Employee Benefits. New Hire Enrollment Hillsboro School District Benefits Office

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1 Employee Benefits New Hire Enrollment Hillsboro School District Benefits Office

2 H illsboro School District B ENEFITS OFFICE Welcome to the Hillsboro School District! The District offers a variety of medical, dental, and vision plans, basic and optional life, accidental death and dismemberment, short and long term disability, and long term care insurance through the Oregon Educators Benefit Board (OEBB). Information about the plans and rates are included in this New Hire Benefits Enrollment packet and the Employee Benefits Handbook. Most of the information can also be found on the District Benefits webpage at MEDICAL, DENTAL, AND VISION PLAN SUMMARIES AND MONTHLY PREMIUMS: All medical, dental, and vision plans are available to choose from. The only restriction is to have Kaiser Vision you must select one of the Kaiser medical plans. A benefits calculator is provided on the Benefits webpage to help calculate any monthly employee out of pocket costs. Classified and Licensed Three-Quarter and Full-Time employees participate in the Classified or Licensed Premium Reduction Insurance Pool and must use the benefits calculator or contact the Benefits Office to determine monthly out of pocket expenses. Any out of pocket expense is taken out pre-tax. DISTRICT PAID COVERAGE: The District pays the monthly premium for eligible employees. You will be enrolled in these plans but you will not be charged. BASIC LIFE INSURANCE BASIC ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D) INSURANCE LONG TERM DISABILITY OPTIONAL COVERAGES: Monthly premiums for these selections will be automatically deducted from your paycheck. Please note these coverages are not pre-tax eligible expenses OPTIONAL ADDITIONAL LIFE AND AD&D INSURANCE: Available for employee, spouse or domestic partner, and dependent children (To enroll dependents, the employee must enroll in the same amount or more). As a new hire, you may select up to $100,000 in optional employee life insurance and up to $30,000 for optional spouse life insurance without submitting a medical certification. SHORT-TERM DISABILITY: If not taken when first eligible is subject to a late enrollment penalty. LONG-TERM CARE: Available for employee and spouse or domestic partner.

3 ENROLLING: An online account will be created for you in the state MyOEBB module. You will be able to enroll in plan selections, verify current plan selections, and will make future plan selections during open enrollment through this account. Please log onto and select the New Member Registration or Log In if you previously have registered and follow the instructions. If previously registered and have forgotten log-in information, click on the I Forgot? Button. A paper enrollment application is available by request. WAIVING COVERAGE OR OPTING OUT: An employee can waive medical coverage or opt-out if the employee is covered by another group medical plan. To opt-out of medical coverage an employee must meet the following per the requirements under Division 40 of the OEBB Administrative Rules: a) Maintain coverage under another employer-sponsored group medical benefit plan; b) Meet the requirements of the district opt out program in which they are participating; c) Submit their election to opt out through the OEBB benefit management system; and d) If requested, provide proof of current coverage under another employersponsored group medical benefit plan. An employee who chooses to opt-out or waive medical coverage can still enroll in dental, vision, and optional plans. If you decline dental and vision coverage as a new hire and enroll at later open enrollment, you will be subject to basic only coverage for the first year enrolled (Late enrollment penalty). Classified and Licensed employees who choose to opt-out of medical coverage will receive a monthly stipend: Classified Licensed Full-Time $200 Full-Time $300 Three-Quarter Time $150 Three-Quarter Time $225 Part-Time $100 Part-Time $150 Please refer to the HEA or HCU Union contract agreement for. SECTION 125 FLEXIBLE SPENDING ACCOUNTS (FSA) and Health Savings Account (HSA): The District offers Section 125 Flexible Health and Dependent Care Spending Accounts. Also available is a Health Savings Account for Moda Health Plans G and H. The monthly contribution you choose is taken pre-tax from your monthly paycheck. FSA and HSA participants can receive a benefits debit card to pay for eligible health services, prescriptions, and health-related items. The plan requires annual enrollment to participate. The District s plan administrator is American Fidelity Assurance Company. For questions and to enroll, please contact: Kathy Nagy SW 72nd Avenue Suite 120, Tigard OR Phone: (877) Fax: (877) Kathy.Nagy@af-group.com

