Port Lavaca Clinic - Employee Benefit Guide : simplebooklet.com

Port Lavaca Clinic __________________________________________ __ Port Lavaca Clinic thrives on balance balancing professional and personal worlds balancing work and rest while always balancing cost and value We also understand that balance must be individualized What is right for one person may not be appropriate for another It is our goal to offer choices allowing you to tailor your benefits plan specifically to what is best for you and your family members Why do I pay for some benefits with before tax money While not all benefits qualify for pre tax contribution there is a definite advantage to paying for those that do Taking the money out before your taxes are calculated lowers the amount of your taxable income Therefore you pay less in taxes How Your Benefits Work Full time employees are eligible for most benefits on the first day of the month following 30 days of hire _____________________________________ Your Choices Port Lavaca Clinic Provides a complete package of ___ benefits aimed at providing flexible insurance protection and programs to meet your ever changing needs Port Lavaca Clinic shares the cost of some benefits ___ with you while making additional benefits available that you pay for if you choose to enroll The part of the benefit costs that you are responsible for will be automatically deducted from your paycheck either before or after your taxes are calculated Benefit Pre Tax or Post Tax Who pays the cost Health Insurance Pre Tax Employer Shared Dental Insurance Pre Tax Employee Paid Vision Insurance Pre Tax Employee Paid Voluntary Life Insurance Post Tax Employee Paid Short Term Disability Post Tax Employee Paid Long Term Disability Post Tax Employee Paid Accident Post Tax Employee Paid Critical Illness Post Tax Employee Paid Hospital Indemnity Post Tax Employee Paid Making Changes Generally you can only change your benefits choices during the annual Benefits Enrollment Period However you can change your benefits choices during the year if you have a life event change Life event changes include but are not limited to Marriage Divorce Birth adoption or placement for adoption of an eligible child Death of your spouse or covered child Change in you or your spouse s work status that results in cancellation of your benefits Becoming eligible for Medicare or Medicaid during the year If you have a life event change you must notify Human Resources within 31 days of the change for example a marriage or birth certificate If you do not notify Human Resources within 31 days you will have to wait until the next annual Open Enrollment period to make benefits changes unless you have another life event change Any changes you make to your benefit choices must be directly related to the life event change

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Portability If you leave the company some of your benefits end and some of your benefits are portable This means you can take them with you if you leave as long as you continue to pay the premiums yourself Once terminated you will be notified through the mail if any of your benefits are portable When Coverage Ends Benefits end on the last day of the month following termination or when you cease to meet eligibility guidelines Continuing Your Coverage Under certain circumstances you may continue your health care coverage when it would otherwise end This is Cobra called ________________ Cobra applies to these plans Health Insurance Dental Insurance Vision Insurance NOTES _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ When can I continue coverage under Cobra ____________________ You and or your dependents are eligible to continue Cobra health care coverage under ________________________ If coverage is lost because Your employment ends for any reason other than gross misconduct Your work hours are significantly reduced You die You become entitled to and enroll in Medicare prior to losing coverage You divorce or become legally separated from your spouse Your dependent loses dependent status Looking ahead Now let s look at each benefit that makes up the Port Lavaca Clinic benefits program In the following pages you ll learn more about the valuable benefits your employer offers You ll also see how choosing the right combination of benefits can help protect you and your family s health

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TX 100 50 EHDHP 19 PPO Opt 4 LFP TX PPO Copay Opt 49 In Out In Out Deductible 6 250 25 000 5 500 22 000 Family Deductible 12 500 50 000 11 000 44 000 Coinsurance 100 50 100 50 Out Of Pocket 6 250 12 500 30 000 60 000 8 550 17 100 34 200 68 400 Office Visit 100 After Ded 50 After Ded 35 Copay 50 After Ded Specialty Doctor Office Visit 100 After Ded 50 After Ded 70 Copay 50 After Ded Inpatient Hospital Services 100 After Ded 50 After Ded 100 After Ded 50 After Ded Preventative Lab X Ray 100 After Ded 50 After Ded 100 After Ded 50 After Ded Advanced Imagining 100 After Ded 50 After Ded 900 Copay 50 After Ded Urgent Care 100 After Ded 50 After Ded 100 Copay 50 After Ded Emergency Room 100 After Ded As Inn 900 Copay As Inn RX 100 After Ded 50 After Ded 5 20 50 100 450 30 After Network Copay No PCP No Bi Weekly Rate Semi Monthly Rate Bi Weekly Rate Semi Monthly Rate Employee Only 102 97 111 56 141 73 153 54 Employee Spouse 226 54 245 42 311 80 337 78 Employee Child ren 195 65 211 96 269 28 291 72 Employee Family 329 53 356 99 453 53 491 32

