benefit guide 2015

YOUR BENEFITS

Columbia Heights Public Schools create worlds of opportunity for every learner in partnership with supportive small-town communities by challenging all to discover their

talents, to unleash their potential, and to develop tools for lifelong success.

HEALTHVEBA

DENTAL

FLEX PLANS

DISABILITYLIFE

A D & DVISION

RETIREMENT

EAPIDENTITY THEFTGROUP LEGAL

HEAR PO

DISCOUNTS

COLUMBIA HEIGHTS PUBLIC SCHOOLS

BE INFORMED!

Your Benefit Resources

The enrollment process, Summary of Plan Descriptions and Certificates of Insurance can be located in Benefit Ready, your benefits hub: https://chps.benefitready.com General questions regarding Health, VEBA, Dental, Flex Plans, Disability, Life, AD&D, Vision and Group Legal may be directed to:

CieloStar, Inc./Columbia Heights Administrator

730 Second Avenue South, Suite 530

Minneapolis, MN 55402

Fax: (612) 338-2673

Phone: (877) 576-8314

Email: [email protected]

Specific claim or deductible questions should be directed to the appropriate carrier.

Retirees and COBRA Participants May Contact: TASC/Columbia Heights Retiree and COBRA Administrator 2302 International Lane Madison, WI 53704 Customer Care: (800) 422-4661

All benefits are brokered by: National Insurance Services of WI, Inc. 14852 Scenic Heights Road Suite 210 Eden Prairie, MN 55344 Toll Free: 1-800-627-3660

*Please refer to your Employment Agreement or Contract for benefit eligibility criteria and availability.*

https://chps.benefitready.com/

Medical includes VEBA

Dental

Flex Spending

Disability

Life

AD&D

Vision

Group Legal

Contained in the Benefit Ready Enrollment Process

Medical Insurance

All Summary of Plan Descriptions (Certificates of Insurance) are available to view and print on https://chps.benefitready.com under the Knowledge Base.

You have the choice of four plans: o Double Gold o VEBA 834 $1200/$2400 o VEBA 835 $1850/$3700 o Minimum Value Plan with VEBA

These plans are further described below. All are coverage through the Blue Cross Blue Shield Network: Minnesota Service Cooperatives/AWARE. Our plans allow employees to self-refer for services. However, some services must be pre-authorized to receive coverage. Premiums are withheld pre-tax via payroll deduction.

Double Gold Plan (Group # SC0780-10)

This is a traditional health insurance plan with co-pays. This plan will be subject to the Cadillac Tax provision of the Affordable Care Act beginning in 2018. Non-Premium Cost Components:

Individual Lifetime Maximum: unlimited

Out of Pocket Annual Maximum: $2500 per person per calendar year

Office visit copay: $20

ER visit copay: $40

Prescription copays: $8, $16 or $32

Prescription Out of Pocket Annual Maximum: $300 per person or $500 per family

Please see the Benefits Summary for coverage information.


https://www.selectaccount.com/

VEBA 834 $1200/$2400

(Group # SC113-Vo) This is a high deductible health insurance plan that provides comprehensive coverage at a low cost. The deductible is fully funded by the district. Non-Premium Cost Components:


Deductible amounts: $1200 for single coverage and $2400 for family coverage

Family deductible applied as: $1200 per person, with a $2400 maximum per family o These are called embedded deductibles

Office visit, ER, prescription copays: $0

Out of Pocket Annual Maximum: $0 Please see the Benefits Summary for coverage information.

VEBA 835 $1850/$3700 (Group # SC113-VA)

This is a higher deductible health insurance plan that provides comprehensive coverage at a low cost. The deductible is partially funded by the district. Non-Premium Cost Components:




Office visit, ER, prescription copays: $0 after deductible is met

Out of Pocket Annual Maximum: $650 for single coverage and $1300 for family coverage


For these two plans described above, deposits to the VEBA account are made in the following increments:

Single Family

Early July (on or about the 1st) $ 200 $ 400

Early September (on or about the 1st)* $1,000 $2,000

*If your employment terminates before September 1st you will not receive the second deposit. Any expenses that exceed your available balance will be out of pocket for you. *If you are newly hired between September and June you will receive a lump sum deposit in your first year only.

Minimum Value Plan with VEBA (Group # SC113-Q0)

This is the highest deductible plan offered by CHPS. The deductible is partially funded by the district. Non-Premium Cost Components:




Office visit, ER, prescription copays: $0 after deductible is met

Out of Pocket Annual Maximum: $3644.00 for single coverage and $6946.00 for family coverage

For this plan described above, deposits to the VEBA account are made in the following increments:

Single Family

Early July (on or about the 1st) $ 451 $ 959

Early September (on or about the 1st)* $2,255 $4,795

*If your employment terminates before September 1st you will not receive the second deposit. Any expenses that exceed your available balance will be out of pocket for you. *If you are newly hired between September and June you will receive a lump sum deposit in your first year only.


A VEBA (Voluntary Employees’ Beneficiary Association) is similar to a Health Reimbursement Arrangement and is administered by Select Account. The VEBA plans give employees more control over how they spend their health care dollars. You are automatically enrolled in claims crossover. This means that Blue Cross Blue Shield works in coordination with Select Account to process your claims. (If you have a coordination of benefits, please contact CieloStar or Select Account for further information on crossover.) While the VEBA does not directly pay your provider, the funds are sent to you to make the payment once the bill is received. This is only until the deductible is met; then BCBS covers at 100% per the Certificate of Coverage. However, prescriptions are paid for at the point of sale from your VEBA account as long as funds are available. The funds in your VEBA account earn interest and can be used to pay for eligible expenses now or in retirement. Please see the VEBA supplemental materials for more information.

Plan Coverage Differences

The Double Gold has an open drug formulary; the VEBAs and Minimum Value Plan are closed. Closed formulary plans require an approved exception for medical necessity to use non-preferred medications.

The Double Gold provides coverage for oral surgery and anesthesia for removal of impacted teeth, removal of tooth root without removal of the whole tooth and Root Canal Therapy. The VEBAs and Minimum Value Plan do not provide coverage for these.

The Double Gold provides coverage for Foot Orthoses when prescribed by a physician. The VEBAs provides coverage for Custom foot orthoses if you have a diagnosis of diabetes with neurological manifestations of one (1) or both feet.

The Double Gold and VEBAs have coverage for Reproductive Treatments and Bariatric Surgery. The Minimum Value Plan has no coverage for these.

Employee Cost Comparison

2015/2016 Rates

Total Monthly

Cost

Employee Per

Check Amount

Employee Monthly

Contribution

Total Employee

Annual Cost

Active Employees - .75 FTE or greater

Single Double Gold 752.00 59.00 118.00 1416.00

Family Double Gold 2007.50 218.25 436.50 5238.00

Single VEBA $1200 703.50 34.75 69.50 834.00

Family VEBA $2400 1812.50 120.75 241.50 2898.00

Single VEBA $1850 664.50 15.25 30.50 366.00

Family VEBA $3700 1707.00 68.00 136.00 1632.00

Single Minimum Value Plan w/ VEBA 634.00 0.00 0.00 0.00

Family Minimum Value Plan w/ VEBA 1571.00 0.00 0.00 0.00

More information is available on Benefit Ready and in IRS Publication 969. Blue Cross Blue Shield Customer Service: (888) 878-0136 Select Account Customer Service: (800) 859-2144

We strongly recommend creating an online account at www.selectaccount.com

http://www.selectaccount.com/

Dental Insurance

We offer a traditional dental insurance plan. Preventative and diagnostic services are covered at 100%; all other dental services are subject to a coverage percentage and annual maximum benefit amount of $1000. (Annual benefit period is July – June) Orthodontic coverage is $1000 per child lifetime maximum for eligible dependents ages 8 - 19. Premiums are withheld pre-tax via payroll deduction. Please see the summary of benefits for more information.

Comprehensive Standard with Orthodontic Coverage Delta Dental PPO & Delta Dental Premier Networks

(Group # 004107-0001) Premium information is as below:

Total Premium per Month

District Contribution per Month

Employee Contribution per Month

2015/2016 Employee Contribution per Pay Period

Single 36.00 17.50 18.50 $ 9.25

Family 83.50 30.50 53.00 $ 26.50

Delta Dental Customer Service: (800) 448-3815

Do you have adult children that need health and dental coverage? Under the Affordable Care Act of 2010, adult children to age 26 are generally eligible to remain covered on your insurance. Please see the notice later in this guide and the Certificates of Coverage for more specific information.

For more information on the Affordable Care Act visit: www.healthcare.gov

http://wsprod.deltadental.com/Public/index.jsp?DView=HomePage

http://www.healthcare.gov/

Section 125 Spending Accounts (Flex Spending/Cafeteria Plans)

Select Account processes reimbursements for both accounts once per week on Thursdays. Employees who receive payments via check should allow up to 10 business days for payment to be received. Employees who receive direct deposits should allow up to 5 business days for payment to be received. The average reimbursement time for medical expenses submitted via mail or fax is three weeks.

Dependent Care Spending Account The IRS allows up to $5000 per calendar year to be withheld pre-tax for use towards daycare expenses. You must make payment to your provider and request reimbursement. Reimbursements cannot be processed until the account is funded with contributions from your paycheck. Married couples cannot exceed $5000 with combined elections.

Health Care Spending Account

CHPS allows up to $2500 per calendar year to be withheld pre-tax for use towards eligible healthcare expenses. Eligible expenses are typically for medical, dental or vision care that is not covered by your health insurance. You make payment to your provider and request reimbursement. Reimbursements can be processed prior to the account being fully funded to cover the expense. See the list of eligible expenses for more information. The Health Care Spending Account works in conjunction with the VEBA health insurance plans. You are allowed to carry over $500 to the next plan year.

Please see the Select Account Materials for more information on both of these options. Select Account Customer Service: (800) 859-2144 We strongly recommend creating an online account at www.selectaccount.com

With an online account you can:

Submit electronic claims Track claim payments View deposits and payments

http://www.selectaccount.com/

Disability Insurance

Long Term Disability (Group # GN90193)

Employer Paid Group Insurance Benefits pay at 66 2/3%* of your annual base salary after 60 consecutive work days are missed (generally 12 weeks) for qualifying cause. The district pays the premium for this policy. Employees who are .75 FTE or greater qualify for this benefit and are automatically enrolled; it is not part of the benefit enrollment process. Teachers FTE .5-.75, please contact WageWorks with

enrollment questions. *Benefit amounts could vary. See employment agreement or certificate of insurance for more information.

Short Term Disability

(Group # 7383) Optional Employee Supplemental Insurance You pay the premium for this policy via post-tax payroll deduction. Benefits pay at 66 2/3% of your annual base salary for a maximum of 60 workdays once the elimination period is met. You can receive 1/3 of a day of sick leave to remain whole until sick leave is exhausted or you have used the maximum of 30 days total. Benefits are not taxable since premiums are withheld post-tax. The elimination period is 7 work days for accidents and 14 work days for illness. (Bed rest is classified as an illness.) Benefits paid for childbirth are 6 weeks maximum for regular delivery; 8 weeks maximum for caesarean. There is a pre-existing look back period of three months. Any illness where treatment was received within three months of the start of the policy will not be a covered event until after 12 months. Premiums are age-banded as follows:

The calculation for premium is as follows: (Base annual salary * benefit %) / 52 weeks = weekly benefit; then (weekly benefit * rate from table) / $10 of weekly benefit = monthly premium Evidence of Insurability is required for late entrants.

Age Rate per $10

0-24 1.06

25-29 0.82

30-34 0.82

35-39 0.52

40-44 0.45

45-49 0.50

50-54 0.62

55-59 0.76

60-64 0.96

65+ 1.14

Life Insurance Beneficiary Assignments Required; Evidence of Insurability required for Late Entrants. All plans are Group Term Life Insurance Policies. Premiums are shown within Benefit Ready.

(Group # 3931)

Employer Provided Policy Benefit amounts are based on your employment agreement or contract. The district pays the premium for this policy. (Teachers working FTE of .5 - .75: you will be responsible for a percentage of the premium based on your FTE. See your contract for further information.) If applicable (employer paid policy amounts over $50,000), excess benefit amounts are taxable per IRC 79; IRC 3121 (a) (2) (C); IRC 3306 (b) (2) (C); IRS Reg. 1.79-1et seq; IRS Temp. Reg. 1.79-4T. Contact the Payroll Department for more information.

Optional Employee Life Insurance You pay the premium for this policy via post-tax payroll deduction. You must elect this benefit in order to be eligible for the optional spouse and child insurance benefits listed below. The maximum benefit is $300,000. The Guaranteed Issue amount for all employees is $80,000 ($40,000 if age 65-70). All elections above the Guarantee Issue amount, all late entrants and all increases are subject to evidence of insurability. All coverage amounts reduce to 50% at age 70.

Optional Spouse Life Insurance You pay the premium for this policy via post-tax payroll deduction. You must participate in the Optional Employee Life Insurance to be eligible for this benefit. The Guarantee Issue amount for all new hires is $50,000; however, this coverage value may not exceed 50% of the optional employee life coverage election amount. The maximum benefit is $50,000. All new elections are subject to evidence of insurability. Coverage amounts reduce to 50% value upon the employee reaching age 70. Coverage terminates upon the spouse reaching age 70.

Optional Child Life Insurance You pay the premium for this policy via post-tax payroll deduction. Coverage options are: $2,500, $5,000 or $10,000 for each child up to age 19 or age 25 if they are a full-time student. Evidence of insurability is required for all late entrants and all increases. Optional Dependent Life Insurance You pay the premium for this policy via post-tax payroll deduction. This is a separate policy from the optional spouse and/or child life benefits. It is an additional coverage amount with the following benefits:

Spouse $10,000

and/or Children 14 days to 6 months of age $ 200

and/or Children older than 6 months $ 2,000

Accidental Death or Dismemberment (A D & D)

(Beneficiary Assignment Recommended) (Group # GTU 4380634)

Voluntary Insurance Program As an employee of ISD #13, you are eligible to elect this benefit. You pay the premium for this policy via post-tax payroll deduction. Coverage is provided regardless of health history and benefits pay in addition to any other insurance you may carry. The maximum benefit is $500,000; elections over $150,000 are limited to ten times your base annual earnings. There is a maximum benefit of $250,000 for your spouse and $50,000 for your dependent children, if applicable. Premiums are shown within Benefit Ready.

Vision (Group # tbd – new for 15/16) We offer two vision plans:

Low Plan: Vision Perfect

High Plan: Focus Both are coverage through Ameritas with an additional value of EyeMed Discounts. Premiums are withheld pre-tax via payroll deduction. Dependent children can be covered to age 26 regardless of student status. The Low Plan: Vision Perfect is a materials only plan. Employees carrying our medical coverage might consider this plan as our medical insurance plans through Blue Cross Blue Shield do offer exam only coverage at a Blue Cross Provider. The High Plan: Focus offers exam and materials coverage. Employees not carrying our medical insurance might consider this option. Neither plan offers coverage for LASIK but there are discounts available thru EyeMed and also Blue Cross Blue Shield. Ameritas also offers their plan members a Wal-MartRx discount valid at either Wal-Mart or Sam’s Club pharmacies. Please see the Eye Care Highlight Sheet (Benefit Summary) for more information. Premiums are shown within Benefit Ready.

http://www.zurichna.com/zna

Group Legal (Group # tbd – new for 15/16) Have you ever had some questions for an attorney but not had any idea how to pick one to call? CHPS offers a group legal plan where you can obtain assistance on a variety of topics: Estate Family Financial Auto Home LegalShield uses The Provider Network for 24/7 access to attorneys during covered emergencies and has been providing these services for over 40 years. The post-tax payroll deduction for $18.95 per month provides you, your spouse, dependent children under age 18 and never-married children under age 26 living at home access to this plan. A sampling of services covered are:

Will preparation

Advice

Letters and phone calls on your behalf

Legal document review, up to 15 pages each

Trial defense hours

Video law library

Forms service center Additionally, should you require more service time than is covered, you can get further services at a 25% discount. Please see the LegalShield Service Definition Listing for more information.

Supplementary

Benefits

Not Contained in the Benefit Ready Enrollment Process

Statutory Benefits

Teachers Retirement Association (Beneficiary Assignment Recommended)

Coordinated Plan Licensed personnel whose position requires a license will be automatically enrolled in the TRA Coordinated Plan per Minnesota Statutes. Contributions are withheld via payroll deduction and are pre-tax with regard to Federal and State Withholding. Employer and employee contributions are 7.50% of eligible earnings. Please visit www.minnesotatra.org for more information

Public Employees Retirement Association (Beneficiary Assignment Recommended)

Coordinated Plan Personnel in non-licensed positions are automatically enrolled in the PERA Coordinated Plan per Minnesota Statutes. (Please see the exclusion list for ineligible positions.) Contributions are withheld via payroll deduction and are pre-tax with regard to Federal and State Withholding. Contributions are based on eligible earnings. Employees contribute 6.50% and employers contribute 7.50% of all eligible earnings. Please visit www.mnpera.org for more information. School Board members are eligible to elect participation. Contact the Payroll & Benefits Office for further information.

Social Security & Medicare (FICA)

Retirement, Disability & Medical Benefits Anyone born in 1929 or later needs 40 Social Security Credits to be eligible for retirement benefits. You can earn up to four credits per year; so you will need at least 10 years to become eligible for retirement benefits. During your working years, earnings eligible for Social Security are posted to your Social Security record and you earn credits based on those earnings. FICA contributions are as follows:

Social Security Medicare

Employee 6.20% 1.45%

Employer 6.20% 1.45%

For more information, please visit their website at: www.socialsecurity.gov

http://www.minnesotatra.org/

http://www.mnpera.org/

http://www.socialsecurity.gov/

Unemployment Insurance Job Loss Protection Provides income to you in the event of a job loss. This is an employer paid benefit. For further information, please visit their website: www.uimn.org

Additional Benefits Offered

Voluntary Retirement Options 403(b), Roth 403(b) & 457 Deferred Compensation Planning for your retirement? Contributions are made either as pre or post tax deductions from your paycheck depending on the plan you elect. Changes to contribution election amounts can be made at any time during the year. Please review your employment agreement or contract for participation and district match eligibility. See the enclosed approved vendor listing for agent contact information as part of the Transaction Processing Kit for more information and forms. The Minnesota Deferred Compensation plan information is available at: www.mndcplan.com

These retirement plans are administered by Educators Benefit Consultants, LLC (EBC).

Employee Assistance Program (EAP) A Resourceful & Caring Ear Sometimes life deals us tough problems. If you aren’t sure where to turn, give the EAP a call. This is a confidential service that is available to our employees covered under our long term disability plan providing you support and resources. There is no charge for this service. Masters-degreed counselors from Bensinger, Dupont & Associates are available 24 hours a day at: (866) 451-5465. See the EAP insert for more information.

http://www.uimn.org/

http://www.mndcplan.com/

Identity Theft Assistance Services Help for Victims of Identity Theft The average victim of identity theft spends $500 and 30 hours to resolve each incident when doing it on their own. Should you find yourself in this circumstance, contact an Identity Theft Certified Risk Management Specialist for guidance and support through the process. There is no charge for this service. This valuable amenity is provided by AMT Consumer Services. They can be reached 24/7 at: (855) 860-3727. Please see the Identity Theft Assistance insert for more information.

Worker’s Compensation Workplace Injury Protection The worker’s compensation system provides benefits if you become injured or ill from your job. Worker’s compensation covers injuries or illnesses caused or made worse by work or the workplace. Worker’s compensation benefits are paid regardless of any fault of either the employer or employee. This is an employer paid benefit. See the Staff Handbook for further information.

