Pearsall ISD - Edl · Guide to your 2017–18 ... Pearsall ISD. Table of Contents You ... John...

Guide to your 2017–18Employee Benefit Plans and Options

Pearsall ISD

Table of ContentsYou can jump to any section by clicking its title below. You can return to the Table of Contents by clicking near the top of any page.

Overview

Enrollment Instructions

Contacts

Flexible Spending Accounts

Health Savings Accounts

Medical Coverage

Dental Coverage

Vision Coverage

Term Life Coverage

Whole Life Coverage

Disability Coverage

Critical Illness Coverage

Cancer Coverage

Accident Coverage

2017–18 Employee Benefit Plans and Options/Pearsall ISD

OverviewPearsall ISD is excited to offer you a comprehensive benefits package for the upcoming plan year. Plan year dates are September 1, 2017, through August 31, 2018.

Medical coverage for district employees is provided by TRS-ActiveCare. Optional supplemental plans are available for:

• Dental• Vision• Disability• Term Life• Whole Life• Accident• Critical Illness• Cancer

Also, tax-savings plans allow you to designate a portion of your income to an account to pay for certain qualified expenses (including medical/dental expenses and dependent care) on a pre-tax basis. Called “cafeteria plans,” these flexible spending accounts and health savings accounts are governed by Section 125 of the Internal Revenue Code and are designed to reduce employees’ total taxable income and increase take-home income.

Need help?If you have questions regarding coverage options, contact the Benefit Center at 844-217-8221. The toll-free call number is open from 7 a.m. to 10 p.m. CST, Monday through Friday.

Also, you can access information about your benefits at any time on a special website created especially for Pearsall ISD: www.nextgenerationenrollment.com/pearsallisd.


Information on coverage proposed by carriers is provided for general information purposes only. Terms, coverages, exclusions, limitations, and other specifics are defined in individual plan policies and contracts that can be obtained by calling the Benefit Center at 844-217-8221. None of the information is intended to provide or be construed as personal financial or legal advice.

Enrollment InstructionsAccess your benefits online: www.nextgenerationenrollment.com/pearsallisd

Enter your username. Your username is the first initial of your first name, the first six characters of your last name (if your name is less than six characters long, enter complete name), and the last four digits of your Social Security number. For example, if your name is John Williams, and the last four digits of your Social Security number are 1234, your user-name will look like this: jwillia1234. Enter your password. Your password is your date of birth in a number format without any punctuation, starting with the year you were born, then the month, and then the day (YYYYMMDD). For example, if your date of birth is January 5, 1970, your password will look like this: 19700105. Once you have logged in, you will be prompted to change your password. After doing this, you will have full access to view your current benefits, update your personal information and elections, and review plan documents.

Or contact us by phone:If you prefer to speak directly to a representative who will assist you in making your elections and help with technical support, please call the Benefit Center toll-free at 844-217-8221. Representatives are available 7 a.m.–10 p.m. CST, Monday–Friday. When you call, the Benefit Center will ask you to verify the last four digits of your Social Security number and your date of birth. The representative will then walk you through your personal information on file to confirm its accuracy.

Please be prepared to first provide verbal authorization if you would like your spouse to speak with a representative on your behalf.


ContactsPearsall ISD 318 Berry Ranch RoadPearsall, Texas 78061830-334-8001pearsallisd.org

AccidentBay Bridge baybridgeadministrators.

com 800-845-7519

CancerColonial Lifecoloniallife.com 800-325-4368

Critical Illness Allstate allstatebenefits.com 800-521-3535

Dental Ameritas ameritas.com 800-487-5553

DisabilityAetna aetna.com 800-872-3862

FSABenefit Center844-217-8221

HSABenefit Center844-217-8221

MedicalTRS www.trsactivecareaetna.com 800-222-9205

Term LifeLincolnLFG.com 800-819-1987

VisionHumana humana.com 877-877-1051

Whole LifeUnum unum.com 866-679-3054

Need answers about your coverage? Call the Benefit Center toll-free at 844-217-8221.

If you have specific questions about each coverage line or you need help with filing claims, contact the carriers listed below.


Health Savings Accounts

Health Savings Accounts coverage information is provided by the carrier for general purposes only. For more information on this coverage, call the Benefit Center at 844-217-8221.

Health Savings Account (HSA) Frequently Asked Questions

What is a Health Savings Account (HSA)? An HSA is a tax-‐advantaged medical savings account available to taxpayers in the United States who are enrolled in a high deductible health plan (HDHP). This is not an option for someone who is not enrolled in a high deductible health plan or someone who is age 65 or older. The funds contributed to an HSA are not subject to federal income tax at the time of deposit.

What is a High Deductible Health Plan (HDHP)? An HDHP is a health insurance plan with lower premiums and higher deductibles than a traditional health plan.

Why do I need to know this? Your medical plan option is a High Deductible Health Plan (HDHP) accompanied by a Health Savings Account (HSA).

What is the difference between an HSA and a Flexible Spending Account (FSA)? Unlike a flexible spending account (FSA), HSA funds roll over and accumulate year to year if not spent. HSAs are owned by the individual, which differentiates them from company-‐owned Health Reimbursement Arrangements (HRA) that are an alternate tax-‐deductible source of funds paired with either HDHPs or standard health plans. HSA funds may currently be used to pay for qualified medical expenses at any time without federal tax liability or penalty. Withdrawals for non-‐medical expenses are treated very similarly to those in an individual retirement account (IRA) in that they may provide tax advantages if taken after retirement age, and they incur penalties if taken earlier.

Can I be enrolled into both the HSA and FSA plans? No, you cannot be enrolled into the HSA and the traditional FSA plan. However, you can use your existing HSA account for medical, dental, and vision expenses.

What are my options if I am age 65 (or over)? If you are age 65 or over, IRS regulations prevent you from enrolling into the HSA. However, you will be eligible to enroll into the traditional FSA plan.

Are there any eligibility requirements that would make me ineligible to enroll into the HSA plan? Yes, during the enrollment process you will be asked the following six questions to determine your eligibility to enroll into the HSA. If you can answer yes to any of these questions, you are not eligible to enroll into the HSA.

1. Are you currently enrolled in Medicare?2. Are you or your spouse enrolled in another medical plan that is not a high-‐deductible health plan?3. On January 1, will you or your spouse have a health care flexible spending account or have money left in a

health care flexible spending account?4. Will you be claimed as a dependent on another person's tax return this year? 5. Are you eligible for benefits through the Department of Veterans Affairs (VA)?6. Do you receive health benefits under TRICARE (the health care program for active duty and retired

members of the uniformed services, their families and survivors)?

What are the maximum contribution amounts for the HSA? The IRS regulates the maximum contribution limits for HSA accounts. Below are the details for the upcoming and the full plan year.

2017 HSA Limits (Full Plan Year January 1 through December 31, 2017 • For Single Coverage - $3,400• For Family Coverage - $6,750

Will my district be funding any portion of my HSA? If you enroll into the HSA plan, your district may be funding a portion of your HSA election. The amount will be detailed on your confirmation statement, which you will receive in the mail once open enrollment ends.

Flexible Spending Accounts

Flexible Spending Accounts coverage information is provided by the carrier for general purposes only. For more information on this coverage, call the Benefit Center at 844-217-8221.

Questions? 888-266-1732 | Monday – Friday, 8 AM – 11 PM EST | www.plansource.com

4.17

The primary advantage to enrolling in an IRS approved Flexible Spending plan is to reduce your taxable income. The secondary advantage is to help offset your eligible out-of-pocket expenses.

This plan, offered by your Employer, allows you to set aside PRE-TAX dollars for health and dependent care expenses that you would otherwise pay for with post-tax dollars. Flexible Spending Accounts (FSA) are exempt from federal taxes, Social Security taxes (FICA), and in most cases state income taxes.

For example, if you incur a deductible expense or office visit co-payment you may be reimbursed for those expenses through a Healthcare Flexible Spending Account. This plan allows you the opportunity to save approximately 30% or more on the expenses you, your spouse, or your dependents already incur for health care. The same holds true for the Dependent Care Flexible Spending Plan. By setting aside pre-tax dollars in a Dependent Care Flexible Spending Plan, you can take advantage of paying for child care costs on a pre-tax basis.

The plan and process works like this:• You elect to participate in either or both the

health care or dependent care Flexible Spendingplan

• Through payroll deduction, you begin setting pre-tax dollars aside based on your annual election

• You incur an expense that qualifies forreimbursement

You may either:• Use your Benefits MasterCard for the purchase, if

the merchant accepts the card, or• Pay out-of-pocket and submit a claim for

reimbursement

Remember, the funds from that account were never taxed; that is how you will save approximately 30% or more on your health and/or dependent care expenses!

The information in this packet is a brief overview of Flexible Spending plans and is in no way meant to guarantee benefits. More detailed information regarding both the health and dependent care reimbursement plans can be found online at www.plansource.com.

Flexible Spending Accounts How they work and why you want to participate

Health Care Flexible Spending Plan

Save potentially 30% or more on your out-of-pocket health care

expenses

Healthcare Flexible Spending PlanA Flexible Spending Account, or FSA, lets you set aside pre-tax money from your paychecks to spend on out-of-pocket healthcare expenses (i.e. co-pays, deductibles, over-the-counter items, etc.) that your insurance plans do not cover in full or are ineligible under the plans. Money that goes into an FSA is pre-tax, so you can save as much as 30% of each dollar you put into your FSA, as long as you spend the money on qualified health costs for you, your spouse or eligible dependents. Whether or not you are enrolled in the medical insurance plan through your employer, you are eligible for the FSA.

For access to a tax savings calculator, list of eligible items, reimbursement claim forms and frequently asked questions,

visit www.plansource.com.

http://www.plansource.com


4.17

FSA Eligible Medical Care Expenses 2017Healthcare Flexible Spending Plan. Medical and dental expenses that qualify as expenses for medical care under IRS rules generally qualify as Eligible Expenses for reimbursement under the Plan. Those may take the form of co-pays, deductibles, and medical expenses not covered by other insurance. Often expenses that qualify for deductions under IRS rules are Eligible Expenses, but in some instances expenses that are deductible will not be reimbursable and expenses that are not deductible will be reimbursable. Some specific examples are identified below. The following is not an exhaustive list and there are other expenses that are eligible if they satisfy the IRS rules.

