2013 Summary Plan Description

Transcription

1 2013 Summary Plan Description for the Health and Welfare Benefit Plan Your This Summary Plan Description is designed to provide general information about the Providence Health & Services Health and Welfare Benefit Plan. The terms of your benefit plans are governed by legal documents, including plan documents and insurance contracts. This Summary does not include all plan rules and details. Providence Health & Services reserves the right to amend, modify or terminate any plan, in whole or in part, at any time for any reason. PHP-Amended: July, 2013

2 Table of Contents I. Overview of Coverage Who Is Eligible? Enrollment Requirements When Coverage Begins When Coverage Ends How Does the Providence Health and Welfare Benefit Plan Work? Summary of Options What Are Employer Contributions? What Are Benefit Options? What Is the Total Plan Cost? How Much Do I Have to Pay? Making Your Elections/Changing Your Elections Default Benefits Limitations on Assignment About this Summary Plan Description Glossary of Terms II. Medical Your Medical Options Choosing Medical Coverage Working Spouse Surcharge About Your Medical Benefits: Health Reimbursement and Health Savings Medical Plans Using In-Network Providers Health Reimbursement Medical Plan Health Savings Plan Health Incentive Providence RN Benefit Summary of Covered Medical Expenses Benefit Maximums Financial Hardship Caused by Medical Expenses Pre-Authorization/ Medical Review Required Second Surgical Opinion Pregnancy Individual Case Management Medical Expenses Not Covered Prescription Drug Summary of Benefits Pharmacy Exclusions Glossary of Terms III. Dental Your Dental Options Dental Coverage Choosing Dental Coverage About Your Dental Benefits Covered Procedures Predetermination of Dental Health Dental Expenses Not Covered Glossary of Terms ii Overview of Coverage

3 IV. Vision Choosing Vision Coverage What is Covered How Does it Work? Vision Expenses Not Covered or Limited Benefits V. General Medical, Dental, and Vision Information Claims Paid Based on Date of Service Filing Claims for the Providence Health and Welfare Benefit Plan Options Questions about Claims, Eligibility, and Benefits for Medical Plans (administered by Providence Health Plan) Flexible Spending Accounts Dental Claims Vision Claims Claim Review and Appeal Termination of Coverage Due to Fraud or Abuse Recovery/Reimbursement Coordination of Benefits Rights to Receive and Release Necessary Information Assignment of Benefits Coverage During a Leave of Absence Optional Continuation of Coverage (COBRA) VI. Employee Assistance Program (EAP) Overview For Alaska Region Employees and PSMS Employees in Alaska For California Region Employees and PSMS Employees in California For Western Montana and Washington Regions, and PSMS Employees in WA and MT For Oregon Region Employees and PSMS Employees in Oregon VII. Basic Employee Life and AD&D Insurance How the Plan Works Glossary of Terms for All Life and Accidental Death & Dismemberment VIII. Supplemental Employee Life Insurance Your Supplemental Employee Life Options Actively at Work Provision Dual Coverage Choosing Supplemental Employee Life Insurance How the Plan Works Designation of Beneficiary Benefits Coverage If Totally Disabled Filing Claims Leave of Absence Termination of Coverage Portability and Conversion of Supplemental Employee Life Insurance Accelerated Death Benefit IX. Dependent Life Insurance Your Dependent Life Insurance Options Choosing Dependent Life Coverage How the Plan Works Designation of a Beneficiary Benefits Filing Claims Leave of Absence iii Overview of Coverage

4 Termination of Coverage Portability and Conversion of Dependent Life Coverage Accelerated Death Benefit X. Supplemental Accidental Death and Dismemberment Your Supplemental AD&D Options Designation of Beneficiary Filing Claims Benefits Exclusions Leave of Absence Termination of Insurance XI. Dependent Accidental Death and Dismemberment Your Dependent AD&D Insurance Options Benefits Filing Claims Exclusions Leave of Absence Termination of Insurance XII. Business Travel Accident Eligibility Description of Coverage Loss of Life Benefit Amount Schedule of Benefits Exclusions Filing Claims Termination of Coverage Emergency Assistance Program XIII. Disability Your Long Term Disability Options Active Employment Requirement Maximum Benefit Period Temporary Recovery (Successive Periods of Disability) How the Plan Works Benefits Definition of Disability When Benefits Begin Minimum Benefit Return to Work Incentives (Work Incentive Benefit) Limitations Exclusions Survivor Benefits Filing Claims Termination of Disability Benefits Conversion Physician Plans Executive LTD Plan Providence Hood River Memorial Hospital Short Term Disability Plan Glossary of Terms XIV. Health Care Flexible Spending Account Deciding on Participation What Is Covered? Exclusions iv Overview of Coverage

5 How Does the Account Work? Orthodontia Claims Statements Termination of Coverage HEART Act of XV. Dependent Care Flexible Spending Account Deciding on Participation What Is Covered? Exclusions How Does the Account Work? Statements Termination of Coverage Which Is Better the Reimbursement or the Tax Credit? XVI. Problem Resolution, ERISA & HIPAA Information Informal Member Problem Resolution under the Medical Plan (administered by Providence Health Plan) Filing and Processing of Claims Your Grievance and Appeal Rights Statement of ERISA Rights Plan Benefits Can Be Changed or Discontinued Non-Discrimination Testing HIPAA Health Insurance Portability and Accountability Act of XVII. Welfare Plan Information v Overview of Coverage