Additional Life Insurance Option

Columbia Heights Public Schools is a participating employer for the Group Decreasing Term Life Insurance Plan offered by the National Conference on Public Employees Retirement Systems (NCPERS). Coverage is available to PERA covered employees and is a Prudential Financial, Inc. policy. The premium is $16 per month and the coverage can be continued into retirement. For more information, please visit www.mnpera.org > Resources > Life Insurance. Please see the NCPERS insert for more information. Enrollment forms are available in the Payroll & Benefits Office.

http://www.mnpera.org/

Extra Perks

Discounts on Alternative Care Options (i.e. acupuncture and massage therapy) Discounts for home medical equipment and supplies Fitness Membership Discounts Weight Watchers Discount LASIK Discount

Visit www.bluecrossmn.org for more information

HearPO Program partnered with Delta Dental – Discounts on Hearing Aids

Visit www.hearpo.com for more information

Various Potential Discounts for Government Employees – dependent on company

Hotels Rental cars Auto insurance Cell phone services Technology purchases Government Employee Travel Opportunities (GETO) Program

Just ask the company if they offer discounts!

http://www.bluecrossmn.org/

http://www.hearpo.com/

Summary of Benefits Medical, Dental & Vision

Columbia Heights ISD #13 2015 Summary of Benefits

Double Gold Plan Benefits In-network provider Out-of-network provider Eligible Dependents Spouse and unmarried dependent children to age 26. Individual Lifetime Maximum unlimited Deductible (applies to all networks) N/A $300 per individual/calendar year

$900 per family/calendar year Copay $20 copay N/A Out of pocket maximum $2,500 per person / calendar year Physician Services Office Calls for Illness or Injury In-office Surgery Speech therapy Physical therapy Occupational therapy

100% after $20 office call copay

80% after deductible

Preventive Care Routine physicals, Vision & hearing exams Routine lab/x-rays Immunizations Gynecological exams Cancer screening

100%


Routine services for : Prenatal Well-child up to age 6 Immunizations up to age 18

100%

100%

Inpatient Hospital Services Room and board Obstetrics Lab, x-ray Nursery

100%

100%

100%,

100%

In-patient Physician Services In-patient visits Surgery, anesthesia Labor/Deliver/Postpartum

100%


Outpatient Hospital Services

100%


Outpatient Physician Services Lab, x-ray Surgery, anesthesia Physical Therapy Occupational Therapy Speech Therapy

100%


Benefits In-network provider Out-of-network provider Medical supplies 80% 80% Chiropractic Care Evaluation Manipulations, therapy Lab, x-ray

100% after $20 office call copay


Ambulance 80% 80%

Emergency Room Services 100% after $40 copay 100% after $40 copay

Mental Health Hospital Care

100% 100%

Mental Health Professional Care 100% 80% after deductible Chemical Dependency Facility Care

100% 100%

Professional Chemical Dependency Care

100% 80% after deductible

Prescription Drugs Retail

Preferred Generic $8 copay Preferred Brand $16 copay Non Preferred $32 copay

Mail order pharmacy Preferred Generic $16 copay Preferred Brand $32 copay Non Preferred $64 copay

Prescription Drugs Annual Out-of-Pocket Maximum

$300 Rx out-of-pocket per individual $500 Rx out-of-pocket per family

For questions concerning your benefits or a claim, please contact the Blue Cross and Blue

Shield of Minnesota Customer Service Specialists at:

651-662-5517 or 1-888-878-0136 or

www.bluecrossmn.com

This is only a summary and is subject to the terms of the Contract. If there is a discrepancy between this Summary and the Contract, the Contract is considered correct.

We feature a large network of health care providers.

Each provider is an independent contractor and is not our agent.

$1,200 CDHP 2015

THIS IS ONLY A SUMMARY AND IS SUBJECT TO THE TERMS OF THE CONTRACT**

In Network Out of Network

Plan Year Deductible $1,200 Single $2,400 Family- Embedded Fourth Quarter carryover

Plan Year Out-of-Pocket Maximum The in and out-of-network maximums Cross apply

Non-covered charges and charges in excess of our allowed amount do not apply to the out-of-pocket maximum.

Medical and Prescription $1,200 Single $2,400 Family


Coinsurance 100% 80%

Benefit Payment Levels Payment for Participating Network Providers as described. Most payments are based on allowed amount.

If non-participating provider services are covered, you are responsible for the difference between the billed charges and allowed amount. Most payments are based on allowed amount.

Lifetime Maximum per Person Unlimited.

Dependent Child Age Limit To age 26, through the calendar month of the birthday.

COVERED CHARGES Preventive Care • Well Child Care through age 5• Prenatal Care 100% 100%

• Routine Physicals ages 6 and older• Office Visits• Cancer Screening• Routine Hearing and Vision Exams• Immunizations and Vaccinations

100% Deductible then 80% coinsurance.

Physician Services • In-Hospital Medical Visits• Surgery and Anesthesia• Inpatient Lab and X-rays, etc.

Deductible then 100% coinsurance. Deductible then 80% coinsurance.

• Office Visits due to Illness or Injury• Urgent Care (Clinic Based)


• Outpatient Lab and X-ray Deductible then 100% coinsurance. Deductible then 80% coinsurance.

• Allergy Injections and SerumDeductible then 100% coinsurance.

Deductible then 80% coinsurance.

Other Professional Services • Chiropractic Care Deductible then 100% coinsurance.

Deductible then 80% coinsurance

• Home Health CareDeductible then 100% coinsurance.


• Physical Therapy, OccupationalTherapy, Speech Therapy Deductible then 100% coinsurance. Deductible then 80% coinsurance


Inpatient Hospital Services 365 days of medically necessary care in an average semi-private room.


Outpatient Hospital Services • Diagnostic Tests • Pre-Admission Tests and Exams • Lab and X-Ray


• Chemotherapy and Radiation Therapy • Physical, Occupational and Speech

Therapy • Kidney Dialysis • Scheduled Outpatient Surgery • Non-emergency – Illness Related visits


• Urgent Care (Hospital based) Deductible then 100% coinsurance. Deductible then 80% coinsurance. Emergency Care • Emergency Room Deductible then 100% coinsurance.

• Physician Services Deductible then 100% coinsurance.

Ambulance Medically necessary transport to nearest facility


Medical Supplies Deductible then 100% coinsurance. Deductible then 80% coinsurance. Behavioral Health Care (Mental Health and Chemical Dependency Care) • Inpatient Care Deductible then 100% coinsurance. Deductible then 80% coinsurance.

• Outpatient Care Deductible then 100% coinsurance. Deductible then 80% coinsurance.

• Professional Care Deductible then 100% coinsurance. Deductible then 80% coinsurance. Prescription Drugs Retail – 31 day limit Flex RX Formulary

Deductible then 100% coinsurance No coverage for prescriptions not on our Preferred list. If generic is available and name brand selected patient pays the difference.

90dayRx – 90 day limit (PrimeMail and Participating Retail Pharmacies)


Deductible amounts and out-of-pocket maximums may increase annually to keep pace with inflation.

**This is only an outline of plan benefits. The contract and certificate include complete details of what is and isn’t covered. Services not covered include items primarily used for non-medical purposes, over-the-counter drugs/nutritional supplements, services that are complementary, experimental, not medically necessary, or covered by workers’ compensation or no-fault auto insurance. We feature a large network of health care providers. Each provider is an independent contractor and is not our agent. Nonparticipating providers do not have contracts with Blue Cross and Blue Shield of Minnesota. Blue Cross and Blue Shield of Minnesota is an independent licensee of the Blue Cross and Blue Shield Association.

Administered by Blue Cross and Blue Shield of Minnesota, a nonprofit independent licensee of the Blue Cross and Blue Shield Association

$1,850 CDHP 2015

THIS IS ONLY A SUMMARY AND IS SUBJECT TO THE TERMS OF THE CONTRACT**


Plan Year Deductible $1,850 Single $3,700 Family- Embedded Fourth Quarter carryover

Plan Year Out-of-Pocket Maximum The in and out-of-network maximums Cross apply

Non-covered charges and charges in excess of our allowed amount do not apply to the out-of-pocket maximum.



Coinsurance 100% 80%

Benefit Payment Levels Payment for Participating Network Providers as described. Most payments are based on allowed amount.

If non-participating provider services are covered, you are responsible for the difference between the billed charges and allowed amount. Most payments are based on allowed amount.

Lifetime Maximum per Person Unlimited.

Dependent Child Age Limit To age 26, through the calendar month of the birthday.

COVERED CHARGES Preventive Care • Well Child Care through age 5• Prenatal Care 100% 100%

• Routine Physicals ages 6 and older• Office Visits• Cancer Screening• Routine Hearing and Vision Exams• Immunizations and Vaccinations

100% Deductible then 80% coinsurance.

Physician Services • In-Hospital Medical Visits• Surgery and Anesthesia• Inpatient Lab and X-rays, etc.


• Office Visits due to Illness or Injury• Urgent Care (Clinic Based)


• Outpatient Lab and X-ray Deductible then 100% coinsurance. Deductible then 80% coinsurance.

• Allergy Injections and SerumDeductible then 100% coinsurance.


Other Professional Services • Chiropractic Care Deductible then 100% coinsurance.

Deductible then 80% coinsurance

• Home Health CareDeductible then 100% coinsurance.


• Physical Therapy, OccupationalTherapy, Speech Therapy Deductible then 100% coinsurance. Deductible then 80% coinsurance


Inpatient Hospital Services 365 days of medically necessary care in an average semi-private room.


Outpatient Hospital Services • Diagnostic Tests • Pre-Admission Tests and Exams • Lab and X-Ray


• Chemotherapy and Radiation Therapy • Physical, Occupational and Speech

Therapy • Kidney Dialysis • Scheduled Outpatient Surgery • Non-emergency – Illness Related visits


• Urgent Care (Hospital based) Deductible then 100% coinsurance. Deductible then 80% coinsurance. Emergency Care • Emergency Room Deductible then 100% coinsurance.

• Physician Services Deductible then 100% coinsurance.

Ambulance Medically necessary transport to nearest facility


Medical Supplies Deductible then 100% coinsurance. Deductible then 80% coinsurance. Behavioral Health Care (Mental Health and Chemical Dependency Care) • Inpatient Care Deductible then 100% coinsurance. Deductible then 80% coinsurance.

• Outpatient Care Deductible then 100% coinsurance. Deductible then 80% coinsurance.

• Professional Care Deductible then 100% coinsurance. Deductible then 80% coinsurance. Prescription Drugs Retail – 31 day limit Flex RX Formulary


90dayRx – 90 day limit (PrimeMail and Participating Retail Pharmacies)


Deductible amounts and out-of-pocket maximums may increase annually to keep pace with inflation.

**This is only an outline of plan benefits. The contract and certificate include complete details of what is and isn’t covered. Services not covered include items primarily used for non-medical purposes, over-the-counter drugs/nutritional supplements, services that are complementary, experimental, not medically necessary, or covered by workers’ compensation or no-fault auto insurance. We feature a large network of health care providers. Each provider is an independent contractor and is not our agent. Nonparticipating providers do not have contracts with Blue Cross and Blue Shield of Minnesota. Blue Cross and Blue Shield of Minnesota is an independent licensee of the Blue Cross and Blue Shield Association.

Administered by Blue Cross and Blue Shield of Minnesota, a nonprofit independent licensee of the Blue Cross and Blue Shield Association

2015 $6,350/$12,700 Embedded Open Formulary

In network* MN network — Aware

National network — BlueCard PPO

Out of network**

Calendar-year deductible

All network deductibles accumulate

separately. Deductible carryover does not

apply.

Medical and prescription combined

$6,350 single

$12,700 family


$8,250 single

$16,500 family

Coinsurance (aka 'coins.') Deductible then 100% coins. Deductible then 80% coins.

Calendar-year out-of-pocket maximum

The out-of-pocket maximums for all networks

accumulate separately.

Non-covered charges and charges in excess

of the allowed amount do not apply to the out-

of-pocket maximum.


$6,350 single

$12,700 family


$10,000 single

$20,000 family

Benefit payment levels Payment for participating network providers as

described. Most payments are based on

allowed amount.

If nonparticipating provider services are

covered, you are responsible for the difference

between the billed charges and allowed

amount. Most payments are based on allowed

amount.

Lifetime maximum per person Unlimited Unlimited

Dependent child age limit To age 26 through the calendar month of the birthday.

Preventive care

• well-child care to age 6

• prenatal care

• preventive medical evaluation age 6 and

older

• cancer screening

• preventive hearing and vision exams

• immunizations and vaccinations

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

Physician services

• in-hospital medical visits

• surgery and anesthesia

• professional lab services

• office visits due to illness or injury

• urgent care (clinic-based)

• retail health clinic

• professional diagnostic imaging

• allergy injections and serum

Deductible then 100% coins.
















Other professional services

• chiropractic manipulation

• chiropractic therapy

• home health care

• physical therapy, occupational therapy,

speech therapy









Inpatient hospital services Deductible then 100% coins. Deductible then 80% coins.

Outpatient hospital services

• facility diagnostic imaging

• preadmission tests and exams

• facility lab services

• chemotherapy and radiation therapy

• physical, occupational and speech therapy

• kidney dialysis

• scheduled outpatient surgery

• non-emergency illness-related visits

• urgent care (hospital-based)



















In network* MN network — Aware

National network — BlueCard PPO

Out of network**

Emergency care

• emergency room

• physician services

• ambulance (medically necessary transport to

the nearest facility)




Medical supplies Deductible then 100% coins. Deductible then 80% coins.

Bariatric surgery No coverage

Reproduction treatments No coverage

Behavioral health (mental health and

chemical dependency care)

• inpatient care

• outpatient care

• professional care







Prescription Drugs

• retail (31-day limit)

FlexRx preferred drug list

• open plan design

• preferred generic

• preferred brand

• non-preferred

• specialty






• 90dayRx

FlexRx preferred drug list

• open plan design

• preferred generic

• preferred brand

• non-preferred





90dayRx applies to participating and/or mail service pharmacy.

Identified specialty drugs purchased through a specialty pharmacy network supplier are eligible

for coverage (no coverage for specialty drugs purchased through a nonparticipating specialty

pharmacy supplier).

The patient will pay the difference if a brand-name drug is selected when a generic drug is

available.

The drug list uses a step therapy program. Visit the prescription drugs section of

www.bluecrossmn.com for more details.

Your out-of-pocket costs depend on the network status of your provider. To check the status of a provider, call Blue Cross and Blue Shield of Minnesota customer service or visit bluecrossmn.com.

Lowest out-of-pocket costs: in-network providers*

Higher out-of-pocket costs: out-of-network participating providers**

Highest out-of-pocket costs: out-of-network nonparticipating providers (You are responsible for the difference between Blue Cross’ allowed amount and the amount billed by nonparticipating providers.

This is in addition to any applicable deductible, copay or coinsurance. Benefit payments are calculated on Blue Cross’ allowed amount, which is typically lower than the amount billed by the provider.)

This is only a summary. Read your Summary Plan Description for more information about what is and isn’t covered. Services that aren’t covered include those that are cosmetic, investigative, not

medically necessary or covered by workers’ compensation or non-fault insurance. Preexisting conditions may not be covered for a limited period of time for age 19 and older. This limit is reduced by prior

continuous coverage and doesn’t apply to pregnancy, newborns, adopted children, individuals under 19 or handicapped dependents. Consumer Price Index Annual Adjustment: the deductible, copay and

out-of-pocket maximum amounts are subject to annual adjustments. These adjustments are based on the medical care component of the Consumer Price Index (CPI) published by the U.S. Department

of Labor. These annual adjustments are effective on the annual renewal date.

For more information, visit bluecrossmn.com or call Blue Cross customer service at (651) 662-5001 and 1-800-531-6676.

OE10032R03_005EG_(0613)

http://www.bluecrossmn.com/

A Snapshot of Your Coverage*

Service & Description

Delta Dental PPO

Delta Dental Premier

Non-Participating

Diagnostic & Preventive Services Exams & cleanings, x-rays, fluoride treatments, space maintainers

100% 100% 100% of

maximum allowable fee**

Basic Services Emergency treatment for relief of pain, amalgam restorations (silver fillings) and composite resin restorations (white fillings) on anterior (front) teeth. For white fillings on posterior (back) teeth, benefits pay up to the cost of an amalgam

80% 80% 80% of


Endodontics Pulpotomies on primary teeth for dependent children, root canal therapy on permanent teeth

80% 80% 80% of


Periodontics Non Surgical and Surgical periodontal care

80% 80% 80% of


Oral Surgery Surgical/Nonsurgical extractions, all other oral surgery

80% 80% 80% of


Major Restorative Crowns 80% 80%

80% of maximum

allowable fee**

Prosthetic Repairs and Adjustments Denture adjustments and repairs, bridge repair

50% 50% 50% of


Prosthetics Dentures (full and partial), bridges 50% 50%

50% of maximum

allowable fee**

Orthodontics Treatment for the prevention/ correction of malocclusion, available for dependent children only, age 8 to age 19 (must be banded by age 19)

50% 50% 50% of


Deductible Per person/per family (calendar year) No deductible for diagnostic and preventive services or orthodontics

$50/$100 $50/$100 $50/$100

Calendar Year Plan Maximum Per person

$1,000 $1,000 $1,000

Lifetime Ortho Maximum Per eligible children age 8 to age 19

$1,000 $1,000 $1,000

Eligible Dependents Spouse and dependent children up to age 26

*This is a summary of benefits only and does not guarantee coverage. For a complete list of covered services and limitations/exclusions, please refer to the Dental Benefit Plan Summary. **Dentist who have signed a participating network agreement with Delta Dental have agreed to accept the maximum allowable fee as payment if full. Non-participating dentists have not signed an agreement and are not obligated to limit the amount they charge; the member is responsible for paying any difference to the non-participating dentists.

COLUMBIA HEIGHTS SCHOOLS ISD #13

Group #4107

Group #

Delta Dental PPO and Delta Dental Premier

Delta Dental Premier®

Welcome to Delta Dental

Welcome to Delta Dental of Minnesota.

We’ve designed your dental plan so it is

easy to use and gives you and your family

maximum flexibility, network savings, an

unparalleled commitment to service and

peace of mind. Together with your

employer, our goal is to help you maintain

healthy, happy smiles all year round.

Prevention is the key to good

long-term oral health Our plans are designed to encourage you to

visit the dentist and help ensure your basic

dental needs are met in a timely, cost-

effective manner.

Access to regular checkups and sound

preventive care are key to long-term oral

health. Furthermore, new research suggests

that good oral health can positively impact

the burden of illness caused by

cardiovascular disease and diabetes.

In addition to visiting your dentist for regular

preventive care, talk to your dentist about

your specific oral health needs. Your dental

plan is intended only to help you pay for

care—your dentist is the one who will help

you determine your actual care needs.

Helpful Online Tools As part of our commitment to your

long-term oral health, we provide

members free access to valuable oral

health information and dental benefit

tools through our Web site,

www.deltadentalmn.org.

DELTA DENTAL OF MINNESOTA

Frequently Asked Questions May I go to any dentist? You have the freedom to see any dentist. However, dentists who

participate in our Delta Dental PPO (formerly DeltaPreferred Option) or

Delta Dental Premier networks have agreed not to charge more than our

maximum allowable amount. This can result in lower out-of-pocket costs.

Choosing a dentist in the Delta Dental PPO network may save you even

more money. As an added convenience, you never have to file a claim

when you use a participating dentist—the dentist files the claim for you.

Through a unique contractual agreement, Delta Dental maintains a

network of participating dentists that includes about 80 percent of the

licensed, practicing dentists in Minnesota. In Minnesota, Delta Dental

PPO has about 1,400 participating dentists, while Delta Dental Premier

has about 2,600 participating dentists. Nationally, Delta Dental PPO has

about 63,000 participating dentists. Delta Dental Premier is the largest

dental network in the country with about 124,000 participating dentists.

How do I find a participating dentist?

Finding a participating dentist is easy. Simply visit

www.deltadentalmn.org and use our interactive Dentist Search tool or

call Customer Service locally at 651-406-5916 or toll free at 1-800-553-

9536.

What happens if I visit a non-participating dentist?

If dental services are received from a non-participating dentist, you will

be responsible for paying the difference between our maximum allowable

amount and what the dentist charges. You may be responsible for

submitting your own claim. The address to submit claims is on the back

of your Delta Dental ID card. In addition, reimbursement for covered

services will be paid directly to you.

What if I have an emergency outside the United States?

Delta Dental automatically includes international emergency coverage in

137 countries. English-speaking customer service representatives are

available 24 hours a day, seven days a week to help members arrange

emergency care. For more information, visit www.deltadentalmn.org.

How do I find out if my claim was paid?

Our online claims inquiry tool provides claims detail. Our Web site

offers other interactive features including eligibility and benefits inquiry,

oral health resources and much more. You may also call Customer

Service to get claims status and payment information.

How is work in progress handled?

For services started prior to your effective date under the Delta Dental

plan, payment of the claim is based on the service completion date.

How do I know how much I’ll be responsible for?

For major dental procedures, the dentist can submit a pre-treatment

estimate to Delta Dental of Minnesota for determination of benefits and

financial responsibility prior to the service.