“Preventive care” includes periodic health examinations (e.g., annual physicals, routine prenatal and well-child care), immunizations, tobacco cessation and obesity weight-loss programs, and screening services that are not for the treatment of an existing illness, injury, or condition. Preventive care also includes treatment of a related condition during the preventive care service or screening. Preventive Care also includes preventive drugs/medications (e.g. drugs/medications taken by a person who has developed risk factors for a disease that has not yet manifested itself or taken to prevent the reoccurrence of a disease).

Dental & Orthodontic CareAllowable expenses:• Dental treatment• Artificial teeth/dentures• Braces, orthodontic devices

Expenses specifically disallowed by the IRS or courts:• Teeth whitening• Toothbrushes and toothpaste,

even if special type isrecommended by dentist

Therapy TreatmentsAllowable expenses:• X-ray treatments• Treatment for alcoholism or

drug dependency• Legal sterilization• Acupuncture• Vaccinations• Hair transplant• Physical therapy (as a medical

treatment)• Fee to use swimming pool

for exercises prescribed byphysician to alleviate specificmedical condition such asrheumatoid arthritis

• Speech therapy• Smoking cessation programs

and prescribed drugs toalleviate nicotine withdrawal

Expenses specifically disallowed by the IRS or courts:• Physical treatments unrelated

to a specific health problem(e.g., massage for general wellbeing)

• Any illegal treatment• Cosmetic surgery• Treatment for baldness (unless

it is for a specific medicalcondition and not for cosmeticpurposes)

• Electrolysis (unless it is for aspecific medical condition andnot for cosmetic purposes)

Listing of Allowable and Disallowable Expenses



4.17

Fees/Services Allowable expenses:• Physician’s fees and

hospital services• Nursing services for care of a

specific medical ailment• Cost of a nurse’s room and

board if paid by the taxpayerwhere nurse’s services qualify

• Social Security tax paid withrespect to wages of a nursewhere nurse’s services qualify

• Services of chiropractors• Christian Science

practitioner fees• Diagnostic tests

Expenses specifically disallowed by the IRS or courts:• Payments to domestic help,

companion, babysitter,chauffeur, etc. who primarilyrender services of a non-medical nature

• Nursemaids or practicalnurses who render generalcare for healthy infants

• Fees for exercise, athletic,or health club membershipwhen there is no specifichealth reason for needingmembership

• Marriage counseling providedby clergyman

Hearing Expenses Allowable expenses:• Hearing aids and hearing

aid battery• Hearing aid repair• Special telephone equipment

Medicine and Drugs Allowable expenses:• Medicine and drugs that

require a prescription• Insulin• Prescribed over the counter

medicine and drugswhen used to alleviate ortreat personal injuries orsickness (including antacids,antihistamines, aspirin/painrelievers, cold medicines,acne medicine, etc.)

Expenses specifically disallowed by the IRS or courts:• Medicine and drugs for

personal, general health, orcosmetic purposes

• Dietary supplements if forgeneral health

Medical Equipment Allowable expenses:• Blood Sugar test kits• Wheelchair or autoette (cost

of operating/maintaining)• Crutches (purchased

or rented)• Special mattress & plywood

boards prescribed toalleviate arthritis

• Oxygen equipment andoxygen used to relievebreathing problems that resultfrom a medical condition

• Artificial limbs• Support hose (if medical

necessary)• Wigs (where necessary

to mental health of individualwho loses hair becauseof disease)

• Excess cost of orthopedicshoes over cost ofordinary shoes

• Breast pumps for nursingmothers

Expenses specifically disallowed by the IRS or courts:• Wigs, when not medically

necessary for mental health• Vacuum cleaner purchased by

an individual with dust allergy• Mechanical exercise device

not specifically prescribedby physician

Physicals Allowable expenses:• Physicals and other well visits• Immunizations

Expenses specifically disallowed by the IRS or courts:• Physicals for employment

purposes

Vision Care Allowable expenses:• Optometrist’s or

ophthalmologist’s fees• Eyeglasses and prescription

sunglasses• Insurance for replacement

of lost or damaged contactlenses

• Contact lens and contactlens solutions

• Laser eye surgery

Listing of Allowable and Disallowable Expenses CONTINUED



4.17

Assistance for the Handicapped Allowable expenses:

• Cost of guide for ablind person

• Cost of note-taker for adeaf child in school

• Cost of Braille books andmagazines in excess of costof regular editions

• Seeing eye dog (costof buying, training andmaintaining)

• Household visual alertsystem for deaf person

• Excess costs of specificallyequipping automobilefor handicapped personover cost of ordinaryautomobile; device for liftinghandicapped person intoautomobile

• Special devices, suchas tape recorder andtypewriter, for a blind person

Miscellaneous Charges Allowable expenses:

• X-rays

• Expenses of servicesconnected with donatingan organ

• Excess cost of medicallyprescribed diet

• The cost of a medicallyprescribed weight lossprogram

• Breast reconstructive surgeryfollowing mastectomy aspart of treatment for cancer

• Contraceptives

• Fertility treatments

• Medical records charges

• Bandages

• Lactation supplies fornursing mothers

• Cost of transportation (e.g.)mileage) primarily for andessential to medical care

Expenses specifically disallowed by the IRS or courts:

• Expenses of divorce whendoctor or psychiatristrecommends divorce

• Cost of toiletries, cosmetics,and sundry items (e.g., soap,toothbrushes)

• Cost of special foods takenas a substitute for regulardiet, when the special dietis not medically necessaryor taxpayer cannot showcost in excess of cost of anormal diet

• Maternity clothes

• Diaper service

• Distilled water purchased toavoid drinking fluoridatedcounty water supply

• Installation of powersteering in automobile

• Pajamas purchased to wearin hospital

• Mobile telephone used forpersonal calls as well as callsto physician

• Union dues for sick benefitsfor members

• Contributions to statedisability funds

• Auto insurance providingmedical coverage for allpersons injured in or bythe taxpayer’s automobile,where amounts allocable totaxpayer and dependent isnot stated separately

• Long-term care services

• Funeral expenses

Insurance Allowable expenses:

• None

Expenses specifically disallowed by the IRS or courts:

• Health insurance premiums(including individual andnon-employer sponsoredcoverage)

• Long term care insurancepremiums

Listing of Allowable and Disallowable Expenses CONTINUED



4.17

Dependent Care Flexible Spending plans are designed to help you save money on the child care expenses you and your spouse (if applicable) incur during the year. Child care expenses may include day care, nursery school costs, or after-school programs. This plan can also be used for expenses incurred in the care of elderly parents, a disabled spouse or a disabled child. Please note, the Dependent Care Flexible Spending Account is not for dependent medical expenses; this account is specifically for the care of your child or dependent while you and/or your spouse are at work or attending school.

A requirement for eligibility is that you are employed and covered under this plan at the time your eligible dependent receives care.

You must also meet one of the following requirements for eligibility:• Your spouse is working or looking for employment• You are a single parent or guardian• At a time when you are employed, your spouse is a

full-time student at least five months during the year• Your spouse is mentally or physically disabled and

unable to provide for his/her own care• You are legally separated or divorced and have

custody of your child, even if you cannot claim anexemption for this dependent on your income taxes(for the time period that the child resides with you, thisplan can be used to pay for child care services)

An Eligible Dependent is a qualifying individual spending at least eight hours a day in your home and is one of the following:• Your dependent under age 13 for whom you claim

an exemption on your income taxes (expenses areno longer eligible for reimbursement upon thedependent’s thirteenth birthday)

• A child under the age of 13 for whom you havecustody, if divorced or legally separated

• Your spouse, if mentally or physically unable toprovide self care

• Your dependent, regardless of age, who is mentallyor physically unable to provide self care, even if you

cannot claim an exemption for this dependent on your income taxes

Eligible Expenses for Reimbursement include:• Care received inside or outside your home by

someone other than: your spouse, a person listed as adependent on your income tax return, or one of yourchildren under age 19; the child care provider mustclaim the payments received as income

• Care received from a qualifying child day care centeror adult or dependent care center

• Care provided by a housekeeper as long as theservices provided, in part, are for the care of aqualified dependent

• Care provided through nursery, preschool, after-school, or summer day camp programs

• Taxes for wages spent on eligible dependent carecan also be submitted for reimbursement

Ineligible Expenses• Include, but are not limited to: dependent health

care expenses, dependent care for a child age 13or over, non work-related babysitting, care that iseducational in nature (kindergarten and beyond),or overnight camp. All submitted claims andreceipts are reviewed and processed prior to issuingreimbursement (IRC §125; 129).

By contributing to this plan through payroll deduction, your Dependent Care Flexible Spending Account is funded from your check on a PRE-TAX basis. It is through this pre-tax deduction you save a percentage of each dollar you spend on eligible dependent care expenses.

By setting aside pre-tax dollars and participating in the Dependent Care Flexible Spending Plan, you can take advantage of paying for these incurred expenses on a PRE-TAX basis.

Dependent Care Flexible Spending Plan (Child Care)Save potentially 30% or more on your dependent care expenses.



4.174.17

• Acid Controllers

• Allergy & Sinus

• Antibiotic Products

• Anti-Diarrheal

• Anti-Gas

• Anti-Itch & Insect Bite

• Anti-parasitic Treatments

• Baby Rash Ointments/Creams

• Cold Sore Remedies

• Cough, Cold & Flu

• Digestive Aids

• Feminine Anti-Fungal/Anti-Itch

• Laxatives

• Motion Sickness

• Pain Relief

• Respiratory Treatments

• Sleep Aids & Sedatives

• Stomach Remedies

Health Care Reform and Flexible Spending Accounts Changes to Over-the-counter Eligibility for ReimbursementIn March 2010, President Obama signed the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 (collectively “the Act”). The Act includes a number of modifications to employee benefit programs. One provision that affected employee participants beginning January 1, 2011 was the requirement for over-the-counter (OTC) drugs, medicines and biologicals to be accompanied by a physician’s prescription in order to be eligible for reimbursement under health flexible spending accounts (FSAs), health reimbursement arrangements (HRAs) and health savings accounts (HSAs).