6 I. Overview of Coverage Every employee is unique, each with different needs and family situations. The Providence Health and Welfare Benefit Plan (mylife myhealth) is designed to meet the diverse needs of Providence Health & Services (Providence) employees well into the future. As your personal situation changes from year to year, you may want to change some of your benefit elections. With the Providence Health and Welfare Benefit Plan you have the flexibility to meet these needs and many more. Who Is Eligible? Employees with a payroll status of Full Time Equivalency (FTE) of.5 or above are eligible for health welfare benefits, with one exception noted below. Benefits-eligible employees, as defined above, are eligible for the Providence Health and Welfare Benefit Plan the first day of the month following or coincident with the date you are hired, or with the date on which your FTE status becomes.5 or above (as entered in ProvConnect), with two exceptions noted below. Employees of Providence Saint Joseph Medical Center in Burbank, CA who are represented by United Healthcare Workers, Local 399 for Service and Technical Employees are eligible if scheduled hours in ProvConnect are 24 hours per week (.6 FTE) or above New hire eligibility begins the first of the month coincident with or following 60 days of continuous employment; if you are newly eligible due to an increase in scheduled hours you become eligible on the first of the month coincident with or following 30 days of continuous employment in the new status. Please see 2012 Summary Plan Description/ California. Employees of Providence Sacred Heart Medical Center in Spokane, WA who are represented by Washington State Nurses Association are eligible if scheduled hours in ProvConnect are 20 hours per week or above New hire eligibility begins the first of the month coincident with or following 90 days of continuous employment; newly eligible due to an increase in scheduled hours you are eligible on the first of the month coincident with or following 30 days of continuous employment in the new status. Please see page 1-7, When Coverage Begins. Your dependents may also be eligible to participate. Eligible dependents mean your spouse, biological children, stepchildren, adopted children, foster children and children for whom you are the legal guardian by court order. Spouse is defined to mean a person who is treated as your lawful spouse under applicable state law. Prior to June 26, 2013, Federal law, and the Plan, defined a spouse as a person of the opposite sex who is a husband or a wife. To be considered a husband or wife, Federal law required a marriage, which was defined as a legal union between one woman and one man. As of June 26, 2013, due to the fact that the Federal definition of marriage has been found unconstitutional and it appears that self-funded plans may be required to provide coverage for same-sex spouses in certain situations, persons of the same sex may be considered a spouse under the plan if their marriage was performed in a state which legally recognizes marriage between persons of the same sex and those persons currently live in a state where same-sex marriage is recognized. Currently, this treatment means that employees married to a same-sex spouse who live in Washington and California may obtain coverage for their spouses. Providence reserves the right to modify this treatment pending future guidance which may or may not alter the definition of spouse. If your child does not live with you, is not supported by you, or is married, you may still enroll him or her as a child under your medical, dental, and/or vision coverage until the child reaches age 26. For children for whom you are the legal guardian, a dependent remains eligible only until the expiration date stipulated by the court within the Letters of Guardianship and typically does not extend beyond the dependent s age of emancipation, typically age 18. For dependent life and accidental death & dismemberment insurance for children, an eligible child is defined as your natural child, adopted 1-1 Overview of Coverage

7 child or stepchild who is less than age 26, not in the military, and not insured under the Plan as an employee. If you are required by the court to provide medical coverage for a child pursuant to a qualified medical child support order (QMCSO), please contact the HR Service Center for more information. Coverage of a currently enrolled dependent child may be extended past age 26 if they are incapable of self-support because of developmental or physical disability and is your tax dependent under IRS Code Section 152. Contact the HR Service Center for more information. The Plan reserves the right to request documentation to verify the eligible relationship of those you have enrolled as dependents. Documentation includes but is not limited to marriage certificates, birth certificates, court orders, tax returns, and other declarations or affidavits. The request may originate either from the Benefits Department, the HR Service Center or ConSova Corporation (ConSova), a service provider for the Plan. If the requested documentation is not received in entirety by the deadline or within the enrollment/ change period, is incomplete, or does not provide sufficient evidence of meeting the eligibility requirements of the plan, either the person will not be enrolled or an existing enrollment of the non-qualified individual will be cancelled for the plan year on a prospective basis. If there is fraud or material misrepresentation by you, coverage may be cancelled retroactive to the date of ineligibility (rescission of coverage). You will have appeal rights under the rescission of coverage rules of the Patient Protection and Affordable Care Act. Adult Benefit Recipient You may also cover an Adult Benefit Recipient as a dependent. A completed Declaration will need to be filed. You may enroll your Adult Benefit Recipient in medical, dental and vision insurance. They are also eligible for EAP benefits. An Adult Benefit Recipient who meets criteria specified by the insurance carrier may be eligible for dependent life and AD&D insurance. insurance See page 9-1 for the definition of a domestic partner for dependent life and AD&D insurance. A different adult dependent cannot be covered under the various plans. For example, if an Adult Benefit Recipient is covered under your medical plan, a legal spouse cannot be covered under your dental plan. In addition, coverage is limited to a maximum of two adults per household. If two adult members of your household both work for Providence, you cannot add an Adult Benefit Recipient. Providence Health & Services defines an Adult Benefit Recipient as an individual who meets all of the following conditions: at least 18 years of age, during the Plan Year, and for a minimum of 12 months prior to enrollment has as his or her principal place of residence your home, is a member of your household*, is not your employee (e.g. nanny), is not an eligible child, and does not have access to other medical coverage (group or Medicare).** * A member of your household is a person who is part of your family unit and intends to remain so for the foreseeable future; someone with whom you have a close personal relationship, provide financial support, and to whom you are committed to a relationship of mutual caring. This does not include a renter, roommate or other person living in your home on a casual basis. **Having access to Medicare means the person is not eligible as an ABR for medical, dental and/or vision coverage. Your Adult Benefit Recipient must have physically resided with you in your home for the 12 months prior to enrollment and will continue to do so during the Plan Year to meet the residency requirement. This applies to your children over the age of 26 who do not live with you while attending school full-time. 1-2 Overview of Coverage