To learn more about your dental plan, please contact us toll free at 1-800-553-9536 or visit www.deltadentalmn.org.

An innovator in oral health benefit plans, Delta Dental of Minnesota is an independently operated, nonprofit dental services company that administers self-insured and prepaid dental service plans. Delta Dental serves more than 8,400 employer groups with more than 3.4 million members in Minnesota and across the nation. Delta Dental of Minnesota is headquartered in Eagan, and has a customer service center on Minnesota’s Iron Range.

http://www.deltadentalmn.org/

COLUMBIA HEIGHTS PUBLIC SCHOOLS Eye Care Highlight Sheet

Low Plan: Vision Perfect® Plan Summary Effective Date: 7/1/2015 Deductibles

$10 Calendar Year Eye Glass Lenses or Frames* Maximum

Calendar Year None Annual Eye Exam NA Lenses (per pair)

Single Vision Up to $40 Bifocal Up to $60 Trifocal Up to $75 Lenticular Up to $80 Progressive Up to $80

Contacts Elective/Medically Necessary Up to $140

Frames $100 Frequencies (months)

Lens/Frame 12/24 Based on date of service***

*Deductible applies to the first service received ***Please submit claims within 90 days of the date of service so that the plan can consider benefits (subject to State requirements). Monthly Rates Employee Only (EE) $6.85 EE + 1 Dependent $12.51 EE + 2 or more Dependents $17.85 EyeMed Discounts (These discounts are not insurance.)

Exam $5 off routine exam with dilation as necessary $10 off contact lens exam

Standard Plastic Lenses Single Vision Member pays $50 Bifocal Member pays $70 Trifocal Member pays $105

Frame 35% off retail price with a complete pair of glasses (Items purchased separately - 20% off

retail price) Standard Progressive Lenses

$65 + Standard Plastic Lens cost

Premium Progressive Lenses

20% discount

Standard Polycarbonate Member pays $40 Tint (Solid & Gradient) Member pays $15 Scratch Resistant Coating Member pays $15 Anti-Reflective Coating Member pays $45 Ultraviolet Coating Member pays $15 Other Add-Ons 20% discount Contact Lenses

Conventional 15% off retail price (does not apply to fitting).

After initial purchase, replacements by mail are offered at substantial savings via

eyemedvisioncare.com.

LASIK or PRK Average discount of 15% off retail price, or 5% off

promotional price through U.S. Laser Network. LIMITATIONS AND EXCLUSIONS These discounts from providers on the EyeMed Access

Network are only available to groups who have a specific

schedule/defined benefit eye care plan in place. The

discounts may not be combined with any other discounts

or promotional offers. Retail prices may vary by location.

Discounts are not available for the following procedures,

material or services. � Orthoptic or vision training, subnormal vision aids,

and any associated supplement testing. � Medical and/or surgical treatment of the eye, eyes, or

supporting structures. � Corrective eye wear required by an employer as a

condition of employment, and safety eye wear unless specifically covered under the plan.

� Services provided as a result of any Worker's Compensation law.

� Plano non-prescription lenses and non-prescription sunglasses (except for 20% discount).

� EyeMed's providers' professional services or disposable contact lenses.

� Two pairs of glasses in lieu of bifocal.


Ameritas Vision Perfect® Eye Care Vision Perfect eye care plans from Ameritas Group are simple, straightforward, easy-to-administer plans designed to help your employees receive and pay for the eye care they need. Vision Perfect plan members are free to select any eye doctor, pay the doctor for all services, and then submit a claim form and receipt to Ameritas Group for reimbursement. Benefits are reimbursed according to the plan the employer selects. EyeMed Discounts Vision Perfect plan members receive an additional value, called the EyeMed Discounts, which results from a partnership between Ameritas Group and EyeMed Vision Care. These stand-alone discounts are not insurance. These discounts are provided at no extra cost to plan members who use an EyeMed Access network provider. These discounts are included on Vision Perfect plans in all states. Discounts listed were current at the time of this printing and are not guaranteed. Up-to-date information concerning discount levels can be found at eyemedvisioncare.com/member (select "A" under Discount Plan Members to locate Ameritas Discount - Access). Rx Savings Our valued plan members and their covered dependents (even their pets) can save on prescription medications through any Walmart or Sam's Club pharmacy across the nation. This Rx discount is offered at no additional cost, and it is not insurance. To receive the Walmart Rx discount, Ameritas plan members just need to visit us at ameritasgroup.com and sign into (or create) a secure member account where they can access and print an online-only Rx discount savings ID card. Ameritas Information We're Here to Help This plan was designed specifically for the associates of COLUMBIA HEIGHTS PUBLIC SCHOOLS. At Ameritas Group, we do more than provide coverage - we make sure there's always a friendly voice to explain your benefits, listen to your concerns, and answer your questions. Our customer relations associates will be pleased to assist you 7 a.m. to midnight (Central Time) Monday through Thursday, and 7 a.m. to 6:30 p.m. on Friday. You can speak to them by calling toll-free: 800-487-5553. For plan information any time, access our automated voice response system or go online to ameritasgroup.com/member.

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

Worldwide Support When our members travel abroad, they’ll have peace of mind knowing that should a dental or vision need arise, help is just a phone call away. Through AXA Assistance, Ameritas offers its dental and vision plan members 24-hour access to dental or vision provider referrals when traveling outside the U.S. Immediately after a call is made to AXA, an assistance coordinator assesses the situation, provides credible provider referrals and can even assist with making the appointment. Within 48 hours following the appointment, the coordinator calls the member to find out if additional assistance is needed. If all is well, the case is closed. Then, the plan member may submit a claim to Ameritas for reimbursement consideration based on applicable plan benefits. Contact AXA Assistance USA toll free by calling 866-662-2731, or call collect from anywhere in the world by dialing 1-312-935-3727.

Language Services We recognize the importance of communicating with our growing number of multilingual customers. That is why we offer a language assistance program that gives you access to: Spanish-speaking claims contact center representatives, telephone interpretation services in a wide range of languages, online dental network provider search in Spanish and a variety of Spanish documents such as enrollment forms, claim forms and certificates of insurance.

This document is a highlight of plan benefits provi ded by Ameritas Life Insurance Corp. as selected by your employer. It is not a certificate of insurance and does not include exclusions and limit ations. For exclusions and limitations, or a compl ete list of covered procedures, contact your benefits administrator.


High Plan: Focus® Plan Summary Effective Date: 7/1/2015 VSP Choice Network + Affiliates Out of Network

Deductibles $10 Exam $10 Exam $25 Eye Glass Lenses or Frames* $25 Eye Glass Lenses or Frames

Annual Eye Exam Covered in full Up to $43 Lenses (per pair)

Single Vision Covered in full Up to $26 Bifocal Covered in full Up to $43 Trifocal Covered in full Up to $60 Lenticular Covered in full Up to $91 Progressive See lens options NA

Contacts Fit & Follow Up Exams Member cost up to $60 No benefit Elective Up to $105 Up to $100 Medically Necessary Covered in full Up to $210

Frames $120** Up to $40 Frequencies (months)

Exam/Lens/Frame 12/12/24 12/12/24 Based on date of service Based on date of service

*Deductible applies to a complete pair of glasses or to frames, whichever is selected. Lens Options (member cost)*

VSP Choice Network + Affiliates Out of Network (Other than Costco)

Progressive Lenses Up to provider’s contracted fee for Lined Bifocal Lenses. The patient is responsible

for the difference between the base lens and the Progressive Lens charge.

Up to Lined Bifocal allowance.

Std. Polycarbonate Covered in full for dependent children $33 adults

No benefit

Solid Plastic Dye $15 (except Pink I & II)

No benefit

Plastic Gradient Dye $17 No benefit Photochromatic Lenses

(Glass & Plastic) $31-$82 No benefit

Scratch Resistant Coating $17-$33 No benefit Anti-Reflective Coating $43-$85 No benefit Ultraviolet Coating $16 No benefit *Lens Option member costs vary by prescription, option chosen and retail locations. Monthly Rates Employee Only (EE) $12.42 EE + 1 Dependent $21.62 EE + 2 or more Dependents $29.53


Additional Focus® Choice Network Features Contact Lenses Elective Allowance can be applied to disposables, but the dollar amount must be used all at once

(provider will order 3 or 6 month supply). Applies when contacts are chosen in lieu of glasses. For plans without a separate contact lens fit & follow up exam allowance, the cost of the fitting and evaluation is deducted from the contact allowance.

Additional Glasses 20% discount off the retail price on additional pairs of prescription glasses (complete pair).

Frame Discount VSP offers a 20% discount off the remaining balance in excess of the frame allowance.

Laser VisionCare VSP offers an average discount of 15% on LASIK and PRK. The maximum out-of-pocket per eye for members is $1,800 for LASIK and $2,300 for custom LASIK using Wavefront technology, and $1,500 for PRK. In order to receive the benefit, a VSP provider must coordinate the procedure.

Low Vision With prior authorization, 75% of approved amount (up to $1,000 is covered every two years).

Rx Savings Our valued plan members and their covered dependents (even their pets) can save on prescription medications through any Walmart or Sam's Club pharmacy across the nation. This Rx discount is offered at no additional cost, and it is not insurance. To receive the Walmart Rx discount, Ameritas plan members just need to visit us at ameritasgroup.com and sign into (or create) a secure member account where they can access and print an online-only Rx discount savings ID card.

Eye Care Plan Member Service Focus eye care from Ameritas Group features the money-saving eye care network of VSP. Customer service is available to plan members through VSP's well-trained and helpful service representatives. Call or go online to locate the nearest VSP network provider, view plan benefit information and more. VSP Call Center: 1-800-877-7195 � Service representative hours: 5 a.m. to 7 p.m. PST Monday through Friday, 6 a.m. to 2:30 p.m. PST Saturday � Interactive Voice Response available 24/7 Locate a VSP provider at: ameritasgroup.com/member View plan benefit information at: vsp.com

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

Worldwide Support When our members travel abroad, they’ll have peace of mind knowing that should a dental or vision need arise, help is just a phone call away. Through AXA Assistance, Ameritas offers its dental and vision plan members 24-hour access to dental or vision provider referrals when traveling outside the U.S. Immediately after a call is made to AXA, an assistance coordinator assesses the situation, provides credible provider referrals and can even assist with making the appointment. Within 48 hours following the appointment, the coordinator calls the member to find out if additional assistance is needed. If all is well, the case is closed. Then, the plan member may submit a claim to Ameritas for reimbursement consideration based on applicable plan benefits. Contact AXA Assistance USA toll free by calling 866-662-2731, or call collect from anywhere in the world by dialing 1-312-935-3727.

Language Services We recognize the importance of communicating with our growing number of multilingual customers. That is why we offer a language assistance program that gives you access to: Spanish-speaking claims contact center representatives, telephone interpretation services in a wide range of languages, online dental network provider search in Spanish and a variety of Spanish documents such as enrollment forms, claim forms and certificates of insurance.


This document is a highlight of plan benefits provi ded by Ameritas Life Insurance Corp. as selected by your employer. It is not a certificate of insurance and does not include exclusions and limit ations. For exclusions and limitations, or a compl ete list of covered procedures, contact your benefits administrator.

Medical & Dental

Addenda

Blue Cross® and Blue Shield

® of Minnesota is a nonprofit independent licensee of the Blue Cross and Blue Shield Association. Service Cooperative 1

Member Communication for 2015 Group Renewal Bulletin Blue Cross and Blue Shield of Minnesota Service Cooperatives

Each year there are a number of health plan changes that may affect members. Typically these include benefit clarifications, process modifications and other plan changes. This document provides a summary of changes that will be implemented upon your 2015 health plan renewal. The following provides a summary of changes or informational items that will be implemented with your health plan renewal, on or after January 1, 2015.

Out-of-pocket maximum requirements

Prescription drugs – 90dayRx benefit

Preventive health benefits

Select Behavioral Health network changes

Wigs for alopecia areata Out-of-pocket maximum requirements An OOP max is an annually determined cap on the amount of cost-sharing a member must pay out-of-pocket for covered health care costs, including:

• Deductibles • Copays • Coinsurance

This does not include the premium amount for the plan Cost-sharing accumulates to the OOP max based on:

• Covered Benefits (Essential Health Benefits (EHBs), EHB and other designated benefits or all benefits) • Network (in-network only or more generous network tiers); and • Plan design

For plan years beginning on or after January 1, 2015, the max OOP limits are:

$6,600 for single coverage ($6200 closed formulary)

$13,200 for family coverage ($12,400 closed formulary) Large group plans are not required to provide EHBs, BUT to the extent covered benefits are EHBs:

No lifetime or annual dollar limits can apply to covered benefits that are EHBs but visit limits may apply.

EHBs delivered by an in-network provider must accumulate to the OOP max. Non-EHB services may accumulate to the OOP max.

Blue Cross® and Blue Shield

® of Minnesota is a nonprofit independent licensee of the Blue Cross and Blue Shield Association. Service Cooperative 2

Member Communication for 2015 Group Renewal Bulletin Blue Cross and Blue Shield of Minnesota Service Cooperatives

Prescription drugs – 90dayRx benefit In order to align with common industry practice, Blue Cross is offering a new benefit option for managing a 90dayRx benefit with prescription copay plans. The 90dayRx benefit for ongoing or maintenance medications that are filled in a retail pharmacy can be moved to hold three copays. With this change, prescriptions filled through mail order would then be processed with two and half copays. Preventive health benefits The preventive care package will be updated to include:

Lung cancer screening for ages 55-80. Coverage for lung cancer screening as a preventive benefit is subject to the medical necessity requirements of Blue Cross’ medical policy “Lung Cancer screening using low-dose computed tomography (LDCT)” (V-08).

Select Behavioral Health network change In an effort to better meet the needs of our members and network providers, Blue Cross has discontinued the select behavioral health network. All groups will be moved to the Aware network of providers for these services. Wigs for alopecia areata Due to ACA requirements the $350 maximum was replaced with one wig per year.

HOW TO USE DELTA DENTAL OF MINNESOTA PROVIDERS

FOR EMPLOYEES OF COLUMBIA HEIGHTS PUBLIC SCHOOLS

You may select any dentist when receiving dental treatment. Here are your options:

Option 1: DELTA DENTAL PPO PROVIDER

Using a provider in this network will guarantee the subscriber the highest level of

benefits. The Delta Dental PPO providers have agreed to offer a larger discount to Delta

Dental Plan participants. This will mean less out of pocket expenses for you. It is the

most economical choice when receiving dental treatment.

To find a Delta Dental PPO Provider, you may use Delta Dental of Minnesota’s website,

www.deltadentalmn.org. Click on “Provider Search”, and then choose the PPO Network

Option 2: DELTA PREMIER PROVIDER

Using a provider in this network will guarantee the subscriber the second highest level of

benefits. You will still have the benefit of discounted dental services based on the

contract providers that have signed an agreement with Delta Dental of Minnesota. This

will still mean less out of pocket expenses for you, than you would receive if you visited

a dentist who is not participating in any Delta Dental network.

Option 3: NON-PARTICIPATING PROVIDER

“NON-PARTICIPATING” means that this provider has NOT signed an agreement with

Delta Dental of Minnesota to offer discounts to Delta Dental members. This means that

your out of pocket dental expenses will be higher than if you were to choose a provider in

the Delta Premier or Delta PPO network.


HOW TO FIND A PARTICIPATING PROVIDER

The best and most accurate way to find a participating provider is through Delta Dental’s

user friendly web site, www.deltadentalmn.org. This is an interactive website, and will

provide you with a real-time listing of participating dentists. To go directly to the

“dentist search” portion of the web site, enter:

http://www.deltadentalmn.org/dentist/search.asp. Enter your zip code, city or state to

find local participating dentists. You may also search by dentist or clinic name. The web

site also allows you to print out a map directing you to the dental office you select.

To search for providers in the Delta PPO Network, or Delta Premier Network, select

either “PPO” or “Premier” from the networks shown in the drop down menu, and search

by city and state, zip code, or provider or clinic name.

If your dentist does not participate in the Delta Dental of Minnesota networks, you may

continue to use that dentist, although you will share more of the cost of your care and

could be responsible for dental charges up to the dentist’s full billed amount.

If you do not have Internet access, other options are available to find a network dentist or

verify that your current dentist is in the network.

When you call to make a dental appointment, always verify the dentist is a

participating dentist in the network you are seeking, either the PPO

Network or the Premier Network. Be sure to specifically state that your

employer is providing the Dental program.

Contact Delta’s Customer Service Center at: 651-406-5916 or 800-553-

9536. Customer Service hours are 7:00 a.m. to 7:00 p.m., Monday

through Friday, Central Standard Time.

Remember that Delta Dental of Minnesota contracts directly with each individual dentist.

You cannot assume that all dentists in the same clinic are Delta Dental providers. When

you make your appointment, ask at that time if this dentist is participating with Delta

Dental of Minnesota, and if they are a PPO dentist or a Premier dentist.


http://www.deltadentalmn.org/dentist/search.asp

Select Account Materials VEBA & Flex Spending

F7415R15 (10/14) MII Life, Inc. d.b.a.SelectAccount

AUTHORIZATION FOR DIRECT DEPOSIT

Member Information

Name of member (please print): ___________________________________________________________________

SelectAccount ID or Social Security Number: __________________________________________________________

Email Address: ________________________________________________________________________________

Employer’s Name (if applicable): ___________________________________________________________________

Authorization Details

I authorize SelectAccount to deposit my claim reimbursement payments to the account indicated and I authorize the bank named below to accept my claim deposit and credit the amount to my account. (Complete the fields below with the bank information.)

I am changing my existing direct deposit bank information as indicated below. (Complete the fields below with the new bank information. This will automatically cancel your old Direct Deposit Account and activate your new Direct Deposit Banking Account.)

I wish to cancel my direct deposit and have my claim reimbursements sent to me by mail. (Sign and date at the bottom of this form.)

Banking Information checking or savings account

Please note that we cannot transfer funds into investment accounts at this time.

Bank name: __________________________________________________________________________________

Bank telephone number: _________________________________________________________________________

Bank ABA Routing Number: __ __ __ __ __ __ __ __ __(The ABA routing number is the nine-digit number located in the bottom left corner of your check)

Bank Account Number ___________________________________________________________________________

Member Signature• Authorizationfordirectdepositofclaimreimbursementpaymentsprovidesaconvenientmethodofelectronically

transferring claim funds directly into your checking or savings account. Direct deposit will apply to all your spending account products with SelectAccount.

• Pleaseallow10-15businessdaysfromthedatethisformisreceivedbySelectAccountforyourrequesttobeprocessed.You may receive a manual check if claims are processed before the direct deposit is effective.

• OnceyouhaveauthorizedSelectAccounttoautomaticallydeposityourclaimreimbursements,thereisnoneedtore-enrollinsubsequentplanyearsunlessthereisachangeinyourbankinformation.

________________________________________________________ Signature Date _______________________ Signature of Bank Account Holder

To complete this request online, visit www.selectaccount.com and sign in to your account.

