Twin Falls School District #411

Transcription

1 Twin Falls School District #411 Employee Benefits Enrollment Guide Plan Year:

2 Welcome to Open Enrollment for your Benefits!! Elections you make during open enrollment will become effective September 1, Twin Falls School District #411 offers you and your eligible family members a comprehensive and valuable benefits program. We encourage you to take the time to educate yourself about your options and choose the best coverage for you and your family. Who is Eligible? If you are a full-time employee (working 30 or more hours per week) you are eligible to enroll in the benefits described in this guide. How to Enroll The first step is to review your current benefit elections. Verify your personal information and make any changes if necessary. Make your benefit elections. Once you have made your elections, you will not be able to change them until the next open enrollment period unless you have a qualified change in status. When to Enroll The open enrollment period runs from August 1, 2014 through August 23, The benefits you elect during open enrollment will be effective from September 1, 2014, through August 31, How to Make Changes Unless you have a qualified change in status, you cannot make changes to the benefits you elect until the next open enrollment period. Qualified changes in status include: marriage, divorce, legal separation, domestic partnership status, death of a spouse, child, or other qualified dependent, change in residence due to an employment transfer for you, your spouse or domestic partner, commencement or termination of adoption proceedings, or change in spouse s or domestic partner s benefits or employment status. 1

3 Rhonda Bartholomew Broker Contact Information HUB International Sue Stokesberry Account Manager Pete Cavender Broker Tara Tandrow Broker Medical Employee Assistance Program Dental Vision Carriers Blue Cross of Idaho Customer Service Claims Website Business Psychology Associates Customer Service Website LifeMap Customer Service Website Willamette Dental Customer Service Website LifeMap(VSP) Customer Service Website

4 Life and Accidental Death & Dismemberment Health Savings Account Section 125 Voluntary Ancillary Plans LifeMap Assurance Customer Service Website American Fidelity Customer Service Website

5 HUB International Mountain States Limited Insurance Employee Benefits Wellness In-Network Benefits for Twin Falls School District #411 September 1, 2014 Blue Cross of Idaho Medical Option 1: Blue Cross of Idaho HSA Deductible: $3,000 Individual / $6,000 Family Co-Insurance: 70% after deductible is met Max Out of Pocket: $5,800 Individual / $11,600 Family Rx Coverage: 70% after deductible is met Option 2: Blue Cross of Idaho PPO Deductible: $1,000 Individual / $2,000 Family Co-Insurance: 80% after deductible Max Out of Pocket: $4,000 Individual / $8,000 Family Physician Copay : $20 Rx Coverage: $10 / $30 / $30 Business Psychology Associates EAP 1-3 Sessions LifeMap - Dental Deductible: $25 Individual / $75 Family Preventative: 100% Basic: 90% Major: 50% Maximum Benefit : $1,500 per person per calendar year Orthodontic : None Willamette - Dental Deductible: None Office Copay: $15 Preventative: Office Copay Basic: See Plan Design Major: See Plan Design Maximum Benefit: None Orthodontic : $1,500 Copay LifeMap (VSP) Vision Service Frequencies: Exam / Lenses / Frame mo / 12 mo / 12 mo Copays: Exam / Materials -- $10 / $25 Allowance: $130 frames OR Contact Lens This is a brief description of your coverage. For additional details on coverage definitions, exclusions, limitations and out of network benefits, please read your plan booklet carefully. 4

6 HUB International Mountain States Limited Insurance Employee Benefits Wellness In-Network Benefits for Twin Falls School District #411 September 1, 2014 Group Life and AD&D LifeMap All Employees: $20,000 Administrators: Can buy up to $70,000 Spouse: $ 5,000 Dependent Child(ren) $ 2,000 Voluntary Life LifeMap Employees: Increments of $10,000 to a maximum of $400,000 or 5x Annual Earnings Spouse: Increments of $10,000 to a maximum of $300,000 Dependent Child(ren) Increments of $2,000 to a maxiumum of $10,000 Voluntary Ancillary Plans American Fidelity Health Savings Account Administrator American Fidelity Section 125 Administrator American Fidelity This is a brief description of your coverage. For additional details on coverage definitions, exclusions, limitations and out of network benefits, please read your plan booklet carefully. 5

7 Twin Falls School District #411 Insurance Rates - September 1, 2014 Blue Cross - PPO Economy H.S.A Total Monthly Benefit Amount Paid by TFSD #411 Health Savings Acct Dep Employee Cost Premium Cost Part-Time Full-Time Part-Time Full-Time Part-Time Full-Time Employee Only Employee & One Child Employee & 2+ Children Employee & Spouse Employee & Family Blue Cross - PPO Preferred Total Monthly Benefit Amount Paid by TFSD #411 Employee Cost Premium Cost Part-Time Full-Time Part-Time Full-Time Employee Only Employee & One Child Employee & 2+ Children Employee & Spouse Employee & Family LifeMap - Dental Total Monthly Benefit Amount Paid by TFSD #411 Employee Cost Premium Cost Part-Time Full-Time Part-Time Full-Time Employee Only Employee & One Child Employee & 2+ Children Employee & Spouse Employee & Family Willamette - Dental Total Monthly Benefit Amount Paid by TFSD #411 Employee Cost Premium Cost Part-Time Full-Time Part-Time Full-Time Employee Only Employee & One Child Employee & 2+ Children Employee & Spouse Employee & Family LifeMap - Vision Total Monthly Premium Cost Part-Time Full-Time Part-Time Full-Time Employee Only Employee & One Child Employee & 2+ Children Employee & Spouse Employee & Family LifeMap - Life Total Monthly Benefit Amount Paid by TFSD #411 Benefit Amount Paid by TFSD #411 Employee Cost Employee Cost Premium Cost Part-Time Full-Time Part-Time Full-Time $20, Employee Life AD&D Dependent Life - Spouse $5000 Dependent Life - Children $ $70, Administrator Life AD&D Additional Voluntary Life available at 5x Annual Earnings; $400, Maximum Employee Assistance Program up to 3 visits per incident - No Charge to Employee 6

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9 SWS HSA Single Blue PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: Beginning 9/1/2014 Coverage for: Enrollee Plan Type: PPO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan by calling Important Questions Answers Why This Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out-of-pocket limit on my expenses? What is not included in the out-of-pocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn't cover? $3,000 person. Does not apply to copays, immunizations and in-network preventive care. No. There are no other specific deductibles. Yes. $5,800 person Premiums, balance-billed charges, and health care this plan doesn't cover. No. Yes. For a list of in-network providers, see or call No. You don't need a referral to see a specialist. Yes. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. You don't have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don't count toward the out-of-pocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some of all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Some of the services this plan doesn't cover are listed on page 5. See your policy or plan document for additional information about excluded services. Questions: Call or visit us at Twin Falls School District SWS HSA Single Blue PPO 3,000 09/01/14 PPO 2010C AGRF SBC ID: If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary 8 at or call to request a copy. Page 1 of 8

10 SWS HSA Single Blue PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: Beginning 9/1/2014 Coverage for: Enrollee Plan Type: PPO Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use in-network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event Services You May Need Your Cost If You Use an In-Network Provider Your Cost If You Use an Out-Of-Network Provider Limitations & Exceptions If you visit a health care provider's office or clinic Primary care visit to treat an injury or illness Specialist visit Other practitioner office visit 30% coinsurance 50% coinsurance none % coinsurance 50% coinsurance none % coinsurance 50% coinsurance none Preventive care/screening/immunization No charge for listed preventive, screening and immunization services. No charge for listed immunizations, 50% coinsurance preventive and screening none If you have a test Diagnostic test (x-ray, blood work) 30% coinsurance 50% coinsurance none Imaging (CT/PET scans, MRIs) 30% coinsurance 50% coinsurance Preauthorization required. Questions: Call or visit us at Twin Falls School District SWS HSA Single Blue PPO 3,000 09/01/14 PPO 2010C AGRF SBC ID: If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary 9 at or call to request a copy. Page 2 of 8

11 SWS HSA Single Blue PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: Beginning 9/1/2014 Coverage for: Enrollee Plan Type: PPO Common Medical Event Services You May Need Your Cost If You Use an In-Network Provider Your Cost If You Use an Out-Of-Network Provider Limitations & Exceptions If you need drugs to treat your illness or condition More information about prescription drug coverage is available at If you have outpatient surgery If you need immediate medical attention Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty drugs Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Emergency room services Emergency medical transportation 30% coinsurance 30% coinsurance Covers up to a 90 day supply. Pharmacy discount. 30% coinsurance 30% coinsurance Covers up to a 90 day supply. Pharmacy discount. 30% coinsurance 30% coinsurance Covers up to a 90 day supply. Pharmacy discount. 30% coinsurance 30% coinsurance Coverage may include limitations and preauthorization may be required. Pharmacy discount. 30% coinsurance 50% coinsurance Preauthorization required. 30% coinsurance 50% coinsurance Preauthorization required. $100 copay/visit, 30% coinsurance $100 copay/visit, 50% coinsurance Copay waived if admitted. 30% coinsurance 50% coinsurance none If you have a hospital stay If you have mental health, behavioral health, or substance abuse needs Urgent care Facility fee (e.g., hospital room) Physician/surgeon fee Mental/Behavioral health outpatient services Mental/Behavioral health inpatient services Substance use disorder outpatient services Substance use disorder inpatient services 30% coinsurance 50% coinsurance none % coinsurance 50% coinsurance Preauthorization required. 30% coinsurance 50% coinsurance Preauthorization required. 30% coinsurance 50% coinsurance Preauthorization required. 30% coinsurance 50% coinsurance Preauthorization required. 30% coinsurance 50% coinsurance Preauthorization required. 30% coinsurance 50% coinsurance Preauthorization required. If you are pregnant Prenatal and postnatal care 30% coinsurance 50% coinsurance none Delivery and all inpatient services 30% coinsurance 50% coinsurance none Questions: Call or visit us at Twin Falls School District SWS HSA Single Blue PPO 3,000 09/01/14 PPO 2010C AGRF SBC ID: If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary 10 at or call to request a copy. Page 3 of 8

12 SWS HSA Single Blue PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: Beginning 9/1/2014 Coverage for: Enrollee Plan Type: PPO Common Medical Event Services You May Need Your Cost If You Use an In-Network Provider Your Cost If You Use an Out-Of-Network Provider Limitations & Exceptions If you need help recovering or have other special health needs If your child needs dental or eye care Home health care Rehabilitation services Habilitation services Skilled nursing care Durable medical equipment Hospice service Eye exam Glasses Dental check-up 30% coinsurance 50% coinsurance Preauthorization required. 50% coinsurance 80% coinsurance Coverage is limited to 20 visit annual max for habilitation and rehabilitation services. 50% coinsurance 80% coinsurance Coverage is limited to 20 visit annual max for habilitation and rehabilitation services. 30% coinsurance 50% coinsurance Coverage is limited to 30 day annual max. 30% coinsurance 50% coinsurance Preauthorization required. No charge 50% coinsurance Preauthorization required. Not covered Not covered none Not covered Not covered none Not covered Not covered none Questions: Call or visit us at Twin Falls School District SWS HSA Single Blue PPO 3,000 09/01/14 PPO 2010C AGRF SBC ID: If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary 11 at or call to request a copy. Page 4 of 8

13 SWS HSA Single Blue PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: Beginning 9/1/2014 Coverage for: Enrollee Plan Type: PPO Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.) Acupuncture Private-duty nursing Bariatric surgery Routine eye care (Adult) Cosmetic surgery Routine foot care Dental care (Adult) Weight loss programs Dental check-up (Child) Eye exam (Child) Glasses (Child) Hearing aids Infertility treatment Long-term care Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.) Chiropractic care Non-emergency care when traveling outside the U.S. Questions: Call or visit us at Twin Falls School District SWS HSA Single Blue PPO 3,000 09/01/14 PPO 2010C AGRF SBC ID: If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary 12 at or call to request a copy. Page 5 of 8

14 SWS HSA Single Blue PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: Beginning 9/1/2014 Coverage for: Enrollee Plan Type: PPO Your Rights to Continue Coverage: ** Group health coverage - If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at or You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at or or the U.S. Department of Health and Human Services at x61565 or Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Your Grievance and Appeals Rights: For any initial questions concerning a claim, or to appeal a claim or benefit decision, please contact Customer Service at or , or at P.O. Box 7408, Boise, ID If your plan is subject to ERISA, you may contact the Department of Labor s Employee Benefits Security Administration at EBSA or If your plan is fully insured or a self-funded subject to the Idaho Insurance Code, you may also receive assistance from the Idaho Department of Insurance at or Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al or Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa or Chinese ( 中 文 ): 如 果 需 要 中 文 的 帮 助, 请 拨 打 这 个 号 码 or Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' or Questions: Call or visit us at Twin Falls School District SWS HSA Single Blue PPO 3,000 09/01/14 PPO 2010C AGRF SBC ID: If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary 13 at or call to request a copy. Page 6 of 8

15 SWS HSA Single Blue PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: Beginning 9/1/2014 Coverage for: Enrollee Plan Type: PPO About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $3,190 Patient pays $4,350 Sample care costs: Hospital charges (mother) Routine obstetric care Hospital charges (baby) $2,700 $2,100 $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles Co-pays Co-insurance Limits or exclusions Total $3,000 $1,350 $4,350 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $1,710 Patient pays $3,690 Sample care costs: Prescriptions Medical Equipment and Supplies Office Visits and Procedures $2,900 $1,300 $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles Co-pays Co-insurance Limits or exclusions Total $3,000 $690 $3,690 Questions: Call or visit us at Twin Falls School District SWS HSA Single Blue PPO 3,000 09/01/14 PPO 2010C AGRF SBC ID: If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary 14 at or call to request a copy. Page 7 of 8