8 Children or legal dependents of the Adult Benefit Recipient are not eligible plan participants. If you enroll your adult child as your Adult Benefit Recipient at the time he or she reaches age 26 and is no longer eligible to be enrolled as a child, the cost of coverage will not be taxable to you for federal tax purposes for the remainder of the calendar year in which the child reaches age 26. Please check local state tax laws. Expanded Adult Benefit Recipient Eligibility For Qualifying Relationships For employees In Washington: Washington State Chapter RCW Registered Domestic Partners under Washington Chapter RCW are eligible as Adult Benefit Recipients with expanded eligibility. With a completed declaration and a copy of the Declaration of State Registered Domestic Partnership (on file with the state of Washington), the eligibility criteria on the previous page is deemed as having been met. Your Adult Benefit Recipient Registered Domestic Partner (ABR RDP) is eligible for coverage even if he/she has access to other group medical coverage. Additionally, the biological and legally adopted children of your ABR RDP are also eligible for coverage if you have enrolled your ABR RDPfor coverage on the plan. The children of your ABR RDP are also eligible for Dependent Life coverage. Note: Eligibility for same sex spouses under Washington SB6239 was administered under the ABR RDP eligibility previous to June 26, For Employees in Oregon: Oregon House Bill 2007 If you and your partner have a Declaration of Domestic Partnership on file with the state of Oregon, your partner is eligible for enrollment as an Adult Benefit Recipient. The eligibility criteria on the left of this page is deemed as having been met by filing your Registered Domestic Partnership with the state. You will need to submit a completed declaration along with proof of registration to enroll. Your Adult Benefit Recipient Registered Domestic Partner (ABR RDP) is eligible for coverage even if he/she has access to other group medical coverage. An opposite gender domestic partnership may also qualify under the Providence ABR RDP eligibility if one of you is at least 62 years of age and you meet the other criteria under House Bill 2007: at least one of you is a resident of Oregon. neither party to the domestic partnership had a partner, wife or husband living at the time of the domestic partnership unless the partner, wife or husband was the other party to the domestic partnership; neither parties in the domestic partnership are first cousins or any nearer of kin to each other, whether of the whole or half blood or adoption, computing by the rules of the civil law; neither party is incapable of making a civil contract or consenting to a contract for want of legal age or sufficient understanding; and/or, when the consent of either party is obtained by force or fraud, the domestic partnership is void from the time it is so declared by a judgment of a court having jurisdiction of the domestic partnership NOTE: When parties are first cousins by adoption only, the domestic partnership is not prohibited or void. Additionally, the biological and legally adopted children of your ABR RDP are also eligible for coverage if you have enrolled your ABR RDP for coverage on a plan. The children of your ABR RDP are also eligible for Dependent Life coverage. For Employees in Southern California: California Assembly Bill 2208 If you and your partner have Declaration of Domestic Partnership on file with the state of California, your partner is eligible for enrollment as an Adult Benefit Recipient. The eligibility criteria on page 1-2 is deemed as having been met by filing your Registered Domestic Partnership with the state. You will need to submit a completed declaration along with proof of registration to enroll. Your Adult Benefit Recipient Registered 1-3 Overview of Coverage

9 Domestic Partner (ABR RDP) is eligible for coverage even if he/she has access to other group medical coverage. Additionally, the biological and legally adopted children of your ABR RDP are also eligible for coverage if you have enrolled your ABR RDP for coverage on a plan. The children of your ABR RDP are also eliglble for Dependent Life coverage. For Employees in Alaska and Montana If you and your partner meet the following criteria, your partner is eligible to be enrolled for coverage as a domestic partner. You share a common residence and have shared financial responsibilities; You are both at least eighteen (18) years of age; Neither of you is married to anyone else, or in a state registered domestic partnership with any other person; You are both capable of consenting to this domestic partnership; You are not of any relation to each other nearer than second cousin and neither partner is a sibling, child, grandchild, aunt, uncle, niece or nephew to the other; and You are both of the same sex, or one of you is at least 62 years of age Your Adult Benefit Recipient Domestic Partner s (ABR DP) biological and legally adopted children are also eligible for coverage if you have enrolled your ABR DP for coverage on a plan. The children of your ABR DP are also eligible for Dependent Life coverage. If you live in Montana and have a common law spouse under the laws of Montana, you may cover your common law spouse under the Plan as a spouse by providing a declaration of the common law marriage and submitting a copy of a recent federal tax return showing filing as married filing jointly or married filing individually. Declaration Required for Covering Adult Benefit Recipient If you are newly eligible for benefits and enroll an Adult Benefit Recipient for coverage, you will be sent a declaration to complete by either the HR Service Center or ConSova Corporation (ConSova), a service provider for the Plan. The completed declaration is required for coverage on your Adult Benefit Recipient. If the completed declaration along with any required documentation is not received by the stated deadline coverage on your Adult Benefit Recipient will not go into effect or existing coverage will be cancelled. If you add an Adult Benefit Recipient during open enrollment, you will be sent a declaration to complete by ConSova, a service provider for the Plan. The completed declaration is required for coverage on your Adult Benefit Recipient. If the completed declaration along with any required documentation is not received by ConSova by the stated deadline coverage on your Adult Benefit Recipient will not go into effect or existing coverage will be cancelled on a prospective basis. If you are adding an Adult Benefit Recipient due to a qualifying status change event, you will need to submit a completed declaration along with your Benefits Change Form to the HR Service Center. FAQs containing the declarations are available on benefits.providence.org under Eligible Dependents. If the completed declaration and change form are not received by the HR Service Center within 31 days of the qualifying event, coverage on your Adult Benefit Recipient will not go into effect. Incomplete forms or not meeting the criteria for coverage as an Adult Benefit Recipient will result in no coverage. Imputed Income on ABRs and Other Non-Tax Dependents The amount you pay towards the cost of your Adult Benefit Recipient s (ABR and ABR RDP/DP) coverage will be on an after tax basis, and you will be taxed on Providences contributions toward such coverage, unless you claim your Adult Benefit Recipient as a Section 152 dependent on your federal income tax return. If you enroll the eligible children of your ABR RDP, the amount you pay for their coverage and Providence contributions toward the coverage 1-4 Overview of Coverage