Though the specific list of items affected has not been completely assessed, the following categories of OTC items will require a doctor’s prescription as of January 1, 2011 in order to be eligible for reimbursement through an FSA, HRA or HSA:

The Act will also impact the use of all Benefit MasterCards. Beginning January 1, 2011, items that require a doctor’s prescription for reimbursement can no longer be auto substantiated at the point-of-sale. Therefore, purchases of OTC drugs, medicines and biologicals will require another form of payment. The employee can then submit a claim or request for reimbursement by using a reimbursement form and submitting the receipt for the purchase along with the doctor’s prescription for the item purchased. This change affects only OTC drugs, medicines and biologicals; bandages, home health-aids and other OTC items (mentioned below) will still be eligible and can be purchased using the Benefit MasterCard without further documentation.

The following are examples of some of the OTC items that will remain eligible for reimbursement without a doctor’s prescription:

• Band Aids

• Birth Control

• Braces & Supports

• Catheters

• Contact Lens Supplies &Solutions

• Denture Adhesives

• Diagnostic Tests & Monitors

• Elastic Bandages & Wraps

• First Aid Supplies

• Insulin & Diabetic Supplies

• Ostomy Products

• Reading Glasses

• Wheelchairs, Walkers, Canes

Please feel free to contact PlanSource with questions regarding the change to OTC eligibility and reimbursement at (888) 266-1732.


Medical Coverage

Information included in this section summarizes health and medical coverages provided by TRS-ActiveCare and is provided for general purposes only. HIPAA and Medicare information, as well as terms, coverages, exclusions, limitations, and other specifics defined in individual plan policies and contracts, can be obtained by calling TRS at 800-222-9205 or visiting www.activecareaetna.com.

TRS ActiveCare 1‐HD 2016‐2017 Rate Per Month

PISD Contribution per Month

Employee Total Cost Per

Month

Employee Total Cost

Per Pay Period

Per pay period rate change from 15/16

Deductibles Deductible change from 15/16 plan year

Employee $ 341.00 $ (300.00) $ 41.00 $ 20.50 no change $2,500 employee no change

Employee + Spouse $ 914.00 $ (300.00) $ 614.00 $ 307.00 no change $5,000 family no change

Employee + Children $ 615.00 $ (300.00) $ 315.00 $ 157.50 no change 80/20 after deductible

Employee + Family $ 1,231.00 $ (300.00) $ 931.00 $ 465.50 no change OOPM: $6450 Indivivdual/ $12,900

Family OOPM: $6550 employee/ $13,100 Family

TRS ActiveCare Select 2016‐2017 Rate Per Month



Month

Employee Total Cost Per Pay Period


Deductibles

Employee $ 484.00 $ (300.00) $ 184.00 $ 92.00 $ (11.00) $1,200 employee no change

Employee + Spouse $ 1,147.00 $ (300.00) $ 847.00 $ 423.50 $ (4.00) $3,600 family no change

Employee + Children $ 779.00 $ (300.00) $ 479.00 $ 239.50 $ (8.00) 80/20 after deductible no change

Employee + Family $ 1,361.00 $ (300.00) $ 1,061.00 $ 530.50 $ (1.50) Family OOPM:$6,850 Individual/$13,700 Family

Rx $35/$60/ Copay

TRS ActiveCare 2 2016‐2017 Rate Per Month



Month

Employee Total Cost

Per Pay Period


Deductibles

Employee $ 645.00 $ (300.00) $ 345.00 $ 172.50 $ (1.00) $1,000 employee no change

Employee + Spouse $ 1,552.00 $ (300.00) $ 1,252.00 $ 626.00 $ 20.50 $3,000 family no change

Employee + Children $ 1,042.00 $ (300.00) $ 742.00 $ 371.00 $ 8.50 80/20 after deductible no change

Employee + Family $ 1,597.00 $ (300.00) $ 1,297.00 $ 648.50 $ 21.50 Family OOPM:$6,850 Individual/$13,700 Family

Rx $35/60/90Dr. Co‐pay $30/$50 RX $20/$50/$80

No Dr. Co‐pay No Short Term Rx

Dr. Co‐pay $30/$60 $25/$50/50% Rx

Dental Coverage

Dental coverage information is provided by the carrier for general purposes only. For more information on this coverage, call the Benefit Center at 844-217-8221.

Pearsall Independent School District Dental Highlight Sheet

Low Plan: Dental Plan Summary Policy # 39700 Effective Date: 9/1/2015

Coinsurance

Type 1 80% Type 2 50% Type 3 50%

Deductible $50/Calendar Year Type 2 & 3

Waived Type 1

3 Family Maximum

Maximum (per person) $750 per calendar year

Allowance Contracted Fee

Waiting Period None

Annual Open Enrollment Included

Sample Procedure Listing (Current Dental Terminology © American Dental Association.)

Type 1 Type 2 Type 3

� Routine Exam

(1 in 6 months)

� Bitewing X-rays

(1 in 12 months)

� Full Mouth/Panoramic X-rays

(1 in 5 years)

� Periapical X-rays

� Cleaning

(1 in 6 months)

� Fluoride for Children 13 and under

(1 per benefit period)

� Sealants (age 13 and under)

� Restorative Amalgams

� Restorative Composites

� Simple Extractions

� Space Maintainers

� Onlays

� Crowns

(1 in 10 years per tooth)

� Crown Repair

� Endodontics (nonsurgical)

� Endodontics (surgical)

� Periodontics (nonsurgical)

� Periodontics (surgical)

� Denture Repair

� Prosthodontics (fixed bridge; removable

complete/partial dentures)

(1 in 10 years)

� Complex Extractions

� Anesthesia

Monthly Rates

Employee Only (EE) $11.28

EE + Spouse $28.40

EE + Children $25.20

EE + Spouse & Children $42.32

Ameritas Information We're Here to Help This plan was designed specifically for the associates of PEARSALL INDEPENDENT SCHOOL DISTRICT. 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 a.m. to 6:30 p.m. on Friday. You can speak to them by calling toll-free: 800-487-5553. For plan information any time, access our automated voice response system or go online to ameritasgroup.com/member.

Rx Savings Our valued plan members and their covered dependents (even their pets) can save on prescription medications through any Walmart or Sam's Club pharmacy across the nation. This Rx discount is offered at no additional cost, and it is not insurance. To receive the Walmart Rx discount, Ameritas plan members just need to visit us at ameritasgroup.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 ameritasgroup.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.

Contracted Provider Information To find a provider, visit ameritasgroup.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 PPO Dental Network.

Dental Network In Texas, our network and plans are referred to as the Ameritas Dental Network.

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.

Open Enrollment If a member does not elect to participate when initially eligible, the member may elect to participate at the policyholder's next enrollment period. This enrollment period will be held each year and those who elect to participate in this policy at that time will have their insurance become effective on September 1.

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.

Section 125 This plan is provided as part of the Policyholder's Section 125 Plan. Each employee has the option under the Section 125 Plan of participating or not participating in this plan. If an employee does not elect to participate when initially eligible, he/she may elect to participate at the Policyholder's next Annual Election Period.

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.


High Plan: Dental Plan Summary Policy # 39700 Effective Date: 9/1/2015

Coinsurance

Type 1 100% Type 2 80% Type 3 50%

Deductible $50/Calendar Year Type 2 & 3

Waived Type 1

3 Family Maximum

Maximum (per person) $1,000 per calendar year

Allowance 80th U&C

Waiting Period None

Annual Open Enrollment Included

Orthodontia Summary - Child Only Coverage

Allowance U&C

Coinsurance 50%

Lifetime Maximum (per person) $1,000

Waiting Period None

Sample Procedure Listing (Current Dental Terminology © American Dental Association.)

Type 1 Type 2 Type 3

� Routine Exam

(1 in 6 months)

� Bitewing X-rays

(1 in 12 months)

� Full Mouth/Panoramic X-rays

(1 in 5 years)

� Periapical X-rays

� Cleaning

(1 in 6 months)

� Fluoride for Children 16 and under

(1 per benefit period)

� Sealants (age 16 and under)

� Space Maintainers

� Restorative Amalgams

� Restorative Composites

� Simple Extractions

� Complex Extractions

� Anesthesia

� Onlays

� Crowns

(1 in 10 years per tooth)

� Crown Repair

� Endodontics (nonsurgical)

� Endodontics (surgical)

� Periodontics (nonsurgical)

� Periodontics (surgical)

� Denture Repair

� Prosthodontics (fixed bridge; removable

complete/partial dentures)

(1 in 10 years)

Dental Rewards® 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. 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 $1,000 Maximum possible accumulation for Dental Rewards

Monthly Rates

Employee Only (EE) $21.32

EE + Spouse $53.44

EE + Children $58.72

EE + Spouse & Children $90.80


Ameritas Information We're Here to Help This plan was designed specifically for the associates of PEARSALL INDEPENDENT SCHOOL DISTRICT. 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 a.m. to 6:30 p.m. on Friday. You can speak to them by calling toll-free: 800-487-5553. For plan information any time, access our automated voice response system or go online to ameritasgroup.com/member.

Rx Savings Our valued plan members and their covered dependents (even their pets) can save on prescription medications through any Walmart or Sam's Club pharmacy across the nation. This Rx discount is offered at no additional cost, and it is not insurance. To receive the Walmart Rx discount, Ameritas plan members just need to visit us at ameritasgroup.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 ameritasgroup.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.

Contracted Provider Information To find a provider, visit ameritasgroup.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 PPO Dental Network.

Dental Network In Texas, our network and plans are referred to as the Ameritas Dental Network.

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.