16 SWS HSA Single Blue PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: Beginning 9/1/2014 Coverage for: Enrollee Plan Type: PPO Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don't include premiums Sample care costs are based on a national averages supplied by the US Department of Health and Human Services; and aren't specific to a particular geographic area or health plan. The patient's condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from in-network providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? û No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? û No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? üyes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? üyes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-of-pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Questions: Call or visit us at Twin Falls School District SWS HSA Single Blue PPO 3,000 09/01/14 PPO 2010C AGRF SBC ID: If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary 15 at or call to request a copy. Page 8 of 8

17 SWS HSA Family Blue PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: Beginning 9/1/2014 Coverage for: Enrollee + Eligible Dependents Plan Type: PPO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan by calling Important Questions Answers Why This Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out-of-pocket limit on my expenses? What is not included in the out-of-pocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn't cover? $3,000 person/$6,000 family. Does not apply to copays, immunizations and in-network preventive care. No. There are no other specific deductibles. Yes. $5,800 person/$11,600 family Premiums, balance-billed charges, and health care this plan doesn't cover. No. Yes. For a list of in-network providers, see or call No. You don't need a referral to see a specialist. Yes. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. You don't have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don't count toward the out-of-pocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some of all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Some of the services this plan doesn't cover are listed on page 5. See your policy or plan document for additional information about excluded services. Questions: Call or visit us at Twin Falls School District SWS HSA Family Blue PPO 3,000 09/01/14 PPO 2010C AGRF SBC ID: If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary 16 at or call to request a copy. Page 1 of 8

18 SWS HSA Family Blue PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: Beginning 9/1/2014 Coverage for: Enrollee + Eligible Dependents Plan Type: PPO Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use in-network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event Services You May Need Your Cost If You Use an In-Network Provider Your Cost If You Use an Out-Of-Network Provider Limitations & Exceptions If you visit a health care provider's office or clinic Primary care visit to treat an injury or illness Specialist visit Other practitioner office visit 30% coinsurance 50% coinsurance none % coinsurance 50% coinsurance none % coinsurance 50% coinsurance none Preventive care/screening/immunization No charge for listed preventive, screening and immunization services. No charge for listed immunizations, 50% coinsurance preventive and screening none If you have a test Diagnostic test (x-ray, blood work) 30% coinsurance 50% coinsurance none Imaging (CT/PET scans, MRIs) 30% coinsurance 50% coinsurance Preauthorization required. Questions: Call or visit us at Twin Falls School District SWS HSA Family Blue PPO 3,000 09/01/14 PPO 2010C AGRF SBC ID: If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary 17 at or call to request a copy. Page 2 of 8

19 SWS HSA Family Blue PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: Beginning 9/1/2014 Coverage for: Enrollee + Eligible Dependents Plan Type: PPO Common Medical Event Services You May Need Your Cost If You Use an In-Network Provider Your Cost If You Use an Out-Of-Network Provider Limitations & Exceptions If you need drugs to treat your illness or condition More information about prescription drug coverage is available at If you have outpatient surgery If you need immediate medical attention Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty drugs Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Emergency room services Emergency medical transportation 30% coinsurance 30% coinsurance Covers up to a 90 day supply. Pharmacy discount. 30% coinsurance 30% coinsurance Covers up to a 90 day supply. Pharmacy discount. 30% coinsurance 30% coinsurance Covers up to a 90 day supply. Pharmacy discount. 30% coinsurance 30% coinsurance Coverage may include limitations and preauthorization may be required. Pharmacy discount. 30% coinsurance 50% coinsurance Preauthorization required. 30% coinsurance 50% coinsurance Preauthorization required. $100 copay/visit, 30% coinsurance $100 copay/visit, 50% coinsurance Copay waived if admitted. 30% coinsurance 50% coinsurance none If you have a hospital stay If you have mental health, behavioral health, or substance abuse needs Urgent care Facility fee (e.g., hospital room) Physician/surgeon fee Mental/Behavioral health outpatient services Mental/Behavioral health inpatient services Substance use disorder outpatient services Substance use disorder inpatient services 30% coinsurance 50% coinsurance none % coinsurance 50% coinsurance Preauthorization required. 30% coinsurance 50% coinsurance Preauthorization required. 30% coinsurance 50% coinsurance Preauthorization required. 30% coinsurance 50% coinsurance Preauthorization required. 30% coinsurance 50% coinsurance Preauthorization required. 30% coinsurance 50% coinsurance Preauthorization required. If you are pregnant Prenatal and postnatal care 30% coinsurance 50% coinsurance none Delivery and all inpatient services 30% coinsurance 50% coinsurance none Questions: Call or visit us at Twin Falls School District SWS HSA Family Blue PPO 3,000 09/01/14 PPO 2010C AGRF SBC ID: If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary 18 at or call to request a copy. Page 3 of 8

20 SWS HSA Family Blue PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: Beginning 9/1/2014 Coverage for: Enrollee + Eligible Dependents Plan Type: PPO Common Medical Event Services You May Need Your Cost If You Use an In-Network Provider Your Cost If You Use an Out-Of-Network Provider Limitations & Exceptions If you need help recovering or have other special health needs If your child needs dental or eye care Home health care Rehabilitation services Habilitation services Skilled nursing care Durable medical equipment Hospice service Eye exam Glasses Dental check-up 30% coinsurance 50% coinsurance Preauthorization required. 50% coinsurance 80% coinsurance Coverage is limited to 20 visit annual max for habilitation and rehabilitation services. 50% coinsurance 80% coinsurance Coverage is limited to 20 visit annual max for habilitation and rehabilitation services. 30% coinsurance 50% coinsurance Coverage is limited to 30 day annual max. 30% coinsurance 50% coinsurance Preauthorization required. No charge 50% coinsurance Preauthorization required. Not covered Not covered none Not covered Not covered none Not covered Not covered none Questions: Call or visit us at Twin Falls School District SWS HSA Family Blue PPO 3,000 09/01/14 PPO 2010C AGRF SBC ID: If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary 19 at or call to request a copy. Page 4 of 8

21 SWS HSA Family Blue PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: Beginning 9/1/2014 Coverage for: Enrollee + Eligible Dependents Plan Type: PPO Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.) Acupuncture Private-duty nursing Bariatric surgery Routine eye care (Adult) Cosmetic surgery Routine foot care Dental care (Adult) Weight loss programs Dental check-up (Child) Eye exam (Child) Glasses (Child) Hearing aids Infertility treatment Long-term care Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.) Chiropractic care Non-emergency care when traveling outside the U.S. Questions: Call or visit us at Twin Falls School District SWS HSA Family Blue PPO 3,000 09/01/14 PPO 2010C AGRF SBC ID: If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary 20 at or call to request a copy. Page 5 of 8

22 SWS HSA Family Blue PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: Beginning 9/1/2014 Coverage for: Enrollee + Eligible Dependents Plan Type: PPO Your Rights to Continue Coverage: ** Group health coverage - If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at or You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at or or the U.S. Department of Health and Human Services at x61565 or Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Your Grievance and Appeals Rights: For any initial questions concerning a claim, or to appeal a claim or benefit decision, please contact Customer Service at or , or at P.O. Box 7408, Boise, ID If your plan is subject to ERISA, you may contact the Department of Labor s Employee Benefits Security Administration at EBSA or If your plan is fully insured or a self-funded subject to the Idaho Insurance Code, you may also receive assistance from the Idaho Department of Insurance at or Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al or Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa or Chinese ( 中 文 ): 如 果 需 要 中 文 的 帮 助, 请 拨 打 这 个 号 码 or Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' or Questions: Call or visit us at Twin Falls School District SWS HSA Family Blue PPO 3,000 09/01/14 PPO 2010C AGRF SBC ID: If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary 21 at or call to request a copy. Page 6 of 8

23 SWS HSA Family Blue PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: Beginning 9/1/2014 Coverage for: Enrollee + Eligible Dependents Plan Type: PPO About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $3,190 Patient pays $4,350 Sample care costs: Hospital charges (mother) Routine obstetric care Hospital charges (baby) $2,700 $2,100 $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles Co-pays Co-insurance Limits or exclusions Total $3,000 $1,350 $4,350 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $1,710 Patient pays $3,690 Sample care costs: Prescriptions Medical Equipment and Supplies Office Visits and Procedures $2,900 $1,300 $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles Co-pays Co-insurance Limits or exclusions Total $3,000 $690 $3,690 Questions: Call or visit us at Twin Falls School District SWS HSA Family Blue PPO 3,000 09/01/14 PPO 2010C AGRF SBC ID: If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary 22 at or call to request a copy. Page 7 of 8

24 SWS HSA Family Blue PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: Beginning 9/1/2014 Coverage for: Enrollee + Eligible Dependents Plan Type: PPO Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don't include premiums Sample care costs are based on a national averages supplied by the US Department of Health and Human Services; and aren't specific to a particular geographic area or health plan. The patient's condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from in-network providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? û No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? û No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? üyes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? üyes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-of-pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Questions: Call or visit us at Twin Falls School District SWS HSA Family Blue PPO 3,000 09/01/14 PPO 2010C AGRF SBC ID: If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary 23 at or call to request a copy. Page 8 of 8

25 SWS Large Group PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: Beginning 9/1/2014 Coverage for: Enrollee + Eligible Dependents Plan Type: PPO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan by calling Important Questions Answers Why This Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out-of-pocket limit on my expenses? What is not included in the out-of-pocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn't cover? $1,000 person/$2,000 family. Does not apply to pharmacy, copays, immunizations or in-network hospice care and preventive care. No. There are no other specific deductibles. Yes. For in-network provider $4,000 person/$8,000 family, For out-of-network provider $6,000 person/$12,000 family Premiums, balance-billed charges, pharmacy and health care this plan doesn't cover. No. Yes. For a list of in-network providers, see or call No. You don't need a referral to see a specialist. Yes. You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. You don't have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don't count toward the out-of-pocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some of all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Some of the services this plan doesn't cover are listed on page 5. See your policy or plan document for additional information about excluded services. Questions: Call or visit us at Twin Falls School District SWS Large Group PPO 1,000 09/01/14 PPO 2010C AHCR SBC ID: If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary 24 at or call to request a copy. Page 1 of 8

26 SWS Large Group PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: Beginning 9/1/2014 Coverage for: Enrollee + Eligible Dependents Plan Type: PPO Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use in-network providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event Services You May Need Your Cost If You Use an In-Network Provider Your Cost If You Use an Out-Of-Network Provider Limitations & Exceptions If you visit a health care provider's office or clinic Primary care visit to treat an injury or illness Specialist visit Other practitioner office visit $20 copay/visit 40% coinsurance Does not apply to additional services. $20 copay/visit 40% coinsurance Does not apply to additional services. $20 copay/visit 40% coinsurance Does not apply to additional services. Preventive care/screening/immunization No charge for listed preventive, screening and immunization services. If you have a test Diagnostic test (x-ray, blood work) No charge up to $100, then 20% coinsurance Imaging (CT/PET scans, MRIs) No charge up to $100, then 20% coinsurance No charge for listed none immunizations, 40% coinsurance preventive and screening. 40% coinsurance none % coinsurance Preauthorization required. Questions: Call or visit us at Twin Falls School District SWS Large Group PPO 1,000 09/01/14 PPO 2010C AHCR SBC ID: If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary 25 at or call to request a copy. Page 2 of 8

27 SWS Large Group PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: Beginning 9/1/2014 Coverage for: Enrollee + Eligible Dependents Plan Type: PPO Common Medical Event Services You May Need Your Cost If You Use an In-Network Provider Your Cost If You Use an Out-Of-Network Provider Limitations & Exceptions If you need drugs to treat your illness or condition More information about prescription drug coverage is available at If you have outpatient surgery If you need immediate medical attention If you have a hospital stay Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty drugs Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Emergency room services Emergency medical transportation Urgent care Facility fee (e.g., hospital room) Physician/surgeon fee $10 copay/prescription, 20% coinsurance (retail and mail order) $30 copay/prescription, 20% coinsurance (retail and mail order) $30 copay/prescription, 20% coinsurance (retail and mail order) $30 copay/prescription, 20% coinsurance (retail and mail order) $10 copay/prescription, 20% coinsurance (retail and mail order) $30 copay/prescription, 20% coinsurance (retail and mail order) $30 copay/prescription, 20% coinsurance (retail and mail order) $30 copay/prescription, 20% coinsurance (retail and mail order) Covers up to a 90 day supply with multiple copays. Covers up to a 90 day supply with multiple copays. Covers up to a 90 day supply with multiple copays. 20% coinsurance 40% coinsurance Preauthorization required. 20% coinsurance 40% coinsurance Preauthorization required. $100 copay/visit, 20% coinsurance $100 copay/visit, 40% coinsurance Coverage may include limitations and preauthorization may be required. Copay waived if admitted. 20% coinsurance 40% coinsurance none $20 copay/visit 40% coinsurance Does not apply to additional services. 20% coinsurance 40% coinsurance Preauthorization required. 20% coinsurance 40% coinsurance Preauthorization required. Questions: Call or visit us at Twin Falls School District SWS Large Group PPO 1,000 09/01/14 PPO 2010C AHCR SBC ID: If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary 26 at or call to request a copy. Page 3 of 8

