NEW HIRE ENROLLMENT GUIDE

Tennessee

2017– 2018

2

TABLE OF CONTENTS

2 Eligibility

3 How to Enroll through Workday

4 Medical Benefits

5 Medical Plan Comparison Chart

6 Dental Benefits

7 Dental Plan Comparison Chart

8 Vision Benefits

9 Flexible Spending Accounts (FSAs)

10 Life and Accidental Death & Dismemberment (AD&D) Insurance

12 Disability Benefits

12 Retirement Benefits

13 Voluntary Benefits through Aflac

13 Employee Assistance Program (EAP)

14 Contribution Rates

15 Contact Information

1

This guide is designed to help you and your family understand your benefit choices and enrollment options. When you are ready to select your benefits, you will enroll online through Workday. Enrollment details can be found on page 4 of this guide. You can also email benefits@greendot.org with any questions during enrollment or throughout the year.

IT’S TIME TO ENROLL IN YOUR GREEN DOT BENEFITS!

2017-2018

Don’t miss the deadline. You have 30 days from your date of hire to enroll in your benefits for 2017-2018.

2

ELIGIBILITY

All active, eligible full-time employees scheduled to work 30 hours or more per week are eligible to enroll in the Green Dot Public Schools benefits program.

Eligible DependentsWhen you enroll yourself in medical, dental and/or vision coverage, you may also cover your eligible dependents, including:

ll Your legal spouse or domestic partner*

ll Your children up to age 26, including biological and adopted children, stepchildren, children of your domestic partner*, children for whom you are the legal guardian and children whom you are required to provide coverage under a Qualified Medical Child Support Order (QMCSO)

ll Your children age 26 and over who have a physical or mental handicap that began before age 26

* Note: You must submit a completed and notarized affidavit to verify eligibility.

Coverage LevelsWhen you enroll in our health care plans, you can choose from the following four coverage levels:

ll Employee Only

ll Employee + Spouse/Domestic Partner

ll Employee + Child(ren)

ll Employee + Family

Making Changes during the YearAfter your initial enrollment period, Open Enrollment is the only time you can make changes and/or add or drop dependents from your benefit coverage, unless you have a qualified status change, including:

ll Marriage, divorce or legal separation

ll Birth or adoption of a child

ll Death of your spouse/domestic partner or dependent child

ll A change in your spouse/domestic partner’s employment status

ll A change in your dependent’s eligibility for benefits

ll A move out of the coverage area

ll Receipt of a QMCSO that requires you to cover a child under your medical plan

If you experience a qualified status change, please contact the Benefits Department within 30 days to make changes to your coverage. Otherwise, you will have to wait until the next annual Open Enrollment period next spring to change your coverage.

3

HOW TO ENROLL THROUGH WORKDAY

Follow these easy steps to log into our benefits enrollment website:

 1. Go to www.greendot.org/workday.

 2. Click on Login with Google.

 3. Select your Green Dot Gmail address ending in either @greendot.org or @animo.org. If your Green Dot Gmail account is not listed, click Add Account and enter your Green Dot Google credentials.

 4. Click Allow.

Once in the enrollment site, you can access your personal information to help you make your benefit elections and to add or remove dependents from coverage, if applicable.

After completing the dependent section, you can add eligible dependents to your medical, dental and/or vision coverage. You can also choose to enroll your eligible dependents in supplemental life insurance if you elect coverage yourself.

In addition to enrolling in your benefits during your initial enrollment period, you will also go through Workday if you experience a qualified change in status during the year and need to change your benefits or add/drop dependents.

You can find detailed enrollment instructions by clicking HERE.

You can also email benefits@greendot.org if you need more help.

4

You have the choice of three Aetna medical plans:

ll Aetna HMO Plan

ll Aetna EPO Plan

ll Aetna PPO Plan

All three options cover the same services and provide 100% coverage for in-network preventive care. Each of the plans’ networks is a little different, so visit aetna.com to search for network providers specific to each plan.