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Group Dental Group Dental Class All Eligible Employees Plan design and rates Plan design summary Dental plan overview Eligible Employees All Full Time United States Employees working in the United States who are scheduled to work a minimum of 30 hours per week Effective Date Plan type May 1 2023 PPO Dental PPO Network Sun Life Dental NetworkSM In Network Reimbursement Sun Life Dental NetworkSM Out of Network Reimbursement 90th Percentile of the Usual and Customary Charge This plan includes Child Only Orthodontic coverage Orthodontic coverage Type IV A person must be covered under a Dental Plan to be eligible for Orthodontic coverage Dependent Coverage Children Children to age 26 Open enrollment at Issue and each Annual Enrollment Yes Employee coverage contributions Employee pays for a portion or all of the cost of Employee coverage Dependent coverage contributions Employee pays for a portion or all of the cost of Dependent coverage The listed coinsurance percentages shown below represent the portion of Sun Life s allowable charge for which the plan will be responsible Network providers agree to accept the network s allowable charge for covered services as payment in full If covered employees or their eligible dependents receive services from a non network provider Sun Life will apply the coinsurance percentages shown below to 90th Percentile of the usual and customary charge for covered services and they will be responsible for the difference up to the provider s charge

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Calendar Year Deductible Procedure Type In Network Deductible Type I Preventive Services Type II Basic Services Type III Major Services Out of Network Deductible Not applicable 50 individual 150 family Type IV Ortho Services 50 individual 150 family Not applicable Deductible values are combined between In Network and Out of Network Coinsurance In Network Out of Network Type I Preventive Services 100 100 Type II Basic Services 80 80 Type III Major Services 50 50 Type IV Ortho Services 50 50 Benefit Waiting Periods A Late Entrant Benefit Waiting Period of 6 months for Type II Basic Restorations 12 months for all other Type II Basic Services and 12 months for Type III Major Services will apply to employees who enroll in this dental plan more than 31 days after becoming eligible A Late Entrant Benefit Waiting Period of 12 months for Type IV Orthodontic Services will apply to employees who enroll in this dental plan more than 31 days after becoming eligible Calendar Year Maximum Benefit In Network Out of Network Types I II and III Preventive Basic and Major Services 1 500 per person 1 500 per person Type IV Ortho Services 1 500 lifetime per child under age 26 1 500 lifetime per child under age 26

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Covered expenses Type I Preventive covered dental expenses Coverage limitations Oral Evaluations 2 in any 12 consecutive months Dental Prophylaxis Cleanings 2 per 12 months is limited to 2 of these services in any 12 consecutive month period Fluoride Treatments Covered Persons under age 14 1 in any 6 consecutive months Sealants Covered Persons under age 14 Once per tooth per 36 consecutive months on permanent first and second molars Bite Wing X Rays 1 in 12 consecutive months Intraoral X Rays Type II Basic covered dental expenses 4 Films in any 12 month period Full Mouth X Rays 1 in 24 consecutive months Paid as a separate benefit only if no treatment except x rays was rendered during the visit No Limitation Once per tooth surface in any 24 consecutive months Palliative Treatment Simple Extractions Amalgam Restorations Composite and Silicate Restorations Space Maintainers Type III Major covered dental expenses Inlays and Onlays Crowns Crown Buildup Full or Partial Dentures Fixed Bridges Coverage limitations Once per tooth surface in any 24 consecutive months and excluding posterior teeth Covered Persons under age 19 Once per tooth in any 3 year period Coverage limitations Covered if tooth cannot be restored by fillings Once per tooth in any 10 years period Covered if tooth cannot be restored by filling or other means Once per tooth in any 10 years period Once per 10 years Once in any 10 years Once in any 10 years Periodontal Maintenance Periodontal Maintenance following active Periodontal Therapy 2 per 12 months Periodontics Non Surgical Scaling and Root Planing Once per 24 consecutive months per area of the mouth Surgical Periodontics Endodontics Root Canal Therapy Oral Surgery Surgical Extraction of Erupted and Impacted Teeth General Anesthesia Once per 36 consecutive months per area of the mouth Root Canal Therapy is limited to 1 time per tooth in any consecutive 24 months period Multiple surgical services on 1 area of the mouth will be based on the most inclusive procedure Benefits payable as a separate expense only when required for the surgical extraction of an impacted tooth

