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

21 coverage ends at the end of the month in which he or she no longer qualifies as disabled or an IRS tax dependent. If you and your spouse are ending your marriage, coverage for your spouse and step children, if applicable, will end on the last day of the month in which the date of the final divorce decree or the granting of legal separation or annulment occurs. In these cases, you must file a Benefit Change Form with the required documentation removing those dependents who are no longer eligible within 31 days of the event. See the Optional Continuation of Coverage section (Chapter 5, pages 5-10 to 5-12) for further information. If you are covering an Adult Benefit Recipient, coverage for your Adult Benefit Recipient (and the children of your Adult Benefit Recipient Registered Domestic Partner) will cease on the last day of the month during which the Adult Benefit Recipient no longer meets all the conditions for eligibility. In these cases, you must file a new declaration. If a dependent who loses coverage becomes eligible again, you can reapply for coverage for him or her. This must be done within 31 days of when the dependent becomes eligible or you must wait until the next annual Open Enrollment period. If You Die. Coverage for your dependents will end on the last day of the month during which you die. See the Optional Continuation of Coverage section (Chapter 5, pages 5-10 to 5-12) for further information. If You Retire. Your coverage ends on the last day of the month in which you retire. See the Optional Continuation of Coverage section (Chapter 5, pages 5-10 to 5-12) for further information. How Often May I Change? You may request an enrollment change with each qualifying change in status/event you experience during the plan year. The actual changes to your benefits allowable must be consistent with the type of qualifying change. Default Benefits New Hire/Newly Eligible If you are newly eligible for benefits and you do not enroll in benefits within 31 days from your date of hire or first day as a benefits eligible employee, you will be assigned default benefits. The default benefits may not reflect the best benefit choices for your particular situation. Default benefits may include: Medical: Health Reimbursement Medical Employee Only Dental: Delta Dental PPO 1500 Employee Only LTD: depending on the ministry s base plan income replacement to Social Security Normal Retirement Age /180-day waiting period Basic Life and Accidental Death & Dismemberment You will have no coverage in the VSP Vision Plan, Supplemental Employee Life, Supplemental AD&D, and Dependent Life plans, and you will not participate in the Flexible Spending Accounts. Employees of Providence Saint Joseph Medical Center in Burbank, CA who are represented by United Healthcare Workers, Local 399 for Service and Technical Employees will be assigned default coverage in the PPO 1000 option - Employee Only, LTD - 50% after 180 days, and Basic Life and AD&D. Please see 2012 Summary Plan Description/ California. Employees of Providence Sacred Heart Medical Center who are represented by Washington State Nurses Association will be assigned default coverage in the PHP Primary option - Employee Only, Delta Dental Employee Only, LTD 55% after 180 days, and Basic Life and AD&D. After default elections become effective, changes can only be made due to qualifying family status changes, see page 1-13, or during the annual Open Enrollment. Annual Open Enrollment The annual open enrollment period occurs each fall giving you the opportunity to change your elections for the upcoming plan year effective January 1. Unless announced otherwise, if you do not make changes to your current plan elections during the specified open enrollment dates including who you are covering: Your existing Medical, Dental, Vision, Long Term Disability, Supplemental Employee Life, Supplemental Employee AD&D, Dependent Life, and Dependent AD&D coverage will roll over automatically to the next plan year at the corresponding plan year s full employee contribution rates 1-16 Overview of Coverage

22 If there has been a change in the options and your option is not offered, you will receive the designated replacement plan option and price, and your dependents as currently listed will be covered. This plan will not necessarily be identical in coverage to your previous plan. You will not have Health Care or Dependent Care Flexible Spending Account contributions as these require annual elections. Important: Review the annual open enrollment materials to learn whether an active enrollment will be required in order for there to be coverage or whether there is a change in the assigned default process for the new (upcoming) plan year s elections. You will not be able to make changes to your benefits until the next annual open enrollment period unless you have a change in your family status (such as a birth, death, marriage or divorce). Transfers to Another Providence Location You may have the opportunity to elect a new Medical or Dental option if: your current medical coverage is no longer available to you in the new location,or your share of the benefit cost of your current option is 15% higher (net of any premium credit) as a result of the transfer. If you are eligible to elect a new option due to your transfer, you have 31 days to enroll. Your new option will be effective the first day of the month after you enroll, or on the same day if you enroll on the first day of the month. If you have not elected a new option by the first day of the month immediately following your transfer date and your coverage option is no longer available, you will be defaulted into the option determined to be most similar to your current option at your current coverage level. You will remain defaulted in the coverage determined to be most similar to your prior coverage. You will not be able to make changes to your benefits until the next annual open enrollment period unless you have a change in your family status (such as birth, death, marriage or divorce). Dependent coverage cannot be changed unless due to Adult Benefit Recipient domestic partner eligibility requirements. Unless your medical (and, for a legacy group in California, dental) coverage will not be available in your new location/ministry without significant cost increase, your elections will carry forward without change. Basic Life and AD&D will be set to the certificate levels of your new facility. Your current supplemental life, supplemental AD&D, health flexible spending account, dependent care flexible spending account and, generally, long term disability coverage will carry forward without change. If your transfer results in other qualifying change in status events, those events will be processed under Family Status Change rules and processes. Rehire (or Return to Benefits-Eligible Status) If you are rehired or return to a benefits eligible status within 30 days of your termination date (or change to non-benefits eligible), your previous benefit elections will be reinstated the first of the month following your rehire date (or return to benefits eligible status) without limitations, except your long term disability will be subject to the preexisting condition limitation. If you were contributing to an FSA, your per pay period amount will resume. No arrears will be collected for your time away. Charges incurred during your termination period are not eligible for reimbursement. Changes can only be made due to qualifying family status changes or during the annual Open Enrollment. If you are rehired or return to a benefits eligible status 30 or more days after your termination date, you will considered a new hire and need to make new elections. You will be subject to the benefit waiting period rules. The following limitations may also apply: If you were contributing to an FSA, your per pay period amount will not resume. Health charges incurred during your termination period are not eligible for reimbursement unless you had COBRA coverage for your Health FSA. If you are covering an Adult Benefit Recipient, you may be asked to complete a new declaration Overview of Coverage

23 Note: If you are being rehired at Providence Saint Joseph Medical Center in Burbank, CA and are represented by United Healthcare Workers, Local 399 for Service and Technical Employees, your coverage will be effective the first of the month after you enroll so long as you were employed at Providence for 60 days prior to your termination. If you are being rehired at Providence Sacred Heart Medical Center in Spokane, WA and are represented by Washington State Nurses Association, your coverage will be effective the first of the month after you enroll so long as you were employed at Providence for 90 days prior to your termination. Note in all situations of default benefits, the Plan still 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. Limitations on Assignment Your rights and benefits under the Providence Health and Welfare Benefit Plan Benefit Plan cannot be assigned, sold, transferred, or pledged by you or reached by your creditors or anyone else except under limited circumstances (for example, Qualified Domestic Relations Order). About this Summary Plan Description This Summary Plan Description is designed to provide detailed information about Providence Health and Welfare Benefit Plan benefits and how they work as of January 1, The Summary Plan Description does not constitute an implied or expressed contract or guarantee of employment. If any conflicts arise between this summary and the Plan documents and contracts, the Plan documents and contracts as interpreted by the Plan Administrator and fiduciaries will govern. Likewise, the Summary Plan Description, Plan documents and contracts will govern, as interpretted by the Plan Administrator and fiduciaries, in the even of conflict with benefit communication materials and forms. Glossary of Terms From Chapter 1 Sections of this chapter explained the meaning of various terms or phrases such as Dependent, Adult Benefit Recipient, Employer Contributions and Benefit Options. Other words or phrases used in the Summary Plan Description for which the following defintions are available. After-tax Contributions/After-tax Dollars Dollars you authorize Providence Health & Services to withhold from your pay after taxes are deducted. Benefit Year The 12-month period beginning January 1 and ending December 31. All annual deductibles and benefit maximums accumulate during the benefit year. Flexible Spending Accounts The Health Care and the Dependent Care Flexible Spending Accounts are designed to save taxes. You elect to fund them at the beginning of the plan year and then are reimbursed from your account for eligible expenses you incur during the plan year. Imputed Income The assessed value of your benefits which is subject to taxation. Taxable amount is shown on your pay stub and includable on your W-2 statement. For Basic Life Insurance, Providence is required to calculate imputed income for Basic employee coverage over $50,000 using an IRS table, based on your age and amount of coverage. For Adult Benefit Recipient coverage, see page 1-4. Medicare Title XVIII (Health Insurance for the Aged) of the United States Social Security Act as amended. Medicare has two parts: Part A, which provides benefits for hospital care, and Part B, which provides benefits for doctors fees and certain other covered expenses Overview of Coverage

24 Physically or Mentally Disabled The inability of a person to be self-sufficient as the result of a condition such as mental retardation, cerebral palsy, epilepsy, or another neurological disorder which is diagnosed by a physician as a permanent and continuing condition. Plan Administrator The Plan Administrator is the sole fiduciary of the Plan and has all discretionary authority and control over the operation and administration of the Plan. The Plan Administrator has the discretionary authority to determine eligibility for benefits and to construe the terms of the Plan, and unless there was an abuse of discretion, such discretionary determinations regarding plan terms and eligibility shall be binding upon all participants and upon the employers. The Plan Administrator may choose to hire a consultant and/or contract administrator to perform specified duties in relation to the Plan. The Plan Administrator also has the right to amend, modify or terminate the Plan at any time or in any manner. Plan Year The 12-month period beginning January 1 and ending December Overview of Coverage

25 II. Medical: Health Reimbursement and Health Savings Plans Administered by Providence Health Plan Employees of St. Patrick Hospital (Missoula, MT), Providence Medical Group - Western Montan, or Providence St. Joseph Medical Center (Polson, MT), your medical plans are administered by Allegiance Benefit Plan Management with a separate medical plan summary. Your Medical Options Your medical options are: Health Reimbursement Medical Plan Health Savings Medical Plan Group Health HMO, where offered Blue Shield Access+ HMO, where offered Providence OptionPLUS HMO, where offered No Coverage (Waive)* *Available for Employee Coverage if you have medical coverage through another group plan and can provide proof of this coverage. The following legacy medical groups are available only to employees in the listed groups: PHP Primary offered to employees of Providence Sacred Heart Medical Center who are represented by the Washington State Nurses Association union Blue Shield PPO 600, Blue Shield PPO 1000 and Blue Shield HMO High, offered to employees of Providence Saint Joseph Medical Center in Burbank CA who are represented by United Healthcare Workers, Local 399 for Service and Technical Employees Choosing Medical Coverage You choose your Medical option and family category when you initially enroll. Then each fall, you elect your Medical option and family category for the following calendar year. How do you decide which Medical option is best for you? Consider the following questions: Which members of your family need coverage? What do you expect your medical expenses will be for the coming year? What will the various Medical options pay for your expected level of expense and what is the associated cost? How well could you withstand a high level of medical expenses if you had higher deductibles and differing coinsurance? Are you comfortable with receiving all of your care from in-network providers? Do you have any other coverage? Check the Coordination of Benefits section (Chapter 5, page 5-5) to see how the Plans work with any other medical, vision and/or dental coverage you may have. Family Categories The family categories for Medical are: Employee Only Employee Plus Child(ren) Employee Plus One Adult Employee Plus One Adult Plus Child(ren) Your family category choice for Medical does not affect your choice for Dental or Vision. Considering the No Medical Coverage Option If you have group medical coverage elsewhere, you may wish to consider the no coverage or waive option. This option is available for employee only coverage. By electing the waive option you are certifying you have other group medical coverage and qualify to choose no medical coverage through the Plan. If an HMO medical option is available in your area, please see the Appendix for information. If a legacy plan is offered for your specific group, please see the Appendix. 2-1 Medical

26 Under this option, you will have no medical coverage through the Providence offered medical plans. If you lose your other group medical coverage, you may enroll in a medical option outside of Open Enrollment if your loss of other group coverage is caused by: divorce, legal separation or annulment; your spouse s termination of coverage as a result of loss of employment, loss of benefit eligible status, change in employer benefit contributions, or eligibility for Medicare coverage; spouse s employer has a plan year which results in a different open enrollment period from Providence; your spouse s disability or death; loss of eligibility for group health coverage sponsored by a governmental institution eligibility by you, your spouse, or dependent children. You must submit a Benefit Change Form and the required documentation of the loss of the prior coverage within 31 days of the date coverage under the other plan is terminated. Coverage under Providence Health and Welfare Benefit Plan will begin on the first day of the month following the month in which the enrollment is processed. You will be responsible for any premium contribution required for the coverage you select. Working Spouse Surcharge If your spouse/adult Benefit Recipient Registered Domestic Partner (ABR RDP) (ABR DP in Alaska and Montana) has access to a medical plan through his or her employer, but waives that coverage and instead enrolls in a Providence medical plan, a $150 monthly surcharge will apply. The surcharge will be deducted on a pre-tax basis in $75 increments twice a month. The surcharge will not apply if your spouse/abr RDP/ABR DP: Is enrolled in Medicare, Medicaid, Tricare or Tribal health insurance (and is their only other coverage) Is a Providence benefits-eligible employee Has employer-provided medical coverage with an annual out-of-pocket maximum greater than $6,250 for employee-only coverage and $12,500 if covering dependents Becomes/is eligible for other group coverage with eligibility expected to, by the nature of the position, be variable in duration and result in eligibility of less than three continuous months (e.g. interim job coverage) If you enroll your spouse/abr RDP/ABR DP in a Providence medical plan during benefits enrollment for 2013, you will receive a request from ConSova, our dependent eligibility administrator that is to be completed by you and your spouse/abr RDP/ABR DP declaring whether other employer group coverage is available. ConSova will send the declaration to you after you enroll. If you do not return the declaration by the deadline indicated, the surcharge will be applied. If your spouse/abr RDP/ABR DP gains or loses employer coverage mid-year, or his or her employer s annual enrollment occurs at a different time of year and your spouse/abr RDP changes enrollment on the other employer plan, the change should be reported to the HR Service Center at or [email protected] within 31 days so the surcharge can be adjusted accordingly. Note: Employees of Providence Sacred Heart Medical Center in Spokane, WA who are represented by the Washington State Nurses Association, Providence Saint Joseph Medical Center in Burbank, CA who are represented by United Healthcare Workers, and all employees represented by the Oregon Nurses Association and Oregon Federation of Nurses and Health Professionals are not subject to the Working Spouse Surcharge provision for the year Does not have coverage through his or her employer 2-2 Medical