Save time: enter this information online. Sign into your account at SelectAccount.com. Questions?Call Member Services at (651) 662-5065 or 1-800-859-2144

Send via secured email only: Fax to: Mail to: SelectAccount.documents 651-662-7247 P.O.Box64193 @SelectAccount.com 866-231-0214 St.Paul,MN55164-0193

Since Expense

Symbol YTD 1yr 3yr 5yr 10yr Inception Ratio*

Large Cap Value

MDDVX P M 9.1% 9.1% 14.9% 12.6% 8.5% 10.2% 0.95

Load Waived

HWLAX P M 13.2% 13.2% 23.2% 16.4% 5.0% 8.0% 1.26

Load Waived

Large Cap Income

IFAFX P M 8.3% 8.3% 12.7% 11.1% 6.8% 7.5% 0.65

No Load

Large Cap Growth & Income

CVTRX P M 7.3% 7.3% 10.7% 8.6% 6.4% 11.4% 1.09

Load Waived

Large Cap Blend

ITHAX P M 7.3% 7.3% 22.3% 11.8% 7.6% 13.2% 1.14

Load Waived

Large Cap Growth

MGRIX P M 8.7% 8.7% 18.3% 14.3% 6.5% 7.6% 1.37

No Load

CVGRX P M 8.4% 8.4% 16.4% 11.5% 5.9% 13.5% 1.28

Load Waived

GFAFX P M 9.2% 9.2% 20.8% 13.5% 8.1% 6.9% 0.69

No Load

Mid Cap

NBGNX P M -0.2% -0.2% 14.5% 13.8% 9.4% 12.6% 1.01

No Load

Small Cap

DCCAX P M 8.6% 8.6% 21.4% 18.2% 8.3% 11.2% 1.31

Load Waived

FKASX P M 5.7% 5.7% 21.6% 15.2% 7.9% 13.9% 2.19

Load Waived

International

FAIDX P M -5.9% -5.9% 12.5% 5.9% 5.3% 5.6% 1.26

Load Waived

TGVAX P M -5.9% -5.9% 7.8% 4.3% 5.9% 7.7% 1.25

Load Waived

SGOVX P M -1.0% -1.0% 8.0% 7.2% 7.7% 11.2% 1.15

Load Waived

Index

PEOPX P M 13.2% 13.2% 19.8% 14.9% 7.2% 9.0% 0.51

No Load

COLUMBIA MID CAP INDEX NTIAX P M 9.2% 9.2% 19.4% 16.0% 9.3% 8.9% 0.67

No Load

VANGUARD SMALL CAP INDEX NAESX P M 7.4% 7.4% 20.4% 16.7% 9.0% 10.8% 0.24

No Load

Resource

Links

CALAMOS GROWTH & INCOME FUND²

FEDERATED KAUFMANN SMALL CAP²

THORNBURG INTERNATIONAL VALUE²

DREYFUS S&P 500 FUND

VEBA Mutual Fund Options :: Updated 12/31/2014

HOTCHKIS & WILEY VALUE²

AMERICAN FUNDS INC FD OF AMER²

MARSICO GROWTH²

FIRST EAGLE OVERSEAS FUND²

AMERICAN FUNDS GR FD OF AMER²

BLACKROCK EQUITY DIVIDEND²

HARTFORD CAPITAL APPRECIATION²

CALAMOS GROWTH²

NEUBERGER BERMAN GENESIS

DELAWARE SMALL CAP CORE²

FIDELITY ADVISOR INTL DISCOVERY²

https://www2.blackrock.com/webcore/litService/search/getDocument.seam?contentId=51467&Source=SEARCH&Venue=PUB_IND

http://quote.morningstar.com/fund/f.aspx?t=MDDVX.lw

http://hwcm.onlineprospectus.net/hwcm/MOB_library/MOB_data/LIB_SummaryProspectus/HWF-STATPROS/HWF-STATPROS.pdf

http://quicktake.morningstar.com/fundnet/Snapshot.aspx?Country=USA&Symbol=HWLAX.LW&fdtab=snapshot

https://www.americanfunds.com/pdf/mfgeprx-006_ifap.pdf

http://quicktake.morningstar.com/fundnet/snapshot.aspx?Country=USA&Symbol=IFAFX

http://www.calamos.com/~/media/documents/product-literature/prospectus/calamos-mutual-fund-statutory-prospectus-abc.ashx?

http://quicktake.morningstar.com/fundnet/snapshot.aspx?Country=USA&Symbol=CVTRX.LW

http://pe.hartfordmutualfunds.com/summary.asp?clientid=hartfordll&fundid=416645406&doctype=pros&lpos=416645406_stat

http://quote.morningstar.com/fund/f.aspx?t=ITHAX.lw

http://www.marsicofunds.com/resources/docs/literature/prospectus/prospectus.pdf

http://quicktake.morningstar.com/fundnet/snapshot.aspx?Country=USA&Symbol=MGRIX

http://www.calamos.com/~/media/documents/product-literature/prospectus/calamos-mutual-fund-statutory-prospectus-abc.ashx?

http://quicktake.morningstar.com/fundnet/snapshot.aspx?Country=USA&Symbol=CVGRX.LW

https://www.americanfunds.com/pdf/mfgeprx-005_gfap.pdf

http://quicktake.morningstar.com/FundNet/Snapshot.aspx?Country=USA&pgid=hetopquote&Symbol=gfafx

C:/Users/lhansen.DEV/Downloads/a0088_equity_funds_inv_prospectus.pdf

http://quote.morningstar.com/fund/f.aspx?t=NBGNX

http://prospectus-express.newriver.com/summary.asp?clientid=delawarell&doctype=pros&fundid=24610B883

http://quote.morningstar.com/fund/f.aspx?t=DCCAX.lw

http://www.federatedinvestors.com/FII/daf/pdf/regulatory/prospectus/28057.pdf

http://quicktake.morningstar.com/FundNet/Snapshot.aspx?Country=USA&pgid=hetopquote&Symbol=fkasx.lw

http://fiiscontent.fidelity.com/B-CAID.PDF?pos=R

http://quote.morningstar.com/fund/f.aspx?t=FAIDX.lw

http://www.thornburg.com/pdf/TH306_Prospectus_All.pdf

http://quote.morningstar.com/fund/f.aspx?t=TGVAX.lw

http://firsteaglefunds.onlineprospectus.net/FirstEagleFunds/MOB_library/MOB_data/LIB_SummaryProspectus/PROSPECTUS/PROSPECTUS.pdf

http://quote.morningstar.com/fund/f.aspx?t=SGOVX.lw

https://public.dreyfus.com/documents/compliancedocs/prospectus/annual/0078_prs.pdf

http://quicktake.morningstar.com/fundnet/snapshot.aspx?Country=USA&Symbol=PEOPX

http://hosted.rightprospectus.com/documents/Columbia/PRO_MidCapIndex.pdf

http://quote.morningstar.com/fund/f.aspx?t=NTIAX

https://personal.vanguard.com/pub/Pdf/p048.pdf?2210071229

http://quotes.morningstar.com/fund/naesx/f?t=NAESX

Fixed Income

PLDDX P M 0.4% 0.4% 2.0% 2.4% 3.5% 4.2% 0.75

No Load

PTTDX P M 4.4% 4.4% 4.0% 4.8% 5.7% 6.2% 0.75

No Load

FRANKLIN HIGH INCOME¹ FHAIX P M -0.4% -0.4% 7.5% 8.0% 6.8% 7.9% 0.76

Load Waived

Real Estate

NEUBERGER BERMAN REAL ESTATE NREAX P M 23.7% 23.7% 13.2% 15.5% 9.1% 13.1% 1.43

Load Waived

Commodities

PIMCO COMMODITY REAL RETURN PCRDX P M -18.5% -18.5% -10.1% -3.8% -0.8% 3.4% 1.35

No Load

Lifestyle

GGSAX P M 2.4% 2.4% 11.5% 7.7% 4.4% 4.5% 1.45

Load Waived

GOIAX P M 2.2% 2.2% 9.1% 6.7% 4.4% 4.8% 1.42

Load Waived

GIPAX P M 2.4% 2.4% 6.8% 5.3% 4.3% 4.6% 1.42

Load Waived

Money Market

JHMXX P M 0.0% 0.0% 0.0% 0.0% 1.3% N/A 0.98

No Load

Source: Morningstar®

Resource Links :: P - Prospectus, M - Morningstar®

Disclosure: These funds may pay a 12b-1annual distribution fee to the broker dealer of: ¹.15, ² .25 basis points

* Gross Expense Ratio Disclosure: Example Expense Ratio of 0.64% would result in $1,000 invested = $6.40 annual expense

LARGE CAP

MID / SMALL CAP

INTERNATIONAL

INDEX

LIFESTYLE

FIXED INCOME

SPECIALTY

MONEY MARKET

PIMCO TOTAL RETURN

DREYFUS S&P 500

COLUMBIA MID CAP

VANGUARD SMALL CAP

GROWTH

GOLDMAN SACHS BALANCED STRAT²

PIMCO TOTAL RETURN FUND²

GOLDMAN SACHS GROWTH STRAT²

JOHN HANCOCK MONEY MARKET²

DELAWARE SMALL CORE

VALUE BLEND

MARSICO GROWTH

AMERICAN FUNDS GROWTH

CALAMOS GROWTH

PIMCO LOW DURATION

FEDERATED KAUFMANN SM

NB GENESIS

FIDELITY ADVISOR INTL DISCOVERY

FIRST EAGLE OVERSEAS

THORNBURG INTERNATIONAL VALUE

GS GROWTH STRATEGYGS GROWTH & INCOME STRATEGY

CALAMOS GROWTH & INCOME

HARTFORD CAPITAL APPRECIATION

JOHN HANCOCK MONEY MARKET

NB REAL ESTATE

PIMCO COMMODITY REAL RETURN

FRANKLIN HIGH INCOME

The mutual fund performance data quoted represents past performance, which is no guarantee of future results. Current performance may be higher or lower than the

performance data quoted.Prospectuses containing complete information, including most recent month-end total returns, management fee charges and expenses, are available

online or by calling the toll free telephone numbers provided on the Investment Options page. Investment return and principal value of an investment will fluctuate so that

shares, when redeemed, may be more or less than their original cost. An investment in a money market fund is not insured by the FDIC or any other government agency.

Although money market funds seek to preserve capital, it is possible to lose money by investing in these funds. All funds in your HSA are purchased at NAV without a front end

load. Each fund company may charge a short-term redemption fee if held for less than the timeframe listed in the prospectus.

BLACKROCK EQUITY DIVIDEND

HOTCHKIS & WILEY VALUE

AMERICAN FUNDS INCOME

GS BALANCED STRATEGY

PIMCO LOW DURATION FUND²

GOLDMAN SACHS GR & INC STRAT²

http://pe.newriver.com/summary.asp?doctype=pros&cid=PIMCOLL&cusip=693391732

http://quicktake.morningstar.com/fundnet/snapshot.aspx?Country=USA&Symbol=PLDDX

http://pe.newriver.com/summary.asp?doctype=pros&cid=PIMCOLL&cusip=693391674&oldurl=%2FRegulatory%2FExternal%20Documents%2FPIMCO_Bond_Funds_Inst_Statutory.pdf

http://quicktake.morningstar.com/fundnet/snapshot.aspx?Country=USA&Symbol=PTTDX

https://www.franklintempleton.com/forms-literature/download/105-P

http://quote.morningstar.com/fund/f.aspx?t=FHAIX.lw

C:/Users/lhansen.DEV/Downloads/k0376_equity_funds_aci_prospectus (1).pdf

http://quotes.morningstar.com/fund/nreax.lw/f?t=NREAX.lw

http://pe.newriver.com/summary.asp?doctype=pros&cid=PIMCOLL&cusip=722005550&oldurl=%2FRegulatory%2FExternal%20Documents%2FPIMCO_Strategic_Markets_Inst_Statutory.pdf

http://quotes.morningstar.com/fund/pcrdx/f?t=PCRDX

https://assetmanagement.gs.com/bin/gsam/servlets/LiteratureViewerServlet?pdflink=%2Fcontent%2Fdam%2Fgsam%2Fpdfs%2Fus%2Fen%2Fprospectus-and-regulatory%2Fprospectus%2Fdividend-focus-funds-pro.pdf&RequestURI=/content/gsam/us/en/advisors/literature-and-forms/

http://quicktake.morningstar.com/FundNet/Snapshot.aspx?Country=USA&pgid=hetopquote&Symbol=GGSAX.LW


http://quicktake.morningstar.com/FundNet/Snapshot.aspx?Country=USA&pgid=hetopquote&Symbol=goiax.lw


http://quicktake.morningstar.com/FundNet/Snapshot.aspx?Country=USA&pgid=hetopquote&Symbol=gipax.lw

http://www.jhfunds.com/CMS/DownloadableItems/Funds/Prospectuses/JH440PN.pdf

http://financials.morningstar.com/money-market/quote?t=JHMXX

Online tools and tips Manage your VEBA investment account at selectaccount.com

As a VEBA investment account holder, you have access to a very powerful tool. One that will help you manage and track activity on your VEBA account and your VEBA investment account. It’s at your fingertips whenever you need it — day or night. It’s your VEBA investment Web site, and it offers many tools to help you manage your VEBA investments.

Access your account information The first step to managing your health care dollars is to login to the VEBA Investment Account site. This will take a matter of minutes. • First, visit selectaccount.com.• Second, choose the “VEBA” link and login to your VEBA account.• Third, select the “View My VEBA Investment Account” link.• Fourth, a separate “Welcome” page will appear. Use your Social Security Number as your

user ID and the last four digits of your Social Security Number as your PIN.Now you can enjoy the wealth of tools and information at your fingertips!

Once you’re in the site, you’ll see a welcome screen that looks like this.

Here are a few important sections of the Web site and what they’ll allow you to do or see: • Participant summary - This screen includes your name, address, Social Security Number

and general account information. • Investment summary – This screen shows your investment balances by fund, current

portfolio percentage of investment, and future investment elections. • Investment performance – This shows your historical performance data on each of the

funds available in the platform. You can also view a Morningstar® report by clicking on the fund name.

• Pending activity – This shows any pending buy or sell orders for your account.• Transaction history – This shows your past transaction history by date range.

Activate your Basic Investment Account Once the base balance in your VEBA account reaches $1,000, any amount over the $1,000 balance can be transferred to your VEBA Basic Investment Account. Here’s how it works: 1. Visit selectaccount.com, select the “VEBA” link and login to your VEBA account2. Choose the “Manage My Account” link. Follow the instructions that are provided.3. Complete the VEBA Account Self-directed Basic Investment Account Activation Form. You

can find this form on the SelectAccount Web site under “Forms and Materials” or you cancall SelectAccount customer service at toll free 1-800-859-2144 or (651) 662-5065 in theTwin Cities metro area from 7 a.m. to 7 p.m., Monday through Friday.

4. Once you submit this form (either online or in the mail; you choose), your transfer will beprocessed and you’ll then have access to the VEBA investment account Web site for futureinvestment elections. On average, it takes five business days to process your activation formand initial transfer request.

Transfer money from your VEBA account to your investment account, or make a cash contribution to your investment account Making your initial investment contribution — or fund purchase — is easy. In fact, it involves just two simple steps. 1. From your investment account home page, select the “Current Asset Alignments” link.2. Select your investment percentage elections ... and print! (O.k., that was three steps!)

• To set up future contributions or elections, select the “Future Investment Elections”link, indicate your desired contribution percentages for future contributions and print thispage as your confirmation.

• If you’d like to change your elections at any time, including buying and sellingadditional shares, then select the “Current Asset Realignments” or “TransferInvestments” links and follow the on-screen directions.

In addition to these important activities, the VEBA investment Web site will also allow you to: • View the mutual fund options available• Buy and sell mutual funds• Change investment elections• View Morningstar reports• View and print on-line statements, confirmations, and prospectuses• Customize your statements and choose to receive electronic statements versus paper

statements• View your personal performance• Move money from your VEBA Basic Investment account back to your VEBA base balance*• Transfer money between mutual fund holdings by dollar amount or percentage (look for the

“Transfer investments” link)• Manage your personal profile, including changing your user ID and PIN

* When you transfer funds back to your VEBA base balance your investments will be automaticallyliquidated according to the percentages of your current asset alignments. On the settlement date, your dollars will be sent electronically to your VEBA base balance.

X17747 (11/09)

MEDICAL EXPENSE REIMBURSEMENTACCOUNT CLAIM FORM

Use this form for eligible expensesincurred by you or your eligible dependents.

4 if this includes documentation for previously denied claim

4 if new email address 4 if new addressNumber of pages _____

S A

Section A – Account Holder Information (Please Print)ACCOUNT HOLDER’S NAME LAST FIRST MIDDLE SELECT ACCOUNT ID#

STREET ADDRESS SOCIAL SECURITY # (if SA# not known)

CITY STATE ZIP CODE DAYTIME PHONE NUMBER

ACCOUNT HOLDER EMAIL ADDRESS EMPLOYER NAME

Section B – Claim Detail (Please Print)All fields in this section must be completed. If information is missing, the processing of your claim may be delayed or denied. Supporting documentation must be attached. See the reverse side of this form for more detailed Claim Filing directions.

Date(s) of Service

Name of Person Receiving Service

Name of Provider of Service

Type of Service/ Supply Provided

Reimbursement Requested

- - to - - $

- - to - - $

- - to - - $

- - to - - $

- - to - - $

- - to - - $

TOTAL $

Section C – Account Holder SignatureI certify that the expenses listed above have been incurred by me and/or my eligible dependents and qualify as valid medical expenses according to my Summary Plan Description. These expenses have not been reimbursed and I will not seek reimbursement under my medical plan or any other health plan, such as an individual policy or my spouse’s or dependent’s health plan or a flexible spending account plan. I understand that the expense for which I am reimbursed may not be used to claim any Federal income tax deduction or credit. I also understand that I may be asked to provide further details about some expenses (e.g., a statement from a medical practitioner that the expense is to treat a specific medical condition or a more detailed certification from me).

ACCOUNT HOLDER SIGNATURE DATE

Save time: submit this information online. Questions? Call Member Services at (651) 662-5065 or 1-800-859-2144.

Submit online:Log into your account atwww.SelectAccount.com

Send via secured email only:[email protected]

Fax to:651-662-7247866-231-0214

Mail to:P.O. Box 64193St. Paul, MN 55164-0193


Appeal Information

The Explanation of Processing Report explains how your claim was processed based upon the information submitted to us. You or your designated representative may appeal a denial, partial denial, or reduction of your claim by following our appeal procedures. You may contact customer service at 1-800-859-2144 or 651-662-5065 for an explanation of your appeal rights. If you disagree with our decision on your claim, you have the right to submit a written request for an appeal review to SelectAccount, P.O. Box 64193, St. Paul, MN 55164-0193. We can send you a form to file your appeal or you can obtain a copy of the appeal form at www.SelectAccount.com. You have until the later of your plan’s run out end date or 180 days from the date of this notice to file an appeal. If you have terminated employment during the year or if you are unsure of your plan’s run out end date please contact your group representative or contact our customer service department. You may also submit any documents, records, or other information that relates to your claim for benefits. Upon receipt of your request, we will provide a full and fair review of your appeal and a written notice of our decision either by letter or an explanation on the Explanation of Processing Report within 30 days.

If you are a member of a group plan that is subject to the Employee Retirement Income Security Act (ERISA), once you have exhausted our appeal process, you have the right to file suit in Federal Court under Section 502(a) of ERISA.

How to File a Claim

To receive reimbursement for eligible medical, dental, drug, behavioral health and vision expenses that are not covered by any other plan follow the steps below. If the expense is reimbursable by health insurance, you must submit the expense to the insurance company first.

1. Sign into your account at www.SelectAccount.com, select submit a claim, and complete the required fields.

2. Provide supporting documentation of your eligible expenses for each claim line item. This documentation is required by the IRS and can be an Explanation of Benefits (EOB), detailed receipt or provider statement. Cancelled checks do not qualify as IRS acceptable documentation.

Supporting documentation must include:

• Dateofserviceorpurchase • Nameofpersonreceivingservice • Nameofproviderofservice • Typeofserviceorsupplyprovided • Amountchargedforeachservice/supply • Explanationofbenefitsfromallinsurancecarriers,ifapplicable • IfyourHealthReimbursementArrangement (HRA) rate reimbursesyouat less than100%,donotcalculate thedollaramount.The reimbursement

percentage will automatically be calculated and deducted from your account based on the dollar amount you enter in the reimbursement requested field.

3. If you can’t submit online, fax or mail your claim form with supporting documentation to SelectAccount.

• To fax your claim form and supporting documentation: a) complete and sign the claim form using a dark pen. b) make sure your supporting documentation is on white paper c) fax to: 651-662-7247 or 1-866-231-0214

• Tomail your claim form and supporting documentation a) complete and sign the claim form using a dark pen. b) include copies of documentation. Do not mail originals. c) mail to: SelectAccount, PO Box 64193, St. Paul, MN 55164-0193

Note: Do not highlight items on your claim form or supporting documentation, as it interferes with claims processing. Instead, circle with a dark pen as needed.

4. Keep a copy of the claim form and supporting documentation for your records or upload to eVault found at www.SelectAccount.com.

5. To receive your reimbursement faster, sign up for direct deposit by logging into your account at www.SelectAccount.com.

F8503R08 (01/15)

DAYCARE EXPENSE REIMBURSEMENT CLAIM FORM

Use this form for dependent child or adult daycare expenses.