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Group Vision Group Vision Vision Insurance Schedule Full Service Benefit Exam Services WellVision Exam Laser Vision Correction Discount Lenses Single Lined Bifocal Lined Trifocal Lenticular Necessary Contacts Frequency In Network Member Cost 1 per 12 months 10 Once per eye per lifetime 1 per 12 months Average 15 off the regular price or 5 off the promotional price Discounts only available from contracted facilities Frames Includes a wide selection of frames at Walmart Elective Contact Lenses Contact lenses are in place of lenses and frame Additional Glasses and Sunglasses Discount Coverage with Retail Providers N A 25 lenses and frame Lens Enhancements Standard progressive Premium progressive Custom progressive Out of Network Benefit Up to 45 Up to 30 Up to 50 Up to 60 Up to 100 Up to 210 N A No cost 95 105 copay 150 175 copay Average savings of 20 25 on other lens enhancements 1 per 24 months 150 for the frame of your choice and 20 off the amount over your allowance 80 allowance at Costco 1 per 12 months Up to 60 15 savings for your contact lens exam fitting and evaluation 150 for contact lenses 20 off additional glasses and sunglasses including lens options from the same VSP doctor on the same day as your exam Or get 20 off from any VSP doctor within 12 months of your last exam Coverage with retail providers may be different Check with Costco and Walmart for VSP member pricing The Costco allowance is equivalent to the allowance at preferred providers and other retail providers Up to 70 Up to 105 N A

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Voluntary Life and AD D Voluntary Life and AD D Plan Design PLAN ELEMENT Benefit amount Maximum benefit Guaranteed issue amount Class 1 ALL ACTIVE FULL TIME EMPLOYEES Increments of 10 000 5 times BAE up to 300 000 100 000 AD D Benefit amount Same as Voluntary Life benefit AD D Maximum Same as Voluntary benefit Life benefit AD D Minimum benefit Same as Voluntary Life benefit Contributions Participation requirement Contributory 41 of eligible employees Voluntary Life and AD D Plan Design Dependent PLAN ELEMENT Class 1 ALL ACTIVE FULL TIME EMPLOYEES Spouse Benefit amount Increments of 5 000 Spouse Maximum 100 of Employee amount Voluntary Amount up to 100 000 Spouse GI Amount 25 000 Spouse Term age N A Child benefit 6 mo or older Increment of birth to

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Plan Design Summary Plan 1 Included Benefits Life waiver of premium Life waiver of premium Included premium is waived to age 67 if disabled prior to age 60 with no elimination period to satisfy Continuation of Life coverage Layoff or leave of absence up to 2 months Sabbatical up to 12 months Injury Sickness up to 12 months Employees who are insured for life and LTD with SLF MGIS and who do not qualify for life waiver may continue their life coverage with premium payment if they are receiving an LTD benefit from Sun Life Accelerated Death benefit Up to 75 of benefit to maximum of 500 000 Portability Included Conversion Included Employee age reductions Age 65 65 of pre 65 benefit Age 70 50 of pre 65 benefit Spouse age reductions Age 65 65 of pre 65 benefit Age 70 50 of pre 65 benefit Special AD D benefit Air Bag benefit 10 of AD D benefit to a maximum of 5 000 Child Care benefit 2 of AD D benefit to a maximum of 2 000 Dependent Child Education benefit 3 of AD D benefit to a maximum of 2 500 Dependent Spouse Education benefit Up to a maximum of 3 000 Seat Belt benefit 25 of AD D benefit to a maximum of 25 000

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Group Accident Accident insurance Sun Life s Accident Plan provides accident insurance protection for a wide range of covered benefits Injured employees and their dependents may use the cash benefits however they want to satisfy deductibles pay out of pocket medical expenses or pay household bills for example Here are some highlights Guaranteed Issue A Wide Range of Covered Benefits Benefits for injuries are payable once for each covered accident unless stated otherwise in the certificate and benefits for hospital stays and related care are payable up to a specific number of days or visits for each covered accident Categories of Coverage For Injuries Insureds will receive a payment for covered dislocations fractures lacerations burns and other injuries For Diagnosis and Services Insureds will receive a payment for related covered medical services ranging from X rays to office visits hospital services including emergency room admissions and ambulance rides surgeries and emergency dental crown and extraction For Loss The plan includes accidental death and dismemberment coverage and pays benefits for loss of hearing and for loss of sight occurring as a result of a covered accident Coverage for Families Employees can add coverage for spouses and dependent children Wellness screening benefit To promote healthy lifestyles and early detection we will pay employees a defined amount once per calendar year when we receive proof of an eligible health screening like an electrocardiogram We may also pay the employee for spouse or child screening see Plan Design and Rates Portable Employees who terminate employment and who meet other eligibility criteria may apply to port accident insurance Accident insurance is a limited benefit policy It provides accident coverage only It does not provide basic hospital basic medical or major medical insurance The certificate and its riders have exclusions and limitations that may affect any benefits payable Benefits payable are subject to all terms and conditions of the certificate The policy certificate and any rider may not be available in all states If permitted by the Employer s employee benefit plan and not prohibited by state law or if the group s situs state is Oregon or Washington the term spouse in this benefit includes any individual who is either recognized as a spouse a registered domestic partner or a partner in a civil union or otherwise accorded the same rights as a spouse