27 About Your Medical Benefits The self-funded medical plans provide benefits only for covered services and supplies that are medically necessary for the treatment of a covered illness or injury, and that are rendered by a physician, practitioner, nurse, hospital, or specialized treatment facility as those terms are specifically defined on page The treatment must be generally accepted by medical professionals in the United States and considered to be non-experimental/investigational. Plan benefits are based on charges which do not exceed the reasonable and customary charge in the geographic area where services or supplies are provided. Any amounts that exceed the reasonable and customary charges are not recognized by the Plan and are considered your responsibility. The major differences between the Health Reimbursement and Health Savings Medical Plans are: How much you pay out of pocket for deductibles and out of pocket maximums; The Health Reimbursement Medical Plan offers copayments not subject to the deductible for primary care visits, emergency room, and generic drugs; The companion savings account: Health Reimbursement Account or Health Savings Account and how the Health Care Flexible Spending Account, if elected, interacts with each; and Your per pay period premium contribution. Using In-Network Providers Providence Health & Services contracts with the Providence Health Plan to administer plans for employees and dependents covered by our selffunded plans. The Health Reimbursement Medical Plan and Health Savings Medical Plan allow you to choose any health care provider you wish, but in most cases you will save money by using a Preferred Provider (also referred to as participating providers). As a participant in the Providence Health and Welfare Benefit Plan plans, you are automatically eligible to use Preferred Providers. The Preferred Provider Network also referred to as a Preferred Provider Organization (PPO) allows preferred rates for health care services through a network of health care providers. The qualifications of each physician, hospital and other provider have been reviewed so that you and your dependents will be provided quality care at a discounted fee that is less than the general fee in the geographic area in which you receive services. In most cases, Preferred Providers can bill only their contracted rate. They cannot bill you for the difference between their contracted network rate and their retail, or noncontracted rate Participation in the PPO program is completely voluntary. You and any or all of your covered dependents may elect to use a Preferred Provider. It is important that you present your ID card when you obtain medical services, so that your provider knows what type of benefit plan you have The final choice of health care is yours. The Plan pays more if you use PPO services and services are generally discounted. As a result, your out-ofpocket costs will usually be considerably lower. Providence Health Plan, in circumstances of highly specialized care, may initiate negotiations with a compatible network for care to augment the regular provider network. If you receive services from a physician, hospital, or other provider NOT included in the Network/ PPO, the Plan will pay less as shown in the Covered Medical Expenses table starting on page Higher Benefit if Providence Facilities Are Used The Health Reimbursement Medical Plan and Health Savings Medical Plan Plans both provide a higher benefit if Providence Health & Services inpatient and outpatient facilities are used. See Covered Medical Expenses starting on page 2-11 for more information. 2-3 Medical

28 Alaska and California Preferred Provider Network, includes Providence Strategic and Management Services Members in Montana The Preferred Provider network available to members in Alaska and California is managed by Premera Blue Cross. Providence Health Plan is the claims administrator and all questions on your medical plan coverage and claims should be directed to Providence Health Plan. Premera Blue Cross has relationships with other Blue Cross and/or Blue Shield Licensees generally called Inter-Plan Arrangements. They include the BlueCard Program and arrangements for payments to non-network providers. Whenever you obtain health care services outside Washington and Alaska or in Clark County, Washington, the claims are processed through one of these arrangements. You can take advantage of the BlueCard Program when you receive covered services from hospitals, doctors, and other providers that are in the network of the local Blue Cross and/or Blue Shield Licensee, called the Host Blue in this section. At times, you may also obtain care from non-network providers. Payment calculation practices in both instances are described below. It s important to note that receiving services through these Inter-Plan Arrangements does not change covered benefits, benefit levels, or any stated residence requirements of this plan. Network Providers When you receive care from a Host Blue s network provider, in most cases, there are no claim forms to submit because network providers will do that for you. In addition, your out-of-pocket costs may be less, as explained below. Under the BlueCard Program, Premera remains responsible for fulfilling our contractual obligations. However, the Host Blue is responsible for contracting with and generally handling all interactions with its network providers. The provider s billed charges for your covered services; or The allowable charge that the Host Blue makes available to Premera. Often, this allowable charge will be a simple discount that reflects an actual price that the Host Blue considers payable to your provider. Sometimes, it is an estimated price that takes into account special arrangements with your provider that may include types of settlements, incentive payments, and/or other credits or charges. Occasionally, it may be an average price, based on a discount that results in expected average savings for similar types of providers after taking into account the same types of transactions as an estimated price. Estimated pricing and average pricing, going forward, also take into account adjustments to correct for over- or underestimation of modifications of past pricing for the types of transaction modifications noted above. However, such adjustments will not affect the allowable charge used for your claim because they will not be applied retroactively to claims already paid. Clark County Providers Some providers in Clark County, Washington do have contracts with Premera. These providers will submit claims directly and benefits will be based on Premera s allowable charge for the covered service or supply. Non-Network Providers When covered services are provided outside Washington and Alaska or in Clark County, Washington by non-network providers, the allowable charge will generally be based on the Host Blue s allowable charge for non-network providers unless a different allowable charge is required by applicable state law. You are responsible for the difference between the amount that the non-network provider bills and this plan s payment for the covered services. Whenever a claim is processed through the BlueCard Program, the amount you pay for covered services is calculated based on the lower of: 2-4 Medical

29 BlueCard Worldwide If you re outside the United States, the Commonwealth of Puerto Rico, and the U.S. Virgin Islands, you may be able to take advantage of BlueCard Worldwide when accessing covered health services. BlueCard Worldwide is unlike the BlueCard Program available in the United States, the Commonwealth of Puerto Rico, and the U.S. Virgin Islands in certain ways. For instance, although BlueCard Worldwide provides a network of contracting inpatient hospitals, it offers only referrals to doctors and other outpatient providers. Also, when you receive care from doctors and other outpatient providers outside the United States, the Commonwealth of Puerto Rico and the U.S. Virgin Islands, you ll typically have to submit the claims yourself to obtain reimbursement for these services. Finding Providers on the BlueCard Program To locate a provider in another Blue Cross and/or Blue Shield Licensee service area, go to Premera s Web site or call the toll-free BlueCard number BLUE (2583). You can also get BlueCard Worldwide information by calling the toll-free phone number. Oregon and Washington Preferred Provider Network Preferred Partner Facilities Offer a Higher Benefit in Washington State In addition, a higher benefit is provided if the following Preferred Partners are utilized in the state of Washington for inpatient and outpatient facility services: Swedish Health Services MultiCare Franciscan Health System Enumclaw Regional Hospital (Enumclaw, WA) Valley General Hospital (Monroe, WA) Cancer Care Northwest Eye Surgery Center Northwest St. Luke s Rehabilitation Institute Spokane Eye Clinic Spokane Eye Surgery Center Whitman Hospital (Colfax, WA) The Preferred Provider network available to covered persons in Oregon and Washington is managed by Providence Health Plan and First Choice Network. The network of mental health providers and chemical dependency providers is managed by PBH. Providence Health Plan is the claims administrator and all questions on your medical plan coverage and claims should be directed to Providence Health Plan. Network Providers When you receive care from a Providence Health Plan or First Choice Network provider, in most cases, there are no claim forms to submit because network providers will do that for you. In addition, your out-of-pocket costs may be less, as explained below. Whenever a claim is processed through, the amount you pay for covered services is calculated based on the lower of: The provider s billed charges for your covered services; or The allowable charge that the Providence Health Plan or First Choice Network contract with the provider makes available. Often, this allowable charge will be a simple discount that reflects an actual price that the Network considers payable to your provider. Sometimes, it is an estimated price that takes into account special arrangements with your provider that may include types of settlements, incentive payments, and/or other credits or charges. Occasionally, it may be an average price, based on a discount that results in expected average savings for similar types of providers after taking into account the same types of transactions as an estimated price. Inland Eye Center Inland Imaging 2-5 Medical

30 Non-Network Providers When covered services are provided by nonnetwork providers, the allowable charge will generally be based on the Network s allowable charge for non-network providers unless a different allowable charge is required by applicable state law. You are responsible for the difference between the amount that the non-network provider bills and this plan s payment for the covered services. Important Note regarding certain hospitals: Facility charges incurred at Walla Walla General Hospital are payable at a rate of 50% by the Plan unless due to a medical emergency or the specific services are not available at Providence St. Mary Medical Center. Charges incurred at any Community Health Systems (CHS) facility, which include Deaconess Medical Center (Spokane) and Valley Hospital and Medical Center (Spokane Valley), are payable at 50% coinsurance, plus any applicable copayment, unless due to a medical emergency or the specific services are not available at a Providence facility. Medical services covered under the medical plan that are not available at Providence, will be paid at the highest coverage level (Providence tier) except for bariatric surgery, which will not be covered if provided at CHS. Rockwood Clinic physicians are currently in-network providers as they accept First Choice Health network insurance. However, Rockwood primarily admits patients to Deaconess Medical Center and Valley Hospital and Medical Center. Therefore you and your covered dependents can use Rockwood Clinic physicians for primary/specialty care but if admitted to a CHS facility, the facility charge is covered at the out-of-network rate of 50%. Facility charges incurred at Alaska Regional Hospital are payable at a rate of 50% by the plan unless due to a medical emergency or the specific services are not available at Providence Alaska Medical Center Facility charges incurred at Community Medical Center in Missoula, MT are payable at a rate of 50% by the plan unless due to a medical emergency or the specific services are not available at St. Patrick s Hospital in Missoula. To assist with the shortage of primary care physicians Group Health Cooperative physicians in the Spokane area have been added to the network for primary care. All of the Group Health physicians have admitting rights to Providence Sacred Heart Medical Center. If You Are Out-of-Area You and your dependents can access health care from in-network providers when you are away from home and out of your service area. So long as you use contracted providers, your benefits will be paid at the in-network rate and you will receive 2-6 Medical the in-network discount rates from the providers as well. To access a national network provider, call the Providence Health Plan Customer Service toll-free number, , and ask for the name of a national network provider or facility located where you need care. You can also go on-line to the Providence Health Plan provider directory at healthplans.providence.org/phs-employees, then select the provider directory link, you will be asked to search the directory based on where you work. Once there, select the type of provider along with the ZIP Code. Present your medical ID card when you request care, and the provider will either bill the Providence Health Plan for you, or request payment directly and provide an itemized billing for your use in submitting a claim yourself. Choice of Primary Care Provider The plan considers physicians practicing in certain specialties (family practice, general practice, internal medicine, gynecology, and pediatrics) as primary care physicians. You can visit any innetwork provider in these specialties to receive the primary care physician benefit. For information on how to select find a primary care provider, and for a list of the participating primary care providers, contact Providence Health Plan at on-line at healthplans.providence.org/phs-employees or by calling You do not need prior authorization from the Plan or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact Providence Health Plan on-line at healthplans.providence.org/phs-employees or by calling

31 Health Reimbursement Medical Plan You are responsible for expenses up to the annual deductible before the Plan begins paying, except for those services subject to a copayment. If one person meets the individual deductible, the Plan begins paying for his or her eligible expenses. Once the family deductible is met (if you have elected family coverage), additional members of your family do not have to satisfy an individual deductible that year before the Plan begins paying for their eligible medical expenses. Visits to a Primary Care or Personal Physician/ Provider are not subject to the deductible and you pay only a $20 copayment per visit. Generic formulary drugs also are not subject to the deductible with a $10 copayment per 30-day supply. Emergency room visits are not subject to the deductible and you pay only a $250 copayment per visit. Once you have met your individual or family deductible, the Health Reimbursement Medical Plan pays the percentage indicated for eligible expenses. The Plan pays a higher percentage for inpatient or outpatient services provided by a Providence Health & Services facility or a Preferred Partner facility. These charges and other innetwork charges go toward your out-of-pocket maximum. Once the out of pocket maximum has been met, the Plan begins paying eligible expenses at 100% for the remainder of the calendar year. If one person meets the individual out of pocket maximum, the Plan begins paying for his or her eligible expenses at 100%. Once the family out of pocket maximum is met (if you have elected family coverage), additional members of your family do not have to satisfy an individual out of pocket maximum that year before the Plan begins paying their eligible medical expenses at 100%. Please note: If you experience a change in status during the plan year that results in changing your medical plan elections, amounts applied to the deductible and out of pocket maximum applied to the Health Reimbursement Medical Plan are restricted from being credited toward the deductible and out of pocket maximum of another medical plan. Health Reimbursement Account (HRA) While you are enrolled on the Health Reimbursement Medical Plan you can use this account to help pay certain out-of-pocket medical care expenses, including medical and prescription copays, coinsurance and the annual deductible for you and your family members who are enrolled on the Health Reimbursement Medical Plan. Every employee covered under the Health Reimbursement Medical Plan gets a Health Reimbursement Account. If you choose to complete the Health Incentive activities each year, Providence will fund the account. The amount of funding will be based on the elected family coverage tier and completions of the required activities. Using the Funds in Your HRA Your account can be used to pay copayments, coinsurance and the annual deductible under the Health Reimbursement Medical Plan. Providence will arrange for you to receive a debit-style card that can be used at the time of service (or purchase, in the case of prescription drugs). Additional cards for covered family members can be requested from HealthEquity, the claims administrator for the HRA. Expenses Which Do Not Qualify Expenses which do not qualify for reimbursement through the HRA include but are not limited to: Services received prior to your effective date in the Health Reimbursement Medical Plan Services received before the health incentive is received Medical expenses for individuals not covered by the Health Reimbursement Medical Plan Expenses for services not covered by the Providence Health Reimbursement Medical Plan (e.g. dental, vision, amounts above benefit limits) Excluded medical services and procedures (e.g. abortion/sterilization) Payroll deductions You may not use the current year s health incentive to reimburse expenses from the prior plan year. 2-7 Medical

32 Account Vesting and Termination of Coverage Vesting or ownership of your HRA occurs after five years of employment. Once vested, an employee who terminates employment and has unused funds remaining in an HRA can use their HRA to be reimbursed for COBRA medical premiums, Long Term Care premiums, Medicare premiums or individual medical plan premiums. If COBRA medical is elected for Providence medical coverage, the HRA Account may also be used to pay copayments, coinsurance and the annual deductible under the COBRA medical plan. Unused balances for employees who terminate employment and are not vested and do not elect COBRA will be forfeited. If an employee is rehired within one year of termination, unused balances will be restored. Unused HRA Account Balances Unused funds remaining in your HRA at the end of the year will roll over to the next year as long as you remain enrolled in the Health Reimbursement Medical Plan. If you change medical plans or waive medical coverage with less than five years of employment, the unused funds remaining in your HRA at the end of the year (with a brief grace period to submit claims incurred before 12/31) will be forfeited. Funds in the Health Reimbursement Account cannot be transferred to a Health Savings Account. Health Savings Medical Plan Health Savings Medical Plan has an annual deductible and an out-of-pocket maximums similar to the Health Reimbursement Medical Plan except: Family coverage (any level greater than employee only) has no individual deductible, the full family deductible has to be met before the Plan begins paying benefits for anyone in the family. Family coverage (any level greater than employee only) has no individual out of pocket maximum, the full family out of pocket maximum has to be met before the Plan begins paying benefits at 100% for anyone in the family. There are no copayments under the Health Saving Medical Plan. If you enroll in the Health Savings Medical Plan option you may be able to open an individual health savings account. A health savings account allows tax-free contributions which you can then use to pay your eligible health expenses - again tax free. A health savings account (HSA) has other key benefits, including the ability to: Use the HSA to reimburse the out of pocket health care expenses for you and your federal tax dependents. Roll over any unused money left in your HSA at the end of the year to the next year. There is no use it or lose it rule. Invest and grow the HSA funds and make additional contributions while in a qualifying high deductible health plan tax-free. Any unused funds are portable and not tied to continued employment with Providence it s yours to save for future health care expenses, like COBRA costs, long-term care insurance premiums, individual health benefit coverage, even into retirement. You have the opportunity to make contributions of your own money on taxpreferred basis if you open a health savings account. Health savings accounts are available at many financial institutions. You may choose to open a health savings account at any institution and gain the tax advantages at the time you file your annual income tax return. If you open a Health Savings Account with HealthEquity and choose to complete the Health Incentive activities, Providence will fund your account with the Health Incentive dollars. The amount of funding will be based on the elected family coverage tier and completions of the required activities. If you would like to contribute to your Health Savings Account through payroll deductions, you may do so by opening your individual 2-8 Medical