28 SWS Large Group PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: Beginning 9/1/2014 Coverage for: Enrollee + Eligible Dependents Plan Type: PPO Common Medical Event Services You May Need Your Cost If You Use an In-Network Provider Your Cost If You Use an Out-Of-Network Provider Limitations & Exceptions If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services Mental/Behavioral health inpatient services Substance use disorder outpatient services Substance use disorder inpatient services $20 copay/visit, 20% coinsurance for facility and other services 40% coinsurance Preauthorization required. 20% coinsurance 40% coinsurance Preauthorization required. $20 copay/visit, 20% coinsurance for facility and other services 40% coinsurance Preauthorization required. 20% coinsurance 40% coinsurance Preauthorization required. If you are pregnant Prenatal and postnatal care 20% coinsurance 40% coinsurance none If you need help recovering or have other special health needs If your child needs dental or eye care Delivery and all inpatient services Home health care Rehabilitation services Habilitation services Skilled nursing care Durable medical equipment Hospice service Eye exam Glasses Dental check-up 20% coinsurance 40% coinsurance none % coinsurance 40% coinsurance Preauthorization required. 20% coinsurance 40% coinsurance Coverage is limited to 20 visit annual max for habilitation and rehabilitation services. 20% coinsurance 40% coinsurance Coverage is limited to 20 visit annual max for habilitation and rehabilitation services. 20% coinsurance 40% coinsurance Coverage is limited to 30 day annual max. 20% coinsurance 40% coinsurance Preauthorization required. No charge 40% coinsurance Preauthorization required. Not covered Not covered none Not covered Not covered none Not covered Not covered none Questions: Call or visit us at Twin Falls School District SWS Large Group PPO 1,000 09/01/14 PPO 2010C AHCR SBC ID: If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary 27 at or call to request a copy. Page 4 of 8

29 SWS Large Group PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: Beginning 9/1/2014 Coverage for: Enrollee + Eligible Dependents Plan Type: PPO Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.) Acupuncture Routine eye care (Adult) Cosmetic surgery Routine foot care Dental care (Adult) Weight loss programs Dental check-up (Child) Eye exam (Child) Glasses (Child) Hearing aids Infertility treatment Long-term care Private-duty nursing Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.) Bariatric surgery Chiropractic care Non-emergency care when traveling outside the U.S. Questions: Call or visit us at Twin Falls School District SWS Large Group PPO 1,000 09/01/14 PPO 2010C AHCR SBC ID: If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary 28 at or call to request a copy. Page 5 of 8

30 SWS Large Group PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: Beginning 9/1/2014 Coverage for: Enrollee + Eligible Dependents Plan Type: PPO Your Rights to Continue Coverage: ** Group health coverage - If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at or You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at or or the U.S. Department of Health and Human Services at x61565 or Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Your Grievance and Appeals Rights: For any initial questions concerning a claim, or to appeal a claim or benefit decision, please contact Customer Service at or , or at P.O. Box 7408, Boise, ID If your plan is subject to ERISA, you may contact the Department of Labor s Employee Benefits Security Administration at EBSA or If your plan is fully insured or a self-funded subject to the Idaho Insurance Code, you may also receive assistance from the Idaho Department of Insurance at or Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al or Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa or Chinese ( 中 文 ): 如 果 需 要 中 文 的 帮 助, 请 拨 打 这 个 号 码 or Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' or Questions: Call or visit us at Twin Falls School District SWS Large Group PPO 1,000 09/01/14 PPO 2010C AHCR SBC ID: If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary 29 at or call to request a copy. Page 6 of 8

31 SWS Large Group PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: Beginning 9/1/2014 Coverage for: Enrollee + Eligible Dependents Plan Type: PPO About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $5,170 Patient pays $2,370 Sample care costs: Hospital charges (mother) Routine obstetric care Hospital charges (baby) $2,700 $2,100 $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles Co-pays Co-insurance Limits or exclusions Total $1,000 $70 $1,300 $2,370 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $3,140 Patient pays $2,260 Sample care costs: Prescriptions Medical Equipment and Supplies Office Visits and Procedures $2,900 $1,300 $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles Co-pays Co-insurance Limits or exclusions Total $1,000 $600 $660 $2,260 Questions: Call or visit us at Twin Falls School District SWS Large Group PPO 1,000 09/01/14 PPO 2010C AHCR SBC ID: If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary 30 at or call to request a copy. Page 7 of 8

32 SWS Large Group PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: Beginning 9/1/2014 Coverage for: Enrollee + Eligible Dependents Plan Type: PPO Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don't include premiums Sample care costs are based on a national averages supplied by the US Department of Health and Human Services; and aren't specific to a particular geographic area or health plan. The patient's condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from in-network providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? û No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? û No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? üyes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? üyes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-of-pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Questions: Call or visit us at Twin Falls School District SWS Large Group PPO 1,000 09/01/14 PPO 2010C AHCR SBC ID: If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary 31 at or call to request a copy. Page 8 of 8

33 Glossary of Health Coverage and Medical Terms This glossary has many commonly used terms, but isn t a full list. These glossary terms and definitions are intended to be educational and may be different from the terms and definitions in your plan. Some of these terms also might not have exactly the same meaning when used in your policy or plan, and in any such case, the policy or plan governs. (See your Summary of Benefits and Coverage for information on how to get a copy of your policy or plan document.) Bold blue text indicates a term defined in this Glossary. See page 4 for an example showing how deductibles, co-insurance and out-of-pocket limits work together in a real life situation. Allowed Amount Maximum amount on which payment is based for covered health care services. This may be called eligible expense, payment allowance" or "negotiated rate." If your provider charges more than the allowed amount, you may have to pay the difference. (See Balance Billing.) Appeal A request for your health insurer or plan to review a decision or a grievance again. Balance Billing When a provider bills you for the difference between the provider s charge and the allowed amount. For example, if the provider s charge is $100 and the allowed amount is $70, the provider may bill you for the remaining $30. A preferred provider may not balance bill you for covered services. Co-insurance Your share of the costs of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service. Jane pays Her plan pays You pay co-insurance 20% 80% plus any deductibles (See page 4 for a detailed example.) you owe. For example, if the health insurance or plan s allowed amount for an office visit is $100 and you ve met your deductible, your co-insurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount. Co-payment A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service. Deductible The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins Jane pays Her plan pays to pay. For example, if 100% 0% your deductible is $1000, your plan won t pay (See page 4 for a detailed example.) anything until you ve met your $1000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services. Durable Medical Equipment (DME) Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics. Emergency Medical Condition An illness, injury, symptom or condition so serious that a reasonable person would seek care right away to avoid severe harm. Emergency Medical Transportation Ambulance services for an emergency medical condition. Complications of Pregnancy Conditions due to pregnancy, labor and delivery that require medical care to prevent serious harm to the health of the mother or the fetus. Morning sickness and a nonemergency caesarean section aren t complications of pregnancy. Emergency Room Care Emergency services you get in an emergency room. Emergency Services Evaluation of an emergency medical condition and treatment to keep the condition from getting worse. OMB 32 Control Numbers , , and

34 Excluded Services Health care services that your health insurance or plan doesn t pay for or cover. Grievance A complaint that you communicate to your health insurer or plan. Habilitation Services Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. Health Insurance A contract that requires your health insurer to pay some or all of your health care costs in exchange for a premium. Home Health Care Health care services a person receives at home. Hospice Services Services to provide comfort and support for persons in the last stages of a terminal illness and their families. Hospitalization Care in a hospital that requires admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be outpatient care. Hospital Outpatient Care Care in a hospital that usually doesn t require an overnight stay. In-network Co-insurance The percent (for example, 20%) you pay of the allowed amount for covered health care services to providers who contract with your health insurance or plan. In-network co-insurance usually costs you less than out-of-network co-insurance. In-network Co-payment A fixed amount (for example, $15) you pay for covered health care services to providers who contract with your health insurance or plan. In-network co-payments usually are less than out-of-network co-payments. Medically Necessary Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine. Network The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services. Non-Preferred Provider A provider who doesn t have a contract with your health insurer or plan to provide services to you. You ll pay more to see a non-preferred provider. Check your policy to see if you can go to all providers who have contracted with your health insurance or plan, or if your health insurance or plan has a tiered network and you must pay extra to see some providers. Out-of-network Co-insurance The percent (for example, 40%) you pay of the allowed amount for covered health care services to providers who do not contract with your health insurance or plan. Outof-network co-insurance usually costs you more than innetwork co-insurance. Out-of-network Co-payment A fixed amount (for example, $30) you pay for covered health care services from providers who do not contract with your health insurance or plan. Out-of-network copayments usually are more than in-network co-payments. Out-of-Pocket Limit The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, Jane pays Her plan pays 0% 100% balance-billed charges or (See page 4 for a detailed example.) health care your health insurance or plan doesn t cover. Some health insurance or plans don t count all of your co-payments, deductibles, co-insurance payments, out-of-network payments or other expenses toward this limit. Physician Services Health care services a licensed medical physician (M.D. Medical Doctor or D.O. Doctor of Osteopathic Medicine) provides or coordinates. 33

35 Plan A benefit your employer, union or other group sponsor provides to you to pay for your health care services. Preauthorization A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn t a promise your health insurance or plan will cover the cost. Preferred Provider A provider who has a contract with your health insurer or plan to provide services to you at a discount. Check your policy to see if you can see all preferred providers or if your health insurance or plan has a tiered network and you must pay extra to see some providers. Your health insurance or plan may have preferred providers who are also participating providers. Participating providers also contract with your health insurer or plan, but the discount may not be as great, and you may have to pay more. Premium The amount that must be paid for your health insurance or plan. You and/or your employer usually pay it monthly, quarterly or yearly. Prescription Drug Coverage Health insurance or plan that helps pay for prescription drugs and medications. Prescription Drugs Drugs and medications that by law require a prescription. Primary Care Physician A physician (M.D. Medical Doctor or D.O. Doctor of Osteopathic Medicine) who directly provides or coordinates a range of health care services for a patient. Provider A physician (M.D. Medical Doctor or D.O. Doctor of Osteopathic Medicine), health care professional or health care facility licensed, certified or accredited as required by state law. Reconstructive Surgery Surgery and follow-up treatment needed to correct or improve a part of the body because of birth defects, accidents, injuries or medical conditions. Rehabilitation Services Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings. Skilled Nursing Care Services from licensed nurses in your own home or in a nursing home. Skilled care services are from technicians and therapists in your own home or in a nursing home. Specialist A physician specialist focuses on a specific area of medicine or a group of patients to diagnose, manage, prevent or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has more training in a specific area of health care. UCR (Usual, Customary and Reasonable) The amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical service. The UCR amount sometimes is used to determine the allowed amount. Urgent Care Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care. Primary Care Provider A physician (M.D. Medical Doctor or D.O. Doctor of Osteopathic Medicine), nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law, who provides, coordinates or helps a patient access a range of health care services. 34

36 How You and Your Insurer Share Costs - Example Jane s Plan Deductible: $1,500 Co-insurance: 20% Out-of-Pocket Limit: $5,000 January 1 st Beginning of Coverage Period December 31 st End of Coverage Period Jane pays 100% Her plan pays 0% more costs Jane pays 20% Her plan pays 80% more costs Jane pays 0% Her plan pays 100% Jane hasn t reached her $1,500 deductible yet Her plan doesn t pay any of the costs. Office visit costs: $125 Jane pays: $125 Her plan pays: $0 Jane reaches her $1,500 deductible, co-insurance begins Jane has seen a doctor several times and paid $1,500 in total. Her plan pays some of the costs for her next visit. Office visit costs: $75 Jane pays: 20% of $75 = $15 Her plan pays: 80% of $75 = $60 Jane reaches her $5,000 out-of-pocket limit Jane has seen the doctor often and paid $5,000 in total. Her plan pays the full cost of her covered health care services for the rest of the year. Office visit costs: $200 Jane pays: $0 Her plan pays: $200 35

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39 Twin Falls School District Employee Assistance Program (EAP) What is an EAP? How many sessions do I have? Who do I call? What does it cost? What kinds of problems does the EAP address? How long does a Session last? Who will know that I ve used the EAP? Who can use this service? What if I m divorced and my children only live with me part of the time? Who would I see? Where are EAP Providers located? What if my child is away at college or if I go on vacation out of state? How does the EAP interact with our group health benefits? Are there any exclusions? Your EAP is designed to give you and your family members easy, confidential access to professional counseling at no cost to you. The goal of the EAP is to help with any problem that might affect life at work or at home. Members of Twin Falls School District have 1-3 sessions per incident per program year available. Call You may call 24 hours per day/365 days per year. The EAP sessions are no cost to you or your dependents provided you acquire preauthorization for an in network EAP provider from BPA. Referrals beyond the initial 3 EAP sessions or referrals to a provider outside the EAP network are subject to your health plans Mental Health benefits or self-pay. To access EAP benefits, call for preauthorization and referral from BPA. You will be financially responsible for any services obtained outside BPA s EAP contracted network or without pre-authorization from BPA. The EAP is designed to address a wide range of personal problems and issues. Often these will include emotional or behavioral issues. Sometimes, it may be a financial or legal issue that creates stress in your life. People use the EAP to resolve marital, family or work problems. The EAP may be instrumental in addressing alcohol and drug dependency problems. The EAP is designed to accurately evaluate or assess problems, which may include a Mental Health or Substance Abuse diagnosis; however it is not designed to resolve acute Mental Health or Substance Abuse issues. These diagnoses require referral to a specialist, such as a psychiatrist, for longer-term care and attention and will be subject to your health insurance s mental health benefits and/or self-pay. Approximately fifty-five minutes. This allows your counselor time to enter notes into your record. No one. The EAP component of your benefit plan provides services that are private and confidential. No information is released to your employer, other than utilization rates, unless you sign a release of information. You and your eligible dependents, spouse, and children up to age 26 may access the EAP. The EAP benefit has a very generous description of family members. The term child or children includes natural children, stepchildren, adopted children, or children in the process of adoption from the time placed with the eligible employee. The term children includes children up to age 26, regardless of the child s marital, financial, student or residential status. The customer service representative will refer you to a provider which can help with your concern as identified by you during the initial call to the hotline. All counselors have professional degrees, many years experience, state license, and are fully insured. A referral would be made to a Network Provider that would best meet your individual needs. There are EAP providers throughout the country, in rural as well as urban areas. When you call the EAP Hotline at a list of local providers will be given to you so you may call and make an appointment. The EAP Administrator, Business Psychology Associates, has counselors available virtually anywhere in the country. Simply call the EAP Hotline to access the benefit. Your Group Health benefits are different in that they are only available to those enrolled in the health plan. As long as an employee is eligible, their dependents are eligible regardless of insurance coverage. When Necessary the EAP Network of counselors makes referrals to other Mental Health and Substance Abuse professionals that includes; counselors, psychologists, psychiatrists and hospitals or treatment facilities. Any referrals beyond the EAP provider are subject to your health plans Mental Health benefits or self-pay Psychological testing and court-ordered treatment are not covered by the EAP. Business Psychology Associates, ,

