beach, VA Page 38

39 Access FSA Store at bit.ly/fbafsa FSA Store is exclusively stocked with FSA/HSA eligible products so there are no guessing games about what is and is not reimbursable by an FSA. The site also offers tools and resources to help you better understand and manage your funds. FSA Eligibility List FSA Calculator FSA Deadline Tracker FSA Learning Center Eliminate eligibility guessing games. Estimate your annual FSA spending. Receive deadline reminders. Get answers to all your FSA questions! FIRST AID SUN CARE BABY CARE COLD & ALLERGY SKIN CARE PAIN RELIEF EYE CARE FOOT CARE Get $5 Off Orders $35+ Cannot be combined with other offers. 1 use per customer. With Promo Code: FBAOE Page 39

40 Montgomery County Schools Dental Highlight Sheet Members can choose between the Standard PPO Plan and the In Network Only Plan shown below. Eligible dependents can also be covered and will receive the same plan chosen by the employee. Members cannot change their election until the next election period at which time the member can switch between plans without penalty. Plan Benefit Standard Plan In Network Only Type 1 100% 100% Type 2 80% 80% Type 3 50% 50% Deductible $50/Calendar Year Type 2 & 3 $50/Calendar Year Type 2 & 3 Waived Type 1 Waived Type 1 No Family Maximum No Family Maximum Maximum (per person) $750 per calendar year $1100 per calendar year Allowance 85th U&C Discounted Fee Dental Rewards Included Included Waiting Period None None Annual Open Enrollment None None Orthodontia Summary Adult & Child Coverage Allowance U&C U&C Plan Benefit 50% 50% Lifetime Maximum (per person) $1,000 $1,000 Waiting Period None None Sample Procedure Listing - Applies to both plans shown above. (Current Dental Terminology American Dental Association.) Type 1 Type 2 Type 3 Routine Exam (2 per benefit period) Bitewing X-rays (2 per benefit period) Full Mouth/Panoramic X-rays (1 in 3 years) Periapical X-rays Cleaning (2 per benefit period) Fluoride for Children 18 and under (1 per benefit period) Space Maintainers Sealants (age 16 and under) Restorative Amalgams Restorative Composites Denture Repair Simple Extractions Complex Extractions Anesthesia Page 40 Onlays Crowns (1 in 5 years per tooth) Crown Repair Periodontics (nonsurgical & surgical Endodontics (nonsurgical & surgical) Prosthodontics (fixed bridge; removable complete/partial dentures) (1 in 5 years) Dental Rewards - Applies to both plans shown above. This dental plan includes a valuable feature that allows qualifying plan members to carryover part of their unused annual maximum A member earns dental rewards by submitting at least one claim for dental expenses incurred during the benefit year, while staying at or under the threshold amount for benefits received for that year. In addition, a person earning dental rewards who submits a claim for services received through the dental network earns an extra reward, called the PPO Bonus. Employees and their covered dependents may accumulate rewards up to the stated maximum carryover amount, and then use those rewards for any covered dental procedures subject to applicable coinsurance and plan provisions. If a plan member doesn't submit a dental claim during a benefit year, all accumulated rewards are lost. But he or she can begin earning rewards again the very next year Benefit Threshold $500 Dental benefits received for the year cannot exceed this amount Annual Carryover Amount $250 Dental Rewards amount is added to the following year's maximum Maximum Carryover $1000 Maximum possible accumulation for Dental Rewards and PPO Bonus combined Groups with a program similar to Dental Rewards on their previous plan are eligible for Dental Rewards Credits. To qualify for Dental Rewards Credits, the employer must request a list of carryover amounts from the previous carrier, to be sent to Ameritas. Ameritas will credit each account based on amounts identified by the previous carrier. The credit is available only to initial insureds. The credit, and any amounts earned under our plan, will not exceed the maximum carryover proposed for the plan selected. Enrollment data must include information for all dependents enrolling in the plan. Ameritas Information We're Here to Help! This plan was designed specifically for the associates of New Hanover County Schools. At Ameritas Group, we do more than provide coverage - we make sure there's always a friendly voice to explain your benefits, listen to your concerns, and answer your questions Our customer relations associates will be pleased to assist you 7 a.m. to midnight (Central Time) Monday through Thursday, and 7 am to 6:30 pm on Friday. You can speak to them by calling toll-free: For plan information any time, access our automated voice response system or go online to ameritas.com.

41 Montgomery County Schools Dental Highlight Sheet Late Entrant Provision We strongly encourage you to sign up for coverage when you are initially eligible. If you choose not to sign up during this initial enrollment period, you will become a late entrant. Late entrants will be eligible for only exams, cleanings, and fluoride applications for the first 12 months they are covered. Dental Network Information To find a provider, visit ameritas.com and select FIND A PROVIDER, then DENTAL. Enter your criteria to search by location or for a specific dentist or practice. California Residents: When prompted to select your network, choose the Ameritas Network found on your ID Card or contact Customer Connections at Pretreatment While we don't require a pretreatment authorization form for any procedure, we recommend them for any dental work you consider expensive. As a smart consumer, it's best for you to know your share of the cost up front. Simply ask your dentist to submit the information for a pretreatment estimate to our customer relations department. We'll inform both you and your dentist of the exact amount your insurance will cover and the amount that you will be responsible for That way, there won't be any surprises once the work has been completed. Rx Savings Our valued plan members and their covered dependents can save on prescription medications at over 60,000 pharmacies across the nation including CVS, Walgreens, Rite Aid and Walmart. This Rx discount is offered at no additional cost, and it is not insurance. To receive this Rx discount, Ameritas plan members just need to visit us at ameritas.com and sign into (or create) a secure member account where they can access and print an online-only Rx discount savings ID card. Eyewear Savings Ameritas plan members may receive up to 15% off eyewear frames and lenses purchased at any Walmart Vision Center nationwide. Members may also bring in their current vision prescription from any vision care provider and purchase eyewear at Walmart. This savings arrangement is not insurance: it is available to members at no additional cost to their plan premium. To receive the eyewear savings identification card, Ameritas plan members can visit ameritas.com and sign-in (or create) a secure member account. Members must present the Ameritas Eyewear Savings Card at time of purchase to receive the discount. Worldwide Support When our members travel abroad, they ll have peace of mind knowing that should a dental or vision need arise, help is just a phone call away. Through AXA Assistance, Ameritas offers its dental and vision plan members 24-hour access to dental or vision provider referrals when traveling outside the U.S. Immediately after a call is made to AXA, an assistance coordinator assesses the situation, provides credible provider referrals and can even assist with making the appointment. Within 48 hours following the appointment, the coordinator calls the member to find out if additional assistance is needed. If all is well, the case is closed. Then, the plan member may submit a claim to Ameritas for reimbursement consideration based on applicable plan benefits Contact AXA Assistance USA toll free by calling , or call collect from anywhere in the world by dialing Language Services We recognize the importance of communicating with our growing number of multilingual customers. That is why we offer a language assistance program that gives you access to: Spanish-speaking claims contact center representatives, telephone interpretation services in a wide range of languages, online dental network provider search in Spanish and a variety of Spanish documents such as enrollment forms, claim forms and certificates of insurance This document is a highlight of plan benefits provided by Ameritas Life Insurance Corp. as selected by your employer. It is not a certificate of insurance and does not include exclusions and limitations. For exclusions and limitations, or a complete list of covered procedures, contact your benefits administrator. Monthly Rates Standard Dental Plan PPO Dental Plan Employee Only (EE) $3644 $3329 EE + Spouse $6985 $6382 EE + Child $7098 $6485 EE + Children $8823 $8063 EE + Spouse & Children $12164 $11116 Page 41

42 MONTGOMERY COUNTY SCHOOLS Eye Care Highlight Sheet Focus Plan Summary Effective Date: 10/1/2018 VSP Network Out of Network Deductibles $15 Exam $15 Exam $15 Eye Glass Lenses or Frames* $15 Eye Glass Lenses or Frames Annual Eye Exam Covered in full Up to $45 Lenses (per pair) Single Vision Covered in full Up to $35 Bifocal Covered in full Up to $50 Trifocal Covered in full Up to $70 Lenticular Covered in full Up to $90 Progressive See lens options NA Contacts Fit & Follow Up Exams 15% discount No benefit See Additional Focus Features. Elective Up to $120 Up to $105 Medically Necessary Covered in full Up to $210 Frames $120 Up to $50 Frequencies (months) Exam/Lens/Frame 12/12/12 12/12/12 Based on date of service Based on date of service *Deductible applies to a complete pair of glasses or to frames, whichever is selected. Lens Options (member cost) * VSP Network Out of Network Progressive Lenses Up to provider's contracted fee for Lined Trifocal Up to Lined Trifocal allowance. Lenses. The patient is responsible for the difference between the base lens and the Progressive Lens charge. Std. Polycarbonate Covered in full for dependent children No benefit $25 adults Solid Plastic Dye $13 No benefit (except Pink I & II) Plastic Gradient Dye $15 No benefit Photochromatic Lenses $27-$76 No benefit (Glass & Plastic) Scratch Resistant Coating $15-$29 No benefit Anti-Reflective Coating $39-$75 No benefit Ultraviolet Coating $14 No benefit *Lens Option member costs vary by prescription, option chosen and retail locations. Additional Focus Features Contact Lenses Elective Allowance can be applied to disposables, but the dollar amount must be used all at once (provider will order 3 or 6-month supply). Applies when contacts are chosen in lieu of glasses. For plans without a separate contact fitting & evaluation (which includes follow up contact lens exams), the cost of the fitting and evaluation is deducted from the allowance. Additional Glasses 20% off additional complete pairs of prescription glasses and/or prescription sunglasses. * Frame Discount VSP offers 20% off any amount above the retail allowance. * Laser VisionCare Low Vision VSP offers an average discount of 15% off or 5% off a promotional offer for LASIK Custom LASIK and PRK. The maximum out-of-pocket per eye for members is $1,800 for LASIK and $2,300 for custom LASIK using Wavefront technology, and $1,500 for PRK. In order to receive the benefit, a VSP provider must coordinate the procedure. With prior authorization, 75% of approved amount (up to $1,000 is covered every two years). Based on applicable laws, reduced costs may vary by doctor location. Eye Care Plan Member Service Focus eye care from Ameritas Group features the money-saving eye care network of VSP. Customer service is available to plan members through VSP's welltrained and helpful service representatives. Call or go online to locate the nearest VSP network provider, view plan benefit information and more. VSP Call Center: Service representative hours: 5 a.m. to 7 p.m. PST Monday through Friday, 6 a.m. to 2:30 p.m. PST Saturday Interactive Voice Response available 24/7 Locate a VSP provider at: ameritas.com View plan benefit information at: vsp.com Page 42

43 MONTGOMERY COUNTY SCHOOLS Eye Care Highlight Sheet Monthly Rates Employee Only $10.13 Family $24.17 This document is a highlight of plan benefits provided by Ameritas Life Insurance Corp. as selected by your employer. It is not a certificate of insurance and does not include exclusions and limitations. For exclusions and limitations, or a complete list of covered procedures, contact your benefits administrator. Page 43

44 Aflac Group Accident Plan Plan Features Benefits are payable regardless of any other insurance programs. Coverage is guaranteed-issue, provided the applicant is eligible for coverage. The plan features benefits for both inpatient and outpatient treatment of covered accidents. Benefits are available for spouse and/or dependent children. There s no limit on the number of claims an insured can file. Premiums are paid by convenient payroll deduction. Immediate effective date Coverage will be effective the date the employee signs the application 24-Hour Coverage. Eligibility Issue Ages Employee at least age 18 Spouse at least age 18 Children under age 26 The employee may purchase Accident Plus coverage for his spouse and/or dependent children. The spouse and dependent children cannot participate if the employee is not eligible for coverage or elects not to participate. Guaranteed-Issue Coverage is guaranteed-issue, provided the applicants are eligible for coverage. Enrollments take place once each 12-month period. Late enrollees cannot enroll outside of an annual enrollment period. Portability Coverage may be continued with certain stipulations. See certificate for details. Accident Benefits High Option If the fracture requires open reduction, we will pay 150% of the amount shown. A fracture is a break in a bone that can be seen by X-ray. If a bone is fractured in a covered accident, and it is diagnosed and treated by a doctor within 90 days after the accident, we will pay the appropriate amount shown. Multiple fractures refer to more than one fracture requiring either open or closed reduction. If multiple fractures occur in any one covered accident, we will pay the appropriate amounts shown for each fracture. Page 44