33 account through HealthEquity. Log on to www. healthequity.com/providence to open and manage your account. Continued enrollment in the Health Savings Medical Plan option enables you to continue making contributions. However, if you want to make contributions via payroll deduction in the new plan year, you will need to log in to your account online at providence and make a new election each year. If you have coverage under another group health plan which is not a qualifying high deductible health plan, you are not eligible to open or contribute to an existing Health Savings Account. Upon receiving a Welcome Kit from HealthEquity after your first enrollment in the Health Savings Medical Plan, please notify them if you are not eligible for a Health Savings Account. If you have been participating in a Health Savings Account and you gain coverage under another group health plan notify HealthEquity. Additional information on health savings accounts and what expenses can be reimbursed from your HSA is available in IRS Publication Health Savings Accounts and Other Tax-Favored Health Plans. Please note: If you experience a change in status during the plan year that results in changing your medical plan elections, amounts applied to the deductible and out of pocket maximum applied to the Health Reimbursement Medical Plan are restricted from being credited toward the deductible and out of pocket maximum of another medical plan. Funds in the Health Savings Account cannot be transferred to a Health Reimbursement Account Health Incentive You and your spouse/adult benefit recipient (ABR) can each earn up to $700 in 2013, for a total of up to $1,400, if you choose to complete the activities. If you enroll in the employee + child(ren) category, you are eligible to receive the full $1,400 incentive. You, and your spouse/adult Benefit Recipient, will need to meet the requirements for each new plan year if you wish to earn future health incentives. If you are unable to participate in one of the activities to earn the health incentive due to health issues and are interested in learning whether you qualify for an accommodation, please contact the HR Service Center at Your health incentive is deposited into the account associated with your medical plan after your activities have been processed with Healthyroads (it will take approximately 2-4 weeks from the date your Healthyroads Incentive page is showing as 100% complete). If you enroll in an HMO medical option, where available, the incentive will be paid quarterly as a premium credit. The 2013 HMO premium credit is up to $400 each for you and your enrolled spouse/ ABR, for a total of up to $800. You will receive your payment as taxable pay in your paycheck in quarterly installments, no more than $100 per adult per quarter.. You ll receive information about the 2014 health incentive program in late summer or early fall of If you were benefits-eligible before Aug. 31, 2012 To earn the 2013 health incentive, you and your enrolled spouse/abr needed to complete a biometric screening between August 1, 2012 and January 31, The biometric screening could be completed at onsite screening events or with your personal provider with the provider form submitted to Healthyroads. Biometric screenings completed in 2012 could satisfy the requirement if Healthyroads received the provider form by the deadline. You were also asked to report whether you have a Primary Care Physician on the HealthyRoads website but this was not required to receive the incentive. Employees of the Alaska Region ministries had to complete the biometric screening and the outcomes-based activity. If they completed their biometric screening, but did not complete the outcomes-based activity, Alaska employees earned half of the available incentive. 2-9 Medical

34 If you became benefits-eligible between Sept. 1, 2012 and June 30, 2013 To earn the health incentive, you and your enrolled spouse/abr need to complete a biometric screening to learn your key health numbers, including your height, weight, blood pressure and cholesterol and glucose levels. Register at Healthyroads, download the Provider Form, ask your provider to complete the form, and submit it to Healthyroads by July 31, 2013 to get credit. Visits with your health care provider dated back to January 1, 2012 are eligible for credit for the 2013 health incentive. The biometric screening may be covered at 100% as part of your preventive care benefit when received through an in-network provider. If you become benefits-eligible between July 1 and Dec. 31, 2013 You will automatically earn 50 percent of the 2013 health incentive. You do not need to complete a biometric screening, although we recommend you still do so. Providence RN Providence RN (Prov Rn) is a confidential medical advice line for Providence Health Plan participants. You do not need to pay to use Providence RN all costs are paid by Providence Health & Services. You may call Providence RN at (TTY: ) with your health-related questions and speak to a registered nurse, 24 hours a day, seven days a week. Please have your medical identification card available when you call. People often call when they have sick children at home or when they have questions about how to treat flus, colds, or backaches. After a brief recorded message, a registered nurse will come on the line to help. The nurse can answer many of the questions you may have or let you know whether you should seek a doctor s care. Please note: In the event of a conflict between the information you receive from Providence Health Plan or the HR Service Center and the Summary Plan Description or the Plan Document, the Summary Plan Descrption and Plan document will govern Medical

35 Benefit Summary of Covered Medical Expenses All services are subject to the general plan exclusions beginning on page 2-37 in addition to any servicetype exclusions listed in the Benefit Summary. The following table summarizes two preferred provider medical options. Information on HMO plans or legacy plans can be found in the appendix. The claims administrator for employees of the Western Montana region is Allegiance Benefit Plan Management, Inc.; a separate medical summary plan description will be provided. Annual Deductible Benefit The amount of covered medical and prescription drug expenses you pay each year before the Plan pays any benefits. Amount is per Plan year (January 1 December 31); includes covered medical and prescription drug expenses Health Reimbursement Medical Plan $1,150 per person $2,300 per family The per person deductible applies separately to each covered person. The family deductible combines the per person deductible expenses incurred by all covered family members. Once your family has met the family deductible for the plan year, no further deductible will be applied for any covered family member during the remainder of that year. Health Savings Medical Plan $1,500 for employee only coverage $3,000 for family coverage (any level greater than employee only) Employee only coverage has a different deductible amount than family coverage (any level greater than employee only). Family coverage has no per person deductible for each covered person. Family coverage is any coverage level that includes family members. The family deductible can be met by covered charges incurred by the various covered members of the family. Certain expenses do not apply towards the deductible, including but not limited to: services, even if recommended by a physician, not covered by the Plan; services in excess of a maximum benefit limit; fees in excess of reasonable and customary charges; penalties paid for not obtaining required prior authorization; and any copayments for the Health Reimbursement Medical Plan Out of Pocket Maximum The maximum amount, including deductibles, you must pay toward covered medical expenses in any Plan year (January 1 December 31). Once the out-of-pocket maximum is met in a Plan year, the Medical plan pays 100% of any additional covered expenses in that year. With family coverage, once your family has met the family deductible out of pocket maximum for the plan year, covered expenses for any covered family member will be paid at 100% for the remainder of that Plan year. Per person $3,300 Family $6,600 The per person out of pocket maximum applies separately to each covered person. The family out of pocket maximum combines per person expenses incurred by all covered family members. Employee only coverage $3,000 Family coverage $6,000 Employee only coverage has a different out of pocket maximum amount than family coverage (any level greater than employee only). Family coverage has no per person out of pocket maximum for each covered person. Family coverage is any coverage level that includes family members. The family deductible out of pocket maximum can be met by covered charges incurred by the various covered members of the family. Certain expenses do not apply to the out-of-pocket maximum, including but not limited to: services, even if recommended by a physician, not covered by the Plan; services in excess of a maximum benefit limit; fees in excess of reasonable and customary charges; and penalties paid for not obtaining required prior authorization Medical

36 Acupuncture Benefit Care by licensed acupuncturist: -Office visits May include Medically Necessary adjunctive therapy when provided with acupuncture course of treatment for neuromuscloskeletal disorders, nausea or pain Health Reimbursement Medical Plan Subject to the deductible Health Savings Medical Plan Any licensed acupuncturist: Plan pays 80% of the covered amount, you pay remainder of the invoice In combination with any care by a chiropractor and/or naturopathic physician, maximum of $1,500 in covered expenses allowable in a Plan year. Amounts that apply to the deductible also apply to the benefit limit Exclusions: Emergency care; preventive care; adjunctive therapy not associated with acupuncture; acupuncture performed with reusable needles; treatment of alcohol, drug or chemical dependency in a specialized inpatient or residential facility Allergy Services Allergy shots, allergy serum, injectable medications and total parenteral nutrition (TPN) Cancer Screening and Non-surgical Treatment Routine cancer screening Covered as Preventive Services in accordance with the Adult Preventive Care schedule under the Plan and the Patient Protection and Affordable Care Act of Mammogram: at any age Prostate cancer screen: for one prostate specific antigen (PSA) or DRE per calendar year, ages 40+ Colorectal cancer screening exam or tests for fecal blood test, flexible sigmoidoscopy, colonoscopy, barium enema - beginning at age 50. (Under age 50, covered under Inpatient Surgery benefit) Colonoscopy scheduled for other than screening exam, based on medical necessity Subject to the deductible Specialists in Providence Medical Group and specified affiliated groups (see page 2-34): Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 80% of the covered amount, you pay 20% Out-of-network: Plan pays 50% of the covered amount, you pay the remainder of the billed amount See below for the deductible In-network: Not subject to the deductible. Plan pays 100% of the covered amount, you pay 0% Out-of-network: Subject to the deductible. Plan pays 50% of the covered amount, you pay the remainder of the billed amount Subject to the deductible Facility Providence/Preferred Partner: Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 75% of the covered amount, you pay 25% Out-of-network: Plan pays 50%of the covered amount; you pay remainder of the billed amount Physician/Provider Specialists in Providence Medical Group and specified affiliated groups (see page 2-34): Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 80% of the covered amount, you pay 20% Out-of-network: Plan pays 50% of the covered amount, you pay the remainder of the billed amount 2-12 Medical

37 Benefit Outpatient Chemotherapy or Radiation Therapy Health Reimbursement Medical Plan Subject to the deductible Health Savings Medical Plan Facility Providence/Preferred Partner: Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 75% of the covered amount, you pay 25% Out-of-network: Plan pays 50%of the covered amount; you pay remainder of the billed amount Clinical trials relating to cancer Chiropractic Care Care by licensed chiropractor: - Office visits for diagnosis, evaluation and treatment planning for musculoskeletal conditions - Related diagnostic X-rays and laboratory services for the diagnosis and evaluations of musculoskeletal conditions - Manipulation of the spine, joints and/or musculoskeletal soft tissue, a re-evaluation, and/ or other services in various combinations. - Adjunctive physiotherapy which may include ultrasound, hot packs, cold packs, electrical muscle stimulation or other therapies and procedures which are Medically Necessary for the treatment of neuromusculoskeletal disorders, including one unit of massage therapy per visit when billed with manipulation Physician/Provider Specialists in Providence Medical Group and specified affiliated groups (see page 2-34): Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 80% of the covered amount, you pay 20% Out-of-network: Plan pays 50% of the covered amount, you pay the remainder of the billed amount Clinical trials are not covered under the plan. In-network & Out-of-Network: However, for care provided by the health care practitioners associated with the clinical trial that would otherwise be covered (preventive services, diagnosis, treatment, palliative care), coverage is available under regular plan provision. Please contact Providence Health Plan with questions. Subject to the deductible Any licensed chiropractor: Plan pays 80% of the covered amount, you pay the remainder of the billed amount. In combination with any care by an acupuncturist and/or naturopathic physician, maximum of $1,500 in covered expenses allowable in a Plan year. Exclusions: Emergency care; preventive care; services, exams and/or treatments for conditions other than neuromusculoskeletal disorders; all chiropractic appliances or Durable Medical Equipment; adjunctive physiotherapy not associated with chiropractic manipulation of the spine, joints, and/or musculoskeletal soft tissues; clinical laboratory studies performed in a chiropractor s office; venipuncture; massage therapy when billed without manipulation; massage therapy in excess of one unit per visit with manipulation 2-13 Medical

38 Benefit Dental Services and Dental Anesthesia Dental services received after an accidental injury to natural teeth which occurred while covered under the Plan Conditions for receiving this benefit: All treatment, except emergency services, require prior authorization by the Plan. Conditions related to trauma must be diagnosed within six months of injury and treatment must begin within 12 months of injury. Outpatient facility charges and related anesthesia charges for dental services for children under age six or developmentally disabled children or developmentally disabled adults (these services are not otherwise provided under the Medical Plan) Health Reimbursement Medical Plan Subject to the deductible Health Savings Medical Plan In-network: Plan pays 80% of the covered amount, you pay 20% Out-of-network: Plan pays 50% of the covered amount, you pay the remainder of the billed amount Subject to the deductible Facility Providence/Preferred Partner: Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 75% of the covered amount, you pay 25% Out-of-network: Plan pays 50%of the covered amount; you pay remainder of the billed amount Anesthesia Specialists in Providence Medical Group and specified affiliated groups (see page 2-34): Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 80% of the covered amount, you pay 20% Out-of-network: Plan pays 50% of the covered amount, you pay the remainder of the billed amount Prior authorization required Exclusions: Oral surgery (non-dental or dental) or other dental Services (all procedures involving the teeth;, wisdom teeth areas surrounding the teeth, and dental implants), except as approved by Providence Health Plan Diabetic Care Annual preventive exams - Dilated retinal exams by a qualified participating eye care specialist; - Glycosylated hemoglobin (HbA1c) test; - Urine test to test kidney function; - Blood test for lipid levels as appropriate; - Visual exam of mouth and teeth by a personal physician/provider or other provider (dental visits are not covered); and - Foot inspection without shoes or socks. NOTE: With the exception of the dilated retinal exam, all of the above may be performed in your provider s office at the time of your annual exam. The eye exam may be done by an eye care specialist. Exams may be performed more often than once a year if your provider decides they are medically necessary. Additional exams and tests are subject to the deductible and coinsurance See below for the deductible In-network: Not subject to the deductible. Plan pays 100% of the covered amount, you pay 0% Out-of-network: Subject to the deductible. Plan pays 50% of the covered amount, you pay the remainder of the billed amount Additional exams billed with a medical diagnosis Subject to the deductible Specialists in Providence Medical Group and specified affiliated groups (see page 2-34): Plan pays 90% of the covered amount, you pay 10% In-network: Subject to the deductible, Plan pays 80% of the covered amount. Out-of-network: Subject to the deductible. Plan pays 50% of the covered amount, you pay the remainder of the billed amount 2-14 Medical

39 Benefit Diabetes supplies (covered under preventive medication benefit) - Glucose control solution - Pump supplies - Test strips: - Lancets: - Syringes. Diabetes self-management education program Initial self-management education program. Your provider can recommend a Specialist or facility that provides these services. You must be enrolled on the date services are received through the program for benefits to be paid. Diagnostic X-ray and Laboratory Outpatient Diagnostic charges for x-ray and laboratory services - Pre-admission testing (PAT) - Ultrasound - Allergy testing Includes contrast materials (dyes) that may be required for a diagnostic procedure High technology radiological/imaging services such as MRI, CT and PET scans require prior authorization for coverage Dialysis Outpatient Renal Dialysis Health Reimbursement Medical Plan See below for the deductible Health Savings Medical Plan In-network: Not subject to the deductible. Plan pays 100% of the covered amount, you pay 0% Out-of-network: Subject to the deductible. Plan pays 50% of the covered amount, you pay the remainder of the billed amount See below for the deductible In-network: Not subject to the deductible. Plan pays 100% of the covered amount, you pay 0% Out-of-network: Subject to the deductible. Plan pays 50% of the covered amount, you pay the remainder of the billed amount Subject to the deductible Facility: Providence/Preferred Partner: Plan pays 80% of the covered amount, you pay 20% In-network: Plan pays 80% of the covered amount, you pay 20% Out-of-network: Plan pays 50%of the covered amount; you pay remainder of the billed amount Prior authorization required for high tech imaging Subject to the deductible Facility Providence/Preferred Partner: Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 75% of the covered amount, you pay 25% Out-of-network: Plan pays 50%of the covered amount; you pay remainder of the billed amount Physician/Provider Specialists in Providence Medical Group and specified affiliated groups (see page 2-34): Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 80% of the covered amount; you pay 20% Out-of-network: Plan pays 50% of the covered amount, you pay remainder of the billed amount Medical