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Accident insurance Plan design and rates Accident Insurance plan design Eligible employees Effective Date Participation requirement Class description Eligibility Waiting Period Contributions Member direct billing All Full Time United States Employees working in the United States who are scheduled to work a minimum of 20 hours per week May 1 2023 5 enrolled employees Class 1 All Eligible Employees First of the month following 30 days of employment Contributory Not included Covered benefits Life and Dismemberment Losses Accidental Death Accidental Death Common Carrier Catastrophic Loss Both arms or both hands both legs or both feet one hand and one foot or one arm and one leg or irrecoverable loss of sight of both eyes One hand one foot one leg one arm Loss of sight of one eye or loss of one eye Two or more fingers or toes One finger or one toe Loss of hearing of one ear or loss of one ear 50 000 200 000 25 000 15 000 15 000 3 000 1 500 5 000 Dislocations Hip Knee ankle or bones of the foot Elbow wrist Shoulder Collarbone bones of the hand or Lower jaw Finger s or toe s Open 8 000 4 000 Closed 4 000 1 000 2 000 400 1 000 200

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Fractures Hip or thigh Skull depressed Skull simple Vertebral processes Bones of the face Nose Upper jaw upper arm Lower jaw Collarbone Shoulder Forearm Hand Wrist Foot Ankle Kneecap Elbow or Heel Leg Vertebrae or Sternum Pelvis Rib Finger Toe or Coccyx Multiple ribs Additional Injuries Eye Injury surgical repair Eye Injury object remove Gunshot wound Paralysis paraplegia Paralysis quadriplegia Coma Concussion Lacerations No sutures and treated by doctor Single laceration under 5 cm with sutures 5 15 cm with sutures total of all lacerations Greater than 15 cm with sutures total of all lacerations Open 6 000 10 000 5 000 Closed 3 000 5 000 2 500 1 500 3 000 3 200 600 2 000 750 1 500 1 600 300 1 000 250 250 500 25 000 50 000 10 000 100 35 65 250 500 Burns 20 40 square centimeters 40 65 square centimeters 65 160 square centimeters 160 225 square centimeters More than 225 square centimeters Skin graft 2nd Degree 3rd Degree 400 1 000 800 2 000 1 200 6 000 1 600 14 000 2 000 20 000 50 of the applicable Burn Benefit

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Medical Services Diagnostic Exam Arteriogram Angiogram CT CAT EKG EEG or MRI 1 time per benefit year Diagnostic Exam X ray 1 time per covered accident Accident Emergency Treatment nonemergency room once per covered accident Physician s Follow up Treatment office visit per visit up to 6 times per covered accident Physical Therapy per visit up to 10 visits per covered accident Medical Devices Epidural Pain Management up to 2 times per covered accident Prescription drug Prosthesis one Prosthesis two Blood Plasma or Platelet Transfusion Hospital Hospital Admission once per benefit year Hospital Confinement per day up to 365 days per covered accident Intensive Care Unit Admission once per Benefit Year payable instead of Hospital Admission benefit if Confined immediately to ICU Intensive Care Unit Confinement per day up to 14 days payable in addition to any Hospital Confinement benefit Ambulance Ground Ambulance Air Emergency Room Admission Family Lodging per day up to 30 days per benefit year Transportation 100 or more miles up to 3 times per covered accident Rehabilitation Unit per day up to 30 days per covered accident Surgery Miscellaneous Surgery requiring general anesthesia not covered by any other benefit Open Surgery Exploratory Surgery or Debridement Tendon Ligament Rotator Cuff Tear Torn Knee Cartilage Ruptured Herniated Disc 200 100 150 100 50 500 150 50 500 1 000 200 2 000 400 3 000 500 400 2 000 200 100 500 100 750 2 500 500 1 250 1 250 1 250