45 However, we will pay no more than 150% of the benefit amount for the fractured bone which has the highest dollar amount. Chip fracture refers to a piece of bone that is completely broken off near a joint. If a doctor diagnoses the fracture as a chip fracture, we will pay 10% of the amount shown for the affected bone. The maximum amount payable for the Fracture Benefit per covered accident is 150% the benefit amount for the fractured bone that has the higher dollar amount. If the dislocation requires open reduction, we will pay 150% of the amount shown. Dislocation refers to a completely separated joint. If a joint is dislocated in a covered accident, and it is diagnosed and treated by a doctor within 90 days after the accident, we will pay the amount shown. We will pay benefits only for the first dislocation of a joint. We will not pay for recurring dislocations of the same joint. If the insured dislocated a joint before the effective date of the certificate and then dislocates the same joint again, it will not be covered by this plan. Multiple dislocations refer to more than one dislocation requiring either open or closed reduction in any one covered accident. For each covered dislocation, we will pay the amounts shown. However, we will pay no more than 150% of the benefit amount for the dislocated joint that has the higher dollar amount. Partial dislocation is one in which the joint is not completely separated. If a doctor diagnoses and treats the accidental injury as a partial dislocation, we will pay 25% of the amount shown in the benefit schedule for the affected joint. The maximum amount payable for the Dislocation Benefit per covered accident is 150% of the benefit amount for the dislocated joint that has the higher dollar amount. If you have both fracture and dislocation in the same covered accident, we will pay for both. However, we will pay no more than 150% the benefit amount for the fractured bone or dislocated joint that has the higher dollar amount. Paralysis means the permanent loss of movement of two or more limbs. We will pay the appropriate amount shown if, because of a covered accident: The insured is injured, The injury causes paralysis which lasts more than 90 days, and The paralysis is diagnosed by a doctor within 90 days after the accident. The amount paid will be based on the number of limbs paralyzed. If this benefit is paid and the insured later dies as a result of the same covered accident, we will pay the appropriate Death Benefit, less any amounts paid under the Paralysis Benefit. Page 45

46 The laceration must be repaired with stitches by a doctor within 14 days after the accident. The amount paid will be based on the length of the laceration. If an insured suffers multiple lacerations in a covered accident, and the lacerations are repaired with stitches by a doctor within 14 days after the accident, we will pay this benefit based on the largest single laceration which requires stitches. We will pay the amount shown for X-rays or doctor services. For benefits to be payable, because of a covered accident, the insured must be injured and receive initial treatment from a doctor within 14 days after the accident. We will pay the Medical Fees Benefit: For treatment received due to injuries from a covered accident and For each covered accident up to one year after the accident date. Page 46

47 We will pay the amount shown for injuries received in a covered accident if the insured: Receives treatment in a hospital emergency room and Receives initial treatment within 14 days after the covered accident. This benefit is payable only once per 24-hour period and only once per covered accident. We will not pay the Accident Emergency Room Treatment Benefit and the Medical Fees Benefit for the same covered accident. We will pay the highest eligible benefit amount. We will pay the amount shown for injuries received in a covered accident if the insured: Receives treatment in a hospital emergency room, and Is held in a hospital for observation for at least 24 hours, and Receives initial treatment within 14 days after the accident. This benefit is payable only once per 24-hour period and only once per covered accident. This benefit would be paid in addition to Accident Emergency Room Treatment Benefit. We will pay the amount shown for up to six treatments per covered accident, per covered person. The insured must have received initial treatment within 14 days of the accident, and the follow-up treatment must begin within 30 days of the covered accident or discharge from the hospital. We will pay the amount shown for up to six treatments (one per day) per covered accident, per covered person for treatment from a physical therapist. A physician must prescribe the physical therapy. The insured must have received initial treatment within 14 days of the accident, and physical therapy must begin within 30 days of the covered accident or discharge from the hospital. Treatment must take place within six months after the accident. This benefit is not payable for the same visit that the Accident Follow-up Treatment benefit is paid. If an insured requires transportation to a hospital by a professional ambulance service within 90 days after a covered accident, we will pay the amount shown. If hospital treatment or diagnostic study is recommended by your physician and is not available in the insured s city of residence, we will pay the amount shown. The distance to the location of the hospital must be more than 50 miles from the insured s residence. If the insured receives blood and plasma within 90 days following a covered accident, we will pay the amount shown. If a covered accident requires the use of a prosthetic device, we will pay the amount shown. Hearing aids, wigs, or dental aids including false teeth are not covered. Page 47

48 We will pay the amount shown for use of a medical appliance due to injuries received in a covered accident. Benefits are payable for crutches, wheelchairs, leg braces, back braces, and walkers. If an insured is required to travel more than 100 miles for inpatient treatment of injuries received in a covered accident, we will pay the amount shown for an immediate family member's lodging. Benefits are payable up to 30 days per accident and only while the insured is confined to the hospital. This benefit is payable while coverage is in force. This benefit is only payable for Wellness Tests performed as the result of preventive care, including tests and diagnostic procedures ordered in connection with routine examinations. We will pay the amount shown once each 12-month period for each covered person for the following: Annual physical exams Blood screenings Eye examinations Immunizations Flexible sigmoidoscopies Ultrasounds Mammograms Pap smears PSA tests We will pay the amount shown, when because of a covered accident, the insured: Is injured, Requires hospital confinement, and Is confined to a hospital for at least 24 hours within 6 months after the accident date. We will pay this benefit once per calendar year. We will not pay this benefit for confinement to an observation unit. We will not pay this benefit for emergency room treatment or outpatient surgery or treatment. We will pay the amount shown when, because of a covered accident, the insured: Is injured, and Those injuries cause confinement to a hospital for at least 24 hours within 90 days after the accident date. The maximum period for which you can collect the Hospital Confinement Benefit for the same injury is 365 days. This benefit is payable once per hospital confinement even if the confinement is caused by more than one accidental injury. We will not pay this benefit for confinement to an observation unit. We will not pay this benefit for emergency room treatment or outpatient surgery or treatment. We will pay the amount shown when, because of a covered accident, the insured: Is injured, and Those injuries cause confinement to a hospital intensive care unit. The maximum period for which an insured can collect the Hospital Intensive Care Benefit for the same injury is 30 days. This benefit is payable in addition to the Hospital Confinement Benefit. Page 48

49 Dismemberment means: Loss of a hand The hand is cut off at or above the wrist joint; or Loss of a foot The foot is cut off at or above the ankle; or Loss of sight At least 80% of the vision in one eye is lost. Such loss of sight must be permanent and irrecoverable; or Loss of a finger/toe The finger or toe is cut off at or above the joint where it is attached to the hand or foot. If the employee does not qualify for the Dismemberment Benefit but loses at least one joint of a finger or toe, we will pay the Partial Dismemberment Benefit shown. If this benefit is paid and the employee later dies as a result of the same covered accident, we will pay the appropriate death benefit, less any amounts paid under this benefit. Accidental Death If the employee is injured in a covered accident and the injury causes him/her to die within 90 days after the accident, we will pay the Accidental Death Benefit shown. Accidental Common Carrier Death If the employee is injured in a covered accident and the injury causes him/her to die within 90 days after the accident, we will pay the Accidental Common Carrier Death Benefit in the amount shown if the injury is the result of traveling as a fare-paying passenger on a common carrier, as defined below. This benefit is paid in addition to the Accidental Death Benefit. Common carrier means: An airline carrier which is licensed by the United States Federal Aviation Administration and operated by a licensed pilot on a regular schedule between established airports; or A railroad train which is licensed and operated for passenger service only; or A boat or ship that is licensed for passenger service and operated on a regular schedule between established ports. LIMITATIONS AND EXCLUSIONS WE WILL NOT PAY BENEFITS FOR INJURY, TOTAL DISABILITY, OR DEATH CONTRIBUTED TO, CAUSED BY, OR RESULTING FROM: War participating in war or any act of war, declared or not; participating in the armed forces of, or contracting with, any country or international authority. We will return the prorated premium for any period not covered by this certificate when you are in such service. Suicide committing or attempting to commit suicide, while sane or insane. Sickness having any disease or bodily/mental illness or degenerative process. We also will not pay benefits for any related medical/surgical treatment or diagnostic procedures for such illness. Self-Inflicted Injuries injuring or attempting to injure yourself intentionally. Racing riding in or driving any motor-driven vehicle in a race, stunt show, or speed test. Intoxication being legally intoxicated, or being under the influence of any narcotic, unless taken under the direction of a doctor. Legally intoxicated means that condition as defined by the law of the jurisdiction in which the accident occurred. Illegal Acts participating or attempting to participate in an illegal activity or working at an illegal job. Sports participating in any organized sport professional or semiprofessional. Cosmetic Surgery having cosmetic surgery or other elective procedures that are not medically necessary or having dental treatment except as a result of a covered accident. AGCM378VA-10-BK R2 IV (3/18) Page 49

50 Montgomery County Public Schools HIGH OPTION - 24 HOUR PLAN Monthly (12pp/yr) Employee $16.20 Employee and Spouse $23.16 Employee and Dependent Children $30.90 Family $37.86 Wellness Benefit included in Rates Please Note: Premiums and benefits shown are accurate as of publication. They are subject to change. Published: Feb-15 AC RB1-CU-NC-AC78-12PP-HIGH-24HR-WB - ZZXX15149 Page 50

51 Aflac Group Critical Illness Plan Plan Features Benefits are paid directly to you, unless otherwise assigned. Premiums are paid through convenient payroll deduction. Guaranteed-issue coverage available to employee and spouse. Each dependent child is covered at 50% of the primary insured amount at no additional charge. Benefit amounts are available from $5,000 up to $50,000 for employees and up to $30,000 for spouse. An annual Health Screening benefit is included. The plan is portable, which means you can take your coverage with you if you change jobs or retire (with certain stipulations). Underwriting Guidelines Guaranteed-Issue Guaranteed-issue coverage is available for all eligible employees. The following options are available: Up to $30,000 for employees and up to $15,000 for spouses with no participation requirement. For employee amounts over $30,000 and spouse amounts over $15,000: All applicants are required to answer underwriting questions. Employees who would otherwise be declined will be issued the lesser of the amount applied for or the guaranteed-issue limit. Individual Eligibility Issue Ages Employee Spouse Children under age 26 Benefit-eligible employees, working at least 20 hours or more weekly by the date of the enrollment are eligible. If an employee is eligible, his spouse is eligible and all children of the insured who are younger than 26 years of age are eligible for coverage. Seasonal and temporary workers are not eligible to participate. Spouse Coverage Available The employee may elect to purchase spouse coverage. In order to apply for spouse coverage, the employee must also apply. Spouses are eligible for benefit amounts equaling 100% of the employee amount, not to exceed the $30,000 maximum benefit. If the employee does not meet the underwriting requirements necessary to participate in the plan, the spouse can still obtain coverage. The spouse would then become the primary insured and is limited to face amounts up to $30,000. Dependent Children Coverage at No Additional Charge Each eligible dependent child is covered at 50% of the primary insured amount at no additional charge. The payment of benefits for a dependent child does not reduce the face amount of the primary insured. Children-only coverage is not available. Portability Coverage may be continued with certain stipulations. See certificate for details. Group Critical Illness Benefits First Occurrence Benefit After the waiting period, an insured may receive up to 100% of the benefit selected upon the first diagnosis of each covered critical illness; if the date of diagnosis is while coverage is in force, and the certificate does not exclude the illness or condition by name or by specific description. We will pay benefits for a critical illness in the order the events occur. We will deduct any previously-paid partial benefits from the appropriate critical illness benefit. Critical Illnesses Covered Under Plan Percentage of Face Amount Heart Attack 100% Major Organ Transplant 100% Renal Failure (End Stage) 100% Stroke 100% Coronary Artery Bypass Surgery+ 25% Separate Diagnosis Benefit We will pay benefits for each different critical illness after the first when the following conditions are met: the two dates of diagnosis must be separated by at least 6 months, and are not caused by or contributed to by a critical illness for which benefits have been paid. Page 51