4 if this includes documentation for previously denied claim

4 if new email address 4 if new addressNumber of pages _____


S A

Section A – Account Holder Information (Please Print)ACCOUNT HOLDER’S NAME LAST FIRST MIDDLE SELECT ACCOUNT ID#

STREET ADDRESS SOCIAL SECURITY # (if SA# not known)

CITY STATE ZIP CODE DAYTIME PHONE NUMBER

ACCOUNT HOLDER EMAIL ADDRESS EMPLOYER NAME

Section B – Claim Detail (Please Print)DEPENDENT(S) NAME(S) TOTAL REIMBURSEMENT REQUESTED $

DATE(S) OF SERVICE OR DATE SPAN

Section C – Daycare Provider InformationFor fastest service, please have your provider complete this section. If completed, additional supporting documentation is NOT needed. For expenses to be eligible, this section must be completed and signed by the Provider of dependent care services or documentation must be attached from the Provider.

PROVIDER’S NAME PROVIDER’S SIGNATURE This signature verifies that I am an eligible provider, the claim details above are accurate, and the account holder is being billed for these services.

PROVIDER TAX ID OR SOCIAL SECURITY # (Optional)

___ ___ ___ ___ ___ ___ ___ ___ ___

Section D – Account Holder SignatureI certify that the information on this page is accurate and complete. I am requesting reimbursement for work-related dependent care expenses incurred by an eligible dependent (for a child under the age of 13 or other dependents that are physically and mentally incapable of taking care of themselves) while I was a participant in the plan. These services have already been provided and confirm that by requesting reimbursement here that I have not and will not seek reimbursement of this expense from any other plan or party.

ACCOUNT HOLDER SIGNATURE DATE

Save time: submit this information online. Questions? Call Member Services at (651) 662-5065 or 1-800-859-2144.

Submit online:Log into your account atwww.SelectAccount.com

Send via secured email only:[email protected]

Fax to:651-662-7247866-231-0214

Mail to:P.O. Box 64193St. Paul, MN 55164-0193

Each field must be completed or the processing of your claim will be delayed or denied. See the

reverse side for eligibility and submittal information.

F8420R08 (01/15)

How to File a Claim For faster reimbursement, submit claim online at www.SelectAccount.com. Be sure to complete the form in it’s entirety. If the form is incomplete or unsigned, your claim request will be delayed or denied. Based on IRS regulations, supporting documentation is not required with your claim if Section C of the claim form is completed. Keep documentation for your tax records.

If you cannot submit online, fax OR mail completed claim form.

You will be reimbursed up to your account balance for all eligible dependent care expenses according to your employer’s claim processing schedule.

Withdrawals requested that exceed your account balance will be pended until eligible for reimbursement within the same plan year as incurred.

Submission Tips4 Complete claim form using a dark pen 4 Do not use a highlighter on this claim form4 Retain confirmation of successful fax transmission4 Do not mail originals, keep a copy for your records or upload to eVault found at www.SelectAccount.com4 To receive your reimbursement faster, sign up for direct deposit by logging into your account at www.SelectAccount.com.

Eligibility Information • Care must be for a child under age 13, unless they are incapable of self care. • If child is over 13 and incapable of self care, a yearly Letter of Medical Necessity is required and the form can be found at www.selectaccount.com.• Care must be provided by an individual with a tax ID or Social Security Number• Care must allow the parent(s) to be gainfully employed•Care must be custodial in nature• Household limit for dependent care reimbursement cannot exceed $5000 per year, including annual election, any child care subsidies that received, and/

or amounts that your spouse has elected through another account.

Ineligible Services• School expenses including kindergarten• Overnight camp• Care provided by a family member under the age of 19• Care provided by a parent or family member that can be claimed as a tax dependent of the parent• Activity fees/field trips• Late payment fees• Food items

Appeal Information The Explanation of Processing Report explains how your claim was processed based upon the information submitted to us. You or your designated representative may appeal a denial, partial denial, or reduction of your claim by following our appeal procedures. You may contact customer service at 1-800-859-2144 or 651-662-5065 for an explanation of your appeal rights. If you disagree with our decision on your claim, you have the right to submit a written request for an appeal review to SelectAccount, P.O. Box 64193, St. Paul, MN 55164-0193. We can send you a form to file your appeal or you can obtain a copy of the appeal form at www.selectaccount.com. You have until the later of your plan’s run out end date or 180 days from the date of this notice to file an appeal. If you have terminated employment during the year or if you are unsure of your plan’s run out end date please contact your group representative or contact our customer service department. You may also submit any documents, records, or other information that relates to your claim for benefits. Upon receipt of your request, we will provide a full and fair review of your appeal and a written notice of our decision either by letter or an explanation on the Explanation of Processing Report within 30 days.

If you are a member of a group plan that is subject to the Employee Retirement Income Security Act (ERISA), once you have exhausted our appeal process, you have the right to file suit in Federal Court under Section 502(a) of ERISA.

Voluntary Retirement Transaction Processing Kit

403(b) and ROTH 403(b)

Approved Vendors

Please review your Employment Agreement or Contract for participation & district match eligibility. Never provide personal information via email; use caution when providing it via voicemail.

VOYA - 403(b) and ROTH 403 (b)

Capital Street Financial Services Office: (651) 665-4300 Ext: 103

Joseph F. Batkiewicz, Financial Advisor Mobile: (763) 370-9050

85 East 7th Place, Suite 275 Toll Free: (800) 728-0144

St. Paul, MN 55101 Fax: (651) 665-0121


VALIC- 403(b) and ROTH 403 (b)

VALIC Financial Advisors, Inc. Office: (952) 838-7800

Jeffrey Lehman, ChFC Mobile: (763) 439-7180

7650 Edinborough Way, Suite 320 National Office: (800) 892-5558

Edina, MN 55435 Fax: (952) 838-3898


Educators Financial Services, Inc. - 403(b)

Jason Janes, Financial Advisor David Wolfe, Financial Advisor

33447 Xenon Drive 11599 Robinson Dr. NW

Princeton, MN 55371 Coon Rapids, MN 55433

Office: (651) 353-7984 Office: (763) 789-4010

Fax: (763) 689-3742 Fax: (763) 706-3955

Email: [email protected] Email: [email protected]

The Minnesota Deferred Compensation (457) plan information is available at: www.mndcplan.com

mailto:[email protected]



http://www.mndcplan.com/

403(b)/457(b) Administration &

Compliance Service (ACS)

403(b)/457(b) Plan

Transaction Processing Kit

This Kit is for Representatives of Investment Providers and/or Employees

that are self-directing their 403(b) investments

ACS PLUS Service Option Updated April 2, 2011

Educators Benefit Consultants

3125 Airport Parkway, N.E.

Cambridge, MN 55008

www.ebcsolutions.com

763-689-0111

1-855-369-5518

Fax: 763-689-6685

http://www.ebcsolutions.com/

This page intentionally left blank.

Procedures for Exchanges, Transfers, and Rollovers

There are Three Ways You can Move 403(b) Funds ........

Type Universal

Vendor

Agreement

(Equivalent of

ISA)

Procedure Representative is defined as the investment

provider’s local representative or the employee if

the employee is self administering his/her 403(b)

Plan.

Transfer

Move funds from one plan

into another.

Example

Transfer funds from

previous employer’s

plan to current

employer’s plan

Transfer funds from

inactive vendor to

active/approved

vendor

YES

1. Representative shall complete forms,

provided by investment company, to

move the funds.

2. Representative shall complete the

“Transaction Processing Form” along

with forms from the investment company,

and submit to EBC for signature.

3. EBC shall provide Representative with

copy of UVA signed by the company that

is receiving the funds.

4. EBC shall return signed copy of form to

Representative via mail or fax.

5. Representative shall submit paperwork to

appropriate investment provider.

6. EBC shall enter transaction into the ACS

for tracking purposes.

Exchange

Move funds within the same

plan

Example:

Move funds between product

providers on employer’s

approved vendor list

YES

Rollover

(e.g., moving funds

from 403(b) to IRA) A rollover shall only occur as

a result of a qualifying event.

A qualifying event includes

any one of the following:

Termination of

Employment/Separati

on from Service

Death

Disability

Age 59 ½

NO

However, some

vendors still insist

an ISA be signed.

1. Representative shall complete appropriate

forms, provided by investment company,

to roll funds.





3. EBC shall sign forms and return to

Representative.

4. If required, EBC shall provide

Representative with copy of UVA signed

by the investment company that is

receiving the funds.



6. EBC shall enter transaction into the ACS

for tracking purposes.

In-Service Distribution

Must have a qualifying event

Age 59 ½

Disabled

Death

NO

However, some

vendors still insist

an ISA be signed

1. Representative shall complete appropriate

forms for withdrawal provided by

investment company.





3. EBC shall sign and return to

Representative.



5. EBC shall enter distribution into the ACS

for historical purposes.

Procedures for Loans and Hardship Withdrawals

Type Procedure Representative is defined as the investment provider’s

local representative or the employee if the employee is

self administering his/her 403(b) Plan.

Loan

Loans are optional. The District will establish

through the District’s Written Plan and

Adoption Agreement whether Loans are

allowed or disallowed in the District’s Plan.

If allowed .......

The District does not determine whether an

employee qualifies for a loan or not. That

decision is made by the Product Provider and

EBC.

Loan Rules:

If an employee has defaulted on a loan from

any retirement plan or deferred compensation

arrangement sponsored by the Employer and

has not repaid the loan, in full, the employee

shall not be permitted to take a loan from

his/her Account.

Maximum Loan Amount

$50,000 reduced by any outstanding balance on

any loan; OR, one half of the value of the

participant’s vested account balance.

1. Representative completes loan application

provided by the investment provider.

2. Representative shall complete the “Transaction

Processing Form” along with forms from the

investment company ALONG WITH AN

ACCOUNT STATEMENT SHOWING

FUND BALANCE and submit to EBC for

Signature.

3. If no outstanding loans, EBC shall sign and

return to Representative.

4. Representative shall submit loan application to

investment provider.

5. EBC shall enter loan information into the ACS

software system.

Hardship Withdrawal

Hardship Withdrawals are optional. The

District will establish through the District’s

Written Plan and Adoption Agreement whether

Hardship Withdrawals are allowed or

disallowed in the District’s Plan.

If allowed......

The District does not make a determination

whether an employee qualifies for a Hardship

Withdrawal or not. That decision is made by

the Product Provider and EBC.

1. Representative completes a Hardship

Withdrawal Application provided by

investment provider.

2. Representative must complete EBC’s

“Hardship Withdrawal Processing Form” and

complete the “Transaction Processing Form”

(both are provided in this kit) along with

forms from the investment company and

submit to EBC for signature.

3. If hardship is approved, EBC shall sign and

return to Representative.

4. Representative shall submit Hardship

Withdrawal Application to provider.

5. EBC informs District Administrator that

employee and employer contributions into the

403(b) Plan are suspended for 6 months.

6. EBC shall enter Hardship Status into the ACS

software system.


403(b)/457(b) Administration and Compliance Service

TRANSACTION PROCESSING FORM

Name of Representative

OR

Attach Business Card

Address

Phone Number

Name of Plan Sponsor (School District)

Please check box that indicates nature of transaction

Exchange

Transfer

Rollover

Hardship Withdrawal

Loan

In-Service Distribution

Distribution due to termination/retirement

Please complete this form and send along with necessary transactions documents to Educators

Benefit Consultants for signature.


ACS Division


Cambridge, MN 55008

EBC will sign and attach copy of UVA and return to you so you may

send to appropriate investment provider.

Client Name / SSN

Releasing Carrier

Accepting Carrier

Amount of

Exchange/Transfer/Rollover/Hardship/Loan/Withdrawal

For EBC Use Only

Copy of Universal Vendor Agreement (UVA) is only required for an exchange, transfer,

and in some cases a rollover transaction. Attach copy of UVA signed by the investment

provider that is receiving the funds.

Attached: ___Yes ______No Initials: _____ Date: _____


Cambridge, MN 55008

Metro: 763-552-6053

Toll-free: 1-888-507-6053

HARDSHIP WITHDRAWAL PROCESSING FORM Before you apply for a hardship withdrawal you must first determine whether you are eligible for a

hardship distribution or not.

Please read the “Rules Applicable to Hardship Distributions” on the back of this form.

If you determine that you are eligible for a hardship withdrawal, please check appropriate boxes and sign

this form. Make sure you attach documentation that proves and/or supports your financial need. You will

also need to complete the hardship distribution form provided by your investment provider.1

I have reviewed the attached “Rules Applicable to Hardship Distributions” and attest that I have an

immediate and heavy financial need.

The immediate and heavy financial need falls into the following category (you may check more than one

if it applies):

_____Medical Care _____Funeral or Burial Expenses

_____Purchase of Principal Residence _____Repair of Damage to Principal Residence

_____Tuition or Educational Related _____Tax Cost Associated with this Withdrawal

_____Prevent Eviction or Foreclosure

I have reviewed the list of “Other Financial Resources” demonstrated in the Treasury Rules, and disclosed

to me on the back of this form; none of those resources are available to me.

I have read, and I understand the meaning of the information provided to me in this “Hardship

Withdrawal Processing Form”, and I attest that my answers on this form are true and correct, and I have

attached supporting documentation to prove my claim of a heavy and immediate financial burden (e.g.,

medical bills, eviction or foreclosure notice, tuition bill, purchase agreement, burial or funeral bill, etc.).

I hereby request a hardship withdrawal this ___ day of _________________ 20___.

_______________________________ _______________________________

Participant’s Signature Spouse’s Signature

1 This paperwork should be obtained from your investment company or registered investment advisor. This

paperwork will need to be completed and submitted to EBC for signature.

Rules Applicable to Hardship Distributions

A hardship distribution shall only be approved based on participant’s ability to prove that the

request for the hardship distribution is on account of an immediate and heavy financial need and

that the withdrawal is necessary to satisfy the financial need.

Other Financial Resources

A hardship withdrawal can not be approved if the need may be relieved from other resources

reasonably available to the employee. Other resources listed in the Treasury rules are:

Assets of the employee’s spouse and minor children that are reasonably available to

the employee (for example a vacation home owned by the employee and the

employee’s spouse, whether as community property, joint tenants, tenants by the

entirety, or tenants in common).

Through insurance payment

By liquidation of employee’s assets

By cessation of elective contributions to the employee’s 403(b) Plan

By borrowing from commercial sources on reasonable terms

By taking a loan from the 403(b) or any other available plan maintained by the

employer (e.g., 457 Plan)

Expenses That Could Qualify Under The Treasury Rules Are As Follow:

Medical care

Costs related to the purchase of a principal residence for the employee—not

mortgage payments

Tuition, related educational expenses, and room and board for up to the next 12

months of post-secondary education for the employee, the employee’s spouse,

children or legal dependents.

Payments necessary to prevent the eviction of employee from principal residence or

foreclosure on the mortgage of principal residence

Funeral or burial expenses for the employee’s deceased parents, spouse, children or

dependents

Repair of damage to the employee’s principal residence that would qualify for the

casualty deduction under section 165

The hardship distribution must not exceed the amount of the financial need. The

amount may include the federal, state, or local income tax or penalties that are a

result of the distribution.

It is the burden of the employee to prove that he/she is in a hardship status according to the

Treasury Department’s rules.

Service Provider

(See list of allowed

TSA companies)

Salary Reduction Agreement for 403(b)/403(b) Roth/457 TSA with Match

Type New Change Stop Salary Reduction

Amount/Percent

Per Pay Period

Annualized Salary

Reduction Amount

Employer

Match/Percent

per Pay Period

Annualized

Employer Match

403(b) 403(b) 403(b)

Roth

403(b) Totals 457 457

Grand Totals

24

Independent School District # 13

Columbia Heights Public Schools

1440 49th

Ave. NE

Columbia Heights, MN 55421

Part 1. Employee Information (please print)

Name Employee # Birth Date

Pay periods per year Requested Start Date Occupation

Part 2. Contribution Information (fill in all that apply.)

Salary Reduction Employee Contribution Employer Match

Part 3. Catch Up Provisions

If you are contributing more than the basic limit to a 403(b), 403(b) Roth and/or 457, you must be using one (or both) of the following:

I am contributing $ using the 15-years service election. (Attach documentation).

I am contributing $ using the Age 50 and older catch up election.

By signing this Agreement, Employee agrees to modify his/her

salary as indicated above and Employer agrees to contribute this

amount on Employee’s behalf into the 403(b)/403 Roth/457

annuity(ies) or custodial account(s) selected by the Employee. It is

intended that the requirements of all applicable state and federal tax

rules and regulations (Applicable Law) will be met. The Employee

understands and agrees that this Agreement:

1. Is legally binding and irrevocable with respect to amounts paid or

available while it is in effect;

2. May be terminated at any time for amounts not yet paid or

available, and that a termination request is permanent and remains in

effect until a new salary reduction agreement is submitted;

3. Is effective only for amounts not yet earned or made available in

accordance with the Employer’s administrative procedures.

Employee further agrees that:

He/she is responsible for determining that his/her salary reduction

amount does not exceed the limits of the Applicable Law;

He/she is responsible for the accuracy of the information provided by

Employee, which is used in determining Employee’s Maximum

Annual Contribution limit; and Employer has no liability for any

losses suffered by Employee that resulted from his/her participation in

the 403(b)/403(b) Roth/457 program.

Employee acknowledges that Employer has made no representation to

Employee regarding advisability, appropriateness or tax consequences

of the purchase of the 403(b) program. Nothing herein shall affect the

terms of employment between Employer and Employee.

This agreement supersedes all prior salary reduction agreements

and shall automatically terminate if your employment with the

Employer is terminated.

Part 4. Agreement

Note: Your employer’s administrative policies will determine when 403(b)/403(b) Roth/457 salary reduction instructions are implemented

Important Information

1. Employer does not choose the annuity contract(s) or

custodial account(s) in which contributions are invested.

2. Employees are responsible for setting up and signing the

legal documents to establish the annuity contract or

custodial account. However, in certain group annuity

contracts, Employer may be required to establish the

contract.

3. In order to receive the expected tax results, Employees

are responsible for investing in annuity contracts or

custodial accounts that meet the requirements of Section

403(b)/403(b)/457 in the Internal Revenue Code.

4. Employees are responsible for naming a death benefit

under the 403(b)/403(b) Roth/457 program. This is

normally done at the time the annuity contract or custodial

account is established. Beneficiary designations should be

reviewed periodically.

5. Employees are responsible for all distributions and any

other transactions with their service provider. All rights

under the annuity contracts or custodial accounts are

enforceable solely by the Employee, Employee Beneficiary

or Employee’s Authorized Representative. Employee must

work directly with the service provider to transfer

contract(s) or custodial accounts(s) to another service

provider, begin distributions, make loans, or otherwise

access 403(b)/403(b) Roth/457 program assets.

6. Employees are responsible for determining that salary

reductions do not exceed the allowable contribution limits

under Applicable Law. Limits should be checked each year

for the scheduled increases through 2011.

Read Before You Sign:

By signing this Agreement, you are declaring that the

amount you have elected to withhold does not exceed the

allowable contribution limits under Applicable Law. If

selected in Part 2 above, you are declaring that you are

eligible for one or both of the catch up elections as

indicated. And you are accepting full responsibility for the

amount you have elected to have withheld from your salary

and contributed to the 403(b)/403(b) Roth/457 arrangement.

Disclaimer – Other Fees: If an investment company does not agree to pay the third

party administrator’s fee associated with this employer’s

403(b) Plan the fee, upon consent of the employer, shall be

passed along to the 403(b) participant. This fee equates to

.60 cents per participant per month.

Part 5. Employee Signature

I certify that I have read this complete Agreement and that

my salary reductions do not exceed contribution limits as

determined by Applicable Law. I also certify that I am

eligible for the catch up election(s), if selected, under Part 2

above. I understand my responsibilities as an Employee

under the 403(b)/403(b) Roth/457 programs, and I request

Employer to take the action specified in this Agreement. I

understand that all rights under annuity(ies) or custodial

account(s) established by me under the 403(b)/403(b)

Roth/457 program are enforceable only by me, my

beneficiary or my authorized representative.

Employee Signature Date

Part 6. Acknowledgement and Representative of

Sales Agent/Representative

I hereby acknowledge my responsibility to comply with

Employer’s written directives regarding solicitation of

Employees. I also acknowledge my responsibility to assist

the Employee in determining the maximum contribution

limits.

Sales Agent/Representative (please print clearly)

Phone

Address

Signature Date

Part 7. Employer Signature

Employer hereby agrees to this Salary Reduction

Agreement.