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Group Critical Illness Critical Illness Plan design and rates Eligible employees Effective Date Class description All Full Time United States Employees working in the United States who are scheduled to work a minimum of 30 hours per week May 1 2023 Class 1 All Eligible Employees EMPLOYEE Benefit amount Guaranteed issue amount Eligibility waiting period Contributions Member direct billing Employer contribution Participation requirement Policy issue requirement Benefit amounts may range from 5 000 to 10 000 in 5 000 increments 10 000 First of the month following 30 days of employment Contributory Not included 0 15 5 enrolled employees CHILD Benefit amounts may range from 2 500 to 5 000 in 2 500 increments Amount cannot exceed 100 of the employee amount 10 000 Amount cannot exceed 50 of the employee amount 5 000 N A Contributory Not included 0 N A N A N A Contributory Not included 0 N A N A Class 1 All Eligible Employees Class description Core conditions Heart attack Stroke Major organ failure End stage kidney disease Occupational HIV Hepatitis B C or D Coronary artery bypass graft Angioplasty Cancer conditions Invasive cancer Non invasive cancer Skin cancer Supplemental conditions option 1 Complete blindness Loss of speech Complete loss of hearing Supplemental conditions option 2 Benign brain tumor Paralysis Coma Severe burns SPOUSE Benefit amounts may range from 5 000 to 10 000 in 5 000 increments Initial Diagnosis Recurrence 100 100 100 100 100 25 5 100 of face amount 100 of face amount 100 of face amount 100 of face amount N A 25 of face amount 5 of face amount 100 25 5 100 of face amount 25 of face amount 5 of face amount 100 100 100 N A N A N A 100 100 100 100 N A N A N A N A Group Critical Illness coverage is underwritten by Sun Life Assurance Company of Canada Wellesley Hills MA under Policy Form Series 12 GP 01 12 SD C 01 13 SD C 01 16 SD C 01 15 GP 01 12 SDPort C 01 13 SDPort C 01 16 SDPort C 01 12 SD R 01 and 13 SD R 01 subject to state availability March 1 2023 Proposal for Port Lavaca Clinic Associates P A Case ID 2160848 rev 06090615 GCIOT 6288

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Supplemental conditions option 3 Advanced ALS or Lou Gehrig s disease Advanced Alzheimer s Advanced Parkinson s Childhood conditions child only Down syndrome Cerebral palsy Cystic fibrosis Cleft lip palate Type 1 diabetes mellitus Muscular dystrophy Complex congenital heart disease Spina bifida Wellness benefit Annual wellness screening benefit 100 25 25 N A N A N A 100 100 100 100 100 100 100 100 N A N A N A N A N A N A N A N A Employee 50 Spouse 50 Child 50 Additional Provisions Additional occurrence waiting period Maximum benefit Recurrence waiting period Cancer recurrence waiting period Recurrence maximum Pre existing conditions limitation 6 Months between diagnosis 1 time per condition 12 months 12 months Unlimited 12 12

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Critical Illness rates Class 1 Employee benefit Age band Under age 25 25 29 30 34 35 39 40 44 45 49 50 54 55 59 60 64 65 69 70 74 75 and over Rate basis Per 1 000 of coverage Uni Tobacco Monthly rate 0 57 0 64 0 83 1 16 1 68 2 40 3 38 4 36 5 33 6 67 8 86 11 73 Class 1 Spouse benefit Age band Under age 25 25 29 30 34 35 39 40 44 45 49 50 54 55 59 60 64 65 69 70 74 75 and over Rate basis Per 1 000 of coverage Uni Tobacco Monthly rate 0 57 0 64 0 83 1 16 1 68 2 40 3 38 4 36 5 33 6 67 8 86 11 73 The employee s age is used to determine rates Class 1 Child benefit Coverage All age bands Rate basis Per 1 000 of coverage Monthly Wellness Premium if included in your choice Monthly add on rate Wellness Benefit Employee 50 1 25 Monthly rate 0 13 Spouse 1 25 The wellness premium will be added to the elected Critical Illness premium amounts Child No charge