10 will be taxed, even if you are also covering your biological or adopted children. State laws vary on recognition of Registered Domestic Partner and Same Sex Spouses which can affect imputed income (and how your partner/ spouse needs to be coded in ProvConnect to execute imputed income). Please consult your tax advisor for the implications of this election. PLEASE NOTE: When you enroll a family member or ABR in the Plan, you represent that the person is eligible under the terms of the Plan and you will provide evidence of eligibility upon request. The Plan is relying on your representation of eligibility in enrolling those persons. Providing false information, not providing evidence of eligibility when requested, and/or attempting to cover individuals who do not meet the Plan s definitions of eligible dependents above is evidence of fraud and material misrepresentation which can result in retroactive cancellation of coverage to the date of ineligibility (rescission of coverage) with claims for those individuals not being paid, payments being recovered from you,and/or your employment being terminated. If you have any questions about whether or not your dependent(s) may be eligible, please consult the HR Service Center. Enrollment Requirements You must enroll within 31 days of hire or becoming benefits-eligible (the date your FTE status becomes.5 or above). The enrollment period begins with the date of the event. The date of entry into ProvConnect or sending of enrollment materials do not begin the counting of the 31 day period. Even if you do not want coverage, you must take action to waive coverage otherwise you will be assigned coverage. (see page 1-16) If you want dependent coverage, you must also enroll your eligible dependents during the initial 31 day period. Coverage is not automatic. You may also enroll yourself or your eligible dependents during the annual enrollment period. If spouses both work for Providence, or a parent and an adult child, there are restrictions on enrollment which result in double/dual coverage. See page 5-5, page 8-1 and page 9-2 for more information. If enrollment is made for dual coverage, claims will not be paid, payments made in error will be subject to recovery, and enrollment will be cancelled with no refund of premium contributions paid for the dependent coverage. Special Enrollments Acquiring a new spouse or dependent by marriage, birth, adoption or placement for adoption. Your newborn biological children must be enrolled within 60 days of birth and coverage is retroactive to the date of birth. Coverage is not automatic. Children who are adopted or placed in your home for adoption must be enrolled within 60 days of the legal date of placement (or adoption) and are covered retroactive to the date of placement (or the adoption is finalized). Legal date of placement is documented either through a state agency, a fully licensed adoption agency or applicable court order. If you have a newborn child, or have a child newly placed in your home for adoption, and you or your spouse were not previously covered under the Providence plan, you may enroll yourself, the newborn child, and your spouse so long as you do so within 60 days of the birth or, in the case of adoption, placement. All other new dependents, including your spouse, acquired by marriage must be enrolled within 31 days of the date they became your dependents. If you acquire a dependent by marriage and you are benefits eligible, but not previously covered, you may also enroll yourself within 31 days of the event. Coverage will begin on the first day of the month following the month in which your enrollment process is completed. All other new dependents must be enrolled within 31 days of the date they became your dependents. The Plan does require verification of the qualifying event and relationship. Both the Benefit Change Form and the required documentation must be received by the HR Service Center within 31 days of acquiring the new dependent; 60 days for birth, placement for adoption or adoption or you will have to wait until open enrollment for the next plan year. 1-5 Overview of Coverage

11 Effective April 1, 2013, you may enroll all eligible dependents not previously covered as part of enrolling the newborn child or the child newly placed for adoption. new dependents gained through marriage. Loss of eligibility for health insurance coverage If you waived medical coverage because you had other group coverage (including COBRA coverage), and you lose medical coverage due to one of the following, you may elect health coverage for you and your eligible dependents. you and your spouse divorce, legally separate or annul the marriage; your spouse becomes eligible for Medicare or Medicaid; your spouse loses coverage due to termination of employment, loss of benefits-eligible status, disability, or death and can no longer cover you; your spouse s employer s benefits contributions end; or you have exhausted your COBRA coverage from another group plan If your eligible dependents are covered under the group medical program provided by your spouse s employer or by your dependent child s own employer, and coverage ends for any of the above reasons, you may enroll those dependents, including your spouse and eligible dependent children, in the Plan. You must apply for a coverage change within 31 days of the date coverage under the other plan is terminated. Coverage will begin on the first day of the month following the month in which your enrollment process is completed. The Plan does require verification of the loss of eligibility and relationship of dependents. Both the Benefit Change Form and the required documentation must be received by the HR Service Center within 31 days of the event or you will have to wait until open enrollment for the next Plan year. Eligibility for state premium assistance subsidy You may also elect coverage if you, your spouse and/or your dependents are no longer eligible for group health coverage sponsored by a governmental institution or you become eligible for a premium assistance subsidy. for loss of eligibility under Medicaid or a state child health insurance plan (CHIP), you have 60 days from termination of that coverage to request coverage under a Providence health plan. gain of eligibility by you, your spouse, or dependent children for premium assistance subsidy under Medicaid or CHIP. You have 60 days after the date you, your spouse or child is determined to be eligible for such premium assistance to request coverage under a Providence health plan. Coverage will begin on the first day of the month following the month in which your enrollment process is completed. The Plan does require verification of the qualifying event and relationship. Both the Benefit Change Form and the required documentation have to be received by the HR Service Center within 60 days of the event or you will have to wait until the open enrollment for the next Plan year. If you or your dependent have gained access to Medicaid or CHIP coverage and wish to end coverage (waive) coverage, this is not part of the HIPAA special enrollment rights. If the event qualifies as a family status change, you have 31 days to submit the documentation to request a change. Once your application for coverage as a special enrollment is accepted, you are responsible for any additional contributions required. You may also request a change in your existing medical plan as part of your HIPAA Special Enrollment rights; however, there are restrictions on transferring claims history between plans. Qualified Medical Child Support Orders (QMCSOs) Federal law requires group health plans to honor Qualified Medical Child Support Orders (QMCSOs). In general, a QMCSO is a judgment, decree, or 1-6 Overview of Coverage