40 How do I log in to the website? How do I access my Legal, Financial, ID Theft Assistance Services? How can the legal service help me? How can the financial service help me? What is a Debt Management Plan? What is ID Theft Assistance? What is excluded from the Legal/Financial Assistance? What is a frivolous matter? Go to Areas of this site containing protected information require you to register in order to receive a username and password. Otherwise, to view the general benefits you have available, you may login using your Twin Falls School District plan s toll free number Simply call BPA s hotline at and ask to get referrals to speak with an attorney. The legal consultant will refer you to a local attorney for a no cost 30 minute face to face consultation or to a nationwide network of attorneys for a telephonic consultation of up to 30 minutes. In the event that you wish to retain a participating local attorney after the initial consultation, you will be provided with a preferred rate reduction of 25% from the attorney's normal hourly rate in most instances. You may receive consultation for any legal issue with the exception of those issues in the exclusions below. A financial counselor can address questions on all matters of financial management including debt reduction, home buying, budgeting, foreclosure and bankruptcy prevention. This service is for individuals who have trouble making ends meet, are receiving collection calls or letters, or are not able to pay down debt. Provides you with a telephonic, 30-minute consultation with a financial counselor to objectively assess your situation, create an action plan, and provide the knowledge and tools to implement that plan most effectively. You also have available a 25% discount if you opt to self-purchase additional assistance. Preparing, completing or filing of federal, state or local tax returns, any legal questions or problems involving: antitrust, business matters, securities law, environmental torts, administrative law, trademarks, copyrights, patents, or other related matters. Frivolous matters are excluded. A matter is defined as frivolous" if it has no merit, is brought for the sole purpose of harassing, vexing, or annoying another party, or as otherwise defined by the code of Professional Responsibility of the state in which the Plan Attorney is handling the matter for any Plan Members. (Please Note: If there is a conflict between this summary and the contract for this program, the terms of the contract will govern.) Visit our website at: There are many articles, tools and calculators to use in the Resource Links and Library, and we re especially pleased to offer the Depression Education Center which is accessible for anyone visiting our site. Simply click on the Members button to access the provider look-up, benefit description and authorization viewing features. For information about your benefits you can choose between two login options. Areas of this site that contain protected information will require you to register in order to receive a username and password. Otherwise, to view the general Twin Falls School District benefits you have available, you may login using your company s name. Organization Name: Twin Falls School District EAP Phone Number: Business Psychology Associates, ,

41 Twin Falls School District Employees have a 1-3 Session EAP Up to 3 Sessions Per Incident Per Program Year HOW TO CALL YOUR EMPLOYEE ASSISTANCE PROGRAM Business Psychology Associates Professional Counseling & Referral Services At No Cost to You! Easy to Access Always Confidential (Be assured that personal health information is not shared with your employer) 24-HOUR HOTLINE CALL TOLL-FREE ANYTIME TO FIND A PROVIDER NEAR YOU Log into our website to review your benefits at: Organization Name: Twin Falls School District Phone Number: REMEMBER The EAP can assist you with many different kinds of issues: Job related issues Relationship problems Child/Adolescent behavior problems Smoking cessation Alcohol and drug abuse Stress Anger Management Legal and Financial 40

42 Visit our website at: There are many articles, tools and calculators to use in the Resource Links and Library, and we re especially pleased to offer the Depression Education Center which is accessible for anyone visiting our site. Simply click on the Members button to access to the provider look-up, benefit description and authorization viewing features. For information about your benefits you can choose between two login options. Areas of this site that contain protected information will require you to register in order to receive a username and password. Otherwise, to view the general benefits you have available, you may login using your company s name. Organization Name: Twin Falls School District EAP Phone Number: Please feel free to contact BPA at with any questions. 41

43 Employee Support Program LEGAL, FINANCIAL, and ID RECOVERY LEGAL ASSIST: Provides a free half-hour consultation with an attorney on most legal issues. In most cases, discounted rates are available if further legal representation is required. FINANCIAL ASSIST: Provides a free telephonic consultation with a financial professional. ID THEFT PREVENTION AND RECOVERY: Provides a free telephonic consultation with an ID theft prevention and recovery professional. It also provides free registration to Control Your ID, an online ID monitoring program. If your identity is stolen while you are registered with Control Your ID, an ID theft professional will help you restore it. When a legal issue, financial matter, or an instance of identity fraud disrupts your life, it can create substantial stress for you and your family. To help minimize the impact, your employee support program will assist you with managing the many complexities of these events. Through professional consultation, these programs can save you time, while providing valuable information and peace of mind. TOLL-FREE: 800/ WEBSITE: USERNAME: Twin Falls School District PASSWORD:

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45 Group Effective Date: September 1, 2014 Twin Falls School District #411 Group Dental Plan Benefit Summary Members may seek care from any dental provider. Payments for services are based on a percentage of the allowed amount. Participating providers have agreed to accept the allowed amounts as payment for services. Members who receive care from a nonparticipating provider will be responsible for any charges over the allowed amounts, in addition to the coinsurance and the deductible. ENROLLMENT If you enroll during your initial 31 day eligibility period, a Qualifying Event or the Annual Enrollment Period, there are no waiting periods. If you enroll OUTSIDE of your initial 31 day eligibility period, a Qualifying Event or the Annual Enrollment Period, Class A benefits will have a 3 month waiting period month waiting period, Class B benefits will have a 6 month waiting period and Class C will have a 12 month waiting period. DEDUCTIBLE (Per calendar year) $25 per member $75 per family BENEFIT MAXIMUM (Per calendar year) $1,500 per member CLASS A: PREVENTIVE & DAGNOSTIC SERVICES Oral exams, limited to 2 per Calendar Year or up to 3 oral examinations per Calendar Year if the Member has been diagnosed with periodontal disease, diabetes or is pregnant Dental cleanings, including periodontal maintenance, limited to 2 per Calendar Year (whether they are considered cleanings or periodontal maintenance) or 3 cleanings or periodontal maintenance per Calendar Year if the Member has been diagnosed with periodontal disease, diabetes or is pregnant Fluoride treatment for members under age 18, limited to 1 treatment per Calendar Year Bitewing x-rays, limited to 1 set per Calendar Year Space maintainers for members under age 18, limited to 1 per Lifetime per area Intraoral periapical x-rays Intraoral complete mouth x-rays and panoramic mouth x-rays limited to 1 in a 3 year period Intraoral occlusal and extraoral x-rays Sealants for members under age 18, limited to 1 per molar every 5 years Preventive resin limited to 1 per tooth in every 5 years In-Network We Pay 100% (deductible waived) Out-of-Network We Pay (90% UCR allowed) 100% (deductible waived) CLASS B: RESTORATIVE SERVICES Fillings consisting of amalgam and composite restorations Emergency treatment for pain relief Sedative fillings General anesthesia or intravenous sedation Oral surgery - simple and surgical extractions of teeth Other oral surgery procedures Periodontal non surgical consisting of full mouth debridement Periodontal scaling and root planing, limited to once per Member per quadrant in a 2 year period Periodontal surgery including gingivectomy and gingivoplasty (gum surgery), osseous and mucogingival (bone) surgery, limited to once per member in a 5 year period Endodontic services consisting of pulpal debridement, apicoectomy and root canal limited to 1 tooth in a 2 year period Endodontics - direct pulp capping Endodontics - pulp therapy, apexification and recalcification 90% 80% 44

46 CLASS C: MAJOR SERVICES Prefabricated stainless steel crowns, limited to 1 in a 7 year period Crowns, inlays and onlays, limited to 1 in a 7 year period Crown build-ups, core & post, limited to 1 in a 7 year period Recementations Repair of crowns, bridges and implant supported prosthesis limited to 1 per tooth per Member per lifetime Fixed bridges, limited to 1 in a 7 year period Implants, limited to 4 per Member per Lifetime Repair of implants, limited to 1 per tooth in a 7 year period Dentures, complete, partial and overdenture, limited to 1 per Member per arch in a 7 year period Dentures rebased and relines, limited to 1 per Member per arch in a 3 year period Adjustments and repair of dentures, except when the adjustments or repairs are done within 1 year of initial placement, limited to 1 adjustment or repair per Calendar Year Tissue conditioning limited to 1 in a 7 year period Occlusal guard and repair 50% 40% General Exclusions: Noncovered services and supplies include, but are not limited to: Aesthetic Dental Procedures Antimicrobial Agents Benefits Not Stated. This means services and supplies that are not identified as benefits under the Policy. When a non-covered service or supply is performed or received at the same time as a Covered Service, only the portion of charges relating to the Covered Service will be considered eligible for payment. Collection of Cultures and Specimens Connector Bar or Stress Breaker Cosmetic/Reconstructive Services and Supplies, except in the treatment of a congenital anomaly for Members up to age 18; or to restore a physical bodily function lost as result of Injury or Illness. Desensitizing Diagnostic Casts or Study Models Duplicate X-Rays Experimental/Investigational treatments or procedures Facility Charges Fees, Taxes, Interest, etc, unless required by law. Fractures of the Mandible Gold Foil Restorations Home Visits Medication and Supply Charges Military Service-Related Expenses for services and supplies that are payable under any Motor Vehicle Coverage and Other Insurance Liability Nitrous Oxide Non-Direct Patient Care Occlusal Treatment Oral Hygiene Instructions Personal Comfort Items Photographic Images Pin Retention in Addition to Restoration Precision Attachments Prosthesis Services Provisional Splinting Replacements Services Riot, Rebellion, War and Illegal Acts Self-Help, Non Dental Self-Care, Training, or Instructional Programs Separate Charges Services and Supplies Provided by a Member of your Immediate Family Services Performed in a Laboratory Surgical Procedures Third Party Liability 45

47 General Exclusions: Noncovered services and supplies include, but are not limited to: Tooth Transplantation Services Travel and Transportation Expenses Treatment, Procedures, Techniques or Therapies Outside Generally Accepted Dental Care Practices Treatment started prior to the Member s Effective Date under this Policy or completed more than 30 days after coverage under this Policy terminates. Work-Related Conditions Orthodontic Services (except as specifically stated in the Orthodontic Benefits Rider, when elected). Temporomandibular Joint (TMJ) Dysfunction Treatment Services (except as specifically stated in the TMJ Benefits Rider, when elected). HOW TO FIND A DENTIST: Go to lifemapco.com, click the green Employers and Employees box, then Find a Provider button at the bottom of the screen. Select Dental Provider. Enter your search criteria and click submit. 46

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49 Group Number: ID308 Effective Date: September 1, 2014 Twin Falls School District #411 COPAYS No Annual Maximum No Deductible You pay $15 per Visit DIAGNOSTIC AND PREVENTIVE SERVICES Routine and Emergency Exams Covered with the Office Visit Copay Covered with the Office Visit Copay X-rays Covered with the Office Visit Copay Teeth Cleaning Covered with the Office Visit Copay Fluoride Treatment Covered with the Office Visit Copay Sealants (per Tooth) Covered with the Office Visit Copay Head and Neck Cancer Screening Covered with the Office Visit Copay Oral Hygiene Instruction Covered with the Office Visit Copay Periodontal Charting Covered with the Office Visit Copay Periodontal Evaluation RESTORATIVE DENTISTRY Covered with the Office Visit Copay Fillings (Amalgam) Porcelain-Metal Crown You pay a $50 Copay PROSTHODONTICS You pay a $150 Copay Complete Upper or Lower Denture You pay a $50 Copay Bridge (per Tooth) ENDODONTICS AND PERIODONTICS Covered with the Office Visit Copay Root Canal Therapy Anterior Covered with the Office Visit Copay Root Canal Therapy Bicuspid Covered with the Office Visit Copay Root Canal Therapy Molar Covered with the Office Visit Copay Osseous Surgery (per Quadrant) Covered with the Office Visit Copay Root Planing (per Quadrant) ORAL SURGERY Covered with the Office Visit Copay Routine Extraction (Single Tooth) Surgical Extraction Covered with the Office Visit Copay ORTHODONTIA TREATMENT Pre-Orthodontia Treatment You pay a $150 Copay* Comprehensive Orthodontia Treatment You pay a $1,500 Copay MISCELLANEOUS Local Anesthesia Covered with the Office Visit Copay Dental Lab Fees Covered with the Office Visit Copay Nitrous Oxide You pay a $20 Copay Specialty Office Visit You pay a $30 Copay per visit Out of Area Emergency Care Reimbursement You pay charges in excess of $250 Annual Maximum Deductible General Office Visit *Copayment credited towards the Comprehensive Orthodontic Service copayment if patient accepts treatment plan. Underwritten by Willamette Dental of Idaho, Inc. This plan provides extensive coverage of services and supplies to prevent, diagnose, and treat diseases or conditions of the teeth and supporting tissues. Presented are just some of the most common procedures covered in your plan. Please see the Certificate of Coverage for a complete plan description, limitations, and exclusions. Form No. 025-ID(6/13) Contract No. 001-ID(1/12) 48