HMO PlanThe HMO Plan includes in-network coverage only. Unlike the other two plan options, you must select a Primary Care Physician (PCP) when you enroll in the plan and use that provider each time you need care. If you need to see a specialist, a referral by your PCP is required. The plan pays 100% after you pay a $10 copay for office visits and most services.

If you elect the HMO Plan and have a dependent who attends college or resides outside the plan’s network service area, he or she will not have coverage under the plan (except in the case of emergency or urgently needed care). If this situation applies to you, consider electing either the EPO Plan or the PPO Plan, which offer both in- and out-of-network coverage. This will ensure your dependent has coverage for preventive and non-emergency medical care when needed.

EPO PlanYou have both in-network and out-of-network coverage under the EPO Plan, but your out-of-pocket costs will be less when you use Aetna in-network providers. If you receive care within the network, no deductible applies and you pay a $10 copay for most office visits and services. If you go out-of-network, you must first satisfy a deductible before benefits begin. After you meet the plan’s deductible, you pay 50% coinsurance for care.

PPO PlanUnder the PPO Plan, you can also use any medical provider you choose, but you will pay less out-of-pocket when you receive care from Aetna in-network providers. You pay copays for office visits when you see in-network providers. For other types of care, you must first meet a deductible and then you pay 10% coinsurance. If you go out of Aetna’s network to receive care, you pay 30% coinsurance after you meet your out-of-network deductible.

MEDICAL BENEFITS

You may be eligible to receive $150 per month if you opt out of medical coverage through Green Dot and can prove you have coverage elsewhere. You will only receive the payment if you actively log into the enrollment system and elect “decline medical plan.” You will not receive the incentive if you miss the enrollment deadline and default to “no coverage.”

All three of the medical plans include retail and mail order prescription drug coverage.

There is no annual deductible for prescription drugs, so you begin paying copayments with your first prescription purchase. The category, or tier, your drug is in determines the amount you pay. See the Medical Plan Comparison Chart for coverage amounts

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MEDICAL PLAN COMPARISON CHART

HMO PLAN EPO PLAN PPO PLAN

Plan Provisions In-Network Only In-Network Out-of-Network In-Network Out-of-Network

Annual DeductibleIndividual / Family

$0 $0 $3,000 / $6,000Combined in- and out-of-network:

$250 / $750

Out-of-Pocket Maximum $1,500 / $3,000 $1,500 / $4,500 $9,000 / $27,000 $2,000 / $4,000 $6,000 / $12,000

PCP Required Yes No No

Preventive Care Covered in full Covered in full 50% after Ded. Covered in full 30% after Ded.

Primary Care / Specialist Office Visits

$10 copay $10 copay 50% after Ded. $10 copay 30% after Ded.

Urgent Care Visit $10 copay $10 copay 50% after Ded. $10 copay 30% after Ded.

Emergency Room Visit $50 copay $50 copay $50 copay10% after

$100 copay10% after

$100 copay

Maternity Care No copay, covered 100%

No copay, covered 100%

50% after Ded. 10% after Ded. 30% after Ded.

Inpatient Hospital Covered in full Covered in full 50% after Ded. 10% after Ded. 30% after Ded.

Outpatient Surgery Covered in full Covered in full 50% after Ded. 10% after Ded. 30% after Ded.

Prescription Drugs

Retail (30-day Supply)Tier 1Tier 2Tier 3Tier 4

$10 copay

$20 copay

$35 copay

20% coinsurance

$10 copay

$20 copay

$35 copay

$40 copay

Mail Order (90-day Supply)Tier 1Tier 2Tier 3

$20

$40

$70

$20

$40

$70

This chart does not describe all covered services. Please review the plan summaries for complete coverage information or call Aetna at 800.238.6716 (EPO and PPO) or 800.445.5299 (HMO).

Make your health care dollars go further by choosing an urgent care center instead of an emergency room when you need non-life threatening care. The in-network copay is consid-erably less for an urgent care visit than it is for an ER visit under each of our medical plans.

Another way to save time and money if you can’t get in to see your regular doctor for a minor issue is to use Teladoc.

