15-Exhibit A-1 - 24-25 Stop Loss Policy.pdf

HM LIFE INSURANCE COMPANY

FIFTH AVENUE PLACE, 120 FIFTH AVENUE, PITTSBURGH, PA 15222-3099

1-800-328-5433

POLICY NUMBER

POLICYHOLDER

TYPE OF COVERAGE

EFFECTIVE DATE

POLICY TERM

POLICY ISSUED IN

409369-A

Schertz-Cibolo-Universal City Independent School District

Stop Loss Insurance

September 01, 2024

September 01, 2024 through August 31, 2025

Texas

THIS IS NOT A POLICY OF WORKERS' COMPENSATION INSURANCE. THE EMPLOYER DOES

NOT BECOME A SUBSCRIBER TO THE WORKERS' COMPENSATION SYSTEM BY PURCHASING

THIS POLICY, AND IF THE EMPLOYER IS A NON-SUBSCRIBER, THE EMPLOYER LOSES THOSE

BENEFITS WHICH WOULD OTHERWISE ACCRUE UNDER THE WORKERS' COMPENSATION

LAWS. THE EMPLOYER MUST COMPLY WITH THE WORKERS' COMPENSATION LAW AS IT

PERTAINS TO NON-SUBSCRIBERS AND THE REQUIRED NOTIFICATIONS THAT MUST BE FILED

AND POSTED.

HM Life Insurance Company agrees to pay the benefits provided by this Policy, in accordance with the provisions of this Policy.

The consideration for this Policy is the application of the Policyholder and the payment by the Policyholder of premiums as provided herein.

This Policy provides benefits to the Policyholder when Eligible Claims Expenses, which are Paid by the Policyholder through the Covered Underlying Plan(s), exceed the levels defined in this Policy. The benefits of this Policy and the terms and conditions that apply to this Policy are explained herein.

The Effective Date of this Policy is 12:01 AM Eastern Time on the first day of the Policy Term and the expiration date of this Policy is 11 :59 PM Eastern Time on the last day of the Policy Term.

This Policy may be renewed for subsequent Policy Terms in accordance with the renewal terms outlined in this Policy. If this Policy is renewed the terms and conditions of this Policy may be revised.

This Policy is governed by the laws of the jurisdiction in which it is issued and will be administered in accordance with such laws.

All provisions on this and the following pages are a part of the Policy.

HMP-SL (06/20) 1 409369-A

Specific and Aggregate Stop Loss

09/19/2024

Exhibit A-1: 2024-2025 Stop Loss Insurance Policy

HMP-SL (06/20)

HM Life Insurance Company

By

President

This Policy is Non-Participating

2 409369-A Specific and Aggregate Stop Loss

Have a complaint or need help?

If you have a problem with a claim or your premium, call your insurance company or HMO first. If you can't work out the issue, the Texas Department of Insurance may be able to help.

Even if you file a complaint with the Texas Department of Insurance, you should also file a complaint or appeal through your insurance company or HMO. If you don't, you may lose your right to appeal.

HM Life Insurance Company

To get information or file a complaint with your insurance company or HMO:

Call: Compliance Department Complaint Coordinator at 1-800-328-5433

Toll-free: 1-800-328-5433

Email: HMIGComplaints@highmark.com

Mail: 120 Fifth Avenue, Suite PAP HM-063A, Pittsburgh, PA 15222

The Texas Department of Insurance

To get help with an insurance question or file a complaint with the state:

Call with a question: 1-800-252-3439

File a complaint: www.tdi.texas.gov

Email: ConsumerProtection@tdi. texas.qov

Mail: P.O. Box 12030, Austin, TX 78711 l Tiene una queja o necesita ayuda?

Si tiene un problema con una reclamaci6n o con su prima de seguro, llame primero a su compal'iia de seguros o HMO. Si no puede resolver el problema, es posible que el Departamento de Seguros de Texas (Texas Department of Insurance, par su nombre en ingles) pueda ayudar.

Aun si usted presenta una queja ante el Departamento de Seguros de Texas, tambien debe presentar una queja a traves del proceso de quejas o de apelaciones de su compal'iia de seguros o HMO. Si no lo hace, podria perder su derecho para apelar.