4 TAX SHELTERED ANNUNITY (403 (b)): The District allows employee participation in 403(b) retirement accounts as a voluntary monthly payroll deduction. Please see the Carruth Compliance Company website for information about retirement accounts and a list of approved vendors: STATE OF OREGON PUBLIC EMPLOYEE RETIREMENT SYSTEM (PERS): The employee contribution is 6% and will be an automatic payroll deduction once the probationary period is met (around 6 months). Eligibility and participation information about PERS can be found on the website at: OPEN ENROLLMENT: The District s open enrollment period is August 15 through the beginning of September. During this time you can change plans, add dependents, or update your contact information. After open enrollment ends no changes are allowed until the next open enrollment period unless you experience a qualifying life event (see Mid-Year Changes). All coverage changes are effective on October 1 of any year. To determine monthly out-of-pocket costs a benefits calculator is available on the benefits webpage at BENEFITS FAIR: The District hosts an annual benefits fair during open enrollment. The Benefits Fair will be held at the Administration Center on Thursday, September 5, 2013 from 1:30 6:30 p.m. MID-YEAR CHANGES: If you experience a qualifying event during the year (e.g. marriage, divorce, birth, adoption, employment change), you are eligible to make midyear changes. You have 30 days from the date of the event to contact the Benefits Office. ENROLLMENT DEADLINE: New employees have 15 days to enroll in benefits or default plans will be selected by the HSD Benefits Office. To meet payroll deadlines, enrollments must be completed by the 5 th of the month, prior to when your benefits are scheduled to begin. If enrollment is completed after the 5 th a double deduction will be taken from the next month s payroll check. TRANSFER SICK LEAVE: Sick leave from another public State of Oregon school district or college can be transferred to the Hillsboro School District. Please fill out the enclosed Verification of Sick Leave form to each of your previous qualifying employers. You can make copies of the enclosed form or print additional forms from /BO212%20Verification%20of%20Sick%20Leave.pdf. If you have questions or need assistance, please contact the Employee Benefits Office at or District extension 5818 or by at hsdbenefits@hsd.k12.or.us. Sincerely, HSD Benefits Office

5 Benefits Contact Information Moda Health (Formerly ODS) (Medical, Pharmacy, Vision, & Dental) Kaiser Permanente (Medical, Pharmacy, Vision, & Dental) To Find Kaiser Chiropractic and Alternative Care Providers: and click on Find a Provider Willamette Dental (Dental) Reliant Behavioral Health (Employee Assistance Program) Code: OEBB The Standard (Life, AD&D, & Disability Insurance) UNUM (Long Term Care Insurance) Weight Watchers (866) (b) Information, List of Approved Vendors, and Salary Reduction Agreement (503) Oregon Educator Benefits Board (OEBB) (888) Public Employee Retirement System (PERS) (888) American Fidelity Assurance Company (FSA, HSA, and Cancer, Accident, and Critical Illness) Ext. 37 Kathy Nagy

6 Medical and Pharmacy Plans

7 Oregon Educators Benefit Board Plan Year Summary of Medical and Pharmacy Benefits Med Plan 1 Med Plan 2 Med Plan A Med Plan B Med Plan C Med Plan D Med Plan E Med Plan F Med Plan G Med Plan H Moda Health/ODS Medical Plans Moda Health/ODS Moda Health/ODS Moda Health/ODS Moda Health/ODS Moda Health/ODS Moda Health/ODS Moda Health/ODS MAJOR MED (Non Kaiser (HMO) Kaiser (HMO) MAJOR MED (HSA- HSA-Compliant no lifetime maximum on any medical plans Compliant Plan) Plan) System of Care None/None $200/$600 Deductible (Individual/Family) PPO Network $200/$600 $350/$1050 $500/$1500 $750/$2,250 $1,000/$3,000 $1,250/$3,750 $1,500/$4,500 $1,500/$3,000*** Coinsurance Out-of-Network System of Care 20% 20% 20% 20% 20% 20% 20% 20% 20% PPO Network Out-of-Network NA 20% 20% 20% 20% 20% 20% 20% 20% 50% 50% 50% 50% 50% 50% 50% 50% System of Care $1,500/$3,000 $2,200/$4,400 $2,000/$6,000** $2,400/$7,200** $2,600/$7,800** $2,800/$8,400** $3,000/$9,000** $4,000/$12,000** $5,000/$15,000** Maximum Out-of-Pocket costs per Plan Year (Individual/Family) Preventative Care Services Adult, Well-child & Well-baby exams; Immunizations; and Preventive Care Services as described in Plan Handbooks Wellness assessment visit (one per plan year) Provider Services Incentive Office Visits for asthma, heart conditions (CHF, cholesterol & high BP) & diabetes management Primary Care Services as described in Plan Handbook Specialist Ofice Visits Additional Cost Tier** as described in Plan Handbook PPO Network Out-of-Network $2,000/$6,000** $2,400/$7,200** $2,600/$7,800** $2,800/$8,400** $3,000/$9,000** $4,000/$12,000** $5,000/$15,000** $4,000/$12,000** $4,800/$14,400** $5,200/$15,600** $5,600/$16,800** $6,000/$18,000** $8,000/$24,000** $10,000/$30,000** $ and % shown is the Member Cost; $ Amounts = Copayments $5,000/$10,000*** System of Care $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 PPO Network NA NA $0 $0 $0 $0 $0 $0 $0 $0 System of Care $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 $0 1 PPO Network NA NA NA NA NA NA NA NA NA NA Out-of-Network NA NA NA NA NA NA NA NA $ and % shown is the Member Cost; $ Amounts = Copayments System of Care $10* 1 $10* 1 $10* 1 $15* 1 $15* 1 $15* 1 $15* 1 20% PPO Network NA NA 20%* 20%* 20%* 20%* 20%* 20%* 20%* 20% Out-of-Network 50% 50% 50% 50% 50% 50% 50% 50% System of Care $20 $25* $20* 1 $20* 1 $20* 1 $30* 1 $30* 1 $30* 1 $30* 1 20% PPO Network NA NA 20% 20% 20% 20% 20% 20% 20% 20% System of Care $30 $35* 20% 20% 20% 20% 20% 20% 20% 20% PPO Network NA NA 20% 20% 20% 20% 20% 20% 20% 20% System of Care $ % $ % $ % $ % $ % $ % $ % 20% PPO Network NA NA $ % $ % $ % $ % $ % $ % $ % 20% Out-of-Network $ % $ % $ % $ % $ % $ % $ % 50%