40 Benefit Emergency and Urgent Care Urgent/Immediate Care Urgent care is treatment you need right away for an illness or injury that is not life threatening. This includes, but is not limited to, minor sprains, minor cuts and burns, and ear, nose, and throat infections. Routine care that can be delayed until you can be seen by a physician or provider in his or her office is not urgent care. If you are admitted to a non-participating Hospital, you, or a relative, should call Providence Health Plan within 48 hours or as soon as reasonably possible. Emergency Care (Hospital) A medical emergency is a sudden unexpected illness or injury that you believe would place your life in danger or cause serious damage to your health if you do not seek immediate medical treatment. Medical emergencies include, but are not limited to: - Heart attack - Stroke - Poisoning - Loss of consciousness - Acute abdominal pain - Severe chest pain - Serious burn - Bleeding that does not stop - Unexpected premature childbirth - Medically necessary detoxification Coverage is provided without Prior Authorization for Emergency Medical Screening Exams and stabilization of an Emergency Medical Condition. Hospitalization for an Emergency Medical Condition requires notification to Providence Health Plan within 48 hours, or as soon as reasonably possible following the onset of treatment in order for coverage to continue Health Reimbursement Medical Plan Subject to the deductible Health Savings Medical Plan Providence/Preferred Partner: January 1 - June 30, 2013: Plan pays 80% of the covered amount, you pay 20% Effective July 1, 2013 Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 80% of the covered amount, you pay 20% Out-of-network: Plan pays 80%of the covered amount; you pay remainder of the billed amount Not subject to the deductible Facility Providence/Preferred Partner: You pay $250 copay per visit; the Plan pays the remainder In-network: You pay $250 copay per visit; the Plan pays the remainder Out-of-network: You pay $250 copay per visit; the Plan pays the remainder Copay is waived if patient is directly admitted from emergency room. Physician/Provider In-network: Plan pays 100% of the covered amount Out-of-network: Plan pays 100% of the covered amount, you pay for any charges above the covered amount Subject to the deductible Facility Providence/Preferred Partner: Plan pays 80% of the covered amount, you pay 20% In-network: Plan pays 80% of the covered amount, you pay 20% Out-of-network: Plan pays 80%of the covered amount; you pay remainder of the billed amount Physician/Provider In-network: Plan pays 80% of the covered amount, you pay 20% Out-of-network: Plan pays 80% of the covered amount, you pay the remainder of the billed amount The definition of an Emergency Medical Condition is a medical condition that manifests itself by symptoms of sufficient severity that a prudent layperson, possessing an average knowledge of health and medicine, would reasonably expect that failure to receive immediate medical attention would place the health of a person (or a fetus in the case of a pregnant woman) in serious jeopardy. Emergency Services are those health care items and Services furnished in an emergency department. Services include all ancillary services routinely available to an emergency department to the extent they are required for the stabilization of the patient. Plan benefits cover Emergency Services in the emergency room of any Hospital. Emergency room Services are covered when your medical condition meets the guidelines for emergency care as stated above. Coverage includes Services to stabilize an Emergency Medical Condition and Emergency Medical Screening Exams Medical

41 Benefit Equipment and Supplies Durable medical equipment Including expenses related to necessary setup, repairs, and maintenance. A statement is required from the prescribing physician describing how long the equipment is expected to be necessary and whether the equipment is medically necessary. This statement will determine whether the equipment will be covered and if covered whether rented or purchased. If approved for rental, the plan will pay the equipment rental cost up to the purchase price of such equipment. Replacement equipment will be covered if the replacement equipment is required due to a change in the patient s physical condition, because of normal wear and tear, or because purchase of new equipment is less expensive than repair of existing equipment. Other equipment and supplies Health Reimbursement Medical Plan Subject to the deductible Health Savings Medical Plan In-network: Plan pays 80% of the covered amount, you pay 20% Out-of-network: Plan pays 50% of the covered amount, you pay the remainder of the billed amount Prior authorization required for - power-wheel chairs and supplies - seat lift mechanisms -select nerve stimulators - skin substitutes - oral appliances - flexion/extension devices - wound therapy pumps - speech generating devices - purchase of CPAP post trial rental period Subject to the deductible In-network: Plan pays 80% of the covered amount, you pay 20% Out-of-network: Plan pays 50% of the covered amount, you pay the remainder of the billed amount - Medical devices that are surgically implanted into the body to replace or aid function: artificial limbs and eyes and replacement of artificial eyes and limbs if required due to a change in the patient s physical condition or if replacement is less expensive than repair of existing prostheses. - Original fitting, adjustment, and placement of orthopedic braces, casts, splints, crutches, cervical collars, head halters, traction apparatus, or prosthetic appliances to replace lost body parts or to aid in their function when impaired. Replacement of such devices will be covered only if the replacement is necessary due to a change in the physical condition of the covered person or because of normal wear and tear. - Oxygen and rental of equipment required for its use, not to exceed the purchase price of such equipment. - Orthopedic or corrective shoes and other supportive appliances for the feet when prescribed by a covered health care provider. - Orthotics, up to $500 in covered expenses every calendar year. - Blood and/or plasma, and the equipment for its administration, including autologous blood transfer. - Insulin infusion pumps and glucose monitor Medical

42 Genetic Testing Benefit BRCA1 and BRCA2 Mutation Testing must be specifically ordered by the Covered Person s treating Physician and have prior authorization by Providence Health Plan. Health Reimbursement Medical Plan Subject to the deductible Health Savings Medical Plan Providence/Preferred Partner/In-network: Plan pays 100% of the covered amount, you pay 0% Out-of-network: Plan pays 50%of the covered amount; you pay remainder of the billed amount Prior authorization required Both A and B must be documented prior to approval of Hereditary Breast and/or Ovarian Cancer Syndrome testing: A. There must be a documented genetic counseling visit where the alternatives and possible outcomes are discussed. The testing is not approved for informational reasons but for the person tested to either take medical or surgical action or to increase surveillance for cancer. B. The patient must have a medical and family history that meets one of the following National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology; Genetic/Familial High-Risk Assessment: Breast and Ovarian. V.I Genetic testing for BRCA1 and BRCA2 mutation, specifically included as a benefit, will be limited to once per lifetime. Coverage of this testing shall not be construed in any manner to be authorization for coverage of either prophylactic mastectomy or oophorectomy. Other Genetic Screening and Counseling When there is a medical condition that requires genetic testing to make a certain diagnosis or to aide in planning a treatment course. Identification of a genetic disorder should result in medical interventions and solutions that are corrective and therapeutic in nature Subject to the deductible Providence/Preferred Partner/In-network: Plan pays 80% of the covered amount, you pay 20% Out-of-network: Plan pays 50%of the covered amount; you pay remainder of the billed amount Prior authorization required Exclusions: Prophylactic mastectomy or oophorectomy unless medically necessary; genetic testing is not covered for screening, to diagnose carrier states, or for informational purposes in the absence of disease. Home Health Care Up to 130 home health care visits per calendar year Each visit by a person providing Services under a home health care plan or evaluating the need for or developing a plan is considered one home health care visit. Up to four consecutive hours in a 24-hour period of home health care Service is considered one home health care visit. A home health care visit of more than four hours is considered one visit for every four hours or part thereof. (cont d. next page) Subject to the deductible Providence/Preferred Partner: Plan pays 80% of the covered amount, you pay 20% In-network: Plan pays 80% of the covered amount, you pay 20% Out-of-network: Plan pays 50%of the covered amount; you pay remainder of the billed amount Prior authorization required 2-18 Medical

43 Benefit Health Reimbursement Medical Plan Health Savings Medical Plan Home Health Care (cont d.) All Covered Services for home health care must be skilled services and do not include coverage for Custodial Care. Home health care will not be reimbursed unless your Qualified Practitioner certifies that the home health care Services will be provided or coordinated by a state-licensed or Medicare-certified Home Health Agency or certified rehabilitation agency. If you were hospitalized immediately prior to the commencement of home health care, the home health care plan must be initially approved by the Qualified Practitioner who was the primary provider of Services during the hospitalization. Rehabilitation Services provided under an authorized home health care plan will be covered as home health care Services. Exclusions: charges for mileage or travel time to and from your home; wage or shift differentials for Home Health Providers; charges for supervision of Home Health Providers; or services that consist principally of Custodial Care including, but not limited to, care for senile deterioration, mental deficiency, mental illness, developmental disability or care of a chronic or congenital condition on a long-term basis. Hospice Care Hospice care is a coordinated program of home care and inpatient care for a terminally ill patient, combined with support for the patient s family. The program provides for special needs arising from physical, psychological, spiritual, and economic stresses people experience during the final stages of a terminal illness. The following criteria must be met: 1. Your Qualified Practitioner certifies that you have a terminal illness with a life expectancy not exceeding six months; and 2. The Covered Services provided are reasonable and necessary for the condition and symptoms being treated. Subject to the deductible Providence/Preferred Partner: Plan pays 100% of the covered amount, you pay 0% In-network: Plan pays 100% of the covered amount, you pay 0% Out-of-network: Plan pays 100%of the covered amount; you pay 0% Prior authorization required Covered services and supplies include: - Charges made by a hospice facility, hospital, or skilled nursing facility, which are for: - Room and board and other services and supplies furnished to a person while a full-time inpatient for pain control; and other acute and chronic symptom management. - Services and supplies furnished to a person while not confined as a full-time inpatient. Charges made by a hospice care agency for: - Part-time or intermittent nursing care by a R.N. or L.P.N. for up to eight hours in any one day. - Medical social services under the direction of a physician. These include: assessment of the person s social, emotional, and medical needs and the home and family situation; identification of the community resources which are available to the person; and assisting the person to obtain those resources needed to meet the person s assessed needs. - Psychological and dietary counseling. - Consultation or case management services by a physician. - Physical and occupational therapy. - Part-time or intermittent home health aide services for up to eight hours in any one day. These consist mainly of caring for the person. - Medical supplies. - Drugs and medicines prescribed by a physician. (cont d on next page) 2-19 Medical

44 Benefit Health Reimbursement Medical Plan Health Savings Medical Plan Hospice Care (cont d.) Charges made by the providers below, but only if the provider is not an employee of a hospice care agency and such agency retains responsibility for the care of the person. - A physician for consultant or case management services. - A physical or occupational therapist. - A home health care agency for: - physical and occupational therapy; - part-time or intermittent home health aide services for up to eight hours in any one day; these consist mainly of caring for the person; - medical supplies; - drugs and medicines prescribed by a physician; and - psychological and dietary counseling. Exclusions: any charge for daily room and board in a private room over the facility s semiprivate room rate; bereavement counseling; funeral arrangements; pastoral counseling; financial or legal counseling (including estate planning and the drafting of a will); homemaker or caretaker services (these are services not solely related to care of the person including: sitter or companion services for either the person who is ill or other members of the family, transportation, housecleaning, and maintenance of the house);respite care furnished during a period of time when the person s family or usual caretaker cannot, or will not, attend to the person s needs) Hospital and Specialized Facilities Hospital Inpatient Acute Care, Skilled Nursing Facility All in-patient admissions require prior authorization; for emergency admissions, claims administrator (Providence Health Plan) needs to be advised within 48 hours or as soon as reasonably possible. The Plan will cover: - Room and board, not to exceed the semiprivate room charge. If a private room is the only accommodation available, the Plan will cover an amount equal to the hospital s average semiprivate room rate. - Intensive care unit (ICU) and coronary care unit - Miscellaneous hospital services and supplies required for treatment during a hospital confinement. - Well-baby nursery charges for the initial confinement of an enrolled newborn (not covered as part of the mother s maternity benefit, newborn must be enrolled within 60 days of date of birth for biological child or placement for adoption to be covered). Inpatient rehabilitation. Subject to the deductible Inpatient, Acute Care Facility Providence/Preferred Partner: Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 75% of the covered amount, you pay 25% Out-of-network: Plan pays 50%of the covered amount; you pay remainder of the billed amount Skilled Nursing Facility In-network: Plan pays 80% of the covered amount, you pay 20% Out-of-network: Plan pays 50%of the covered amount; you pay remainder of the billed amount Prior authorization required. If emergency admission, PHP to be notified within 48 hours or as soon as reasonably possible 2-20 Medical

45 Benefit Hospital - Outpatient Some outpatient procedures require prior authorization Includes ambulatory surgical facility, and birthing center. Health Reimbursement Medical Plan Subject to the deductible Health Savings Medical Plan Out-patient Facility Providence/Preferred Partner: Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 75% of the covered amount, you pay 25% Out-of-network: Plan pays 50%of the covered amount; you pay remainder of the billed amount (Additional note on inpatient and outpatient hospital coverage on next page) Physician/Provider Specialists in Providence Medical Group and specified affiliated groups (see page 2-34): Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 80% of the covered amount, you pay 20% Out-of-network: Plan pays 50% of the covered amount, you pay the remainder of the billed amount Note: Spokane, WA, Community Health System s facilities (Deaconess and Valley) paid at 50% of covered amount; Walla Walla, WA, Services at Walla Walla General are paid at 50% of covered amount; Community Medical Center in Missoula, MT, is covered at 50% of covered amount; Alaska Regional Hospital services paid at 50% of covered amount. If service is not available at a Providence facility, then services at the above mentioned hospitals are eligible for the Providence benefit level. Infertility Infertility Testing and Counseling Diagnostic testing and associated office visits to determine the cause of infertility. This includes the physical examination, related laboratory testing, instruction, and medical/surgical procedures when performed for the sole purpose of diagnosing. Diagnostic Services include hysterosalpingogram, laparoscopy and pelvic ultrasound. Maximum allowable expense for screening for infertility testing/counseling is $500 per calendar year Subject to the deductible Specialists in Providence Medical Group and specified affiliated groups (see page 2-34): Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 80% of the covered amount, you pay 20% Out-of-network: Plan pays 50%of the covered amount; you pay remainder of the billed amount Exclusions: treatment of infertility (including surgical); infertility related drugs or injectables; reversal of reproductive sterilization; artificial insemination including cost of acquiring semen; in-vitro and in vivo fertilization or services supporting in vitro fertilization; services for non-member surrogate mother; home and water births; all services associated with surrogate parenting, including infertility testing and treatment; fees for surrogate parent; services, supplies, drugs, and procedures for reproductive disorders, defects, and/or inadequacies, whether or not the consequence of Illness, disease, or Injury. Disorders, defects, and/or inadequacies shall include, but not be limited to: impotency, frigidity, infertility, sterility, and reversal of surgical sterilization Medical

46 Infusion Therapy Benefit A type of care involving non-self-administered intravenous drugs. Maternity and Pregnancy Prenatal as preventive care, including Obstetrical Specialist for High Risk Pregnancy For amniocentesis and ultrasound services, see Diagnostic X-ray and Laboratory. Health Reimbursement Medical Plan Subject to the deductible Health Savings Medical Plan Facility Providence/Preferred Partner: Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 75% of the covered amount, you pay 25% Out-of-network: Plan pays 50%of the covered amount; you pay remainder of the billed amount Physician/Provider Specialists in Providence Medical Group and specified affiliated groups (see page 2-34): Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 80% of the covered amount, you pay 20% Out-of-network: Plan pays 50% of the covered amount, you pay the remainder of the billed amount See below for deductible In-network: Not subject to the deductible. Plan pays 100% of the covered amount; you pay 0% Out-of-network: Subject to the deductible. Plan pays 50%of the covered amount; you pay remainder of the billed amount Delivery and post-natal care, including Obstetrical Specialist for High Risk Pregnancy See below for the deductible Physician/Provider In-network: Not subject to the deductible. Plan pays 100% of the covered amount; you pay 0% Out-of-network: Subject to the deductible. Plan pays 50%of the covered amount; you pay remainder of the billed amount Subject to the deductible Physician/Provider Specialists in Providence Medical Group and specified affiliated groups (see page 2-34): Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 80% of the covered amount, you pay 20% Out-of-network: Plan pays 50%of the covered amount; you pay remainder of the billed amount Lactation Therapy Covered under the terms of the Plan and the Patient Protection and Affordable Care Act of 2010 Includes breast pump rental or purchase For delivery facility, see Hospital and Specialized Facilities Not subject to the deductible For delivery facility, see Hospital and Specialized Facilitie In-network: Plan pays 100% of covered amount; you pay 0% Out-of-network: Plan pays 100% of covered amount; you pay any remainder of billed amount. Exclusions: reproductive sterilization; maternity expenses of non-member surrogate; services by a Certified Direct-entry Midwife; home and water births 2-22 Medical