Open Enrollment If a member does not elect to participate when initially eligible, the member may elect to participate at the policyholder's next enrollment period. This enrollment period will be held each year and those who elect to participate in this policy at that time will have their insurance become effective on September 1.

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.

Section 125 This plan is provided as part of the Policyholder's Section 125 Plan. Each employee has the option under the Section 125 Plan of participating or not participating in this plan. If an employee does not elect to participate when initially eligible, he/she may elect to participate at the Policyholder's next Annual Election Period.

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.

Vision Coverage

Vision coverage information is provided by the carrier for general purposes only. For more information on this coverage, call the Benefit Center at 844-217-8221.

TX51514HVC 1213 Page 1 of 3

Vision Care PlanHumanaVision Texas

See a participating provider See a nonparticipating providerExam1 with dilation as necessary 100% after $35 allowance

Lenses• Single 100% after $25 allowance• Bifocal 100% after $40 allowance• Trifocal 100% after $60 allowance

Frames $40 retail allowance

Contact lenses2

• Elective (conventional and disposable)3

• Medically necessary (limit one pair)4 100% $210 allowance

Frequency (based on date of service)• Examination Once every 12 months Once every 12 months• Lenses or contact lenses Once every 12 months Once every 12 months• Frame Once every Once every Additional plan discounts• Members may benefit with fixed pricing for most lens options including anti-reflective and scratch-resistant

coatings.• Members may also be eligible to receive up to a 20 percent retail discount on a second pair of eyeglasses, which is

available for 12 months after the covered eye exam through the participating provider who sold the initial pair ofeyeglasses.

• After copay, standard polycarbonate available at no charge for dependents less than 19 years old.1 Material copay is required for a complete pair of eyeglasses, lenses or frames.2 If a member prefers contact lenses, the plan provides an allowance for contacts in lieu of all other benefits

(including frames) (Vision Care Plan only).3 The contact lens allowance applies to professional services (evaluation and fitting fee) and materials. Members

may be eligible to receive up to a 15 percent discount on in-network professional services, which is available for 12 months after the covered eye exam.

4 Benefit provides coverage for professional services and one pair of medically necessary contact lenses with prior plan authorization.

Employee $7.40Employee & spouse $14.64Employee & child(ren) $13.92Family $21.78

Effective09/01/2015-08/31/2016


Use your HumanaVision benefitsHumanaVision options have you covered and make eye care affordable. You have access to one of the largest vision networks in the United States, with more than 35,000 participating optometrist, ophthalmologists, and national retail locations, including LensCrafters®, Pearle Vision®, Sears® Optical, Target® Optical, and JCPenney® Optical. In addition you’ll enjoy:• The same benefits at all participating providers, no

matter where they’re located• Wholesale pricing on frames, avoiding high retail markups• Simple access to plan information, provider search,

Customer Care and other automated services at HumanaVisionCare.com

How it Works 1. After signing up for your vision plan, you will receive an

ID card in the mail2. Prior to scheduling your appointment, select a network

provider through the Customer Care Center, automated information line, or HumanaVisionCare.com

3. Schedule an appointment, providing your name, the patient’s name and employer

4. Sign your provider’s form after your exam, you’ll pay any copayments and/or costs of any upgrades at this time

HumanaVision Lasik discount We have contracted with many well-known facilities and eye doctors to offer Lasik procedures at substantially reduced fees. You can take advantage of these low fees when procedures are done by network providers. The network locations listed below offer the following prices (per eye):

Conventional / Traditional** Custom**TLC888-358-3937 (designated locations only)

$895 $1,295 $1,895*

LasikPlus866-757-8082

$695* LasikPlus free

enhancements for 1 year

$1,395* LasikPlus free

enhancements for life

$1,895* LasikPlus free enhancements for

life

QualSight LASIK855-456-2020

$895 QualSight free enhancements

for 1 year

$1,295 with QualSight

Lifetime Assurance Plan

$1,320$1,995*

with QualSight Lifetime

Assurance Plan

*with IntraLaseTM

** Pricing varies by section procedure offered by the provider you choose and options in your area. Not all locations offer fixed pricing. Please call the provider for details

Vision Care Plan

How does the wholesale frame allowance work? Benefits include a wholesale frame allowance. If the wholesale cost exceeds the frame allowance, members pay twice the wholesale difference. They never pay full retail.

Retail price* Wholesale price Wholesale allowance Member pays Savings$125 $50 $50 $0 $125$187.50 $75 $50 $50 ($75-$50=$25x2=$50) $137.50

* Retail costs may differ and are based on 2½ times the wholesale cost. Actual savings may vary.

You may receive a 10% discount from retail prices at certain independent Lasik participating providers and pay no more than $1,800 per eye for Conventional Lasik and $2,300 per eye for Custom Lasik.

JCPenney® Optical


This is not a complete disclosure of plan qualifications and limitations.Check with your local Humana or HumanaDental sales office to verify product availability.Vision products insured by The Dental Concern Inc.

Humana.com

Vision health impacts overall healthRoutine eye exams can lead to early detection of vision problems and other diseases such as diabetes, hypertension, multiple sclerosis, high blood pressure, osteoporosis, and rheumatoid arthritis.1

Know what your plan covers Attached is a summary of HumanaVision benefits that are described in detail in your certificate. You can find your certificate on HumanaVisionCare.com or call 1-866-537-0229. Here’s what you can expect:• Quality routine eye health care from independent eye

care professionals and national retail locations.• Services and materials provided on a prepaid basis,

and the plan pays in-network providers directly, you also have the freedom to use out-of-network providers if you prefer

• Life without claim forms! With HumanaVision, you pay your eye care professional directly for copayments and any extra cosmetic options selected at the time of service

• Select a vision provider from our network simply by visiting HumanaVisionCare.com, if you prefer, call us at 1-866-537-0229

Know what your plan doesn’t coverSome items and services not included in HumanaVision are:• Orthoptics or vision training, subnormal vision aids or

Plano (non-prescription) lenses• Replacement of lost or broken lenses, except at the

regularly-scheduled plan intervals• Medical or surgical treatment of eyes• Care provided through or required by any government

agency or program, including Workers’ Compensation or a similar law

1 Thompson Media Inc.

Term Life Coverage

Term Life coverage information is provided by the carrier for general purposes only. For more information on this coverage, call the Benefit Center at 844-217-8221.

Group Term Life and AD&D Insurance

SUMMARY OF BENEFITS Sponsored by: Pearsall Independent School District All Full-Time Employees and all Bus Drivers

Coverage Benefit Amount Employee

Life $10,000

Guarantee Issue $10,000

AD&D Will Equal the Life Benefit

Benefit Reduction Employee

Benefits will reduce: 35% at age 65; An additional 15% of original amount at age 70; An additional 25% of original amount at age 75; Benefits terminate at retirement

Additional Benefits

See Understanding Your Benefits Page: Accelerated Death Benefit

Seatbelt Benefit – Air Bag Benefit - Common Carrier Benefit

Conversion

Enrolling for Coverage Employee

Eligibility: All employees in an eligible class.

(Please see other side)

Insurance products are issued by The Lincoln National Life Insurance Company (Fort Wayne, IN), which does not solicit business in New York, nor is it licensed to do so. Product availability and/or features may vary by state. Limitations and exclusions apply. Not for use in New York.

Understanding Your Benefits

Accelerated Death Benefit Accelerated Death Benefit provides an option to be paid a portion of your life insurance benefit when diagnosed as terminally ill (as defined in the policy). The death benefit will be reduced by the amount withdrawn. To qualify, you must be covered under this policy for the amount of time defined by the policy.

AD&D Accidental Death and Dismemberment (AD&D) insurance provides specified benefits for a covered accidental bodily injury that directly causes death or dismemberment (e.g., the loss of a hand, foot, or eye), subject to policy limitations.

Conversion If you terminate your employment or become ineligible for this coverage, you have the option to convert all or part of the amount of coverage in force to an individual life policy on the date of termination without Evidence of Insurability. Conversion election normally must be made within 31 days of your date of termination.

Guarantee Issue For timely entrants enrolled within 31 days of becoming eligible, the Guarantee Issue amount is available without providing Evidence of Insurability. Evidence of Insurability will be required for any amounts above this, for late enrollees or increases in insurance, and it will be provided at your own expense.

Seatbelt Benefit – Air Bag Benefit - Common Carrier Benefit

If you die as a result of a covered auto accident while wearing a seat belt or in a vehicle equipped with an airbag, additional benefits are payable up to $10,000 or 10% of the principal sum, whichever is less. If loss occurs due to an accident while riding as a passenger in a common carrier, benefits will be double the amount that would otherwise apply as outlined in the certificate.

Term Life A death benefit is paid to the designated beneficiary upon the death of the insured. Coverage is provided for the time period that you are eligible and premium is paid. There is no cash value associated with this product.

Additional Benefits LifeKeysSM Online will & testament preparation service, identity theft resources and beneficiary

assistance support for all employees and eligible dependents covered under the Group Term Life and/or AD&D policy.

TravelConnectSM Travel assistance services for employees and eligible dependents traveling more than 100 miles from home.

For assistance or additional information Contact Lincoln Financial Group at

(800) 423-2765; reference ID: TASBPEARS www.LincolnFinancial.com If there is any discrepancy between this benefit summary and the policy, the policy shall control. This summary is not

intended to contain a complete description of the coverage offered. This summary does not modify the policy. This is not a binding contract

©2015 Lincoln National Corporation - TASBPEARS - 8/15-Employee Choice - Increments- Gen -4/25/2017

Voluntary Life Insurance

with Accidental Death and Dismemberment (AD&D)

SUMMARY OF BENEFITS

Sponsored by: Pearsall Independent School District All Full-Time Employees and all Bus Drivers Life Benefit Employee Spouse Dependent

Employee must elect coverage for Spouse or dependents to be eligible.