Signature of Employer Representative

Date

Date Received in HR

Date Received in Payroll

Supplemental Inserts

Everyone deserves legal protection.At LegalShield, we’ve been offering legal plans to our members for over 40 years, creating a world where everyone can access legal protection—and everyone can afford it. Unexpected legal questions arise every day and with LegalShield on your side, you’ll have access to a quality law firm 24/7, for covered personal situations. From real estate to divorce advice, speeding tickets to Will preparation, and beyond, we’re here to help you with any personal legal matter—no matter how traumatic or how trivial it may seem. Because our dedicated law firms are prepaid, their sole focus is on serving you, rather than billing you.

Our Promise to YouAs one of the first companies in North America to provide legal expense plans to consumers, we now provide legal services to over 1.4 million families across the U.S. and Canada—representing approximately 4 million people. And with over 650 employees dedicated to serving you, our promise remains the same: to provide outstanding legal services by quality law firms at an affordable price.

Why LegalShieldFor as little as $20 a month, LegalShield gives you the ability to talk to an attorney on any personal legal matter without worrying about high hourly costs. That’s why, under the protection of LegalShield, you and your family can live your lives worry free.

Some of the services you will receive for personal legal matters include the following:

• Advice on an unlimited number of topics • Trial defense hours

• Letters and phone calls on your behalf • Video law library

• Legal document review, up to 15 pages each • Forms service center

• Will preparation

Even better, you don’t have to worry about figuring out which attorney to use—we’ll do that for you. Our experienced attorneys focus specifically on our members and provide 24/7 access for covered emergencies.

Learn more about the LegalShield Legal Plan atwww.legalshield.com/info/legalplan

• The member

• The member’s spouse

• Never-married dependent children under age 26 living at home

• Dependent children under age 18 for whom the member is legal guardian

• Never married, dependent, children who are full-time college students up to age 26

• Physically or mentally disabled children living at home

Your Plan Covers:

LegalShield Legal Plan

• Uncontested Adoption Representation*

• Alimony

• Child Custody

• Child Support

• Child Visitation Rights

• Conservatorship

• Domestic Violence Protection

• Guardianship

• Juvenile Court Proceedings

• Uncontested Name Change Assistance*

• Parental Responsibilities

• Prenuptial Agreements

• School Administrative Hearing

• Uncontested Divorce Representation*

• Uncontested Separation Representation*

• Drivers License Restoration, Revocation, Suspension

• Non-Commercial, Non-Criminal

Moving Traffic Violations

• Motor Vehicular Homicide Defense

• Property damage claims up to $5,000

• Codicils

• Health Care Power of Attorney

• Irrevocable Trust

• Living Will

• Revocable Trust

• Wills

• Affidavits

• Bankruptcy

• Consumer Credit

• Consumer Protection

• Contracts/Financial Disputes

• Debt Collection

• Durable/Financial Power of Attorney

• Estate Administration/Closing

• Inheritance Rights Protection

• Installment Sale Contracts

• IRS Audit Protection

• IRS Collection Defense

• Rental Agreements

• Medical Disputes

• Medicare Disputes

• Personal Property Disputes

• Promissory Notes

• Social Security Disputes

• Veterans Benefits Disputes

• Building Code Disputes

• Contractor Disputes

• Deeds

• Evictions

• Foreclosure

• Neighbor Disputes/Easements

• Primary Residence Refinancing

• Purchase/Sale of House

• Real Estate Contracts/Financial Disputes

• Secondary Residence Coverage

• Security Deposits

• Smalls Claims Assistance

• Zoning Variances

• Residential Loan Document Assistance

Family Matters

Auto

Financial

Home

Estate Issues

Your LegalShield provider law firm will be there to offer advice or assistance on a variety of legal issues. Below is a brief sampling of the areas that the LegalShield Legal Plan covers.

For detailed information about the legal services provided for personal matters by the LegalShield contract, go to http://www.legalshield.com/info/legalplan. Business issues are not included; however, plans providing those services are available. Ask your Independent Associate for details.

Marketed by: Pre-Paid Legal Services, Inc. dba LegalShield® and subsidiaries; Pre-Paid Legal CasualtySM, Inc.; Pre-Paid Legal Access, Inc.; In FL: Pre-Paid Legal Services, Inc. of Florida; In VA: Legal Service Plans of Virginia, Inc.; and PPL Legal Care of Canada Corporation

SHEET.1995 53943 (1/14) ©2014 LegalShield®, Ada, OK

25% off additional legal services If you are in need of additional legal services, you may continue to use your provider law firm for legal situations that extend beyond plan coverage. The additional services are 25% off the law firm’s standard hourly rates. Your provider law firm will let you know when the 25% discount applies and will go over these fees with you. Please note: Class actions, interventions, or amicus curiae filings in which you are a party or potential party are not covered by the LegalShield membership.

Legal services may vary by state.

*Available after the membership has been active 90 consecutive days.

Please note the time required to give notice to courts to file an answer varies by state. You should consult with your Provider Law Firm as soon you are aware of a legal matter. This is a general overview of your legal plan coverage for illustration purposes only. See a plan contract for complete terms, coverage, amounts, conditions and exclusions. Some of the benefits are not available in New York and Washington and are not available in Canada.If additional legal services are necessary beyond the amount of coverage provided based on the contract provisions then the member is entitled to the preferred member discount. The Provider Law Firm is the law firm designated by LegalShield to represent its members in your geographic area, and the Provider Law Firm may designate other law firms to provide covered services.

Marketed by: Pre-Paid Legal Services, Inc. dba LegalShieldSM and subsidiaries; Pre-Paid Legal CasualtySM, Inc.; Pre-Paid Legal Access, Inc.; In FL: Pre-Paid Legal Services, Inc. of Florida; In VA: Legal Service Plans of Virginia; and PPL Legal Care of Canada CorporationBOOK.SDL 53911 (4/2013) © 2013 LegalShieldSM, Ada, OK

LegalShield Service Definition Listing

Advice & Consultation Provider Network

Covered

Covered

Covered

Covered

Covered

Attorney Advice & Consultation

LegalShield gives the member the ability to talk to an attorney on any of his/her legal matters without worrying about high hourly rates. The monthly membership fee provides access to legal advice on any legal matter, no matter how traumatic or trivial the issue.

Under this service, an attorney from the Provider Law Firm will discuss the situation with the member, explain the member’s rights and options and recommend a course of action.

Business Document Review

The Provider Law Firm will also review one business legal document of 10 pages or less per membership year that the member is signing on behalf of a business so long as the business is a sole proprietorship owned by the member.

Trial Defense

This membership provides representation to a member who is a defendant in a covered civil action or covered criminal action. The Provider Law Firm will provide advice and consultation regarding criminal and civil litigation matters and answer general questions. More specific services including representation in court and negotiation of settlement will be provided under the preferred member discount.

The Provider Law Firm will provide representation to the member or member’s spouse as a defendant for a covered civil action or covered job related criminal action.

Personal Document Review

Our document review service provides members access to the Provider Law Firm for review of any legal documents that are 10 pages in length or less to include, but not limited to:

• Affidavits • Deeds • Demand letters• Mortgages• Notes• Leases• Contracts

Letters and Phone Calls Written/Made on the Member’s Behalf

If, after researching the member’s legal situation, the Provider Law Firm handling the matter feels the best course of action to resolve the issue is to make a phone call or write a letter on the member’s behalf the Provider Law Firm will do so at no additional cost to the member.



Advice & Consultation (continued)

Family Matters

Provider Network

Provider Network

Covered

Covered

Covered

The action must be filed in a state or federal district court. The Provider Law Firm will provide services under the following schedule of hours based on membership year:

Year Pre-Trial Hours Trial Hours Total Hours 1 2.5 57.5 60 2 3.0 117 120 3 3.5 176.5 180 4 4.0 236 240 5 4.5 295.5 300

Adoption

The Provider Law Firm will provide advice and consultation on how to obtain a birth certificate for the adopted child and answer questions related to adoption, such as:

• Financing your adoption• The difference between interstate adoption and international adoptions• Open versus closed adoptions• Stepparent adoptions• Surrogacy issues • Re-adoption

More specific services will be provided under the preferred member discount such as:

• Obtaining the necessary consent of the parent who is giving up the child• Filing the adoption petition• Representing you in court• Obtaining a new birth certificate indicating the new parent or parents

Child Custody/Child Support

The Provider Law Firm will provide advice and consultation on child custody and child support, such as:

• Statutory rights to/obligations of child support and custody• Steps and procedures to initiate or modify child support• Process and options to collect unpaid child support• Rules, procedures and options for visitation and custody• Collecting unpaid back child support• What to expect in court

More specific services and representation in court will be provided under the preferred member discount.



Family Matters (continued) Provider Network

CoveredGuardianship or Conservatorship

The Provider Law Firm will provide advice and consultation on guardianship and conservatorship. Some examples are:

• How to determine if someone needs guardianship/conservatorship• Am I eligible to be a guardian/conservator?• What is temporary and permanent guardianship?• When are guardianships available or necessary?


CoveredJuvenile Court Defense

The Provider Law Firm will provide advice and consultation on juvenile court matters, including advice on state and local laws on such as:

• Truancy• Running away from home• When to report Abuse/Neglect


CoveredPrenuptial Agreement

The Provider Law Firm will provide advice and consultation and review prenuptial agreements and provide an explanation to questions such as:

• When is a prenup needed?• Is a prenup enforceable in my state?• How do I protect my children in a prenup?


CoveredProtection from Domestic Violence

The Provider Law Firm will provide advice, consultation and document review on issues regarding protection from domestic violence, victim protective orders, temporary restrain-ing orders and similar issues. Also, the Provider Law Firm will provide advice on necessary filing of documentation with the appropriate police and county or district attorney’s office. More specific coverage will be provided under the preferred member discount.

CoveredName Change

The Provider Law Firm will provide advice and consultation on name changes such as:

• When and how to legally change a name • An explanation of the documentation and information necessary • The court process





CoveredDivorce

The Provider Law Firm will provide advice, consultation and document review. They will also address the following:

• The distinction between a Contested and Uncontested divorce• Considerations of children and custody in divorce• General outline of state laws on division of property• The court process and timing involved in a divorce proceeding and what steps can be

taken to speed up the process and reduce the cost.


CoveredElder Law Matters

The Provider Law Firm will provide advice, telephone consultation and document review to members on elder law matters as it relates to the member, including what protections are available to senior citizens under state or local laws and rights and obligations under Medicare or Medicaid, and general legal information on nursing home options.

CoveredSeparation

The Provider Law Firm will provide advice and consultation on separation and civil annulments, including:

• Whether your state recognizes a legal separation and the requirements for a separation• The affect of an annulment on your family, business and children • What paperwork and legal proceedings are required for separations and annulments• What decisions need to be made


CoveredImmigration Matters

The Provider Law Firm will provide advice, telephone consultation and document review to members on immigration issues, such as:

• How to request citizenship, or a work or student Visa• The validity and duration of Visas and other papers

This service also includes the Provider Law Firm writing a letter or making a phone call on behalf of the member. The Firm will review documents (up to 10 pages in length per document) that relate to immigration.

More specific services will be provided under the preferred member discount.



Auto Provider Network


CoveredIncompetency Defense

The Provider Law Firm will provide advice and consultation on any incompetency action and the legal necessity and requirements of any proceeding to determine or assess competency, and how mental or physical competency may be relevant in estate matters or guardianship matters.


CoveredMoving Traffic Violations

The service provides defense of all covered non-criminal moving traffic violations. The Provider Law Firm must have five business days’ notice for court representation. Service is available 15 days after enrollment.

CoveredDriver’s License Recovery

This service provides a total of 2 ½ hours of attorney time at no additional charge in each of the following situations: member has been denied a driver’s license or a driver’s license has been cancelled, suspended or revoked by the Department of Public Safety or Department of Motor Vehicles where a right to appeal is provided by the statute; when legal assistance is needed to reinstate or maintain a driver’s license because of job related matters; and when legal assistance is needed to reinstate or maintain a driver’s license because of medical reasons.

CoveredAccidents

This service provides defense of the member by the Provider Law Firm on any criminal charge for manslaughter, involuntary manslaughter, negligent homicide, or vehicular homicide, arising from the permitted use of a licensed motor vehicle.

CoveredPersonal Injury Assistance

The Provider Law Firm will provide the member with assistance up to, but not including, the filing of a lawsuit, to collect all personal injury and property damage claims of $2,000.00 or less for personal injuries or property damages received as a result of the member driving, riding in or being struck by a motor vehicle or boat.



Estate Issues

Financial

Provider Network

Provider Network

Covered

Covered

Wills and Codicils (Including Simple Support Trust for Minor Child)

The member is entitled to have a standard last Will and testament prepared by the Provider Law Firm. The Provider Law Firm will provide a simple support trust for a minor child if it is included in the Will. The Provider Law Firm also provides annual reviews and makes any necessary changes each membership year. Wills for covered family members are $20.

Bankruptcy

Our Provider Law Firm will provide advice, telephone consultation and document review on bankruptcy regardless of whether you are the debtor or a creditor, including the differences between Chapter 7, 11 and 13, the requirements for filing any bankruptcy and any plan of reorganization, and the necessary documentation required for any bankruptcy filing. The Provider Law Firm, at their discretion, will review documents up to 10 pages and counsel the member to see if he/she is eligible to file bankruptcy.


CoveredHealthcare Powers of Attorney

Healthcare powers of attorney are prepared for the member and spouse by the Provider Law Firm.

CoveredStatutory Powers of Attorney

The Provider Law Firm will provide members and spouses with Statutory Powers of Attorney in those states which create such documents. Such documents can give someone power or rights to make certain decisions on your behalf.

CoveredConsumer Protection Assistance

This service also includes the Provider Law Firm writing a letter or making a phone call on behalf of the member when deemed appropriate and helpful by the Provider Law Firm.

CoveredLiving Wills or Healthcare Directives

Living Wills are prepared for the member and spouse by the Provider Law Firm.

CoveredTrusts

The Provider Law Firm will provide advice and consultation on the types of trusts available (including revocable or living trust), and the general reasons to create a trust to protect family or assets. More specific services and trust document preparation will be provided under the preferred member discount.



CoveredThe Provider Law Firm will provide representation to the member or member’s spouse as a defendant for a covered civil action or covered job related criminal action, including but not limited to situations such as:

• Real Estate• Insurance• Construction• Consumer goods and services

The action must be filed in a state or federal district court. The Provider Law Firm will provide services under the schedule of hours based on membership year. Please see the Trial Defense section for more details.

CoveredDebt Collection Defense

The Provider Law Firm will engage with any creditor to limit creditor harassment prior to a civil litigation being filed. The Provider Law Firm will represent the member in the defense of a covered action for foreclosure, repossessions or debt collection based upon the number of hours available as defined by the membership year, as long as there is a meritorious defense. For example, the first membership year has up to 60 trial hours with 2.5 hours of pre-trial.


CoveredIRS Audit Representation

Representation when you receive written notice of a covered audit or when we are required to appear at the IRS office.

Members receive one hour of consultation, advice or assistance when notified of an audit or official notice by the IRS of examination in your office, home, or a local IRS office. The member will receive an additional 2.5 hours if settlement is not achieved within 30 days. If the case goes before a court, the member will receive 46.5 hours of Provider Law Firm

CoveredCivil Lawsuits and Criminal Charges

The Provider Law Firm will provide representation to the member or member’s spouse as a defendant for a covered civil action or covered job related criminal action, including but not limited to situations such as:

• Real Estate• Insurance• Construction• Consumer goods and services


Financial (continued)

Litigation

Provider Network

Provider Network



CoveredIRS Collection Defense

The Provider Law Firm will provide advice, consultation and document review, including advice regarding offers in compromise and payment arrangements, when you receive written notice that the Internal Revenue Service intends to collect past due taxes.

CoveredIdentity Theft Defense

Our Provider Law Firm will provide advice and consultation on identity theft matters involving creditor actions. The Provider Law Firm will provide a phone call or letter to creditors, credit bureaus and financial institutions. They will also answer questions such as:

• Obtaining copies of documents related to theft• Stopping collection of the fraudulent debts• Placing fraud alerts on credit files• Working with credit reporting agencies to block further fraudulent reports• Dispute fraudulent information, investigate information and fix reports


CoveredPost Judgment Matters

The Provider Law Firm will provide advice and consultation on post judgment matters and answer general questions such as:

• Telephone consultation after a judicial proceeding to review a judgment or discuss how to execute on a judgment

• The right of appeal or how to collect or garnish a judgment debtor and when appropriate how to modify a judgment


CoveredSmall Claims Assistance

This service provides phone advice and consultation for small claims proceedings including review of pleadings as allowed by state regulations, procedure, etc. The small claim action must be filed in a state or federal district court. The Provider Law Firm will provide services under the same schedule of hours as Trial Defense section.

Advice and counseling in the filing and presentation of a claim as a plaintiff in a Small Claims Court.

Advice and counseling in the defense of a claim in a Small Claims Court.

This applies to representation of a member as a defendant in a Small Claims Court in states which permit a party to be represented by an attorney in proceedings.

Litigation (continued) Provider Network

services. Coverage for this service begins with the tax return due April 15 of the year the member enrolls.



Home Provider Network

CoveredProperty Disputes and Questions

The Provider Law Firm will provide advice, consultation and document review for all personal real estate matters including:

• Boundary or title disputes• Landlord/tenant issues• Security deposit disputes• Property tax assessments• Home equity loans• Mortgage issues


CoveredTenant Rental Issues

Enforcement and defense against covered disputes with your landlord about your rights, agreement or obligations as a renter/tenant for your primary residence including coverage for tenant eviction defense.


CoveredForeclosure, Repossession and Garnishment Defense

The Provider Law Firm will provide assistance in including advice concerning any creditor issue to limit creditor harassment. The Provider Law Firm may represent the member in the defense of a covered lawsuit in state or federal district court for foreclosure, repossessions or debt collection based upon the number of hours available as defined by the membership year, as long as, in the provider’s independent judgment, there is a meritorious defense. For example, the first membership year has up to 60 trial hours with 2.5 hours of pre-trial.

Our Provider Law Firm will provide advice and consultation on any garnishment defense. More specific services and representation in court on garnishment proceedings will be provided under the preferred member discount.

CoveredBoundary-Title Disputes

The Provider Law Firm may represent the member in the defense of a covered lawsuit in state or federal district court for boundary-title disputes (such as a dispute over the ownership or size or description of real property, a review of deed, plat maps or title rights, and disputes relating to easements or encroachments) based upon the number of hours available as defined by the membership year, as long as, in the provider’s independent judgment, there is a meritorious defense. For example, the first membership year has up to 60 trial hours with 2.5 hours of pre-trial.




CoveredPreferred Member Discount

As with any benefit, not every item is covered under the detailed benefits. For those areas that are not expressly covered, our members have access to our Provider Law Firms at the 25% discount hourly rate.

CoveredForm Service Center

Our members have access to several legal forms through our online Forms Service Center. The member can select the form needed, complete it and then send to his/her Provider Law Firm for review. Access to these documents is only a few clicks away.

CoveredOnline Video Law Library

Our Member’s Only website has an online legal library of videos that focus on many of today’s most common legal concerns.

Home (continued)

Additional Benefits

Provider Network

Provider Network

CoveredProperty Tax Assessment

The Provider Law Firm will provide advice, consultation and document review on property tax assessment issues, such as tax assessment review or appraisal by state or local tax authorities, or the annual assessment in connection with the sale or purchase of a home.

Covered24/7 Emergency Access

After-hours legal consultation for covered legal emergencies such as: if the Covered Person is arrested or detained, seriously injured, served with a warrant, or if the state tries to take the member’s child(ren).

CoveredZoning Applications

The Provider Law Firm will provide advice, consultation and document review on zoning applications, which includes advice on county, city or state codes and ordinances and the general process for obtaining necessary variances or permits or licenses; review of building or construction codes of real property.

CoveredMortgage Document Assistance

Review of up to 10 pages of documents that have already been prepared by the lending institution will be provided by the Provider Law Firm.

Embedded Employee Assistance Program (EAP) with Claimant Assist

#137-rev.06.12

Telephone assistance:EAP: 866.451.5465

Claimant Assist: 866.472.2734

Online:www.niseap.com

Password: NISenhanced

Offered by:

Corporate Headquarters250 South Executive Drive, Suite 300, Brookfield, WI 53005

OfficesNationwide800.627.3660

www.NISBenefits.com

Your EAP and Claimant Assist Administrator:

134 North LaSalle Street, Suite 2200Chicago, IL 60602

Support for Employees* with Life or Disability Insurance Through National Insurance Services

Noproblemistoolargeor too small.