With Teladoc, you can speak to a licensed doctor online, by phone or by mobile app any time of the day…from anywhere. Simply set up an account at teladoc.com and you’ll be ready the next time you need quick care.

6

DENTAL COVERAGE

You have the choice of three dental plan options, each administered by Aetna:

ll Aetna DMO Plan

ll Aetna Low Plan

ll Aetna High Plan

Under the DMO Plan, you choose a primary care dentist and receive all of your care within the plan’s network – there is no out-of-network coverage. There is also no deductible or annual maximum benefit under the DMO Plan.

Under both the High and Low Plans, you can see any dentist you want, but you must first meet a deductible before coverage begins. These plans also include an annual maximum benefit. The difference between the two is in the deductibles, out-of-network coverage and orthodontic lifetime maximums.

To find an Aetna network dental provider, visit aetna.com.

Aetna Navigator can help you manage your benefits.

When you enroll in an Aetna medical or dental plan, you will have a number of tools and resources available to you through Aetna Navigator. By logging in through Aetna.com, you can access a personalized, secure account where you can:

• Access claim forms and information

• Search for a doctor, dentist, hospital or pharmacy using DocFind®

• Join health and wellness programs

• Use medical and drug cost calculators

• View or print an ID card

• Speak with a registered nurse 24/7

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7

DMO PLAN LOW PLAN HIGH PLAN

Plan Provisions In-Network Only In-Network Out-of-Network In-Network Out-of-Network

You must select a primary care dentist

Yes No No No No

Annual DeductibleIndividual / Family

None $50 / $150 $75 / $255 $25 / $75 $50 / $150

Annual Maximum Benefit None $1,500 $1,000 $1,500

Diagnostic and Preventive Services

Covered in full Covered in fullYou pay 20%, no deductible

Covered in full Covered in full

Basic Services Fee schedule 20% after Ded. 50% after Ded. 20% after Ded. 20% after Ded.

Major Services Fee schedule 50% after Ded. 50% after Ded. 50% after Ded. 50% after Ded.

Orthodontics(adults and children)

Fee schedule 40% after Ded. 40% after Ded. 40% after Ded. 40% after Ded.

Orthodontic Lifetime Benefit(per adult and child)

Fee schedule $1,000 $1,000 $2,500 $2,500

This chart does not describe all covered services. Please review the plan summaries for complete coverage information or call Aetna at 877.238.6200.

DENTAL PLAN COMPARISON CHART

8

VISION COVERAGE

Green Dot offers vision coverage through VSP. Coverage includes access to VSP’s nationwide network of vision providers who have agreed to discounts on your eye care needs. Under the VSP Plan, you can go to any vision provider, but you will get the best value from your plan benefits when you receive care from a VSP provider. If you see a VSP provider, copays will apply. If you see an out-of-network provider, you will be reimbursed up to the plan’s out-of-network allowance.

To find a VSP provider near you, call VSP 800.877.7195 or go to vsp.com.

VSP PLAN

Plan Provisions In-Network Out-of-Network

WellVision Eye Exam (every 12 months)

$10 copay Reimbursed up to $45

Prescription Glasses $25 materials copay for frame and lenses combined (lens enhancements have separate copays)

See frames, lenses and lens enhancements

Frames (every 12 months)

l� $120 allowance for a wide selection of framesl� $140 allowance for featured frame brandsl� 20% savings on the amount over your allowancel� $65 Costco® frame allowance

Reimbursed up to $70

Lenses (every 12 months)

l� Single vision, lined bifocal, and lined trifocal lensesl� Polycarbonate lenses for dependent childrenl� Photochromic/tints/dyes for dependent children covered in full

Single vision: Reimbursed up to $30

Lined bifocal: Reimbursed up to $50

Lined trifocal: Reimbursed up to $65

Lens Enhancements (every 12 months)

l� Standard progressive: $55 copayl� Premium progressive: $95-$105 copayl� Custom progressive: $150-$175 copayl� Average savings of 20-25% on other lens enhancements

Progressive: Reimbursed up to $50

Contact Lenses (instead of glasses) (every 12 months)

l� Contact lens exam (fitting and evaluation): up to $60 copayl� $120 allowance for contacts; copay does not apply

Reimbursed up to $105

Diabetic Eyecare Plus Program

$20 copay for services related to diabetic eye disease, glaucoma and age-related macular degeneration (AMD); Retinal screening for eligible members with diabetes. Limitations and coordination with

medical coverage may apply. Ask your VSP doctor for details.