8 no lifetime maximum on any medical plans Other Services Medical Plans Laboratory/X-Ray Imaging (CT, PET & MRI), Lumbar Discographies, and Sleep Studies** Viscosupplementation** Upper Endoscopies** Durable Medical Equipment Hearing Aids ($4,000 benefit every 48 months) as described in Plan Handbook Maternity Outpatient Maternity Care Delivery & Routine Newborn Nursery Care System of Care Mental Health & Chemical Dependency Services Mental Health Outpatient Services Mental Health Inpatient and Residential Services Substance Abuse Outpatient, Inpatient and Residential Services 20% (applies to Maximum Out-of- Pocket) Oregon Educators Benefit Board Plan Year Summary of Medical and Pharmacy Benefits Med Plan 1 Med Plan 2 Med Plan A Med Plan B Med Plan C Med Plan D Med Plan E Med Plan F Med Plan G Med Plan H Kaiser (HMO) Kaiser (HMO) Moda Health/ODS Moda Health/ODS Moda Health/ODS Moda Health/ODS Moda Health/ODS Moda Health/ODS Moda Health/ODS Moda Health/ODS MAJOR MED (Non MAJOR MED (HSA- HSA-Compliant Compliant Plan) Plan) $ and % shown is the Member Cost; $ Amounts = Copayments System of Care $20 per visit $25* per visit 20% 20% 20% 20% 20% 20% 20% 20% PPO Network NA NA 20% 20% 20% 20% 20% 20% 20% 20% System of Care $20 $25* $ % $ % $ % $ % $ % $ % $ % 20% PPO Network NA NA $ % $ % $ % $ % $ % $ % $ % 20% Out-of-Network NA NA $ % $ % $ % $ % $ % $ % $ % 50% System of Care $30 $35* $ % $ % $ % $ % $ % $ % $ % 20% PPO Network NA NA $ % $ % $ % $ % $ % $ % $ % 20% Out-of-Network NA NA $ % $ % $ % $ % $ % $ % $ % 50% System of Care $75 20%* $ % $ % $ % $ % $ % $ % $ % 20% PPO Network NA NA $ % $ % $ % $ % $ % $ % $ % 20% Out-of-Network NA NA $ % $ % $ % $ % $ % $ % $ % 50% 20%* 20% 20% 20% 20% 20% 20% 20% 20% PPO Network NA NA 20% 20% 20% 20% 20% 20% 20% 20% System of Care 10% 10%* 10% 10% 10% 10% 10% 10% 10% 20% PPO Network NA NA 10% 10% 10% 10% 10% 10% 10% 20% $ and % shown is the Member Cost; $ Amounts = Copayments System of Care $0 $0 $20* 1 $20* 1 $20* 1 $30* 1 $30* 1 $30* 1 $30* 1 20% PPO Network NA NA 20% 20% 20% 20% 20% 20% 20% 20% System of Care $100 per day, up to $500 per admission 20% 20% 20% 20% 20% 20% 20% 20% 20% maximum PPO Network NA NA 20% 20% 20% 20% 20% 20% 20% 20% $ and % shown is the Member Cost; $ Amounts = Copayments System of Care $20 $25* $20* 1 $20* 1 $20* 1 $30* 1 $30* 1 $30* 1 $30* 1 20% PPO Network NA NA 20% 20% 20% 20% 20% 20% 20% 20% System of Care $100 per day, up to $500 per admission 20% 20% 20% 20% 20% 20% 20% 20% 20% maximum PPO Network NA NA 20% 20% 20% 20% 20% 20% 20% 20% System of Care $0 $0 $0 $0 $0 $0 $0 $0 $0 20% PPO Network NA NA $0 $0 $0 $0 $0 $0 $0 20%