12 order from a state court or state administrative agency that requires a parent to provide medical support to a child. A QMCSO may require the Plan to make health, dental, and/or vision coverage available for your child even though, for income tax or Plan purposes, the child is not your dependent due to divorce or legal separation. In order to qualify as a QMCSO, the medical support order must: specify your last known name and address, and the child s name and last known address unless the order otherwise provides the name and mailing address of an official of a state or political subdivision thereof in place of the name and address of the child; provide a reasonable description of the type of coverage to be provided by the Plan or the manner in which the type of coverage is to be determined; state the period to which it applies; and specify each plan to which it applies. The QMCSO may not require the Plan to provide coverage for any type or form of benefit or any option not otherwise provided under the terms of the Plan. You must pay for coverage through payroll deductions, and you and/or the child may be enrolled as required by the order, whether or not you consent. The Plan Administrator shall permit any child who is the subject of a QMSCO to designate a representative for receipt of copies of notices that are sent to such child with respect to a QMSCO. You and the affected child will be notified if an order is received and may be provided with a copy of Providence s QMCSO procedures. A child covered under the Plan pursuant to a QMCSO will be treated as an eligible dependent under the Plan. Any payment for benefits made by this plan pursuant to a QMSCO for expenses paid by the child or the child s custodial parent or legal guardian shall be made to the child or the child s custodial parent or legal guardian if so specified. Participants and beneficiaries can obtain, at no charge, a copy of the Plan s QMCSO procedures from the Plan Administrator. If you have support order or dissolution of marriage decree that provides for coverage of a child on a group health plan but which does not meet the criteria of a QMSCO, you may submit such for consideration of coverage of the child. An order from a state agency addressed to an employer other than Providence to enforce the provisions of a medical support order, judgment or decree by requiring enrollment of specified children under that employer s plan is not a qualifying event for a mid-year change to add the children for coverage. Consideration for a qualifying event may be given if the person named in the underlying QMCSO is a Providence employee. If you are covering a child under a QMSCO, you may drop the child from coverage only if you can provide proof that a family relations court has ordered someone else to provide coverage (for example, an ex-spouse), that the other coverage meets the court s requirement, and has become effective. When Coverage Begins Medical, Dental, and Vision If you are a new employee or newly benefits eligible, your coverage will begin on the first day of the month after you enroll, or on the same day if you enroll on the first day of the month - as long as you enroll within 31 days of the day you are hired or become eligible for benefits. Note: Coverage for benefit-eligible employees of Providence Saint Joseph Medical Center in Burbank, CA who are represented by United Healthcare Workers, Local 399 for Service and Technical Employees begins on the first of the month coincident with or following 60 days of continuous employment, enrollment for benefits must occur within 31 days of date of hire; newly eligible due to an increase in scheduled hours must enroll within 31 days with benefits effective following 30 days of continuous employment in the new status. Coverage for benefit-eligible employees of Providence Sacred Heart Medical Center in Spokane, WA who are represented by Washington State Nurses Association begins on the first of the month coincident with or following 90 days of continuous employment, enrollment for benefits must occur within 31 days of date of hire; newly eligible due to an increase in scheduled hours must enroll within 31 days with benefits effective the first of the month coincident with or following enrollment. 1-7 Overview of Coverage

13 If you are a new hire or a newly benefits-eligible employee and do not elect benefits within the specified enrollment period, you will receive the default benefits until the next annual Open Enrollment. (see page 1-16) If you elect coverage during an annual Open Enrollment period, your benefit coverage will begin on the January 1 following making your elections if you: are eligible for benefits; and have completed the enrollment process during the specified enrollment period. Once the Open Enrollment period has closed no new elections may be made for the new Plan year unless you have a qualifying change in status event. If you do not elect benefits by the annual Open Enrollment deadline, your previous elections will continue into the new plan year at the new rates, with some exceptions. See page 1-16 for more information. For special enrollments and qualifying family status changes, new elections are effective as follows: Event Election Period Effective Date Birth, adoption, placement for adoption 60 days from the date of the event to enroll for coverage As of the date of birth, adoption, placement for adoption Eligibility for state premium assistance 60 days from becoming eligible to enroll for coverage First of the month following making the new election to add coverage All other qualifying events 31 days from the date of the event First of the month following making the new election Due to IRS regulations, elected coverages cannot begin before the HR Service Center receives confirmation of your benefit elections. Note: If a completed Adult Benefit Recipient declaration is not received before your effective date, or other required date, coverage on that person will not be put into effect or will be terminated. Life Insurance, Long Term Disability, and Flexible Spending Accounts At all locations (except Providence Saint Joseph Medical Center in Burbank, CA who are represented by United Healthcare Workers, Local 399 for Service and Technical Employees), if you are a new employee or newly benefits eligible, your coverage will begin on the first day of the month after you enroll, or on the same day if you enroll on the first day of the month, as long as you enroll within 31 days of the day you are hired or become eligible for benefits. If you are absent from work on the effective date of coverage due to sickness, injury or on leave of absence, coverage will not begin until the first of day of the month following your return to active work. Coverage for new dependents begins the first day legally acquired, if properly enrolled. Coverage for adopted children begins on the legal date of placement. If you elect coverage for a dependent and the dependent is hospitalized on the effective date of coverage, coverage will not begin until the first day of the policy month following the date the dependent is released from the hospital. For Dependent Life Insurance, if one of your dependents is disabled on the day coverage is scheduled to begin, that dependent s coverage will begin when he or she recovers and resumes normal activities. Elected contributions to one or both of the flexible spending accounts will begin with the first payroll following the effective date of your elections. For purposes of the Long Term Disability Plan, a pre-existing condition limitation provision applies. Please see Chapter 13. When Coverage Ends Your coverage ends the last day of the month of which the earliest of the following events occur: your employment with Providence Health & Services ends, you are no longer eligible to participate in this Plan (for example, because of a reduction in your scheduled work hours), 1-8 Overview of Coverage

14 you move to a non-covered position premium contributions cease to be paid you are laid off and, if applicable, your severance period ends, or you die. Coverage for your dependents ends on the same date your coverage ends; the last day of the month in which a dependent no longer meets the definition of dependent; or the last day of the month in which your contributions for dependent coverage cease based the event which first occurs. If you and your spouse are divorced, coverage for your spouse will end on the last day of the month in which the date of the final divorce decree occurs. For legal separation or annullment, coverage ends on the last day of the month in which the court grants the legal separation or annullment. In these cases, you must file a Benefits Change Form and a copy of the court order. If an enrolled dependent child is physically or mentally disabled on the date coverage would otherwise end due to reaching age 26, the child s eligibility will be extended for as long as the disability continues, the child continues to qualify for coverage in all aspects other than age, you continue to be covered under the Plan and you continue to pay the required premium, as applicable. The Plan may require you at any time to obtain a physician s statement certifying the physical or mental disability and/or your tax returns for your child s tax dependent status. For dependent life and AD&D, MetLife requires a completed form be submitted within 31 days of the disabled child reaching age 26. Certificates of Coverage If you or a covered dependent cancel or have a loss of medical coverage, your plan administrator will send you a certificate of coverage. This certificate will include the information you might need to give to another employer or plan administrator. The certificate will show that you had medical coverage through a Providence-sponsored medical plan. How Does the Providence Health and Welfare Benefit Plan Work? Providence pays a percent of the total cost of the health benefits, long term disability and basic life/ accidental death & dismemberment. The difference between the total cost of coverage and what Providence pays toward the benefit options are the rates you see when making your elections. With Providence s Health and Welfare Benefit Plan: You select the Medical, Dental, and Vision coverages which best meet your needs. You have a variety of choices of Supplemental Life Insurance. A variety of Dependent Life Insurance coverage levels are available for your spouse/abr domestic partner and $10,000 of coverage for your children. Supplemental Accidental Death and Dismemberment choices allow you to further increase your Life and Disability protection Dependent Accidental Death and Dismemberment allows for increased coverage on your spouse/abr domestic partner and children. You may use the Health Care Flexible Spending Account (Health FSA) to cover certain outof-pocket health care expenses with pre-tax dollars. (If you have a Health Reimbursement or Health Savings Account, see Chapter 14 for how the Health FSA works with these accounts.) You may use the Dependent Care Flexible Spending Account to pay for day care or other dependent care with pre-tax dollars. If you elect a health option for which you will be paying a premium contribution, you pay that cost with pre-tax dollars. In effect, you are shifting part of your taxable pay to nontaxable benefits. 1-9 Overview of Coverage