52 Re-occurrence Benefit - Once benefits have been paid for a critical illness, we will pay additional benefits for that same critical illness when the dates of diagnosis are separated by at least 12 months. + Payment of the partial benefit for coronary artery bypass surgery will reduce by 25% the benefit for a heart attack. Health Screening Benefit- $100 After the Waiting Period, we will pay a maximum of $100 for health screening tests performed while an insured s coverage is in force. We will pay this benefit once per calendar year. This benefit is only payable for health screening tests performed as the result of preventative care, including tests and diagnostic procedures ordered in connection with routine examinations. This benefit is payable for the covered employee and spouse. This benefit is not paid for Dependent Children. The covered health screening tests include but are not limited to: Stress test on a bicycle or treadmill Fasting blood glucose test, blood test for triglycerides or serum cholesterol test to determine level of HDL and LDL Bone marrow testing Breast ultrasound CA 15-3 (blood test for breast Cancer) CA 125 (blood test for ovarian Cancer) CEA (blood test for colon Cancer) Chest x-ray Colonoscopy Flexible sigmoidoscopy Hemocult stool analysis Mammography Pap smear PSA (blood test for prostate Cancer) Serum protein electrophoresis (blood test for myeloma) Thermograph Specified Critical Illness Rider Illnesses Covered Under Plan Percentage of Face Amount Coma 100% Paralysis 100% Severe Burns 100% Loss of Speech 100% Loss of Sight 100% Loss of Hearing 100% Advanced Alzheimer s Disease 25% Advanced Parkinson s Disease 25% Benign Brain Tumor 100% We will pay the specified critical illness benefit if the insured is diagnosed with one of the specified critical illnesses shown in the rider schedule if the date of diagnosis is after the waiting period, the date of diagnosis occurs while the rider is in force, and the specified critical illness is not excluded by name or specific description in the rider. We will not pay benefits under the rider if these conditions result from another specified critical illness. Page 52

53 Heart Event Rider Covered Surgeries and Procedures Percentage of Face Amount Category 1 Coronary Artery Bypass Surgery 100% Mitral valve replacement or repair 100% Aortic valve replacement or repair 100% Surgical Treatment of Abdominal aortic aneurysm 100% Category 2** AngioJet Clot Busting 10% Balloon Angioplasty (or Balloon valvuloplasty ) 10% Laser Angioplasty 10% Atherectomy 10% Stent implantation 10% Cardiac catheterization 10% Automatic Implantable (or Internal) Cardioverter Defibrillator (AICD) 10% Pacemakers 10% We will pay the applicable category I or category II benefit if the insured is treated with one of the procedures shown on the rider schedule as long as the date of treatment is after the waiting period, treatment is incurred while the rider is in force, treatment is recommended by a physician, and it is not excluded by name of specific description in the rider. Benefits are not payable under the rider for loss if these conditions result from another specified critical illness other than heart attack. For heart attack, we will pay applicable benefits. Payment of initial, reoccurrence, or separate diagnosis benefits are subject to the benefit provisions section of the certificate. **This 100% represents the combination of total of applicable benefits available in the rider and benefits available in the certificate (for the same conditions). When combined, benefits from the rider and certificate will not exceed 100% of the maximum applicable benefit. Note that the 25% Coronary Artery Bypass Surgery (CABS) partial benefit in your base certificate is increased to 100% with this rider. The CABS benefit in this Rider, combined with the benefit in your base certificate, equal 100% of the maximum benefit not 125%. Benefits for Category II will reduce the benefit amounts payable for Category I benefits. Benefits will be paid only at the highest benefit level. If a Category I and a Category II procedure are performed at the same time, benefits are eligible only at the 100% (higher) event and will not exceed the applicable face amount shown on the benefit schedule in the certificate. An insured is eligible to receive only one payment for each benefit category listed on the schedule page. The dates of loss for covered procedures must be separated by at least 6 months for benefits to be payable for multiple covered procedures. Limitations and Exclusions The plan contains a 30-day waiting period. This means that we will not pay benefits to an insured who has been diagnosed or had a health screening test performed before his coverage has been in force 30 days from the effective date. If a critical Illness is first diagnosed during the waiting period, we will only pay benefits for loss beginning after coverage has been in force for 12 months. Or, the insured may elect to void the certificate from the beginning and receive a full premium refund. Pre-Existing Conditions Limitations Pre-existing Condition is a sickness or physical condition that existed within the 12-month period before the insured s effective date. For this preexisting condition, a medical professional must have advised, diagnosed, or treated the insured. We will not pay benefits for any critical illness resulting from or affected by a pre-existing condition if the critical illness was diagnosed within the12- month period after the insured s effective date. We will not reduce or deny a claim for benefits for any critical illness that was diagnosed more than 12 months after the insured s effective date. Page 53

54 Exclusions We will not pay for loss due to any of the following: Self-Inflicted Injuries injuring or attempting to injure oneself intentionally or taking action that causes oneself to become injured Suicide committing or attempting to commit suicide, while sane or insane Illegal Acts participating or attempting to participate in an illegal activity, or working at an illegal job Participation in Aggressive Conflict of any kind, including: o War (declared or undeclared) or military conflicts o Insurrection or riot o Civil commotion or civil state of belligerence Illegal substance abuse Specified Critical Illness Rider Exclusions: All limitations and exclusions that apply to the critical illness plan also apply to the rider unless amended by the rider. The waiting period and preexisting condition limitation apply from the date the rider is effective. No benefits will be paid for loss which occurred prior to the effective date of the rider. Benefits are not payable under for loss if these conditions result from another specified critical illness. Heart Event Rider Exclusions: All limitations and exclusions that apply to the critical illness plan also apply to the rider unless amended by the rider. The waiting period and preexisting condition limitation apply from the date the rider is effective. No benefits will be paid for loss which occurred prior to the effective date of this rider. Any benefits for coronary artery bypass denied under the rider due to pre-existing conditions may be paid at the reduced benefit amount under the certificate, subject to the terms of the certificate. Page 54

55 Aflac Critical Illness Plan (without cancer) Employee and Spouse Monthly Rates NONTOBACCO - Employee AGES $ 5,000 $ 10,000 $ 15,000 $20,000 $25,000 $ 30,000 $ 35,000 $ 40,000 $ 45,000 $ 50, $ 552 $ 754 $ 956 $ 1157 $ 1359 $ 1561 $ 1763 $ 1965 $ 2167 $ $ 689 $ 1027 $ 1366 $ 1704 $ 2043 $ 2382 $ 2720 $ 3059 $ 3397 $ $ 1044 $ 1738 $ 2432 $ 3126 $ 3820 $ 4514 $ 5208 $ 5902 $ 6596 $ $ 1520 $ 2689 $ 3859 $ 5028 $ 6198 $ 7367 $ 8537 $ 9706 $ $ $ 2534 $ 4718 $ 6902 $ 9086 $ $ $ $ $ $ NONTOBACCO - Spouse AGES $ 5,000 $ 7,500 $ 10,000 $ 12,500 $ 15,000 $17,500 $20,000 $22,500 $25,000 $30, $ 552 $ 653 $ 754 $ 855 $ 956 $ 1057 $ 1157 $ 1258 $ 1359 $ $ 689 $ 858 $ 1027 $ 1196 $ 1366 $ 1535 $ 1704 $ 1874 $ 2043 $ $ 1044 $ 1391 $ 1738 $ 2085 $ 2432 $ 2779 $ 3126 $ 3473 $ 3820 $ $ 1520 $ 2104 $ 2689 $ 3274 $ 3859 $ 4443 $ 5028 $ 5613 $ 6198 $ $ 2534 $ 3626 $ 4718 $ 5810 $ 6902 $ 7994 $ 9086 $ $ $ TOBACCO - Employee AGES $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50, $ 661 $ 972 $ 1283 $ 1594 $ 1904 $ 2215 $ 2526 $ 2837 $ 3148 $ $ 885 $ 1420 $ 1955 $ 2490 $ 3024 $ 3559 $ 4094 $ 4629 $ 5164 $ $ 1721 $ 3092 $ 4463 $ 5834 $ 7205 $ 8576 $ 9947 $ $ $ $ 2668 $ 4986 $ 7304 $ 9622 $ $ $ $ $ $ $ 4528 $ 8706 $ $ $ $ $ $ $ $ TOBACCO - Spouse AGES $5,000 $7,500 $10,000 $12,500 $15,000 $17,500 $20,000 $22,500 $25,000 $30, $ 661 $ 816 $ 972 $ 1127 $ 1283 $ 1438 $ 1594 $ 1749 $ 1904 $ $ 885 $ 1152 $ 1420 $ 1687 $ 1955 $ 2222 $ 2490 $ 2757 $ 3024 $ $ 1721 $ 2406 $ 3092 $ 3777 $ 4463 $ 5148 $ 5834 $ 6519 $ 7205 $ $ 2668 $ 3827 $ 4986 $ 6145 $ 7304 $ 8463 $ 9622 $ $ $ $ 4528 $ 6617 $ 8706 $ $ $ $ $ $ $ Rates do not include cancer benefit. Rates include: $100 Health Screening Benefit, Additional Benefits Rider, Heart Rider, and no additional riders. No benefit reduction at age 70. Please Note: Premiums are accurate as of publication. They are subject to change. Page 55

56 Aflac Group Critical Illness Plan Plan Features Benefits are paid directly to you, unless otherwise assigned. Premiums are paid through convenient payroll deduction. Guaranteed-issue coverage available to employee and spouse. Each dependent child is covered at 50% of the primary insured amount at no additional charge. Benefit amounts are available from $5,000 up to $50,000 for employees and up to $30,000 for spouse. An annual Health Screening benefit is included. The plan is portable, which means you can take your coverage with you if you change jobs or retire (with certain stipulations). Underwriting Guidelines Guaranteed-Issue Guaranteed-issue coverage is available for all eligible employees. The following options are available: Up to $30,00 for employees and up to $15,000 for spouses with no participation requirement. For employee amounts over $30,000 and spouse amounts over $15,000: All applicants are required to answer underwriting questions. Employees who would otherwise be declined will be issued the lesser of the amount applied for or the guaranteed-issue limit. Individual Eligibility Issue Ages Employee Spouse Children under age 26 Benefit-eligible employees, working at least 20 hours or more weekly by the date of the enrollment are eligible. If an employee is eligible, his spouse is eligible and all children of the insured who are younger than 26 years of age are eligible for coverage. Seasonal and temporary workers are not eligible to participate. Spouse Coverage Available The employee may elect to purchase spouse coverage. In order to apply for spouse coverage, the employee must also apply. Spouses are eligible for benefit amounts equaling 100% of the employee amount, not to exceed the $30,000 maximum benefit. If the employee does not meet the underwriting requirements necessary to participate in the plan, the spouse can still obtain coverage. The spouse would then become the primary insured and is limited to face amounts up to $30,000. Dependent Children Coverage at No Additional Charge Each eligible dependent child is covered at 50% of the primary insured amount at no additional charge. The payment of benefits for a dependent child does not reduce the face amount of the primary insured. Children-only coverage is not available. Portability Coverage may be continued with certain stipulations. See certificate for details. Group Critical Illness Benefits First Occurrence Benefit After the waiting period, an insured may receive up to 100% of the benefit selected upon the first diagnosis of each covered critical illness; if the date of diagnosis is while coverage is in force, and the certificate does not exclude the illness or condition by name or by specific description. We will pay benefits for a critical illness in the order the events occur. We will deduct any previously-paid partial benefits from the appropriate critical illness benefit. Critical Illnesses Covered Under Plan Percentage of Face Amount Cancer (Internal or Invasive)* 100% Heart Attack 100% Major Organ Transplant 100% Renal Failure (End Stage) 100% Stroke 100% Carcinoma in Situ+* 25% Coronary Artery Bypass Surgery+ 25% Page 56

57 Separate Diagnosis Benefit We will pay benefits for each different critical illness after the first when the following conditions are met: the two dates of diagnosis must be separated by at least 6 months, or if the insured is treatment-free from cancer for at least 6 months, and are not caused by or contributed to by a critical illness for which benefits have been paid. Re-occurrence Benefit - Once benefits have been paid for a critical illness, we will pay additional benefits for that same critical illness when the dates of diagnosis are separated by at least 12 months, or the insured has been treatment-free from cancer for at least 12 months and is currently treatment-free. Cancer that has metastasized (spread), even though there is a new tumor, is not considered an additional occurrence unless the insured has been treatment-tree for 12 months and is currently treatment-free. + Payment of the partial benefit for carcinoma in situ will reduce by 25% the benefit for internal cancer. Payment of the partial benefit for coronary artery bypass surgery will reduce by 25% the benefit for a heart attack. *For employees who have chosen the without cancer plan option, these cancer benefits do not apply. Health Screening Benefit- $100 After the Waiting Period, we will pay a maximum of $100 for health screening tests performed while an insured s coverage is in force. We will pay this benefit once per calendar year. This benefit is only payable for health screening tests performed as the result of preventative care, including tests and diagnostic procedures ordered in connection with routine examinations. This benefit is payable for the covered employee and spouse. This benefit is not paid for Dependent Children. The covered health screening tests include but are not limited to: Stress test on a bicycle or treadmill Fasting blood glucose test, blood test for triglycerides or serum cholesterol test to determine level of HDL and LDL Bone marrow testing Breast ultrasound CA 15-3 (blood test for breast Cancer) CA 125 (blood test for ovarian Cancer) CEA (blood test for colon Cancer) Chest x-ray Colonoscopy Flexible sigmoidoscopy Hemoccult stool analysis Mammography Pap smear PSA (blood test for prostate Cancer) Serum protein electrophoresis (blood test for myeloma) Thermograph Specified Critical Illness Rider Illnesses Covered Under Plan Percentage of Face Amount Coma 100% Paralysis 100% Severe Burns 100% Loss of Speech 100% Loss of Sight 100% Loss of Hearing 100% Advanced Alzheimer s Disease 25% Advanced Parkinson s Disease 25% Benign Brain Tumor 100% We will pay the specified critical illness benefit if the insured is diagnosed with one of the specified critical illnesses shown in the rider schedule if the date of diagnosis is after the waiting period, the date of diagnosis occurs while the rider is in force, and the specified critical illness is not excluded by name or specific description in the rider. We will not pay benefits under the rider if these conditions result from another specified critical illness. Page 57