Contact the EAPfor assistance.

866.451.5465

Under our EAP you can receive no-cost, confidential help for a wide variety of needs and concerns:

• Depression

• Stress Management

• Anxiety

• Marital Difficulties

• Relationship Problems

• Family Conflict

• Alcohol or Drug Addictions

• Financial or Legal Concerns

• Parenting Concerns

• Problem Gambling

• Eating Disorders

• Childcare and Eldercare

© National Insurance Services of WI, Inc.*The EAP is for use by the covered employee only. While

issues may concern family members, all contacts to the EAP must be made by the employee.

The EAP ProgramEveryday life can be stressful and can affect your health, well-being and performance. Fortunately, our Employee Assistance Program can aid in finding solutions. When facing personal problems, you might struggle with where to turn for help. The first step is usually the hardest, and guidance is often the key. That’s why National Insurance Services (NIS) offers an Employee Assistance Program (EAP). An EAP offers a confidential place to find the answers that work for you.

Your EAP Service ProviderBensinger, DuPont & Associates (BDA) is a leader in the field of Employee Assistance and has been providing employee assistance services for over 20 years. BDA has the experience to provide the broad range of services and guidance that is paramount to an EAP – whether it’s help with day-to-day concerns or guidance through a challenging crisis. The information you discuss through the EAP is kept confidential in accordance with federal and state laws.

The EAP ProcessWhen you access the EAP, BDA counselors listen and take action toward finding solutions. The next step may include meeting with a mental health

counselor for up to three face-to-face visits, negotiating health insurance benefits or referrals to community resources for legal and financial services.

Referrals and ResourcesYou can receive information and a listing of childcare and eldercare resources with confirmed vacancies meeting your specifications. If face-to-face mental health counseling sessions are required, BDA counselors will refer you for counseling at a location that is convenient to your home or work. BDA counselors can also refer you to self-help groups such as Alcoholics Anonymous or Gamblers Anonymous and community financial and legal resources for debt management.

Claimant AssistNIS's Claimant Assist program offers special services to Long-Term Disability claimants or Life insurance beneficiaries at no charge. If you have Disability insurance coverage through NIS, our Long-Term Disability Claimant Services are available to guide and counsel claimants and their immediate family members. If you have Life insurance coverage through NIS, our Beneficiary Services Program provides counseling and assistance to beneficiaries when faced with the challenge of coping with loss.

• Access to masters-degreed counselors 24-hours a day through a toll-free number.

• Up to three in-person assessment and counseling sessions.

• Legal Assistance – Counselors may refer you to a telephone and/or one in-person consultation with an attorney.

• Financial Assistance – Telephone consultation with a financial consultant to address questions on budgeting, taxes and debt consolidation.

• Childcare and Eldercare Assistance – Telephone consultation with a work-life professional to provide information, referrals and resources related to childcare or eldercare concerns.

• Memorial Planning Assistance** – Telephone consultation with a work-life specialist to assist with memorial and funeral planning. Services include identifying potential locations, associated costs for services and providing information to help coordinate logistics.

** Available to Life insurance beneficiaries only.

EAP services are available to you two ways:

Call toll-free: 866.451.5465

Online: www.niseap.comyour password is: NISenhanced

Claimant Assist services are available toll-free at: 866.472.2734

From a lost wallet to full-on credit card fraud, having your personal information compromised is stressful. Our risk management specialists are trained and certified to help restore your peace of mind, and the good name you’ve worked hard to achieve. We can guide you, or your family member, through the resolution process with understanding and common sense. We hope you never need us – but we’re here if you do!

The certified risk management specialists* can assist you with:

• Accessing the scope of suspected or actual fraud • Putting you in contact with law enforcement or local governmental agencies as necessary• Filing the Identity Theft Victim’s Complaint and Affidavit• Assisting with credit bureau fraud alerts• Guiding you through the resolution process

You will receive complete documentation for your records and continued follow-up and ongoing support as needed.

Call us toll-free 24/7 at 855.860.3727

*Institute for Fraud Risk Management certified.

Identity Theft Assistance Services

Identity theft assistance services are provided by AMT Consumer Services, Inc., which is not affiliated with Madison National Life Insurance Company. Services provided by AMTCS are not part of the Madison National insurance policy, and Madison National is not responsible for any acts or omissions of AMTCS in connection with or arising under identify theft assistance services.

ID Theft Assistance Disclosure: Access to this program is conditioned upon: (i) you remaining a Madison National Life customer during the term of the program; (ii) the payment of the monthly fee to AMT Consumer Services, Inc., by your provider for your participation; and (iii) the program terms and conditions. This program does not provide credit repair services or any form of legal advice.

Corporate Headquarters250SouthExecutiveDrive,Suite300,Brookfield,WI53005

Offices Nationwide800.627.3660

PO Box 5008, Madison, WI 53705

Resolution services offered to you by your employer and

#72.idt.ee.rev.01.14©National Insurance Services of WI, Inc.

M I N N E S O T A

0203197 Ed. 0214

The Prudential Insurance Company of America

Extra Protection For Your Family

Group Decreasing Term Life Insurance

National Conference on Public Employee Retirement Systems

The Voice for Public Pensions

Extra Financial SecurityDesigned especially for public employees

like you, this voluntary plan offers a

supplementary survivor’s benefit to

augment your retirement system’s benefits.

Solid as a RockSince our plan’s inception more than

40 years ago, Prudential has paid over

$105 million to NCPERS members and

their beneficiaries. The plan is well designed

and financially sound, with plan reserves

committed to maximize benefits to

participants. It currently serves the needs

of over 85,000 public employee retirement

system members nationwide.

For More InformationRead on to find out…

• Why you may need this extra protection.

• What kind of coverage you can get.

• What it costs.

• Why you should buy it at work.

• How and when to enroll.

+Dear Member:

Participating in a pension plan for public employees is a great first step to protecting your family’s future. But, if you’re like many, your needs may not be fully met by your pension plan. That’s where the NCPERS Group Decreasing Term Life Insurance Plan can help.

The plan is custom designed to give your family extra financial security when they need it most. A valuable member benefit regardless of your age, it offers supplemental protection, including:

Decreasing Term Life Insurance— For you.

Accidental Death & Dismemberment Insurance— For you.

Dependent Term Life Insurance— For your spouse or domestic partner and all of your eligible children.

Plus, you get all of this protection for just $16 a month—that’s less than the cost of a cup of coffee per day.

Our plan is issued by The Prudential Insurance Company of America (Prudential)—a name you know and trust.

We’re pleased to offer you the opportunity to review your insurance needs and purchase supplemental insurance for you and your family.

Don’t miss out—enroll today!

Sincerely,

President

“ Why do I need extra protection?”

Protecting your family’s future through your pension

benefit is something you can feel good about. But, how

would your family support themselves if something tragic

happened to you before you could accrue a substantial

pension benefit? Even if your pension was sizeable, how

much of it would be eaten up by costly final expenses?

Designed for employees of all ages, this Group Decreasing

Term Life Insurance plan is valuable for…

Members Under 50:

It provides a substantial benefit—an easy way to

supplement pension survivor benefits during the

early family-building years when pension plan

survivor benefits are lower and your family’s

needs are greatest.

Members Over 50:

It provides a good way to help cover incidental

expenses associated with death—like those

for burial, medical, and debt, so other life

insurance coverages can be used to maintain

your family’s lifestyle.

“ What coverages can I get?”For an affordable price, you get all of the following

coverages for you and your family.

Group Decreasing Term Life This coverage—which pays your beneficiary a maximum

benefit amount in your younger years and a gradually

decreasing benefit amount in your older years—will help

give you peace of mind for your family’s well-being.

Accidental Death & Dismemberment (AD&D) This additional coverage pays you or your beneficiary a

benefit for loss of life or other injuries resulting from

a covered accident—100% for loss of life and a lesser

percentage for other injuries. Injuries covered may

include loss of sight and dismemberment of hands or feet.

AD&D Exclusions—No benefit will be paid due to loss

from the following: war; suicide or attempted suicide;

any bacterial or viral infection (unless the infection was

the result of an accidental cut or wound); bodily or

mental infirmity or disease, or medical or surgical

treatment thereof; or by aircraft travel if you have

any duties aboard the aircraft, or if you are giving or

receiving training for such duties.

Dependent Term Life This plan provides Group Decreasing Term Life

Insurance for your spouse or domestic partner and a flat

benefit for all of your dependent children. The benefit

amount will be paid to you in a lump sum on an eligible

dependent’s death due to any cause. Spousal or domestic

partner benefits are determined by your age at the time

of your spouse’s or domestic partner’s death.

Domestic partners may not be recognized in all states.

“ What are the advantages of this insurance?”

• Guaranteed Acceptance—no health questions asked.

• 24/7 Coverage—on or off the job.

• Affordable—$16 a month regardless of your age.

• Easy Payment—by automatic payroll deductions.

“ How much does this coverage cost?”

Coverage is available at a lower group cost through the

purchasing power of the National Conference on Public

Employee Retirement Systems. Every member, regardless

of age, pays the same cost—just $16 a month. Your cost

does not increase with your age. The plan pays a maximum

benefit amount in your younger years and a gradually

decreasing benefit amount in your older years.

Payment Examples:

1. If an insured member age 38 dies of natural causes, the beneficiary would receive $100,000. If death is due to a covered accident, $200,000 would be payable.

2. If the spouse or domestic partner of a 42-year-old member dies, the member would receive $18,000.

3. If a dependent child less than age 26 dies, the payment to the member would be $4,000.

* Unmarried children age 14 days but less than 26 years old are covered, including adopted children, stepchildren, and foster children who depend on you for support. Dependents in military service are not eligible.

For your convenience, payment is made by payroll deduction. Please send no money.

MEMBER DEPENDENT

Monthly cost effective 6/1/2002.

Schedule of Benefits – $16 Monthly Contribution(Covers You, Your Spouse or Domestic Partner, and Your Children)

Group Accidental Death & Dismemberment

$100,000

$100,000

$100,000

$100,000

$100,000

$100,000

$100,000

$100,000

$7,500

Group Term Life Spouse/Domestic Partner Child(ren)*

$20,000 $4,000

$20,000 $4,000

$20,000 $4,000

$18,000 $4,000

$15,000 $4,000

$10,000 $4,000

$7,000 $4,000

$5,000 $4,000

$4,000 $4,000

Member’s Age at Time of Claim

Less than 25

25 - 29

30 - 39

40 - 44

45 - 49

50 - 54

55 - 59

60 - 64

65 and over

Group Term Life

$225,000

$170,000

$100,000

$65,000

$40,000

$30,000

$18,000

$12,000

$7,500

Total Benefit For Accidental Death

$325,000

$270,000

$200,000

$165,000

$140,000

$130,000

$118,000

$112,000

$15,000

“How can I enroll?”You may enroll within 90

days of the date of your

employment or during the

open enrollment period.

To enroll: • Complete the enclosed

Enrollment and Beneficiary

Form, or

• Go to the Life Plan’s link on the plan sponsor’s website

to obtain a printable copy of the form.

Make certain to complete the form in full to avoid any

problems with future claims submission.

Submit your completed enrollment form to your

employer. Your employer will begin payroll deductions

and forward your enrollment information to

HealthSmart Benefit Solutions, Inc.

“ What special features are offered?”

Waiver of Premium If you are less than 60 years old and become totally

disabled for at least nine months, your insurance may

be continued without further premiums, as long as you

furnish annual proof of your continued total disability

satisfactory to Prudential.

Accelerated Benefit Option* If you are terminally ill with a life expectancy of six

months or less, you may receive up to 50% of your

insurance benefits—up to $112,500 in advance—

provided you’ve been in the NCPERS plan for at least

one year. The death benefit, payable to your beneficiary,

will be reduced by that amount.

Additional AD&D Benefits • Education Benefit

• Seat Belt Benefit

• Air Bag Benefit

• Repatriation Benefit

Conversion of Coverage If you cease to be a member, you can convert your

insurance to a Prudential individual life policy within

31 days following termination of insurance. Dependent

Spouse or Domestic Partner Term Life coverage can

also be converted if you cease to be a member or die.

Retirement Coverage Coverage can be continued into retirement if you are

insured as an active member and will receive a benefit

upon retiring. Simply authorize the retirement system to

deduct your contributions from your retirement check.

“More questions?” Q. Is a medical exam required?A. No, you and your family are guaranteed coverage

without having to answer any health questions or

take any medical exams.

Q. Does the plan pay in addition to a retirement system’s survivor benefits?

A. Yes, this plan will pay a benefit in addition to

pension and other insurance plans you may have.

Q. Who is eligible for this coverage?A. All active members of the retirement system who are

actively at work may enroll.

Q. When will my coverage go into effect?A. If you enroll within 90 days of your date of employment,

you will become insured on the first day of the month

following your first payroll deduction. If you enroll

during the open enrollment period, your coverage

begins on the first day of the month following your

first payroll deduction after open enrollment. Your

member coverage will be delayed if you are not actively

at work on the coverage effective date. Instead,

your coverage will begin on the date you meet the

actively-at-work and other insurance requirements

for covered members. Dependent coverage begins

when your insurance coverage becomes effective.†

Q. When will my coverage end?A. Coverage will end if you discontinue payments, cease

to be a member of the eligible classes, or if the plan is

discontinued. Refer to the Booklet-Certificate for details

Q. What if I want to change my beneficiary?A. To change your beneficiary, simply indicate your new

designation on the Enrollment and Beneficiary Form

and return it to your employer.

“ How do I get more information?”

For additional information about life insurance

or how to file a claim, please contact:

HealthSmart Benefit Solutions, Inc.

10303 East Dry Creek Road, Suite 200

Englewood, CO 80112

Phone: 800-525-8056

E-mail: [email protected]

www.NCPERSVoluntaryLife.com/mn

Sign Up For This

Exclusive Member Benefit TODAY!

* Note—The acceleration of life insurance benefits offered under this certificate is intended to qualify for favorable tax treatment under the Internal Revenue Code of 1986, IRC Section code 101(g). If the acceleration of life insurance benefits qualifies for such favorable tax treatment, the benefits will be excludable from your income and not subject to federal taxation. Tax laws relating to the acceleration of life insurance benefits are complex. You are advised to consult with a qualified tax advisor about circumstances under which you could receive acceleration of life insurance benefits excludable from income under federal law.

† If a dependent is confined for medical treatment, coverage will become effective when the dependent is released by a doctor from such confinement.

Accelerated Death Benefit option is a feature that is made available to group life insurance participants. It is not a health, nursing home, or long-term care insurance benefit and is not designed to eliminate the need for those types of insurance coverage. The death benefit is reduced by the amount of the accelerated death benefit paid. There is no administrative fee to accelerate benefits. Receipt of accelerated death benefits may affect eligibility for public assistance and may be taxable. The federal income tax treatment of payments made under this rider depends upon whether the insured is the recipient of the benefits and is considered terminally ill. You may wish to seek professional tax advice before exercising this option. This brochure describes the Group Insurance Plan in a general manner.

A Booklet-Certificate with complete plan information, including limitations and exclusions, will be provided when you enroll. If there is a discrepancy between this communication and the Booklet-Certificate issued by The Prudential Insurance Company of America, the Booklet-Certificate will govern.

NCPERS is a non-profit organization that provides education and support to public employee retirement systems. NCPERS has no role in the administration of the life insurance program and the benefits are guaranteed solely by the insurance carrier. NCPERS is compensated solely for the use of its name, service marks, and mailing lists.

Plan arranged and managed by Gallagher Benefit Services, Inc., the employee benefits division of Arthur J. Gallagher & Co. Gallagher receives compensation for the marketing and services they provide, which is discussed and disclosed annually with NCPERS.

Group Decreasing Term Life Insurance, Dependent Group Decreasing Term Life Insurance, and Accidental Death & Dismemberment Insurance are issued by The Prudential Insurance Company of America, 751 Broad Street, Newark, New Jersey 07102. Contract Series: 83500.

This AD&D policy provides ACCIDENT insurance only. It does NOT provide basic hospital, basic medical, or major medical insurance as defined by the New York Department of Financial Services.

IMPORTANT NOTICE—THIS POLICY DOES NOT PROVIDE COVERAGE FOR SICKNESS.

The plan is administered by HealthSmart Benefit Solutions, Inc. Gallagher Benefit Services, Inc. and HealthSmart Benefit Solutions, Inc. are not affiliates of Prudential.

© 2014 Prudential Financial, Inc. and its related entities.

Prudential, the Prudential logo, and the Rock symbol are service marks of Prudential Financial, Inc. and its related entities, registered in many jurisdictions worldwide.

Ver 07-MN Ed. 0214 97706-PDF

0203197-00003-00

© 2012 HearPO, Corp. 2039MISC

HearPO Program OverviewAs you may know, most insurance plans do not adequately cover hearing health care. HearPO, however,

provides money-saving benefits that extend to employees’/members’ friends, family, and extended

family. With nearly 35 million Americans experiencing hearing loss (and only 10% wearing hearing

aids), these benefits are the most important part of your free hearing health care plan.

Program FeaturesGuaranteed Lowest Pricing* on any hearing aid available through manufacturing partners

Hearing aids offered from multiple manufacturers (Siemens, Phonak, Unitron, Sonic Innovations,GN ReSound, Widex, Starkey, Miracle Ear, and Rexton)

Offering a complete line of hearings aids from each manufacturer, including the newest technologyto hit the market

Over 2,600 credentialed locations

65% of Provider Network is staffed by licensed audiologists.

Highest provider reimbursement of any network to assure quality care

Customer satisfaction of over 90% for over a decade

3 year manufacturer’s warranty included in low price guarantee

3 year manufacturer’s loss & damage coverage** included in low price guarantee

60 day trial period with no restocking fees

1 year of follow-up services included with purchase of hearing aid

2 years of FREE batteries (up to 160 cells per hearing aid, valued at approximately $150)

Initial ear molds for Behind the Ear products included in low price guarantee

Over 141 million current members using the program

National Strategic Partnership with American Diabetes Association

Easy process for Member to access their hearing discounts

✓

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✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

*Competitor coupon required for verifiction of price and mold. Limited to manufacturers offered through theHearPO program. Local provider quotes only will be matched.**Some exclusions apply. Limited to one-time claim for loss and damage. Deductible charges apply.

a national strategic partner of

Maybe you’re not sure if you need the help availablethrough your HearPO® hearing health care program.Only through a hearing test performed by a qualifiedhearing health care provider can you be certain. However, hearing-impaired individuals (or their lovedones) may notice a number of common symptoms.

Take this quick test to find out.

Don’t wait — get in touch withHearPO now.Hearing loss is one of today’s must common healthconditions affecting nearly 35 million americans according to the Better Hearing Institute.

Hearing loss usually comes on so gradually, you might not realize it’s happening. The important thing is to catch it and resolve it in the early stages. Left untreated, hearing loss may profoundly undermine your quality of life. Which can result in reduced participation in organized social activities.*

*The National Council on the Aging, May 1999. Study conducted by the Senior Research Group.

1

2

3

Call 1-888-432-7464or visit www.hearpo.com

© 2010 HearPO Corp 1807FULL/B

You deserve tohear better.

Hearing Health Program Overview

How to access yourHearPO® Program.

Do you need helpwith hearing?

Do you feel that people mumble or donot speak clearly?

Do you have trouble with understandingconversations in restaurants?

Do you turn the TV up louder than others need to?

Do you have problems following conversations between the front andback seat of cars?

If you’ve answered yes to any one of these questions, we encourage you to call HearPO tolearn more about how you can take advantage of your hearing health benefit.

Yes No

Call HearPO to start the process• Call 1-888-432-7464 to locate a hearing healthcare provider in your area.

• Our representative will explain the HearPOprocess and help you make an appointment witha hearing health care provider.

• A HearPO authorization packet will be mailed; thisactivates your hearing health care program.

At your appointment• The HearPO hearing health care provider will testyour hearing to determine whether you can behelped and which hearing aid is the most appropriate for you.

• At the end of your hearing test appointment, you’ll pay the discounted HearPO rate for all testprocedures.

• Once the hearing aid is selected, the hearinghealth care professional will order the hearing aids.

Receive your hearing aids• You’ll be contacted for a fitting when the productis received by your hearing health care provider.