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Group Hospital Indemnity Hospital Indemnity Help employees with out of pocket medical costs incurred with a hospital stay Sun Life s Hospital Indemnity plan provides flexible options that make it easy to meet cost and coverage goals Employees with hospital stays of 10 days or more may receive additional Extended Hospitalization benefits Here are some benefits available under our Hospital Indemnity plan You can work with your employee benefits representative to customize your plan with these benefits Please refer to the plan design and rates section of this proposal for the benefits being proposed for your employees State variations will apply No health questions required to enroll Covered conditions Plans can include coverage for hospital confinements due to accident and sickness mental and nervous disorders substance abuse routine pregnancy and newborn routine care Benefit options Benefits are available for hospital confinements stays in rehabilitation units intensive care units intermediate step down units emergency room treatment and more First Day benefits Benefits can include a First Day Hospital or First Day ICU Benefits can add up Add additional value to your plan by including the option for benefits such as First Day Hospital Confinement or ICU benefits to be paid on the same day Extended Hospitalization benefit Covered employees and dependents with hospital ICU confinements of 10 consecutive days or more can receive additional benefits for the duration of their confinement No lifetime maximums There is no limit to the number of hospital claims that may be submitted This may be of particular interest to employees with chronic conditions Portable In approved states employees who terminate employment and who meet other eligibility criteria may apply to port this insurance In other states Continuation will be available Complements other plans Hospital Indemnity complements Critical Illness Cancer and Accident coverage in their goal to help protect employees from out of pocket medical expenses Benefits are paid regardless of what other coverages employees may have Wellness Screening Benefit When included this benefit can help to promote healthy lifestyles and early detection We will pay employees a defined amount once per benefit year when we receive proof of an eligible health screening full list enclosed if included We may also pay the employee for spouse or child screening Hospital Indemnity Insurance is a limited benefit policy It does NOT provide basic hospital basic medical or major medical insurance It is not a Medicare Supplement policy The certificate has exclusions limitations and benefit waiting periods for certain conditions that may affect any benefits payable Benefits payable are subject to all terms and conditions of the certificate The policy certificate and any rider if applicable may not be available in all states and may vary based on state laws and regulations

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Hospital Indemnity insurance Plan design and rates Eligible employees Effective Date Policy issue requirement All Full Time United States Employees working in the United States who are scheduled to work a minimum of 30 hours per week May 1 2023 5 enrolled employees Class 1 Class description Eligibility Waiting Period Contributions Member direct billing Employer contributions First Day Benefits Payable per benefit year First Day Hospital First Day ICU Confinement Benefits Payable per benefit year Hospital Confinement ICU Confinement All Eligible Employees First of the month following 30 days of employment Contributory Not included Employee 0 Spouse 0 Child ren 0 Family 0 500 per day 1 day 1 000 per day 1 day 100 per day 30 days 100 per day 15 days Additional Enhanced Benefits Payable per benefit year Wellness Screening 50 per day 1 day per insured per benefit year Covered Conditions Newborn Care Complications of Pregnancy Normal Pregnancy Normal Pregnancy Waiting Period Mental Nervous Substance Abuse Sickness and Accidents Pre existing Condition Limitation Complications only payable under Hospital or ICU Confinement Included Included 9 Months Included Included Sickness 24 hour coverage Accident 24 Hour coverage Not included Hospital Indemnity monthly rates Employee only Employee and Spouse Employee and Children Employee and Family 25 48 43 24 37 02 54 78

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Definitions State variations may apply and not all definitions below may apply to your plan Benefit year means a calendar year beginning on January 1 of any year and ending on December 31 of that year Confinement means on the advice of a Physician the assignment of a person to a bed as a resident inpatient in a Hospital for not less than 20 continuous hours There must be a charge for room and board The requirement that an Insured be charged for room and board does not apply to confinement in a Veteran s Administration Hospital or other federal government operated Hospital Observation unit is not covered under First day Hospital Confinement or First Day ICU benefit An Observation Unit stay of 20 hours or more will be covered under the Daily Hospital Confinement Benefit Confinement does not include that period of time during which an Insured is in a Hospital Emergency Room Observation Room a freestanding surgical facility or an outpatient facility Confinement does not include a newborn child s initial confinement in a Hospital following birth for routine medical and nursing care except as specifically provided for in the Newborn Nursery Confinement if covered under your plan Covered Accident means an Accident that is not excluded by the Policy or applicable riders or endorsements attached to it Covered Sickness means a Sickness that is not excluded by the Policy or applicable riders or endorsements attached to it Hospital means a facility licensed in the applicable jurisdiction that provides medical care and Treatment to sick and injured persons on an Inpatient basis with 24 hour nursing service by or under the supervision of a Physician Hospital does not include a rest home a Skilled Nursing Facility an extended care facility a place of convalescence a Rehabilitation Unit a Hospice Facility a place providing custodial care a Mental and Nervous Disorder Facility or a Substance Abuse Facility Hospital Intensive Care Unit ICU means a specifically designated part of a Hospital called an intensive care unit that provides the highest level of medical care and is restricted to patients who are critically ill or injured and who require intensive comprehensive observation and care including a neonatal intensive care unit specializing in the care of ill or premature newborn infants is separate and apart from the surgical recovery room and from rooms beds and wards customarily used for patient confinement is permanently equipped with special lifesaving equipment for the care of the critically ill or injured is under constant and continuous observation by a specially trained nursing staff assigned exclusively to the intensive care unit on a 24 hour basis and has an assigned Physician on a full time basis A hospital intensive care unit is not any of the following step down units a progressive care unit an intermediate care unit a private monitored room sub acute intensive care unit or an Observation Unit Inpatient or Inpatient Treatment means the Insured who receives Treatment as a resident patient using and being charged for the room and board facilities of a Hospital The requirement that an Insured be charged does not apply to confinement in a Veteran s Administration Hospital or other federal government operated Hospital Observation Unit means a specified area within a Hospital apart from the Emergency Room where a patient can be monitored by a Physician and which is under the direct supervision of a Physician or registered nurse is staffed by nurses assigned specifically to that unit and provides care seven days per week 24 hours per day