58 Heart Event Rider Covered Surgeries and Procedures Percentage of Face Amount Category 1 Coronary Artery Bypass Surgery 100% Mitral valve replacement or repair 100% Aortic valve replacement or repair 100% Surgical Treatment of Abdominal aortic aneurysm 100% Category 2** AngioJet Clot Busting 10% Balloon Angioplasty (or Balloon valvuloplasty ) 10% Laser Angioplasty 10% Atherectomy 10% Stent implantation 10% Cardiac catheterization 10% Automatic Implantable (or Internal) Cardioverter Defibrillator (AICD) 10% Pacemakers 10% We will pay the applicable category I or category II benefit if the insured is treated with one of the procedures shown on the rider schedule as long as the date of treatment is after the waiting period, treatment is incurred while the rider is in force, treatment is recommended by a physician, and it is not excluded by name of specific description in the rider. Benefits are not payable under the rider for loss if these conditions result from another specified critical illness other than heart attack. For heart attack, we will pay applicable benefits. Payment of initial, reoccurrence, or separate diagnosis benefits are subject to the benefit provisions section of the certificate. **This 100% represents the combination of total of applicable benefits available in the rider and benefits available in the certificate (for the same conditions). When combined, benefits from the rider and certificate will not exceed 100% of the maximum applicable benefit. Note that the 25% Coronary Artery Bypass Surgery (CABS) partial benefit in your base certificate is increased to 100% with this rider. The CABS benefit in this Rider, combined with the benefit in your base certificate, equal 100% of the maximum benefit not 125%. Benefits for Category II will reduce the benefit amounts payable for Category I benefits. Benefits will be paid only at the highest benefit level. If a Category I and a Category II procedure are performed at the same time, benefits are eligible only at the 100% (higher) event and will not exceed the applicable face amount shown on the benefit schedule in the certificate. An insured is eligible to receive only one payment for each benefit category listed on the schedule page. The dates of loss for covered procedures must be separated by at least 6 months for benefits to be payable for multiple covered procedures. Limitations and Exclusions The plan contains a 30-day waiting period. This means that we will not pay benefits to an insured who has been diagnosed or had a health screening test performed before his coverage has been in force 30 days from the effective date. If a critical Illness is first diagnosed during the waiting period, we will only pay benefits for loss beginning after coverage has been in force for 12 months. Or, the insured may elect to void the certificate from the beginning and receive a full premium refund. Pre-Existing Conditions Limitations* Pre-existing Condition is a sickness or physical condition that existed within the 12-month period before the insured s effective date. For this preexisting condition, a medical professional must have advised, diagnosed, or treated the insured. We will not pay benefits for any critical illness resulting from or affected by a pre-existing condition if the critical illness was diagnosed within the12- month period after the insured s effective date. We will not reduce or deny a claim for benefits for any critical illness that was diagnosed more than 12 months after the insured s effective date. Page 58

59 *Benefits are payable for the reoccurrence of a previously diagnosed cancer and/or carcinoma in situ as long as the insured: Has been free from signs or symptoms of that cancer for a consecutive 12-month period before the date of diagnosis (for the reoccurrence) and Has been treatment-free from that cancer for the 12 consecutive months before the date of diagnosis (for the reoccurrence). Exclusions We will not pay for loss due to any of the following: Self-Inflicted Injuries injuring or attempting to injure oneself intentionally or taking action that causes oneself to become injured Suicide committing or attempting to commit suicide, while sane or insane Illegal Acts participating or attempting to participate in an illegal activity, or working at an illegal job Participation in Aggressive Conflict of any kind, including: o War (declared or undeclared) or military conflicts o Insurrection or riot o Civil commotion or civil state of belligerence Illegal substance abuse Specified Critical Illness Rider Exclusions: All limitations and exclusions that apply to the critical illness plan also apply to the rider unless amended by the rider. The waiting period and preexisting condition limitation apply from the date the rider is effective. No benefits will be paid for loss which occurred prior to the effective date of the rider. Benefits are not payable under for loss if these conditions result from another specified critical illness. Heart Event Rider Exclusions: All limitations and exclusions that apply to the critical illness plan also apply to the rider unless amended by the rider. The waiting period and preexisting condition limitation apply from the date the rider is effective. No benefits will be paid for loss which occurred prior to the effective date of this rider. Any benefits for coronary artery bypass denied under the rider due to pre-existing conditions may be paid at the reduced benefit amount under the certificate, subject to the terms of the certificate. Notices This booklet is a brief description of coverage, not a contract. Read your certificate carefully for exact plan language, terms, and conditions. If this coverage will replace any existing individual policy, please be aware that it may be in your best interest to maintain your individual guaranteedrenewable policy. Notice to Consumer: The coverages provided by Continental American Insurance Company (CAIC) represent supplemental benefits only. They do not constitute comprehensive health insurance coverage and do not satisfy the requirement of minimum essential coverage under the Affordable Care Act. CAIC coverage is not intended to replace or be issued in lieu of major medical coverage. It is designed to supplement a major medical program. Continental American Insurance Company (CAIC), a proud member of the Aflac family of insurers, is a wholly-owned subsidiary of Aflac Incorporated and underwrites group coverage. CAIC is not licensed to solicit business in New York, Guam, Puerto Rico, or the Virgin Islands. Continental American Insurance Company, Columbia, South Carolina. AGCM320C-VA-BK R2 IV (3/18) Page 59

60 NONTOBACCO - Employee AGES $ 5,000 $ 10,000 $ 15,000 $20,000 $25,000 $ 30,000 $ 35,000 $ 40,000 $ 45,000 $ 50, $ 652 $ 954 $ 1256 $ 1557 $ 1859 $ 2161 $ 2463 $ 2765 $ 3067 $ $ 844 $ 1337 $ 1831 $ 2324 $ 2818 $ 3312 $ 3805 $ 4299 $ 4792 $ $ 1394 $ 2438 $ 3482 $ 4526 $ 5570 $ 6614 $ 7658 $ 8702 $ 9746 $ $ 2195 $ 4039 $ 5884 $ 7728 $ 9573 $ $ $ $ $ $ 3764 $ 7178 $ $ $ $ $ $ $ $ NONTOBACCO - Spouse AGES $ 5,000 $ 7,500 $ 10,000 $ 12,500 $ 15,000 $17,500 $20,000 $22,500 $25,000 $30, $ 652 $ 803 $ 954 $ 1105 $ 1256 $ 1407 $ 1557 $ 1708 $ 1859 $ $ 844 $ 1090 $ 1337 $ 1584 $ 1831 $ 2078 $ 2324 $ 2571 $ 2818 $ $ 1394 $ 1916 $ 2438 $ 2960 $ 3482 $ 4004 $ 4526 $ 5048 $ 5570 $ $ 2195 $ 3117 $ 4039 $ 4961 $ 5884 $ 6806 $ 7728 $ 8650 $ 9573 $ $ 3764 $ 5471 $ 7178 $ 8885 $ $ $ $ $ $ TOBACCO - Employee AGES $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50, $ 831 $ 1312 $ 1793 $ 2274 $ 2754 $ 3235 $ 3716 $ 4197 $ 4678 $ $ 1175 $ 2000 $ 2825 $ 3650 $ 4474 $ 5299 $ 6124 $ 6949 $ 7774 $ $ 2501 $ 4652 $ 6803 $ 8954 $ $ $ $ $ $ $ 3993 $ 7636 $ $ $ $ $ $ $ $ $ 7093 $ $ $ $ $ $ $ $ $ TOBACCO - Spouse AGES $5,000 $7,500 $10,000 $12,500 $15,000 $17,500 $20,000 $22,500 $25,000 $30, $ 831 $ 1071 $ 1312 $ 1552 $ 1793 $ 2033 $ 2274 $ 2514 $ 2754 $ $ 1175 $ 1587 $ 2000 $ 2412 $ 2825 $ 3237 $ 3650 $ 4062 $ 4474 $ $ 2501 $ 3576 $ 4652 $ 5727 $ 6803 $ 7878 $ 8954 $ $ $ $ 3993 $ 5815 $ 7636 $ 9458 $ $ $ $ $ $ $ 7093 $ $ $ $ $ $ $ $ $ Rates include cancer benefit. Aflac Critical Illness Plan (with cancer) Employee and Spouse Monthly Rates Rates include: $100 Health Screening Benefit, Additional Benefits Rider, Heart Rider, and no additional riders. No benefit reduction at age 70. Please Note: Premiums are accurate as of publication. They are subject to change. Page 60

61 Need help with healthcare? We ve got your lifeline. Introducing Health Advocacy, Medical Bill Saver and Telemedicine services, now part of your Aflac plan. We ve enhanced your plan without adding cost. Now, if you have Aflac Group Critical Illness, Group Accident or Group Hospital Indemnity plans, you also have access to three new services that make it easier to access care, reduce out-of-pocket medical expenses and navigate the healthcare system with greater ease: Get answers and expert help with Health Advocacy from Health Advocate. Let advocates negotiate your medical bills with Medical Bill Saver TM, also from Health Advocate Connect with health providers via phone, app or online with MeMD. These three services are now embedded in your group plan. Best of all, you can start using them as soon as your Aflac coverage starts. SERVICES AVAILABLE AS SOON AS YOUR COVERAGE STARTS Start using Health Advocacy and Medical Bill Saver from Health Advocate and Telemedicine from MeMD when your coverage begins. Questions? Call DID YOU KNOW? You can also use Health Advocate s Health Advocacy and Medical Bill Saver TM services for your spouse, dependent children, parents and parents-in-law, while Telemedicine is available for you and your family. Page 61

62 Get more without spending more. More than just peace of mind. Health Advocacy from Health Advocate You have 24/7 access to Personal Health Advocates who start helping from the first call: Find doctors, dentists, specialists, hospitals and other providers Schedule appointments, treatments and tests Resolve benefits issues and coordinate benefits Assist with eldercare issues, Medicare and more Help transfer medical records, lab results and X-rays Work with insurance companies to obtain approvals and clarify coverage More than just cash benefits. Medical Bill Saver TM from Health Advocate Aflac already pays claims quickly. Now, with Medical Bill Saver, Health Advocate professionals also help you negotiate medical bills not covered by health insurance: Just send in your medical and dental bills of $400 or more They contact the provider to negotiate a discount Negotiations can lead to a reduction in out-ofpocket costs Once an agreement is made, the provider approves payment terms and conditions You get an easy-to-read personal Savings Result Statement, summarizing the outcome and payment terms More than just care. Telemedicine from MeMD You can quickly connect with board-certified, U.S. licensed health providers online for 24/7/365 access to medical care fast: Create your account at When you have a health issue, log on and request a provider consultation You can request consultations via webcam, app or phone Get eprescriptions,* referrals and more Use it for a range of health issues, from allergies and colds to medication refills $25.00 per visit! CAIC s affiliation with the Value-Added Service providers is limited only to a marketing alliance, and CAIC and the Value-Added Service providers are not under any sort of mutual ownership, joint venture, or are otherwise related. CAIC makes no representations or warranties regarding the Value- Added Service Providers, and does not own or administer any of the products or services provided by the Value Added Service providers. Each Value-Added Service Provider offers its products and services subject to its own terms, limitations and exclusions. Value Added Services are not available in Idaho or Minnesota. Value Added Services are also not available with group plans underwritten by American Family Life Assurance Company of New York. State availability may vary. Medical Bill Saver has restrictions for negotiations on in-network deductibles and co-insurance in Arizona, Colorado, District of Columbia, Illinois, Indiana, New Jersey, New York, North Carolina, Ohio, South Dakota, Texas, Utah and Vermont. Telemedicine by MeMD Due to Arkansas state regulations, insureds physically located in Arkansas at the time of a telemedicine session may only receive consultation services from physicians. Physicians are prohibited from providing diagnoses or prescribing drugs to persons located in Arkansas at the time of service. *When medically necessary, MeMD providers can submit a prescription electronically for purchase and pick-up at your local pharmacy. Continental American Insurance Company (CAIC), a proud member of the Aflac family of insurers, is a wholly-owned subsidiary of Aflac Incorporated and underwrites group coverage. CAIC is not licensed to solicit business in New York, Guam, Puerto Rico, or the Virgin Islands. For groups sitused in California, group coverage is underwritten by Continental American Life Insurance Company. aflacgroupinsurance.com Continental American Insurance Company Columbia, South Carolina AGC R7 IV (6/17) Page 62