9 Oregon Educators Benefit Board Plan Year Summary of Medical and Pharmacy Benefits Medical Plans no lifetime maximum on any medical plans Weight Management (subscriber and covered dependents unless noted otherwise) Med Plan 1 Med Plan 2 Med Plan A Med Plan B Med Plan C Med Plan D Med Plan E Med Plan F Med Plan G Med Plan H Moda Health/ODS Moda Health/ODS Moda Health/ODS Moda Health/ODS Moda Health/ODS Moda Health/ODS Moda Health/ODS Moda Health/ODS MAJOR MED (Non Kaiser (HMO) Kaiser (HMO) MAJOR MED (HSA- HSA-Compliant Compliant Plan) Plan) $ and % shown is the Member Cost; $ Amounts = Copayments Up to four 13-week Weight Watchers Sessions per Plan Year (age restrictions may apply) 12 Health Coaching Sessions per Plan Year & Online Educational Resources $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 Bariatric Surgery** (subscribers only, not covered for dependents) See Plan Handbook for specific criteria Approved providers only - see criteria $500 + Inpatient Care costs $ % $ % $ % $ % $ % $ % $ % $ % $500 ǂ + 20% Hospital & Outpatient Services Inpatient Care Outpatient Surgery Outpatient Rehabilitation (physical, occupational & speech therapy) System of Care $ and % shown is the Member Cost; $ Amounts = Copayments $100 per day, up to $500 per admission maximum 20% 20% 20% 20% 20% 20% 20% 20% 20% PPO Network 20% 20% 20% 20% 20% 20% 20% 20% Out-of-Network 50% 50% 50% 50% 50% 50% 50% 50% System of Care $75 20% 20% 20% 20% 20% 20% 20% 20% 20% PPO Network NA NA 20% 20% 20% 20% 20% 20% 20% 20% System of Care $30 per visit (max 20 visits per therapy per Plan Year) $35* per visit (max 20 visits per therapy per Plan Year) PPO Network NA NA Out-of-Network NA NA 50% (max 30 visits 50% (max 30 visits 50% (max 30 visits 50% (max 30 visits 50% (max 30 visits 50% (max 30 visits per Plan Year) per Plan Year) 50% (max 30 visits per Plan Year) per Plan Year) per Plan Year) 50% (max 30 visits per Plan Year) Ambulance $75 $100* 20% 20% 20% 20% 20% 20% 20% 20% Emergency Room (copay $ amounts listed are waived if admitted) Urgent Care $100 per visit 20% $100 per visit then 20% $100 per visit then 20% $ and % shown is the Member Cost; $ Amounts = Copayments System of Care $35 $40* PPO Network Out-of-Network $100 per visit then 20% $100 per visit then 20% $100 per visit then 20% $100 per visit then 20% $100 per visit then 20% Urgent Care Visit $50* $50* $50* $50* $50* $50* $50* 20% 20%

10 Oregon Educators Benefit Board Plan Year Summary of Medical and Pharmacy Benefits Medical Plans no lifetime maximum on any medical plans Tobacco Cessation Program Telephone Consults, Web- Coaching, Patches, Gum & Prescribed Medications Alternative Care Services Accuupuncture, Chiropractic & Naturopathic Services $2,000 Maximum Combined Benefit Cost of lab, x-rays, supplies & procedures performed in Alternative Care Provider's office applies to Benefit Maximum Med Plan 1 Med Plan 2 Med Plan A Med Plan B Med Plan C Med Plan D Med Plan E Med Plan F Med Plan G Med Plan H Moda Health/ODS Moda Health/ODS Moda Health/ODS Moda Health/ODS Moda Health/ODS Moda Health/ODS Moda Health/ODS Moda Health/ODS MAJOR MED (Non Kaiser (HMO) Kaiser (HMO) MAJOR MED (HSA- HSA-Compliant Compliant Plan) Plan) Four 30-minute phone calls (more if needed) to Kaiser Health Coaching at no charge. Prescription required for patches, gum & medications, all subject to Rx copays.. Unlimited calls to Alere Wellbeing. Maximum 5 calls from Alere Wellbeing per Plan Year. $ and % shown is the Member Cost; $ Amounts = Copayments Patches, gum & prescribed medications are subject to Rx copyas.. System of Care $20 $25* 20% 20% 20% 20% 20% 20% 20% 20% PPO Network NA NA 20% 20% 20% 20% 20% 20% 20% 20% Pharmacy Pharmacy Pharmacy Services Medical Plans Pharmacy Out-of-Pocket Maximum (per person) Kaiser Plan 1 Kaiser Plan 2 Moda Plan A Moda Plan B Moda Plan C Moda Plan D Moda Plan E Moda Plan F Moda Plan G Moda Plan H $ and % shown is the Member Cost; $ Amounts = Copayments $1,100 $1,100 NA NA NA NA NA NA NA NA Retail Value Select Generic up to a 90-day NA NA $0 $0 $0 $0 $0 $0 $0 $0 Ϯ 30/31-day $5 $5 $8 $8 $8 $8 $8 $8 $8 90-day NA NA $24 $24 $24 $24 $24 $24 $24 Preferred 30/31-day $25 $25 Non-preferred 30/31-day $25 if criteria met $25 if criteria met 25% upt to $50 50% up to $150 25% upt to $50 50% up to $150 25% upt to $50 50% up to $150 25% upt to $50 50% up to $150 25% upt to $50 50% up to $150 25% upt to $50 50% up to $150 25% upt to $50 per 30/31-day 50% up to $150 per 30/31-day 20% participating pharmacy 50% non-participating 20% participating pharmacy 50% non-participating 20% participating pharmacy 50% non-participating