N/A

Extra Savings

Glasses and Sunglasses

l� Extra $20 to spend on featured frame brands (see vsp.com/specialoffers for details)l� 20% savings on additional glasses and sunglasses, including lens enhancements from any VSP provider within 12 months of your WellVision exam

N/A

Retinal Screening No more than a $39 copay on routine retinal screening as an enhancement to a WellVision exam

N/A

Laser Vision Correction Average 15% off regular price or 5% off promotional price; discounts only available from contracted facilities

N/A

This chart does not describe all covered services. Please review the plan summary for complete coverage information or call VSP at 800.877.7195.

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FLEXIBLE SPENDING ACCOUNTS (FSAs)

Green Dot offers two types of Flexible Spending Accounts (FSAs) administered by WageWorks. FSAs allow you to set aside money from your paychecks to pay certain out-of-pocket expenses with pre-tax dollars. Your FSA contributions reduce your taxable income, so you pay less income tax.

Account Used for 2017 Maximum Contribution*

Healthcare FSAMedical, dental, and vision expenses

not covered by your plans, such as deductibles, coinsurance and copayments.

$2,600

Dependent Care FSA

Dependent care expenses such as before- and after-school programs, day care, preschool or elder care programs. Care must be necessary

to allow you and your spouse or domestic partner to work or attend school full time.

$5,000, or $2,500 if married and file separate tax returns

* This amount may change for 2018.

More about FSAs

ll You choose how much you want to contribute to your FSA(s) for the year, up the IRS maximum. This amount is then deducted from your paycheck in equal installments before federal and social security taxes are withheld.

ll You can only change your contribution amount during the year if you experience a qualified status change.

ll The money in one FSA cannot be used to pay expenses in the other FSA.

ll FSAs typically have a “use it or lose it” rule where you forfeit any remaining funds at the end of the calendar year, which is the case for the Dependent Care FSA. With our Healthcare FSA, you have the option to roll over up to $500 to the next year as long as you also make a contribution.

Our FSAs run on a calendar year basis.

There will be a separate enrollment opportunity in the Fall where you will be able to re-enroll and continue or change your election amounts if you wish to participate in one or both FSAs again.

A list of eligible health care expenses can be found in Publication 502 on the IRS website at www.irs.gov/publications/p502/index.html.

For more about eligible child and dependent care expenses, view Publication 503 at www.irs.gov/publications/p503/index.html.

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Life and AD&D insurance is designed to provide a benefit to you and/or your family members if you die or are injured in an accident.

Basic Life and AD&D InsuranceGreen Dot provides Basic Life and AD&D insurance at no cost to you through Anthem. Basic Life coverage is equal to one times your annual earnings, up to a maximum of $200,000. If your death is the result of an accident, your benefit will be an additional $200,000. If you become dismembered or lose any senses as the result of an accident, you will receive all or a portion of the full benefit based on the loss suffered.

Voluntary Life and AD&D InsuranceIf you wish to supplement your basic insurance provided by Green Dot, you can purchase additional insurance for yourself and your dependents through Anthem. You pay the full cost of this voluntary coverage through after-tax payroll deductions. Coverage options include:

For You

Choose coverage amount of up to $500,000, or five times your annual covered salary, whichever is less, in $10,000 increments. Coverage over $150,000 requires you to provide evidence of insurability (EOI).

Note: Voluntary AD&D insurance is automatically provided to you if you elect Voluntary Life and is equal to your elected Voluntary Life insurance amount.