63 Group Cancer and Specified Disease Insurance POLICY FORM HIC-GP-CAN-POL-VA 2/11 Underwritten by Humana Insurance Company Plan Features Donor Benefits Wellness Benefits Many Benefits have No Lifetime Maximum Covers Certain Lodging and Transportation Benefit Portable (take it with You) In and Out of Hospital benefits Pays regardless of other coverage Benefit Options Wellness Benefit. For Cancer screening tests such as mammogram, flexible sigmoidoscopy, pap smear, chest X-ray, hemocult stool specimen, or prostate screen. No Lifetime Maximum Positive Diagnosis Test. Payable for a test that leads to positive diagnosis of Cancer or Specified Disease within 90 days. This benefit is not payable if the same Cancer or Specified Disease recurs. First Diagnosis Benefit. One-time benefit payable when a Covered Person is first diagnosed with Cancer (other than Skin Cancer) or a Specified Disease. Must occur after the Certificate Effective Date. Up to $100 per calendar year Up to $300 per calendar year 1. $0 2. $2, $0 4. $5,000 Second and Third Surgical Opinions. Covers written opinions received after a Positive Diagnosis and before surgery. No Lifetime Maximum Non-Local Transportation. Payable for transportation to a Hospital, clinic or treatment center which is more than 60 miles and less than 700 miles from a Covered Person s home. No Lifetime Maximum Ambulance. For ambulance service if the Covered Person is taken to a Hospital and admitted as an inpatient. No Lifetime Maximum Surgery. Covers actual surgeon s fee for an operation up to the amount listed on the schedule. Benefits for surgery performed on an outpatient basis will be 150% of the schedule benefit amount, not to exceed the actual surgeon s fees. No Lifetime Maximum Actual Charges Actual charges by a common carrier or 50 cents per mile if a personal vehicle is used. Actual Charges Up to $3,000 Donor Benefit Bone Marrow and Stem Cell Transplant. We will pay the following expenses incurred by the Covered Person and his or her live donor: (a) Medical expense allowance of two times the selected Hospital Confinement benefit. (b) Actual charges for round trip coach fare on a Common Carrier to the city where the transplant is performed; or personal automobile expense allowance of 50 cents per mile. Mileage is measured from the home of the Donor or Covered Person to the Hospital in which the Covered Person is staying. We will pay for up to 700 miles per Hospital stay. (c) Actual Charges up to $50 per day for lodging and meals expense for donor to remain near Hospital. (a) $200 (b) Actual charges for round trip coach fare; or personal automobile expense of 50 cents per mile. (c) Actual charges up to $50 per day Bone Marrow and Stem Cell Transplant. We will pay Actual Charges per Covered Person for surgical and anesthetic charges associated with bone marrow transplant and/or peripheral stem cell transplant Actual charges to a combined lifetime maximum of $15,000 Anesthesia. For services of an anesthesiologist during a Covered Person s surgery. No Lifetime Maximum For anesthesia in connection with the treatment of skin Cancer. No Lifetime Maximum Up to 25% of surgical benefit paid. $100 maximum per Covered Person Form Number: HIC-GP-CAN-SB-VA Page 63

64 Benefit Benefit Options Ambulatory Surgical Center. We will pay the expense incurred at an Ambulatory Surgical Center. No Lifetime Maximum Drugs and Medicines. Payable for drugs and medicine received while the Covered Person is Hospital confined. No Lifetime Maximum Outpatient Anti-Nausea Drugs. Payable for drugs prescribed by a Physician to suppress nausea due to Cancer or Specified Disease. No Lifetime Maximum $250 Per Day Up to $25 per day, $600 per calendar year Up to $250 per calendar year Radiation, Radioactive Isotopes Therapy, Chemotherapy, or Immunotherapy. Covers treatment administered by a Radiologist, Chemotherapist or Oncologist on an inpatient or outpatient basis. No Lifetime Maximum Option I: Actual charges up to $2,500 per month Option 2: Actual charges up to $2,500 per month Option 3: Actual charges up to $5,000 per month Option 4: Actual charges up to $5,000 per month Miscellaneous Therapy Charges. Covers charges for lab work or x-rays in connection with radiation and chemotherapy treatment. Service must be performed while receiving treatment(s) in Item 15 or within 30 days following a covered treatment. Self-Administered Drugs. We will pay the actual expenses incurred for self-administered chemotherapy, including hormone therapy, or immunotherapy agents. This benefit is not payable for planning, monitoring, or other agents used to treat or prevent side effects, or other procedures related to this therapy treatment. No Lifetime Maximum Colony Stimulating Factors. We will pay expenses incurred for: [a] cost of the chemical substances and [b] their administration to stimulate the production of blood cells. Treatment must be administered by an Oncologist or Chemotherapist. No Lifetime Maximum Blood, Plasma and Platelets. For blood, plasma and platelets, and transfusions: including administration. No Lifetime Maximum Physician's Attendance. For one visit per day while Hospital confined. No Lifetime Maximum Private Duty Nursing Service. For private nursing services ordered by the Physician while Hospital confined. No Lifetime Maximum National Cancer Institute Designated Comprehensive Cancer Treatment Center Evaluation/Consultation Benefit. We will pay the expense incurred if an Covered Person is diagnosed with Internal Cancer and seeks evaluation or consultation from a National Cancer Institute designated Comprehensive Cancer Treatment Center. If the Comprehensive Cancer Treatment Center is located more than 30 miles from the Covered Person s place of residence, We will also pay the transportation and lodging expenses incurred. This benefit is not payable on the same day a Second or Third Surgical Opinion Benefit is payable and is in lieu of the Non-Local Transportation Benefits of the policy. Breast Prosthesis. Covers the prosthesis and its implantation if it is required due to breast cancer. No Lifetime Maximum Artificial Limb or Prosthesis. Covers implantation of an artificial limb or prosthesis when an amputation is performed. Physical or Speech Therapy. Payable when therapy is needed to restore normal bodily function. No Lifetime Maximum Extended Benefits. If a Covered Person is confined in a Hospital for 60 continuous days We will pay three times the selected Hospital Confinement Benefit beginning on the 61st day for Hospital Confinement. This benefit is payable in place of the Hospital Confinement Benefit. No Lifetime Maximum Extended Care Facility. Limited to number of days of prior Hospital confinement. Must begin within 14 days after Hospital confinement, and be at the direction of the attending Physician. No Lifetime Maximum At Home Nursing. Limited to number of days of prior Hospital confinement. Must begin immediately following a Hospital confinement, and be authorized by the attending Physician. No Lifetime Maximum New or Experimental Treatment. We will pay the expenses incurred by a Covered Person for New or Experimental Treatment judged necessary by the attending Physician and received in the United States or in its territories. No Lifetime Maximum Hospice Care. If a Covered Person elects to receive hospice care, We will pay the expenses incurred for care received in a Free Standing Hospice Care Center. No Lifetime Maximum Government or Charity Hospital. Payable if the Covered Person is confined in a U. S. Government Hospital or a Hospital that does not charge for its services. Paid in place of all other benefits under the Policy. No Lifetime Maximum Hairpiece. We will pay the actual expense incurred per Covered Person for a hairpiece when hair loss is a result of Cancer Treatment. Actual charges up to a lifetime maximum of $10,000 Actual charges up to $4,000 per month Actual charges up to $500 per month Actual charges up to $200 per day Up to $35 per day Up to $100 per day Expenses incurred limited to a lifetime maximum up to $750 for evaluation. Expenses incurred limited to a lifetime maximum up to $350 for transportation and lodging. Actual Charges $1,500 lifetime maximum per amputation. Up to $35 per session $300 per day Up to $50 per day Up to $100 per day Up to $7,500 per calendar year Up to $50 per day $200 per day Actual charge up to a lifetime maximum of $150 Form Number: HIC-GP-CAN-SB-VA Page 64

65 Benefit Rental or Purchase of Durable Goods. We will pay the actual expenses incurred for the rental or purchase of the following pieces of durable medical equipment: a respirator or similar mechanical device, brace, crutches, Hospital bed, or wheelchair. No Lifetime Maximum Waiver of Premium. After 60 continuous days of disability due to Cancer or Specified Disease, We will waive premiums starting on the first day of policy renewal. Hospital Confinement. Payable for each day a Covered Person is charged the daily room rate by a Hospital, for up to 60 days of continuous stay. The benefit for covered children under age 21 is two times the Covered Person s daily benefit. No Lifetime Maximum Benefit Options Actual charges up to $1,500 per calendar year After 60 days $100 per day Other Specified Diseases Covered: Addison s Disease Meningitis (epidemic cerebrospinal) Scarlet Fever Amyotrophic Lateral Sclerosis Multiple Sclerosis Sickle Cell Anemia Cystic Fibrosis Muscular Dystrophy Tay-Sachs Disease Diphtheria Myasthenia Gravis Tetanus Encephalitis Niemann-Pick Disease Toxic Epidermal Necrolysis Epilepsy Osteomyelitis Tuberculosis Hansen s Disease Poliomyelitis Tularemia Legionnaire s Disease Rabies Typhoid Fever Lupus Erythematosus Reye s Syndrome Undulant Fever Lyme Disease Rheumatic Fever Whipple s Disease Malaria Rocky Mountain Spotted Fever Payment of Benefits Benefits are payable for a Covered Person s Positive Diagnosis of a Cancer or Specified Disease that begins after the Certificate Effective Date and while this Certificate has remained in force. Pre-Existing Condition Limitation During the first 12 months of a Covered Person s insurance, losses incurred for Pre-Existing Conditions are not covered. During the first 12 months following the date a Covered Person makes a change in coverage that increases his or her benefits, the increase will not be paid for Pre-Existing Conditions. After this 12 month period, however, benefits for such conditions will be payable unless specifically excluded from coverage. This 12 month period is measured from the Certificate Effective Date for each Covered Person. Pre-Existing Condition means Cancer or a Specified Disease, for which a Covered Person has received medical consultation, treatment, care, services, or for which diagnostic test(s) have been recommended or for which medication has been prescribed during the 12 months immediately preceding the Certificate Effective Date of coverage for each Covered Person. Exceptions and Other Limitations The Policy pays benefits only for diagnoses resulting from Cancer or Specified Diseases, as defined in the Policy. It does not cover: 1. any other disease or sickness; 2. injuries; 3. any disease, condition, or incapacity that has been caused, complicated, worsened, or affected by: a. Specified Disease or Specified Disease treatment; or b. Cancer or Cancer treatment, or unless otherwise defined in the Policy 4. care and treatment received outside the United States or its territories; 5. treatment not approved by a Physician as medically necessary; 6. Experimental Treatment by any program that does not qualify as Experimental Treatment as defined in the Policy. Termination of Coverage A Covered Person s insurance under the Policy will automatically terminate on the earliest of the following dates: 1. the date that the Policy terminates. 2. the date of termination of any section or part of the Policy with respect to insurance under such section or part. 3. the date the Policy is amended to terminate the eligibility of the Employee class. 4. any premium due date, if premium remains unpaid by the end of the grace period. 5. the premium due date coinciding with or next following the date the Covered Person ceases to be a member of an eligible class. 6. the date the Policyholder no longer meets participation requirements. Portability On the date the Policy terminates or the date the Named Insured ceases to be a member of an eligible class, Named Insureds and their covered dependents will be eligible to exercise the portability privilege. Portability coverage may continue beyond the termination date of the Policy, subject to the timely payment of premiums. Portability coverage will be effective on the day after insurance under the Policy terminates. The benefits, terms and conditions of the portability coverage will be the same as those provided under the Policy when the insurance terminated. The initial portability premium rate is the rate in effect under the Policy for active employees who have the same coverage. The premium rate for portability coverage may change for the class of Covered Persons on portability on any premium due date. Form Number: HIC-GP-CAN-SB-VA Page 65