11 Oregon Educators Benefit Board Plan Year Summary of Medical and Pharmacy Benefits Pharmacy Continued Pharmacy Continued Medical Plans Kaiser Plan 1 Kaiser Plan 2 Moda Plan A Moda Plan B Moda Plan C Moda Plan D Moda Plan E Moda Plan F Moda Plan G Moda Plan H Mail Value 90-day NA NA $0 $0 $0 $0 $0 $0 $0 $0 Ϯ Select Generic 90-day $10 $10 $16 $16 $16 $16 $16 $16 $16 20% participating pharmacy 50% non-participating Preferred 90-day $50 $50 per 90-day per 90-day per 90-day per 90-day per 90-day per 90-day per 90-day 20% participating pharmacy 50% non-participating Non-preferred 90-day $50 if criteria met $50 if criteria met per 90-day per 90-day per 90-day per 90-day per 90-day per 90-day per 90-day 20% participating pharmacy 50% non-participating Specialty Select Generic 30/31-day NA NA $16 $16 $16 $16 $16 $16 $16 20% participating pharmacy 50% non-participating Preferred 30/31-day NA NA per 30/31-day 20% participating pharmacy 50% non-participating Non-preferred 30/31-day NA NA per 30/31-day 20% participating pharmacy 50% non-participating NA = not applicable In order to remain HSA compliant, certain conditions are not included in the Plan H value tier.. * Deductible Waived On Plan H, after Out-of-Pocket Maximum has been met, fixed dollar copays no longer apply. ** Additional Cost Tier copayments ($100 or $500 as applicable) on Plans A G do not count toward Deductible or Out of Pocket Maximum. The $500 Bariatric Surgery copayment does not apply toward Deductible or Out of Pocket Maximum on any plan except Plan H 1 Must use a Moda Medical Home to receive this benefit. Moda Medical Homes consist of specific local primary care providers. Visit for. *** Moda Health/ODS Plan H individual Deductible and Out-of-Pocket Maximum apply to single coverage only. Family Deductible and Outof-Pocket Maximum apply when two or more individuals are covered on the Plan. This Deductible must be met before benefits will be paid (except where * indicates Deductible Waived). On Plan H, the Deductible applies toward the Out-of-Pocket Maximum. This document is for comparison purposes only and is not intended to fully describe the benefits of each Plan. Refer to your member handbook for more of benefit coverage. In the case of a conflict between this comparison and your member handbook, the member handbook will prevail.

12 Dental Plans

13 Oregon Educators Benefit Board Plan Year Summary of Dental Benefits Plan Option Dental Plan 1 Dental Plan 2 Dental Plan 3 Dental Plan 4 Dental Plan 6 Dental Plan 8 Ϯ Dental Plan 8 ǂ Dental Moda Health/ODS Moda Health/ODS Moda Health/ODS Moda Health/ODS Moda Health/ODS Kaiser Willamette Dental Group Dental Office Visit Copayment NA NA NA NA NA $20* $20* Benefit Maximum $2,200 $1,500 $1,500 $1,500 $1,200 NA NA Deductible $50 $50 $50 $50 $50 NA NA Plan Year Maximum $2,200 $1,500 $1,500 $1,500 $1,200 NA NA Preventative and Diagnostic Services* Oral exams, X-rays, cleaning (prophylaxis), fluoride treatments, and space maintainers Restorative Services* Routine fillings, inlays and stainless steel crowns Simple Extraction* Simple tooth extractions Oral Surgery* Surgical tooth extractions, including diagnosis and evaluation Peridontics* Diagnosis, evaluation, and treatment of gum disease including scaling and root planing Endodontics* Root canal and related therapy including diagnosis and evaluation Major Restorative Services* Gold or porcelain crowns and onlays Implants Fixed and Removable Prosthetic Services* Full and partial dentures, relines, rebases Bridge retainers and pontics Orthodontics* (All plans except Moda Plan 6) Orthodontic Treatment 80% to $1,800 lifetime max 80% to $1,800 lifetime max Deductible Waived for Preventive & Diagnostic Services on Moda Plans 100% 100% 100%* 100%* 80% 1 80% 1 100% 2* 100% 2* 80% 80% 100%* 100%* 80% 80% 100%* 100%* 80% 80% 100%* 100%* 80% 80% 100%* 100%* 80% 80% 100%* 100%* 50% 50% 50% 50%* (limit of 4 per lifetime) See Certificate of Coverage for copays 50% 50% 50% 100%* 100%* 50% 50% 50% 100%* 100%* 80% to $1,800 lifetime max 80% to $1,800 lifetime max NA $1,500 copay + $20 per visit $1,500 copay + $20 per visit Under Moda Health/ODS Plans 1-3, benefits start at 70% the first plan year then increase by 10% each plan year (up to a maximum of 100%) provided the individual has visited the dentist at least once during the previous plan year. Switching between incentive plans (1-3) and non-incentive plans (4,6 and 8) will have an affect on benefit level. ** Pre-Orthodontic Service fee of $150 is credited toward the orthodontic benefit if patient accepts treatment plan. Kaiser Dental Plan 8 no longer requires enrollment in a Kaiser medical plan. Services must be provided by a contracted Kaiser provider in order for benefits to be payable. See handbook for. Under Willamette Dental Group Plan 8, services must be provided by a Willamette Dental Group provider in order for benefits to be payable. See handbook for. ¹ Posterior fillings paid to amalgam fee. ² Fillings are covered at 100% for all amalgam tooth surfaces, composite anteriors and one-surface composite posteriors. Patients can request composite fillings, which are considered a buy-up and additional fees apply. Please contact Kaiser Permanente or Willamette Dental Group directly for actual fees. * For Kaiser Permanente and Willamette Dental Group plans: Office visit copayment applies at each visit, in addition to any plan copayments for services. This document is for comparison purposes only and is not intended to fully describe the benefits of each Plan. Refer to your member handbook for more of benefit coverage. In the case of a conflict between this comparison and your member handbook, the member handbook will prevail.

