Mark III Employee Benefts will be enrolling you in your Supplemental and Voluntary Benefts and your Medical and Dental plans this year. For changes to your Reliance Standard LTD plan or

United HealthCare Spectara Vision plan you must contact Mrs. Marie Waldron in the Human Resources department ([email protected] or 276-634-4715) to complete change forms during the open enrollment period which ends May 11, 2018. Changes made during the open enrollment period will become effective July 1, 2018. New employees hired after July July 1, 2018, must enroll in benefts at the time of hire. Changes outside of the annual open enrollment period will be allowed only if you experience a qualifying event outlined by IRS regulations (for example, marriage, divorce, birth or adoption of a child, etc.). You have 31 days from the date of the event to make a change; otherwise, you will be required to wait until the next open enrollment period/next plan year to make changes.

Flexible Spending Accounts must be elected each year. If you participated in a Flexible Spending Account last year, it will not automatically carry over this year. You must meet with a Mark III Representative to elect your fexible medical and/or dependent care account for the 2018-2019 plan year.

All benefts effective July 1, 2018 Table of Contents

Pre-Tax Benefts

Blue Cross Blue Shield of VA Summary of Benefts and Coverage � � � � � � � � � � � � � � � � � � � 3 HIPAA Privacy Notice � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 13 Annual Notices including Medicare Part D Creditable Coverage & Marketplace Exchange Notices � � 19 FBA Flexible Spending Account � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 28 Delta Dental � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 33 Humana Cancer � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 35 Afac Group Accident Plan � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 40 Afac Group Critical Illness Plan � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 49 Afac Hospital Indemnity Plan � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 54

After-Tax Benefts AUL Short Term Disability Plans � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 58 Texas Life Whole Life � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 61

For Your Reference Continuation of Benefts� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 66 Company Contact Information� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 67

All full-time employees working a minimum of 30 hours per week are eligible to participate in the plan, as well as some transportation workers grandfathered in the health plan and school nutrition employees regularly scheduled to work 5.5 hours or more per day.

All information in this booklet is a brief description of your coverage and is not a contract. Refer to your policy or certifcate for each product for the exact terms and conditions.

Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 07/01/2018– 06/30/2019 Henry County and Schools: KeyCare 20 Coverage for: Individual + Family | Plan Type: PPO

The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care se rvices. NOTE: Information about the cost of this plan (called the premium ) will be provided separately. Th is is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, https://eoc.anthem.com/eocdps/aso . For general definitions of common terms, such as allowed amount , balance billing , coinsurance , copayment , deductible , provider , or other underlined terms see the Glossary. You can view the Glossary at www.healthcare.gov/sbc-glossary/ or call (833) 592-9956 to request a copy.

Important Questions Answers Why This Matters: What is the overall $0/individual or $0/family for Generally, you must pay all of the costs from providers up to the deductible amount before deductible ? Participating Providers . this plan begins to pay. If you have other family members on the plan, each family member $500/individual or must meet their own individual deductible until the total amount of deductible expenses paid $1,000 /family for Non- by all family members meets the overall family deductible . Participating Providers . Are there services No. You will have to meet the deductible before the plan pays for any services. covered before you meet your deductible ? Are there other No. You don't have to meet deductibles for specific services. deductibles for specific services? What is the out-of - $3,000 /individual or The out-of-pocket limi t is the most you could pay in a year for covered services. If you have pocket limit for this $6,000 /family for Participating other family members in this plan, they have to meet their own out-of-pocket limits until the plan? Providers . $4,500 /individual or overall family out-of-pocket limit has been met. $9,000 /family for Non- Participating Providers . This plan has a separate Out of Pocket Maximum of $3,500 /individual or $7,200 /family for Prescription Drugs . What is not included Prescription Drugs , Premiums , Even though you pay these expenses, they don’t count toward the out-of-pocket limi t. in the out-of-pocket balance-billing charges, and limit? health care this plan doesn't cover. Will you pay less if Yes, KeyCare PPO. See This plan uses a provider network . You will pay less if you use a provider in the plan’s you use a network www.anthem.com or call (833) network . You will pay the most if you use an out-of- network provider , and you might receive provider ? 592-9956 for a list of network a bill from a provider for the difference between the provider’s charge and what your plan

VA/L/A/HenryCountySchoolKC20-PPO/NA/SMOWF/NA/07-18 1 of 10 Page 3

providers . pays (balance billin g). Be aware your network provider might use an ou t-of-network provider for some services (such as lab work). Check with your provider before you get services.

Do you need a referral No. You can see the specialis t you choose without a referral. to see a specialist ?

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

What You Will Pay Common Non-Participating Limitations, Exceptions, & Other Services You May Need Participating Provider Medical Event Provider Important Information (You will pay the least) (You will pay the most) Primary care visit to treat an $20/visit 30% coinsurance ------none------injury or illness If you visit a Specialist visit $40/visit 30% coinsurance ------none------health care You may have to pay for services that provider’s office aren't preventive. Ask your provider if Preventive care /screening / or clinic No charge 30% coinsurance the services needed are preventive. immunization Then check what your plan will pay for. Diagnostic test (x-ray, blood 20% coinsurance 30% coinsurance ------none------If you have a test work) Imaging (CT/PET scans, MRIs) 20% coinsurance 30% coinsurance ------none------$10/prescription (retail) $10/prescription (retail) Tier 1 - Typically Generic and $10/prescription and $10/prescription If you need drugs (home delivery) (home delivery) to treat your $30/prescription (retail) $30/prescription (retail) Tier 2 - Typically Preferred / illness or and $60/prescription and $60/prescription Brand condition (home delivery) (home delivery) More information $50/prescription (retail) $50/prescription (retail) about prescription Tier 3 - Typically Non- Preferred and $150/prescription and $150/prescription drug coverage is / Specialty Drugs *See Prescription Drug section (home delivery) (home delivery) available at http://www.anthe 20% coinsurance up to m.com/pharmacyin $200 maximum /prescription (retail) and formation/ Tier 4 - Typically Specialty 20% coinsurance up to Not covered (brand and generic) National $400 maximum /prescription (home delivery)

* For more information about limitations and exceptions, see plan or policy document at https://eoc.anthem.com/eocdps/aso . 2 of 10 Page 4 What You Will Pay Common Non-Participating Limitations, Exceptions, & Other Services You May Need Participating Provider Medical Event Provider Important Information (You will pay the least) (You will pay the most) Facility fee (e.g., ambulatory $200/visit then 20% 30% coinsurance ------none------If you have surgery center) coinsurance outpatient surgery $20 PCP/ $40 specialist Physician/surgeon fees 30% coinsurance ------none------/visit $200/visit then 20% Emergency room care 30% coinsurance ------none------If you need coinsurance immediate Emergency medical $150/transport 30% coinsurance ------none------medical attention transportation Urgent care $40/visit 30% coinsurance ------none------$400/admission then 20% Facility fee (e.g., hospital room) 30% coinsurance ------none------If you have a coinsurance hospital stay Physician/surgeon fees 20% coinsurance 30% coinsurance ------none------Office Visit Office Visit Office Visit If you need $20/visit 30% coinsurance ------none------Outpatient services mental health, Other Outpatient Other Outpatient Other Outpatient behavioral health, 20% coinsurance 30% coinsurance ------none------or substance $400/admission then 20% abuse services Inpatient services 30% coinsurance ------none------coinsurance Office visits $200/visit 30% coinsurance Childbirth/delivery professional Maternity care may include tests and If you are 20% coinsurance 30% coinsurance services services described elsewhere in the pregnant Childbirth/delivery facility $400/admission then 20% SBC (i.e. ultrasound). 30% coinsurance services coinsurance Home health care 20% coinsurance 30% coinsurance 100 visits/benefit period. $20 PCP/$40 specialist or Rehabilitation services 30% coinsurance facility copay/visit If you need help *See Therapy Services section $20 PCP/ $40 specialist or recovering or have Habilitation services 30% coinsurance other special facility copay/visit health needs Skilled nursing care 20% coinsurance 30% coinsurance 100 days limit/stay. Durable medical equipment 20% coinsurance 30% coinsurance ------none------Hospice services No charge 30% coinsurance ------none------Children’s eye exam Not covered Not covered If your child *See Vision Services section needs dental or Children’s glasses Not covered Not covered eye care Children’s dental check-up Not covered Not covered *See Dental Services section * For more information about limitations and exceptions, see plan or policy document at https://eoc. anthem.com/eocdps/aso . 3 of 10 Page 5

Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services .) • Acupuncture • Bariatric surgery • Cosmetic surgery • Dental care (adult) • Dental Check-up • Eye exams for a child • Hearing aids • Infertility treatment • Long- term care • Routine eye care • Routine foot care unless you have been diagnosed with diabetes. • Weight loss programs • Private-duty nursing

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.) • Chiropractic care 30 visits/benefit period. • Most coverage provided outside the United States. See www.bcbsglobalcore.com

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Health and Hu man Services, Center for Consumer Informati on and Insurance Oversight, 1-877-267-2323 x 61565, www.cciio.cms.gov . Other coverage options may be available to you too, includin g buying individual insurance coverage through the Health Insuran ce Marketplace . For more information about the Marketplace , visit www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal . For more information about your rights, look at the ex planation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal , or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact:

ATTN: Grievances and Appeals , P.O. Box 27401, Richmond, VA 23279 Department of Health and Human Services , Center for Consumer Information and In surance Oversight, 1-877-267-2323 x61565, www.cciio.cms.gov

Does this plan provide Mi nimum Essential Coverage? Yes If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month.

Does this plan meet the Minimum Value Standards? Yes If your plan doesn’t meet the Minimum Value Standards , you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace .

–––––––––––––––––––––– To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––– –––––––––––

* For more information about limitations and exceptions, see plan or policy document at https://eoc.anthem.com/eocdps/aso . 4 of 10 Page 6 About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this pl an might cover medical care. Your actual costs will be different depending on the actual ca re you receive, the prices your providers charge, and many other factors. Focus on the cost sharin g amounts ( deductibles , copayments and coinsurance ) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby Managing Joe’s type 2 Diabetes Mia’s Simple Fracture (9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow hospital delivery) controlled condition) up care)

The plan’s overall deductible $0 The plan’s overall deductible $0 The plan’s overall deductible $0 Specialist copayment $40 Specialist copayment $40 Specialist copayment $40 Hospital (facility) copayment $400 Hospital (facility) copayment $400 Hospital (facility) copayment $400 Other coinsurance 20% Other coinsurance 20% Other coinsurance 20%

This EXAMPLE event includes services This EXAMPLE event includes services This EXAMPLE event includes services like: like: like: Specialist office visits ( prenatal care Primary care physician office visits ( including Emergency room care including medic al supplies Childbirth/Delivery Professional Services disease education Diagnostic test xra Childbirth/Delivery Facility Services Diagnostic tests lood wor Durable medical equipment crutches Diagnostic tests (ultrasounds and lood wor Prescription drugs Rehabilitation services phsical therap Specialist visit anesthesia Durable medical equipment glucose meter Total Example Cost $12,800 Total Example Cost $7,400 Total Example Cost $1,900 In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay: Cost Sharing Cost Sharing Cost Sharing Deductibles $0 Deductibles $0 Deductibles $0 Copayments $80 Copayments $2,000 Copayments $700 Coinsurance $2,500 Coinsurance $30 Coinsurance $100 hat isnt covere d hat isnt covere d hat isnt covere d Limits or exclusions $60 Limits or exclusions $60 Limits or exclusions $0 The total Peg would pay is $2,640 The total Joe would pay is $2,090 The total Mia would pay is $800

The plan would be responsible for the other costs of these EXAMPLE covered services. 5 of 10 Page 7

Language Access Services:

(TTY/TDD: 711) Albanian (Shqip): Nëse keni pyetje në lidhje me këtë dokument, keni të drejtë të merrni falas ndihmë dhe informacion në gjuhën tuaj. Për të kont aktuar me një përkthyes, telefononi (833)592-9956

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. (833)592-9956

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(833)592-9956.

(833)592-9956

(833)592-9956

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(833)592-9956.

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(833)592-9956

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(833)592-9956.

(833)592-9956.

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(833)592-9956.-

(833)592-9956.

9 of 10 Page 11 Language Access Services: It’s important we treat you fairly That’s why we follow federal civil rights laws in our health pr ograms and activities. We don’t discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disa bility. For people with disabilities, we offer free aids and services. F or people whose primary language isn’t English, we offer free language assistance services through inter preters and other written languages. Interested in these servi ces? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinat or in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 2327 9. Or you can file a complaint with the U.S. Department o f Health and Human Services, Office for Civil Rights at 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C. 20201 or by c alling 1-800-368- 1019 (TDD: 1- 800-537-7697) or online at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf . Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Anthem BCBS Virginia Henry County Schools 2018/2019 Employee Monthly Rates

Employee Only = $ 0.00 Employee & 1 Child = $ 543.33 Employee & Children = $ 715.64 Employee & Spouse = $ 736.88 Employee & Family = $1248.95

10 of 10 Page 12 HIPAA PRIVACY NOTICE

HIPAA Privacy Notice

County of Henry and Henry County Public Schools Health Insurance Portability and Accountability Act (HIPAA)

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) imposes numerous requirements on employer health plans concerning the use and disclosure of individual health information. This information, known as protected health information, includes virtually all individually identifiable health information held by a plan – whether received in writing, in an electronic medium, or as an oral communication. This notice describes the privacy practices of the following plans: EAP (Employee Assistance Program), Healthcare FSA (Flexible Spending Account) and the County of Henry and Henry County Public Schools Health Plan. The plans covered by this notice may share health information with each other to carry out Treatment, Payment, or Health Care Operations. These Plans are collectively referred to as the Plan in this notice, unless specified otherwise.