50 Exclusions Bridges, crowns, dentures or any prosthetic devices requiring multiple treatment dates or fittings if the prosthetic item is installed or delivered more than 60 days after termination of coverage. The completion or delivery of treatments, services, or supplies initiated prior to the effective date of coverage Dental implants, including attachment devices and their maintenance. Endodontic services, prosthetic services, and implants that were provided prior to the effective date of coverage. Endodontic therapy completed more than 60 days after termination of coverage. Exams or consultations needed solely in connection with a service or supply not listed as covered. Experimental or investigational services or supplies and related exams or consultations. Full mouth reconstruction, including the extensive restoration of the mouth with crowns, bridges, or implants; and occlusal rehabilitation, including crowns, bridges, or implants used for the purpose of splinting, altering vertical dimension, restoring occlusions or correcting attrition, abrasion, or erosion. General anesthesia, moderate sedation and deep sedation. Hospital care or other care outside of a dental office for dental procedures, physician services, or facility fees. Maxillofacial prosthetic services. Nightguards. Orthognathic surgery. Personalized restorations. Plastic, reconstructive, or cosmetic surgery and other services or supplies, which are primarily intended to improve, alter, or enhance appearance. Prescription and over-the-counter drugs and premedications. Provider charges for a missed appointment or appointment cancelled without 24 hours prior notice. Replacement of lost, missing, or stolen dental appliances; replacement of dental appliances that are damaged due to abuse, misuse, or neglect. Replacement of sound restorations. Services or supplies and related exams or consultations that are not within the prescribed treatment plan and/or are not recommended and approved by a Willamette Dental Group dentist. Services or supplies and related exams or consultations to the extent they are not necessary for the diagnosis, care, or treatment of the condition involved. Services or supplies by any person other than a licensed dentist, denturist, hygienist, or dental assistant. Services or supplies for the diagnosis or treatment of temporomandibular joint disorders. Form No. 025-ID(6/13) Contract No. 001-ID(1/12) Services or supplies for the treatment of an occupational injury or disease, including an injury or disease arising out of self-employment or for which benefits are available under workers compensation or similar law. Services or supplies for treatment of injuries sustained while practicing for or competing in a professional athletic contest. Services or supplies for treatment of intentionally selfinflicted injuries. Services or supplies for which coverage is available under any federal, state, or other governmental program, unless required by law. Services or supplies not included in the contract. Services or supplies where there is no evidence of pathology, dysfunction, or disease other than covered preventive services. Limitations If alternative services can be used to treat a condition, the service recommended by the Willamette Dental Group dentist is covered. Services or supplies listed in the contract, which are provided to correct congenital or developmental malformations which impair functions of the teeth and supporting structures will be covered for dependent children if dental necessity has been established. Crowns, casts, or other indirect fabricated restorations are covered only if dentally necessary and if recommended by the Willamette Dental Group dentist. When initial root canal therapy was performed by a Willamette Dental Group dentist, the retreatment of such root canal therapy will be covered as part of the initial treatment for the first 24 months. When the initial root canal therapy was performed by a non-participating provider, the retreatment of such root canal therapy by a Willamette Dental Group dentist will be subject to the applicable copayments. The services provided by a dentist in a hospital setting are covered if medically necessary; pre-authorized in writing by a Willamette Dental Group dentist; the services provided are the same services that would be provided in a dental office; and applicable copayments are paid. The replacement of an existing denture, crown, inlay, onlay, or other prosthetic appliance or restoration denture is covered if the appliance is more than 5 years old and replacement is dentally necessary. 49

51 LifeMap Assurance Company TM PO Box 1271 M/S E3A Portland, OR Twin Falls School District #411 Eligible Active Employees and Eligible Retirees Benefits as of September 1, 2014 If you meet the insurance benefit eligibility criteria as established by your employer, you may purchase coverage for yourself and any eligible dependents. To maximize your Voluntary Vision Benefits, please visit a VSP Choice Network Preferred Provider; however you may visit a vision care provider out of the VSP Choice Network and submit your claim for reimbursement at the levels defined below. Well Vision Exam (does not include Contact Lens Exams) Every 12 months from first date of service Lenses VSP Choice Network Provider Covered in Full $10 copay Non-VSP Choice Network provider Up to $45 $10 copay Hardware (includes Lenses and Frames) Only One $25 copay every 12 months from first date of service* Every 12 months from the first date of service Frames Single Vision $25 copay* $25 copay*, then Plan covers up to $30 Lined Bifocal $25 copay* $25 copay*, then Plan covers up to $50 Lined Trifocal $25 copay* $25 copay*, then Plan covers up to $65 Every 12 months from first date of service Elective Contact Lenses For Contacts and Contact Lens exam (fitting and evaluation) Every 12 months from first date of service $25 copay*, then Plan covers up to $130 allowance -OR- Plan covers up to $130 allowance Copay waived 15% off contact lens exam (fitting and evaluation) $25 copay*, then Plan covers up to $70 Plan covers up to $105 Cost of coverage is based upon the number of family members electing coverage. Rates listed below are monthly and will be paid through payroll deduction. Rate Employee Only $6.44 Employee + Spouse $12.88 Employee + Child(ren) $13.79 Employee + Family $22.04 Additional Benefits include Laser VisionCare Program offers discounts for laser surgery including PRK, LASIK, and Custom LASIK Low Vision is vision loss sufficient enough to prevent reading and performing daily activities. With pre-approval from VSP, low vision supplemental testing is covered every two years and VSP will pay 75% of the cost for approved low vision aids, up to the maximum of $1,000 (less any amount paid for supplemental testing) per member every two years Exclusions The following items are excluded under this plan: Two pairs of glasses instead of bifocals Replacement of lenses, frames or contacts Medical or surgical treatment Orthoptics, vision training or supplemental testing Items not covered under the contact lens coverage: Insurance policies or service agreements Artistically painted or non-prescription lenses Additional office visits for contact lens pathology Contact lens modification, polishing or cleaning To find a VSP Provider 1. Go to vsp.com. 2. Click on the Members tab. 3. Enter Zip Code in the field on Find a VSP Doctor. 4. Click on Search. Customer Service can also help you find an eye doctor or tell you whether yours is in the network. Just give VSP a call at 1 (800)

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53 TruHearing Hearing Aid Discount Program At VSP Vision Care, we care about the overall health of our members, and we re committed to helping them experience life to the fullest. Like vision loss, hearing loss can have a huge impact on both workplace productivity and home life. In fact, the largest hearing impaired group in the United States is comprised of those under the age of 65 many of whom are still in the workforce and leading active lives. With the average cost of a pair of hearing aids topping $5,000, it's no wonder that 70% of the more than 30 million Americans who need hearing aids don't have them because they can't afford them. Discounts on Hearing Aids through TruHearing TruHearing is offering all VSP members and their covered dependents free access ($108 value) to the TruHearing MemberPlus Program* to enjoy deep discounts on some of the most popular digital hearing aids on the market. The TruHearing MemberPlus Program includes: Savings of up to 50%** on hearing aids Yearly comprehensive hearing exams for $75 3 visits with a hearing professional after purchase (fitting, programming and/or adjustments) Manufacturer s coverage for a one-time loss or damage for three years (replacement fee paid to manufacturer) 3-year repair warranty 48 batteries per purchased hearing aid TruHearing Discounts: Simple as 1-2-3! Taking advantage of the TruHearing discounts is easy. All a VSP member has to do is: 1. Sign up at vsp.truhearing.com and choose whether to enroll dependents and guest members as well. 2. Call TruHearing at to schedule an appointment. 3. Visit hearing aid center, receive exam, and purchase discounted aids. That s it! All transactions are between the VSP member and TruHearing. VSP members may also add up to four guest members (parents, grandparents, siblings) for a VSP-exclusive rate of $71 each. Best of all, if a member already has a hearing aid benefit from their health plan or employer, they can combine it with this program to maximize the benefit and reduce their out-of-pocket expense. Learn more about this VSP member offer at vsp.truhearing.com. *Through December 15, 2013 **Savings over national average retail prices; vary based on hearing aid model purchased 2012 Vision Service Plan. All rights reserved. VSP is a registered trademark of Vision Service Plan. TruHearing and TruHearing MemberPlus are registered trademarks of TruHearing, Inc. 52

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55 This summary is provided for your convenience only and is not intended to be inclusive of all policy provisions. Please see your certificate for complete details. If there is any discrepancy between this document and the master policy, master policy provisions will prevail. Twin Falls School District #411 Benefits As of 9/1/14 Life and Accidental Death & Dismemberment (AD&D) Class 1 Administrators (working 30+ hours per week) Basic Life/AD&D Insurance Additional Life/AD&D Additional Life Underwriting Age Reduction AD&D Schedule Seat Belt Benefit Accelerated Benefit Total Disability Repatriation Additional AD&D Benefits Included Basic Life Insurance Exclusions AD&D Insurance Exclusions Conversion Portability (Total Disability and Accelerated Benefits not available under the Portability provision) $20,000 (100% Employer Paid) $50,000 (100% Employee Paid) Coverage is guarantee issue (no medical questions) if you enroll within your first 31 days of initial eligibility. If you do not elect coverage within your 31 day initial election period, you may only enroll in the future by completing a health statement and being approved by LifeMap. If approved, we will notified of your effective date. If you are still working the required number of hours to be eligible for this insurance at age 65, your benefits will reduce to 65% at age 65, to 50% at age 70, and to 35% at age 75. If due to an accident you die, lose a limb, sight of an eye or become paralyzed, the following benefits are available. 100% of the Basic AD&D 75% of the Basic AD&D 50% of the Basic AD&D Life Paraplegia One hand Both hands Triplegia One foot Both feet Sight of one eye Sight of both eyes 25% of the Basic AD&D Speech One hand and one foot Thumb and Index finger Hemiplegia One hand and sight of one eye Uniplegia Hearing One foot and sight of one eye Quadriplegia If you die in an automobile accident and were wearing your seat belt, your beneficiary (ies) will collect an amount equal to the AD&D benefit to a maximum of $10,000 in addition to the Basic Life and Basic AD&D benefits described above. You may collect part of your Basic Life insurance prior to death if you are diagnosed as terminally ill and have a life expectancy of less than 12 months. You may apply for up to 80% of the Basic Life insurance in force. The remaining benefit you do not elect is payable to your beneficiary upon your death. If you become totally disabled (as defined by the policy) prior to age 60 and are disabled for at least 6 consecutive months, your basic life insurance may be continued until you reach age 65 without further premium payment by either your employer or you. At age 65 coverage terminates, however you may continue coverage by applying for a conversion policy at that time. If death occurs more than 100 miles from your primary residence, we will pay the lesser of; the actual expense, 10% of the Life benefit or $5,000 to prepare and ship your body to the place of burial or cremation. Adaptive Home/Vehicle, AirBag, Child Education, Coma, Day Care, Exposure and Disappearance, Felonious Assault, and Spouse Education. None Benefits are not payable for losses due to suicide or attempted suicide, riot, war or act of war, military service, committing or attempting to commit an assault or felony, use of drugs (legal or illegal) unless prescribed by and used in accordance with directions of the prescribing physician, bacterial or viral infections not the result of an injury, heart attack or stroke, travel and flight in or descent from any aircraft, including balloons and gliders, except as a fare-paying passenger on a regularly scheduled flight and intoxication at or above the state legal limit. You may convert your Basic Life insurance to an individual policy if your coverage is terminated due to termination of employment or other loss of eligibility. You have 31 days from the earliest of, the date your employment terminates or other loss of eligibility to apply for the Conversion policy. Portability allows you continue your Basic Life insurance up to a $500,000 maximum if your coverage ends provided you are under age 65, not retiring, not in the military and are not disabled. The rates charged will be the current rates plus a billing fee. To elect coverage, please contact us for a Portability Application and return it to us with your premium check to LifeMap within 31 days from the date your group coverage ends. If elected, Portability coverage will end the earliest of when you reach age 65 or when this master policy terminates. Travel Assistance - You and dependents traveling with you, when 100 or more miles away from home, or outside of your home country, can obtain emergency medical, travel, and personal security assistance 24 hours a day, anywhere in the world. You can find out more about this benefit by visiting our website at LifeMapCo.com or by contacting FrontierMEDEX directly at , your FrontierMEDEX ID Number is This product is not insured by LifeMap Assurance Company. It is a service provided through FrontierMEDEX, a leading provider of international travel assistance services. Twin Falls SD - CL 1 Basic Life AD&D Buy up Eff docx 8/5/ All Coverage Underwritten by LifeMap Assurance Company LifeMap Assurance Company, all rights reserved.