47 Benefit Mental Health and Chemical Dependency Inpatient Services (Mental Health & Chemical Dependency) Health Reimbursement Medical Plan Subject to the deductible Health Savings Medical Plan In-patient Facility Providence/Preferred Partner: Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 75% of the covered amount, you pay 25% Out-of-network: Plan pays 50%of the covered amount; you pay remainder of the billed amount Residential Services Providence/Preferred Partner: Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 75% of the covered amount, you pay 25% Out-of-network: Plan pays 50% of the covered amount, you pay the remainder of the billed amount. Prior authorization required Inpatient, residential, and day or partial hospitalization for the treatment of mental or chemical dependency disorders, including detoxification, when they meet the American Society of Addiction Medicine Placement Guidelines for Substance Related Disorders (ASAM) criteria. These services must be obtained at an approved treatment facility. Non emergency inpatient, residential and day treatment mental health and chemical dependency services are covered benefits only when prior authorized by Providence Health Plan s authorizing agent, PBH, at PBH is available as a resource for outpatient services and will work with your qualified practitioner to coordinate your care. If you have concerns about the confidentiality of mental health or substance abuse treatment in an in-network facility, treatment elsewhere may be covered at the in-network rate if authorized by PHP. Outpatient Services Outpatient diagnostic evaluation and mental health treatment, including individual and group therapy. Outpatient diagnosis and treatment for chemical dependency. Treatment includes individual and group therapy. PBH, at , is available as a resource for outpatient services and will work with your qualified practitioner to coordinate your care. See below for the deductible In-network: Not subject to the deductible. Plan pays 100% of the covered amount, you pay 0% Out-of-network: Subject to the deductible. Plan pays 50% of the covered amount, you pay the remainder of the billed amount Neuropsychological testing requires prior authorization Subject to the deductible Specialists in Providence Medical Group and specified affiliated groups (see page 2-34): Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 80% of the covered amount; you pay 20% Out-of-network: Plan pays 50% of the covered amount; you pay the remainder of the billed amount Neuropsychological testing requires prior authorization Exclusions: conditions other than mental or chemical dependency disorders specified in the current edition of the Diagnostic and Statistical Manual of Disorders (DSM); services provided under a court order or as a condition of parole or probation; personal growth services, such as assertiveness or consciousness raising; treatments which do not meet the national standards for mental health or chemical dependency practice; counseling related to sexual disorders or career; treatments involving the use of methadone if such treatment is not part of a medically-supervised treatment program that has been prior authorized by PBH; non-emergency inpatient, residential and day treatment, and all chemical dependency treatments if not prior authorized by PBH; mental health services related to developmental or learning disabilities, Autistic Disorder, Asperger Disorder or Pervasive Developmental Disorder not otherwise specified coded with ICD-9 299, or Medical

48 Naturopathic Care Benefit Care by licensed naturopathic physician are examination, clinical laboratory, diagnostic x-ray, office visit consultation, and/or adjunct therapy delivered by a naturopathic physician within a course of treatment that both: -includes natural treatment methods, modalites, nutritional advice, recommendation of homeopathic protocols, and -excludes surgery or invasive therapeutic procedures Health Reimbursement Medical Plan Subject to the deductible Health Savings Medical Plan In-network: Plan pays 80% of the covered amount, you pay 20% Out-of-network: Plan pays 50% of the covered amount, you pay the remainder of the billed amount In combination with any care by an acupuncturist and/or chiropractor, maximum of $1,500 in covered expenses allowable in a Plan year. Exclusions: herbal supplements and natural medicines prescribed by a naturopathic physician, surgery, massage, physical therapy, or invasive therapeutic procedures. Emergency care; preventive care; immunizations, vaccinations, injectables and intravenous infusions (does not include venipuncture for the purpose of obtaining blood samples for laboratory studies); topical and oral drugs, pharmaceuticals, intravenous administered treatments, minor surgery; vaccines/vaccination services, massage, physical therapy, homeopathic products, botanical medicine products; dietary and nutritional supplements, including vitamins, minerals, herbs, herbals and herbal products, injectable supplements and injection services, or other similar products; the following tests: Comprehensive digestive stool analysis; Melatonin biorhythm challenge; Cytotoxic food allergy test; Salivary caffeine clearance; Darkfield examination for toxicity or parasites; Sulfate/creatinine ratio; EAV and electronic tests for diagnosis and allergy; Urinary sodium benzoate; Fecal transient and retention time; Urine/saliva ph; Henshaw test; Tryptophan load test; Intestinal permeability; Loomis 24-hour urine nutrient/enzyme analysis; Zinc tolerance test Newborn Care Inpatient Newborn services are separate from that of the mother. Newborn nursery care is a facility service covered under your Hospital Services benefit. All other services provided to a newborn, including physician/provider services, are covered under the applicable benefit level. Reminder: Coverage of newborns is not automatic. If you want to enroll the newborn, you must complete within 60 days of the date of birth (or date of placement for a newborn being adopted) including required documentation. Contact the HR Service Center for the form. Contacting Providence Health Plan does not add the child to coverage. See below for the deductible Facility (Not subject to the deductible) Providence/Preferred Partner: Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 75% of the covered amount, you pay 25% Out-of-network: Plan pays 50%of the covered amount; you pay remainder of the billed amount Physician/Provider In-network: Not subject to the deductible. Plan pays 100% of the covered amount, you pay 0% Out-of-network: Subject to the deductible. Plan pays 50% of the covered amount, you pay the remainder of the billed amount See below for the deductible Facility (Subject to the deductible) Providence/Preferred Partner: Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 75% of the covered amount, you pay 25% Out-of-network: Plan pays 50%of the covered amount; you pay remainder of the billed amount Physician/Provider Specialists in Providence Medical Group and specified affiliated groups (see page 2-34): Plan pays 90% of the covered amount, you pay 10% In-network: Not subject to the deductible. Plan pays 80% of the covered amount, you pay 20% Out-of-network: Subject to the deductible. Plan pays 50% of the covered amount, you pay the remainder of the billed amount 2-24 Medical

49 Nutrition Benefit Preventive Nutritional Counseling First two nutritional counseling sessions in a calendar year for any diagnosis Nutritional Counseling Visits in a calendar year in addition to the first two paid as preventive; any diagnosis Nutritional Services Medical foods are covered for supplemental or dietary replacement, including non- prescription elemental enteral formula for home use, when determined to be medically necessary for the treatment of severe intestinal malabsorption. Medical foods are defined as foods that are formulated to be consumed or administered enterally under strict medical supervision for the treatment of inborn errors of metabolism Health Reimbursement Medical Plan See below for the deductible Health Savings Medical Plan In-network: Not subject to the deductible. Plan pays 100% of the covered amount, you pay 0% Out-of-network: Subject to the deductible. Plan pays 50% of the covered amount, you pay the remainder of the billed amount Subject to the deductible Specialists in Providence Medical Group and specified affiliated groups (see page 2-34): Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 80% of the covered amount, you pay 20% Out-of-network: Plan pays 50% of the covered amount, you pay the remainder of the billed amount Subject to the deductible Specialists in Providence Medical Group and specified affiliated groups (see page 2-34): Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 80% of the covered amount, you pay 20% Out-of-network: Plan pays 50% of the covered amount, you pay the remainder of the billed amount Approval of these services will be based on criteria established by Providence Health Plan and in accordance with regulatory requirements. Exclusions: Medical foods do not include total parenternal nutrition (TPN); this is covered under Allergy shots, serums and injectable medications. Obesity Related/Bariatric Surgery Coverage of open and laparoscopic Roux-en-Y gastric bypass surgery for morbid obesity is provided in accordance with medical policy and criteria established and maintained by Providence Health Plan. Benefits are limited to one bariatric procedure per lifetime while an individual is covered by a plan sponsored by Providence Health & Services. Subject to the deductible In-patient Facility Providence/Swedish: Plan pays 90% of the covered amount, you pay 10% In-network: Not Covered Out-of-network: Not Covered Professional Fees Specialists in Providence Medical Group and specified affiliated groups (see page 2-34): Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 80% of the covered amount, you pay 20% only when procedures are performed at a Providence or Swedish facility Out-of-network: Not Covered Travel Benefit If services through a Providence or Swedish facility: Plan pays $150 per diem food and lodging (alcohol is excluded); mileage reimbursement at federal IRS rates with minimum travel distance between home and provider of 100 miles each way; $5,000 lifetime maximum for bariatric travel expenses Prior authorization is required Medical

50 Benefit Health Reimbursement Medical Plan Health Savings Medical Plan Bariatric Surgery (cont.) The surgery and related services, including complications, will be covered as any other medical condition and subject to applicable plan limits. Services to stabilize complications from gastric stapling, gastroplasty or Lap Band adjustable gastric banding system bariatric procedures performed prior to January 1, 2013 will be covered. Any new procedures will be limited to Plan provisions in place at the time of the complications. Exclusions: Open vertical banded gastroplasty; (Laparoscopic vertical banded gastroplasty; Open and laparoscopic adjustable gastric band; Gastric balloon; Intestinal bypass surgery other than listed above and any procedure(s) associated with it; Supplemental fasting is not a covered benefit.; other treatments for obesity Physician/Health Care Provider Primary Care Provider Office Visit (non- Preventive Services) Can be physician/provider specializing in family practice, internal medicine, general practice, obstetrics/gynecology or pediatrics Non-Primary Care Provider/Specialist Visit No referral required See below for the deductible In-network: Not subject to the deductible. You pay $20 copay per visit, the Plan pays 100% of the remainder of covered amount Out-of-network: Subject to the deductible. Plan pays 50% of the covered amount, you pay the remainder of the billed amount. Subject to the deductible Subject to the deductible In-network: Plan pays 90% of the covered amount, you pay 10% Out-of-network: Plan pays 50% of the covered amount, you pay the remainder of the billed amount Specialists in Providence Medical Group and specified affiliated groups (see page 2-34): Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 80% of the covered amount, you pay 20% Out-of-network: Plan pays 50% of the covered amount, you pay the remainder of the billed amount Inpatient Hospital Visit Subject to the deductible Specialists in Providence Medical Group and specified affiliated groups (see page 2-34): Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 80% of the covered amount, you pay 20% Out-of-network: Plan pays 50% of the covered amount, you pay the remainder of the billed amount Other office procedures; other professional services (radiology, pathology) Prescription Drugs Prescription Drugs Providence Rx Subject to the deductible Physician/Provider Specialists in Providence Medical Group and specified affiliated groups (see page 2-34): Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 80% of the covered amount, you pay 20% Out-of-network: Plan pays 50% of the covered amount, you pay the remainder of the billed amount Prescription drug coverage information begins on page Eligible prescription drug charges apply to the shared deductible and out of pocket maximum shown on page Medical

51 Preventive Care Benefit Well Child Care Unlimited up to age 3 years, up to 1 exam each calendar year thereafter to age 18 years. Vision and hearing screening services are covered when performed during a periodic health examination or well-baby care examination. Includes covered preventive care, including routine immunizations/shots for children under the provisions of the Patient Protection and Affordable Care Act. For more information: provisions/services/lists.html Health Reimbursement Medical Plan See below for the deductible Health Savings Medical Plan In-network: When billed as preventive care not subject to the deductible. Plan pays 100% of the covered amount, you pay 0%. To receive in-network benefit, services must be provided by a Primary Care Provider. You may have out of pocket costs due to the deductible and/or copay or coinsurance for the office visit, if the preventive service is not the primary purpose of the visit, or if your doctor bills you for the preventive services separately from the office visit. Out-of-network: Subject to the deductible. Plan pays 50% of the covered amount, you pay the remainder of the billed amount Adult Preventive Care Your provider will determine which tests are necessary for your physical exam according to your medical history and your current health status. Recommended guidelines for periodic exams: Age 20 29: one exam every five years Age 30 49: one exam every two years Age 50 and older: one exam every year Ancillary Services, such as immunizations, are covered at the specified benefit levels when billed separately by the provider. Includes the covered preventive care services under the provisions of the Patient Protection and Affordable Care Act. For more information: provisions/services/lists.html See below for the deductible In-network: When billed as preventive care not subject to the deductible. Plan pays 100% of the covered amount, you pay 0%. To receive in-network benefit, services must be provided by a Primary Care Provider. You may have out of pocket costs due to the deductible and/or copay or coinsurance for the office visit, if the preventive service is not the primary purpose of the visit, or if your doctor bills you for the preventive services separately from the office visit. Out-of-network: Subject to the deductible. Plan pays 50% of the covered amount, you pay the remainder of the billed amount 2-27 Medical

52 Benefit Well Woman Visit/Women s Preventive Care Gynecological exams and Pap tests, (mammograms, see Cancer Screening), and women s health preventive care and screenings supported by the Health Resources and Services Administration. Includes the covered preventive care services, including routine immunizations/shots, under the provisions of the Patient Protection and Affordable Care Act. For more information: provisions/services/lists.html Providence Health & Services has certified that it qualifies for a temporary safe harbor with respect to the federal requirement to cover contraceptive services without cost sharing. During this one year period (2013), coverage under this health plan will not include coverage of certain contraceptive services in accordance with the terms of the plan. Laboratory Services for Preventive Care Including, but not limited to, pap smear, CBC, urinalysis, chemical profile, and glucose For more information: providence.org/pdfs/wamt/documents/ preventive-services.pdf Hearing Exam $250 maximum covered expenses per calendar year Health Reimbursement Medical Plan See below for the deductible Health Savings Medical Plan In-network: When billed as preventive care not subject to the deductible. Plan pays 100% of the covered amount, you pay 0%. To receive in-network benefit, services must be provided by a Primary Care Provider. You may have out of pocket costs due to the deductible and/or copay or coinsurance for the office visit, if the preventive service is not the primary purpose of the visit, or if your doctor bills you for the preventive services separately from the office visit. Out-of-network: Subject to the deductible. Plan pays 50% of the covered amount, you pay the remainder of the billed amount See below for the deductible In-network: If billed with preventive diagnosis: not subject to the deductible. Plan pays 100% of the covered amount, you pay 0%. If billed with diagnosis other than preventive: subject to the deductible. Plan pays 80% of the covered amount and you pay 20% Out-of-network: Subject to the deductible. Plan pays 50% of the covered amount, you pay the remainder of the billed amount See below for the deductible In-network: Not subject to the deductible. Plan pays 100% of the covered amount, you pay 0% Out-of-network: Subject to the deductible. Plan pays 50% of the covered amount, you pay the remainder of the billed amount Exclusions: sterilization, spermicides over the counter contraceptives and barrier methods: diaphragm, cervical sponge, cervical cap, vaginal ring; hearing aids, hearing therapies and/or devices, including all services related to the examination and fitting of the hearing aids; hearing aid supplies; fee for completing paperwork needed for third party (school, work, team sports, travel, etc.) 2-28 Medical