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An observation unit stay lasting 20 hours or more is treated as a Hospital Confinement Rehabilitation Unit means a distinct unit within a Hospital that provides rehabilitation care services on an Inpatient basis Rehabilitation care services consist of multidisciplinary physical restorative services to achieve the highest possible functional ability for disability due to Sickness or Injury Services are provided by or under the supervision of a trained and experienced rehabilitation Physician A rehabilitation unit is not a freestanding rehabilitative facility a nursing home an extended care facility a Skilled Nursing Facility a rest home or home for the aged a Hospice Facility a facility for the Treatment of alcoholism or drug addiction or an assisted living facility Important Information Please also refer to the Policy Disclosures for additional details The Confinement must occur on or after the effective date of insurance Based on the limited available regulatory guidance Sun Life believes its Hospital Indemnity insurance is appropriate for use with an HSA and may be purchased when the employee and or their family members are covered under an HDHP However Sun Life cannot provide legal or tax advice If there are legal or tax questions we suggest that the employee consult their own legal or tax advisor before purchasing this insurance This is a limited benefit policy It does NOT provide basic hospital basic medical or major medical insurance It is not a Medicare Supplement policy The certificate has exclusions limitations and benefit waiting periods for certain conditions that may affect any benefits payable Benefits payable are subject to all terms and conditions of the certificate The policy certificate and any rider if applicable may not be available in all states and may vary based on state laws and regulations Included in this plan No health questions required 36 month rate guarantee from the Effective Date Eligible Child ren to age 26 Portability greater of Up to Age 70 or 12 months

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PORT LAVACA CLINIC ASSOCIATES P A Short Term Disability Benefit Summary Group Number 00357684 About Your Benefits You probably have insurance for your car or home but what about the source of income that pays for it You rely on your paycheck for so many things but what if you were suddenly unable to work due to an accident or illness How will you put food on the table pay your mortgage or heat your home Disability insurance can help replace lost income and make a difficult time a little easier Protect your most valuable asset your paycheck enroll today What Your Benefits Cover Short Term Disability Coverage amount 60 of salary to maximum 1000 week Maximum payment period Maximum length of time you can receive disability benefits 26 weeks Accident benefits begin The length of time you must be disabled before benefits begin Day 15 Illness benefits begin The length of time you must be disabled before benefits begin Day 15 Evidence of Insurability A health statement requiring you to answer a few medical history questions Health Statement may be required Guarantee Issue The guarantee means you are not required to answer health questions to qualify for coverage up to and including the specified amount when applicant signs up for coverage during the initial enrollment period We Guarantee Issue 1000 in coverage Minimum work hours week Minimum number of hours you must regularly work each week to be eligible for coverage Planholder Determines Pre existing conditions A pre existing condition includes any condition symptom for which you in the specified time period prior to coverage in this plan consulted with a physician received treatment or took prescribed drugs 3 months look back 12 months after 2 week limitation Premium waived if disabled Premium will not need to be paid when you are receiving benefits Yes UNDERSTANDING YOUR BENEFITS DISABILITY Some information may vary by state l Earnings definition Your covered salary excludes bonuses and commissions