15 To understand how Providence s benefit plan can help you reduce your taxes, it is important to remember that your total compensation consists of two components: cash compensation and benefits. Your cash compensation is taxed. Generally, your benefits are not taxed. Tax Impact of Pre-tax Premium Contributions You generally pay your share of the cost of your benefits with contributions which are not taxed: pre-tax contributions. By converting salary into pretax contributions, you reduce your taxable income, so you pay lower taxes. This can actually increase your take-home pay. For example, if you are in the 15% federal tax bracket with 7.65% Social Security tax, every $100 you spend on Providence s health benefits will buy over $22 more in benefits than if you had used after-tax income. 1. Income allocated for benefit costs 2. Federal income and Social Security taxes 3. Purchasing power available for benefit costs Without Providence Benefit Plan (After-Tax) With Providence Benefit Plan (Pre-tax) $ $ $22.65 None $77.35 $ The person in this example saves $22.65 in taxes for every $ spent on pre-tax benefits through Providence Health and Welfare Benefit Plan. The example assumes a federal income tax rate of 15%, no state income tax and a Social Security tax rate of 7.65%. You should also be aware that any reduction in your pay subject to Social Security taxes could also lead to a reduction in your Social Security benefits. For most employees, the reduction in Social Security benefits will be insignificant in comparison to the value of paying lower taxes today. You pay the full cost of your Adult Benefit Recipient s coverage (ABR and ABR RDP/DP and ABR RDP/DP s children) on an after-tax basis, unless you can claim as a dependent on your federal tax return. You will be taxed on your and Providence s contributions toward such coverage, unless you claim your Adult Benefit Recipient as a dependent on your federal income tax return. Please note for Federal tax purposes: Under the Health Care and Education Reconciliation Act effective March 30, 2010, the contribution for medical coverage on your child ABR can be made on a pre-tax basis up to and including the calendar year in which the child reaches age 26. Additionally, the employer contribution for the adult child ABR is not considered taxable income to you under Federal tax law up until December 31 of the year prior to the adult child ABR reaching age 27. Since tax laws vary from state to state, please consult your tax advisor for the implications of your elections. Summary of Options MEDICAL Health Reimbursement Medical Plan Health Savings Medical Plan Group Health (HMO), where offered in Washington Tax Laws Can Change The tax advantages available under Providence s Health and Welfare Benefit Plan apply to federal taxes (income tax and Social Security tax), and generally also apply to state and local income taxes, if applicable. These advantages are based on the federal and various state laws as they stand today. In the future, it is possible that these laws may change. Blue Shield Access+ HMO, where offered in California Providence HMO OptionPLUS, where offered in California No Coverage (Waive) Some represented groups may have legacy medical options. If you are a member of such a represented group, you will see your options in your enrollment information Overview of Coverage

16 DENTAL Delta Dental PPO 1500 Delta Dental PPO 2000 (with orthodontia), No Coverage Some represented groups may have legacy a dental option. If you are a member of such a represented group, you will see your options in your enrollment information. VISION Vision Service Plan No Coverage EMPLOYEE SUPPLEMENTAL LIFE INSURANCE If you elect Supplemental Employee Life, you will receive at least $10,000 of coverage. You can choose coverage in increments of $10,000. Coverage is limited as follows: If your annual compensation is equal to or less than $25,000: maximum coverage is $150,000 If your annual compensation is more than $25,000: Maximum coverage is the lesser of six times compensation rounded down to the nearest $10,000, or $1,000,000. Coverage elected over $500,000, or four times compensation (two times for executives), requires the approval of a Statement of Health application. During the annual enrollment period, requests to increase employee coverage are limited to a two-level increase until the Statement of Health application has been approved. DEPENDENT LIFE INSURANCE Spouse/Adult Benefit Recipient Domestic Partner* Coverage If you elect coverage for your spouse/domestic partner, you can receive at least $10,000 of coverage. You can choose coverage in increments of $10,000. Coverage is limited to the lesser of 100% of your total life benefit amount, or $500,000. * A person has an insurable interest in something when loss or damage to it would cause that person to suffer a financial loss or certain other kinds of losses. Domestic partners meet the definition of insurable interest while other adult dependents, such as a parent, or other relatives, do not. Therefore, you can cover your legally qualified spouse or your same or opposite gender domestic partner, but not other Adult Benefit Recipients. Child(ren) Coverage $10,000 No Coverage Children must be at least 14 days old for coverage to be in effect. If your child is under six months old, he or she will only be covered for $500. SUPPLEMENTAL ACCIDENTAL DEATH & DISMEMBERMENT INSURANCE If you elect supplemental employee AD&D insurance, you will receive at least $10,000 of coverage. Coverage is available in increments of $10,000, up to a maximum of $1,000,000 or ten times your compensation, whichever is less and rounded down to the nearest $10,000. DEPENDENT ACCIDENTAL DEATH & DISMEMBERMENT INSURANCE Coverage is available in amounts from $10,000 to $500,000, in $10,000 increments, on your spouse/ Adult Benefit Recipient domestic partner. You can elect to cover your child(ren) for $10,000 per child 6 months and older; $500 per child less than 6 months of age. HEALTH CARE FLEXIBLE SPENDING ACCOUNT Contribute between $120 and $2,500 per calendar year (pro-rated for those newly eligible during the plan year) to pay for uninsured medical, dental, or vision expenses on a pre-tax basis (There are rules regarding the use of the Health FSA with a Health Reimbursement Account or Health Savings Account) No Contribution DEPENDENT CARE FLEXIBLE SPENDING ACCOUNT Contribute between $120 and $5,000 per calendar year to pay for dependent care expenses (or care for a dependent adult) on a pre-tax basis No Contribution 1-11 Overview of Coverage