14 Vision Plans

15 Oregon Educators Benefit Board Plan Year Summary of Vision Benefits Plan Option Vision Plan 1 Vision Plan 2 Vision Plan 3 Vision Plan 4 Vision Plan 5** Vision Moda Health/ODS Moda Health/ODS Moda Health/ODS Moda Health/ODS Kaiser Plan Year Maximum $250* $350* $450* $600* See allowances Routine Eye Exam 100% 100% 100% 100% $5 office visit copay Exam Frequency Once per Plan Year Once per Plan Year Once per Plan Year Once per Plan Year Once every 12 months Lenses Either one pair of lenses or contacts Either one pair of lenses or contacts Either one pair of lenses or contacts Either one pair of lenses or contacts Either one pair of lenses or contacts Single Vision 100% 100% 100% 100% 100% up to $58.50 per Plan Year Bifocal 100% 100% 100% 100% 100% up to $86 per Plan Year Lenticular 100% 100% 100% 100% 100% up to $86.00 per Plan Year Trifocal 100% 100% 100% 100% 100% up to $109 per Plan Year Contact Lenses 100% 100% 100% 100% 100% up to $ per Plan Year Lens Frequency Once per Plan Year Once per Plan Year Once per Plan Year Once per Plan Year Once every 12 months Frames 100% 100% 100% 100% 100% up to $75.00 per Plan Year Child: once per Plan Year Child: once per Plan Year Child: once per Plan Year Child: once per Plan Year Child: once every 12 months Frame Frequency Adult: once every two Plan Adult: once every two Plan Adult: once every two Plan Adult: once every two Plan Years Years Years Years Adult: once every 24 months * Exam and hardware charges all apply to the Plan Year maximum on Moda Health/ODS Plans 1-4. ** Must be simultaneously enrolled in a Kaiser medical plan to be enrolled in Kaiser Vision Plan 5. This document is for comparison purposes only and is not intended to fully describe the benefits of each Plan. Refer to your member handbook for more of benefit coverage. In the case of a conflict between this comparison and your member handbook, the member handbook will prevail.

16 Plan Rates & District Contribution

17 Employer Contribution Towards Medical, Dental, and Vision Employee Classification Monthly District Contribution Administrator (Benefit Flex Pay) Classified Part-Time Tier I and Tier II (4 to 5.99 Hours per Day) Classified Three-Quarter Time Tier II (Hired on or after July 1, 2007) (6 to 6.99 Hours per Day) Classified Full-Time Tier I (Hired before July 1, to 8 Hours per Day) Tier II (Hired on or after July 1, to 8 Hours per Day) Licensed Part-Time (0.375 to FTE) $1,050 $525 Medical Opt Out $100 $ Medical Opt Out $150 $1,050 Medical Opt Out $200 $525 Medical Opt Out $150 Licensed Three-Quarter Time (0.6 to FTE) $ Medical Opt Out $225 Licensed Full-Time (0.8 to 1.0 FTE) $1,050 Medical Opt Out $300 Super/Tech (Benefit Flex Pay) $1,050

18 Medical, Dental, and Vision Plan Rates Administrator & Super/Tech - All Classified & Licensed Part-Time All Retirees Administrator, Classified, Licensed, and Super/Tech Medical Plans Employee Only Employee + Spouse Employee + Child Family Kaiser Plan 1 $ $1, $1, $1, Kaiser Plan 2 $ $1, $ $1, Moda Plan A $ $1, $1, $2, Moda Plan B $ $1, $1, $1, Moda Plan C $ $1, $ $1, Moda Plan D $ $1, $ $1, Moda Plan E $ $ $ $1, Moda Plan F $ $ $ $1, Moda Plan G $ $ $ $1, Moda Plan H $ $ $ $1, Dental Plans Employee Only Employee + Spouse Employee + Child Family Kaiser $60.84 $ $ $ Moda Plan 1 $60.40 $ $ $ Moda Plan 2 $53.88 $ $ $ Moda Plan 3 $52.72 $ $ $ Moda Plan 4 $49.62 $98.29 $ $ Moda Plan 6 (No Ortho) $39.88 $78.94 $80.13 $ Willamette $40.51 $80.22 $ $ Vision Plans Employee Only Employee + Spouse Employee + Child Family Kaiser $7.59 $16.70 $14.42 $23.52 Moda Plan 1 $11.00 $24.22 $20.90 $34.09 Moda Plan 2 $14.44 $31.80 $27.46 $44.81 Moda Plan 3 $16.29 $35.85 $30.97 $50.50 Moda Plan 4 $19.07 $41.93 $36.21 $59.10 Classified & Licensed Three-Quarter and Full-Time *Must use Rate Calculator located on the District website to determine cost Medical Plans Kaiser Kaiser Moda Moda Moda Moda Moda Moda Moda Moda Plan 1 Plan 2 Plan 1 Plan B Plan C Plan D Plan E Plan F Plan G Plan H $1, $1, $1, $1, $1, $1, $1, $ $ $ Dental Plans Kaiser Moda Plan 1 Moda Plan 2 Moda Plan 3 Moda Plan 4 Moda Plan 6 Willamette (No Ortho) Dental $ $ $ $ $ $91.67 $ Vision Plans Kaiser Moda Plan 1 Moda Plan 2 Moda Plan 3 Moda Plan 4 $18.06 $25.12 $33.00 $37.22 $43.53