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Short Term Disability Plan Monthly Cost Illustration To determine the most appropriate level of coverage you should consider your current basic monthly expenses To help you assess your needs you can also go to Guardian Anytime and view a video https www guardiananytime com gafd wps portal fdhome employees products coverage disability Policy amounts shown based on sample salary amounts only Your premium rate 0 780 10 000 Annual Salary 115 Weekly Benefit 8 97 Deduction 15 000 Annual Salary 173 Weekly Benefit 13 49 Deduction 20 000 Annual Salary 231 Weekly Benefit 18 02 Deduction 25 000 Annual Salary 288 Weekly Benefit 22 46 Deduction 30 000 Annual Salary 346 Weekly Benefit 26 99 Deduction 35 000 Annual Salary 404 Weekly Benefit 31 51 Deduction 40 000 Annual Salary 462 Weekly Benefit 36 04 Deduction 45 000 Annual Salary 519 Weekly Benefit 40 48 Deduction 50 000 Annual Salary 577 Weekly Benefit 45 01 Deduction 55 000 Annual Salary 635 Weekly Benefit 49 53 Deduction 60 000 Annual Salary 692 Weekly Benefit 53 98 Deduction 65 000 Annual Salary 750 Weekly Benefit 58 50 Deduction 70 000 Annual Salary 808 Weekly Benefit 63 02 Deduction 75 000 Annual Salary 865 Weekly Benefit 67 47 Deduction 80 000 Annual Salary 923 Weekly Benefit 71 99 Deduction 85 000 Annual Salary 981 Weekly Benefit 76 52 Deduction 90 000 Annual Salary 1 000 Weekly Benefit 78 00 Deduction 95 000 Annual Salary 1 000 Weekly Benefit 78 00 Deduction 100 000 Annual Salary 1 000 Weekly Benefit 78 00 Deduction PORT LAVACA CLINIC ASSOCIATES P A ALL ELIGIBLE EMPLOYEES Benefit Summary The Guardian Life Insurance Company of America New York NY

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105 000 Annual Salary 1 000 Weekly Benefit 78 00 Deduction 110 000 Annual Salary 1 000 Weekly Benefit 78 00 Deduction 115 000 Annual Salary 1 000 Weekly Benefit 78 00 Deduction Manage Your Benefits Go to www GuardianAnytime com to access secure information about your Guardian benefits Your on line account will be set up within 30 days after your plan effective date A SUMMARY OF DISABILITY PLAN LIMITATIONS AND EXCLUSIONS n Evidence of Insurability is required on all late enrollees This coverage will not be effective until approved by a Guardian underwriter This proposal is hedged subject to satisfactory financial evaluation Please refer to certificate of coverage for full plan description n You must be working full time on the effective date of your coverage otherwise your coverage becomes effective after you have completed a specific waiting period n Employees must be legally working in the United States in order to be eligible for coverage Underwriting must approve coverage for employees on temporary assignment a exceeding one year or b in an area under travel warning by the US Department of State Subject to state specific variations n n For Short Term Disability coverage benefits for a disability caused or contributed to by a pre existing condition are limited unless the disability starts after you have been insured under this plan for a specified period of time We do not pay short term disability benefits for any job related or on the job injury or conditions for which Workers Compensation benefits are payable We do not pay benefits for charges relating to a covered person taking part in any war or act of war including service in the armed forces committing a felony or taking part in any riot or other civil disorder or intentionally injuring themselves or attempting suicide while sane or insane We do not pay benefits for charges relating to legal intoxication including but not limited to the operation of a motor vehicle and for the voluntary use of any poison chemical prescription or non prescription drug or controlled substance unless it has been prescribed by a doctor and is used as prescribed We limit the duration of payments for long term disabilities caused by mental or emotional conditions or alcohol or drug abuse We do not pay benefits during any period in which a covered person is confined to a correctional facility an employee is not under the care of a doctor an employee is receiving treatment outside of the US or Canada and the employee s loss of earnings is not solely due to disability n This policy provides disability income insurance only It does not provide basic hospital basic medical or medical insurance as defined by the New York State Insurance Department n If this plan is transferred from another insurance carrier the time an insured is covered under that plan will count toward satisfying Guardian s pre existing condition limitation period State variations may apply n When applicable this coverage will integrate with NJ TDB NY DBL CA SDI RI TDI Hawaii TDI and Puerto Rico DBA Contract GP 1 STD 15 1 0 et al This document is a summary of the major features of the referenced insurance coverage It is intended for illustrative purposes only and does not constitute a contract The insurance plan documents including the policy and certificate comprise the contract for coverage The full plan description including the benefits and all terms limitations and exclusions that apply will be contained in your insurance certificate The plan documents are the final arbiter of coverage Coverage terms may vary by state and actual sold plan The premium amounts reflected in this summary are an approximation if there is a discrepancy between this amount and the premium actually billed the latter prevails

Port Lavaca Clinic - Employee Benefit Guide

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