17 What Are Employer Contributions? Employer contributions are what Providence provides you to purchase plan benefits. The amount of dollars contributed vary based on the family members you elect to cover. The relationship and number of dependents enrolled will require you to elect one of the following coverage options: Employee Only Employee Plus Child(ren) Employee Plus One Adult Employee Plus One Adult Plus Child(ren) Note that under IRS regulations, your and Providence s contributions for covering an Adult Benefit Recipient must be made on an after-tax basis resulting in imputed income with higher tax withholding. For more information about Adult Benefit Recipient benefits and the tax consequences, contact a tax advisor. What Are Benefit Options? Each plan included in Providence s Benefit Plan has at least two coverage choices (or benefit options). In some plans, one of the options is to waive coverage. All of your benefit options are listed through ProvConnect Employee Self-Service or, if provided, on a paper Enrollment Form. What Is the Total Plan Cost? Each benefit option has an associated total plan cost. The total plan cost generally represents the full cost of that benefit per pay period. The more expensive the coverage, the higher the total plan cost. The total plan cost for all of your benefit options appear on ESS. How Much Do I Have to Pay? If the total plan costs of your benefit options exceed the amount Providence contributes, you will make up the difference through payroll deductions. With Providence s benefit plan, the pay is redirected to benefits before taxes are calculated (except for Supplement Life Insurance premiums and one level of Long Term Disability, which are after-tax). The additional dollars you put into the program called pre-tax contributions are not taxed. Making Your Elections/Changing Your Elections You will receive information describing your benefit options and instructions on how to enroll using ProvConnect Employee Self-Service. The benefits you elect will stay fixed for the plan year January 1 through December 31 (or the remainder of the plan year if you make midyear elections), unless certain family or employment circumstances change significantly; or a dependent becomes ineligible as defined by the Plan, and you request a benefit change; and you submit a completed Benefit Change form with the required documentation to the HR Service Center by the deadline. New Hire/Newly Eligible You must enroll within 31 days of hire or becoming benefits-eligible. The 31 days is based on the date of the event, not the date it is entered into ProvConnect. If you want dependent coverage, you must also enroll your eligible dependents at this time. Coverage is not automatic. An enrollment packet will be sent to your home address. You make your elections by logging into ProvConnect Employee Self-Service and clicking on New Hire Enrollment. If your enrollment packet has not yet arrived at your home and the end of the 31 day enrollment period is fast approaching, you can log on to providence.org and ProvConnect for benefit plan information. Premium contributions can be viewed by going through the enrollment screens. You are responsible for enrolling on Employee Self- Service within the 31 days from your date of hire or becoming a benefits-eligible employee. You must click Submit when you are done for your elections to be entered to the system. It is recommended you print out a copy of your online elections. Even if you do not want coverage, you must enroll within the 31 day period to make that election otherwise you will be assigned coverage. (see page 1-15) 1-12 Overview of Coverage

18 Annual Enrollments You will be given the opportunity to review your participation in the benefit plans, and select the dependents you are covering under each of the available plans, on an annual basis each fall. Any changes made during the defined open enrollment period will be effective the beginning of the next plan year. If you add a dependent under Dependent Life coverage who could have been covered before, but was not, any coverage over $10,000 is subject to evidence of the dependent s good health. A Statement of Health may also be required if you wish to change your Supplemental Employee Life Insurance coverage by more than two levels from one year to the next or in an amount that exceeds four times pay (two times for executives), and/or to change Dependent Life Insurance by more than one level up to $50,000, or any level above $50,000. Family Status Changes In general, you may not change your elections during the plan year. However, if your family status changes, you can change your Family Category under the Medical, Dental, and Vision plans, and in limited circumstances, your Supplemental Life and Flexible Spending Account(s). Benefit changes must be consistent with the qualifying change in status and must be made within 31 days of the qualifying event (60 days for birth, placement for adoption, adoption and certain Medicaid/CHIP events). There are regulatory and plan provisions governing what changes can be made to the your elections. A change is considered consistent with an event only if the event caused a gain or loss of coverage and the elected change corresponds with that gain/loss of coverage. Federal law and Plan rules allow changes for the following situations: change in marital status: marriage, divorce, legal separation, death or annulment; change in number of dependents due to birth (your biological child), adoption, placement for adoption, death; termination or change in spouse s employment; the employer of your spouse/abr RDP/ABR DP or dependent has a plan year which results in a different open enrollment period from Providence; change in dependent eligibility of a child such as reaching his/her 26th birthday, or loss of IRS eligible dependent status; change in employment status of employee s spouse or dependent from full-time to part-time or from part-time to full-time or any other change in employment status (i.e., change in worksite) that results in the gain or loss of eligibility for an employee, spouse, or dependent. If the spouse s or dependent s employment status change does not result in a change in eligible coverage, no change in elections is allowed; commencement of, or loss of, Medicare or Medicaid coverage on you, your spouse or other dependent; commencement of an unpaid leave of absence of employee or employee s spouse; significant change in insurance coverage or cost through spouse or dependent s employer; a judgment decree or order requires an election change on a dependent child, including a foster child, as a result of divorce, legal separation, an annulment, or a change in legal custody; and add a dependent spouse or child who is not a United States (U.S.) citizen, national of the U.S., or resident of the U.S. on the earlier date they become a U.S. Citizen, national of the U.S. or a resident of the U.S. If a dependent is no longer eligible for coverage for one of the above reasons and/or he/she no longer meets the definition of an eligible dependent (for example, the dependent is no longer your legal spouse), you must notify the HR Service Center within 31 days of the event. Coverage will end at the end of the month in which the event occurs unless COBRA is requested and approved. If you cover an Adult Benefit Recipient and the qualifying relationship ends, your former Adult Benefit Recipient (and the children of your Adult Benefit 1-13 Overview of Coverage