53 Benefit Rehabilitative Services - Outpatient Covered services are for outpatient physical, occupational, speech and neuro-developmental therapy. Short-term outpatient rehabilitative services are covered up to 75 visits per calendar year, all therapies combined (physical therapy, speech therapy, occupational therapy and neurodevelopmental therapy). Therapy is provided by physicians and/or licensed or registered therapists to restore or improve function lost due to illness or injury. Benefits are limited to covered services that can be expected to result in the significant improvement of the condition. The treatment must be part of a written treatment plan prescribed by a qualified provider. This benefit includes treatment for Autistic Disorder, Asperger s Disorder or Pervasive Developmental Disorder not otherwise specified. Health Reimbursement Medical Plan Subject to the deductible Health Savings Medical Plan Facility Providence/Preferred Partner: Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 75% of the covered amount, you pay 25% Out-of-network: Plan pays 50%of the covered amount; you pay remainder of the billed amount Physician/Provider Specialists in Providence Medical Group and specified affiliated groups (see page 2-34): Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 80% of the covered amount, you pay 20% Out-of-network: Plan pays 50% of the covered amount, you pay the remainder of the billed amount Pulmonary rehabilitation requires prior authorization. Neuropsychological testing requires prior authorization. Exclusions: exercise programs; rolfing, polarity therapy, applied behavioral analysis (ABA), and similar therapies; and growth and cognitive therapies, including sensory integration and treatment of developmental delay except for diagnosed neuro-developmental conditions. Sleep Disorders Treatment of sleep disorders and/or sleep studies Home sleep studies are also covered Subject to the deductible Prior authorization required Exclusions: services not having prior authorization by claims administrator Facility Providence/Preferred Partner: Plan pays 90% of the covered amount, you pay 10% In-network: Not covered Out-of-network: Not covered Physician/Provider Specialists in Providence Medical Group and specified affiliated groups (see page 2-34): Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 80% of the covered amount, you pay 20% Out-of-network: Plan pays 50% of the covered amount, you pay the remainder of the billed amount 2-29 Medical

54 Benefit Surgery and Anesthesia Surgeon s expenses for the performance of a surgical procedure, and the services of an assistant surgeon not to exceed 20% of the reasonable and customary charge of the primary surgeon or in accordance with PPO contract limits. Anesthesia, when administered by a licensed anesthesiologist or certified registered nurse anesthetist (C.R.N.A.) in connection with a surgical procedure. Health Reimbursement Medical Plan Subject to the deductible Health Savings Medical Plan Specialists in Providence Medical Group and specified affiliated groups (see page 2-34): Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 80% of the covered amount, you pay 20% Out-of-network: Plan pays 50% of the covered amount, you pay the remainder of the billed amount Select surgical procedures must have prior authorization Cosmetic surgery, only when needed to correct damage caused by an accidental injury or a birth defect resulting in the malformation or absence of a body part, and only if approved by PHP Breast Reconstruction A covered person will be covered for all stages of one breast reconstruction/reduction on the non-diseased breast to make it equivalent in size with the diseased breast after definitive reconstructive surgery on the diseased breast has been performed following a mastectomy. A prostheses may be covered after a mastectomy if recommended by the treating physician following the mastectomy. Up to two mastectomy bras are covered every 12 months. Subject to the deductible (See Hospital and Specialized Facilities for facility coverage.) Specialists in Providence Medical Group and specified affiliated groups (see page 2-34): Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 80% of the covered amount, you pay 20% Out-of-network: Plan pays 50% of the covered amount, you pay the remainder of the billed amount All out-patient surgical procedures must have prior authorization Coverage for breast reconstruction and related services will be subject to all applicable deductibles, co-payments and coinsurance amounts that are consistent with those that apply to other benefits under the Plan. The Plan will at all times comply with the terms of the Women s Health and Cancer Rights Act of 1998 and will not deny a patient eligibility to enroll or to renew coverage, under the terms of the Plan solely to avoid the requirements of this section. Additionally, the Plan will not penalize the patient or physician, or induce him or her to provide care to a participant in a manner inconsistent with this provision. Any Plan exclusions or limitations that exclude the benefit described above are hereby omitted to the extent that they specifically prohibit the above coverage. Reconstructive Surgery To restore the anatomy and/or functions of the body which are lost or impaired due to an illness or injury. Head/facial structures: restoration and management of head and facial structures, including teeth, dental implants and bridges, that cannot be replaced with living tissue and that are defective because of trauma, disease or birth or developmental deformities, not including malocclusion of the jaw, when Services are Medically Necessary for the purpose of controlling or eliminating pain, or restoring facial configuration or functions such as speech, swallowing or chewing Subject to the deductible (See Hospital and Specialized Facilities for facility coverage.) Specialists in Providence Medical Group and specified affiliated groups (see page 2-34): Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 80% of the covered amount, you pay 20% Out-of-network: Plan pays 50% of the covered amount, you pay the remainder of the billed amount All out-patient surgical procedures must have prior authorization Exclusions: cosmetic surgery (primarily to preserve or improve appearance);dental services including but not limited to orthodontia, tooth decay, impacted teeth; orthognathic surgery to shorted or lengthen jaw unless related to injury or neoplastic/degenerative disease 2-30 Medical

55 Benefit Temporomandibular Joint (TMJ) and Orthognathic Services Health Reimbursement Medical Plan Health Savings Medical Plan A diagnostic examination including a history, physical examination and range of motion measurements, as necessary; diagnostic X-rays; physical therapy of necessary frequency and duration; therapeutic injections; surgery; therapy utilizing an appliance/splint which does not permanently alter tooth position, jaw position or bite. Coverage of the appliance/splint is under the provisions of this section. The benefit for the appliance splint therapy will include an allowance for diagnostic services, office visits and adjustments. Surgical Services. Subject to the deductible Specialists in Providence Medical Group and specified affiliated groups (see page 2-34): Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 80% of the covered amount, you pay 20% Out-of-network: Plan pays 50% of the covered amount, you pay the remainder of the billed amount The benefit is limited to a combined medical and surgical benefit for all related services of $3,000 per lifetime. Prior authorization required Orthognathic services, including surgical treatment of TMJ, only when there is significant evidence of pathology as a result of illness or injury. Illness refers to a neoplastic process, degenerative disease or infection. Exclusions: dental or orthodontia services Tobacco Cessation Covered under the terms of the Plan and the Patient Protection and Affordable Care Act of 2010 Coverage is provided for participation in a PHPapproved, physician-recommended tobacco use cessation program that follows the United States Public Health Service guidelines. Also includes participation in the Alere Quit for Life Program. See below for the deductible In-network: Not subject to the deductible. Plan pays 100% of covered amount; you pay 0% Out-of-network: Subject to the deductible. Plan pays 50% of covered amount; you pay any remainder of billed amount Transplants, Human Organ/Tissue A transplant is defined as a procedure or series of procedures by which an organ or tissue is either removed: - from the body of one person (the donor) and implanted in the body of another person (the recipient who is a participant); or - from and replaced in the same person s body (a self-donor who is a participant). The term transplant does not include services related to the transfusion of blood or blood derivatives (except hematopoietic stem cells) or replacement of a cornea. Subject to the deductible In-patient Facility Providence/Preferred Partner: Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 75% of the covered amount, you pay 25% Out-of-network: Plan pays 50%of the covered amount; you pay remainder of the billed amount Surgeon/Physician/Provider Specialists in Providence Medical Group and specified affiliated groups (see page 2-34): Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 80% of the covered amount, you pay 20% Out-of-network: Plan pays 50% of the covered amount, you pay the remainder of the billed amount Prior authorization required Medical

56 Benefit Health Reimbursement Medical Plan Health Savings Medical Plan (Transplant, cont d) To qualify for coverage all transplant related services, procedures, treatment protocols, and facilities must have prior authorization by Providence Health Plan to be medically necessary and medically appropriate according to national standards of care, including initial consultation, evaluation, transplant facilities, donor evaluation, donor services, HLA typing. pre-transplant car, self-donation services, transplant services, and follow-up treatment NOTE: Prior authorization is not a treatment directive. The actual course of medical treatment that a participant chooses remains strictly a matter between the participant and his/her physician and is separate from the prior authorization requirements. Covered Services Once prior authorization received, covered services for transplants are limited to services that: -are provided at a facility approved by Providence Health Plan, using one of their credentialed Centers of Excellence or a Providence transplant program; - involve one or more of the following organs or tissues: - heart, - lung, - liver, - kidney, - pancreas, - small bowel, - autologous hematopoietic stem cell/bone marrow, or - allogeneic hematopoietic stem cell/bone marrow/cord blood, and - are directly related to the transplant procedure, including services that occur before, during and after the transplant procedure. Covered services for transplant recipients include medical services, hospital services, medical supplies, medications and prescription drugs while hospitalized, diagnostic modalities, prostheses, and high dosage chemotherapy for stem cell/bone marrow/cord blood transplants. Travel expenses Subject to a $5,000 benefit maximum for transportation, food and lodging. Food and lodging is subject to a $150 per diem and apply to the $5,000 travel expenses benefit maximum. Charges for alcohol are not covered. They are available for the recipient only. Travel benefit is subject to medical policy provisions and requires prior approval. (Note: Travel services are not covered for donors.) Subject to the deductible Travel Benefit $150 per diem food and lodging; mileage reimbursement at federal IRS rates with minimum travel distance between home and provider of 100 miles each way; $5,000 lifetime maximum for travel expenses 2-32 Medical

57 Benefit Services for transplant donors Covered when both of the following apply: - the transplant recipient is a member of the Plan and is eligible for transplant benefits, and - the donor is not eligible for coverage of donation services under any other health benefit plan or government funding. Covered services for donors include: - initial evaluation of the donor and related program administration costs, - preserving the organ or tissue, transporting the organ or tissue to the transplant site, - acquisition charges for cadaver or live donor, - services required to remove the organ or tissue from the donor, - and treatment of medical complications directly resulting from the surgery performed to obtain the organ or tissue for a period of time not to exceed 30 consecutive days following that surgery. Health Reimbursement Medical Plan Subject to the deductible Health Savings Medical Plan In-patient Facility Providence/Preferred Partner: Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 75% of the covered amount, you pay 25% Out-of-network: Plan pays 50%of the covered amount; you pay remainder of the billed amount Physician/Provider Specialists in Providence Medical Group and specified affiliated groups (see page 2-34): Plan pays 90% of the covered amount, you pay 10% In-network: Plan pays 80% of the covered amount, you pay 20% Out-of-network: Plan pays 50% of the covered amount, you pay the remainder of the billed amount Benefits for Outpatient Medications Benefits for outpatient medications and anti-rejection (immunosuppressive) drugs are covered under the prescription drug benefits Exclusions: any transplant procedure performed at a transplant facility that has not been approved by Providence Health Plan (PHP); any transplant that is Experimental/Investigational, as determined by PHP; services or supplies for any transplant that are not specified as covered services, such as transplantation of animal organs or artificial organs; services related to organ/tissue donation by a member of the Plan if the recipient is not a member or the member/recipient is not eligible for transplant benefits under this plan; and transplantrelated travel expenses for the donor and the donor s and recipient s family members. Transportation Ambulance Services for emergency medical transportation by state certified ambulance and certified air ambulance transportation. Ambulance services are provided for transportation to the nearest facility capable of providing the necessary care or to a facility specified by Providence Health Plan. Subject to the deductible Plan pays 80% of the covered amount, you pay 20% Prior authorization required for air ambulance services except in medical emergencies Exclusions: care cars, other medical transportation vehicles and other non-emergency medical transportation services; air ambulance transportation for non-emergency situations unless authorized by Providence Health Plan in advance. For Valdez and Kodiak (Alaska) Only: Medically necessary transportation will be reimbursed by the Plan. Benefits include reimbursement of charges for round trip air or ferry transportation for the ill or injured enrollee by a licensed commercial carrier. Subject to the deductible Air transportation between locations in Alaska, the Plan pays 100% of the covered amount, Limited to three round trip fares per condition 2-33 Medical

58 Benefit Health Reimbursement Medical Plan Health Savings Medical Plan For air transportation within Alaska, the plan will pay 100% of the cost after the deductible, limited to three round trip air fares or ferry trips per condition. Benefits will only be provided if at least one of the following apply: - The illness or accidental injury occurred suddenly, unexpectedly, and was life-endangering, or - The enrollee was admitted at the end of the trip, or - Medically necessary covered treatment could not be performed locally. - A letter of medical necessity may be requested from the treating/referring provider as part of approving the air travel benefit. If the member who is traveling to get medical care is unable to travel alone as deemed so by their physician, transportation charges will also be reimbursed for an accompanying custodial parent or an adult attendant if the attending physician certifies the need for such attendance. If the member is a child under 18, transportation charges will also be reimbursed for an accompanying custodial parent or adult. Coverage for the accompanying parent or adult is subject to the same limitations as noted above for the eligible member. For Alaska members only: If a medically necessary service is not available from any provider in Alaska, the plan will pay 100% of the cost after the deductible up to a maximum reimbursement of $600 per round trip for air transportation to locations outside of Alaska. Benefits will only be provided if the medically necessary covered treatment could not be performed within Alaska. A letter of medical necessity may be requested from the treating/referring provider as part of approving the air travel benefit. Subject to the deductible Air transportation to a location outside of Alaska, the Plan pays 100%, up to a maximum of $600 in allowable expenses per trip. Exclusions for Alaska member travel benefits: Air transportation services not meeting the criteria for coverage; transport by taxi, bus, private car or rental car; meals and lodging; transportation other than provided via commercial air carrier or Alaska State ferry; expenses in excess of $600 per trip for travel to locations outside Alaska; transportation expenses for trips in excess of the three trip limit for travel within Alaska; services that are covered under the vision or dental plans Effective for services on or after July 1, 2013: If you receive care from a specialist in one of the following groups, eligible charges will be covered at 90%: Providence Medical Group (Alaska, Oregon, Montana, Washington) In California Providence Medical Institute (PMI) - Affiliates in Medical Specialties - Axminster Medical Group - Providence Medical Group Facey Medical Group Providence Partners for Health (a group of almost 900 specialty and primary care providers) In Western Washington Swedish Medical Group Minor & James Medical Other Important Notes: No coverage is provided for treatment or services rendered outside the USA or its territories except for an accidental injury or medical emergency. Out-of-network plan benefits are based on charges which do not exceed the usual and customary charge in the geographic area where services or supplies are provided. Any amounts that exceed the usual and customary charges are not recognized by the Plan and are considered your responsibility Medical