Amount Choice of $10,000 increments

Choice of $5,000 increments

Age 14 Days to 6 months: $250

6 months to age 25: $5,000 - $10,000

Newborn children to age 14 days are not eligible for a benefit

Minimum Amount

$10,000 $5,000 $5,000

Maximum Amount

$500,000, limited to 5 times your annual salary Employees age 70 and older, maximum benefit is $50,000

$250,000, limited to 50% of employee amount

$10,000

Guarantee Issue for Newly Eligible Employee

$150,000

$30,000

Current Eligible Employees

You or your Spouse may elect or increase insurance coverage equal to 2 benefit levels on a guaranteed acceptance basis during your company's defined annual open enrollment period, provided that you or your Spouse have not been previously declined, withdrawn, or pending for coverage.

AD&D Benefit Employee Spouse

Amount Optional coverage can be purchased by you for additional premium. Benefit amount equal to the life amount elected by you.

Same as employee

Benefit Reduction

Employee Spouse

Benefits will reduce:

35% at age 65; Additional 15% of original amount at age 70; Benefits terminate at retirement

35% at Employee Age 65;

Additional 15% of original amount at Employee Age 70

Benefits terminate at Employee Retirement

Eligibility Employee Spouse and Dependents

All employees in an eligible class.

Cannot be in a period of limited activity on the day coverage takes effect.

Additional Benefits

See Definition: Accelerated Death Benefit

See Definition: Portability

See Definition: Conversion

See Definition: Seat Belt, Airbag, and Common Carrier

NOTE: This is not intended as a complete description of the insurance coverage offered. Controlling provisions are provided in the policy, and this summary does not modify those provisions or the insurance in any way. This is not a binding contract. A certificate of coverage will be made available to you that describes the benefits in greater details. Should there be a difference between this summary and the contract, the contract will govern.

Insurance products are issued by The Lincoln National Life Insurance Company (Fort Wayne, IN), which does not solicit business in New York, nor is it licensed to do so. Product availability and/or features may vary by state. Limitations and exclusions apply. Not for use in New York.

Definitions

Accelerated Death Benefit

Accelerated Death Benefit provides an option to withdraw a percentage of your life insurance coverage when diagnosed as terminally ill (as defined in the policy). The death benefit will be reduced by the amount withdrawn. To qualify, you have satisfied the Active Work rule and have been covered under this policy for the required amount of time as defined by the policy. Check with your tax advisor or attorney before exercising this option.

AD&D Accidental Death and Dismemberment (AD&D) insurance provides specified benefits for a covered accidental bodily injury that directly causes dismemberment (e.g., the loss of a hand, foot, or eye). In the event that death occurs from a covered accident, both the life and the AD&D benefit would be payable. This insurance is optional and can be purchased by you and your Spouse .

Conversion If you terminate your employment or become ineligible for this coverage, you have the option to convert all or part of the amount of coverage in force to an individual life policy on the date of termination without Evidence of Insurability. Conversion election must be made within 31 days of your date of termination.

Guarantee Issue For timely entrants enrolled within 31 days of becoming eligible, the Guarantee Issue amount is available without any Evidence of Insurability requirement. Evidence of Insurability will be required for any amounts above this, for late enrollees or increase in insurance, and it will be provided at your own expense.

Limited Activity A period when a Spouse or dependent is confined in a health care facility; or, whether confined or not, is unable to perform the regular and usual activities of a healthy person of the same age and sex.

Portability If coverage has been in force for at least 12 months, you may continue coverage for a specified period of time after your employment by paying the required premium. Portability is available if you cease employment for a reason other than total disability or retirement at Social Security Normal Retirement Age. A written application must be made within 31 days of your termination.

Seat Belt, Airbag, and Common Carrier

If you die as a result of a covered auto accident while wearing a seat belt or in a vehicle equipped with an airbag, additional benefits are payable up to $10,000 or 10% of the principal sum, whichever is less. If loss occurs for you due to an accident while riding as a passenger in a common carrier, benefits will be double the amount that would otherwise apply as outlined in the certificate.

Term Life Benefit provided to the designated beneficiary upon the death of the insured. The benefit is provided for the time period that you are eligible and premium is paid. There is no cash value associated with this product.

Exclusion: Suicide Benefits will not be paid if the death results from suicide within 2 years after coverage is effective. May apply if employee contributes toward the premium.

Additional Benefits LifeKeysSM

Online will & testament preparation service, identity theft resources and beneficiary assistance support for all employees and eligible dependents covered under the Group Term Life and/or AD&D policy.

TravelConnectSM Travel assistance services for employees and eligible dependents traveling more than 100 miles from home.

For assistance or additional information Contact Lincoln Financial Group at

(800) 423-2765; reference ID: TASBPEARS www.LincolnFinancial.com

Whole Life Coverage

Whole Life coverage information is provided by the carrier for general purposes only. For more information on this coverage, call the Benefit Center at 844-217-8221.

Whole Life Insurance

UNUM’s Whole Life Insurance is designed to pay a death benefit to your beneficiaries, but can also build cash value you can use during your working years. This benefit offers an affordable, guaranteed level of premium that won’t increase with age. Coverage is available for you, your spouse (ages 15-80) and dependent children (up to age 26). Employees can elect life amounts between $3/week and $12/week without having to answer any medical questions. You do not have to apply for coverage for yourself in order to purchase spouse or child coverage and coverage is portable so you can take it with you even if you leave the company or retire. Employees between ages 15-50 may purchase a Paid Up Age 70 policy, so that premiums are no longer due when you turn 70.

Whole Life Insurance Benefit

Election Amount (min—max)

Employee: $3 - $12 per week

Spouse: $3 per week

Child(ren): $3 per week

Benefit Amount ranges from

$2,000—$300,000 for employees

$2,000—$75, 000 for spouses depending on age and premium election

$5,000—$50,000 for child(ren)

Issue Ages

Employee & Spouse

Child(ren)

15—80 (Paid Up at Age 70: 15—50)

14 days—26 years (14 years in NY)

Evidence of Insurability (Health Questions)

Employee

Spouse

Child(ren)

Not required for amounts between $3 and $12 weekly premium. Required for amounts between $13 and $20.

One qualifying question required for $3 weekly premium. Additional health questions required for amounts between $4 and $10.

Not required for amounts up to $3 weekly premium.

Additional Benefits: Accidental Death Benefit (ADB); Waiver of Premium

Please refer to your Certificate of Coverage and Summary of Benefits for a complete listing of available services, service limitations and exclusions.

Whole Life Insurance Weekly Rate & Cost Projections

Face amounts based on money purchase of $5 per week

Employee & Spouse Money Purchase; Paid Up Age 120

Non-Tobacco Tobacco

Issue Age Face Amount Guaranteed CV at age 65

ADB Rider Additional Cost

Face Amount Guaranteed CV at age 65


25 $29,851 $11,749 $0.55 $17,128 $7,664 $0.32

35 $19,417 $6,874 $0.36 $11,786 $4,725 $0.22

45 $11,581 $3,308 $0.21 $6,835 $2,185 $0.13

55 $6,066 $998 $0.11 $3,636 $646 $0.07

Employee & Spouse Money Purchase; Paid Up Age 70

Non-Tobacco Tobacco

Issue Age Face Amount Guaranteed CV at age 65


Face Amount Guaranteed CV at age 65


25 $25,440 $11,190 $0.47 $15,178 $7,547 $0.28

35 $16,109 $6,809 $0.30 $10,224 $4,863 $0.19

45 $8,978 $3,489 $0.17 $5,630 $2,440 $0.10

55 N/A N/A N/A N/A N/A N/A

The guaranteed interest rate is 4.5%. Surrender value will be reduced by any outstanding loans.

Disability Coverage

Disability coverage information is provided by the carrier for general purposes only. For more information on this coverage, call the Benefit Center at 844-217-8221.

This Summary of Benefits and the accompanying Brochure and Enrollment Form explain/explains the general purpose of the insurance described, but in no way changes or affects the policy as it is actually issued. In the event of any discrepancy between any of these documents and the policy, the terms of the policy apply. Life, AD&D Ultra, STD, and LTD products contain limitations and exclusions, complete coverage information can be found in your Booklet-Certificate if you become insured. Please read it carefully and keep it in a safe place with your other important papers.

Benefit Summary Highlights for Pearsall Independent School District

Underwritten by Aetna Life Insurance Company Long Term Disability Insurance

Eligibility: All active full time employees working 20 hours per week or more.

Purpose: Long Term Disability insurance provides income replacement benefits for you and your family in the event you are unable to work due to an accident or sickness.

Maximizing Income Protection

Long Term Disability (LTD) Insurance can offer an affordable way for educators and administrators to protect their lifestyles—and the people who depend upon them.

Employees can choose from a selection of LTD features they feel best match their financial needs.

Employees can choose their Monthly Benefit Amount in $100 increments, from $200 to $7,500 (not to exceed 66 2/3% of monthly earnings).

Employees can choose from among six accident/sickness Benefit Waiting Periods. A benefit waiting

period is the period of time in which an employee must be continuously disabled before you are eligible

for benefits.

Accident Sickness

14 Days 30 Days

14 Days 30 Days

60 Days 90 Days

180 Days

60Days 90 Days 180 Days

Maximum Benefit Period: SSNRA – Social Security Normal Retirement Age Your period of disability will end when the later of the following events occur:

The calendar month when you reach normal

retirement age, as determined by the 1983 Amended Social Security Normal Retirement Age; or


The expiration of the number of months of disability, after the elimination period is met as figured from the following Schedule, if your disability starts on or after the date you reach age 62.

Maximum Benefit Duration Schedule Age When Period of Disability Starts Months of Disability 62 but less than 63 42 months 63 but less than 64 36 months 64 but less than 65 30 months 65 but less than 66 24 months 66 but less than 67 21 months 67 but less than 68 18 months 68 but less than 69 15 months 69 and over 12 months

1983 Amended Social Security Normal Retirement Age Year of Birth Normal Retirement Age Before 1938 65 1938 65 and 2 months 1939 65 and 4 months 1940 65 and 6 months 1941 65 and 8 months 1942 65 and 10 months 1943 to 1954 66 1955 66 and 2 months 1956 66 and 4 months 1957 66 and 6 months 1958 66 and 8 months 1959 66 and 10 months After 1959 67

Limitations & Exclusions: Benefits for Mental/Nervous/Substance Abuse/Self-Reported Illnesses are limited to 24 months lifetime combined

Pre-Existing Exclusion: There is a 12/12 pre-existing conditions clause. This is a look back period to

see if you were treatment-free for a 12-month period prior to the effective date of your coverage. If you weren’t treatment-free, the pre-existing condition is excluded from coverage if you’re disabled within 12-months of first becoming insured. In addition, if during an annual enrollment period you apply for additional benefits or select a shorter elimination period, this plan will not cover the increase in your coverage if you have a pre-existing condition.