56 This summary is provided for your convenience only and is not intended to be inclusive of all policy provisions. Please see your certificate for complete details. If there is any discrepancy between this document and the master policy, master policy provisions will prevail. Twin Falls School District #411 Benefits As of 9/1/14 Dependent Life Benefits Eligible Dependents Exclusions Conversion Portability Underwriting Dependent Life Employee Paid Payroll Deduction $5,000 Spouse, $2,000 per Child Legal spouse and children to age 26. See Certificate of Coverage for definition of eligible dependent child. None You may convert your Dependent Life insurance to an individual policy if your coverage is terminated due to termination of employment or other loss of eligibility. You have 31 days from the earliest of, the date your employment terminates or other loss of eligibility to apply for the Conversion policy. Portability allows you (or your spouse) to continue Basic Dependent Life for your covered dependents if their coverage ends provided your spouse is under age 65 and dependent children are under age 26. The rates charged will be the current rates plus a billing fee. To elect coverage, please contact us for a Portability Application and return it to us with your premium check to LifeMap within 31 days from the date your group coverage ends. If elected, Portability coverage will end the earliest of; the date your spouse reaches age 65, dependent children reach age 26 or when this master policy terminates. This coverage is guarantee issue (no medical questions) if applied for within your initial 31 day eligibility waiting period or within 31 days of you acquiring new dependents (birth or marriage). If applied for outside of these time periods, a health statement will be required and your dependents will need to be approved by LifeMap. If approved, we will notify you of the effective date. If one dependent is declined, all dependents are declined. 55

57 This summary is provided for your convenience only and is not intended to be inclusive of all policy provisions. Please see your certificate for complete details. If there is any discrepancy between this document and the master policy, master policy provisions will prevail. Twin Falls School District #411 Benefits As of 9/1/14 Life and Accidental Death & Dismemberment (AD&D) Class 2 Administrators (working between hours per week) Basic Life/AD&D Insurance Additional Life/AD&D Basic and Additional Life Underwriting Age Reduction AD&D Schedule Seat Belt Benefit Accelerated Benefit Total Disability Repatriation Additional AD&D Benefits Included Basic Life Insurance Exclusions AD&D Insurance Exclusions Conversion Portability (Total Disability and Accelerated Benefits not available under the Portability provision) $20,000 (50% Employer Paid) $50,000 (100% Employee Paid) Coverage is guarantee issue (no medical questions) if you enroll within your first 31 days of initial eligibility. If you do not elect coverage within your 31 day initial election period, you may only enroll in the future by completing a health statement and being approved by LifeMap. If approved, we will notified of your effective date. If you are still working the required number of hours to be eligible for this insurance at age 65, your benefits will reduce to 65% at age 65, to 50% at age 70, and to 35% at age 75. If due to an accident you die, lose a limb, sight of an eye or become paralyzed, the following benefits are available. 100% of the Basic AD&D 75% of the Basic AD&D 50% of the Basic AD&D Life Paraplegia One hand Both hands Triplegia One foot Both feet Sight of both eyes 25% of the Basic AD&D Speech One hand and one foot Thumb and Index finger Hemiplegia One hand and sight of one eye Uniplegia Hearing One foot and sight of one eye Quadriplegia Sight of one eye If you die in an automobile accident and were wearing your seat belt, your beneficiary (ies) will collect an amount equal to the AD&D benefit to a maximum of $10,000 in addition to the Basic Life and Basic AD&D benefits described above. You may collect part of your Basic Life insurance prior to death if you are diagnosed as terminally ill and have a life expectancy of less than 12 months. You may apply for up to 80% of the Basic Life insurance in force. The remaining benefit you do not elect is payable to your beneficiary upon your death. If you become totally disabled (as defined by the policy) prior to age 60 and are disabled for at least 6 consecutive months, your basic life insurance may be continued until you reach age 65 without further premium payment by either your employer or you. At age 65 coverage terminates, however you may continue coverage by applying for a conversion policy at that time. If death occurs more than 100 miles from your primary residence, we will pay the lesser of; the actual expense, 10% of the Life benefit or $5,000 to prepare and ship your body to the place of burial or cremation. Adaptive Home/Vehicle, AirBag, Child Education, Coma, Day Care, Exposure and Disappearance, Felonious Assault, and Spouse Education. None Benefits are not payable for losses due to suicide or attempted suicide, riot, war or act of war, military service, committing or attempting to commit an assault or felony, use of drugs (legal or illegal) unless prescribed by and used in accordance with directions of the prescribing physician, bacterial or viral infections not the result of an injury, heart attack or stroke, travel and flight in or descent from any aircraft, including balloons and gliders, except as a fare-paying passenger on a regularly scheduled flight and intoxication at or above the state legal limit. You may convert your Basic Life insurance to an individual policy if your coverage is terminated due to termination of employment or other loss of eligibility. You have 31 days from the earliest of, the date your employment terminates or other loss of eligibility to apply for the Conversion policy. Portability allows you continue your Basic Life insurance up to a $500,000 maximum if your coverage ends provided you are under age 65, not retiring, not in the military and are not disabled. The rates charged will be the current rates plus a billing fee. To elect coverage, please contact us for a Portability Application and return it to us with your premium check to LifeMap within 31 days from the date your group coverage ends. If elected, Portability coverage will end the earliest of when you reach age 65 or when this master policy terminates. Travel Assistance - You and dependents traveling with you, when 100 or more miles away from home, or outside of your home country, can obtain emergency medical, travel, and personal security assistance 24 hours a day, anywhere in the world. You can find out more about this benefit by visiting our website at LifeMapCo.com or by contacting FrontierMEDEX directly at , your FrontierMEDEX ID Number is This product is not insured by LifeMap Assurance Company. It is a service provided through FrontierMEDEX, a leading provider of international travel assistance services. 56

58 This summary is provided for your convenience only and is not intended to be inclusive of all policy provisions. Please see your certificate for complete details. If there is any discrepancy between this document and the master policy, master policy provisions will prevail. Twin Falls School District #411 Benefits As of 9/1/14 Dependent Life Benefits Eligible Dependents Exclusions Conversion Portability Underwriting Dependent Life Employee Paid Payroll Deduction $5,000 Spouse, $2,000 per Child Legal spouse and children to age 26. See Certificate of Coverage for definition of eligible dependent child. None You may convert your Dependent Life insurance to an individual policy if your coverage is terminated due to termination of employment or other loss of eligibility. You have 31 days from the earliest of, the date your employment terminates or other loss of eligibility to apply for the Conversion policy. Portability allows you (or your spouse) to continue Basic Dependent Life for your covered dependents if their coverage ends provided your spouse is under age 65 and dependent children are under age 26. The rates charged will be the current rates plus a billing fee. To elect coverage, please contact us for a Portability Application and return it to us with your premium check to LifeMap within 31 days from the date your group coverage ends. If elected, Portability coverage will end the earliest of; the date your spouse reaches age 65, dependent children reach age 26 or when this master policy terminates. This coverage is guarantee issue (no medical questions) if applied for within your initial 31 day eligibility waiting period or within 31 days of you acquiring new dependents (birth or marriage). If applied for outside of these time periods, a health statement will be required and your dependents will need to be approved by LifeMap. If approved, we will notify you of the effective date. If one dependent is declined, all dependents are declined. 57

59 This summary is provided for your convenience only and is not intended to be inclusive of all policy provisions. Please see your certificate for complete details. If there is any discrepancy between this document and the master policy, master policy provisions will prevail. Twin Falls School District #411 Benefits As of 9/1/14 Life and Accidental Death & Dismemberment (AD&D) Class 3 All Others 100% Employer Paid (working 30+ hours per week) Basic Life Insurance $20,000 Basic AD&D $20,000 Insurance Age Reduction If you are still working the required number of hours to be eligible for this insurance at age 65, your benefits will reduce to 65% at age 65, to 50% at age 70, and to 35% at age 70. AD&D Schedule If due to an accident you die, lose a limb, sight of an eye or become paralyzed, the following benefits are available. 100% of the Basic AD&D 75% of the Basic AD&D 50% of the Basic AD&D Life Paraplegia One hand Both hands Triplegia One foot Both feet Sight of one eye Sight of both eyes 25% of the Basic AD&D Speech One hand and one foot Thumb and Index finger Hemiplegia One hand and sight of one eye Uniplegia Hearing One foot and sight of one eye Quadriplegia Seat Belt Benefit If you die in an automobile accident and were wearing your seat belt, your beneficiary (ies) will collect an amount equal to the AD&D benefit to a maximum of $10,000 in addition to the Basic Life and Basic AD&D benefits described above. Accelerated Benefit You may collect part of your Basic Life insurance prior to death if you are diagnosed as terminally ill and have a life expectancy of less than 12 months. You may apply for up to 80% of the Basic Life insurance in force. The remaining benefit you do not elect is payable to your beneficiary upon your death. Total Disability If you become totally disabled (as defined by the policy) prior to age 60 and are disabled for at least 6 consecutive months, your basic life insurance may be continued until you reach age 65 without further premium payment by either your employer or you. At age 65 coverage terminates, however you may continue coverage by applying for a conversion policy at that time. Repatriation If death occurs more than 100 miles from your primary residence, we will pay the lesser of; the actual expense, 10% of the Life benefit or $5,000 to prepare and ship your body to the place of burial or cremation. Additional AD&D Benefits Included Adaptive Home/Vehicle, AirBag, Child Education, Coma, Day Care, Exposure and Disappearance, Felonious Assault, and Spouse Education. Basic Life Insurance None Exclusions AD&D Insurance Exclusions Benefits are not payable for losses due to suicide or attempted suicide, riot, war or act of war, military service, committing or attempting to commit an assault or felony, use of drugs (legal or illegal) unless prescribed by and used in accordance with directions of the prescribing physician, bacterial or viral infections not the result of an injury, heart attack or stroke, travel and flight in or descent from any aircraft, including balloons and gliders, except as a fare-paying passenger on a regularly scheduled flight and intoxication at or above the state legal limit. Conversion You may convert your Basic Life insurance to an individual policy if your coverage is terminated due to termination of employment or other loss of eligibility. You have 31 days from the earliest of, the date your employment terminates or other loss of eligibility to apply for the Conversion policy. Portability (Total Disability and Accelerated Benefits not available under the Portability provision) Portability allows you continue your Basic Life insurance up to a $500,000 maximum if your coverage ends provided you are under age 65, not retiring, not in the military and are not disabled. The rates charged will be the current rates plus a billing fee. To elect coverage, please contact us for a Portability Application and return it to us with your premium check to LifeMap within 31 days from the date your group coverage ends. If elected, Portability coverage will end the earliest of when you reach age 65 or when this master policy terminates. Travel Assistance - You and dependents traveling with you, when 100 or more miles away from home, or outside of your home country, can obtain emergency medical, travel, and personal security assistance 24 hours a day, anywhere in the world. You can find out more about this benefit by visiting our website at LifeMapCo.com or by contacting FrontierMEDEX directly at , your FrontierMEDEX ID Number is This product is not insured by LifeMap Assurance Company. It is a service provided through FrontierMEDEX, a leading provider of international travel assistance services. 58

60 This summary is provided for your convenience only and is not intended to be inclusive of all policy provisions. Please see your certificate for complete details. If there is any discrepancy between this document and the master policy, master policy provisions will prevail. Twin Falls School District #411 Benefits As of 9/1/14 Dependent Life Benefits Eligible Dependents Exclusions Conversion Portability Underwriting Dependent Life Employee Paid Payroll Deduction $5,000 Spouse, $2,000 per Child Legal spouse and children to age 26. See Certificate of Coverage for definition of eligible dependent child. None You may convert your Dependent Life insurance to an individual policy if your coverage is terminated due to termination of employment or other loss of eligibility. You have 31 days from the earliest of, the date your employment terminates or other loss of eligibility to apply for the Conversion policy. Portability allows you (or your spouse) to continue Basic Dependent Life for your covered dependents if their coverage ends provided your spouse is under age 65 and dependent children are under age 26. The rates charged will be the current rates plus a billing fee. To elect coverage, please contact us for a Portability Application and return it to us with your premium check to LifeMap within 31 days from the date your group coverage ends. If elected, Portability coverage will end the earliest of; the date your spouse reaches age 65, dependent children reach age 26 or when this master policy terminates. This coverage is guarantee issue (no medical questions) if applied for within your initial 31 day eligibility waiting period or within 31 days of you acquiring new dependents (birth or marriage). If applied for outside of these time periods, a health statement will be required and your dependents will need to be approved by LifeMap. If approved, we will notify you of the effective date. If one dependent is declined, all dependents are declined. 59

61 This summary is provided for your convenience only and is not intended to be inclusive of all policy provisions. Please see your certificate for complete details. If there is any discrepancy between this document and the master policy, master policy provisions will prevail. Twin Falls School District #411 Benefits As of 9/1/14 Life and Accidental Death & Dismemberment (AD&D) Class 4 All Others 50% Employer Paid (working hours per week) Basic Life Insurance $20,000 Basic AD&D $20,000 Insurance Basic Life Underwriting Coverage is guarantee issue (no medical questions) if you enroll within your first 31 days of initial eligibility. If you do not elect coverage within your 31 day initial election period, you may only enroll in the future by completing a health statement and being approved by LifeMap. If approved, we will notified of your effective date. Age Reduction If you are still working the required number of hours to be eligible for this insurance at age 65, your benefits will reduce to 65% at age 65, to 50% at age 70, and to 35% at age 70. AD&D Schedule If due to an accident you die, lose a limb, sight of an eye or become paralyzed, the following benefits are available. 100% of the Basic AD&D 75% of the Basic AD&D 50% of the Basic AD&D Life Paraplegia One hand Both hands Triplegia One foot Both feet Sight of one eye Sight of both eyes 25% of the Basic AD&D Speech One hand and one foot Thumb and Index finger Hemiplegia One hand and sight of one eye Uniplegia Hearing One foot and sight of one eye Quadriplegia Seat Belt Benefit If you die in an automobile accident and were wearing your seat belt, your beneficiary (ies) will collect an amount equal to the AD&D benefit to a maximum of $10,000 in addition to the Basic Life and Basic AD&D benefits described above. Accelerated Benefit You may collect part of your Basic Life insurance prior to death if you are diagnosed as terminally ill and have a life expectancy of less than 12 months. You may apply for up to 80% of the Basic Life insurance in force. The remaining benefit you do not elect is payable to your beneficiary upon your death. Total Disability If you become totally disabled (as defined by the policy) prior to age 60 and are disabled for at least 6 consecutive months, your basic life insurance may be continued until you reach age 65 without further premium payment by either your employer or you. At age 65 coverage terminates, however you may continue coverage by applying for a conversion policy at that time. Repatriation If death occurs more than 100 miles from your primary residence, we will pay the lesser of; the actual expense, 10% of the Life benefit or $5,000 to prepare and ship your body to the place of burial or cremation. Additional AD&D Benefits Included Adaptive Home/Vehicle, AirBag, Child Education, Coma, Day Care, Exposure and Disappearance, Felonious Assault, and Spouse Education. Basic Life Insurance None Exclusions AD&D Insurance Exclusions Conversion Portability (Total Disability and Accelerated Benefits not available under the Portability provision) Benefits are not payable for losses due to suicide or attempted suicide, riot, war or act of war, military service, committing or attempting to commit an assault or felony, use of drugs (legal or illegal) unless prescribed by and used in accordance with directions of the prescribing physician, bacterial or viral infections not the result of an injury, heart attack or stroke, travel and flight in or descent from any aircraft, including balloons and gliders, except as a fare-paying passenger on a regularly scheduled flight and intoxication at or above the state legal limit. You may convert your Basic Life insurance to an individual policy if your coverage is terminated due to termination of employment or other loss of eligibility. You have 31 days from the earliest of, the date your employment terminates or other loss of eligibility to apply for the Conversion policy. Portability allows you continue your Basic Life insurance up to a $500,000 maximum if your coverage ends provided you are under age 65, not retiring, not in the military and are not disabled. The rates charged will be the current rates plus a billing fee. To elect coverage, please contact us for a Portability Application and return it to us with your premium check to LifeMap within 31 days from the date your group coverage ends. If elected, Portability coverage will end the earliest of when you reach age 65 or when this master policy terminates. Travel Assistance - You and dependents traveling with you, when 100 or more miles away from home, or outside of your home country, can obtain emergency medical, travel, and personal security assistance 24 hours a day, anywhere in the world. You can find out more about this benefit by visiting our website at LifeMapCo.com or by contacting FrontierMEDEX directly at , your FrontierMEDEX ID Number is This product is not insured by LifeMap Assurance Company. It is a service provided through FrontierMEDEX, a leading provider of international travel assistance services. 60