59 Benefit Maximums Total plan payments for each covered person are limited to certain maximum benefit amounts. A benefit maximum can apply to specific benefit categories or to all benefits. A benefit maximum amount also applies to a specific time period, such as a year or a lifetime. Whenever the word lifetime appears in this plan in reference to benefit maximums, it refers to the time you or your dependents are covered by any health plan provided by Providence Health & Services. Your Medical options will not pay more than the following for medical expenses incurred over your (or your dependents ) lifetime: Orthognathic Services, including TMJ... $3,000 Bariatric Surgery... One per lifetime Genetic Testing for BRCA1 and BRCA2 Mutation... One per lifetime Financial Hardship Caused by Medical Expenses Providence Health & Services will attempt to help you if you suffer financial hardship because of unreimbursed medical expenses. You are encouraged to discuss your financial needs with your Human Resources Department or Director of Finance. Prior Authorization/ Medical Review Providence Health & Services contracts with Providence Health Plan to help you and the Plan determine whether or not proposed services are appropriate. The program is not intended to diagnose or treat medical conditions, guarantee benefits, or validate eligibility. The medical professionals who conduct the program focus their review on the appropriateness of hospital stays and proposed procedures. Nothing in this provision will increase benefits to cover a confinement or service that is not medically necessary or otherwise not covered. Prior authorization is NOT a guarantee of benefit payment Medical Covered Services that Require Prior Authorization Required Prior Authorization (Pre-authorization) and Review for Hospital Admissions, Outpatient Surgery and Other Services As the patient it is your responsibility to advise your physician/provider of the requirement for prior authorization if any of the services listed below are being recommended by your health care provider, and to ensure the prior authorization process under the Plan has been completed at least 48 hours before services are provided. In the event of an emergency hospitalization, PHP needs to be notified within 48 hours or as soon as reasonably possible. all inpatient admissions (except emergency room care) including admission to a hospital, skilled nursing facility, rehabilitation facility, and hospice select outpatient surgical procedures, including but not limited to miscellaneous cosmetic (if allowable), reconstructive, nasal, oral/dental/ orthognathic procedures cervical, thoracic and lumbar spinal surgeries all bariatric services organ/tissue and bone marrow transplants (including pre-transplant evaluations and HLA typing) uvulectomy, uvulopalatopharyngoplasty (UPPP), laser-assisted uvulopalatoplasty (LAUP) select hip, knee and shoulder procedures sleep studies and/or treatment of sleep disorders all inpatient chemical dependency services; high technology radiological/imaging services such as MRI, MRA, SPECT, CT, CTA, nuclear cardiology and PET scans;

60 pulmonary rehabilitation cardiac rehabilitation genetic testing and counseling neuropsychological testing prosthetics select durable medical equipment including but not limited to the following: power-wheel chairs & supplies seat Lift Mechanisms, select nerve stimulators, skin substitutes oral appliances flexion/extension devices wound therapy pumps speech generating devices purchase of CPAP post trial rental period, and general anesthesia for dental services Talk with your provider about getting prior authorization. Many times a provider will obtain the prior authorization on your behalf. You can call Providence Health Plan Customer Service to verify if prior authorization has been obtained. If you do not obtain prior authorization for services received from a non-participating provider, a financial penalty may apply. NOTE: Prior authorization is not a treatment directive. The actual course of medical treatment that a participant chooses remains strictly a matter between the participant and his/ her physician and is separate from the prior authorization requirements. Additional plan requirements may apply. How to Obtain Prior Authorization Providence Health Plan (PHP) will provide a prior authorization form upon oral or written request. If you need information on how to obtain prior authorization, please call your Customer Service Team at the number listed on your Medical ID Card, Medical Non-emergency inpatient, residential and day treatment mental health and chemical dependency services and all outpatient chemical dependency services must have prior authorization by PHP s authorizing agent, PBH, at If an emergency medical, mental health or chemical dependency condition prevents you from obtaining prior authorization, you must call the PHP Customer Service Team within 48 hours following the onset of treatment or as soon as reasonably possible, to continue coverage of these services. Penalty for Failure to Obtain Prior Authorization It is your responsibility to make sure your provider obtains the prior authorization when needed. If prior authorization is not obtained you may be responsible for the entire cost of the service received. For out-of-network providers, you must contact PHP or ensure that your provider does or you will have to pay 50% of the cost of the claim, up to $2,500. This penalty does not apply to the out-of-pocket maximum or to the deductible. Required Second Surgical Opinion You must obtain a second surgical opinion when asked to do so by Providence Health Plan (PHP). Second surgical opinions must be given by a physician who is certified by the American Board of Medical Specialists in a field related to the proposed surgery. The physician giving the opinion must also be independent of the physician who first advised surgery and is excluded from performing the surgery. Second surgical opinions are paid at 100% with no deductible for the Health Reimbursement Medical Plan. A second surgical opinion can be paid at 100% after the deductible has been met for the Health Savings Medical Plan. If surgery is not recommended in the second surgical opinion, you may still have the originally proposed surgery and receive full plan benefits. The intent of the second surgical opinion is primarily to ensure you have all the facts before having surgery.

61 If you have any questions about required or elective surgery, call PHP. In all cases, the Summary Plan Description or Plan document will govern. chronic illnesses such as multiple sclerosis, renal failure, obstructive pulmonary disease, cardiac conditions, cancer or AIDS Pregnancy In accordance with the Newborn s and Mothers Health Protection Act, the Medical plans do not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a normal vaginal delivery or less than 96 hours following a cesarean section or require that a provider or mother obtain authorization from PHP for prescribing a length of stay not in excess of the above periods. Being pregnant is an exciting and, also, exhausting time. Your body is working overtime every step of the way, which is why it s so important to take excellent care of yourself. Finding the right health care provider can help make your pregnancy experience what you want it to be. We ve got expert advice, resources and providers to get you started on the path to a healthy and memorable pregnancy. Call a care nurse at or [email protected] NOTE: Newborn babies must be enrolled in the Plan within 60 days of birth through the HR Service Center if you want to cover them under your plan. Calling PHP does not enroll your baby in the benefit plan. Individual Case Management Individual case management is designed to help manage the care of patients who have catastrophic or extended care illnesses or injuries. The primary objective of individual case management is to identify and coordinate costeffective medical care alternatives which meet accepted standards of medical practice. Individual case management also monitors the care of the patient, offers emotional support to the family, and coordinates communications among health care providers, patients, and others. Individual Case Management is often used in situations like, but are not limited to: accident victims requiring long-term rehabilitative therapy newborn infants with high risk complications or multiple birth defects diagnosis involving long-term intravenous therapy illnesses not responding to medical care child and adolescent mental health and substance abuse disorders transplant cases PHP will contact you if Individual Case Management is appropriate in your case. You may also request case management by contacting PHP s customer service. Medical Expenses Not Covered In addition to the plan exclusions (not covered expenses) previously listed in the Covered Medical Expenses table on pages 2-11 to 2-34, the Plan will not provide benefits for any of the items listed in this section regardless of medical necessity or recommendation of a physician. This list is intended to give you a general description of expenses for services and supplies not covered by the Plan. Expenses exceeding the usual and customary charge for the geographic area in which services are rendered. Expenses not necessary for diagnosis of an illness or injury, except as specified under Preventive Care. Treatment not prescribed or recommended by a physician or other covered health care provider. Drugs, procedures, treatments, services, supplies, and/or devices which are not medically necessary or are not provided according to Providence Health Plan s policy Medical

62 Services or supplies for which there is no legal obligation to pay or expenses which would not be made except for the availability of benefits under this Plan. Experimental and investigational drugs, treatments, devices, services, and/or supplies. Services furnished by or for the United States Government or any other government, unless payment is legally required. Any injury or illness that is sustained by you or covered family member that arises out of, or as the result of, any work for wage or profit when coverage under any Workers Compensation Act or similar law is required for you or your covered family member. This exclusion also applies to injuries and illnesses that are the subject of a disputed claim settlement or claim disposition agreement under a Workers Compensation Act or similar law. This applies even if you waive your rights to those benefits or chose not to participate in them. This exclusion does not apply to covered persons who are exempt under any Workers Compensation Act or similar law. Services that are payable under any automobile medical, personal injury protection ( PIP ), automobile no-fault, homeowner, commercial premises coverage, or similar contract or insurance, when such contract or insurance makes benefits or services available to you whether or not you make application for such benefits or services. If such coverage is required by law and you lawfully fail to obtain it, benefits will be deemed to have been payable to the extent of that requirement. Any benefits or services provided under this plan that are subject to this exclusion are provided solely to assist you and such assistance does not waive the Plan s right to reimbursement or subrogation as specified under Third-Party Liability, page 5-7. This exclusion also applies to services and supplies after you have received proceeds from a settlement as specified in the Benefits From Other Sources section, pages 5-7 to Educational, vocational, or training services and supplies including, but not limited to, videos and books, educational programs to which drivers are referred by the judicial system and volunteer mutual support groups.. Expenses for missed appointments or telephone calls. Travel expenses of a physician or a covered person, except as approved by PHP and specified in Human Organ/Tissue Transplants and Obesity Related/Bariatric Surgery. Services for immunizations or vaccinations for employment, licensing, passports, travel purposes, and high risk occupations. Professional services, including diagnosis, treatment or prescribing other care, performed by a person who ordinarily resides in the covered person s household or is related to the covered person, including self care and care of a spouse/adult Benefit Recipient, parent, child, brother, sister, or in-law. Sanitarium, rest, or custodial care. Expenses eligible for consideration under any other plan of the employer. Treatment or services rendered outside the United States of America or its territories except for an accidental injury or a medical emergency. Dental services or treatment, except as a result of accidental injury. Hospitalization for dental services (except when approved by PHP to safeguard the health of the patient). Personal comfort or service items while confined in a hospital, such as, but not limited to, radio, television, telephone, and guest meals. Complications arising from any non-covered services, with the exception of bariatric surgery and emergency care Medical

63 Cosmetic services, including supplies and drugs, except as approved by PHP and specified under Surgical Services on page Human organ and tissue transplants, except as specified in Covered Medical Expenses. Expenses related to insertion or maintenance of an artificial heart. for neuro-developmental therapies, page 2-29, whether or not services are rendered in a facility that also provides medical and/or mental health treatment. Treatment, instructions, activities or drugs for weight reduction or control. Hearing aids or related supplies. All services related to to and including a sexchange operation. Penile prosthetic implant. All services and supplies, including prescriptions, for the diagnosis and treatment of sexual disorders or dysfunctions, regardless of gender or cause. Treatment of infertility (surgical or other) including fertility drugs. Reproductive sterilization including reversal, diaphragms, cervical sponges, spermicides, over the counter contraceptives. Services of homeopaths; faith healers; or lay, Direct Entry or Certified Professional midwives. Adoption expenses. Surrogacy expenses. Treatment of metatarsalgia or bunions, except for open cutting operations; corns, calluses or toe nails, except for removal of nail roots. Non-surgical treatment for or prevention of, temporomandibular joint dysfunction (TMJ) and craniomandibular disorder and other conditions of the joint linking the jawbone and skull, and the muscles, nerves and other tissues related to that joint, except as specified under TMJ Services. Biofeedback. Hypnosis. Surgical procedures which alter the refractive character of the eye, including, but not limited to laser eye surgery, radial keratotomy, myopic keratomelelusis and other surgical procedures of the refractive keratoplasty type, the purpose of which is to cure or reduce myopia, hyperopia or astigmatism. Routine vision exams and the fitting of eyeglasses or lenses orthoptics, vision therapy or supplies. Massage therapy or rolfing. Certified ambulance services and preauthorized air ambulance services are covered. However, care cars, other medical transportation vehicles and other non-emergency medical transportation services are not covered. Career or sex counseling. Expenses for education, counseling, job training or care for learning disorders or behavioral problems, except as provided Mental illness treatment for Autistic Disorder; Asperger s Disorder; or Pervasive Developmental Disorder not otherwise specified coded with ICD , or Sleep studies and treatment of sleep disorders unless prior authorized by PHP as medically necessary. Wigs and artificial hair pieces except as stated in Other Equipment and Supplies. Non-prescription drugs or medicines. Equipment such as air conditioners, air purifiers, dehumidifiers, heating pads, hot water bottles, water beds, swimming pools, hot tubs, and any other clothing or equipment which could be used in the absence of an illness or injury. A service or supply for which a charge would not have been made in the absence of insurance Medical

64 A service or supply furnished in connection with or during a hospital stay of a person incurred before effective date of coverage, or after termination of coverage even if the confinement began while the person was insured by the plan. Services and supplies received under the Washington or Oregon Death with Dignity Act. Ending of pregnancy unless consistent with the Ethical and Religious Directives for Catholic Health Care Services Part 4 (fifth edition). Nonpermitted: Abortion: the directly intended termination of pregnancy before viability or the directly intended destruction of a viable fetus. Exclusions that apply to Mental Health and Chemical Dependency Services: Services provided under a court order or as a condition of parole or probation or instead of incarceration which are not Medically Necessary; Personal growth services such as assertiveness training or consciousness raising; Services related to developmental disabilities, developmental delays or learning disabilities including, but not limited to, education Services. A learning disability is a condition where there is meaningful difference between a child s current academic function and the level expected for a child that age. Educational Services include, but are not limited to, language and speech training, reading, and psychological and visual integration training as defined by the American Academy of Pediatrics Policy Statement - Learning Disabilities, Dyslexia and Vision: A Subject Review ; School counseling and support services, home-based behavioral management, household management training, peer support services, recreation, tutor and mentor services; independent living Services, therapeutic foster care, wraparound services; emergency aid for household items and expenses; services to improve economic stability, and interpretation services; Evaluation or treatment for education, professional training, employment investigations, and fitness for duty evaluations; Community Care Facilities that provide 24 hour non-medical residential care; Speech therapy, physical therapy and occupational therapy services provided in connection with treatment of psychosocial speech delay, learning disorders, including mental retardation and motor skill disorders, and educational speech delay including delayed language development; Counseling related to family, marriage, sex and career including, but not limited to, counseling for adoption, custody, family planning or pregnancy, in the absence of a DSM-IV-TR diagnosis; Neurological services and tests including, but not limited to, EEGs; PET, CT and MRI imaging Services, and beam scans; Services related to the treatment of sexual disorders, dysfunctions or addiction; Vocational, pastoral or spiritual counseling; Dance, poetry, music or art therapy, except as part of an approved treatment program; and Treatments that do not meet the national standards for Mental Health/Chemical Dependency professional practice. The following services are excluded from all alternative care providers (Acupuncturist, Chiropractor, Naturopathic Physician): Alternative care services not stated as a covered service Medical

65 Preventive care and women s health services (except for certain services which are allowable when provided by naturopathic physician). Hypnotherapy, behavior training, sleep therapy and weight programs. Education programs, self-care or self-help programs or any self-help physical. Training or any related diagnostic testing. Massage therapy. Thermography. Therapeutic modalities and procedures that are considered by Providence Health Plan or their authorizing agent to be invasive. Emergency care and Urgent/Immediate care services. Transportation costs including local ambulance charges. Any service or supply that is not permitted by state law with respect to the alternative care provider s scope of practice. Services in excess of the benefit limits listed in the Covered Medical Expenses. Services provided while in the custody of any law enforcement authorities or incarcerated. Expenses related to any condition sustained by a covered member as a result of engagement in an illegal occupation or the commission or attempted commission of an assault or other illegal act by the member, if such member is convicted of a crime on account of such illegal engagement or act. For purposes of this exclusion, illegal means any engagement or act that would constitute a felony or misdemeanor punishable by up to a year s imprisonment under applicable law if such member is convicted for the conduct. Nothing in this paragraph shall be construed to exclude covered services for a member for injuries resulting from an act of domestic violence or a medical condition (i.e., a physical or mental health condition). NOTE: The Plan will not pay benefits for any condition, disability or expense sustained as a result of: intentional or accidental atomic explosion or other release of nuclear energy (whether in peace time or war time), participation in a riot or civil revolution, service as a member of the armed forces of any state or country, war or an act of war, whether declared or undeclared. This exclusion does not apply if the injury results from an act of domestic violence or a medical condition (whether physical or mental) Medical