Plan Features Maximum Benefit— Employees can protect as much as $7,500 of their income as long as the benefit is not greater than 66 2/3% of their salary. Definition of Disability—2 Year Own Occ with Residual. Covers Non-Occupational disabilities – not in lieu of Workers Compensation. During the Elimination Period and the Own Occupation Period – any day that an individual is unable to perform the material duties of his/her own occupation; or while unable to perform the material duties of his/her own occupation, is performing at least one of the material duties of any occupation on a part-time or full-time basis and has lost at least 20% of their indexed pre-disability earnings due to a disable condition. During the any reasonable Occupation Period – any day that an individual is unable to perform the material duties of any occupation for which he/she is or may become fitted, based on training, education or experience; or while unable to perform the material duties of any reasonable occupation, is performing at least one of the material duties of any occupation on a part-time or full-time basis and has lost at least 40% of his/her pre-indexed earnings due to a disabling condition. 1st Day Hospital Benefit—This feature waives the waiting period if an insured is hospitalized. Hospitalized means that, if because of your disability, you are hospital confined as an inpatient, benefits begin the first day of inpatient confinement. Inpatient means you are confined to a hospital room due to your sickness or injury, for 24 or more consecutive hours. This benefit is included in the 14/14 waiting periods. 12 Month Return-to-Work Incentive—This benefit gives an employee the opportunity to return to work part time earning some income plus receive LTD benefits allowing them to receive up to 100% income replacement during the first 12 months. Deductible Income— Income benefit sources payable to the employee, employee’s spouse, children and/or dependents due to the employee’s disability or retirement. Sources include, but are not limited to, benefits payable from: unemployment compensation, Workers’ Comp, statutory disability plans, veteran’s benefits, Assault Leave Benefits, and any other group or association disability or retirement plans. The following Income benefit sources have a 3 month deferral in which no offset will be applied. Employer provided sick leave or salary continuation, Auto Liability Insurance, Social Security, 3rd party liability, statutory disability plans or any other group or association disability. All other offsets are immediate. Survivor Benefit—Pays a lump sum equal to 3 times the non-integrated LTD benefit after 180 days of disability. Waiver of Premium—If you become disabled, your premium payment for your insurance will be waived on any premium due date on which: (1) You remain Disabled for 90 consecutive days; and (2) Disability Benefits are being paid or are payable for the Disability.


Rehabilitation Plan Benefit—During the employee’s active participation in an Aetna Approved Rehab Program, Aetna will pay an additional 10% of the monthly benefit, after all applicable reductions for other income benefits, but not more than $500 per month. This incentive will be paid up to 6 consecutive months for each period of disability Continuity of Coverage — Insured individuals do not lose coverage due to an employer’s change in group insurance carriers. Minimum Benefit—The greater of 10% of the gross maximum Monthly Benefit, or $100. Child/Dependent Care —After 6 months of benefit are paid, a benefit is available to reimburse an employee for dependent care expenses while participating in an approved rehabilitation program. An amount of $350 per month per dependent to a maximum of $1,000 is payable for up to 24 months. Worksite Modification Benefit—This benefit allows Aetna to pay for expenses of worksite modifications that result in a disabled employee’s return to work. Social Security Assistance – Assistance for eligible employees with the application process for Social Security disability benefits. EAP – Enhanced EAP includes 3 face to face counseling sessions for covered members and their immediate household members per year and unlimited telephonic EAP consultations. Recurrent Periods of Disability – If 2 or more separate periods of disability are due to the same or related causes they will be deemed to be one period of disability and only one elimination period will apply if the separation occurs during the elimination period and the periods are separated by less than 30 days of work or the separation occurs after the elimination period and the periods are separated by less than 6 months of work. Cost- The cost of this benefit is paid by the employee.


Pearsall Independent School District Accident/Sickness Benefit Waiting Period

Monthly Cost

Annual Earnings Monthly Earnings Maximum Monthly Benefit 14 /14 30/30 60/60 90/90 180/180