62 This summary is provided for your convenience only and is not intended to be inclusive of all policy provisions. Please see your certificate for complete details. If there is any discrepancy between this document and the master policy, master policy provisions will prevail. Twin Falls School District #411 Benefits As of 9/1/14 Dependent Life Benefits Eligible Dependents Exclusions Conversion Portability Underwriting Dependent Life Employee Paid Payroll Deduction $5,000 Spouse, $2,000 per Child Legal spouse and children to age 26. See Certificate of Coverage for definition of eligible dependent child. None You may convert your Dependent Life insurance to an individual policy if your coverage is terminated due to termination of employment or other loss of eligibility. You have 31 days from the earliest of, the date your employment terminates or other loss of eligibility to apply for the Conversion policy. Portability allows you (or your spouse) to continue Basic Dependent Life for your covered dependents if their coverage ends provided your spouse is under age 65 and dependent children are under age 26. The rates charged will be the current rates plus a billing fee. To elect coverage, please contact us for a Portability Application and return it to us with your premium check to LifeMap within 31 days from the date your group coverage ends. If elected, Portability coverage will end the earliest of; the date your spouse reaches age 65, dependent children reach age 26 or when this master policy terminates. This coverage is guarantee issue (no medical questions) if applied for within your initial 31 day eligibility waiting period or within 31 days of you acquiring new dependents (birth or marriage). If applied for outside of these time periods, a health statement will be required and your dependents will need to be approved by LifeMap. If approved, we will notify you of the effective date. If one dependent is declined, all dependents are declined. 61

63 Eligibility Amounts Available Age Reduction Accelerated Benefit Underwriting and Effective Date Total Disability Cost - Rates Repatriation Exclusions Conversion Portability (Total Disability and Accelerated Benefits not available under the Portability provision) This summary is provided for your convenience only and is not intended to be inclusive of all policy provisions. Please see your certificate for complete details. If there is any discrepancy between this document and the master policy, master policy provisions will prevail. Twin Falls School District #411 All Eligible Employees Except Retirees Benefits As of 9/1/14 Select Voluntary Life Insurance (Payroll Deduction) Employees enrolled in the Basic Life plan, their spouses and eligible dependent children. Employees may select, in $10,000 increments, from a minimum of $10,000 to a maximum of 5 times the annual earnings, rounded to the next higher increment, not to exceed $400,000. Spouses may select from a minimum of $10,000 to $300,000 in $10,000 increments. Spouses may enroll in the Voluntary Life plan even if the employee does not enroll. Dependent Child(ren) coverage may be selected if the employee elects and is approved for coverage. Coverage may be elected from a minimum of $2,000 to $10,000 in $2,000 increments. Dependent children are eligible from birth to age 26. If you are still working the required number of hours to be eligible for this insurance at age 65, your benefits will reduce to 65% at age 65, 45% at age 70, 30% at age 75. You may collect part of your Voluntary Life insurance prior to death if you are diagnosed as terminally ill and have a life expectancy of less than 12 months. You may apply for up to 80% of the Voluntary Life insurance in force, to a $250,000 maximum. The remaining benefit you do not elect is payable to your beneficiary upon your death. SPECIAL ONE TIME OPEN ENROLLLMENT - If you, your spouse, or children are currently enrolled in the Voluntary Life plan, YOU NEED TO LOGIN TO the mystro website at and elect a new benefit. Current amounts of coverage will NOT be grandfathered. If you have not participated in the Voluntary Life plan in the past and wish to apply or increase your amount of coverage, you will need to LOGIN TO THE mystro website at and check the appropriate sections on mystro. Any election made between 8/1/14 and 8/22/14 will be guarantee issue (no medical questions) for employees, spouses and children subject to the maximums listed below. Employee - Employees may apply for up to the lesser of 5 times annual earnings or $400,000 guarantee issue (no medial questions required). Spouse Spouses may apply for up to $50,000 guarantee issue (no medical questions required) Amounts over $50,000 require the medical questions. Dependent Children All amounts for Dependent Child(ren) are guarantee issue (no medical questions required). Future open enrollments if you (the employee) elected the minimum coverage of $10,000 when you were initially eligible, you may apply for up to the guarantee issue with no medical questions. All amounts applied for (or increases) for spouses and dependent children require the medical questions and approval by LifeMap Assurance Company. Any amount of coverage (or increase) applied for outside of initial eligibility or Future Open Enrollment for the employee requires the medical questions. Any amount of coverage applied for outside of initial eligibility for spouse or child(ren) require(s) the medical questions and approval by LifeMap Assurance Company. Any coverage requiring the health statement is not effective unless approved in writing by LifeMap. You will be notified of the effective date of coverage after your health statement is approved. In some cases, we may request a Paramed Exam. If requested, the Paramed Exam will be at LifeMap s expense. If you become totally disabled (as defined by the policy) prior to age 60 and are disabled for at least 6 consecutive months, your Voluntary Life insurance may be continued until you reach age 65 without further premium payment by either your employer or you. Employee and Spouse premiums are based on their individual ages and are paid through the employee s payroll deduction. Employee and Spouse Monthly Rate per $1,000 of Coverage Age Rate Age Rate Age Rate Under age 25 $ $ $ Child(ren) - $.224 per $2,000 increment regardless of the number of covered children If death occurs more than 100 miles from your primary residence, we will pay the lesser of; the actual expense, 10% of the Life benefit or $5,000 to prepare and ship your body to the place of burial or cremation. Benefits are not payable for losses due to suicide or attempted suicide during the first two years of coverage. You may convert your Voluntary Life insurance to an individual policy if your coverage is terminated due to termination of employment or other loss of eligibility. You have 31 days from the earliest of, the date your employment terminates or other loss of eligibility to apply for the Conversion policy. Portability allows you to continue Voluntary Life Insurance for yourself and your covered dependents if your coverage ends provided you are under age 65, not retiring, not in the military and are not disabled. The maximum that can be ported will be $500,000 combined with your Basic Life Insurance. The rates charged will be the current rates plus a billing fee. To elect coverage, please contact us for a Portability Application and return it to us with your premium check to LifeMap within 31 days from the date your group coverage ends. If elected, Portability coverage will end the earliest of when you reach age 65 or when this master policy terminates. 62

64 This summary is provided for your convenience only and is not intended to be inclusive of all policy provisions. Please see your certificate for complete details. If there is any discrepancy between this document and the master policy, master policy provisions will prevail. Twin Falls School District #411 All Eligible Employees Except Retirees Benefits As of 9/1/14 Voluntary Accidental Death & Dismemberment Insurance (Payroll Deduction) Eligibility Amounts Available Age Reduction Underwriting and Effective Date AD&D Schedule Cost - Rates Employees enrolled in the Basic Life plan, their spouses and eligible dependent children. Employees may select, in $10,000 increments, from a minimum of $10,000 to a maximum of 5 times the annual earnings, rounded to the next higher increment, not to exceed $400,000. Spouses may select from a minimum of $10,000 to $300,000 in $10,000 increments. Spouses may enroll independently of the employee. Dependent Child(ren) coverage may be selected if the employee is enrolled. Coverage may be elected from a minimum of $2,000 to $10,000 in $2,000 increments. Dependent children are eligible from birth to age 26. The Voluntary AD&D benefit is a separate election from the Voluntary Life and does not need to match the Voluntary Life amount. If you are still working the required number of hours to be eligible for this insurance at age 65, your benefits will reduce to 65% at age 65, to 50% at age 70, and to 35% at age 75. All amounts of coverage are guarantee issue and require no medical questions to be answered. Your effective date will be assigned by LifeMap. If due to an accident you die, lose a limb, sight of an eye or become paralyzed, the following benefits are available. 100% of the Basic AD&D 75% of the Basic AD&D 50% of the Basic AD&D Life Paraplegia One hand Both hands Triplegia One foot Both feet Sight of one eye Sight of both eyes 25% of the Basic AD&D Speech One hand and one foot Thumb and Index finger Hemiplegia One hand and sight of one eye Uniplegia Hearing One foot and sight of one eye Quadriplegia Employee and Spouse monthly rate is $.25/$10,000 increment Child monthly rate is $.03/ $2,000 increment Employee and Spouse x.25 = No. of $10,000 increments Rate per $10,000 increment Monthly Premium Additional Benefits Exclusions Conversion/Portability Child x. 03 = No. of $2,000 increments Rate per $2,000 increment Monthly Premium Adaptive Home and Vehicle Benefit, Air Bag Benefit, Seat Belt Benefit, Child Education Benefit, Coma, Day Care Benefit, Exposure and Disappearance, Felonious Assault, Rehabilitative Benefit, Seat Belt Benefit and Spouse Education Benefit. Voluntary AD&D benefits are not payable for death or dismemberment caused by or as result of: suicide or such attempts; participation in a riot; war or act of war; military service for any country; committing or attempting to commit an assault or felony; sickness, disease or pregnancy or any medical treatment for sickness, disease or pregnancy, heart attack or stroke; bodily infirmity or disease from bacterial or viral infections not the result of an injury; or taking medications, drugs, sedatives, narcotics, barbiturates, amphetamines or hallucinogens unless prescribed and used/consumed in accordance with the directions of the prescribing physician or administered by a licensed physician. Not available. 63

65 LifeMap Assurance Company PLUS PROGRAM ASSISTANCE PROGRAM DESCRIPTION A comprehensive program providing You with 24/7 emergency medical and travel assistance services when You are outside Your Home Country or 100 or more miles away from Your permanent residence in Your Home Country. The program also provides emergency security or political evacuation and repatriation services when You are outside of Your Home Country. (Expatriates are eligible regardless of distance from your expatriate home.) How To Use FrontierMEDEX PLUS Services 24 hours a day, 7 days a week, 365 days a year FrontierMEDEX is your key to travel safety. If You have a medical, security, or travel problem, simply call Us for assistance. Our toll-free and collect-call telephone numbers are printed on Your ID card. Either call the toll-free number of the country You are in, or call the Emergency Response Center collect at: Baltimore, Maryland A FrontierMEDEX assistance coordinator will ask for Your name, Your company or group name, the FrontierMEDEX ID number shown on Your ID card, and a description of Your situation. We will immediately begin assisting You. A full listing of services follows. If the condition is an emergency, You should go immediately to the nearest physician or hospital without delay and then contact the 24-hour Emergency Response Center. We will then take the appropriate action to assist You and monitor Your care until the situation is resolved. FrontierMEDEX PLUS provides You with Medical Assistance Services, Travel Assistance Services, Medical Evacuation and Repatriation Services, Security and Political Evacuation Assistance Services and Worldwide Destination Intelligence as described below. These services are subject to certain Conditions and Limitations also described below. FrontierMEDEX, Inc. P.O. Box Baltimore, MD