The Plan’s duties with respect to health information about you

The Plan is required by law to maintain the privacy of your health information and to provide you with this notice of the Plan’s legal duties and privacy practices with respect to your health information. If you participate in an insured plan option, you will receive a notice directly from the Insurer. It’s important to note that these rules apply to the Plan, not the County of Henry and Henry County Public Schools as an employer.

How the Plan may use or disclose your health information

The privacy rules generally allow the use and disclosure of your health information without your permission (known as an authorization) for purposes of health care Treatment, Payment activities, and Health Care Operations. Here are some examples of what that might entail:

• Treatment includes providing, coordinating, or managing health care by one (1) or more health care providers or doctors. Treatment can also include coordination or management of care between a provider and a third party, and consultation and referrals between providers. For example, the Plan may share health information about you with physicians who are treating you. • Payment includes activities by this Plan, other plans, or providers to obtain premiums, make coverage determinations and provide reimbursement for health care. This can include eligibility determinations, reviewing services for medical necessity or appropriateness, utilization management activities, claims management, and billing; as well as “behind the scenes” plan functions such as risk adjustment, collection, or reinsurance. For example, the Plan may share information about your coverage or the expenses you have incurred with another health plan in order to coordinate payment of benefits. • Health care operations include activities by this Plan (and in limited circumstances other plans or providers, such as wellness and risk assessment programs, quality assessment and improvement activities, customer service, and internal grievance resolution). Health care operations also include vendor evaluations, credentialing, training, accreditation

Page 13 activities, underwriting, premium rating, arranging for medical review and audit activities, and business planning and development. For example, the Plan may use information about your claims to review the effectiveness of wellness programs.

The amount of health information used or disclosed will be limited to the “Minimum Necessary” for these purposes, as defined under the HIPAA rules. The Plan may also contact you to provide appointment reminders or information about treatment alternatives or other health- related benefits and services that may be of interest to you.

How the Plan may share your health information with the County of Henry and Henry County Public Schools

The plan, or its health insurer, may disclose “summary health information” to the County of Henry and Henry County Public Schools if requested, for purposes of obtaining premium bids to provide coverage under the Plan, or for modifying, amending, or terminating the Plan. Summary health information is information that summarizes participants’ claims information, but from which names and other identifying information has been removed.

The Plan, or its Insurer, may disclose to the County of Henry and Henry County Public Schools information on whether an individual is participating in the Plan, or has enrolled or de-enrolled in an insurance option offered by the Plan.

In addition, the Plan, or its Insurer, may disclose your health information without your written authorization to the County of Henry and Henry County Public Schools for plan administration purposes, if the County of Henry and Henry County Public Schools adopt Plan amendments describing its administration activities.

The County of Henry and Henry County Public Schools cannot and will not use health information obtained from the Plan for any employment-related actions. However, health information collected by the County of Henry and Henry County Public Schools from other sources, for example under the Family and Medical Leave Act, Americans with Disabilities Act, or workers’ compensation is not protected under HIPAA (although this type of information may be protected under other federal or state laws).

Other allowable uses or disclosures of your health information

In certain cases, your health information can be disclosed without authorization to a family member, close friend, or other person you identify who is involved in your care or payment for your care. Information describing your location, general condition, or death may be provided to a similar person (or to a public or private entity authorized to assist in disaster relief efforts). You’ll generally be given the chance to agree or object to these disclosures (although exceptions may be made, for example, if you’re not present or if you’re incapacitated). In addition, your health information may be disclosed without authorization to your legal representative. If you die, the Plan may disclose to a family member, close personal friend or someone else that you have identified who was involved with your care or payment for your care prior to your death, protected health information that is relevant to such person’s involvement, unless doing so is inconsistent with your prior expressed preference, which is known to the Plan.

The Plan is also allowed to use or disclose your health information without your written authorization for uses and disclosures required by law, for public health activities, and other specific situations, including:

2

Page 14 • Disclosures to Workers’ Compensation or similar legal programs, as authorized by and necessary to comply with such laws • Disclosures related to situations involving threats to personal or public health or safety • Disclosures related to situations involving judicial proceedings or law enforcement activity • Disclosures to a coroner or medical examiner to identify the deceased or determine cause of death; and to funeral directors to carry out their duties • Disclosures related to organ, eye or tissue donation, and transplantation after death • Disclosures subject to approval by institutional or private privacy review boards and subject to certain assurances by researchers regarding necessity of using your health information and treatment of information during research project, or when the individual identifiers have been removed • Certain disclosures related to health oversight activities, specialized government or military functions and Health and Human Services investigations

Except as described in this notice, other uses and disclosures will be made only with your written authorization. You may revoke your authorization as allowed under the HIPAA rules. However, you can’t revoke your authorization if the Plan has taken action relying on it. In other words, you can’t revoke your authorization with respect to disclosures the Plan has already made.

When a state law requires the Plan to impose stricter standards to protect your protected health information, the Plan will follow state law rather than HIPAA. For example, where such laws have been enacted, the Plan will follow more stringent state privacy laws that relate to uses and disclosures of protected health information concerning HIV or AIDS, mental health, substance abuse, chemical dependency, genetic testing or reproductive rights.

The Plan will not use or disclose protected health information that is genetic information for underwriting purposes. Genetic information is generally defined as information about your genetic tests and the genetic tests of your family members, the manifestation of a disease or disorder in your family members or any request for, or receipt of, genetic services, or participation in clinical research which includes genetic services, by you or any of your family members. Underwriting includes the determination of eligibility for, or determination of, benefits under the Plan, the computation of premiums or contribution amounts under the Plan and other activities related to the creation, renewal or replacement of a contract of health insurance or health benefits.

Your individual rights

You have the following rights with respect to your health information the Plan maintains. These rights are subject to certain limitations, as discussed below. This section of the notice describes how you may exercise each individual right. See the information at the end of this notice for instructions on how to submit requests.

Right to request restrictions on certain uses and disclosures of your health information and the Plan’s riht to refuse

You have the right to ask the Plan to restrict the use and disclosure of your health information for Treatment, Payment, or Health Care Operations, except for uses or disclosures required by law. You have the right to ask the Plan to restrict the use and disclosure of your health information to family members, close friends, or other persons you identify as being involved in

Page 15 your care or payment for your care. You also have the right to ask the Plan to restrict use and disclosure of health information to notify those persons of your location, general condition, or death – or to coordinate those efforts with entities assisting in disaster relief efforts. If you want to exercise this right, your request to the Plan must be in writing.

The Plan generally is not required to agree to a requested restriction. However, the Plan must agree to your request to restrict a disclosure of protected health information to a health plan if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law and the protected health information pertains solely to a health care item or service for which you, or a person other than the health plan on your behalf, has paid the covered entity in full. If the Plan does agree, a restriction may later be terminated by your written request, by agreement between you and the Plan (including an oral agreement), or unilaterally by the Plan for health information created or received after you’re notified that the Plan has removed the restrictions. The Plan may also disclose health information about you if you need emergency treatment, even if the Plan has agreed to a restriction.

Right to receive confidential communications of your health information

If you think that disclosure of your health information by the usual means could endanger you in some way, the Plan will accommodate reasonable requests to receive communications of health information from the Plan by alternative means or at alternative locations.

If you want to exercise this right, your request to the Plan must be in writing and you must include a statement that disclosure of all or part of the information could endanger you. This right may be conditioned on you providing an alternative address or other method of contact and, when appropriate, on you providing information on how payment, if any, will be handled.

Right to inspect and copy your health information

With certain exceptions, you have the right to inspect or copy your health information in a “Designated Record Set.” This may include medical and billing records maintained for a health care provider; enrollment, payment, claims, adjudication, and case or medical management record systems maintained by a plan; or a group of records the Plan uses to make decisions about individuals. However, you do not have a right to inspect or obtain copies of psychotherapy notes or information compiled for civil, criminal, or administrative proceedings. In addition, the Plan may deny your right to access, although in certain circumstances you may request a review of the denial. If you want to exercise this right, your request to the Plan must be in writing.

If the information you request is maintained electronically, and you request an electronic copy, the Plan will provide a copy in the electronic form and format you request, if the information can be readily produced in that form and format. If the information cannot be readily produced in that form and format, the Plan will work with you to come to an agreement on form and format. If agreement cannot be reached on an electronic form and format, the Plan will provide you with a paper copy.

If you request a copy of your protected health information, the Plan may charge a reasonable fee for the costs of copying, mailing or other supplies associated with the request.

If the Plan doesn’t maintain the health information but knows where it is maintained, you will be informed of where to direct your request.

Page 16 Right to amend your health information that is inaccurate or incomplete

With certain exceptions, you have a right to request that the Plan amend your health information in a Designated Record Set. The Plan may deny your request for a number of reasons. For example, your request may be denied if the health information is accurate and complete, was not created by the Plan (unless the person or entity that created the information is no longer available), is not part of the Designated Record Set, or is not available for inspections (e.g., psychotherapy notes or information compiled for civil, criminal, or administrative proceedings). If your request is denied, you have the right to file a statement of disagreement with the Plan and any future disclosures of the disputed information will include your statement. If you want to exercise this right, your request to the Plan must be in writing, and you must include a statement to support the requested amendment.

Right to receive an accounting of disclosures of your health information

You have the right to a list of certain disclosures the Plan has made of your health information. This is often referred to as an “accounting of disclosures.” You generally may receive an accounting of disclosures if the disclosure is required by law, in connection with public health activities, or in similar situations listed in this notice, unless otherwise indicated below. You may also be entitled to an accounting of disclosures that the Plan should not have made without authorization.

You may receive information on disclosures of your health information going back for six (6) years from the date of your request, but not earlier than April 14, 2003 (the general date that the HIPAA privacy rules are effective). You do not have a right to receive an accounting of any disclosures made:

• For Treatment, Payment, Or Health Care Operations; • To you about your own health information; • Incidental to other permitted or required disclosures; • Where authorization was provided; • To family members or friends involved in your care (where disclosure is permitted without authorization); • For national security or intelligence purposes or to correctional institutions or law enforcement officials in certain circumstances; or • As part of a “limited data set” (health information that excludes certain identifying information).

In addition, your right to an accounting of disclosures to a health oversight agency or law enforcement official may be suspended at the request of the agency or official.

If you want to exercise this right, your request to the Plan must be in writing. You may make one (1) request in any 12-month period at no cost to you, but the Plan may charge a fee for subsequent requests. You’ll be notified of the fee in advance and have the opportunity to change or revoke your request.

Right to obtain a paper copy of this notice from the Plan upon request

You have the right to obtain a paper copy of this Privacy Notice upon request. Even individuals who agreed to receive this notice electronically may request a paper copy at any time by contacting Human Resources.

Page 17 Right to be notified of a breach

You have the right to be notified in the event that the Town of Smithfield, the Plan or a Business Associate discovers a breach of unsecured protected health information.

Complaints

If you believe your privacy rights have been violated, you may complain to the Plan and to the Secretary of Health and Human Services. To file a complaint with the Plan, please contact:

Director of Human Resources Henry County Public Schools 276-634-4700 [email protected] 3300 Kings Mountain Rd. Martinsville, VA 24112

You may also file a complaint with the Office of Civil Rights, U.S. Department of Health and Human Services, by emailing your complaint to [email protected] or by mailing or faxing your complaint to the appropriate Office of Civil Rights regional office, based on where the alleged violation took place. A list of regional offices can be obtained by visiting http://www.hhs.gov/ocr/office/about/rgn-hqaddresses.html.

You won’t be retaliated against for filing a complaint.

Changes to the information in this notice

The Plan must abide by the terms of the Privacy Notice currently in effect. This notice takes effect July 1, 2017. However, the Plan reserves the right to change the terms of its privacy policies as described in this notice at any time, and to make new provisions effective for all health information that the Plan maintains. This includes health information that was previously created or received, not just health information created or received after the policy is changed. If changes are made to the Plan’s privacy policies described in this notice, any revised notice will be posted on the Plan’s website at [insert web address] by the effective date of the material change, and Town of Smithfield will provide the revised notice, or information about the material change and how to obtain the revised notice, in the next annual mailing to individuals then covered by the Plan.

Whom to Contact for More Information

If you have any questions regarding this notice or the policies and practices it describes, you may contact the following person: Privacy Officer, 276-634-4700 or 3300 Kings Mountain Road, Martinsville, Virginia 24112.

Conclusion

The Plan’s use and disclosure of protected health information is regulated by HIPAA, as amended. This notice attempts to summarize the regulations. The regulations will supersede any discrepancy between the information in this notice and the regulations.

Policy effective: July 1, 2017

Page 18 HENRY COUNTY PUBLIC SCHOOLS ANNUAL NOTICES INCLUDING MEDICARE PART D CREDITABLE COVERAGE AND MARKETPLACE EXCHANGE NOTICES

Notice to Employees

Opportunity to Make Elective Deferrals to the Henry County Schools 403(b) Plan

This is to notify you that if you are a Henry County Schools employee, you are eligible to make a pre-tax elective deferral from your salary to the Henry County Schools 403(b) Plan (the "Plan"). If the Plan permits after-tax Roth contributions, such elective deferrals may be designated as Roth contributions.

To make an elective contribution to the Plan, you must submit a Salary Reduction Agreement to the Plan’s Third Party Administrator, MidAmerica Administrative & Retirement Solutions. You may make, change, or stop such an election to contribute as often as you wish, and it will be effective on the date indicated on the Salary Reduction Agreement or the next payroll date after it is approved by MidAmerica.

Such elective contributions are subject to applicable Internal Revenue Code limits and the terms of the Plan. The contributions may be suspended for six months following a distribution to you from the Plan if you take a financial hardship withdrawal.

You can submit a Salary Reduction Agreement by logging in to the 403(b)/457 Participant Website at https://fe2.midamerica.biz/login.aspx.

If you are logging in for the first time, your username will be your Social Security number; your default password will be the last four digits of your Social Security number.

Once logged in, select the “Tutorials” icon located under the Popular Tools menu on the left- hand side of the webpage. From here, you have access to a library of educational videos and downloadable guides. Additional details on how to submit your Salary Reduction Agreement online are available through this library.

If you are a new participant, you may need to submit a Salary Reduction Agreement via hardcopy for your initial election. For a copy of the Salary Reduction Agreement or a summary of the Plan—or if you have any other questions—please contact MidAmerica Administrative & Retirement Solutions at (866) 873-4240 or visit their website at https://www.midamerica.biz/forms/participants/.

This Notice is to provide general information regarding availability of the Plan. You should consult with your own financial, tax, or legal advisor as to whether you should contribute to the Plan. Should there be any difference between the information in this Notice and the Plan, the terms of the Plan will control. The information in this Notice is not intended or written to be used, and cannot be used, for the purpose of avoiding penalties under the Internal Revenue Code or promoting, marketing, or recommending to any transaction or matter addressed herein.

Page 19

Form Approved New Health Insurance Marketplace Coverage OMB No. 1210-0149 Options and Your Health Coverage (expires 5-31-2020)

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 Mrs. Marie Waldron, Human Resources, at [email protected] or (276) 634-4715. 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.

Page 20

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)

Henry County Public Schools 54-6001348 5. Employer address 6. Employer phone number P. O. Box 8958 (276) 634-4700 7. City 8. State 9. ZIP code

Collinsville Virginia 24078-8958 10. Who can we contact about employee health coverage at this job?

Marie Waldron, Benefits Specialist

11. Phone number (if different from above) 12. Email address (276) 634-4715 [email protected]

Here is some basic information about health coverage offered by this employer: • As your employer, we offer a health plan to: All employees.

X Some employees. Eligible employees are: All full-time employees School nutrition employees regularly scheduled to work 5.5 hours or more per day Transportation employees hired prior to 7/1/1990 who have been grandfathered in benefits program

• With respect to dependents: X We do offer coverage. Eligible dependents are: Children and/or spouse

We do not offer coverage.

X 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.

Page 21 Important Notice from County of Henry and Henry County Schools 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 County of Henry and Henry County Schools and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. 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. 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. County of Henry and Henry County Schools has determined that the prescription drug coverage offered by Anthem is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable 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 15th to December 7th.

However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also 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 Anthem coverage may not be affected. County of Henry and Henry County Schools employees eligible for Medicare Part D can keep prescription drug coverage under Anthem. If you elect Part D, then the health plan will coordinate with Medicare Part D coverage.

Page 22 Once you are age 65 and a retiree, you will not be covered under the Anthem plan.

If you do decide to join a Medicare drug plan and drop your current Anthem coverage, be aware that you and your dependents may not be able to get this coverage back.

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 Anthem 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 creditable 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… Contact the following person:

Director of Human Resources Henry County Schools Plan Administrator 276-634-4708 [email protected] 3300 Kings Mountain Rd. Martinsville, VA 24112

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 Anthem 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. Page 23 or ore nforaton aout edcare rescrton dru coerae • 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, therefore, whether or not you are required to pay a higher premium (a penalty).

Date: 04/10/18

Newborns’ and Mothers’ Health Protection Act Under federal law, group health plans and health insurance issuers offering group health insurance coverage generally may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a delivery by cesarean section. However, the plan or issuer may pay for a shorter stay if the attending provider (e.g., your doctor, nurse midwife or physician assistant), after consultation with the mother, discharges the mother or newborn earlier.

Also, under federal law, group health plans and health insurance issuers may not set the level of benefits or out-of-pocket costs so that any later portion of the 48 hour (or 96 hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay.

In addition, a plan or issuer may not, under federal law, require that a doctor or other health care provider obtain certification for prescribing a length of stay of up to 48 hours (or 96 hours). However, to use certain providers or facilities, or to reduce your out-of-pocket costs, you may be required to obtain certification.

Mastectomy Benefits In accordance with the Women’s Health and Cancer Rights Act of 1998, our Health Plan provides for the following services related to mastectomy surgery: • Reconstruction of the breast on which the mastectomy has been performed • Surgery and reconstruction of the non-diseased breast to produce a symmetrical appearance without regard to the lapse of time between the mastectomy and the reconstructive surgery • Prostheses and physical complications of all stages of the mastectomy, including lymphedemas. The benefits described above are subject to the same co-payment or coinsurance and limitations as applied to other medical and surgical benefits provided by our Health Plan. Page 24 Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)

If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available.

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1- 877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan.

If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).

If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of January 31, 2017. Contact your State for more information on eligibility –

ALABAMA – Medicaid FLORIDA – Medicaid Website: http://myalhipp.com/ Website: http://flmedicaidtplrecovery.com/hipp/ Phone: 1-855-692-5447 Phone: 1-877-357-3268 ALASKA – Medicaid GEORGIA – Medicaid The AK Health Insurance Premium Payment Program Website: http://dch.georgia.gov/medicaid Website: http://myakhipp.com/ - Click on Health Insurance Premium Payment (HIPP) Phone: 1-866-251-4861 Phone: 404-656-4507 Email: [email protected] Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.asp x ARKANSAS – Medicaid INDIANA – Medicaid Website: http://myarhipp.com/ Healthy Indiana Plan for low-income adults 19-64 Phone: 1-855-MyARHIPP (855-692-7447) Website: http://www.in.gov/fssa/hip/ Phone: 1-877-438-4479 All other Medicaid Website: http://www.indianamedicaid.com Phone 1-800-403-0864 COLORADO – Health First Colorado (Colorado’s Medicaid Program) & IOWA – Medicaid Child Health Plan Plus (CHP+) Health First Colorado Website: Website: https://www.healthfirstcolorado.com/ http://dhs.iowa.gov/ime/members/medicaid-a-to- Health First Colorado Member Contact Center: z/hipp 1-800-221-3943/ State Relay 711 Phone: 1-888-346-9562 CHP+: Colorado.gov/HCPF/Child-Health-Plan-Plus CHP+ Customer Service: 1-800-359-1991/ State Relay 711 Page 25 KANSAS – Medicaid NEW HAMPSHIRE – Medicaid Website: http://www.kdheks.gov/hcf/ Website: Phone: 1-785-296-3512 http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603-271-5218 KENTUCKY – Medicaid NEW JERSEY – Medicaid and CHIP Website: http://chfs.ky.gov/dms/default.htm Medicaid Website: Phone: 1-800-635-2570 http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710 LOUISIANA – Medicaid NEW YORK – Medicaid Website: Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 https://www.health.ny.gov/health_care/medicaid/ Phone: 1-888-695-2447 Phone: 1-800-541-2831

MAINE – Medicaid NORTH CAROLINA – Medicaid Website: http://www.maine.gov/dhhs/ofi/public- Website: https://dma.ncdhhs.gov/ assistance/index.html Phone: 919-855-4100 Phone: 1-800-442-6003 TTY: Maine relay 711 MASSACHUSETTS – Medicaid and CHIP NORTH DAKOTA – Medicaid Website: Website: http://www.mass.gov/eohhs/gov/departments/masshe http://www.nd.gov/dhs/services/medicalserv/medicaid alth/ / Phone: 1-800-462-1120 Phone: 1-844-854-4825 MINNESOTA – Medicaid OKLAHOMA – Medicaid and CHIP Website: http://mn.gov/dhs/people-we- Website: http://www.insureoklahoma.org serve/seniors/health-care/health-care- Phone: 1-888-365-3742 programs/programs-and-services/medical- assistance.jsp Phone: 1-800-657-3739 MISSOURI – Medicaid OREGON – Medicaid Website: Website: http://www.dss.mo.gov/mhd/participants/pages/hipp. http://healthcare.oregon.gov/Pages/index.aspx htm http://www.oregonhealthcare.gov/index-es.html Phone: 573-751-2005 Phone: 1-800-699-9075 MONTANA – Medicaid PENNSYLVANIA – Medicaid Website: Website:http://www.dhs.pa.gov/provider/medicalassist http://dphhs.mt.gov/MontanaHealthcarePrograms/HI ance/healthinsurancepremiumpaymenthippprogram/i PP ndex.htm Phone: 1-800-694-3084 Phone: 1-800-692-7462 NEBRASKA – Medicaid RHODE ISLAND – Medicaid Website: Website: http://www.eohhs.ri.gov/ http://dhhs.ne.gov/Children_Family_Services/AccessN Phone: 401-462-5300 ebraska/Pages/accessnebraska_index.aspx Phone: 1-855-632-7633 NEVADA – Medicaid SOUTH CAROLINA – Medicaid Medicaid Website: https://dwss.nv.gov/ Website: https://www.scdhhs.gov Medicaid Phone: 1-800-992-0900 Phone: 1-888-549-0820

Page 26 SOUTH DAKOTA - Medicaid WASHINGTON – Medicaid Website: http://dss.sd.gov Website: http://www.hca.wa.gov/free-or-low-cost- Phone: 1-888-828-0059 health-care/program-administration/premium-payment- program Phone: 1-800-562-3022 ext. 15473 TEXAS – Medicaid WEST VIRGINIA – Medicaid Website: http://gethipptexas.com/ Website: Phone: 1-800-440-0493 http://www.dhhr.wv.gov/bms/Medicaid%20Expansion/P ages/default.aspx Phone: 1-877-598-5820, HMS Third Party Liability UTAH – Medicaid and CHIP WISCONSIN – Medicaid and CHIP Medicaid Website: https://medicaid.utah.gov/ Website: CHIP Website: http://health.utah.gov/chip https://www.dhs.wisconsin.gov/publications/p1/p10095.p Phone: 1-877-543-7669 df Phone: 1-800-362-3002 VERMONT– Medicaid WYOMING – Medicaid Website: http://www.greenmountaincare.org/ Website: https://wyequalitycare.acs-inc.com/ Phone: 1-800-250-8427 Phone: 307-777-7531 VIRGINIA – Medicaid and CHIP Medicaid Website: http://www.coverva.org/programs_premium_assistance. cfm Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.coverva.org/programs_premium_assistance. cfm CHIP Phone: 1-855-242-8282

To see if any other states have added a premium assistance program since January 31, 2017, or for more information on special enrollment rights, contact either:

U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/agencies/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565

Paperwork Reduction Act Statement

According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512.

The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email [email protected] and reference the OMB Control Number 1210-0137.

OMB Control Number 1210-0137 (expires 12/31/2019) Page 27 Flexible Beneft Administrators Spending Accounts

Henry County Public Schools

Get reimbursed for out-of-pocket healthcare and expenses with tax free dollars!

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Page 22 Page 29 IMPORTANT INFORMATION

PLAN YEAR: July 1, 2018 – June 30, 2019

Healthcare Flexible Spending Account Maximum: $2,650.00 Dependent Care Flexible Spending Account Maximum: $5,000.00

ENROLLMENT PROCESS To participate in a Flexible Spending Account, you must complete an enrollment form each year during the enrollment period. If an enrollment form is not completed during open enrollment, your enrollment will be cancelled and you will not be able to join until the next anniversary date of the plan.

ELIGIBILITY REQUIREMENTS If you are a full-time employee who works at least 30 hours or more per week, you are eligible to participate in the Plan upon your date of hire or, if you are hired after the 15th you will be eligible to join the plan the first day of the next month.

4

Page 23 Page 30 Your FBA Benefits Card

With your FBA Benefits Card you have immediate access to pay for your eligible medical expenses. This allows you to avoid the hassle of paying out of pocket for services and then filing a claim for and waiting for a reimbursement check.

Where can I use my card? Do I need to submit the same Your card can be used at any authorized medical documentation for repeat transactions? provider who accepts MasterCard. A complete list If you have recurring expenses such as chiropractic of authorized providers and retailers is available at care or allergy shots, you are able to have these www.sig‐is.org. transactions coded as recurring in our system. This allows us to automatically substantiate your The debit card system is coded to only accept transaction based on the documentation you will charges from qualified merchants (i.e. doctor’s submit with the first charge. office, dentist’s office, pharmacy, online pharmacy, Remember that recurring expenses can only be etc.). coded in our system if those transactions match Debit card or Credit Card? the exact dollar amount at the same You have the option of choosing credit or debit merchant/provider as the previous charge. when using your FBA Benefits Card. We Recurring expense coding will renew automatically

recommend you utilize the card as a credit card. If from plan year to plan year. you chose to use the debit option, please visit the online portal and select My Cards then View PIN to How do I request an additional card for my obtain your PIN for debit transactions. dependents? Please contact our office to request an additional Do I need to submit documentation for my card for your eligible dependents. Requests can be card transactions? made by email, mail or by fax. Some transactions made when using the FBA Benefits Card do require you to submit documentation as per IRS Regulations. You only need to submit documentation to us if you receive a notice from our office requesting it. These notices will be sent to you by regular mail or email (if on file). To receive these notifications by email, please visit the online portal and update your communication preferences.

Contact Us! Ph: 1-800-437-3539 Email: [email protected] Online Chat: www.flex-admin.com Fax: 757-431-1155

PagePage 38 31

I receied a request for documentation id o now what do I need to send?

IRS regulations require substantiation for any card ow do activate m cad swipe that does not equal a ‘standard’ co‐payment Your new card will be activated upon amount (i.e. $10,$20,$35, etc.) or is not a recurring your first swipe. Your plan year expense that was previously reviewed. Co‐ insurance will generally not match “standard” co‐ election will automatically load on your card with your new annual payment amounts. When submitting your documentation, please election amount. ensure it includes the following: ‐ Date of Service hen does m cad exie ‐ Patient/Dependent’s Name Your card is valid for three years as ‐ Amount Charged long as you are enrolled in the plan. ‐ Provider/Merchant’s Name We will mail you a new card prior to ‐ Prescription Number/Name (if applicable) ‐ Nature of Expense the new plan year if your card Remember cash register receipts are only expires. acceptable for over‐the‐counter items and Prescription Expenses. ow do elace a lost o stolen cad

Can I use my card for my orthodontic You can report your card lost/stolen

payments? and order a replacement card Absolutely! Once you receive your ortho contract, through our online portal or by just send a copy to our office and we will update contacting our office at 800‐437‐ your account. Each month that you charge your 3539. orthodontic contract payment to your card it will be automatically approved. Remember that your ow do eview m cad card swipe must match the payment plan in your tansactions contract in order for it to be automatically approved. Our online portal and mobile app offer you real time access to your Why was my card declined? account transactions and balance.

There are several reasons your card may be Log‐in to declined. mywealthcareonline.com/fba or ‐ No available balance download the mobile app for your ‐ Ineligible Service Provider ‐ Expired Card smartphone or tablet from Google ‐ Card has been Deactivated Play or iTunes Store by searching for We encourage you to review your account activity FBA Mobile. through the online portal and mobile app to ensure you have an available balance. If you need assistance with a card being declined please contact our office.

Contact Us! Ph: 1-800-437-3539 Email: [email protected] Online Chat: www.flex-admin.com Fax: 757-431-1155

Page 39

Page 32 Delta Dental Premier

Benefits for Henry County & Henry County Public Schools Group Number: 6150 Effective Date: July 1, 2018

Annual Deductible (Applies to Basic Services) $25 per person; $75 per family, per contract year Annual Maximum $1,000 per enrollee, per contract year

Healthy Smile, Healthy You® Program Your plan provides additional cleanings and/or application of topical fluoride to enrollees with specific health conditions such as pregnancy, diabetes, high-risk cardiac conditions or who are undergoing cancer treatment via chemotherapy and/or radiation. Enrollment in the Healthy Smile, Healthy You Program is simple. Visit DeltaDentalVA.com to print an enrollment form.

Covered Benefits Delta Dental will pay the stated percentage of the plan allowance based on the dentist’s participation with Delta Dental.

Benefit Waiting Coverage Coinsurance Benefit Limitations Period

Diagnostic and Preventive Services 100% None Oral exams and cleanings Twice in a 12 consecutive month period. Periodontal cleaning is considered a regular cleaning and is subject to the benefit limits for regular cleanings. Fluoride applications Once in a 12 consecutive month periodfor enrollees under the age of 19. Bitewing X-rays One set in a 12 consecutive month period. Full mouth/panelipse X-rays Once in a 3-year period. Space maintainers Once per quadrant per arch for enrollees under the age of 14. Basic Services 80% None Amalgam (silver) and composite (white) Once per surface in a 24-month period; Composite (white) fillings fillings are limited to the upper and lower 6 front teeth. Stainless steel crowns Primary (baby) teeth for enrollees under the age of 14. Simple extractions Endodontic services/root canal therapy Retreatment only after 24 months from initial root canal therapy treatment. Periodontic services** Once per quadrant in a 24-36 month period based on services rendered. Complex oral surgery Surgical extractions and other surgical procedures. Denture repair and recementation of Once in a 12-month period. crowns, bridges and dentures

**You have an additional Benefit Maximum for Periodontic Services. This additional Benefit Maximum is $300 per Enrollee for each Contract Year. The amount credited toward your Benefit Maximum for Periodontic Services will also be credited toward your Benefit Maximum for Basic Dental Care.

Delta Dental of Virginia 4818 Starkey Road, Roanoke, VA 24018-8542 800-237-6060 DeltaDentalVA.com Rev 1.2017 Page 33 COVERAGE IS AVAILABLE FOR Enrollee, spouse Dependent children, only to the end of the month they reach age 19 (the “limiting age”). Full-time students, only to the end of the month they reach age 23 (the “limiting age”). (To qualify as a full-time student, the dependent must be attending a recognized secondary school, trade school, college or university on a full-time basis.)

CHOOSING A DENTIST You may select the dentist of your choice. However, to get the full advantage of your Delta Dental coverage, you should choose a dentist who participates in the Delta Dental network(s) covered by your plan.

Delta Dental Premier dentists have agreed to accept Delta Dental’s plan allowance, plus any required coinsurance and deductible (if applicable) as payment in full. In addition, Delta Dental Premier dentist will submit claims directly to Delta Dental and we will issue the payment to the dentist.

Non-Participating dentists have not agreed to accept Delta Dental’s plan allowance as full payment. After Delta Dental pays its portion of the bill, you are responsible for any required coinsurance and deductible (if applicable), as well as the difference between the non-participating dentist’s charge and Delta Dental’s payment. Payment will be made to you, unless Virginia law requires otherwise.

Please visit DeltaDentalVA.com to find a participating dentist in your area.

The following chart illustrates how choosing a network dentist helps you save on out-of-pocket costs.

Premier Network Dentist Non-Participating Dentist Dentist’s Charge for Covered Procedure $215.00 $215.00 Delta Dental’s Plan Allowance $169.00 $113.00 Coinsurance Percentage 80% 80% Delta Dental’s Payment $135.20 $90.40 Patient Payment* $33.80 $124.60 The example shown is for illustrative purposes only. Payment structures may vary between plans.

The preceding information is a brief description of the services covered under your plan. It is not intended for use as a summary plan description nor is it designed to serve as an Evidence of Coverage. If you have specific questions regarding benefit structure, limitations or exclusions, consult the plan document or call Delta Dental’s Benefit Services Department at 800-237-6060.

8 8

Delta Dental of Virginia 4818 Starkey Road, Roanoke, VA 24018-8542 800-237-6060 DeltaDentalVA.com Rev 1.2017 Page 34 Humana Group Cancer & Specifed Disease Plan Group Cancer and Specified Disease Insurance POLICY FORM HIC-GP-CAN-POL-VA 2/11 Underwritten by Humana Insurance Company

► Plan Features

• Donor Benefits • Wellness Benefits • Portable (take it with You) • Many Benefits have No Lifetime Maximum • In and Out of Hospital benefits • Covers Certain Lodging and Transportation • Pays regardless of other coverage

Benefit Benefit Options

Wellness Benefit. For Cancer screening tests such as mammogram, flexible sigmoidoscopy, pap smear, chest $100 per calendar year X-ray, hemocult stool specimen, or prostate screen. No Lifetime Maximum Payable for a test that leads to positive diagnosis of Cancer or Specified Disease Positive Diagnosis Test. Up to $300 per calendar year within 90 days. This benefit is not payable if the same Cancer or Specified Disease recurs. 1. $0 2. $2,500 One-time benefit payable when a Covered Person is first diagnosed with Cancer First Diagnosis Benefit. 3. $0 (other than Skin Cancer) or a Specified Disease. Must occur after the Certificate Effective Date. 4. $5,000

Covers written opinions received after a Positive Diagnosis and before Second and Third Surgical Opinions. Actual Charges surgery. No Lifetime Maximum Non-Local Transportation. Payable for transportation to a Hospital, clinic or treatment center which is more Actual charges by a common carrier or than 60 miles and less than 700 miles from a Covered Person’s home. No Lifetime Maximum 50 cents per mile if a personal vehicle is used. . For ambulance service if the Covered Person is taken to a Hospital and admitted as an inpatient. Ambulance Actual Charges No Lifetime Maximum . Covers actual surgeon’s fee for an operation up to the amount listed on the schedule. Benefits for Surgery Up to $3,000 surgery performed on an outpatient basis will be 150% of the schedule benefit amount, not to exceed the actual surgeon’s fees. No Lifetime Maximum

Donor Benefit Bone Marrow and Stem Cell Transplant. (a) $200 We will pay the following expenses incurred by the Covered Person and his or her live donor: (a) Medical expense allowance of two times the selected Hospital Confinement benefit. (b) Actual charges (b) Actual charges for round trip coach fare; or for round trip coach fare on a Common Carrier to the city where the transplant is performed; or personal personal automobile expense of 50 cents per automobile expense allowance of 50 cents per mile. Mileage is measured from the home of the Donor or mile. Covered Person to the Hospital in which the Covered Person is staying. We will pay for up to 700 miles per Hospital stay. (c) Actual Charges up to $50 per day for lodging and meals expense for donor to remain near (c) Actual charges up to $50 per day Hospital.

Bone Marrow and Stem Cell Transplant. We will pay Actual Charges per Covered Person for surgical and Actual charges to a combined lifetime anesthetic charges associated with bone marrow transplant and/or peripheral stem cell transplant maximum of $15,000

Anesthesia. Up to 25% of surgical benefit paid. For services of an anesthesiologist during a Covered Person’s surgery. No Lifetime Maximum $100 maximum per Covered Person For anesthesia in connection with the treatment of skin Cancer. No Lifetime Maximum

Form Number: HIC-GP-CAN-SB-VA Page 35 Benefit Benefit Options

Ambulatory Surgical Center. We will pay the expense incurred at an Ambulatory Surgical Center. $250 Per Day No Lifetime Maximum Payable for drugs and medicine received while the Covered Person is Hospital confined. Drugs and Medicines. Up to $25 per day, $600 per calendar year No Lifetime Maximum Payable for drugs prescribed by a Physician to suppress nausea due to Cancer Outpatient Anti-Nausea Drugs. Up to $250 per calendar year or Specified Disease. No Lifetime Maximum 1. Actual charges up to $2,500 per month Covers treatment administered Radiation, Radioactive Isotopes Therapy, Chemotherapy, or Immunotherapy. 2. Actual charges up to $2,500 per month by a Radiologist, Chemotherapist or Oncologist on an inpatient or outpatient basis. 3. Actual charges up to $5,000 per month No Lifetime Maximum 4. Actual charges up to $5,000 per month Covers charges for lab work or x-rays in connection with radiation and Miscellaneous Therapy Charges. Actual charges up to a lifetime maximum of chemotherapy treatment. Service must be performed while receiving treatment(s) in Item 15 or within 30 $10,000 days following a covered treatment. Self-Administered Drugs. We will pay the actual expenses incurred for self-administered chemotherapy, including hormone therapy, or immunotherapy agents. This benefit is not payable for planning, monitoring, Actual charges up to $4,000 per month or other agents used to treat or prevent side effects, or other procedures related to this therapy treatment. No Lifetime Maximum We will pay expenses incurred for: [a] cost of the chemical substances and [b] Colony Stimulating Factors. Actual charges up to $500 per month their administration to stimulate the production of blood cells. Treatment must be administered by an Oncologist or Chemotherapist. No Lifetime Maximum For blood, plasma and platelets, and transfusions: including administration. No Blood, Plasma and Platelets. Actual charges up to $200 per day Lifetime Maximum

Physician's Attendance. For one visit per day while Hospital confined. No Lifetime Maximum Up to $35 per day For private nursing services ordered by the Physician while Hospital confined. Private Duty Nursing Service. Up to $100 per day No Lifetime Maximum National Cancer Institute Designated Comprehensive Cancer Treatment Center Evaluation/Consultation Benefit. We will pay the expense incurred if an Covered Person is diagnosed with Internal Cancer and seeks Expenses incurred limited to a lifetime evaluation or consultation from a National Cancer Institute designated Comprehensive Cancer Treatment maximum up to $750 for evaluation. Center. If the Comprehensive Cancer Treatment Center is located more than 30 miles from the Covered Expenses incurred limited to a lifetime Person’s place of residence, We will also pay the transportation and lodging expenses incurred. This benefit maximum up to $350 for transportation and is not payable on the same day a Second or Third Surgical Opinion Benefit is payable and is in lieu of the Non- lodging. Local Transportation Benefits of the policy. Covers the prosthesis and its implantation if it is required due to breast cancer. Breast Prosthesis. Actual Charges No Lifetime Maximum Covers implantation of an artificial limb or prosthesis when an amputation is Artificial Limb or Prosthesis. $1,500 lifetime maximum per amputation. performed. Payable when therapy is needed to restore normal bodily function. No Lifetime Physical or Speech Therapy. Up to $35 per session Maximum If a Covered Person is confined in a Hospital for 60 continuous days We will pay three Extended Benefits. $300 per day times the selected Hospital Confinement Benefit beginning on the 61st day for Hospital Confinement. This benefit is payable in place of the Hospital Confinement Benefit. No Lifetime Maximum Extended Care Facility. Limited to number of days of prior Hospital confinement. Must begin within 14 days after Hospital confinement, and be at the direction of the attending Physician. Up to $50 per day No Lifetime Maximum At Home Nursing. Limited to number of days of prior Hospital confinement. Must begin immediately Up to $100 per day following a Hospital confinement, and be authorized by the attending Physician. No Lifetime Maximum New or Experimental Treatment. We will pay the expenses incurred by a Covered Person for New or Experimental Treatment judged necessary by the attending Physician and received in the United States or in Up to $7,500 per calendar year its territories. No Lifetime Maximum If a Covered Person elects to receive hospice care, We will pay the expenses incurred for care Hospice Care. Up to $50 per day received in a Free Standing Hospice Care Center. No Lifetime Maximum Government or Charity Hospital. Payable if the Covered Person is confined in a U. S. Government Hospital or a Hospital that does not charge for its services. Paid in place of all other benefits under the Policy. No Lifetime $200 per day Maximum Hairpiece. We will pay the actual expense incurred per Covered Person for a hairpiece when hair loss is a Actual charge up to a lifetime maximum of result of Cancer Treatment. $150 Rental or Purchase of Durable Goods. We will pay the actual expenses incurred for the rental or purchase of the following pieces of durable medical equipment: a respirator or similar mechanical device, brace, crutches, Actual charges up to $1,500 per calendar year Hospital bed, or wheelchair. No Lifetime Maximum

Form Number: HIC-GP-CAN-SB-VA Page 36 Benefit Benefit Options Waiver of Premium. After 60 continuous days of disability due to Cancer or Specified Disease, We will waive After 60 days premiums starting on the first day of policy renewal. Hospital Confinement. Payable for each day a Covered Person is charged the daily room rate by a Hospital, for up to 60 days of continuous stay. The benefit for covered children under age 21 is two times the Covered $100 per day Person’s daily benefit. No Lifetime Maximum

ter Specified Diseases Coered

• Addison’s Disease • Meningitis (epidemic cerebrospinal) • Scarlet Fever • Amyotrophic Lateral Sclerosis • Multiple Sclerosis • Sickle Cell Anemia • Cystic Fibrosis • Muscular Dystrophy • Tay-Sachs Disease • Diphtheria • Myasthenia Gravis • Tetanus • Encephalitis • Niemann-Pick Disease • Toxic Epidermal Necrolysis • Epilepsy • Osteomyelitis • Tuberculosis • Hansen’s Disease • Poliomyelitis • Tularemia • Legionnaire’s Disease • Rabies • Typhoid Fever • Lupus Erythematosus • Reye’s Syndrome • Undulant Fever • Lyme Disease • Rheumatic Fever • Whipple’s Disease • Malaria • Rocky Mountain Spotted Fever

Paent o enefits erination o Coerae Benefits are payable for a Covered Person’s Positive Diagnosis of a Cancer or A Covered Person’s insurance under the Policy will automatically terminate Specified Disease that begins after the Certificate Effective Date and while this on the earliest of the following dates: Certificate has remained in force. 1. the date that the Policy terminates. 2. the date of termination of any section or part of the Policy with respect Preistin Condition iitation to insurance under such section or part. During the first 12 months of a Covered Person’s insurance, losses incurred for 3. the date the Policy is amended to terminate the eligibility of the Pre-Existing Conditions are not covered. During the first 12 months following Employee class. the date a Covered Person makes a change in coverage that increases his or 4. any premium due date, if premium remains unpaid by the end of the her benefits, the increase will not be paid for Pre-Existing Conditions. After grace period. this 12 month period, however, benefits for such conditions will be payable 5. the premium due date coinciding with or next following the date the unless specifically excluded from coverage. This 12 month period is measured Covered Person ceases to be a member of an eligible class. from the Certificate Effective Date for each Covered Person. 6. the date the Policyholder no longer meets participation requirements.

Pre-Existing Condition means Cancer or a Specified Disease, for which Portability a Covered Person has received medical consultation, treatment, care, On the date the Policy terminates or the date the Named Insured ceases to be services, or for which diagnostic test(s) have been recommended or for a member of an eligible class, Named Insureds and their covered dependents which medication has been prescribed during the 12 months immediately will be eligible to exercise the portability privilege. Portability coverage may preceding the Certificate Effective Date of coverage for each Covered Person. continue beyond the termination date of the Policy, subject to the timely payment of premiums. Portability coverage will be effective on the day after ceptions and ter iitations insurance under the Policy terminates. The Policy pays benefits only for diagnoses resulting from Cancer or Specified Diseases, as defined in the Policy. It does not cover: The benefits, terms and conditions of the portability coverage will be the 1. any other disease or sickness; same as those provided under the Policy when the insurance terminated. The 2. injuries; initial portability premium rate is the rate in effect under the Policy for active 3. any disease, condition, or incapacity that has been caused, complicated, employees who have the same coverage. The premium rate for portability worsened, or affected by: coverage may change for the class of Covered Persons on portability on any a. Specified Disease or Specified Disease treatment; or premium due date. b. Cancer or Cancer treatment, or unless otherwise defined in the Policy 4. care and treatment received outside the United States or its territories; 5. treatment not approved by a Physician as medically necessary; 6. Experimental Treatment by any program that does not qualify as Experimental Treatment as defined in the Policy.

Form Number: HIC-GP-CAN-SB-VA Page 37 Coered Persons Covered Person means any of the following: ption to dd dditional enefits a. the Named Insured; or ospital Intensie Care Insurance ider b. any eligible Spouse or Child, as defined and as indicated on the Form Number HIC-GP-ICR 2/11 Certificate Schedule whose coverage has become effective; c. any eligible Spouse or Child, as defined and added to this Certificate In consideration of additional premium, this coverage will provide you with by endorsement after the Certificate Effective Date whose coverage benefits if you go into a Hospital Intensive Care Unit (ICU). has become effective; or d. a newborn child (as described in the Eligibility Section). Benefits Your benefits start the first day you go into ICU. The benefit is payable for up Child (Children) to 45 days per ICU stay. means the Named Insured’s unmarried child, including a natural child from the moment of birth, stepchild, foster or legally adopted child, or child in Hospital Intensive Care Confinement Benefit the process of adoption (including a child while the Named Insured is a party You may choose the benefit of $325 or $625 per day. It is reduced by one-half to a proceeding in which the adoption of such child by the Named Insured at age 75. is sought); a child for whom the Named Insured is required by a court order to provide medical support, and grandchildren who are dependent on the Double Benefits Named Insured for federal income tax purposes at the time of application, We will double the daily benefits for each day you are in an ICU as a result of who is: Cancer or a Specified Disease. We will also double the benefit for an injury a. not yet age 25; or that results from: being struck by an automobile, bus, truck, motorcycle, train, b. not yet age 26 if a full time student at an accredited school. or airplane; or being involved in an accident in which the named insured was the operator or was a passenger in such vehicle. ICU confinement must occur within 48 hours of the accident.

Emergency Hospitalization and Subsequent Transfer to an ICU We will pay the benefit selected by you for the highest level of care in a hospital that does not have an ICU, if you are admitted on an emergency basis, and you are transferred within 48 hours to the ICU of another Hospital.

Step Down Unit We will pay a benefit equal to one half the chosen daily benefit for confinement in a Step Down Unit.

Exceptions and Other Limitations Except as provided in Step Down Unit and Emergency Hospitalization and Subsequent Transfer to an ICU, coverage does not provide benefits for: surgical recovery rooms; progressive care; intermediate care; private monitored rooms; observation units; telemetry units; or other facilities which do not meet the standards for a Hospital Intensive Care Unit. Benefits are not payable: if you go into an ICU before the Certificate Effective Date; if you go into an ICU for intentionally self-inflicted injury or suicide attempts; if you go into an ICU due to being intoxicated or under the influence of alcohol, drugs or any narcotics, unless administered on the advice of a Physician and taken according to the Physician’s instructions. The term “intoxicated” refers to that condition as defined by law in the jurisdiction where the accident or cause of loss occurred.

This is not a Medicare Supplement Policy. If you are eligible for Medicare, see the Medicare Supplement Buyer’s Guide available from the Company. This policy only covers cancer and the diseases specified above, unless the hospital intensive care rider is selected. Upon receipt of your policy, please review it and your application. If any information is incorrect, please contact:

Bay Bridge Administrators P.O. Box 161690 | Austin, Texas 78716 | 1-800-845-7519

Form Number: HIC-GP-CAN-SB-VA Page 38 Henry County Schools VA Group Cancer Rate Quote

Monthly Rates Coverage Tier Option 1 Option 2 Option 3 Option 4 Individual $17.65 $23.38 $19.63 $30.89 Individual + Spouse $35.57 $47.60 $39.44 $62.87 Individual + Child(ren) $25.19 $33.20 $27.64 $43.36 Family $43.10 $57.43 $47.45 $75.34

Variable Benefit Elections Benefit Option 1 Option 2 Option 3 Option 4 Hospital Confinement $100 $100 $100 $100 Surgical $3,000 $3,000 $3,000 $3,000 Radiation/Chemotherapy $2,500 per month $2,500 per month $5,000 per month $5,000 per month First Diagnosis $0 $2,500 $0 $5,000 Colony Stimulating Factors $500 per month $500 per month $500 per month $500 per month Wellness $100 $100 $100 $100 Intensive Care Rider $0 $325 $0 $625

Underwritten by: Humana Insurance Company

Administered by:

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

PagePage 4539 Aflac Group Accident Plan

Plan Features Benefits are payable regardless of any other insurance programs. Coverage is guaranteed-issue, provided the applicant is eligible for coverage. The plan features benefits for both inpatient and outpatient treatment of covered accidents. Benefits are available for spouse and/or dependent children. There’s no limit on the number of claims an insured can file. Premiums are paid by convenient payroll deduction. Immediate effective date – Coverage will be effective the date the employee signs the application 24-Hour Coverage.

Eligibility Issue Ages Employee at least age 18 Spouse at least age 18 Children under age 26 The employee may purchase Accident Plus coverage for his spouse and/or dependent children. The spouse and dependent children cannot participate if the employee is not eligible for coverage or elects not to participate.

Guaranteed-Issue Coverage is guaranteed-issue, provided the applicants are eligible for coverage. Enrollments take place once each 12-month period. Late enrollees cannot enroll outside of an annual enrollment period.

Portability Coverage may be continued with certain stipulations. See certificate for details.

Accident Benefits – High Option

If the fracture requires open reduction, we will pay 150% of the amount shown.

Page 40 A fracture is a break in a bone that can be seen by X-ray. If a bone is fractured in a covered accident, and it is diagnosed and treated by a doctor within 90 days after the accident, we will pay the appropriate amount shown.

Multiple fractures refer to more than one fracture requiring either open or closed reduction. If multiple fractures occur in any one covered accident, we will pay the appropriate amounts shown for each fracture.

However, we will pay no more than 150% of the benefit amount for the fractured bone which has the highest dollar amount.

Chip fracture refers to a piece of bone that is completely broken off near a joint. If a doctor diagnoses the fracture as a chip fracture, we will pay 25% of the amount shown for the affected bone.

The maximum amount payable for the Fracture Benefit per covered accident is 150% the benefit amount for the fractured bone that has the higher dollar amount.

If the dislocation requires open reduction, we will pay 150% of the amount shown. Dislocation refers to a completely separated joint. If a joint is dislocated in a covered accident, and it is diagnosed and treated by a doctor within 90 days after the accident, we will pay the amount shown.

We will pay benefits only for the first dislocation of a joint. We will not pay for recurring dislocations of the same joint. If the insured dislocated a joint before the effective date of the certificate and then dislocates the same joint again, it will not be covered by this plan.

Multiple dislocations refer to more than one dislocation requiring either open or closed reduction in any one covered accident. For each covered dislocation, we will pay the amounts shown. However, we will pay no more than 150% of the benefit amount for the dislocated joint that has the higher dollar amount.

Partial dislocation is one in which the joint is not completely separated. If a doctor diagnoses and treats the accidental injury as a partial dislocation, we will pay 25% of the amount shown in the benefit schedule for the affected joint.

Page 41 The maximum amount payable for the Dislocation Benefit per covered accident is 150% of the benefit amount for the dislocated joint that has the higher dollar amount. If you have both fracture and dislocation in the same covered accident, we will pay for both. However, we will pay no more than 150% the benefit amount for the fractured bone or dislocated joint that has the higher dollar amount.

Paralysis means the permanent loss of movement of two or more limbs. We will pay the appropriate amount shown if, because of a covered accident: •The insured is injured, •The injury causes paralysis which lasts more than 90 days, and •The paralysis is diagnosed by a doctor within 90 days after the accident. The amount paid will be based on the number of limbs paralyzed. If this benefit is paid and the insured later dies as a result of the same covered accident, we will pay the appropriate Death Benefit, less any amounts paid under the Paralysis Benefit.

The laceration must be repaired with stitches by a doctor within 14 days after the accident. The amount paid will be based on the length of the laceration.

If an insured suffers multiple lacerations in a covered accident, and the lacerations are repaired with stitches by a doctor within 14 days after the accident, we will pay this benefit based on the largest single laceration which requires stitches.

Page 42

We will pay the amount shown for X-rays or doctor services. For benefits to be payable, because of a covered accident, the insured must be injured and receive initial treatment from a doctor within 14 days after the accident. We will pay the Medical Fees Benefit: •For treatment received due to injuries from a covered accident and •For each covered accident up to one year after the accident date.

We will pay the amount shown for injuries received in a covered accident if the insured:

• Receives treatment in a hospital emergency room and • Receives initial treatment within 14 days after the covered accident. This benefit is payable only once per 24-hour period and only once per covered accident.

We will not pay the Accident Emergency Room Treatment Benefit and the Medical Fees Benefit for the same covered accident. We will pay the highest eligible benefit amount.

We will pay the amount shown for injuries received in a covered accident if the insured:

• Receives treatment in a hospital emergency room, and • Is held in a hospital for observation for at least 24 hours, and • Receives initial treatment within 14 days after the accident. This benefit is payable only once per 24-hour period and only once per covered accident. This benefit would be paid in addition to Accident Emergency Room Treatment Benefit.

Page 43

We will pay the amount shown for up to six treatments per covered accident, per covered person. The insured must have received initial treatment within 14 days of the accident, and the follow-up treatment must begin within 30 days of the covered accident or discharge from the hospital.

We will pay the amount shown for up to six treatments (one per day) per covered accident, per covered person for treatment from a physical therapist. A physician must prescribe the physical therapy. The insured must have received initial treatment within 14 days of the accident, and physical therapy must begin within 30 days of the covered accident or discharge from the hospital.Treatment must take place within six months after the accident. This benefit is not payable for the same visit that the Accident Follow-up Treatment benefit is paid.

If an insured requires transportation to a hospital by a professional ambulance service within 90 days after a covered accident, we will pay the amount shown.

If hospital treatment or diagnostic study is recommended by your physician and is not available in the insured’s city of residence, we will pay the amount shown. The distance to the location of the hospital must be more than 50 miles from the insured’s residence.

If the insured receives blood and plasma within 90 days following a covered accident, we will pay the amount shown.

If a covered accident requires the use of a prosthetic device, we will pay the amount shown. Hearing aids, wigs, or dental aids—including false teeth—are not covered.

We will pay the amount shown for use of a medical appliance due to injuries received in a covered accident. Benefits are payable for crutches, wheelchairs, leg braces, back braces, and walkers.

If an insured is required to travel more than 100 miles for inpatient treatment of injuries received in a covered accident, we will pay the amount shown for an immediate family member's lodging. Benefits are payable up to 30 days per accident and only while the insured is confined to the hospital.

This benefit is payable while coverage is in force. This benefit is only payable for Wellness Tests performed as the result of preventive care, including tests and diagnostic procedures ordered in

Page 44 connection with routine examinations. We will pay the amount shown once each 12-month period for each covered person for the following: •Annual physical exams •Ultrasounds •Blood screenings •Mammograms •Eye examinations •Pap smears •Immunizations •PSA tests •Flexible sigmoidoscopies

We will pay the amount shown, when because of a covered accident, the insured: •Is injured, •Requires hospital confinement, and •Is confined to a hospital for at least 24 hours within 6 months after the accident date. We will pay this benefit once per calendar year. We will not pay this benefit for confinement to an observation unit. We will not pay this benefit for emergency room treatment or outpatient surgery or treatment.

We will pay the amount shown when, because of a covered accident, the insured: •Is injured, and •Those injuries cause confinement to a hospital for at least 24 hours within 90 days after the accident date. The maximum period for which you can collect the Hospital Confinement Benefit for the same injury is 365 days. This benefit is payable once per hospital confinement even if the confinement is caused by more than one accidental injury. We will not pay this benefit for confinement to an observation unit. We will not pay this benefit for emergency room treatment or outpatient surgery or treatment.

We will pay the amount shown when, because of a covered accident, the insured: •Is injured, and •Those injuries cause confinement to a hospital intensive care unit. The maximum period for which an insured can collect the Hospital Intensive Care Benefit for the same injury is 30 days. This benefit is payable in addition to the Hospital Confinement Benefit.

Dismemberment means: •Loss of a hand – The hand is cut off at or above the wrist joint; or •Loss of a foot – The foot is cut off at or above the ankle; or

Page 45 •Loss of sight – At least 80% of the vision in one eye is lost. Such loss of sight must be permanent and irrecoverable; or •Loss of a finger/toe – The finger or toe is cut off at or above the joint where it is attached to the hand or foot.

If the employee does not qualify for the Dismemberment Benefit but loses at least one joint of a finger or toe, we will pay the Partial Dismemberment Benefit shown. If this benefit is paid and the employee later dies as a result of the same covered accident, we will pay the appropriate death benefit, less any amounts paid under this benefit.

Accidental Death – If the employee is injured in a covered accident and the injury causes him/her to die within 90 days after the accident, we will pay the Accidental Death Benefit shown.

Accidental Common Carrier Death – If the employee is injured in a covered accident and the injury causes him/her to die within 90 days after the accident, we will pay the Accidental Common Carrier Death Benefit in the amount shown if the injury is the result of traveling as a fare-paying passenger on a common carrier, as defined below. This benefit is paid in addition to the Accidental Death Benefit.

Common carrier means: •An airline carrier which is licensed by the United States Federal Aviation Administration and operated by a licensed pilot on a regular schedule between established airports; or •A railroad train which is licensed and operated for passenger service only; or •A boat or ship that is licensed for passenger service and operated on a regular schedule between established ports.

LIMITATIONS AND EXCLUSIONS

WE WILL NOT PAY BENEFITS FOR INJURY, TOTAL DISABILITY, OR DEATH CONTRIBUTED TO, CAUSED BY, OR RESULTING FROM:

• War – participating in war or any act of war, declared or not; participating in the armed forces of, or contracting with, any country or international authority. We will return the prorated premium for any period not covered by this certificate when you are in such service. • Suicide – committing or attempting to commit suicide, while sane or insane. • Sickness – having any disease or bodily/mental illness or degenerative process. We also will not pay benefits for any related medical/surgical treatment or diagnostic procedures for such illness. • Self-Inflicted Injuries – injuring or attempting to injure yourself intentionally. • Racing – riding in or driving any motor-driven vehicle in a race, stunt show, or speed test. • Intoxication – being legally intoxicated, or being under the influence of any narcotic, unless taken under the direction of a doctor. Legally intoxicated means that condition as defined by the law of the jurisdiction in which the accident occurred. • Illegal Acts – participating or attempting to participate in an illegal activity, or working at an illegal job. • Sports – participating in any organized sport—professional or semiprofessional. • Cosmetic Surgery – having cosmetic surgery or other elective procedures that are not medically necessary or having dental treatment except as a

Page 46 result of a covered accident.

Notices This booklet is a brief description of coverage, not a contract. Read your certificate carefully for exact plan language, terms, and conditions.

If this coverage will replace any existing individual policy, please be aware that it may be in your best interest to maintain your individual guaranteed-renewable policy.

Notice to Consumer: The coverages provided by Continental American Insurance Company (CAIC) represent supplemental benefits only. They do not constitute comprehensive health insurance coverage and do not satisfy the requirement of minimum essential coverage under the Affordable Care Act. CAIC coverage is not intended to replace or be issued in lieu of major medical coverage. It is designed to supplement a major medical program.

Continental American Insurance Company (CAIC), a proud member of the Aflac family of insurers, is a wholly-owned subsidiary of Aflac Incorporated and underwrites group coverage. CAIC is not licensed to solicit business in New York, Guam, Puerto Rico, or the Virgin Islands. Continental American Insurance Company, Columbia, South Carolina.

AGCM378VA-25-BK R2 IV (3/18)

Page 47

Henry County Schools VA

Monthly Premium HIGH OPTION - 24 HOUR PLAN (12pp/yr) Employee $16.20

Employee and Spouse $23.16

Employee and Dependent Children $30.90

Family $37.86

Page 48 Aflac Group Critical Illness Advantage Plan

Plan Features • Benefits are paid directly to you, unless • The plan doesn’t have a waiting period for otherwise assigned benefits. • Benefit amounts are available up to • Coverage is portable, with certain $50,000 for employees and up to $25,000 stipulations. for spouses. • Annual health screening benefit is • Dependent children are covered at 50% of included. the primary insured’s amount at no additional charge. • Guaranteed-issue coverage is available (which means you may qualify for coverage without having to answer health questions). • Premiums are paid through convenient payroll deduction.

Underwriting Guidelines – Guaranteed-Issue

Guaranteed-issue coverage is available for all eligible employees. The following options are available: Up to $20,000 for employees and up to $10,000 for spouses with no participation requirement.

For employee amounts over $20,000 and spouse amounts over $10,000: All applicants are required to answer underwriting questions. Employees who would otherwise be declined will be issued the lesser of the amount applied for or the guaranteed-issue limit.

Individual Eligibility Issue Ages: • Employee 18-69 • Spouse 18-69 • Children under age 26

Benefit-eligible employees who work at least 30 hours weekly are eligible. If an employee is eligible, his spouse is also eligible to apply for coverage. Dependent children under the age of 26 are automatically covered. Seasonal and temporary workers are not eligible to participate.

Spouse Coverage Available 1. Spouse coverage is available up to 50% of the employee’s face amount, subject to the minimum face amount of $5,000. To apply for spouse coverage, the employee must also apply. To be eligible, the spouse must not be disabled or unable to work at the time of application.

If the employee does not meet the underwriting requirements necessary to participate in the plan, the spouse can still obtain coverage. The spouse would then become the primary insured and be limited to face amounts between $5,000 and $25,000.

Dependent Children Coverage Dependent children under the age of 26 are automatically covered at 50% of the primary insured’s face amount at no additional charge. Children-only coverage is not available. Page 49 Successor Insured Benefit If spouse coverage is in force at the time of the primary insured’s death, the surviving spouse may elect to continue coverage. Coverage would continue at the existing spouse face amount and would also include any dependent child coverage in force at the time.

You May Continue Your Coverage Your coverage may be continued with certain stipulations. See certificate for details.

Group Critical Illness Benefits Where applicable, covered conditions must be caused by underlying diseases as defined in the plan.

Initial Diagnosis+ An insured may receive up to 100% of his face amount upon the diagnosis of a covered critical illness.

Covered Critical Illnesses Percentage of Face and Additional Benefits Amount/Benefit Cancer (Internal or Invasive) 100% Heart Attack 100% Major Organ Transplant 100% Kidney Failure (End-Stage Renal Failure) 100% Stroke 100% Bone Marrow Transplant (Stem Cell 100% Transplant) Sudden Cardiac Arrest 100% Non-Invasive Cancer 25% Coronary Artery Bypass Surgery 25%

Benefits will be based on the face amount in effect on the critical illness date of diagnosis.

Additional Diagnosis + Once benefits have been paid for a covered critical illness, we will pay benefits for each different critical illness when the date of diagnosis is separated by at least 6 consecutive months.

Reoccurrence +

Once benefits have been paid for a covered critical illness, benefits are payable for that same critical illness when the date of diagnosis is separated by at least 12 consecutive months.

+ If the claim is for a cancer diagnosis, the insured must be treatment-free from cancer for at least 12 months and must be in complete remission before the date of a subsequent cancer diagnosis.

Page 50 Health Screening Benefit

Benefit Benefit Amount Health Screening Benefit $60 per calendar year

The Health Screening Benefit is payable once per calendar year for health screening tests performed as the result of preventive care, including tests and diagnostic procedures ordered in connection with routine examinations.

This benefit is payable for the covered employee and spouse. This benefit is not paid for dependent children. The covered health screening tests include, but are not limited to, the following: • Stress test on a bicycle or treadmill • Bone marrow testing • Breast ultrasound • CA 15-3 (blood test for breast cancer) • CA 125 (blood test for ovarian cancer) • CEA (blood test for colon cancer) • Chest X-ray • Colonoscopy • Flexible sigmoidoscopy • Hemoccult stool analysis • Mammography • Pap smear • PSA (blood test for prostate cancer) • Serum protein electrophoresis (blood test for myeloma) • Thermography • DNA stool analysis • Spiral CT screening for lung cancer • Fasting blood glucose test, blood test for triglycerides, or serum cholesterol test to determine level of HDL and LD

Page 51 Limitations and Exclusions

If diagnosis occurs after age 70, benefits are reduced by 50%.

Pre-Existing Conditions Limitation Pre-existing condition is a sickness or physical condition that existed within the 12-month period before the insured’s effective date. A medical professional must have advised, diagnosed, or treated the Insured for the condition to be considered pre-existing.

We will not pay benefits for any critical illness resulting from or affected by a pre-existing condition if the critical illness was diagnosed within the 12-month period after the insured’s effective date.

Cancer Diagnosis Limitation Benefits are payable for Cancer and/or Non-Invasive Cancer as long as the Insured: • Is treatment-free from cancer for at least 12 months before the diagnosis date; and • Is in complete remission prior to the date of a subsequent diagnosis, as evidenced by the absence of all clinical, radiological, biological, and biochemical proof of the presence of the cancer.

Exclusions We will not pay for loss due to any of the following: • Self-Inflicted Injuries – injuring or attempting to injure oneself intentionally or taking action that causes oneself to become injured. • Suicide – committing or attempting to commit suicide, while sane or insane. • Illegal Acts – participating or attempting to participate in an illegal activity, or working at an illegal job. • Participation in Aggressive Conflict of any kind, including: o War (declared or undeclared) or military conflicts. o Insurrection or riot. o Civil commotion or civil state of belligerence. • Illegal substance abuse, which includes the following: o Abuse of legally-obtained prescription medication. o Illegal use of non-prescription drugs.

Diagnosis, treatment, testing, and confinement must be in the United States or its territories.

All benefits under the plan, including benefits for diagnoses, treatment, confinement and covered tests, may be payable only while coverage is in force.