19 Optional Voluntary Payroll Deduction Plan Rates Optional Life Insurance Optional Employee Life Plans and Rates Optional Spouse Life Plans and Rates Optional Child Life Plan and Rate $10,000 - $500,000 Maximum $10,000 - $500,000 Maximum $2,000 - $10,000 Maximum Age as of each October 1st Monthly rate per each $10,000 Age as of each October 1st Monthly rate per each $10,000 Monthly rate per each $2,000 $0.10 Under 25 $0.40 Under 25 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $37.74 Optional AD&D Insurance Short Term Disability Optional Employee AD&D Plan Short Term Disability $10,000 - $500,000 Maximum Benefit Plan 5 Rate (per $10,000 of benefit) $0.20 Benefit Waiting Period (Days) 14 Benefit Duration (Days) 60 Optional Spouse AD&D Plan Maximum Weekly Benefit $1,500 $10,000 - $500,000 Maximum Benefit Benefit Percentage 66 2/3 % Rate (per $10,000 of benefit) $0.20 Optional Child AD&D Plan $2,000 - $10,000 Maximum Benefit Rate (per $2,000 of benefit) $0.04 Monthly Premium = Employee's average monthly wage multiplied by this rate (Not to exceed maximum monthly pre-disability earnings)

20 Oregon Educators Benefit Board Long Term Care Rates (per $1,000 if Benefit) Employee paid Rates Plan Year (no change from Plan Year) Without Qualified Partnership Program Without Qualified Partnership Program W/Total Home Care W/5% Simple Inflation W/Total Home Care W/5% Simple Inflation EE Paid Rates 3 YEARS 6 YEARS LIFETIME 3 YEARS 6 YEARS LIFETIME EE Paid Rates 3 YEARS 6 YEARS LIFETIME 3 YEARS 6 YEARS LIFETIME $2.40 $3.10 $4.60 $6.00 $8.50 $ $3.90 $5.00 $7.30 $9.30 $13.10 $ $2.50 $3.30 $4.70 $6.30 $8.90 $ $4.00 $5.20 $7.50 $9.70 $13.80 $ $2.70 $3.40 $4.80 $6.60 $9.40 $ $4.20 $5.50 $7.70 $10.20 $14.50 $ $2.80 $3.60 $5.00 $7.00 $9.80 $ $4.40 $5.70 $7.90 $10.80 $15.20 $ $2.90 $3.80 $5.10 $7.30 $10.30 $ $4.70 $6.00 $8.20 $11.30 $16.00 $ $3.10 $3.90 $5.30 $7.70 $10.90 $ $4.90 $6.30 $8.40 $11.90 $16.80 $ $3.20 $4.10 $5.50 $8.10 $11.40 $ $5.10 $6.60 $8.70 $12.50 $17.60 $ $3.40 $4.40 $5.70 $8.50 $12.00 $ $5.40 $6.90 $9.00 $13.20 $18.50 $ $3.60 $4.60 $5.90 $9.00 $12.60 $ $5.70 $7.30 $9.30 $13.90 $19.50 $ $3.80 $4.80 $6.10 $9.50 $13.30 $ $6.00 $7.70 $9.70 $14.60 $20.50 $ $4.00 $5.10 $6.30 $10.00 $13.90 $ $6.30 $8.10 $10.10 $15.40 $21.60 $ $4.10 $5.20 $6.50 $10.40 $14.40 $ $6.60 $8.30 $10.40 $16.00 $22.30 $ $4.30 $5.40 $6.70 $10.80 $14.90 $ $6.80 $8.70 $10.70 $16.60 $23.10 $ $4.50 $5.70 $7.00 $11.20 $15.50 $ $7.10 $9.00 $11.10 $17.30 $23.90 $ $4.70 $5.90 $7.20 $11.70 $16.00 $ $7.40 $9.30 $11.50 $18.10 $24.80 $ $4.90 $6.10 $7.50 $12.20 $16.70 $ $7.80 $9.80 $11.90 $18.90 $25.80 $ $5.10 $6.40 $7.80 $12.80 $17.30 $ $8.10 $10.20 $12.40 $19.70 $26.70 $ $5.30 $6.70 $8.10 $13.20 $17.90 $ $8.50 $10.60 $12.80 $20.40 $27.60 $ $5.70 $7.10 $8.50 $14.10 $18.90 $ $9.00 $11.30 $13.60 $21.80 $29.20 $ $6.10 $7.60 $9.10 $15.00 $20.10 $ $9.70 $12.00 $14.50 $23.20 $31.10 $ $6.50 $8.10 $9.70 $16.10 $21.40 $ $10.30 $12.90 $15.40 $24.80 $33.00 $ $7.00 $8.70 $10.50 $17.20 $22.80 $ $11.20 $13.90 $16.70 $26.60 $35.20 $ $7.60 $9.50 $11.30 $18.50 $24.30 $ $12.10 $15.00 $18.00 $28.60 $37.60 $ $8.00 $10.00 $12.10 $19.40 $25.40 $ $12.80 $16.00 $19.20 $30.00 $39.20 $ $8.50 $10.70 $12.80 $20.40 $26.50 $ $13.60 $17.00 $20.40 $31.60 $41.00 $ $9.10 $11.40 $13.80 $21.50 $27.90 $ $14.50 $18.20 $21.90 $33.30 $43.10 $ $9.70 $12.20 $14.70 $22.70 $29.20 $ $15.40 $19.40 $23.40 $35.10 $45.10 $ $10.30 $13.00 $15.70 $23.80 $30.50 $ $16.40 $20.60 $24.90 $36.80 $47.10 $ $11.10 $14.00 $16.90 $25.40 $32.30 $ $17.70 $22.20 $26.90 $39.20 $49.90 $ $12.00 $15.10 $18.40 $27.10 $34.40 $ $19.20 $24.10 $29.20 $42.00 $53.10 $ $13.10 $16.50 $20.00 $29.10 $36.70 $ $20.80 $26.20 $31.80 $45.00 $56.70 $ $14.30 $17.90 $21.90 $31.30 $39.70 $ $22.70 $28.50 $34.80 $48.40 $61.30 $ $15.50 $19.50 $23.90 $33.60 $42.80 $ $24.70 $31.10 $38.10 $51.90 $66.10 $ $16.80 $21.10 $25.90 $35.60 $45.50 $ $26.70 $33.50 $41.20 $54.90 $70.30 $ $18.00 $22.60 $28.00 $37.50 $48.30 $ $28.70 $36.00 $44.50 $58.00 $74.60 $ $19.90 $25.00 $31.10 $40.00 $51.70 $ $31.70 $39.80 $49.50 $61.70 $79.80 $ $21.40 $26.70 $33.40 $42.10 $54.70 $ $34.00 $42.50 $53.20 $65.10 $84.50 $ $23.70 $29.70 $37.20 $46.00 $60.00 $ $37.70 $47.20 $59.20 $71.10 $92.70 $ $25.70 $32.10 $40.50 $49.10 $64.30 $ $40.90 $51.10 $64.30 $75.90 $99.30 $ $27.80 $34.70 $43.80 $52.20 $68.60 $ $44.20 $55.20 $69.70 $80.70 $ $ $30.20 $37.70 $47.70 $55.80 $73.60 $ $48.10 $59.90 $75.90 $86.20 $ $ $33.20 $41.40 $52.30 $60.20 $79.20 $ $52.80 $65.80 $83.10 $93.00 $ $ $36.80 $45.80 $57.80 $65.60 $86.20 $ $58.50 $72.90 $92.00 $ $ $ $40.70 $50.60 $63.80 $71.10 $93.40 $ $64.70 $80.50 $ $ $ $ $45.00 $56.00 $70.30 $77.30 $ $ $71.60 $89.00 $ $ $ $ $50.90 $63.20 $79.80 $83.20 $ $ $81.00 $ $ $ $ $ $57.00 $70.60 $89.10 $91.40 $ $ $90.60 $ $ $ $ $ $64.10 $79.50 $ $ $ $ $ $ $ $ $ $ $70.90 $87.80 $ $ $ $ $ $ $ $ $ $ $78.50 $97.10 $ $ $ $ $ $ $ $ $ $ $86.40 $ $ $ $ $ $ $ $ $ $ $ * Rates for Active Employees or Retirees that are 81 years of age and older are available upon request

21 HILLSBORO SCHOOL DISTRICT FORM VERIFICATION OF SICK LEAVE School District Name: Employee Name: SSN: This is to certify that the employee named above was employed by this school district and has accumulated the unused sick leave as shown below: 1. Accumulated hours of unused sick leave on our record: 2. Number of hours in item 1 above that were transferred from another Oregon school district: 3. Name of other Oregon school district(s): Signature: Date: Print Name: Title: Return form to: Hillsboro School District 1J Payroll Office 3083 NE 49 th Pl., #110 Hillsboro, OR (503) Payroll BO212 Verification of Sick Leave Rev. 8/3/10

22 Carruth Compliance Consulting - Employer SRA Information - Current only as of: 7/27/2012 8:06:44 AM Page 1 / 2

23 Carruth Compliance Consulting - Employer SRA Information - Current only as of: 7/27/2012 8:06:44 AM Page 2 / 2