66 Covered Persons Covered Person means any of the following: a. the Named Insured; or b. any eligible Spouse or Child, as defined and as indicated on the Certificate Schedule whose coverage has become effective; c. any eligible Spouse or Child, as defined and added to this Certificate by endorsement after the Certificate Effective Date whose coverage has become effective; or d. a newborn child (as described in the Eligibility Section). Child (Children) means the Named Insured s unmarried child, including a natural child from the moment of birth, stepchild, foster or legally adopted child, or child in the process of adoption (including a child while the Named Insured is a party to a proceeding in which the adoption of such child by the Named Insured is sought); a child for whom the Named Insured is required by a court order to provide medical support, and grandchildren who are dependent on the Named Insured for federal income tax purposes at the time of application, who is: a. not yet age 25; or b. not yet age 26 if a full time student at an accredited school. Option to Add Additional Benefits Hospital Intensive Care Insurance Rider Form Number HIC-GP-ICR 2/11 In consideration of additional premium, this coverage will provide you with benefits if you go into a Hospital Intensive Care Unit (ICU). Benefits Your benefits start the first day you go into ICU. The benefit is payable for up to 45 days per ICU stay. Hospital Intensive Care Confinement Benefit You may choose the benefit of $325 (Option 2) or $625 (Option 4) per day. It is reduced by one-half at age 75. Double Benefits We will double the daily benefits for each day you are in an ICU as a result of Cancer or a Specified Disease. We will also double the benefit for an injury that results from: being struck by an automobile, bus, truck, motorcycle, train, or airplane; or being involved in an accident in which the named insured was the operator or was a passenger in such vehicle. ICU confinement must occur within 48 hours of the accident. Emergency Hospitalization and Subsequent Transfer to an ICU We will pay the benefit selected by you for the highest level of care in a hospital that does not have an ICU, if you are admitted on an emergency basis, and you are transferred within 48 hours to the ICU of another Hospital. Step Down Unit We will pay a benefit equal to one half the chosen daily benefit for confinement in a Step Down Unit. Exceptions and Other Limitations Except as provided in Step Down Unit and Emergency Hospitalization and Subsequent Transfer to an ICU, coverage does not provide benefits for: surgical recovery rooms; progressive care; intermediate care; private monitored rooms; observation units; telemetry units; or other facilities which do not meet the standards for a Hospital Intensive Care Unit. Benefits are not payable: if you go into an ICU before the Certificate Effective Date; if you go into an ICU for intentionally self-inflicted injury or suicide attempts; if you go into an ICU due to being intoxicated or under the influence of alcohol, drugs or any narcotics, unless administered on the advice of a Physician and taken according to the Physician s instructions. The term intoxicated refers to that condition as defined by law in the jurisdiction where the accident or cause of loss occurred. This is not a Medicare Supplement Policy. If you are eligible for Medicare, see the Medicare Supplement Buyer s Guide available from the Company. This policy only covers cancer and the diseases specified above, unless the hospital intensive care rider is selected. Upon receipt of your policy, please review it and your application. If any information is incorrect, please contact: Bay Bridge Administrators P.O. Box Austin, Texas Form Number: HIC-GP-CAN-SB-VA Page 66

67 Montgomery County Schools Monthly Rates Coverage Tier Option 1 Option 2 Option 3 Option 4 Individual $17.65 $23.38 $19.63 $30.89 Individual + Spouse $35.57 $47.60 $39.44 $62.87 Individual + Child(ren) $25.19 $33.20 $27.64 $43.36 Family $43.10 $57.43 $47.45 $75.34 Variable Benefit Elections Benefit Option 1 Option 2 Option 3 Option 4 Hospital Confinement $100 $100 $100 $100 Surgical $3,000 $3,000 $3,000 $3,000 Radiation/Chemotherapy $2,500 per month $2,500 per month $5,000 per month $5,000 per month First Diagnosis $0 $2,500 $0 $5,000 Colony Stimulating Factors $500 per month $500 per month $500 per month $500 per month Wellness $100 $100 $100 $100 Intensive Care Rider $0 $325 $0 $625 Underwritten by: Humana Insurance Company Administered by: P.O. Box Austin, Texas (800) Page 67

68 AUL Short Term Disability EMPLOYEE BENEFITS THE NEED FOR DISABILITY INSURANCE Protect your paycheck You insure your home, car and other valuable possessions, so why not also protect what pays for all those things? Your income. Without it, think about how your mortgage/rent, groceries or credit card bills would get paid. That s where disability insurance can help. A disability can happen to anyone at any time and it can last for a short or long period of time. Purchasing disability insurance through your workplace is a way to replace a portion of your pre-disability earnings if you get sick or hurt and are unable to work. Being prepared can help ease the financial burden for you. Things to think about A severe injury or illness can leave you unable to work for years. Workers compensation only covers injuries that happen on the job and, to qualify for coverage, you must meet certain eligibility requirements. Additionally, medical insurance will only help cover your medical costs. You might be able to dip into savings or borrow money from loved ones, but if you don t have these options, can you really afford not to have disability insurance? Protect yourself and your income with disability insurance. Disability insurance can provide you with the income protection you need. Consider purchasing it today. Let s figure it out Everyone s circumstances are different. This calculator can help you figure out how much you need to protect your lifestyle and the lifestyles of those you love if you become disabled. Estimate your essential monthly expenses Living expenses Monthly housing (e.g., mortgage, rent, insurance, taxes) Utilities (e.g., telephone, electricity, gas, oil, cable, TV, Internet) Food Transportation (e.g., car payments, gasoline, insurance) Subtotal = Debt expenses Education (e.g., tuition, books, supplies) Health care (e.g., out-of-pocket costs, insurance premiums) Debt payments (e.g., credit cards, other debt) Subtotal = Other expenses Dependent care Life insurance premiums Subtotal = Minimum monthly amount to cover with disability insurance $ Amount Note: Products issues and underwritten by American United Life Insurance Company (AUL), Indianapolis, IN, a OneAmerica company OneAmerica Financial Partners, Inc. All rights reserved. ONEAMERICA IS THE MARKETING NAME FOR THE COMPANIES OF ONEAMERICA ONEAMERICA.COM G Page 68 G /17/16

69 Class Description: All Benefit Eligible Employees working a minimum of 20 hours per week, electing to participate in the Voluntary Short Term Disability Insurance. Benefit Duration: This is the period of time that benefits will be payable for disability. You can choose a maximum STD benefit duration, if continually disabled, of thirteen (13) weeks. Disability: You are considered disabled if, because of injury or sickness, you cannot perform the mate-rial and substantial duties of your regular occupation, you are not working in any occupation, and are under the regular attendance of a Physician for that injury or sickness. Monthly Benefit: You can choose to insure up to 70% of an Employee s covered basic monthly earn-ings to a maximum monthly benefit of $3,000. Elimination Period: This means a period of time a disabled Employee must be out of work and totally disabled before weekly benefits begin; seven (7) consecutive days for a sickness and zero (0) days for injury. Basis of Coverage: 24 hour coverage, on or off the job. Maternity Coverage: Benefits will be paid the same as any other qualifying disability, subject to any applicable pre-existing condition exclusion. STD Pre-Existing Condition Exclusion: 3/12, If a person receives medical treatment, or service or incurs expenses as a result of an Injury or Sickness within 3 months prior to the Individual Effective Date, then the Group Policy will not cover any Disability which is caused by, contributed to by, or re-sulting from that Injury or Sickness; and begins during the first 12 months after the Person s Individual Effective Date. Recurrent Disability: If you resume Active Work for 30 consecutive workdays following a period of Disability for which the Weekly Benefit was paid, any recurrent Disability will be considered a new period of Disability. A new Elimination Period must be completed before the Weekly Benefit is payable. Exclusions and Limitations: This plan will not cover any disability resulting from war, de-clared or undeclared or any act of war; active participation in a riot; intentionally self-inflicted injuries; commission of an assault or felony; or a pre-existing condition for a specified time period. Annual Enrollment: Enrollees that did not elect coverage during their initial enrollment are eligible to sign up for $500 to $1000 monthly benefit without medical questions, subject to the pre-existing exclusion. Current participants may increase their coverage up to $500 monthly benefit without medical questions. The maximum benefit cannot exceed 70% of basic monthly earnings and must be in $100 increments. Portability: Once an employee is on the AUL disability plan for 3 consecutive months, you may be eligible to port your coverage for one year at the same rate without evidence of insurability. You have 31 days from your date of termination to submit an application to port your coverage. The Portability Privilege is not available to any person that retires (when the Person receives payment from any Employer s Retirement Plan as recognition of past services or has concluded his/her working career). Please refer to the Mark III website for a copy of your certificate, a claim form or application to port form This information is provided as a summary of the product. It is not a part of the insurance contract and does not change or extend AUL s liability under the group policy. If there are any discrepancies between this information and the group policy, the group policy will prevail. Page 69

70 AUL Life Short-Term Disability Monthly Rates Benefit Duration: 13 weeks Monthly Benefit Monthly Premium Monthly Benefit Monthly Premium $500 $10.36 $1,800 $37.28 $600 $12.43 $1,900 $39.35 $700 $14.50 $2,000 $41.42 $800 $16.57 $2,100 $43.49 $900 $18.64 $2,200 $45.56 $1,000 $20.71 $2,300 $47.63 $1,100 $22.78 $2,400 $49.70 $1,200 $24.85 $2,500 $51.78 $1,300 $26.92 $2,600 $53.85 $1,400 $28.99 $2,700 $55.92 $1,500 $31.07 $2,800 $57.99 $1,600 $33.14 $2,900 $60.06 $1,700 $35.21 $3,000 $62.13 Customer Service: Disability Claims: Fax: Disability Claims Page 70

71 Texas Life Voluntary Permanent Life Insurance PureLife-plus Common Issue Date: November 1, 2018 Why do I need more life insurance? Life insurance is a core component of a comprehensive benefits package because it provides employees with essential protection for their families. However, many people depend on their group term life coverage as their only life insurance 1, which can put them at risk of not being adequately prepared during retirement. Permanent life insurance, such as a voluntary universal life individual policy, is a simple way to address employees needs because it complements their existing group term life coverage. It has been designed to serve as a small yet valuable component of one s overall coverage. It can provide continued protection to help alleviate any financial burden, such as funeral costs, that loved ones may need to address. Why PureLife-plus? PureLife-plus, underwritten by Texas Life Insurance Company, combines several outstanding product features that can help you meet your financial needs and objectives: You own it. - This voluntary universal life product is yours to keep, even when you change jobs or retire, as long as you pay the necessary premium. Group and voluntary term, on the other hand, typically are not portable if you change jobs and, even if you can keep them after you retire, usually cost more and decline in death benefit. Refund of Premium. Unique in the marketplace, PureLife-plus offers you a refund of 10 years premium, should you surrender the policy if the premium you pay when you buy the policy ever increases. (Conditions apply). High Death Benefit. With one of the highest death benefits available at the worksite, 2 PureLife-plus gives your loved ones peace of mind for a reasonable cost. Payroll Deducted Premiums. No checks to write or links to click. Long Guarantees. 3 Enjoy the assurance of a policy that has a guaranteed death benefit to age 121 and level premium that guarantees coverage for a significant period of time. 4 Coverage for your family. You may apply for this permanent, portable coverage, not only for yourself, but also for your spouse/domestic partner, children and grandchildren. 5 Applying is Easy You can qualify by answering just 3 questions no exams or needles. 3 Questions to Qualify: During the last six months, has the proposed insured: a) Been actively at work on a full time basis, performing usual duties? b) Been absent from work due to illness or medical treatment for a period of more than five consecutive working days? c) Been disabled or received tests, treatment or care of any kind in a hospital or nursing home or received chemotherapy, hormonal therapy for cancer, radiation therapy, dialysis treatment, or treatment for alcohol or drug abuse? Additional Benefits and Riders Accelerated Death Benefit Due to Terminal Illness Rider. Included on all policies at no additional cost, the Accelerated Death Benefit Due to Terminal Illness Rider pays 92% of the death benefit, minus a $150 processing fee ($100 in Florida) in most cases, upon a physician-certified diagnosis of a terminal illness expected to result in death within 12 months. The policy terminates upon exercise of this rider. Conditions apply. Form ICC07-ULABR-07 or Form Series ULABR-07 Page 71