• As part of the fitting process, you’ll receive complete instructions on the use and care of yourhearing aids.

• HearPO processes your payments for the hearingaids by the provider collecting the payment fromyou and forwards this to HearPO at the time of fitting.

• Keep in mind the important HearPO comprehensiveprogram includes a 60-day trial period and oneyear after care.

HearPO is an American Diabetes Association National Strategic Partner.The American Diabetes Association does not endorse any specific health care program.

Completely in earCIC

Canal(ITC)

Behind the EarBTE

OpenBTEFull Shell

(ITE)

Take control of your hearingand your quality of life. Call HearPO or visit www.hearpo.com

We offerfinancingoptions

The HearPO® package includes:

• Discounted prices on 1,000-plus brand-name hearingaids from several industry-leading manufacturers.

• Low-price guarantee*– if you should find a lowerprice at another local provider, we’ll gladly beat thatprice by 5%.

• 60-day no-risk trial period – if you’re not satisfied, return your hearing aids within the trial period for a100% refund.

• 3-year warranty – one of the longest you’ll find anywhere – on most hearing aids, covering repairs,loss and damage.†

• 1-year of follow-up care– cleaning, adjustment and other hearing aid services–included in the price ofyour hearing aid.

• Free batteries –one year supply mailed directly toyour home (maximum of 80 cells per hearing aid).

*Competitor coupon required for verification or price and model. Limited to manufacturers offered through the HearPO program. Local provider quotes only will be matched.

†Some exclusions apply. Limited to one-time claim for loss and damage. Deductiblecharges apply.

*Competitor coupon required for verification of price and model. Limited tomanufacturers offered through the HearPO program. Local provider quotes only.

Choosing HearPO is a smart decision!Your employer or sponsor organization cares enoughabout you and your quality of life to partner withHearPO, one of the largest providers of hearing healthprograms in the United States.

When you access the HearPO Program, you take animportant step toward reconnecting with the soundsthat are important to you. You’ve made a smart decisionin other ways, too, because no other hearing healthcare program offers you all this:

• Credibility — Many years of partnering with prominent employers, insurance companies and private organizations

• Convenience — Outstanding hearing care at over2,200 hearing health care locations and growing

• Expertise — Hearing health care by providers whomust complete the HearPO credentialing process

• Choices — Access to a wide range of high-quality,name-brand hearing aids

• Value — The lowest price on your hearing aids,guaranteed*

• High Satisfaction — A customer satisfaction ratingof 90% or higher for more than a decade

Open your mind...and your ears...to what’s new.Has it been a while since you checked out hearingaid technology? We think you’ll be amazed whenyou see and hear the latest innovations. Today’shearing aids deliver clearer, more natural sound.**Many models are equipped to reduce the backgroundnoise that can interfere with conversation. Comparedwith the hearing aids of just a few years ago, thelatest products are more comfortable (you mightforget they’re in your ears!), more convenient (howdoes automatic volume control sound to you?)and smaller, less conspicuous than ever (you’rewearing hearing aids — really?!).

The HearPO hearing health care provider will discuss daily activities and provide testing to determine the best solution for your hearingneeds. Rest assured, the brand-name hearing aids offered through HearPO provide today’s most advanced features and exceptional sound quality. Even better, you’ll pay specially discounted prices, thanks to our extensive network size and our long-standing relationshipswith leading manufacturers.

Types of Hearing Aids

** Hearing aids cannot restore natural hearing.

© 2012 HearPO, Corp. 2047MISC

Simple 3-StepProcess

We make it easy for you to access the HearPO® Program.

Call HearPO to select a hearing health care professionalin your area.

Our representative will explain the HearPO process, obtainyour mailing address and assist you in making an appointmentwith the hearing health care provider.

HearPO will send information to you and the provider. This will ensure the HearPO Program is activated.

Take advantage of everything HearPO can do for you. Call us today at 1-855-531-4694.

Call now for more information.

1

2

3

All you have to do is follow our simple 3-step process:

Legal Disclosures

New Health Insurance Marketplace Coverage Options and Your Health Coverage

PART A: General Information When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance: the Health

Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic

information about the new Marketplace and employmentbased health coverage offered by your employer.

What is the Health Insurance Marketplace?

The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The

Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible

for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance

coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014.

Can I Save Money on my Health Insurance Premiums in the Marketplace?

You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or

offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on

your household income.

Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?

Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible

for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be

eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does

not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your

employer that would cover you (and not any other members of your family) is more than 9.5% of your household

income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the

Affordable Care Act, you may be eligible for a tax credit.1

Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your

employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer

contribution -as well as your employee contribution to employer-offered coverage- is often excluded from income for

Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-

tax basis.

How Can I Get More Information?

For more information about your coverage offered by your employer, please check your summary plan description or

contact .

The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the

Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health

insurance coverage and contact information for a Health Insurance Marketplace in your area.

1 An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered

by the plan is no less than 60 percent of such costs.

Form Approved OMB No.

PART B: Information About Health Coverage Offered by Your Employer This section contains information about any health coverage offered by your employer. If you decide to complete an

application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered

to correspond to the Marketplace application.

3. Employer name

4. Employer Identification Number (EIN) 5. Employer address 6. Employer phone number 7. City 8. State 9. ZIP code 10. Who can we contact about employee health coverage at this job? 11. Phone number (if different from above) 12. Email address

Here is some basic information about health coverage offered by this employer:

• As your employer, we offer a health plan to:

All employees.

Some employees. Eligible employees are:

• With respect to dependents:

We do offer coverage. Eligible dependents are:

We do not offer coverage.

If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended to

be affordable, based on employee wages.

** Even if your employer intends your coverage to be affordable, you may still be eligible for a premium

discount through the Marketplace. The Marketplace will use your household income, along with other factors,

to determine whether you may be eligible for a premium discount. If, for example, your wages vary from

week to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly

employed mid-year, or if you have other income losses, you may still qualify for a premium discount.

If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here's the

employer information you'll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower your

monthly premiums.

PART B: Information About Health Coverage Offered by Your Employer (attachment)

To be eligible for coverage under this policy, a Dependent must reside within the United States.

The definition of Dependent is subject to the following conditions and limitations:

Spouse

1. Married spouse.

Dependent Children

1. Natural-born dependent children to age 26.

2. Legally adopted children and children placed with you for legal adoption to age 26. Date of placement means the assumption and retention by a person of a legal obligation for total or partial support of a child in anticipation of adoption of the child. The child's placement with a person terminates upon the termination of the legal obligation of total or partial support.

3. Stepchildren to age 26.

4. Dependent children for whom you or your spouse have been appointed legal guardian to age 26.

5. Grandchildren to age 26 for whom you provide the majority of financial support and who live with you or your

spouse continuously from birth.

6. Otherwise eligible children of the employee who are required to be covered by reason of a Qualified Medical Child Support Order (QMCSO), as defined in Minnesota statute §518A.41. The Plan has detailed procedures for determining whether an order qualifies as a QMCSO. You and your dependents can obtain, without charge, a copy of such procedures from the Plan Administrator.

Disabled Dependents

1. Unmarried disabled dependent children who reach the limiting age while covered under this Plan if all of the following apply:

a. primarily dependent upon you;

b. are incapable of self-sustaining employment because of physical disability, developmental disability, mental

illness, or mental disorders;

c. for whom application for extended coverage as a disabled dependent child is made within 31 days after reaching the age limit. After this initial proof, the Claims Administrator may request proof again two (2) years later, and each year thereafter; and,

d. must have become disabled prior to reaching limiting age.

2. Disabled dependents if both of the following apply:

a. incapable of self-sustaining employment by reason of developmental disability, mental illness or disorder, or physical disability; and,

b. chiefly dependent upon the group member for support and maintenance.

NOTE: If both you and your spouse are employees of the employer, you may be covered as either an employee or as a dependent, but not both. Your eligible dependent children may be covered under either parent’s coverage, but not both.

** Continuation Coverage Rights Under COBRA**

Introduction You are receiving this notice because you have recently become covered under a group health plan (the Plan). This notice contains important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice generally explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it. The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you when you would otherwise lose your group health coverage. It can also become available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage. For additional information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator. What is COBRA Continuation Coverage? COBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. If you are an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because either one of the following qualifying events happens:

Your hours of employment are reduced, or

Your employment ends for any reason other than your gross misconduct. If you are the spouse of an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because any of the following qualifying events happens:

Your spouse dies;

Your spouse’s hours of employment are reduced;

Your spouse’s employment ends for any reason other than his or her gross misconduct;

Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or

You become divorced or legally separated from your spouse. Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because any of the following qualifying events happens:

The parent-employee dies;

The parent-employee’s hours of employment are reduced;

The parent-employee’s employment ends for any reason other than his or her gross misconduct;

The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both);

The parents become divorced or legally separated; or

2

The child stops being eligible for coverage under the plan as a “dependent child.”

When is COBRA Coverage Available? The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. When the qualifying event is the end of employment or reduction of hours of employment, death of the employee, commencement of a proceeding in bankruptcy with respect to the employer, or the employee's becoming entitled to Medicare benefits (under Part A, Part B, or both), the employer must notify the Plan Administrator of the qualifying event. You Must Give Notice of Some Qualifying Events For the other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs. You must provide this notice to: CieloStar, Inc./Columbia Heights Administrator, including the appropriate documentation as outlined on your benefits hub: https://chps.benefitready.com How is COBRA Coverage Provided? Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children. COBRA continuation coverage is a temporary continuation of coverage. When the qualifying event is the death of the employee, the employee's becoming entitled to Medicare benefits (under Part A, Part B, or both), your divorce or legal separation, or a dependent child's losing eligibility as a dependent child, COBRA continuation coverage lasts for up to a total of 36 months. When the qualifying event is the end of employment or reduction of the employee's hours of employment, and the employee became entitled to Medicare benefits less than 18 months before the qualifying event, COBRA continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement. For example, if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates, COBRA continuation coverage for his spouse and children can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event (36 months minus 8 months). Otherwise, when the qualifying event is the end of employment or reduction of the employee’s hours of employment, COBRA continuation coverage generally lasts for only up to a total of 18 months. There are two ways in which this 18-month period of COBRA continuation coverage can be extended. Disability extension of 18-month period of continuation coverage If you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage, for a total maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage. You must notify the Plan Administrator within 60 days after the

Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event. If a proceeding in bankruptcy is filed with respect to Columbia Heights Public Schools, and that bankruptcy results in the loss of coverage of any retired employee covered under the Plan, the retired employee will become a qualified beneficiary with respect to the bankruptcy. The retired employee’s spouse, surviving spouse, and dependent children will also become qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan.


3

qualifying event occurs. You must provide this notice to: TASC/Columbia Heights COBRA Administrator at 1-800-422-4661. Second qualifying event extension of 18-month period of continuation coverage If your family experiences another qualifying event while receiving 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if notice of the second qualifying event is properly given to the Plan. This extension may be available to the spouse and any dependent children receiving continuation coverage if the employee or former employee dies, becomes entitled to Medicare benefits (under Part A, Part B, or both), or gets divorced or legally separated, or if the dependent child stops being eligible under the Plan as a dependent child, but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. If You Have Questions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under ERISA, including COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) Keep Your Plan Informed of Address Changes In order to protect your family’s rights, you should keep the Plan Administrator informed of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. Plan Contact Information CieloStar, Inc./Columbia Heights Administrator 730 Second Avenue South, Suite 530 Minneapolis, MN 55402 Fax: (612) 338-8673 Phone: (877) 576-8314 Email: [email protected]

Retirees and COBRA Participants

TASC/Columbia Heights Retiree and COBRA Administrator 2302 International Lane Madison, WI 53704 Customer Care: (800) 422-4661

HIPAA notice of special enrollment If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, including coverage through medical assistance or Children’s Health Insurance Program (CHIP), you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing towards your or your dependents’ other coverage). However, you must request enrollment within the time period specified by your plan (you can check a copy of your plan document) after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).

You may also be able to enroll yourself and your dependents if you become eligible for premium assistance through your state’s Medicaid agency. You must request enrollment within 60 days after the date you and/or your dependents are determined to be eligible for premium assistance.

In addition, if you acquire a new dependent as a result of marriage, birth, adoption or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within the time period specified by your plan (you can check a copy of your plan document) after the marriage, birth, adoption or placement for adoption.

If you have questions about this notice, you may contact Blue Cross and Blue Shield of Minnesota and Blue Plus customer service at (651) 662-5001 or 1-800-531-6676.

F8381R02 (8/14)

Blue Cross and Blue Shield of Minnesota and Blue Plus

P.O. Box 64560

St. Paul, MN 55164-0560

(651) 662-8000 / (800) 382-2000

bluecrossmn.com

L02R05 Blue Cross® and Blue Shield® of Minnesota and Blue Plus® are nonprofit independent licensees of the Blue Cross and Blue Shield Association.

V,

http://bluecrossmn.com

CMS Form 10182-CC Updated April 1, 2011

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.

The valid OMB control number for this information collection is 0938-0990. The time required to complete this information collection is estimated to average 8 hours

per response initially, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information

collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security

Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850

Important Notice from Blue Cross and Blue Shield of Minnesota About Your Prescription Drug Coverage and Medicare

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Blue Cross and Blue Shield of Minnesota and about your options under Medicare’s prescription drug coverage. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. This information can help you decide whether or not you want to join a Medicare drug plan. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get

this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.

2. Blue Cross and Blue Shield of Minnesota has determined that the prescription drug coverage offered by

Columbia Heights ISD #13 is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is considered Creditable Coverage for the following plans: Double Gold, VEBA $1200/$2400 and VEBA $1850/$3700. Because your existing coverage is, on average, at least as good as standard Medicare prescription drug coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.

When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15

th to

December 7th

. However, if you lose creditable prescription drug coverage through no fault of your own, you will be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What Happens To Your Current Coverage If You Decide to Join a Medicare Drug Plan? If you decide to join a Medicare drug plan, your current Columbia Heights ISD #13 coverage will be affected. You should compare your current coverage, including which drugs are covered, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area. See pages 7-9 of the CMS Disclosure of Creditable Coverage To Medicare Part D Eligible Individuals Guidance (available at http://www.cms.hhs.gov/CreditableCoverage/), which outlines the prescription drug plan provisions/options that Medicare eligible individuals may have available to them when they become eligible for Medicare part D. If you do decide to join a Medicare drug plan and drop your current Blue Cross coverage, be aware that you and your dependents will not be able to get this coverage back.

http://www.cms.hhs.gov/CreditableCoverage/







When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with Columbia Heights ISD #13 and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. For More Information About This Notice Or Your Current Prescription Drug Coverage… See the contact information below. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through Blue Cross and Blue Shield of Minnesota changes. You also may request a copy of this notice at any time. For More Information About Your Options Under Medicare Prescription Drug Coverage… More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage:

Visit www.medicare.gov

Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help,

Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).

Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and whether or not you are required to pay a higher premium (a penalty).

For further information, you may call the Columbia Heights Employee Benefits Administrator, CieloStar, Inc., at 1-877-576-8314. Retirees and COBRA participants please call TASC at 1-800-422-4661.

Blue Cross

® and Blue Shield

® of Minnesota is a nonprofit independent licensee of the Blue Cross and Blue Shield Association.







Important Notice from Blue Cross and Blue Shield of Minnesota About Your Prescription Drug Coverage and Medicare

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Blue Cross and Blue Shield of Minnesota and about your options under Medicare’s prescription drug coverage. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. This information can help you decide whether or not you want to join a Medicare drug plan. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get

this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.

2. Blue Cross and Blue Shield of Minnesota has determined that the prescription drug coverage offered by

Columbia Heights ISD #13 is, on average for all plan participants, not expected to pay out as much as standard Medicare prescription drug coverage pays and is NOT considered Creditable Coverage for the following plan: Minimum Value Plan $6350/12,700 with VEBA. Because your existing coverage is, on average, not at least as good as standard Medicare prescription drug coverage, you can keep this coverage but you may pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.

When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15

th to

December 7th

. However, if you lose creditable prescription drug coverage through no fault of your own, you will be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What Happens To Your Current Coverage If You Decide to Join a Medicare Drug Plan? If you decide to join a Medicare drug plan, your current Columbia Heights ISD #13 coverage will be affected. You should compare your current coverage, including which drugs are covered, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area. See pages 7-9 of the CMS Disclosure of Creditable Coverage To Medicare Part D Eligible Individuals Guidance (available at http://www.cms.hhs.gov/CreditableCoverage/), which outlines the prescription drug plan provisions/options that Medicare eligible individuals may have available to them when they become eligible for Medicare part D. If you do decide to join a Medicare drug plan and drop your current Blue Cross coverage, be aware that you and your dependents will not be able to get this coverage back.

http://www.cms.hhs.gov/CreditableCoverage/







When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with Columbia Heights ISD #13 and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. For More Information About This Notice Or Your Current Prescription Drug Coverage… See the contact information below. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through Blue Cross and Blue Shield of Minnesota changes. You also may request a copy of this notice at any time. For More Information About Your Options Under Medicare Prescription Drug Coverage… More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage:

Visit www.medicare.gov

Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help,

Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).

Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and whether or not you are required to pay a higher premium (a penalty).

For further information, you may call the Columbia Heights Employee Benefits Administrator, CieloStar, Inc., at 1-877-576-8314. Retirees and COBRA participants please call TASC at 1-800-422-4661.

Blue Cross

® and Blue Shield

® of Minnesota is a nonprofit independent licensee of the Blue Cross and Blue Shield Association.

Young Adults and the Affordable Care Act

If you’re age 18-25, you may not be thinking about health insurance. You may think you’re healthy and don’t have to worry about it. Or the cost might be keeping you from getting coverage. But what if you get into an accident or have a serious illness? Your medical bills could put you in debt or ruin your credit and you may not be able to afford the health care you need to recover fully. The Affordable Care Act is expanding your options for health insurance and making them more affordable.

Top Things to Know for Young Adults

• Under the Affordable Care Act, you can now be insured as a dependent on your parent’s health insurance if you’re under age 26. The only exception is if your parent has an existing job-based plan and you can get your own job-based coverage.

• New health plans must now cover certain preventive services without cost sharing.

• Starting in 2014, if you’re unemployed with limited income up to about $15,000 per year for a single person (higher income for couples/families with children), you may be eligible for health coverage through Medicaid.

• Starting in 2014, if your employer doesn’t offer insurance, you will be able to buy insurance directly in an Affordable Insurance Exchange. An Exchange is a new transparent and competitive insurance marketplace where individuals and small businesses can buy affordable and qualified health benefit plans. Exchanges will offer you a choice of health plans that meet certain benefits and cost standards. Starting in 2014, members of Congress will be getting their health care insurance through Exchanges, and you will be able buy your insurance through Exchanges, too.

• Starting in 2014, if your income is less than the equivalent of about $43,000 for a single individual and your job doesn’t offer affordable coverage, you may get tax credits to help pay for insurance.

Resources for Young Adults

Use these resources to find options for coverage and low-cost care:

• Find the coverage and pricing options that work best for you.

• Learn about options for young adults under age 19 with pre-existing conditions.

• Share your thoughts and spread the word on the Young Adult Coverage Facebook page.

Use these resources to get the most out of your insurance:

• Get help using insurance in your state through the Consumer Assistance Program.

• Learn about several no-cost preventive services for women that will be available in 2012.

• See a full list of no-cost preventive services that are now available under the law.

• Understand your health plan and learn how to make it work for you.

Watch this video to learn how young adults now have more affordable options for health coverage.

http://www.healthcare.gov/law/features/choices/young-adult-coverage/index.html



http://www.healthcare.gov/law/features/rights/preventive-care/index.html


http://www.healthcare.gov/law/timeline/index.html#event42-pane


http://www.healthcare.gov/law/features/choices/exchanges/index.html




http://finder.healthcare.gov/

http://www.healthcare.gov/law/features/rights/childrens-pre-existing-conditions/index.html

http://www.facebook.com/YoungAdultCoverage

http://www.facebook.com/YoungAdultCoverage

http://www.healthcare.gov/using-insurance/managing/consumer-help/index.html

http://www.healthcare.gov/using-insurance/managing/consumer-help/index.html

http://www.healthcare.gov/blog/2011/08/prevention08012011a.html


http://www.healthcare.gov/using-insurance/understanding/index.html

http://www.healthcare.gov/videos/2010/06/young-adults.html

benefits office763-528-4532

www.colheights.k12.mn.us/benefits