19 Recipient Registered Domestic Partner) may continue coverage during a transitional period of up to three months. If coverage is not continued, coverage will end at the end of the month in which eligibility as an Adult Benefit Recipient ends. If you notify the HR Service Center more than 31 days after the status change, the ineligible person will be removed from coverage accordingly but no refund of premium will be available. Medical, Dental and Vision If you are covered by a medical HMO (offered at some locations) and you move out of the HMO service area, you can change Medical coverage. If your child, who is not a tax dependent, moves out of the HMO service area, you may choose to remove that dependent from your HMO coverage. If your dependent moves out of the country, coverage is not available under the plans except for emergency care so this may qualify for a change in your health coverage election. Additionally, you may change your Medical and/or Dental election during the year should one of the following events occur: If you are transferring from another work site location and the medical option in which you are currently enrolled is not available in your new location, you may make a change to your medical plan election. You experience a change in employment status from full-time to part-time which results in the amount of your medical and dental premium contribution increasing significantly (15% or more). This scenario would allow for you to change your Medical and/or Dental election to a lower cost plan option with Providence or to waive coverage to enroll in another group plan. Benefit changes must be made within 31 days of the qualifying status event, except as noted for birth, adoption, placement for adoption, and enrolling for coverage due qualifying Medicaid and CHIP events. You may add an Adult Benefit Recipient (and the children of your Adult Benefit Recipient Registered Domestic Partner) within 31 days of when he or she meets the eligibility conditions. You must remove the Adult Benefit Recipient, and any children of your ABR RDP, from coverage within 31 days of when he or she ceases to meet the eligibilty conditions. Election changes are also allowed in accordance to Special Enrollments as discussed on page 1-5. Dependent Care Flexible Spending Account You may also change your Dependent Care Flexible Spending Account contributions if your child reaches the limiting age (13) during the year or as a result of certain status changes listed above. You may also change your Dependent Care election in certain circumstances (for example, raise given to caregiver, relocation forces higher/lower costs, or dependent is no longer eligible). You cannot reduce your annualized contribution to less than the amount reimbursed (or expenses pending reimbursement) for the year to date. Health Care Flexible Spending Account Changes to your Health Care Flexible Spending Account may be made if one of the following events occurs: change in employee s legal marital status, change in the number of employee s dependents, change in employment status of employee, spouse, or dependent that affects eligibility, COBRA qualifying event, or You change your work site location within Providence and as a result the amount of your premium contributions increases significantly (15% or more). This scenario would allow for you to change your Medical and/or Dental election to a lower cost plan option with Providence or to waive coverage to enroll in another group plan. FMLA leave of absence. You cannot reduce your annualized contribution to less than the amount reimbursed (or expenses pending reimbursement) for the year to date Overview of Coverage

20 Supplemental Life Insurance Mid-year changes to your supplemental life insurance coverage(s) are limited to: You may add dependents within 60 days of gaining the dependent by birth (your biological child) or adoption; 31 days if by marriage. Domestic partners can be added within 31 days of meeting the eligibility conditions as a Adult Benefit Recipient domestic partner. In case of a death, divorce, legal separation or annulment, you must cancel coverage for your dependent. You must drop a dependent who dies or from whom you are divorced within 31 days of the death or the date of the final divorce decree. Domestic partners, and the children of your domestic partner, must be removed from coverage within 31 days of no longer meeting the eligibility conditions as a Adult Benefit Recipient domestic partner. Former spouses/ domestic partners are not eligible for coverage and no benefits will be paid on behalf of a former spouse/domestic partner who dies. If your spouse experiences a change in employment status which affects eligibility you may be able to make certain changes within 31 days of the event. You may add a dependent to your dependent life insurance coverage within 60 days of the event if you acquire a dependent through birth or adoption; 31 days if by marriage. No other midyear changes are permitted in your life insurance coverage. Each fall you will be able to review your choices and alter your coverage to meet your needs for the coming year. A Statement of Health may apply. Eligibility Changes A number of events, such as changes in your employment or marital status, may affect your coverage or that of your dependents. The following paragraphs explain what happens in these situations. Leaves of Absence. Contact the HR Service Center or other resource as described in communications from Human Resources for information regarding continuation of coverage during an approved leave of absence, including leaves under the Family Medical Leave Act (FMLA) and military leaves. When You Return from a Leave of Absence. If you keep your group coverage while you re away from your job and continued to make the premium payments due, you don t have to take any action when you return to work. Providence Health and Welfare Benefit Plan elections will continue without interruption (except for any Flexible Spending Account deductions which are not made while you are on an unpaid leave of absence). Upon return from work you will be expected to pay for any benefits deductions that are in arrears. If you do not continue your benefits while on leave, and you return as benefits-eligible employee in the same plan year, your prior benefit elections will be reactivated on the first of the month following or coincident with your return. Your Health Care and Dependent Care Flexible Spending Account deductions will also resume on the first of the month following or coincident with your return from leave in the same plan year. If your annual election has not been changed due to a qualifying status change (see page 1-13), your per pay check deduction will be adjusted in order to collect the full annual election by the end of the plan year. If a qualifying change in status election is made, your per pay period deduction will be calculated to collect your adjusted annual election by the end of the plan year. The balance available for reimbursement from your Health Care Flexible Spending Account upon your return from leave will be based on your adjusted annual election, less any amounts reimbursed from your account before you went on leave. If you do not continue your benefits while on a non- FMLA leave and you return to work in a different plan year, you will be treated like a new hire/newly benefits eligible employee. You will need to re-enroll within 31 days of the date you return to work as a newly benefits eligible employee. If you do not enroll, you will be assigned coverage (see right side of this page) If a Dependent Is No Longer Eligible. Coverage ends for a dependent child on the last day of the month during which the child reaches age 26. For a child age 26 or older covered as a disabled child, including meeting the IRS definition of a qualifying child, 1-15 Overview of Coverage