72 Texas Life Voluntary Permanent Life Insurance PureLife-plus Accidental Death Benefit: The employer chooses whether or not to make this rider available to all employees and spouses. Available to issue ages 17-59, the rider costs 8 cents per thousand of face amount per month and pays the insured s beneficiary double the death benefit if the insured dies within 180 days (90 days in DC, DE, FL, ND and SD) of an accident from injuries incurred in that accident. The benefit is payable to the insured s age 65. Maximum in-force limits and exclusions apply. Form ICC 07-ULCL-ADB-07 or Form Series ULCL-ADB-07 Waiver of Premium: The employer chooses whether or not to make this rider available to all employees at issue ages When purchased, at a cost of 10% of the base plan monthly premium, the Waiver of Premium benefit will waive the entire premium after the insured is disabled for 180 days for as long as the insured remains totally disabled. It also refunds the prior 180 days premium. The benefit is payable to the insured s age 65. Conditions apply. Form ICC07-ULCL-WP-07 or Form Series ULCL-WP-07 Child Term Rider: Available on either the employee s or spouse s policy (issue ages 17-59), this rider covers all children ages 15 days- 18 years for a premium of approximately $5 a month for a $10,000 death benefit. It is issued on a guaranteed issue basis. The coverage terminates on each child when the child reaches age 25, at which time the child can convert to a permanent individual policy for up to a $30,000 death benefit. The rider terminates when the last child reaches age 25. Future children are covered automatically at age 15 days. Conditions apply. Form ICC07-ULCL-CIR-07 or Form Series ULCL-CIR-07 Sample PureLife-plus Rates Includes Cost for Accidental Death Benefit and Waiver of Premium Age Face Amount Monthly Premium Monthly Premium Guaranteed Non-tobacco Tobacco Period* 20 $50,000 $19.95 $ $50,000 $21.05 $ $50,000 $23.25 $ $50,000 $28.20 $ $50,000 $36.45 $ $50,000 $55.15 $ $50,000 $78.80 $ $50,000 $ $ *Age to which coverage is guaranteed at table premium. 1 LIMRA s Life Insurance Ownership Focus, U.S. Household Trends, Voluntary and Universal Whole Life Products, Eastbridge Consulting Group, December Guarantees are subject to product terms, exclusions and limitations and the insurer s claims-paying ability and financial strength. 4 After the guaranteed period, premiums may go down, stay the same, or go up. 5 Texas Life complies with all state laws regarding marriages, domestic and civil union partnerships, and legally recognized familial relationships. Accordingly, we will treat each party to a civil union or domestic partnership that is recognized and valid under applicable state law as a spouse. Coverage not available on children and grandchildren in Washington. Like most life insurance policies, Texas Life policies contain certain exclusions, limitations, exceptions and terms for keeping them in force. Please contact a Texas Life representative for costs and complete details.see the PureLife-plus brochure for details. PureLifeplus is not available in NJ, NY or PA. 17M320-C 2022 (exp1219) If you have any questions regarding your Texas Life policy, please call , prompt #2. Page 72

73 monthly p r e m i u m s PureLife-plus Standard Risk Table Premiums Non-Tobacco Express Issue Monthly Premiums for Life Insurance Face Amounts Shown Includes Added Cost for Non-Tobacco GUARANTEED PERIOD Age to Which Issue Accidental Death Benefit (Ages 17-59) and Waiver of Premium Benefit (Ages 17-59) Coverage is Age Guaranteed at (ALB) $10,000 $15,000 $25,000 $40,000 $50,000 $75,000 $100,000 $125,000 $150,000 Table Premium 15D PureLife-plus is permanent life insurance to Attained Age 121 that can never be cancelled as long as you pay the necessary premiums. After the Guaranteed Period, the premiums can be lower, the same, or higher than the Table Premium. See the brochure under Permanent Coverage. Form: 10M014icd-rplt EXP-A-M-1AW R Page 73

74 monthly p r e m i u m s PureLife-plus Standard Risk Table Premiums Tobacco Express Issue Monthly Premiums for Life Insurance Face Amounts Shown Includes Added Cost for Tobacco GUARANTEED PERIOD Age to Which Issue Accidental Death Benefit (Ages 17-59) and Waiver of Premium Benefit (Ages 17-59) Coverage is Age Guaranteed at (ALB) $10,000 $15,000 $25,000 $40,000 $50,000 $75,000 $100,000 $125,000 $150,000 Table Premium 15D PureLife-plus is permanent life insurance to Attained Age 121 that can never be cancelled as long as you pay the necessary premiums. After the Guaranteed Period, the premiums can be lower, the same, or higher than the Table Premium. See the brochure under Permanent Coverage. Form: 10M014icd-rplt EXP-A-M-1AW R Page 74

75 monthly p r e m i u m s PureLife-plus Standard Risk Table Premiums Non-Tobacco Express Issue Life Insurance Face Amounts for Monthly Premiums Shown Non-Tobacco GUARANTEED PERIOD Prem Includes Added Cost for Age to Which Issue For Accidental Death Benefit (Ages 17-59) and Waiver of Premium Benefit (Ages 17-59) Coverage is Age $10,000 Guaranteed at (ALB) Face $25.00 $30.00 $35.00 $40.00 $45.00 $50.00 $55.00 $60.00 Table Premium 15D ,798 77,460 91, , , , , ,938 75,199 88, , , , , ,938 75,199 88, , , , , ,181 73,062 85,946 98, , , , ,522 71,053 83,584 96, , , , , ,949 69,150 81,342 93, , , , , ,949 69,150 81,342 93, , , , , ,464 67,338 79,209 91, , , , , ,051 65,625 77,200 88, , , , , ,432 62,445 73,455 84,472 95, , , , ,055 59,563 70,064 80,568 91, , , , ,888 56,935 66,968 77,009 87,049 97, , , ,974 53,390 62,807 72,223 81,639 91, , , ,220 51,268 60,313 69,350 78,391 87,433 96, , ,609 49,305 58,000 66,696 75,392 84,087 92, , ,407 46,629 54,852 63,072 71,303 79,524 87,747 95, ,813 43,482 51,151 58,817 66,488 74,157 81,826 89, ,549 40,733 47,920 55,098 62,285 69,469 76,653 83, ,090 37,750 44,408 51,065 57,724 64,381 71,041 77, ,198 34,240 40,278 46,316 52,356 58,394 64,434 70, ,802 31,326 36,851 42,376 47,901 53,426 58,951 64, ,779 28,870 33,962 39,055 44,145 49,237 54,328 59, ,823 26,496 31,169 35,838 40,515 45,187 49,860 54, ,165 24,482 28,802 33,117 37,436 41,754 46,071 50, ,907 22,956 27,004 31,053 35,099 39,150 43,195 47, ,651 21,430 25,207 28,986 32,767 36,546 40,323 44, ,423 19,938 23,453 26,970 30,486 34,002 37,518 41, ,133 18,374 21,614 24,853 28,093 31,334 34,575 37, ,850 16,815 19,781 22,747 25,712 28,678 31,643 34, ,541 15,225 17,911 20,595 23,282 25,966 28,652 31, ,457 13,911 16,365 18,817 21,271 23,725 26,178 28, ,547 12,807 15,064 17,322 19,579 21,837 24,097 26, ,973 14,084 16,194 18,307 20,419 22,530 24, ,441 13,459 15,477 17,494 19,512 21,530 23, ,095 13,053 15,010 16,966 18,924 20,881 22, ,727 12,619 14,511 16,402 18,294 20,187 22, ,299 12,115 13,931 15,746 17,562 19,379 21, ,047 12,985 14,923 16,861 18,799 20,737 22, ,143 11,922 13,702 15,481 17,260 19,040 20, ,842 12,460 14,078 15,696 17,314 18, ,324 12,795 14,265 15,736 17, ,105 11,418 12,730 14,042 15, ,610 11,830 13,049 14, PureLife-plus is permanent life insurance to Attained Age 121 that can never be cancelled as long as you pay the necessary premiums. After the Guaranteed Period, the premiums can be lower, the same, or higher than the Table Premium. See the brochure under Permanent Coverage. Form: 10M014icd-rplt EXP-A-M-1AW R Page 75

76 monthly p r e m i u m s PureLife-plus Standard Risk Table Premiums Tobacco Express Issue Life Insurance Face Amounts for Monthly Premiums Shown Tobacco GUARANTEED PERIOD Prem Includes Added Cost for Age to Which Issue For Accidental Death Benefit (Ages 17-59) and Waiver of Premium Benefit (Ages 17-59) Coverage is Age $10,000 Guaranteed at (ALB) Face $28.00 $30.00 $35.00 $40.00 $45.00 $50.00 $55.00 $60.00 Table Premium 15D ,650 51,268 60,313 69,350 78,391 87,433 96, , ,827 49,305 58,000 66,696 75,392 84,087 92, , ,827 49,305 58,000 66,696 75,392 84,087 92, , ,339 46,629 54,852 63,072 71,303 79,524 87,747 95, ,562 45,807 53,878 61,948 70,033 78,110 86,188 94, ,826 45,000 52,937 60,874 68,810 76,747 84,688 92, ,107 44,225 52,030 59,829 67,629 75,430 83,230 91, ,415 43,482 51,151 58,817 66,488 74,157 81,826 89, ,608 38,311 45,068 51,824 58,582 65,338 72,091 78, ,581 37,201 43,767 50,329 56,890 63,452 70,014 76, ,087 36,676 43,144 49,611 56,081 62,549 69,017 75, ,610 36,165 42,540 48,916 55,294 61,671 68,049 74, ,407 33,791 39,750 45,710 51,669 57,629 63,586 69, ,215 32,512 38,246 43,979 49,714 55,448 61,182 66, ,426 30,583 35,977 41,370 46,764 52,158 57,552 62, ,443 29,532 34,740 39,943 45,157 50,365 55,568 60, ,683 27,632 32,505 37,379 42,252 47,125 51,999 56, ,423 25,201 29,645 34,089 38,534 42,978 47,423 51, ,922 23,583 27,746 31,907 36,063 40,225 44,385 48, ,254 21,791 25,635 29,478 33,319 37,164 41,007 44, ,110 19,483 22,921 26,358 29,796 33,231 36,668 40, ,078 18,374 21,614 24,853 28,093 31,334 34,575 37, ,836 17,039 20,043 23,047 26,053 29,060 32,062 35, ,853 15,981 18,800 21,618 24,438 27,255 30,074 32, ,987 15,048 17,702 20,356 23,010 25,664 28,318 30, ,215 14,218 16,726 19,232 21,741 24,248 26,755 29, ,143 13,065 15,369 17,673 19,976 22,282 24,586 26, ,502 12,375 14,557 16,740 18,923 21,105 23,287 25, ,634 11,441 13,459 15,477 17,494 19,512 21,530 23, ,466 12,312 14,157 16,003 17,847 19,692 21, ,516 13,243 14,969 16,696 18,422 20, ,667 12,265 13,864 15,463 17,062 18, ,131 11,650 13,169 14,687 16,206 17, ,165 12,621 14,076 15,532 16, ,813 12,229 13,639 15,050 16, ,246 11,581 12,918 14,253 15, ,093 12,372 13,652 14, ,520 11,886 13,252 14,618 15, ,097 12,373 13,648 14, ,236 11,412 12,589 13, ,567 11,656 12, ,787 11, ,269 11, PureLife-plus is permanent life insurance to Attained Age 121 that can never be cancelled as long as you pay the necessary premiums. After the Guaranteed Period, the premiums can be lower, the same, or higher than the Table Premium. See the brochure under Permanent Coverage. Form: 10M014icd-rplt EXP-A-M-1AW R Page 76

77 Texas Life Whole Life Insurance SOLUTIONS 121 Common Issue Date: November 1, 2018 An ideal complement to any group term and optional term life insurance your employer might provide, Texas Life s SOLUTIONS 121 is the life insurance you keep, even when you change jobs or retire as long as you pay the premiums. It will help protect your family, both today and, more importantly, tomorrow. Even better, you won t even have to pay for it after age 65 (or 20 years if you re 46 years of age or older), because it s guaranteed to be paid up. 1 SOLUTIONS is an individual permanent life insurance product specifically designed for employees and their families. These policies provide a guaranteed level premium and death benefit for the life of the policy, and all you have to do to qualify for basic amounts of coverage is be actively at work the day you enroll. You also may apply for coverage on your spouse, children and grandchildren with limited underwriting requirements. 2 As an employee, you are eligible to apply once you have satisfied your employer s eligibility period. Why Voluntary Coverage? Most employees typically depend on group term life insurance. Adults covered by both group and individual life insurance replace more of their income upon death than adults having group term alone. 3 Term policies are created to last for a finite period of time that will likely end before you die. 4 When do you want a life insurance policy in force? --Answer: When you die. Term is for IF you die, permanent is for WHEN you die. The SOLUTIONS Advantage Individual Protection SOLUTIONS 121 is a permanent life insurance policy that you own; it can never be canceled, as long as you pay the guaranteed level premiums due, even if your health changes. Because you own it, you can take SOLUTIONS 121 with you when you change jobs or retire, with no change in the premium. Coverage for Your Family You may also apply for an individual SOLUTIONS 121 policy for your spouse/domestic partner, dependent children ages 15 days-26 years and grandchildren ages 15 days-18 years, even if you do not apply for coverage. 2 Paid Up Insurance SOLUTIONS 121 has premiums that are guaranteed to remain level until your age 65, or for 20 years if you purchase the policy after age 45. At that time, the policy becomes fully paid up; no further premiums are due, and the death benefit does not reduce. This gives you the peace of mind that comes with life insurance that s paid for as your income changes in retirement. 16M419-C-M1119 (exp1118) R0318 See the SOLUTIONS brochure for complete details. Policy form WLOTO-NI-11 or ICC11-WLOTO-NI-11 Page 77