$3,600 $300 $200.00 $7.20 $5.70 $4.60 $3.80 $2.50

$5,400 $450 $300.00 $10.80 $8.55 $6.90 $5.70 $3.75

$7,200 $600 $400.00 $14.40 $11.40 $9.20 $7.60 $5.00

$9,000 $750 $500.00 $18.00 $14.25 $11.50 $9.50 $6.25

$10,800 $900 $600.00 $21.60 $17.10 $13.80 $11.40 $7.50

$12,600 $1,050 $700.00 $25.20 $19.95 $16.10 $13.30 $8.75

$14,400 $1,200 $800.00 $28.80 $22.80 $18.40 $15.20 $10.00

$16,200 $1,350 $900.00 $32.40 $25.65 $20.70 $17.10 $11.25

$18,000 $1,500 $1,000.00 $36.00 $28.50 $23.00 $19.00 $12.50

$19,800 $1,650 $1,100.00 $39.60 $31.35 $25.30 $20.90 $13.75

$21,600 $1,800 $1,200.00 $43.20 $34.20 $27.60 $22.80 $15.00

$23,400 $1,950 $1,300.00 $46.80 $37.05 $29.90 $24.70 $16.25

$25,200 $2,100 $1,400.00 $50.40 $39.90 $32.20 $26.60 $17.50

$27,000 $2,250 $1,500.00 $54.00 $42.75 $34.50 $28.50 $18.75

$28,800 $2,400 $1,600.00 $57.60 $45.60 $36.80 $30.40 $20.00

$30,600 $2,550 $1,700.00 $61.20 $48.45 $39.10 $32.30 $21.25

$32,400 $2,700 $1,800.00 $64.80 $51.30 $41.40 $34.20 $22.50

$34,200 $2,850 $1,900.00 $68.40 $54.15 $43.70 $36.10 $23.75

$36,000 $3,000 $2,000.00 $72.00 $57.00 $46.00 $38.00 $25.00

$37,800 $3,150 $2,100.00 $75.60 $59.85 $48.30 $39.90 $26.25

$39,600 $3,300 $2,200.00 $79.20 $62.70 $50.60 $41.80 $27.50

$41,400 $3,450 $2,300.00 $82.80 $65.55 $52.90 $43.70 $28.75

$43,200 $3,600 $2,400.00 $86.40 $68.40 $55.20 $45.60 $30.00

$45,000 $3,750 $2,500.00 $90.00 $71.25 $57.50 $47.50 $31.25

$46,800 $3,900 $2,600.00 $93.60 $74.10 $59.80 $49.40 $32.50

$48,600 $4,050 $2,700.00 $97.20 $76.95 $62.10 $51.30 $33.75

$50,400 $4,200 $2,800.00 $100.80 $79.80 $64.40 $53.20 $35.00

$52,200 $4,350 $2,900.00 $104.40 $82.65 $66.70 $55.10 $36.25

$54,000 $4,500 $3,000.00 $108.00 $85.50 $69.00 $57.00 $37.50

$55,800 $4,650 $3,100.00 $111.60 $88.35 $71.30 $58.90 $38.75

$57,600 $4,800 $3,200.00 $115.20 $91.20 $73.60 $60.80 $40.00

$59,400 $4,950 $3,300.00 $118.80 $94.05 $75.90 $62.70 $41.25

$61,200 $5,100 $3,400.00 $122.40 $96.90 $78.20 $64.60 $42.50

$63,000 $5,250 $3,500.00 $126.00 $99.75 $80.50 $66.50 $43.75

$64,800 $5,400 $3,600.00 $129.60 $102.60 $82.80 $68.40 $45.00

$66,600 $5,550 $3,700.00 $133.20 $105.45 $85.10 $70.30 $46.25



Monthly Cost


$68,400 $5,700 $3,800.00 $136.80 $108.30 $87.40 $72.20 $47.50

$70,200 $5,850 $3,900.00 $140.40 $111.15 $89.70 $74.10 $48.75

$72,000 $6,000 $4,000.00 $144.00 $114.00 $92.00 $76.00 $50.00

$73,800 $6,150 $4,100.00 $147.60 $116.85 $94.30 $77.90 $51.25

$75,600 $6,300 $4,200.00 $151.20 $119.70 $96.60 $79.80 $52.50

$77,400 $6,450 $4,300.00 $154.80 $122.55 $98.90 $81.70 $53.75

$79,200 $6,600 $4,400.00 $158.40 $125.40 $101.20 $83.60 $55.00

$81,000 $6,750 $4,500.00 $162.00 $128.25 $103.50 $85.50 $56.25

$82,800 $6,900 $4,600.00 $165.60 $131.10 $105.80 $87.40 $57.50

$84,600 $7,050 $4,700.00 $169.20 $133.95 $108.10 $89.30 $58.75

$86,400 $7,200 $4,800.00 $172.80 $136.80 $110.40 $91.20 $60.00

$88,200 $7,350 $4,900.00 $176.40 $139.65 $112.70 $93.10 $61.25

$90,000 $7,500 $5,000.00 $180.00 $142.50 $115.00 $95.00 $62.50

$91,800 $7,650 $5,100.00 $183.60 $145.35 $117.30 $96.90 $63.75

$93,600 $7,800 $5,200.00 $187.20 $148.20 $119.60 $98.80 $65.00

$95,400 $7,950 $5,300.00 $190.80 $151.05 $121.90 $100.70 $66.25

$97,200 $8,100 $5,400.00 $194.40 $153.90 $124.20 $102.60 $67.50

$99,000 $8,250 $5,500.00 $198.00 $156.75 $126.50 $104.50 $68.75

$100,800 $8,400 $5,600.00 $201.60 $159.60 $128.80 $106.40 $70.00

$102,600 $8,550 $5,700.00 $205.20 $162.45 $131.10 $108.30 $71.25

$104,400 $8,700 $5,800.00 $208.80 $165.30 $133.40 $110.20 $72.50

$106,200 $8,850 $5,900.00 $212.40 $168.15 $135.70 $112.10 $73.75

$108,000 $9,000 $6,000.00 $216.00 $171.00 $138.00 $114.00 $75.00

$109,800 $9,150 $6,100.00 $219.60 $173.85 $140.30 $115.90 $76.25

$111,600 $9,300 $6,200.00 $223.20 $176.70 $142.60 $117.80 $77.50

$113,400 $9,450 $6,300.00 $226.80 $179.55 $144.90 $119.70 $78.75

$115,200 $9,600 $6,400.00 $230.40 $182.40 $147.20 $121.60 $80.00

$117,000 $9,750 $6,500.00 $234.00 $185.25 $149.50 $123.50 $81.25

$118,800 $9,900 $6,600.00 $237.60 $188.10 $151.80 $125.40 $82.50

$120,600 $1,050 $6,700.00 $241.20 $190.95 $154.10 $127.30 $83.75

$122,400 $10,200 $6,800.00 $244.80 $193.80 $156.40 $129.20 $85.00

$124,200 $10,350 $6,900.00 $248.40 $196.65 $158.70 $131.10 $86.25

$126,000 $10,500 $7,000.00 $252.00 $199.50 $161.00 $133.00 $87.50

$127,800 $10,650 $7,100.00 $255.60 $202.35 $163.30 $134.90 $88.75

$129,600 $10,800 $7,200.00 $259.20 $205.20 $165.60 $136.80 $90.00

$131,400 $10,950 $7,300.00 $262.80 $208.05 $167.90 $138.70 $91.25



Monthly Cost


$133,200 $11,100 $7,400.00 $266.40 $210.90 $170.20 $140.60 $92.50

$135,000 $11,250 $7,500.00 $270.00 $213.75 $172.50 $142.50 $93.75

Find your annual/monthly earnings above to determine your Maximum Monthly Benefit. If your annual/monthly earnings are not

shown, use the next lower annual/monthly earnings and corresponding Maximum Benefit.

Critical Illness Coverage

Critical Illness coverage information is provided by the carrier for general purposes only. For more information on this coverage, call the Benefit Center at 844-217-8221.

Cancer Coverage

Cancer coverage information is provided by the carrier for general purposes only. For more information on this coverage, call the Benefit Center at 844-217-8221.

Pearsall ISD is pleased to partner with Colonial Life & Accident Insurance company to offer you Group Cancer Insurance. Take advantage of this opportunity to protect you and your family.

Open enrollment is coming soonMay 23–27, 2016

The following voluntary benefit will be offered during the enrollment:Group Cancer Insurance

How will you pay for what your health insurance won’t?

If diagnosed with cancer, would you have the money to cover:

� Out-of-network treatments

� Experimental treatments

� Rehabilitation

Features of Colonial Life’s Group Cancer Insurance: � Helps pay some of the direct and indirect costs related

to cancer diagnosis and treatment.

� Helps pay for expenses health insurance may not cover, such as deductibles and coinsurance.

� Pays an annual benefit for specified cancer screening tests.

Talk with your Colonial Life benefits counselor to learn more about group cancer insurance and how it can help provide financial security for you and your family.

ColonialLife.com

Coverage is subject to policy exclusions and limitations that may affect benefits payable. See your Colonial Life benefits counselor for complete details. ©2016 Colonial Life & Accident Insurance Company, Columbia, SC | Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

5-16 | NS-15174

Group Cancer 1000 Base Plus Additional Benefits

Monthly Premium

Levels Level 2 Level 3

Employee $16.65 $23.25

Family $27.70 $38.60

� Travel and lodging

� Child care expenses

Accident Coverage

Accident coverage information is provided by the carrier for general purposes only. For more information on this coverage, call the Benefit Center at 844-217-8221.

Coverage TierBronze Level+ 1 Unit ABR

Silver Level+ 1 Unit ABR

Individual $8.01 $13.92Ind + Spouse $14.94 $25.69

Ind + Child(ren) $24.64 $42.92Family $31.57 $54.69

P.O. Box 16190 - Austin, Texas 78716 - (800) 845-7519

Pearsall ISDGroup Accident Rate Quote

Effective 9/1/2016

Monthly RatesBase Plus 1 Unit Additional Benefit Rider

Underwritten by:Humana Insurance Company

Administered by:

Form Number: HIC-GP-ACC-SB-TX

Group Accident InsurancePOLICY FORM HIC-GP-ACC-POL 0812Underwritten by Humana Insurance Company

► Plan Features• Onandoffthejobbenefits• Paysregardlessofothercoverage• Portable(takeitwithYou)

BenefitsFor:• AccidentMedicalExpenseBenefit• AccidentHospitalIndemnity• DislocationsandFractures• AccidentalDeathandDismemberment

Bronze1Unit

Silver2Units

AccidentMedicalExpenseBenefitWe will pay the Actual Charges incurred up to $250 per unit if, as a result of Injury, a Covered Person requires medical or surgical treatment.

$250 $500

AccidentHospitalIndemnityBenefitWe will pay for each day a Covered Person is Confined during one or more periods of Hospital Confinement if: a) the Confinement is due to Injury; or b) the first day of Confinement occurs within 90 days after the accident.

$100 $200

AmbulanceServiceBenefitWe will pay for regular ambulance service and for air Ambulance if as a result of an injury,a Covered Person requires ambulance service for transfer; a) to a Hospital; or b) from a Hospital.

Regular Ambulance / Air Ambulance

$100 / $200 $200/$400

DislocationandFractureBenefit

We will pay the following amount shown based on Your selection of coverage:

For Fracture of Bone or Bones of: Bronze1Unit

Silver2Units For Complete Dislocation of: Bronze

1UnitSilver2Units

Skull (except Bones of Face or Nose) $1,900 $3,800 Hip Joint $2,000 $4,000Hip, Thigh (Femur) $2,000 $4,000 Knee Joint (Except Patella) $ 800 $1,600Pelvis (Except Coccyx) $2,000 $4,000 Bone or Bones of the Foot, Other than Toes $ 800 $1,600Arm, Between Shoulder and Elbow (Shaft) $1,100 $2,200 Ankle Joint $ 800 $1,600Shoulder Blade (Scapula) $1,100 $2,200 Wrist Joint $ 700 $1,400Leg (Tibia or Fibula) $1,100 $2,200 Elbow Joint $ 600 $1,200Ankle $ 800 $1,600 Shoulder Joint $ 400 $ 800Knee Cap (Patella) $ 800 $1,600 Bone or Bones of the Hand, Other than Fingers $ 300 $ 600Collar Bone (Clavicle) $ 800 $1,600 Collar Bone $ 300 $ 600Forearm (Radius or Ulna) $ 800 $1,600 Two or More Fingers $ 140 $ 280Foot (Except Toes) $ 700 $1,400 Two or More Toes $ 140 $ 280Hand or Wrist (Except Fingers) $ 700 $1,400 One Finger or One Toe $ 60 $ 120Lower Jaw (Except Alveolar Process) $ 400 $ 800Two or More Ribs, Fingers or Toes $ 300 $ 600Bones of Face or Nose $ 300 $ 600 Primary Insured Coverage 100%/Spouse Coverage 50%/ Child Coverage 25%One Rib, Finger or Toe $ 140 $ 280Coccyx $ 140 $ 280


AccidentalDeathandDismembermentBenefit

We will pay the following amount shown based on Your selection of coverage:

For Loss of: Bronze1Unit

Silver2Units

Bronze1Unit

Silver2Units

Life $20,000 $40,000 One Hand or One Arm $10,000 $20,000Both Hands or Both Feet or Sight of Both Eyes $20,000 $40,000 One Foot or One Leg $10,000 $20,000Both Arms or Both Legs $20,000 $40,000 One or More Entire Toes $ 1,000 $ 2,000One Hand or Arm and One Foot or Leg $20,000 $40,000 One or More Entire Fingers $ 800 $ 1,600Sight of One Eye $10,000 $20,000

Primary Insured Coverage 100%/Spouse Coverage 50%/ Child Coverage 25%

Lossmeans with regard to: a) hands and feet--actual severance through or above wrist or ankle joints; b) sight, entire and irrecoverable loss thereof; c) toes and fingers--actual severance through or above the metacarpophalangeal joints. If loss is sustained by a Covered Person while riding as a fare-paying passenger on a scheduled Common Carrier, We will pay three times the amount payable under the Accidental Death and Dismemberment Benefit.

Exclusions and LimitationsNo Benefits are payable when a Covered Person’s loss is caused or contributed to by:• suicide, while sane or insane, or attempted suicide;• intentionally self-inflicted Injury;• any act of war whether or not declared;• participation in a riot, or insurrection;• Injury sustained while on full-time active duty (other than for two (2)

months or less training) in any military, naval or air force. When the Employee gives Us written notice, any unearned Premium will be refunded pro-rata for any period not covered by the Policy due to this exclusion;

• Injury occurring prior to the Employee’s start date of insurance;• Injury while engaged in an illegal activity;• aviation, except flight in a regularly scheduled passenger aircraft;• being intoxicated as established by the laws of his or her state of residence;• the voluntary taking of any sedative, drug, alcohol, poison or inhalation of

any gas unless taken as prescribed or administered by a physician;• participation in a felony;• dental care or treatment unless caused by Injury to natural teeth;• all Sicknesses including pregnancy, illness, mental illness or emotional

disorders, bodily infirmity, rest cure, convalescent care or rehabilitation. Complications of Pregnancy that are the result of accidental Injury are covered;

• Injury while sky diving, hang gliding, parachuting, bungee jumping, rock climbing, ballooning or scuba diving;

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

• services received in an emergency room, unless required because of emergency treatment;

• participating in or practicing for any semi-professional or professional competitive athletic contest in which any compensation is received;

• hernia, carpal tunnel syndrome or any complication therefrom;• any bacterial infection (except pyogenic infections which shall occur with

and through an accidental cut or wound).