For Your Spouse/ Domestic Partner

Choose coverage amount of up to $250,000 in $5,000 increments (not to exceed 50% of employee’s elected amount). Coverage over $20,000 requires EOI.

For Your Child(ren)Choose coverage amount of:

$10,000 – age 6 months to 26 years, no EOI required

$1,000 – under age 6 months, no EOI required

Note: At age 65, your coverage and your spouse’s/domestic partner’s coverage will decrease to 65% of the benefit amount. At age 70, it will decrease to 50% of the benefit amount.

LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D) INSURANCE

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LIFE AND ACCIDENTAL DEATH AND DISMEMBERMENT (AD&D) INSURANCE

If you waive Voluntary Life coverage as a newly hired employee and want to enroll during a future Open Enrollment period, you may be required to provide evidence of insurability for any amount of newly elected coverage.

Voluntary Life Monthly Contributions

EMPLOYEE LIFE & AD&D

SPOUSE LIFE

Employee Age*

Cost per $10,000** of coverage

Cost per $5,000 of coverage

Under 25 $0.860 $0.290

25-29 $0.980 $0.350

30-34 $1.210 $0.465

35-39 $1.320 $0.520

40-44 $1.440 $0.580

45-49 $2.020 $0.870

50-54 $5.270 $2.495

55-59 $5.550 $2.635

60-64 $7.930 $3.825

65-69 $15.010 $7.365

70+ $24.170 $11.945

CHILD(REN) VOLUNTARY LIFE

$0.98 for $10,000***

*Spouse / Domestic Partner rates are based on the Employee’s age.

**Employee Life rates include AD&D coverage of $0.28 / $10,000.

***Children under age 6 months are limited to $1,000 of coverage.

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DISABILITY BENEFITS

RETIREMENT BENEFITS

Disability benefits can help replace a portion of your income if you are unable to work due to an illness, injury or pregnancy. Green Dot provides disability insurance benefits through Anthem. You are automatically enrolled in disability insurance benefits at no cost to you.

Short-Term Disability (STD)After you have been disabled for seven days due to a non-work-related illness or injury, or pregnancy, you are eligible to receive STD benefits. The STD benefits replace up to 60% of your eligible income to a maximum benefit of $1,500 per week for up to 12 weeks.

Long-Term Disability (LTD)If your disability lasts longer than 90 days, you are eligible to receive LTD benefits. The LTD benefits replace up to 60% of your eligible income to maximum benefit of $10,000 per month.

Participating in Green Dot’s retirement benefit program offers an easy way for you to save and invest for your retirement. You can enroll in and make pre-tax contributions to both a 401(k) plan and a 457 deferred compensation plan. You can also make after-tax contributions to a Roth 401(k) plan.

The current contribution limit is $18,000. You can make additional catch-up contributions of up to $6,000 if you are age 50 or older. These limits apply to both regular 401(k) and Roth 401(k) contributions combined. You can make an additional $18,000 in contributions to a 457 plan, as well as up to an additional $6,000 in catch-up contributions.

To learn more about your Green Dot retirement benefits or to request an enrollment kit, email benefits@greendot.org.

13

VOLUNTARY BENEFITS THROUGH AFLAC

As a supplement to the benefits you already receive, Green Dot offers the following voluntary insurance coverages through Aflac:

ll Personal Accident

ll Hospital Indemnity

ll Personal Cancer

ll Critical Illness/Injury and Intensive Care

You pay premiums for these coverages through payroll deductions. For additional information about these benefits or to enroll, call our Aflac representative, Jacob Burns, at 661.733.2979 or email jacob_burns@us.aflac.com.

Anthem’s Resource Advisor Employee Assistance Program (EAP) is available 24/7 to you and your family members at no cost. Through the EAP, you can receive confidential counseling and referral services for a variety of work/life issues. You will also have access to helpful resources, including:

ll Child and elder care provider databases

ll Parenting information and services

ll Tips on dealing with emotions

ll Advice on handling difficult life events

ll Self-assessments

ll Online legal and financial tools

For more information about the EAP or to reach Resource Advisor, call 888.209.7840 or visit powerflexweb.com/1631/loginanthemresourceadvisor.html. Log in with the program name AnthemResourceAdvisor.