78 Texas Life Whole Life Insurance SOLUTIONS 121 Convenience of payroll deduction Thanks to your employer, SOLUTIONS 121 premiums are paid through convenient payroll deductions and sent to Texas Life by your employer. Portable, Permanent You may continue the peace of mind SOLUTIONS 121 provides, even when you change jobs or retire. Once your policy is issued, the coverage is yours to keep. If you should change jobs or retire before the policy becomes paid up, you simply pay the monthly premium directly to Texas Life by automatic bank draft or monthly bill (for monthly bill we may add a billing fee not to exceed $2.00). Premiums are guaranteed to remain level to your age 65, or for 20 years if you purchase the policy after age 45. At that time, the policy becomes fully paid up; no further premiums are due. Accelerated Death Benefit due to Terminal Illness For no additional premium, the policy includes an Accelerated Death Benefit Due to Terminal Illness Rider. Should you be diagnosed as terminally ill with the expectation of death within 12 months, you will have the option to receive 92.6% (92% in CA, CT, DC, DE, FL, ND & SD) of the death benefit, minus a $150 ($100 in Florida) administrative fee in lieu of the insurance proceeds otherwise payable at death. This valuable living benefit gives you peace of mind knowing that, should you need it, you can take the large majority of your death benefit while still alive. (Conditions apply) (Policy Form ICC-ULABR-11 or Form Series ULABR-11) Accelerated Death Benefit due to Chronic Illness Included in the policy at the option of the employer, the Accelerated Death Benefit for Chronic Illness rider covers all applicants. If an insured becomes permanently chronically ill, meaning that he/she is unable to perform two of six Activities of Daily Living (such as bathing, continence, or dressing), or is severely cognitively impaired (such as Alzheimer s), he/she may elect to claim an accelerated death benefit in lieu of the Face Amount payable at death. The single sum payment is 92% of the death benefit less an administrative fee of $150 ($100 in FL). The Accelerated Death Benefit for Chronic Illness Rider premiums are 8% of the base policy premium. Conditions and limitations apply. See the SOLUTIONS 121 Pamphlet for details. (Policy form ULABR-CI-14 or ICC14-ULABR-CI-14.) Waiver of Premium Rider This benefit to age 65 (issue ages 17-59) waives the premium after six months of the insured s total disability and will even refund the prior six months premium. Benefits continue payable until the earlier of the end of the insured s total disability or age 65. Cost is an additional 10% of the basic monthly premium. Self-inflicted or war-related disability is excluded. Notice, proof and waiting period provisions apply. (Policy Form ICC07-ULCL-WP-07 or Form Series ULCL-WP-07). Coverage begins immediately Coverage normally begins when you complete the application and the authorization for your employer to deduct premiums from your paycheck. Two year suicide and contestability provisions apply (one year in ND). 16M419-C-M1119 (exp1118) R0318 See the SOLUTIONS brochure for complete details. Policy form WLOTO-NI-11 or ICC11-WLOTO-NI-11 Page 78

79 Texas Life Whole Life Insurance SOLUTIONS 121 Sample Rates The chart below displays examples of SOLUTIONS 121 Monthly rates at varying ages for a $50,000 policy. Rates shown below for both non-tobacco and tobacco users, and include the cost for Waiver of Premium and the Accelerated Death Benefit due to Chronic Illness rider. SOLUTIONS 121 Monthly Premium Monthly Premium Age Non-Tobacco Tobacco Face Amount Chronic Illness, Chronic Illness, Paid-up Age Waiver Waiver 20 $50,000 $3811 $ $50,000 $4342 $ $50,000 $5345 $ $50,000 $6820 $ $50,000 $9180 $ $50,000 $12543 $ SOLUTIONS Review Permanent and yours to keep when you change jobs or retire, as long as you pay premiums due Non-participating Whole Life (no dividends) Guaranteed death benefit 1 Guaranteed level premium Guaranteed paid-up insurance at age 65, or for 20 years if the policy is purchased after age 45 If you re actively at work the day you enroll, you can qualify for basic amounts with no more underwriting. Includes Accelerated Death Benefit for Chronic Illness on all policies Waiver of Premium included for ages If desired, you may apply for higher amounts of coverage by answering additional underwriting questions Coverage available for spouse, children and grandchildren 2 1 Guarantees are subject to product terms, exclusions and limitations. 2 Texas Life complies with all state laws regarding marriages, domestic and civil union partnerships, and legally recognized familial relationships. Accordingly, we will treat each party to a civil union or domestic partnership that is recognized and valid under applicable state law as a spouse. Coverage not available on children and grandchildren in Washington. 3 LIMRA; Life Insurance Ownership Focus Maurer, Tim. "Term vs Perm (Life Insurance) In 90 Seconds." Forbes. Forbes Magazine, 3 May Web. 08 Nov If you have any questions regarding your Texas Life policy, please call , prompt #2 16M419-C-M1119 (exp1118) R0318 See the SOLUTIONS brochure for complete details. Policy form WLOTO-NI-11 or ICC11-WLOTO-NI-11 Page 79

80 Texas Life SOLUTIONS Series 121 Tier 1/Tier 2 Combo monthly premiums Includes additional cost for Waiver of Premium Benefit (ages 17-59) & Chronic Illness (all issue ages) PAID UP IFA* $ 10,000 $ 15,000 $ 25,000 $ 30,000 For UFA* UFA* $ 10,000 $ 15,000 $ 25,000 $ 30,000 At Attained (ALB) Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Age *IFA * IFA = Initial = Initial Face Face Amount. Amount. UFA = UFA Ultimate = Ultimate Face Amount. Face Gray Amount. areas Gray require areas Tier require 2 Underwriting. Tier 2 Underwriting. Underwriting Underwiting requirements will vary depending on onplan year, participation partipationrates and and other other factors. For more information see seegroup Enrollment Enrollment Guide. Guide. monthly waiver & chronic illness TEXASLIFE INSURANCE COMPANY Form: 11M035-1 (B2) B-M-3WS Form: 11M035-1 (B2) B-M-3WS Page 80

81 Texas Life SOLUTIONS Series 121 Tier 1/Tier 2 Combo Page 81 monthly premiums Includes additional cost for Waiver of Premium Benefit (ages 17-59) & Chronic Illness (all issue ages) PAID UP IFA* $ 50,000 $ 75,000 $ 100,000 $ 150,000 For UFA* UFA* $ 50,000 $ 75,000 $ 100,000 $ 150,000 At Attained (ALB) Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Non-Tobacco Tobacco Age *IFA = Initial Face Amount. UFA = Ultimate Face Amount Gray areas require Tier 2 Underwriting Underwriting requirements will vary depending on plan year, participation rates and other factors. For more information see Group Enrollment Guide Issue Age Rates for Individual Policies for Children and Grandchildren 1 Monthly Premiums for Life Insurance Coverages Shown $10,000 $25,000 Policy is Paid Up at Attained Age Issue Age $10,000 $25,000 Policy is Paid Up at Attained Age 15d-1 $6.35 $ $7.21 $ $6.35 $ $7.32 $ $6.46 $ $7.54 $ $6.56 $ $7.75 $ $6.67 $ $7.97 $ $6.78 $ $8.18 $ $6.89 $ $8.40 $ $7.00 $ $8.62 $ monthly waiver & chronic illness 1 In WA coverage is not available for children or grandchildren. Policies on children and grandchildren require Tier 2 underwriting.

82 LR LEGAL RESOURCES Who We Are: PAY NO ATTORNEY FEES FOR THE MOST OFTEN NEEDED LEGAL SERVICES Legal Resources is a NEW voluntary benefit that allows Montgomery County Schools to have a law firm that they can call whenever a legal need arises and in most cases, pay no attorney fees. Services are covered either in full or discounted depending on the legal need. For 100% covered services, the member and their dependents pay NO attorney fees. A 25% discount is offered for any legal service not covered in full. What We Cover: Advice and Consultation Consumer Issues Refinancing Homes Traffic Court (including DUI) Assistance with Identity Theft Recovery Insurance Matters Wills and Trusts Courtroom Representation Criminal Misdemeanors Divorce and Child Custody Landlord/Tenant Matters Defense of Juveniles Buying and Selling Homes Elder Law More details on following pages Important to Know: At open enrollment, Legal Resources assigns a law firm from their exclusive network based on the employees home zip code. Members may change law firms at any time by calling Members call their law firm directly when a legal need arises to schedule an appointment. The monthly fee is payroll deducted. $17.00 per month covers employee, spouse, children to age 19 or 23 if full time student. There are no limits on usage, no deductibles, no waiting periods, claim forms or copayments. Employees are encouraged to call Member Services whenever there is an issue. Responsive member service is provided by licensed paralegals that advocate for employees should a question about their coverage or their attorney arise. Very Important to Know: The Legal Resources plan cannot be used against Montgomery County Schools. The following is a brief overview of services paid in full under the Legal Resources Master Plan Contract. That s 100% coverage and there are no restrictions, no claim forms or limitations on services except as noted under DUI. 100% Covered: General Consultation and Advice to be provided at the play attorney s office or by telephone Traffic Court Representation DUI Court Representation (1st offense) Estate Advice, Preparation of Will and related documents Credit/Warranty Disputes Representation for Consumer Disputes Page 82

83 Reviewing a Financial Contract or Lease Change of Name Uncontested Adoptions Family Law including Uncontested Divorce Representation Real Estate Transactions (selling or buying a primary residence) Real Estate Refinancing Non-Real Estate Transactions (Deeds) Insurance Matters Tenant-Landlord Matters and Landlord-Tenant Matters Civil Actions (plaintiff and defendant) Bankruptcy Action consultation and advice only for personal bankruptcy. Filing and court representation available under the Expanded Coverage Benefit. Preparation of Formal Legal Documents Defense of Juveniles Elder Law Matters Criminal Misdemeanor Violations Identity Theft Protection All 100% covered services include courtroom representation through General District Court covered in full Representation with Legal Resources for the following services will be provided at a 25% attorney fee discount on customary and usual fees. Any legal issue that is not covered at 100% would be covered under this category. 25% Covered: Contested Family Law issues/custody issues Parental Placement Private Adoptions Bankruptcy Filing Felonies 2nd or More Offense DUI/DWI Appeals Tax issues/irs issues Small Business Matters Immigration Law Pre-existing Legal Matters where member has already retained an attorney, received a summons or has been named in any lawsuit. Exclusions: Exclusions to plan use: No benefits for services shall be provided under the Plan with respect to any matter, controversy, or proceeding which is related to, arises out of, or otherwise results from the employee s (member s) employment relationship with the Employer. Such matters shall include, but not be limited to, employee grievance, unemployment compensation claims, and worker s compensation claims. If you have questions prior to or after enrolling, please call Member Services at Page 83

84 IDENTITY THEFT PROTECTION MONITOR Legal Resources innovative technology and on-going monitoring keep your personal information and identity secure. CONTROL With our protection, you are in control. Know and improve your credit score, protect your personal information online and keep your keystrokes, pin numbers, and credit card information safe. ALERT Legal Resources provides an early warning system with prompt notifications on your computer, phone, or tablet allowing you to take action before the damage is done. MONITOR and ALERT Change of Address Monitoring Credit Report Monitoring Advanced Identity Monitoring Suspicious Activity Alerts Social Security Number Monitoring GOLD PLAN RELAX Certified Protection Experts offer comprehensive, 24/7 recovery services. We make the calls, complete the paperwork, and handle every detail in restoring your identity. Plus, our up to $1 million of identity theft insurance gives you an additional layer of protection. INCLUDED 1 Bureau CONTROL Credit Reports and Scores Credit Report and Score Frequency Credit Score Tracker Identity Risk Level Junk Mail Opt-Out Online Data Protection Tools 1 Bureau Monthly Monthly RELAX Certified Identity Restoration Specialists Identity Theft Insurance $1 Million Lost Wallet Assistance Emergency Cash and Travel Arrangements PRICING The price for the identity theft plan is $9.95 per month. The price for the legal plan is $17.00 per month. The reduced price for the identity theft plan when combined with the legal plan is $9.50 per month (*legal plan required). The total price for both the legal and identity theft plans combined is $ Page 84