66 MEDICAL ASSISTANCE SERVICES Worldwide Medical and Dental Referrals: We will provide referrals to help You locate appropriate treatment or care. Monitoring of Treatment: Our assistance coordinators will continually monitor Your case. In addition, Our FrontierMEDEX Physician Advisors provide Us consultative and advisory services, including review and analysis of the quality of medical care You are receiving. Facilitation of Hospital Payments: Upon securing payment or a guarantee to reimburse, We will either wire funds or guarantee required emergency hospital admittance deposits. You are ultimately responsible for the payment of the cost of medical care and treatment, including hospital expenses. Transfer of Insurance Information to Medical Providers: We will assist You with hospital admission, such as relaying insurance benefit information, to help prevent delays or denials of medical care. We will also assist with discharge planning. Medication, Vaccine and Blood Transfers: In the event medication, vaccines, or blood products are not available locally, or a prescription medication is lost or stolen, We will coordinate their transfer to You upon the prescribing physician s authorization, if it is legally permissible. Dispatch of Doctors/Specialists: In an emergency where You cannot adequately be assessed by telephone for possible evacuation, or You cannot be moved and local treatment is unavailable, We will send an appropriate medical practitioner to You. Transfer of Medical Records: Upon Your consent, We will assist with the transfer of medical information and records to You or the treating physician. Continuous Updates to Family, Employer, and Home Physician: With Your approval, We will provide case updates to appropriate individuals You designate in order to keep them informed. Hotel Arrangements for Convalescence: We will assist You with the arrangement of hotel stays and room requirements before or after hospitalization. Replacement of Corrective Lenses and Medical Devices: We will coordinate the replacement of corrective lenses or medical devices if they are lost, stolen, or broken during travel. TRAVEL ASSISTANCE SERVICES Replacement of Lost or Stolen Travel Documents: We will assist You in taking the necessary steps to replace passports, tickets, and other important travel documents. Emergency Travel Arrangements: We will make new reservations for airlines, hotels, and other travel services in the event of an Illness or Injury. Transfer of Funds: We will provide You with an emergency cash advance subject to Us first securing funds from You or Your family. Legal Referrals: Should You require legal assistance, We will direct You to an attorney and assist You in securing a bail bond. Translation Services: Our multilingual assistance coordinators are available to provide immediate verbal translation assistance in a variety of languages in an emergency; otherwise We will provide You with referrals to local interpreter services. Message Transmittals: You may send and receive emergency messages toll-free, 24-hours a day, through Our Emergency Response Center. WORLDWIDE DESTINATION INTELLIGENCE Destination Profiles: When preparing for travel You can contact the Emergency Response Center to have a pre-trip destination report sent to You. This report draws upon Our intelligence database of over 280 cities covering subject such as health and security risks, immunizations, vaccinations, local hospitals, crime, emergency phone numbers, culture, weather, transportation information, entry and exit requirements, and currency. Our global medical and security database of over 170 countries and 280 cities is continuously updated and includes intelligence from thousands of worldwide sources. 65

67 MEDICAL EVACUATION & REPATRIATION SERVICES The following services are available if the Participant suffers an Injury or a sudden and unexpected Illness and Your medical condition requires these emergency services: Emergency Medical Evacuation: If You sustain an Injury or suffer a sudden and unexpected Illness and adequate medical treatment is not available in Your current location, We will arrange and pay for a medically supervised evacuation to the nearest medical facility We determine to be capable of providing appropriate medical treatment. Your medical condition and situation must be such that, in the professional opinion of the health care provider and FrontierMEDEX, You require immediate emergency medical treatment, without which there would be a significant risk of death or serious impairment. Transportation to Join a Hospitalized Participant: If You are traveling alone and are or will be hospitalized for more than seven consecutive days, We will coordinate and pay for economy round-trip airfare for a person of Your choice to join You. Return of Dependent Children: If Your Dependent child(ren) age 18 or under are present but left unattended as a result of Your Injury or Illness, We will coordinate and pay for one-way economy airfare to send them back to Your Home Country. We will also arrange and pay for the services and transportation expenses of a qualified escort, if required and as determined by FrontierMEDEX. Transportation After Stabilization: Following stabilization of Your condition and discharge from the hospital, We will coordinate and pay for transportation to Your point of origin. Alternatively, We will coordinate and pay for transportation to Your Home Country if We determine that You should return for continuing medical care. We will also arrange and pay for a change to Your existing return travel arrangements if the change is required as a direct result of Your medical condition or treatment. All travel arrangements will be as necessitated by Your medical condition as determined by Your treating physician and FrontierMEDEX. All such arrangements must be coordinated and approved in advance by FrontierMEDEX. Repatriation of Mortal Remains: If You sustain an Injury or suffer a sudden and unexpected Illness that results in Your death, We will assist in obtaining the necessary clearances for Your cremation or the return of Your mortal remains. We will coordinate and pay for the expenses of the preparation and transportation of Your mortal remains to Your Home Country. SECURITY AND POLITICAL EVACUATION SERVICES Political Evacuation Services: In the event the officials of Your Home Country issue a written order that You leave Your Host Country for non-medical reasons, or if You are expelled or declared persona non grata on the written authority of your Host Country, We will assist You in making evacuation arrangements, including flight arrangements, securing visas, and logistical arrangements such as ground transportation and housing. In more complex situations, We will assist You in making arrangements with providers of specialized security services. Security Evacuation Services: In the event of an Emergency Security Situation, We will assist You in making evacuation arrangements, including flight arrangements, securing visas, and logistical arrangements such as ground transportation and housing. In more complex situations, We will assist You in making arrangements with providers of specialized security services. Transportation After Political or Security Evacuation: Following a Security or Political Evacuation and when safety allows, We will coordinate Your return to either Your Host Country or Your Home Country. PROGRAM DEFINITIONS The following definitions apply: Please refer to Your LifeMap Assurance Company Group Life policy for the definition of Dependent. A spouse or child who is insured under this Policy as a Member will not be eligible as a Dependent. Dependents are eligible for services on a full-time basis including when traveling without the Participant. Emergency Security Situation means a civil and/or military uprising, insurrection, war, revolution, or other violent disturbance in a Host Country, which results in either Your Home Country or Host Country ordering immediate evacuation. Emergency Security Situation does not include Natural Disasters. Enrollment Period means the period of time for which You are validly enrolled for FrontierMEDEX PLUS and for which We have received the appropriate enrollment fee. Home Country means the country as shown on Your passport or the country where You have Your permanent residence. Host Country means a country or territory You are visiting or in which You are living which is not Your Home Country. Illness means a sudden and unexpected sickness that manifests itself during Your Enrollment Period. 66

68 Injury means an identifiable accidental injury caused by a sudden, unexpected, unusual, specific event that occurs during Your Enrollment Period. FrontierMEDEX Physician Advisors means physicians, retained by FrontierMEDEX to provide Us with consultative and advisory services, including the review and analysis of the quality of medical care You are receiving. Natural Disaster means an event occurring directly from natural cause, including but not limited to, earthquake, flood, storm (wind, rain, snow, sleet, hail, lightning, dust or sand), tsunami, volcanic eruption, wildfire or other similar event that results in such severe and widespread damage that the area of damage is declared a disaster area by the government of the Home or Host Country. Participant means a person validly enrolled for FrontierMEDEX PLUS and for whom We have received the appropriate enrollment fee. We, Us, and Our means FrontierMEDEX. You and Your means the Participant. CONDITIONS AND LIMITATIONS The services described are available to You only during Your Enrollment Period. Medical services are available to You only when You are outside of Your Home Country or 100 or more miles away from Your permanent residence in Your Home Country. Security services are available to You only when You are outside of Your Home Country. (Expatriates are eligible regardless of distance from your expatriate home.) We will only cover the transportation costs under the Medical Evacuation and Repatriation Services if We have given Our prior approval or if those services are coordinated by Us. We have sole discretion in making the determination as to whether we will cover the cost of Emergency Medical Evacuations. Our decision will be based on medical considerations, including the opinions of the treating physicians, Our FrontierMEDEX Physician Advisors and Our medical director with respect to Your condition and ability to travel. We will determine the appropriate method, destination, and timing of any evacuation. The destination will be the nearest facility capable of providing appropriate care, as determined by Us. We have sole discretion in making the coverage determination for Your Transportation After Stabilization. Our determination will be based on Your need for continuing medical care. We will not return You to Your Home Country for the sole sake of Your convenience. In the event We are arranging transportation by commercial air under the Medical Evacuation and Repatriation Services, and You hold an original return airline ticket, We may use that ticket and are only responsible for any applicable change fees. We are not responsible for the availability, quality, results of, or failure to provide any medical, legal or other care or service caused by conditions beyond Our control. This includes Your failure to obtain care or service or where the rendering of such care or service is prohibited by U.S. law, local laws, or regulatory agencies. Your legal representative shall have the right to act for You and on Your behalf if You are incapacitated or deceased. We shall not be responsible for any costs or expenses for a situation arising from: (1) Hospital or medical expenses of any kind or nature unless those expenses are part of the Emergency Medical Evacuation or Transportation After Stabilization. (2) Your traveling against the advice of a physician or traveling for the purpose of obtaining medical treatment. (3) Initial transportation to local facilities, including ground ambulance fees. (4) Security assistance directly or indirectly related to a Natural Disaster. (5) Suicide, attempted suicide, or willful self-inflicted injury. (6) Taking part in military or police service operations. (7) The commission of, or attempt to commit, an unlawful act. (8) Injury or Illness caused by or contributed to by use of drugs or alcohol. (9) Pregnancies except in the case of a major, vital complication during the first two trimesters of pregnancy which presents a clear and significant risk of death or imminent serious injury or harm to the mother or fetus. (10) Initial transportation to local facilities, including ground ambulance fees, except as arranged by Us. (11) Mountaineering or rock climbing necessitating the use of guides or ropes, spelunking, skydiving, parachuting, ballooning, hang gliding, deep sea diving utilizing hard helmet with air hose attachment, racing of any kind other than on foot, bungee jumping, operating a vehicle when not properly licensed, or participating in professional sports unless otherwise agreed in writing by Us prior to Your Enrollment Period. (12) Psychiatric, psychological, or emotional disorders. (13) Incidental expenses, including but not limited to accommodations, local transportation, meals, telephone, and facsimile charges. (14) Subsequent evacuations for the same or related medical condition, regardless of location, or more than one Security or Political Evacuation from a country or territory per individual per annual term. (15) Failure to properly procure or maintain immigration, work, residence or similar type visas, permits, or documents. 67

69 (16) Political and Security Evacuations from Your Home Country. (17) Political and Security Evacuations when the Emergency Security Situation precedes Your arrival in the Host Country, or when the evacuation order issued by the recognized government of Your Home Country or Host Country has been posted for a period of more than seven (7) days. (18) The actual or threatened use or release of any nuclear, chemical or biological weapon or device, or exposure to nuclear reaction or radiation, regardless of contributory cause. REIMBURSEMENT TO FRONTIERMEDEX AND RIGHTS OF SUBROGATION You or a responsible party on Your behalf shall either pay the cost of medical care and treatment, including hospital expenses directly or shall reimburse Us upon demand for all such costs and expenses which may be imposed upon Us by health care providers for the cost of medical care and treatment, including hospital expenses, or related assistance services either authorized by You or deemed to be advisable and necessary by Us under urgent medical circumstances, to the extent that such expenses are not Our responsibility. Such reimbursement shall be without regard to the specific terms, conditions, or limitations of any insurance policies or benefits available to You. We shall be fully and completely subrogated to Your rights against parties who may be liable for the payment of, or a contribution toward the payment of, the costs and expenses of assistance services provided by Us or medical care and treatment, including hospital expenses, in the event that We pay or contribute to the payment of them. You must assign to Us any and all rights of recovery under any such insurance plans, including any occupational benefit plan, health insurance, or other insurance plan or public assistance program, up to the sum of any payments by Us. FM-Plus-LM

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71 Important Notices Regarding Enrollment (Special, Late and Dependent Coverage up to age 26) Special Enrollment If you are declining coverage for yourself or your dependents (including your spouse) because you have other health insurance coverage at this time, you and your dependents may be able to enroll into this plan at a later date if that coverage is lost. However, you must request enrollment within 31 days after the other coverage ends. If you have a change in dependents you may be entitled to enroll you and your dependents in this group health plan. However, you must apply within 30 days and have one or more of these qualifying events: Marriage (60 days) Divorce Legal Separation Birth (60 days) Adoption (60 days) Death Child Becomes Over Age (26 years old) Employment Begins Employment Ends Full-Time to Part-Time Part-Time to Full-Time Change occurs in spouses employer or other health carrier Late Enrollment A late enrollee is an employee or dependent who did not enroll in the plan when first eligible, or who is not considered a special enrollment applicant. Late enrollees must wait until the group s annual renewal period or open enrollment period before they are eligible for coverage. Dependent Coverage up to age 26 According to the Affordable Care Act (ACA), if a plan covers children, parents can add or keep them on their health insurance policy until they turn 26 years old, even if they are: Married Not living with their parents Attending school Not financially dependent on their parents Eligible to enroll in their employer s plan However, once a dependent turns 26, he or she must purchase a new healthcare plan (if continuing healthcare coverage). 70

72 Important Notices Regarding Your Rights (Women s Health and Cancer Rights Act of 1998 and Newborns and Mothers Health Protection Act) Women s Health and Cancer Rights Act of 1998 (WHCRA) If you are enrolled in a health plan that covers the medical and surgical costs of a mastectomy, the WHCRA states that your plan must also cover the costs of certain reconstructive surgery and other post-mastectomy benefits, including: All stages of reconstruction of the breast on which the mastectomy was performed Surgery and reconstruction of the other breast to produce a symmetrical appearance External breast forms that fit into your bra for before or during reconstruction Treatment of any physical complications of the mastectomy including lymphedema Newborns and Mothers Health Protection Act (NMHPA) If you are enrolled in a health plan that covers the hospital stays after childbirth, under the NMHPA, group health plans may not restrict mothers and newborns benefits for hospital stays after childbirth to less than 48 hours following a vaginal delivery and 96 hours following a delivery by cesarean section. 71

73 Important Notices Regarding Your Rights (Medicaid, CHIPRA and CHIP) Medicaid and Children s Health Insurance Program (CHIP)/The Children s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) Medicaid and CHIP offer free or low-cost health coverage to children and families. If you are eligible for health coverage from your employer, but are unable to afford the premiums, Idaho offers an assistance program that can help pay for coverage. Idaho uses funds from Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage, but need assistance in paying their health premiums. If you or your dependents are already enrolled in Medicaid or CHIP, you can contact the Idaho office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, you can contact the Idaho office or dial KIDS NOW or to find out how to apply. If it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, your employer s health plan is required to permit you and your depends to enroll in the plan as long as you and your dependents are eligible, but not already enrolled in the employers plan. This is called a special enrollment opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. Idaho Medicaid and CHIP Medicaid website: Medicaid phone: CHIP website: CHIP phone: