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Mansfield City Schools Teachers

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This benefit guide only provides a summary of your group’s benefits. All lines of coverage described are subject to the definitions, limitations and exclusions set in each insurance carrier or providers contract. Page l Mansfield City Schools Employee Benefits Enrollment Guide Plan Year: January 1, 2023 – December 31, 2023

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This benefit guide only provides a summary of your group’s benefits. All lines of coverage described are subject to the definitions, limitations and exclusions set in each insurance carrier or providers contract. Page l 2 We know that your benefits are important to you and your family. Helping you understand the benefits offered by Mansfield City Schools is important to us. That is why we have created this Benefit Guide. Included in this guide are summary of the benefits, cost information, and contact information for each provider. It is important to remember that only those benefit programs for which you are eligible and have enrolled in apply to you. We encourage you to review each section and to discuss your benefit options with your family members. Be sure to pay close attention to applicable co-payments and deductibles, along with networks and services that may be limited or not covered (exclusions). This guide is not a contract between you and Mansfield City Schools. It is not intended to cover all provisions of all plans but rather is a quick reference to help answer most of your questions. Please see each Benefits Summary Plan Description for complete details. We hope this guide will give you a clear explanation of your benefits and help you be better prepared for the enrollment process. Enrollment ............................................................................................ Page 3 Medical Benefits—Medical Mutual HSA ...................................................... Page 4 Medical Benefits—Medical Mutual PPO ...................................................... Page 5 SmartShopper ....................................................................................... Page 6 Preventative Care .................................................................................. Page 7 Health Savings Account .......................................................................... Page 8 FAQ for the Health Insurance Plan ........................................................... Page 11 Dental Benefits—Medical Mutual .............................................................. Page 12 Vision Benefits—MetLife .......................................................................... Page 14 Group Term Life Insurance—OneAmerica .................................................. Page 18 Voluntary Life Insurance—OneAmerica ..................................................... Page 19 Hospital Indemnity Insurance—MetLife ..................................................... Page 23 Accident Insurance—MetLife .................................................................... Page 26 Critical Illness Insurance—MetLife ............................................................ Page 30 Whole Life Insurance—MetLife ................................................................. Page 37 Employee Assistance Program—New Directions ......................................... Page 39 Contacts ............................................................................................... Page 41 TABLE OF CONTENTS WELCOME

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This benefit guide only provides a summary of your group’s benefits. All lines of coverage described are subject to the definitions, limitations and exclusions set in each insurance carrier or providers contract. Page l 3 HOW TO ENROLL Open Enrollment The first step is to review your current benefit elections. Verify your personal information and make any changes if necessary. Newly Eligible Make your benefit elections and complete the enrollment paperwork. Once you have made your elections, you will not be able to change them until the next open enrollment period unless you have a qualified change in status. WHEN TO ENROLL Open Enrollment Open enrollment period runs from October 31, 2022 through November 11, 2022. The benefits you elect during open enrollment will be effective from January 1, 2023 through December 31, 2023. Newly Eligible You become eligible for coverage on your date of hire. Your current coverages will end if you no longer meet the eligibility requirements, your contributions are discontinued, or the group policy is terminated. Qualifying Events Employees are able to enroll or make changes to their benefits elections during the group’s annual open enrollment period. Once you elect an option you are bound to the decision for the entirety of the plan year unless you have a “qualifying event”. Employees have 30 days from the date of the qualifying event to add or change coverage. These may include, but are not limited to: • Changes in your employment status • Changes in your legal marital status • Change in number of dependents • Taking an unpaid leave of absence • Dependent satisfies or cease to satisfy eligibility requirement • Family Medical Leave Act (FMLA) leave • A COBRA qualifying event • Entitlement to Medicare or Medicaid • A change in the place of residence of the employee, resulting in the current carrier not being available ENROLLMENT

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This benefit guide only provides a summary of your group’s benefits. All lines of coverage described are subject to the definitions, limitations and exclusions set in each insurance carrier or providers contract. Page l 4 Medical Mutual of OH In-Network Non-Network Deductible (Calendar Year—Embedded ) Single $3,000 $3,000 Family $5,000 $5,000 Out-Of-Pocket Maximums (includes deductible) Single $3,000 $4,000 Family $5,000 $7,500 Co-Insurance (plan pays after deductible) 100% 80% Annual Maximum Benefit Unlimited Preventive Care Health Care reform preventative screenings, labs, etc. (See preventative schedule from carrier or full details) Covered at 100% not subject to deductible You pay 20% after deductible Physicians Services Office Visits 0% after deductible You pay 20% after deductible Specialist Visits 0% after deductible You pay 20% after deductible Urgent Care & Emergency Services Urgent Care 0% after deductible You pay 20% after deductible Emergency Room Services for an Emergency Medical Condition 0% Prescription Drugs - 30 Day Supply Generic Prescription Drugs 0% after deductible You pay the entire amount at the Pharmacy and file a claims form with Medical Mutual Preferred Brand Name 0% after deductible Non-Preferred Name Brand 0% after deductible Prescribed Generic Prescription Drug Contraceptives or Brand Name Prescription Drug Contra-ceptives when and equivalent Generic Prescription Drug Con-traceptive is not available 0%, not subject to the Deductible Preventive Prescription Drugs and Vaccines in accordance with state and federal law 0%, not subject to the Deductible Certain Generic Prescriptions Drugs Contained in MMO Pre-ventive Care List $20 Copayment Benefits include but are not limited to: Network Non-Network Maternity 0% after deductible You pay 20% after deductible Inpatient/Outpatient Professional Services 0% after deductible You pay 20% after deductible Inpatient Facility Services (per admission) 0% after deductible You pay 20% after deductible Outpatient Services (per visit) 0% after deductible You pay 20% after deductible Ambulance Services You pay 20% after deductible You pay 20% after deductible MEDICAL - Embedded H.S.A. Plan not available for part time employees. Coverage Options (Full Time Staff) Cost Per 24 Pays Employee Only $32.50 Employee + Family $65.00

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This benefit guide only provides a summary of your group’s benefits. All lines of coverage described are subject to the definitions, limitations and exclusions set in each insurance carrier or providers contract. Page l 5 Medical Mutual of OH In-Network Non-Network Deductible (Calendar Year—Embedded ) Single $1,500 $3,000 Family $3,000 $6,000 Out-Of-Pocket Maximums (includes deductible) Single $4,500 $9,000 Family $9,000 $18,000 Co-Insurance (plan pays after deductible) 80% 60% Annual Maximum Benefit Unlimited Preventive Care Health Care Reform Preventative Screenings, Labs, etc. Covered at 100% not subject to deductible You pay 50% after deductible Physicians Services Office Visits You pay $20 copay You pay 40% after deductible Specialist Visits You pay $40 copay You pay 40% after deductible Urgent Care & Emergency Services Urgent Care You pay $75 copay You pay 40% after deductible Emergency Room Services: You pay $250 Copay Prescription Drugs - 30 Day Supply Generic or Tier 1 You pay $15 copay Name Brand or Tier 2 You pay $40 copay Non-Preferred Name Brand or Tier 3 You pay $65 copay Specialty Drugs You pay $150 copay Prescription Drugs - 90 Day Supply Generic or Tier 1 You pay $30 copay Name Brand or Tier 2 You pay $80 copay Non-Preferred Name Brand or Tier 3 You pay $130 copay Benefits include but are not limited to: Network Non-Network Maternity You pay 20% after deductible You pay 40% after deductible Inpatient/Outpatient Professional Services You pay 20% after deductible You pay 40% after deductible Inpatient Facility Services (per admission) You pay 20% after deductible You pay 40% after deductible Outpatient Services (per visit) You pay 20% after deductible You pay 40% after deductible Ambulance Services You pay 20% after deductible You pay 40% after deductible Coverage Options (Full Time & Part Time Staff) Cost Per 24 Pays Employee Only $81.00 Employee + Family $171.00 MEDICAL - PPO Plan Coverage Options (J-1 VISA Staff) Cost Per 24 Pays Employee Only $32.50 Employee + Family $65.00

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This benefit guide only provides a summary of your group’s benefits. All lines of coverage described are subject to the definitions, limitations and exclusions set in each insurance carrier or providers contract. Page l 7 PREVENTATIVE CARE WHICH PREVENTATIVE CARE SERVICES ARE COVERED? Understanding the full value of covered benefits allows you to take responsibility for maintaining good health and incorporating healthy habits into your lifestyle. Some examples include getting regular physical examinations, mammograms and immunizations. Through the plans offered by Mansfield City Schools, all covered individuals and family members are eligible to receive routine wellness services like these, at no cost; all copays, coinsurance, and deductibles are waived. The US Preventive Services Task Force maintains a regular list of recommend-ed services that all Affordable Care Act (i.e. Health Care Reform) compliant in-surance plans should cover at 100% for in-network providers. Below is a list of common services that are included in the plans offered this year: • Routine Physical Exam • Well Baby and Child Care • Well woman Visits • Immunizations • Routine Bone Density Test • Routine Breast Exam • Routine Gynecological Exam • Screening for Gestational Diabetes • Obesity Screening and Counseling • Routine Digital Rectal Exam • Routine Colonoscopy • Routine Colorectal Cancer Screening • Routine Prostate Test • Routine Lab Procedures • Routine Mammograms • Routine Pap Smear • Smoking Cessation • Health Education/Counseling Services • Health Counseling for STDs and HIV • Testing for HPV and HIV • Screening and Counseling for Domestic Violence “An ounce of prevention is worth a pound of cure.”

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This benefit guide only provides a summary of your group’s benefits. All lines of coverage described are subject to the definitions, limitations and exclusions set in each insurance carrier or providers contract. Page l 8 WHAT IS A HEALTH SAVINGS ACCOUNT? Health Savings Accounts (HSAs) are tax-exempt accounts where funds grow to pay for medical expenses. They were created to help give control back to consumers and lower healthcare costs. HSAs provide a financial incentive for consumers to select an HSA-compatible health plan. These plans have lower monthly premiums than traditional plans. The combination of the two provides consumers with more incentive to shop carefully for healthcare services. WHAT IS AN EMBEDDED DEDUCTIBLE? The advantage of an embedded deductible is that individual family members don’t have to meet the full family deductible to begin receiving after-deductible benefits. Instead, their benefits begin as soon as they meet their individual deductibles. Used to pay qualied out-of-pocket expenses not covered by the health plan, such as services applied to the deducble, dental, vision and certain over-the-counter medicaons. Intended to cover medical expenses aer the deducble is met. Aer your maximum out-of-pocket is reached, all eligible expenses are covered at 100% An HSA is your account. If you switch jobs, the HSA goes with you. Your money rolls over every year. HSA-Compatible Health Plans - Contribution Limits & IRS Guidelines In order to open an HSA, you must have a qualified HSA-compatible health plan. The IRS determines the guidelines for these plans and they are as follows: HEALTH SAVINGS ACCOUNT IRS Limits for 2023 Single Plan Family Plan Minimum Deductible $1,500 $3,000 Maximum Out-of-Pocket $7,500 $15,000 Contribution Limit $3,850 $7,750 Catch-Up Contribution (55 or older)* $1,000 $1,000 * If a spouse is also 55 or older until enrolled in Medicare, a second HSA may be established in spouse’s name and a second contribution of $1,000 could be made to that account. IRS Limits for 2022 Single Plan Family Plan Minimum Deductible $1,400 $2,800 Maximum Out-of-Pocket $7,050 $14,100 Contribution Limit $3,650 $7,300 Catch-Up Contribution (55 or older)* $1,000 $1,000 * If a spouse is also 55 or older until enrolled in Medicare, a second HSA may be established in spouse’s name and a second contribution of $1,000 could be made to that account.

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This benefit guide only provides a summary of your group’s benefits. All lines of coverage described are subject to the definitions, limitations and exclusions set in each insurance carrier or providers contract. Page l 9 Why Open an HSA? Flexible Options • Even if your HSA-compatible coverage ends, you can still use your HSA funds tax-free for future eligible medical dental, & vision care expenses. • Contributions can come from employers, accountholders, or third parties, until your Federal Tax Filing deadline for the prior Calendar Year if indicated as that Calendar Year’s Contribution. • There is no “use it or lose it” philosophy. If you don’t use it, save it for next year. Or better yet, for retirement. • You can fund your HSA with an existing HSA, MSA, or IRA. • You’re in control. You choose when to use your HSA or pay out-of-pocket. • After age 65, HSA funds can be used for non-qualified expenses and only income tax is assessed. Tax Advantages • HSA contributions are tax-free or third-party or tax-deductible. • Withdrawals are tax-free when used to pay for qualified medical, dental, & vision care expenses. See Internal Revenue Code Section 213(d) list attached • Earnings grow tax-deferred. Long-term Investment Opportunities • HSA funds can be invested for greater earning potential. • Choose from a wide variety of stocks, bonds and mutual funds (fees and charges my apply) When you have a qualifying HDHP, the following contribution guidelines apply. • Anyone can contribute to your HSA. • Your contributions are tax deductible. • If your employer contributes to your HSA, that contribution is done on a pre-tax basis. • Any pay-roll reductions made through Section 125 for your HSA are also on a pre-tax basis. • You may contribute the annual maximum amount as determined by the IRS, regardless of your qualified health plan’s deductible. The maximum for 2023 is $3,850 for individuals and $7,750 for families. Contributions HEALTH SAVINGS ACCOUNT

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This benefit guide only provides a summary of your group’s benefits. All lines of coverage described are subject to the definitions, limitations and exclusions set in each insurance carrier or providers contract. Page l 10 • Acupuncture • Alcoholism Treatment • Ambulance • Artificial Limb • Artificial Teeth • Bandages • Birth Control Pills (by prescription) • Breast Reconstruction Surgery (mastectomy) • Car Special Hand Controls (for disability) • Certain Capital Expenses (e.g. for the disabled) • Chiropractors • Christian Science Practitioners • COBRA premiums • Contact Lenses & Cleaning / Soaking Solutions • Cosmetic Surgery (if due to trauma or disease) • Crutches • Dental Treatment • Dermatologist • Diagnostic Devices • Disabled Dependent Care Expenses • Drug Addiction Treatment (inpatient) • Drugs (prescription) • Elastic Hosiery (prescription) • Eyeglasses • Fertility Enhancement • FICA and FUTA tax paid for medical care services • Guide Dog • Gum Treatment • Gynecologist • Health Institute (if prescribed by physician) • H.M.O. (certain expenses) • Hearing Aids • Home Care • Hospital Services • Laboratory Tests • Lasik Surgery • Lead-Based Paint Removal • Learning Disability Fees (prescription) • Legal Fees (if for mental illness) • Life-Care Fees • Lodging (for out-patient treatment) • Long-Term Care (medical expenses) • Long-Term Care Insurance (allowable limits) • Lodging (for out-patient treatment) • Meals (associated with receiving treatments) • Medical Conferences (ill spouse/dependent) • Medicare Deductibles • Medicare Premiums • Mentally Retarded (specialized homes) • Nursing Care • Nursing Homes • Obstetrician • Operating Room Costs • Operations - Surgical • Ophthalmologist • Optician • Optometrist • Organ Transplant (incl. donor’s expenses) • Orthodontia Services • Orthopedic Shoes • Orthopedist • Osteopath • Out-of-pocket expenditures, Copays and Deductibles for your spouse or Federal Income Tax Dependent even if insured under a non-HSA health plan • Oxygen and Equipment • Pediatrician • Personal Care Services (for chronically ill) • Podiatrist • Post-Nasal Treatments • Prenatal Care • Prescription Medicines • Prosthesis • PSA Test • Psychiatric Care / Psychiatrist • Psychoanalysis / Psychoanalyst • Psychologist • Qualified Long-Term Care Services • Physician monitored weight loss program • Radium Treatment • Smoking Cessation Programs • Special Education for Children (ill / disabled) • Specialists • Spinal Tests • Splints • Sterilization • Surgeon • Telephones & TV for the Hearing Impaired • Telehealth Services • Therapy • Transportation Expenses for Health Care Treatment • Ultra-violet ray Treatment • Vaccines • Vasectomy • Vitamins (if prescribed) • Weight Loss Programs • Wheelchair • Wig (hair loss from disease) • X-Rays • Antacids • Allergy Medications • Pain relievers • Cold Medicine • Anti-diarrhea medicine • Cough drops and throat lozenges • Sinus medications and nasal sprays • Nicotine medications and nasal sprays • Pedialyte • First aid creams • Calamine lotion • Stop-smoking programs • Wart removal medication • Antibiotic ointments • Suppositories and creams for hemorrhoids • Sleep Aids • Menstrual Care Products • Motion sickness pills • Needed material for Quarantine and Social Distancing Eligible Medical Expenses (for HSA Distributions) Ineligible Medical Expenses • Baby Sitting, Childcare, and Nursing Services for a Normal, Healthy Baby • Controlled Substances • Cosmetic Surgery • Dancing Lessons • Diaper Service • Electrolysis or Hair Removal • Flexible Spending Account • Funeral Expenses • Future Medical Care • Hair Transplant • Health Club Dues • Health Coverage Tax Credit • Health Savings Accounts • Household Help • Illegal Operations and Treatments • Insurance Premiums • Maternity Clothes • Medical Savings Account (MSA) • Medicines and Drugs From Other Countries • Nonprescription Drugs and Medicines ** • Nutritional Supplements • Personal Use Items • Premiums for Life & Disability insurance, Income protection. • Specialty designed care for handicapped other than an Autoette or Special Equipment • Stop-smoking programs • Swimming Lessons • Teeth Whitening • Veterinary Fees • Weight-Loss Program • Toiletries (including toothpaste) • Acne Treatments • Lip balm (including Chapstick or Carmex) • Suntan lotion • Medicated shampoos and soaps • Vitamins (daily) • Fiber supplements • Dietary supplements • Weight loss drugs for general well being • Herbs • Any Non-Prescription medication starting January 1, 2011—December 31, 2019 Over-the-Counter Drugs Over-the-Counter Drugs Eligible Medical Expenses eligible expense is defined as an expense for certain healthcare services, equipment, and medications as described in Section 213(d) of the Internal Revenue Code. Below are two lists which may help determine whether an expense is eligible These lists are not comprehensive but are meant to serve as a quick reference. They have been provided to you with the understanding that Keystone Insurance & Benefits Group is not engaged in rendering tax advice. This information can not be used to avoid federal tax pena lties. For more detailed information please refer to IRS Publication 502 titled “Medical and Dental Expenses”. Publications can be ordered directly from the IRS by calling 1-800-TAX-FORM or by visiting www.irs.gov. If tax advice is required, you should seek the services of a qualified professional. HSA MEDICAL EXPENSES

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This benefit guide only provides a summary of your group’s benefits. All lines of coverage described are subject to the definitions, limitations and exclusions set in each insurance carrier or providers contract. Page l 11 FAQ for the Health Insurance Plan • Since you are participating in a High Deductible Health Plan, you are eligible to participate in a health savings account (HSA). This allows you to fund your deductible tax deferred. • The district insurance plan is a High Deductible Health Plan (HDHP) - if you elect family coverage you can’t have PPO or HMO coverage for other family members. • The single deductible will be $3,000 and the family deductible will be $5,000. • Your insurance is effective on day 1 of your employment. You will be prompted by an email to elect coverage, if you are not electing our insurance you will need to log in and elect your term life insurance that is paid by the district. • To receive funds from the district for the HSA account you will need to visit a doctor and have a dental exam. You will need to send your documentation electronically to hsadocs@mansfieldschools.org • Doctor and dental exam period to submit: November 1 of the year prior until October 31st of the current year. If hired after July 1, the doctor and dental note will cover the current and next calendar year. • You will need to enroll into your health insurance within 30 days from your date of hire and when we have open enrollment in the fall of 2022. After this, you will only have to enroll annually. • You must go to a Mechanics Bank to open an HSA account, at any location. Let them know you are employed with Mansfield City Schools; they will help you open your HSA account. You will need to bring the account information to the Treasurer’s office so that we can send your deposits. • The deposits take some time to process—you will see it as an item on your pay stub, then it needs to be sent to Mechanics, then they will need time to post. This may take up to 2 weeks from the pay date. The district contribution for the HSA will be as follows: with submission of doctor and dentist documentation  Employee premiums are outlined in the negotiated agreement. See that for further details.  See the negotiated agreement for additional ways to earn HSA contributions from the district.  PPO option is available; however, the employee contribution is more then the HDHP.  If your spouse has insurance available at their employer, but you elect our coverage you will receive $500 less of the annual HSA contribution. 2022 2023 2024 2025 FAMILY $3,000 $3,000 $2,800 $2,600 SINGLE $1,800 $1,800 $1,700 $1,600

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This benefit guide only provides a summary of your group’s benefits. All lines of coverage described are subject to the definitions, limitations and exclusions set in each insurance carrier or providers contract. Page l 18 GROUP TERM LIFE INSURANCE As an employee of Mansfield City Schools, basic life insurance is provided to you at no cost. OneAmerica Plan Features Basic Life Insurance Employee Benefit Amount $40,000 AD&D Benefit $40,000

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This benefit guide only provides a summary of your group’s benefits. All lines of coverage described are subject to the definitions, limitations and exclusions set in each insurance carrier or providers contract. Page l 41 The information in this Enrollment Guide is presented for illustrative purposes and is based on information provided by the employer. The text contained in this Guide was taken from various summary plan descriptions and benefit information. While every effort was taken to accurately report your benefits, dis-crepancies or errors are always possible. In case of discrepancy between the Guide and the actual plan documents the actual plan documents will prevail. All information is confidential, pursuant to the Health Insurance Portability and Accountability Act of 1996. If you have any questions about your Guide, contact Human Resources. Medical Mutual Customer Service 1-800-382-5729 www.medmutual.com CONTACT INFORMATION Title Name Email Phone Number Director of Sales Joe Turi jturi@keystoneinsgrp.com 216-217-4185 Account Manager Kelly Smith ksmith@rfmeins.com 419-524-8411 Account Coordinator Rodney Pritchard Sandra Woodiwiss rpritchard@keystoneinsgrp.com swoodiwiss@keystoneinsgrp.com 574-406-6919 574-406-6232 Service Team General serviceteam@keystoneinsgrp.com 574-231-6500 877-691-5424 13800 Jackson Rd Mishawaka | IN 46544 keystoneinsgrp.com MetLife Customer Service 1-800-638-5433 www.metlife.com SmartShopper Customer Service 1-877-292-1541 www.medmutual.smartshopper.com Copyright © Keystone Benefits - all rights reserved OneAmerica Customer Service 1-800-249-6269 www.oneamerica.com