AGCM321C-VA-BK-HENRY R1 IV (3/18)

Page 52 Group Critical Illness Advantage

Mark III Accounts - Monthly (12pp/yr) Rates

0 1 2 3 4 5 6 7 8 9 10 1 1 1 1 NONTOBACCO - Employee 1 1 1 1 1 Issue Age $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000 18-29 $ 3.39 $ 4.99 $ 6.58 $ 8.17 $ 9.76 $ 11.36 $ 12.95 $ 14.54 $ 16.13 $ 17.73 30-39 $ 4.53 $ 7.25 $ 9.98 $ 12.71 $ 15.43 $ 18.16 $ 20.88 $ 23.61 $ 26.34 $ 29.06 40-49 $ 7.30 $ 12.81 $ 18.31 $ 23.81 $ 29.32 $ 34.82 $ 40.33 $ 45.83 $ 51.33 $ 56.84 50-59 $ 12.08 $ 22.37 $ 32.65 $ 42.94 $ 53.22 $ 63.51 $ 73.79 $ 84.08 $ 94.36 $ 104.64 60-69 $ 18.99 $ 36.18 $ 53.37 $ 70.56 $ 87.75 $ 104.94 $ 122.13 $ 139.32 $ 156.51 $ 173.69

1 1 1 1 NONTOBACCO - Spouse 1 1 1 1 Issue Age $5,000 $7,500 $10,000 $12,500 $15,000 $17,500 $20,000 $22,500 $25,000 18-29 $ 3.39 $ 4.19 $ 4.99 $ 5.78 $ 6.58 $ 7.37 $ 8.17 $ 8.97 $ 9.76 30-39 $ 4.53 $ 5.89 $ 7.25 $ 8.62 $ 9.98 $ 11.34 $ 12.71 $ 14.07 $ 15.43 40-49 $ 7.30 $ 10.06 $ 12.81 $ 15.56 $ 18.31 $ 21.06 $ 23.81 $ 26.57 $ 29.32 50-59 $ 12.08 $ 17.23 $ 22.37 $ 27.51 $ 32.65 $ 37.80 $ 42.94 $ 48.08 $ 53.22 60-69 $ 18.99 $ 27.58 $ 36.18 $ 44.77 $ 53.37 $ 61.96 $ 70.56 $ 79.15 $ 87.75

1 1 1 1 TOBACCO - Employee 1 1 1 1 1 Issue Age $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000 18-29 $ 4.13 $ 6.46 $ 8.79 $ 11.12 $ 13.45 $ 15.78 $ 18.11 $ 20.43 $ 22.76 $ 25.09 30-39 $ 6.18 $ 10.57 $ 14.95 $ 19.33 $ 23.71 $ 28.10 $ 32.48 $ 36.86 $ 41.24 $ 45.63 40-49 $ 10.61 $ 19.41 $ 28.22 $ 37.02 $ 45.83 $ 54.63 $ 63.44 $ 72.24 $ 81.05 $ 89.85 50-59 $ 18.61 $ 35.43 $ 52.24 $ 69.05 $ 85.87 $ 102.68 $ 119.49 $ 136.30 $ 153.12 $ 169.93 60-69 $ 28.85 $ 55.90 $ 82.95 $ 109.99 $ 137.04 $ 164.09 $ 191.14 $ 218.19 $ 245.24 $ 272.29

1 1 1 1 TOBACCO - Spouse 1 1 1 1 Issue Age $5,000 $7,500 $10,000 $12,500 $15,000 $17,500 $20,000 $22,500 $25,000 18-29 $ 4.13 $ 5.29 $ 6.46 $ 7.62 $ 8.79 $ 9.95 $ 11.12 $ 12.28 $ 13.45 30-39 $ 6.18 $ 8.37 $ 10.57 $ 12.76 $ 14.95 $ 17.14 $ 19.33 $ 21.52 $ 23.71 40-49 $ 10.61 $ 15.01 $ 19.41 $ 23.81 $ 28.22 $ 32.62 $ 37.02 $ 41.42 $ 45.83 50-59 $ 18.61 $ 27.02 $ 35.43 $ 43.83 $ 52.24 $ 60.65 $ 69.05 $ 77.46 $ 85.87 60-69 $ 28.85 $ 42.37 $ 55.90 $ 69.42 $ 82.95 $ 96.47 $ 109.99 $ 123.52 $ 137.04

Base Plan: Riders: Provisions: Group Attributes: -With Cancer Benefit -No additional riders -Pre-Existing Condition Limitation: 12/12 -Situs State: VA -$60 Health Screening Benefit -Add'l Separation Waiting Period: 6 Months -Eligible Lives: 1750 -Without Skin Cancer Benefit -Re-Separation Waiting Period: 12 Months -Without Additional Benefits -Benefit Reduction at Age 70 (Loss of Sight, Speech, Hearing) -Standard Portability (Coma, Burns, Paralysis) -Rate Guarantee: 2 Years

Please Note: Premiums shown are accurate as of publication. They are subject to change. Published: Feb-16 Series C21000 CI21000-160226-115854-Q2yJvwic-037Yl2V-10906

Page 53 Aflac Group Hospital Indemnity Plan

Plan Description The Group Supplemental Hospital Indemnity Plan provides benefits for inpatient and outpatient services as a result of covered accidents and sicknesses.

Plan Features • Benefits available for spouse and/or dependent children. • Pays regardless of any other insurance programs. • Premiums are paid by convenient payroll deduction. • Covers both injuries and sicknesses. • Admission and per day Hospital Confinement Benefits included. • Surgery and Anesthesia Benefits included. • The plan is portable with certain stipulations

Individual Eligibility Issue Ages Employee 18-64 Spouse 18-64 Children under age 26

Spouse and Dependent Children Coverage Available The employee may purchase Group Supplemental Hospital Indemnity coverage for their spouse and/or dependent children. The spouse and dependent children cannot participate if the employee is not eligible for coverage or elects not to participate. If the employee is eligible then the employee’s spouse and dependent children are eligible to participate.

Guaranteed-Issue During the initial enrollment, coverage is guaranteed-issue, which means you may not have to answer health questions to be eligible for coverage. Subsequent to the initial enrollment, evidence of insurability may be required.

Portability Coverage may be continued with certain stipulations. See certificate for details.

Benefits

Hospital Confinement (per day) Plan II $150

We will pay the amount shown when an insured is confined to a hospital as a resident bed patient as the result of an injury or because of a covered sickness. To receive this benefit for injuries received in an injury, the insured must be confined to a hospital within six months of the date of the covered accident.

The maximum period for which a covered person can collect benefits for hospital confinements resulting from covered sickness or from injuries received in the same covered accident is 180 days.

This benefit is payable for only one hospital confinement at a time—even if the confinement is a result of more than one covered accident, more than one covered sickness, or a covered accident and a covered sickness.

Hospital Admission (per confinement) Plan II $1,500

We will pay the amount shown when an insured is admitted to a hospital and confined as a resident bed patient because of an injury or because of a covered sickness. To receive this benefit for injuries received in a covered accident, an insured must be admitted to a hospital within six months of the date of the covered accident.

We will not pay benefits for confinement to an observation unit, for emergency room treatment, or for outpatient treatment. We will pay this benefit only once for each covered accident or covered sickness. If an insured is confined to the hospital because of the same or related injury or sickness, we will not pay this benefit again.

Page 54 This benefit option will be based on the insured’s current major medical plan’s deductible to assist the insured in meeting the out-of- pocket liability.

Residents of Massachusetts are not eligible for Hospital Admission Benefit amounts in excess of $500

Surgical Benefit (per procedure) Plan II Up to $1,500

If an insured has surgery performed by a physician due to an injury or because of a covered sickness, we will pay the appropriate surgical benefit amount shown in the Schedule of Operations. The surgical benefit paid will never exceed the maximum surgical benefit designated in the plan. The surgery can be performed in a hospital (on an inpatient or outpatient basis), in an ambulatory surgical center, or in a physician’s office.

If an operation is not listed in the Schedule of Operations, we will pay an amount comparable to that which would be payable for the operation listed in the Schedule of Operations (the operation that is nearest in severity and complexity).

If two or more surgical procedures are performed at the same time through the same or different incisions, only one benefit—the largest—will be provided.

Anesthesia Benefits

Plan II Up to $375

When an insured receives benefits for a surgical procedure covered under the Surgical Benefit, we will pay the appropriate benefit amount shown in the Schedule of Operations for anesthesia administered by a physician in connection with such procedure. However, the Anesthesia Benefit paid will not exceed 25 percent of the amount paid under Surgical Benefit.

Wellness (per calendar year) Plan II $50

We will pay the amount shown when an insured visits a doctor and he is neither injured nor sick. This benefit is payable once per calendar year per insured.

Limitations and Exclusions

Pre-Existing Condition Limitation A pre-existing condition means, within the 12-month period prior to the insured’s effective date, conditions for which medical advice or treatment was received or recommended. We will not pay benefits for any loss or injury that is caused by, contributed to by, or resulting from a pre-existing condition for 12 months after the insured’s effective date or for 12 months from the date medical care, treatment, or supplies were received for the pre-existing condition—whichever is less.

A claim for benefits for loss starting after 12 months from the effective date of the insured’s certificate will not be reduced or denied on the grounds that it is caused by a pre-existing condition.

Pregnancy will not be covered if conception was before the Effective Date of the Insured Person’s Certificate. Pregnancy will be covered as any other sickness when date of conception is after the Insured Person’s Effective Date of coverage.

Treatment means consultation, care, or services provided by a physician, including diagnostic measures and taking prescribed drugs and medicines.

If the certificate is issued as a replacement for a certificate previously issued under this plan, then the pre-existing condition limitation provision of the new certificate applies only to any increase in benefits over the prior certificate. Any remaining pre-existing condition limitation period of the prior certificate continues to apply to the prior level of benefits.

Exclusions We will not pay benefits for loss caused by pre-existing conditions (except as stated in the Pre-Existing Condition Limitation provision above). Page 55

We will not pay benefits for loss contributed to by, caused by, or resulting from: 1. War – Participating in war or any act of war, declared or not, or participating in the armed forces of or contracting with any country or international authority. We will return the prorated premium for any period not covered by this certificate when the insured is in such service.

2. Suicide – Committing or attempting to commit suicide, while sane or insane.

3. Self–Inflicted Injuries – Injuring or attempting to injure yourself intentionally.

4. Traveling – Traveling more than 40 miles outside the territorial limits of the United States, Canada, Mexico, Puerto Rico, the Bahamas, Virgin Islands, Bermuda, and Jamaica.

5. Racing – Riding in or driving any motor–driven vehicle in a race, stunt show or speed test.

6. Aviation – Operating, learning to operate, serving as a crewmember on, or jumping or falling from any aircraft, including those, which are not motor–driven.

7. Intoxication – Being legally intoxicated, or being under the influence of any narcotic, unless such is taken under the direction of a physician.

8. Illegal Acts – Participating or attempting to participate in an illegal activity, or working at an illegal job.

9. Sports – Participating in any organized sport: professional or semi–professional.

10. Routine physical exams and rest cures.

11. Custodial care. This is care meant simply to help people who cannot take care of themselves.

12. Treatment for being overweight, gastric bypass or stapling, intestinal bypass, and any related procedures, including complications.

13. Services performed by a relative.

14. Services related to sex change, sterilization, in vitro fertilization, reversal of a vasectomy or tubal ligation.

15. A service or a supply furnished by or on behalf of any government agency unless payment of the charge is required in the absence of insurance.

16. Elective abortion.

17. Treatment, services, or supplies received outside the United States and its possessions or Canada.

18. Injury or sickness covered by Worker's Compensation.

19. Dental services or treatment.

20. Cosmetic surgery, except when due to medically necessary reconstructive plastic surgery.

21. Mental or emotional disorders without demonstrable organic disease.

22. Alcoholism, drug addiction, or chemical dependency.

AGCM385VA-H-BK R1 IV (3/18)

Page 56

Aflac Hospital Indemnity Plan Monthly Premium Rates

Employee $2.2

Employee and Spouse $0.3

Employee and Dependent Child(ren) $51.

Employee and Family $2.

Page 57 AUL Short-Term Disability Plan

Why do you need Disability Insurance? Consider this...

Statistics show you are much more likely to be injured in an accident than to die from one. • A fatal injury occurs every 5 minutes, and a disabling injury occurs every 1.5 seconds.1 • There is a death caused by a motor vehicle crash every 12 minutes; there is a disabling injury every 14 seconds.1 • In the home, there is a fatal injury every 16 minutes and a disabling injury every 4 seconds.1

While many people survive accidental injuries, many others live with serious illnesses. • In the United States, men have a little less than a 1-in-2 lifetime risk of developing cancer; for women the risk is a little more than 1-in-3. The fve year relative survival rate for all cancers combined is 63%.2 • One in fve males and females has some form of cardiovascular disease. High blood pressure is the most common form of cardiovascular disease.3 • More than 35 million Americans are now living with chronic lung diseases, such as asthma, emphysema, and chronic bronchitis.4

Advances in medicine are allowing us to live longer. However, recovery from a serious illness or injury often requires time away from work. • In the last 20 years, deaths due to the big three (cancer, heart attack, and stroke) have gone down signifcantly. But disabilities due to those same three diseases are up dramatically. Things that used to kill, now disable.5

You have life insurance, home insurance and automobile insurance. But is your income insured?

Class Description All Eligible Employees working a minimum of 30 hours per week, electing to participate in the Voluntary Short Term Disability Insurance.

Disability You are considered disabled if, because of injury or sickness, you cannot perform the material and substantial duties of your regular occupation. You are not working in any occupation and are under the regular attendance of a Physician for that injury or sickness.

Monthly Beneft You can choose a beneft in $100 increments up to 70% of an Employee’s covered basic monthly earnings to a maximum monthly beneft of $3,000. The minimum monthly beneft is $500.

Elimination Period This means a period of time a disabled Employee must be out of work and totally disabled before weekly benefts begin; seven (7) consecutive days for a sickness and zero (0) days for injury.

Beneft Duration This is the period of time that benefts will be payable for disability. You can choose a maximum STD beneft duration, if continually disabled, of thirteen (13) weeks, twenty-six (26) weeks or ffty-two (52) weeks.

Basis of Coverage 24 Hour Coverage, on or of the job.

Maternity Coverage Benefts will be paid the same as any other qualifying disability, subject to any applicable pre-existing condition exclusion.

STD Pre-Existing Condition Exclusion 3/12, If a person receives medical treatment, or service or incurs expenses as a result of an Injury or Sickness within 3 months prior to the Individual Efective Date, then the Group Policy will not cover any Disability which is caused by, contributed to by, or resulting from that Injury or Sickness; and begins during the frst 12 months after the Person’s Individual Efective Date. This Pre-Existing Condition limitation will be waived for all Persons who were included as part of the fnal premium billing statement received by AUL/ OneAmerica from the prior carrier and will be Actively at work on the efective date.

Page 58 Recurrent Disability If you resume Active Work for 30 consecutive workdays following a period of Disability for which the Weekly Beneft was paid, any recurrent Disability will be considered a new period of Disability. A new Elimination Period must be completed before the Weekly Beneft is payable.

Annual Enrollment Employees who did not elect coverage during their initial enrollment period are eligible to sign up for $500 to $1,000 monthly beneft without medical questions. Employees may increase their coverage up to $500 monthly beneft without medical questions. The maximum beneft cannot exceed 70% of basic monthly earnings and must be in $100 increments.

Employees that elect to increase their Beneft Duration may do so only during the annual enrollment period subject to the pre-existing exclusion. The pre-existing exclusion will apply to the increased beneft duration

Exclusions and Limitations This plan will not cover any disability resulting from war, declared or undeclared or any act of war; active participation in a riot; intentionally self-inficted injuries; commission of an assault or felony; or a pre-existing condition for a specifed time period.