No Benefits of the Policy will be paid for loss that takes place outside of the United States.

Pre-existing Condition LimitationPre-existingCondition means a condition which a Physician has treated or for which a Physician has advised treatment of the Covered Person within 12 months before the Covered Person’s Effective Date. It is also one which would cause a person to seek diagnosis or care within the same 12-month period.

Losses that occur after the Pre-existing Condition provision has been satisfied will be covered for an Injury that occurred before the date the person becomes a Covered Person under the Policy unless the Injury has been specifically excluded by name or description within the Policy or Rider.

Covered PersonsCoveredPerson means: a) You; and b) each person named as Your Dependent in the Enrollment Form

Child(Children) means a person who is primarily dependent upon and living with the Insured in a permanent parent-child relationship and a:• natural or adopted child of the Insured or Spouse;• Child placed with the Insured or Spouse for adoption;• Child legally placed with the Insured or Spouse as a foster Child; or• stepchild of the Insured.

Child does not include a:• person not meeting the above Child definition;• Child living outside of the United States (unless living with an Insured); or• Child on active military duty for a period in excess of 30 days.

Termination of CoverageACoveredPerson’sinsuranceunder the Group Policy will automatically terminate on the earliest of the following dates:(a) the date that the Group Policy terminates.(b) the date the Group Policy is amended to terminate the eligibility of the Employee class.(c) the last day of the grace period, if premium remains unpaid by the end of the grace period.(d) the premium due date coinciding with or next following the date the Employee ceases to be a member of an eligible class;(e) the date of death of the Employee(f) the date of attainment of the Group Policy Age Limit as shown in the Schedule of Benefits


DependentTermination:A Dependent’s coverage will end:(a) with respect to a covered Spouse, on the date he or she is divorced from the Primary Covered Person;(b) on the date the primary Covered Person dies;(c) on the date the required premium for the Dependent’s coverage is not paid;(d) with respect to a covered Dependent, first of the month following the date the Dependent is a member of an eligible Class; or(e) on the date the Primary Covered Person reaches the Policy Age Limit noted on the Insuring Information page. 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.

Additional Benefits Rider HIC-GP-ACC-ABR-0812

In consideration of an additional premium, We will pay the benefits listed below. Coverage for Primary Insured, Spouse and Child/Children based on

Your selection of coverage.

BenefitSchedule(1 Unit of Coverage)

AbdominalorThoracicSurgeryBenefitWe will pay $1,000 if a Covered Person undergoes abdominal or thoracic surgery to repair internal injuries as a result of a covered Accident. The surgery must be performed within 3 days of the covered Accident. We will pay $100 for exploratory surgery with no surgical repair done as a result of a covered Accident. Benefit is payable once per Covered Person per Covered Accident.

AccidentFollowUpTreatmentBenefitWe will pay $50 per visit when a Covered Person receives a follow up treatment provided that a benefit has been paid under the Medical Expense Benefit and such benefit has been exhausted. Treatments must be administered by a Physician in the Physician’s office or in a Hospital on an outpatient basis. Follow up treatments must begin within 90 days of the covered Accident and take place no longer than 6 months after the covered Accident. This Benefit is not payable at the same time a benefit is payable under the Physical Therapy Benefit. This benefit is limited to 2 treatments per covered Accident per Covered Person.

ApplianceBenefit We will pay $125 for medical appliances prescribed by a Physician that aid in personal mobility including a wheelchair, crutches or a walker. Use of these devices must begin within 90 days of a covered Accident. Benefit is payable only once per Covered Person per covered Accident.

BloodandPlasmaBenefitWe will pay $300 for blood or plasma for a required transfusion due to or resulting from a covered Accident. The transfusion must be within 3 days of the covered Accident. Benefit is payable only once per Covered Person per Accident.

BrainInjuryDiagnosisBenefitWe will pay $150 for the first diagnosis of the following traumatic brain injuries: cerebral contusion; cerebral laceration; concussion; or intracranial hemorrhage resulting from a covered Accident. The Covered Person must be diagnosed within 3 days of a covered Accident; and diagnosis must be made by computed tomography (CT) scan, electroencephalogram (EEG), magnetic resonance imaging (MRI), positron emission tomography (PET) scan or X ray. The diagnosis must occur within 30 days of the Accident. This benefit is payable only once per Covered Person. BurnBenefit We will pay $100 if burns cover 15% or less of the body surface and $500 if burns cover more than 15% of the body surface for second or third degree burns resulting from a covered Accident other than a sun burn. Benefit is payable only once per Covered Person per covered Accident.

ComaBenefit We will pay $15,000 if a Covered Person is in a Coma as defined in this Rider which lasts 5 or more consecutive days as a result of a covered Accident. Benefit is payable only once per Covered Person per Covered Accident.

EyeInjuryBenefitWe will pay $100 for surgery on the eye or the removal of a foreign object from the eye resulting from a covered Accident. Surgery must be performed by a Physician and occur within 90 days of the Accident. An examination without anesthesia is not considered a surgery. Benefit is payable only once per Covered Person per covered Accident.

FamilyMemberLodgingBenefitWe will pay $100 per day for lodging of one adult member of a Covered Person’s family when a Covered Person is confined in a Non Local Hospital or Specialty Free Standing Treatment Center undergoing treatment for a covered Accident. This benefit is payable only if the Non Local Transportation Benefit is payable under the covered Accident. This benefit will not be paid if the family member lives within 60 miles of the Hospital or treatment facility. This benefit is payable for 30 days for each covered Accident.

HospitalIntensiveCareConfinementBenefitWe will pay $400 per day that a Covered Person is confined to a Hospital Intensive Care Unit as the result of a covered Accident. Confinement must begin within 3 days after a covered Accident. For a partial day confinement, the daily benefit will be pro rated based on the number of hours confined divided by 24 hours. Benefit is payable for up to 60 days of continuous confinement in the Intensive Care Unit.

ImmediateHospitalizationBenefitWe will pay $1,000 upon the first confinement to a Hospital during a calendar year for a covered Accident providing that a benefit is payable under the Accident Hospital Indemnity Confinement Benefit of the policy. The Covered Person must be confined to the Hospital within 3 days of a covered Accident. Benefit is payable only once per Covered Person per Hospital confinement and only once per calendar year.


LacerationBenefitWe will pay $50 for lacerations or cuts treated by a Physician within 3 days of a covered Accident. Benefit is only payable once per Covered Person per calendar year. NonLocalTransportationBenefit We will pay $300 towards transportation for Non Local treatment at a Hospital or Specialty Free Standing Treatment Center nearest the Covered Person’s home for a covered Accident. Treatment must be prescribed by a Physician and the same treatment or care cannot be obtained locally. We do not pay for visits to a physician’s office or clinic or for services other than actual treatment. This benefit does not cover ground or air ambulance. Benefit is payable 3 times per covered Accident.

ParalysisBenefitWe will pay $10,000 for paraplegia and $20,000 for quadriplegia if a Covered Person receives a spinal cord injury resulting in complete and permanent loss of use of two or more limbs as the result of an Accident. An attending Physician must confirm the paralysis within 3 days of the covered Accident and the paralysis must last for at least 90 consecutive days. Benefit is payable only once per Covered Person.

PhysicalTherapyBenefitWe will pay $30 per day a Covered Person receives physical therapy treatment as the result of an Injury due to a covered Accident. This benefit is only payable if a benefit has been paid under the Medical Expense Benefit of the Policy. This benefit is only payable for Injuries resulting form a covered Accident where physical therapy treatment begins within 90 days of the covered Accident. Treatments after 6 months of a covered Accident are not covered. This Rider is not payable at the same time a benefit is payable under the Accident Follow Up Treatment Benefit. We will pay for a maximum of 1 treatment per day with a maximum of 6 treatments per covered.

ProsthesisBenefitWe will pay $500 for 1 device and $1,000 for 2 or more devices for a prosthetic hand, foot, or eye that is prescribed by a Physician. This benefit is payable only if a benefit is paid for the loss of hand, foot, or eye under the Accidental Dismemberment benefit of the Policy. The device or devices must be received within 180 days of a covered Accident. This benefit is payable only once per Covered Person per covered Accident.

RupturedDiscBenefit We will pay $500 for a ruptured disc of the spine. The ruptured disc must be diagnosed as a result of a covered Accident and surgically repaired by a Physician within 180 days of the date of the covered Accident. Benefit is payable once per Covered Person per Covered Accident SkinGraftBenefitWe will pay 50% of the Burn Benefit under this Rider if a Covered Person receives a skin graft for a burn for which a benefit is paid under the Burn Benefit. The skin graft must be performed by a Physician to treat a covered burn within 90 days of a covered Accident. Benefit is payable only once per Covered Person per covered Accident.

Tendon,Ligament,RotatorCufforKneeCartilageBenefitWe will pay $500 per Accident for an injured tendon, ligament, rotator cuff or knee cartilage. The injury site must be torn, ruptured, or severed and surgically repaired by a Physician within 180 days of a covered Accident. If exploratory surgery using arthroscopy is done and no surgical repair is done, we will pay $150 for the exploratory surgery. This benefit is not paid if a benefit is paid under the Ruptured Disc Benefit. Benefit is payable once per Covered Person per Covered Accident

GENERALPROVISIONSPre-existing Conditions: The benefits under this Rider are subject to the Pre-existing Condition Limitation of the Policy. All other general provisions of the Policy and Certificate remain the same. This Rider does not vary, waive, alter or extend any of the terms, conditions, or provisions of the Policy, except as stated herein.

Uponreceiptofyourpolicy,pleasereviewitandyourapplication.Ifanyinformationisincorrect,pleasecontact:

BayBridgeAdministratorsP.O.Box161690|Austin,Texas78716|1-800-845-7519

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