HM Life Insurance Company

Para obtener informaci6n o para presentar una queja ante su compal'iia de seguros o HMO:

Call: Compliance Department Complaint Coordinator at 1-800-328-5433

Toll-free: 1-800-328-5433

Email: HMIGComplaints@highmark.com

Mail: 120 Fifth Avenue, Suite PAP HM-063A, Pittsburgh, PA 15222

Texas Complaint Notice 05/20

El Departamento de Seguros de Texas

Para obtener ayuda con una pregunta relacionada con las seguros o para presentar una queja ante el estado:

Llame con sus preguntas al: 1-800-252-3439

Presente una queja en: www.tdi.texas.gov

Correo electr6nico: ConsumerProtection@tdi.texas.gov

Direcci6n postal: P.O. Box 12030, Austin, TX 78711

TEXAS DISCLOSURE OF GUARANTY FUND NONPARTICIPATION

In the event the insurer is unable to fulfill its contractual obligation under this policy, the contract-holder is not protected by an insurance guaranty fund or other solvency protection arrangement.

Table of Contents

Part 1. DECLARATION PAGE

Part 2. DEFINITIONS

Part 3. BENEFITS

Part 4. EXCLUSIONS AND LIMITATIONS

Part 5. CLAIMS ADMINISTRATOR

Part 6. CLAIM PROVISIONS

Part 7. MATERIAL CHANGES

Part 8. TERMINATION AND RENEWAL

Part 9. PREMIUMS

Part 10. GENERAL PROVISIONS

Part 11. RECORDS AND REPORTS

Part 12. LIABILITY

Part 13. INDEMNIFICATION

Part 14. ENTIRE CONTRACT, CHANGES

Part 15. INCONTESTABLE CLAUSE

Part 16. LEGAL ACTIONS

Part 17. INSOLVENCY

Part 18. ASSIGNMENT

A

B.

Part 1. DECLARATION PAGE

POLICY INFORMATION

1. Policy Number 409369-A

2. Policyholder Schertz-Cibolo-Universal City Independent School District

3. Policy Term September 01, 2024 through August 31, 2025

4. Covered Underlying Plan(s) Schertz-Cibolo-Universal City Independent Health Plan

5. Claims Administrator(s) Aetna

6. Pharmacy Benefit Manager(s) Express Scripts

SPECIFIC BENEFIT SCHEDULE

For all Eligible Claims Expenses except those to which a Special Risk Limitation applies:

1. Covered Claims Basis:

Eligible Claims Expenses Incurred from September 01, 2023 through August 31, 2025 and Paid from September 01, 2024 through August 31, 2025.

2. Specific Eligible Claims Expenses include:

Medical Prescription Drug Card

3. Number of Covered Units:

Composite

4. Specific Deductible

Per Participant

5. Specific Payable Percentage:

Yes Yes

1,240

$200,000

100%

6. Maximum Specific Benefit in excess of the Specific Deductible per Participant

Per Lifetime Unlimited

HMP-SL (06/20) 1 409369-A

C. AGGREGATE BENEFIT SCHEDULE

For all Eligible Claims Expenses except those to which a Special Risk Limitation applies:

1. Covered Claims Basis:

Eligible Claims Expenses Incurred from September 01, 2023 through August 31, 2025 and Paid from September 01, 2024 through August 31, 2025.

2. Aggregate Eligible Claims Expenses include:

Medical Prescription Drug Card

3. Number of Covered Units:

4.

5.

Composite

Aggregate Payable Percentage:

Aggregate Corridor

6. Annual Aggregate Deductible equals A or B whichever is greater, where:

Yes Yes

1,240

100%

120%

A= The sum of the Monthly Aggregate Deductible Amounts applicable to each Policy Month in the Policy Term.

B = The Minimum Aggregate Deductible.

Note: The Annual Aggregate Deductible cannot be finally determined until the Monthly Aggregate Deductible Amounts have been calculated for each Policy Month of the Policy Term.

7. Monthly Aggregate Factor

Per Composite Covered Unit per Policy Month

8.

9.

Maximum Aggregate Eligible Claims Expense per Participant

Maximum Aggregate Benefit per Policy Term

$837.37

$200,000

$1,000,000

D. PREMIUM

Specific Premium Rate per Policy Month per Covered Unit:

Composite:

Aggregate Premium Rate per Policy Month per Covered Unit:

Composite:

$97.44

$4.87

The Specific Premium Rate per Policy Month and the Aggregate Premium Rate per Policy Month per Covered Unit only apply to this Policy Term.

HMP-SL (06/20) 2 409369-A

E. SPECIAL RISK LIMITATIONS

Disabled/Hospital Confined, actively at work, activity of daily living, out-of-hospital, or similar requirements waived:

Retirees Included:

F. AFFILIATES

None

HMP-SL (06/20) 3

Yes

No

409369-A