Portability Once an employee is on the AUL disability plan for 3 consecutive months, you may be eligible to port your coverage for one year at the same rate without evidence of insurability. You have 31 days from your date of termination to apply for portability by calling 800-553-5318.

The Portability Privilege is not available to any Person that retires (when the Person receives payment from any Employer’s Retirement Plan as recognition of past services or has concluded his/her working career).

This information is provided as a summary of the product. It is not a part of the insurance contract and does not change or extend AUL’s liability under the group policy. If there are any discrepancies between this information and the group policy, the group policy will prevail.

Page 59 AUL Short-Term Disability Monthly Rates

enet uraton: enet uraton: enet uraton: 13 Weeks 26 Weeks 52 Weeks

Monthly Monthly Monthly Monthly Monthly Monthly enet Premium enet Premium enet Premium

$500 $10.36 $500 $15.00 $500 $19.72 $600 $12.43 $600 $18.00 $600 $23.66 $700 $14.50 $700 $21.00 $700 $27.60 $800 $16.57 $800 $24.00 $800 $31.54 $900 $18.64 $900 $27.00 $900 $35.49 $1,000 $20.71 $1,000 $30.00 $1,000 $39.43 $1,100 $22.78 $1,100 $33.00 $1,100 $43.37 $1,200 $24.85 $1,200 $36.00 $1,200 $47.32 $1,300 $26.92 $1,300 $39.00 $1,300 $51.26 $1,400 $28.99 $1,400 $42.00 $1,400 $55.20 $1,500 $31.07 $1,500 $45.00 $1,500 $59.15 $1,600 $33.14 $1,600 $48.00 $1,600 $63.09 $1,700 $35.21 $1,700 $51.00 $1,700 $67.03 $1,800 $37.28 $1,800 $54.00 $1,800 $70.97 $1,900 $39.35 $1,900 $57.00 $1,900 $74.92 $2,000 $41.42 $2,000 $60.00 $2,000 $78.86 $2,100 $43.49 $2,100 $63.00 $2,100 $82.80 $2,200 $45.56 $2,200 $66.00 $2,200 $86.75 $2,300 $47.63 $2,300 $69.00 $2,300 $90.69 $2,400 $49.70 $2,400 $72.00 $2,400 $94.63 $2,500 $51.78 $2,500 $75.00 $2,500 $98.58 $2,600 $53.85 $2,600 $78.00 $2,600 $102.52 $2,700 $55.92 $2,700 $81.00 $2,700 $106.46 $2,800 $57.99 $2,800 $84.00 $2,800 $110.40 $2,900 $60.06 $2,900 $87.00 $2,900 $114.35 $3,000 $62.13 $3,000 $90.00 $3,000 $118.29

Customer Service 800-553-5318 Disability Claims 855-517-6365 fax-1-844-287-9499

Disability Claims Email: [email protected] www.employeebenefts.aul.com Please refer to www.markiiibrokerage.com/henrycountyschoolsva for a copy of your certifcate or claim form.

Page 60 Texas Life Whole Life Policy - Solutions 121

Texas Life Whole Life Insurance – SOLUTIONS 121

CommonCommon Issue Date:Date: August August 1, 1, 2017 2018

An ideal complement to any group term and optional term life insurance your employer might provide, Texas Life’s SOLUTIONS 121 is the life insurance you keep, even when you change jobs or retire as long as you pay the premiums. It will help protect your family, both today and, more importantly, tomorrow. Even better, you won’t even have to pay for it after age 65 (or 20 years if you’re 46 years of age or older), because it’s guaranteed to be paid up.1

SOLUTIONS is an individual permanent life insurance product specifically designed for employees and their families. These policies provide a guaranteed level premium and death benefit for the life of the policy, and all you have to do to qualify for basic amounts of coverage

is be actively at work the day you enroll. You also may apply for coverage on your spouse, children and grandchildren with limited underwriting requirements. 2

As an employee, you are eligible to apply once you have satisfied your employer’s eligibility period.

Why Voluntary Coverage?

• Most employees typically depend on group term life insurance. • Adults covered by both group and individual life insurance replace more of their income upon death than adults having group term alone.3 • Term policies are created to last for a finite period of time that will likely end before you die.4 • When do you want a life insurance policy in force? --Answer: When you die. • Term is for IF you die, permanent is for WHEN you die.

The SOLUTIONS Advantage

Individual Protection SOLUTIONS 121 is a permanent life insurance policy that you own; it can never be canceled, as long as you pay the guaranteed level premiums due, even if your health changes. Because you own it, you can take SOLUTIONS 121 with you when you change jobs or retire, with no change in the premium.

Coverage for Your Family You may also apply for an individual SOLUTIONS 121 policy for your spouse/domestic partner, dependent children ages 15 days-26 years and grandchildren ages 15 days-18 years, even if you do not apply for coverage.2

Paid Up Insurance SOLUTIONS 121 has premiums that are guaranteed to remain level until your age 65, or for 20 years if you purchase the policy after age 45. At that time, the policy becomes fully paid up; no further premiums are due, and the death benefit does not reduce. This gives you the peace of mind that comes with life insurance that’s paid for as your income changes in retirement.

16M419-C 1119 (exp1118) See the SOLUTIONS brochure for complete details. Policy form WLOTO-NI-11 or ICC11-WLOTO-NI-11

Page 61 Texas Life Whole Life Insurance – SOLUTIONS 121

Convenience of payroll deduction Thanks to your employer, SOLUTIONS 121 premiums are paid through convenient payroll deductions and sent to Texas Life by your employer.

Portable, Permanent You may continue the peace of mind SOLUTIONS 121 provides, even when you change jobs or retire. Once your policy is issued, the coverage is yours to keep. If you should change jobs or retire before the policy becomes paid up, you simply pay the monthly premium directly to Texas Life by automatic bank draft or monthly bill (for monthly bill we may add a billing fee not to exceed $2.00). Premiums are guaranteed to remain level to your age 65, or for 20 years if you purchase the policy after age 45. At that time, the policy becomes fully paid up; no further premiums are due.

Accelerated Death Benefit due to Terminal Illness For no additional premium, the policy includes an Accelerated Death Benefit Due to Terminal Illness Rider. Should you be diagnosed as terminally ill with the expectation of death within 12 months, you will have the option to receive 92.6% (92% in CA, CT, DC, DE, FL, ND & SD) of the death benefit, minus a $150 ($100 in Florida) administrative fee in lieu of the insurance proceeds otherwise payable at death. This valuable living benefit gives you peace of mind knowing that, should you need it, you can take the large majority of your death benefit while still alive. (Conditions apply) (Policy Form ICC-ULABR-11 or Form Series ULABR-11)

Accelerated Death Benefit due to Chronic Illness Included in the policy at the option of the employer, the Accelerated Death Benefit for Chronic Illness rider covers all applicants. If an insured becomes permanently chronically ill, meaning that he/she is unable to perform two of six Activities of Daily Living (such as bathing, continence, or dressing), or is severely cognitively impaired (such as Alzheimer’s), he/she may elect to claim an accelerated death benefit in lieu of the Face Amount payable at death. The single sum payment is 92% of the death benefit less an administrative fee of $150 ($100 in FL). The Accelerated Death Benefit for Chronic Illness Rider premiums are 8% of the base policy premium. Conditions and limitations apply. See the SOLUTIONS 121 Pamphlet for details. (Policy form ULABR-CI-14 or ICC14-ULABR-CI-14.)

Waiver of Premium Rider This benefit to age 65 (issue ages 17-59) waives the premium after six months of the insured’s total disability and will even refund the prior six months’ premium. Benefits continue payable until the earlier of the end of the insured’s total disability or age 65. Cost is an additional 10% of the basic monthly premium. Self-inflicted or war-related disability is excluded. Notice, proof and waiting period provisions apply. (Policy Form ICC07-ULCL-WP-07 or Form Series ULCL-WP-07).

Coverage begins immediately Coverage normally begins when you complete the application and the authorization for your employer to deduct premiums from your paycheck. Two year suicide and contestability provisions apply (one year in ND).

16M419-C 1119 (exp1118) See the SOLUTIONS brochure for complete details. Policy form WLOTO-NI-11 or ICC11-WLOTO-NI-11

Page 62 Texas Life Whole Life Insurance – SOLUTIONS 121

Sample Rates The chart below displays examples of SOLUTIONS 121 rates at varying ages for a $50,000 policy. Rates shown below for both non-tobacco and tobacco users, and include the cost for Waiver of Premium and the Accelerated Death Benefit due to Chronic Illness rider.

SOLUTIONS 121 Monthly Premium Monthly Premium Age Non-Tobacco Tobacco Face Amount Paid-up Age Chronic Illness, Chronic Illness, Waiver Waiver 20 $50,000 $38.11 $46.96 65 25 $50,000 $43.42 $54.63 65 30 $50,000 $53.45 $67.02 65 35 $50,000 $68.20 $86.49 65 40 $50,000 $91.80 $115.40 65 45 $50,000 $125.43 $162.01 65

SOLUTIONS Review • Permanent and yours to keep when you change jobs or retire, as long as you pay premiums due • Non-participating Whole Life (no dividends) • Guaranteed death benefit 1 • Guaranteed level premium • Guaranteed paid-up insurance at age 65, or for 20 years if the policy is purchased after age 45 • If you’re actively at work the day you enroll, you can qualify for basic amounts with no more underwriting. • Includes Accelerated Death Benefit for Chronic Illness on all policies • Waiver of Premium included for ages 17-59 • If desired, you may apply for higher amounts of coverage by answering additional underwriting questions • Coverage available for spouse, children and grandchildren2

1 Guarantees are subject to product terms, exclusions and limitations and the insurers claims-paying ability and financial strength. 2 Coverage and spouse/domestic partner eligibility may vary by state. Coverage not available for children and grandchildren in Washington. Texas Life complies with all state laws regarding marriages, domestic and civil union partnerships and legally recognized familial relationships. 3 LIMRA; Life Insurance Ownership Focus – 2016 4 Maurer, Tim. "Term vs Perm (Life Insurance) In 90 Seconds." Forbes. Forbes Magazine, 3 May 2013. Web. 08 Nov. 2016.

If you have any questions regarding your Texas Life policy, please call 800-283-9233, prompt #2

16M419-C 1119 (exp1118) See the SOLUTIONS brochure for complete details. Policy form WLOTO-NI-11 or ICC11-WLOTO-NI-11

Page 63 MONTHLY¯WAIVER 4EXAS,IFE3/,54)/.33ERIES 
 
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         )N7!COVERAGEISNOTAVAILABLEFORCHILDRENORGRANDCHILDREN0OLICIESONCHILDRENANDGRANDCHILDRENREQUIRE4IERUNDERWRITING      Page 65 Continuation of Benefts

Health and Dental Plans Under FSA, Health and Dental & Vision Plans, you and your covered dependents are eligible to continue coverage through COBRA according to the “qualifying events”.

If you and your dependents are enrolled in the dental, vision or health plans or you participate with the FSA, you will be eligible to continue coverage through COBRA after you leave your employment for a specifed period. In addition, while covered under the plan, if you should die, become divorced or legally separated, or become eligible for Medicare, your covered dependents may be eligible to continue dental or vision coverage through COBRA. Also, while you are covered under the plan, your covered children who no longer qualify as an eligible dependent may continue coverage through COBRA. Examples of an ineligible dependent would be when your child reaches the age of 26 not being eligible for dependent coverage. You will receive notifcation with premium and continuation options shortly following your termination of employment. Should you have any questions you may contact your Human Resources Department at 276-634-4715.

AUL Disability Once an employee is on the AUL disability plan for 3 months, you can port the coverage for one year at the same cost without evidence of insurability. You have 31 days from your date of termination to apply for portability by calling 1-800-553-5318�

Humana Cancer Plan You may continue your Humana Cancer Plan on the date the Policy terminates or the date the Named Insured ceases to be a member of an eligible class, Named Insureds and their covered dependents will be eligible to exercise the portability privilege. For more information, contact Bay Bridge Administrators at 1-800-845-7519�

Texas Life Whole Life When you leave employment, you may continue your Texas Life Whole Life coverage by having the premiums that are currently deducted from your paycheck drafted from your bank account. You may do that by contacting Texas Life at 1-800-283-9233 prompt #2.

To Continue Other Plans You may continue your Afac Accident, Afac Hospital Indemnity and Afac Critical Illness plans by having the premiums currently deducted from your paycheck drafted from your bank account or billed to your home. For more information contact: Afac Group at 1-800-433-3036

Page 66 Contact Information for Questions and Claims

Anthem 1-800-445-7490 www.anthem.com

Afac Columbia, South Carolina Customer Service: 1-800-433-3036 Afacgroupinsurance.com American United Life (AUL) Claims Toll-Free Number: 1-855-517-6365 / Claims fax 1-844-287-9499 Customer Service: 1-800-553-5318 Delta Dental of Virginia 4818 Starkey Road, Roanoke, VA 24018 (540) 989-8000 · (800) 237-6060 or Fax: (540) 776-8109 FBA P.O. Box 8188 Virginia Beach Va. 23450 800-437-3539 or (fax)757-431-1155 www.fex-admin.com Humana Bay Bridge Administrators, LLC P.O. Box 161690 • Austin, TX 78716 1-800-845-7519 or (fax) 512-275-9350 www.bbadmin.com Submit claims to [email protected]

Texas Life Insurance Company PO Box 830 Waco, TX 76703-0830 1-800-283-9233 Mark III Employee Benefts 114 E. Unaka Ave. Johnson City, TN 37601 1-800-532-1044 x307 www.markiiibrokerage.com/henrycountyschoolsva [email protected]

Page 67