EMPLOYEE ASSISTANCE PROGRAM (EAP)

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CONTRIBUTION RATES

The following rate tables show your contribution amounts by plan and coverage level for the 2017-2018 plan year. Rates shown are per pay period (based on 24 pay periods).

Medical Plan Contributions per Pay Period

Aetna Medical HMO Plan

Aetna Medical EPO Plan

Aetna Medical PPO Plan

Employee Only $0.00 $70.00 $221.00

Employee + Spouse/ Domestic Partner*

$130.00 $184.50 $506.50

Employee + Child(ren) $108.00 $151.50 $413.00

Employee + Family $188.50 $259.50 $613.50

Dental Plan Contributions per Pay Period

Aetna Dental DMO Plan

Aetna Dental Low Plan

Aetna Dental High Plan

Employee Only $0.00 $10.00 $18.00

Employee + Spouse/ Domestic Partner*

$5.50 $25.00 $35.00

Employee + Child(ren) $4.00 $19.00 $29.00

Employee + Family $7.50 $35.00 $49.00

Vision Plan Contributions per Pay Period

VSP Vision Plan

Employee Only $0.00

Employee + Spouse/ Domestic Partner*

$3.00

Employee + Child(ren) $2.50

Employee + Family $6.00

*The federal law does not recognize a domestic partner as a tax dependent. Unless the domestic partner otherwise qualifies as the employee’s tax dependent under Section 105(b) of IRS, contributions and coverage for your domestic partner and/or his or her eligible dependents (who have not been legally adopted by you) do not qualify for before-tax or tax-free treatment under IRS regulations. As such, any amount that Green Dot pays to cover your domestic partner and/or his or her eligible dependents will be taxable income to you. This amount is called “imputed income” and you are required to pay federal, state and local taxes as well as social security (FICA) and Medicare taxes on this amount.

Green Dot pays 100% of the premium if you elect employee-only coverage for:

• Medical: Aetna HMO Plan

• Dental: Aetna DMO Plan

• Vision: VSP Plan

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Plan Benefit ADMINISTRATOR PHONE NUMBER WEBSITE

Medical Plans AetnaEPO and PPO: 800.238.6716

HMO: 800.445.5299www.aetna.com

Dental Plans Aetna 877.238.6200 www.aetna.com

Vision Plan VSP 800.877.7195 www.vsp.com

Flexible Spending Accounts (FSAs)

WageWorks 877.924.3967 www.wageworks.com

Life, Accident and Disability Insurance

Anthem Claims: 800.232.0113

Life: lifeclaims@anthem.com

Disability: disability@anthem.com

Retirement Benefits401(k) Plan, Roth 401(k) Plan and 457 Defined Contribution Plan

DRS (Digital Retirement

Solutions)888.377.4015 www.drs401k.com

Voluntary BenefitsPersonal Accident, Hospital Indemnity, Personal Cancer, Critical Illness/Injury and Intensive Care Plans

Aflac 661.733.2979Email: jacob_burns@us.aflac.com

www.aflac.com

Employee Assistance Program (EAP)

Anthem 888.209.7840

powerflexweb.com/1631/loginanthemresourceadvisor.html

(log in with Program Name: AnthemResourceAdvisor)

Benefits DepartmentGreen Dot

Public Schools323.565.1607

Email: benefits@greendot.org

www.greendot.org/schools

CONTACT INFORMATION

About this Enrollment Guide

This enrollment guide provides a brief overview of your Green Dot Public Schools benefit plans. More detailed information can be found in the Summary of Benefits and Coverage (SBC) for each plan. If there is a conflict between the information presented in this guide and the official plan documents, the plan documents will govern. Green Dot Public Schools reserves the right to change, amend or terminate these plans at any time. Receipt of this guide is not a guarantee of employment or eligibility for Green Dot Public Schools benefits.