66 Prescription Drug Summary of Benefits Benefit Health Reimbursement Medical Plan Health Savings Medical Plan Retail and preferred retail pharmacies: Up to 30 day supply Mail order and preferred retail pharmacies: 90 day supply Annual Deductible and Out of Pocket Maximum See page 2-11 for combined deductible and out of pocket maximums for medical care and prescriptions drugs. Providence and Swedish Pharmacies Formulary preventive generic and brand-name drugs Generic Drugs Formulary brand-name drugs Non-formulary brand-name drugs, including preventive drugs** Specialty drugs Mail Order (where available) for 90 day supply Not subject to the deductible Plan pays 100% of covered amount; you pay 0% Not subject to the deductible You pay $10 per 30 day supply; the Plan pays the remainder Subject to the deductible Plan pays 90% of covered amount; you pay 10% Subject to the deductible Plan pays 80% of covered amount; you pay 20% up to a maximum of $150* per 30 day supply Subject to the deductible Plan pays 60% of covered amount; you pay 40% up to a maximum of $150* per 30 day supply Subject to the deductible Plan pays 80% of covered amount; you pay 20% up to a maximum of $150* per 30 day supply. Limited to a 30 day supply per fill. Medications must be purchased from Providence Specialty Pharmacy or a Providence pharmacy Not all prescriptions are eligible for mail order pharmacy. Your share of the cost is 3 times that of a 30 day supply as shown above, including 3 times the amount of the maximum for brand-name drugs. Participating Pharmacy Formulary preventive generic and brand-name drugs Generic Drugs Formulary brand-name drugs Non-formulary brand-name drugs, including preventive drugs** Mail Order (where available) for 90 day supply Non-participating Pharmacy 2-42 Medical Not subject to the deductible Plan pays 100% of covered amount; you pay 0% Not subject to the deductible You pay $10 per 30 day supply; the Plan pays the remainder Subject to the deductible Plan pays 90% of covered amount; you pay 10% Subject to the deductible Plan pays 70% of covered amount; you pay 30% up to a maximum of $150* per 30 day supply Subject to the deductible Plan pays 50% of covered amount; you pay 50% up to a maximum of $150* per 30 day supply Not all prescriptions are eligible for mail order pharmacy. Your share of the cost is 3 times that of a 30 day supply as shown above, including 3 times the amount of the maximum for brand-name drugs. Not covered * The $150 maximum per 30 day supply will apply once the deductible has been met. **Some specialty medications may qualify as preventive drugs. Contact Providence Health Plan for more information, including which pharmacies must be used for coverage.

67 Benefits Preventive Drugs A medication is considered preventive when it is generally prescribed to prevent certain risks, complications or recurrence of a disease or condition, and falls under the Internal Revenue Service of safe harbor. The IRS definition of safe harbor is contained in Notice , section 223(c)(2)(C). The following drug categories may qualify as preventive. Since the list is utilized by a qualified high-deductible health plan that is eligible to be used with a Health Savings Account (HSA), the list must meet criteria set by the IRS so not all classes of drugs can be offered at no cost to plan participants. Contact Providence Health Plan (PHP) to confirm whether your medication qualifies as preventive. Preventive Drug Classes Alpha-adrenergic Agonists Anticoagulants Antidiabetic Agents Anti-inflammatories, Inhaled Corticosteroids Antileukotrienes Beta-adrenergic Blocking Agents Blood Products/Modifiers/Volume Expanders Bronchodilators, Sympathomimetic Calcium Channel Blocking Agents, Platelet Aggregation Inhibitors Cardiovascular Agents Contraceptives* Diuretics Dyslipidemics Insulins (includes disposable insulin pump supplies, not insulin pump) Metabolic Bone Disease Agents Platelet Aggregation Inhibitors Prenatal vitamins (prescription) Renin-angiotensin-aldosterone System Inhibitors Respiratory Tract Agents For a copy of the list of the preventive drugs, visit the Providence Health Plan Web site at healthplans.providence.org/phs-employees -or call your Customer Service Team at Medical *Providence Health & Services sponsors your group health plan and has certified that it qualifies for a temporary enforcement safe harbor with respect to the Federal requirement to cover contraceptive services without cost sharing. During this one year period, coverage under your group health plan will not include coverage of over the counter contraceptives even if prescribed by a physician, spermicides, or barrier devices. For a copy of the list of the formulary drugs (brand name and generic), visit the Providence Health Plan Web site at org/phs-employees or call your Customer Service Team at This list also notes those medications considered preventive under the IRS definition. Compounded Prescription Drug Contains at least one ingredient that is an FDA approved prescription drug in a therapeutic amount, meeting PHP s medical necessity criteria. 30 day supply only. Specialty drugs Injectable, infused, oral or inhaled therapies that often require specialized delivery, handling and administration, and are generally high cost. These drugs must be purchased through Providence Specialty Pharmacy, Providence or Swedish pharmacies. Specialty drugs are indicated on the Providence Health Plan formulary as Specialty in the status column. To view the formulary visit or contact the Customer Service team. Self-injectable drugs are only covered if they are intended for self-administration, labeled by the FDA for self-administration, and are on the plan formulary. Using Your Prescription Drug Benefit Your prescription drug benefit requires you to have your prescriptions filled at pharmacies that participate with the Providence Health Plan. There are approximately 25,000 participating pharmacies available for your use nationwide. Please present your identification card at the participating pharmacy. A list of the participating pharmacies

68 is available on the Web site at providence.org/phs-employees. You also may contact your Customer Service Team if you need help locating a participating pharmacy near you or when you are away from your home. You may purchase up to a 90-day supply of each maintenance drug at one time using a preferred retail pharmacy or participating mail order pharmacy. See page 2-41 for copayments/ coinsurance. Normally, diabetes supplies and inhalation extender devices are obtained from a durable medical equipment (DME) supply house and the DME provisions apply. However, for your convenience, diabetes supplies and inhalation extender devices may be obtained at your participating pharmacy. Ordering Prescriptions By Mail You can purchase on-going prescriptions by mail using your ID number from your Providence Health Plan medical ID card. Your physician or provider can call in the prescription or you can mail your prescription to a participating pharmacy. Participating mail order pharmacy information is available on the Providence Health Plan web site at or call your Customer Service Team at You may purchase up to a 90-day supply of each maintenance medication. See page 2-41 for copayments/coinsurance. Not all prescription drugs are available by mail order. Providence Health Plan determines which drugs qualify for purchase by mail. If you have existing prescriptions at another pharmacy and would like to transfer them to the participating mail order pharmacy, contact the mail order pharmacy directly. We recommend that you order refills approximately two weeks before you expect to run out of your current supply of medication. Payment is required before your order is processed. If there is a change in the participating mail order pharmacies, you will be notified at least 30 days in advance. Use of Non-Participating Pharmacies Urgent or emergency medical situations may necessitate the use of a non-participating pharmacy. If this occurs, you will need to pay full price for your prescription at the time of purchase. You may be reimbursed by the Plan upon submission of a Prescription Drug Reimbursement Request form, which can be obtained from the Web site at PHS-employees or by contacting your Customer Service Team and requesting one be sent to you. After you have completed and signed the form, submit it, along with your itemized pharmacy receipts, to the address listed on the form. Once received, your claim will be reviewed (submission of a claim does not guarantee payment). If your claim is approved, you will be reimbursed the cost of your prescription, subject to Plan benefits and limitations, less your applicable copayment, or deductible and coinsurance. Quantities Prescription dispensing limits: topicals, up to 60 grams; liquids, up to eight ounces; tablets or capsules, up to 100 dosage units; and multi-use or unit-of-use, up to one container or package; as prescribed, not to exceed a 30-consecutive-day supply, whichever is less. Other dispensing limits may apply to certain medications requiring limited use, as determined by our medical policy. Prior authorization is required for amounts exceeding any applicable medication dispensing limits. Drugs or hormones to stimulate growth are covered only if there is a laboratory-confirmed diagnosis of growth hormone deficiency. These drugs are covered only for children under age 18, and for adults only if there is documented pituitary destruction and the drug use meets the medical policy criteria Medical

69 Compound prescription drugs must contain at least one ingredient that is an FDA-approved prescription drug in a therapeutic amount and must meet PHP s medical necessity criteria and be purchased at a participating pharmacy. Compounded drugs from bulk powders that are not a component of an FDA approved drug are not covered. Specialty drugs are limited to a 30-day supply (or minimum package size to approximate a 30-day supply). Approved Drugs Limitations and Prior Authorizations All drugs must be Food and Drug Administration (FDA) approved, medically necessary, and require, by law, a prescription to dispense. Not all FDA approved drugs are covered. Newly approved drugs will be reviewed for safety and medical necessity within 12 months following FDA approval. Providence Health Plan (PHP) uses a prescription drug formulary for therapeutic drugs. Some drugs may require prior authorization by PHP. If you need more detailed information about the drug formulary or drug coverage, including information on drugs requiring prior authorization, please visit or call your Customer Service Team. Some drugs require prior authorization for medical necessity, place of therapy, length of therapy, step therapy, or number of doses. Please have your provider contact PHP for prior authorization. Tobacco Cessation Drug Therapy Tobacco cessation drug therapy, including nicotine replacement therapy, is covered at 100% as a Preventive drug when using a participating pharmacy. Over-the-counter nicotine replacement gum and patches are included with physician s prescription. Plan approved tobacco cessation programs are encouraged and included in your tobacco cessation benefit. Pharmacy Exclusions Drugs that are not provided in accordance with the Plan s formulary management program. Drugs for weight loss or cosmetic purposes. Drugs or medications prescribed that do not relate directly to the treatment of a covered illness or injury. Over-the-counter (OTC) drugs (except for nicotine replacement gum and patches, see above), medications, or vitamins that may be purchased without a provider s written prescription and prescription drugs for which there are OTC therapeutically similar forms. Devices, appliances, supplies, and durable medical equipment, even if a prescription is required for purchase. Some of these items may be covered under your medical benefits. Drugs dispensed or compounded by a pharmacist that do not have at least one FDAapproved medication in a therapeutic amount. Drugs used in treatment of fungal nail conditions. Drugs used in treatment of the common cold. Experimental or investigational drugs or drugs used by a covered person in a research study or in another similar investigational environment. Drugs or medications delivered, injected or administered to you by a physician or other provider. Herbal supplements and natural medicines prescribed by naturopathic physicians (N.D.) Amphetamines and amphetamine derivatives, except when used in treatment of narcolepsy or hyperactivity in children and adults. Methadone for pain management is covered. Methadone for the treatment of chemical dependency may be covered under the chemical dependency benefit of the medical benefits Medical

70 Drugs or medications used to treat sexual disorders or dysfunctions or disorders regardless of gender or cause or drugs required for or as a result of sexual transformation. Contraceptive devices, cervical sponges, spermicides and over the counter contraceptives even with a physician s prescription Drugs dispensed from pharmacies outside the United States, except for urgent and emergency medical conditions. Insulin pumps (these may be covered under your medical supply benefit) Injectable medications unless they are intended for self-administration, labeled by the FDA for self-administration, and on the Plan formulary. Prescriptions written by a physician for himself or herself or for a person who ordinarily resides in his or her household or is related to the covered person, such as a spouse/adult Benefit Recipient, parent, child, brother, sister, or inlaw. Drugs or prescribed medications that are not medically necessary or are not provided according to the Plan s medical policy. Drugs used for the treatment of fertility/ infertility. Drugs which act as, or which under the Ethical and Religious Directives for Catholic Health Care Services Part 4 (fifth edition) are considered to act as, abortifacients. Fluoride, for covered persons over the age of 10 years old. Replacement of lost or stolen medication. Drugs to stimulate hair growth, including, but not limited to, Rogaine (i.e., topical minoxidil) or other similar drug preparations. Drugs used for the treatment of drug-induced fatigue, general fatigue, and idiopathic hypersomnia. Drugs placed on prescription-only status as required by state or local law. Drugs that are not FDA approved or designated as less than effective by the FDA, also known as a DESI drug. Drugs prescribed under any state s Death with Dignity Act. Vaccines, immunizations and preventive medications solely for the purpose of travel Medical

71 Glossary of Terms From Chapter 2 Words or phrases used in this chapter of the Summary Plan Description for which the following definitions are available. Accident An unforeseen and unavoidable event resulting in an injury which is not due to any fault of the covered person. Acupuncture A technique of inserting and manipulating needles into acupuncture points on the body. According to acupunctural teachings this will restore health, and is particularly good at treating pain. Ambulatory Surgical Facility A public or private facility, licensed and operated according to the law, which does not provide services or accommodations for a patient to stay overnight. The facility must have an organized medical staff of physicians; maintain permanent facilities equipped and operated primarily for the purpose of performing surgical procedures; and supply registered professional nursing services whenever a patient is in the facility. Birthing Center A public or private facility, licensed and operated according to the law, used to provide services and/ or supplies associated with childbirth. Chiropractic Services The detection and correction, by manual or mechanical means, of the interference with nerve transmissions and expressions resulting from distortion, misalignment or dislocation of the spinal (vertebral) column. Coinsurance Coinsurance percentages represent the portions of covered expenses the Plan pays or you pay after satisfying any applicable deductible. These percentages apply only to covered expenses which do not exceed reasonable and customary charges. You are responsible for the deductible, if any, coinsurance, all non-covered expenses, and any amount which exceeds the reasonable and customary charge for covered expenses. Eligible expenses are paid by the Plan at the percentages shown on the following pages and vary depending on whether you receive your care from an innetwork or out-of-network provider. Copayment A copayment (copay) is a flat dollar amount you pay for covered medical services when provided by an in-network provider. The Plan pays the rest of the cost for medical services up to plan limits for expenses which do not exceed reasonable and customary charges. (There are no copayments under the Health Savings Medical Plan.) Cosmetic Services Cosmetic Services means services or surgery performed to reshape structures of the body in order to improve your appearance or self-esteem. Covered Service Covered Service means a service that is: Listed as a benefit in the Benefit Summary; Medically Necessary; Not listed as an exclusion; and Provided to you while you are a covered person and eligible for the service under the Plan. Custodial Care Services and supplies furnished primarily to assist an individual in the activities of daily living. Activities of daily living include such things as bathing, feeding, administration of oral medicines, or other services that can be provided by persons without the training of a health care provider. Deductible The deductible is the amount you must pay before the Plan pays any benefits. For the Health Reimbursement Medical Plan, once your family has satisfied the family deductible for the plan year, additional deductible payments are not required Medical

72 For Health Savings Medical Plan family coverage, the deductible must be met before the Plan pays benefits on any covered member of your family. Diagnostic Charges The reasonable and customary charges for x-ray or laboratory examinations made or ordered by a physician in order to detect an existing medical condition. Durable Medical Equipment Equipment which is medically necessary and recognized by the medical profession as being a viable therapeutic device which is able to withstand repeated use for the therapeutic treatment of an active illness or injury. Determinations of medical necessity will be made in accordance with Medicare/DSHS coverage guidelines. Such equipment will not be covered under the Plan if it could be useful to a person in the absence of an illness or injury and could be purchased without a physician s prescription. Elective Hospital Admission Any non-emergency hospital admission which may be scheduled at the patient s convenience without jeopardizing the patient s life or causing serious impairment. Elective Surgical Procedure Any non-emergency surgical procedure which may be scheduled at the patient s convenience without jeopardizing the patient s life or causing serious impairment. Eligible Expenses Charges for health care services or supplies that are covered under the Medical, Dental, and Vision options or expenses which can be reimbursed through the Health Care Flexible Spending Accounts. Emergency Care Emergency medical condition is a medical condition that manifests itself by symptoms of sufficient severity that a prudent layperson, possessing an average knowledge of health and medicine, would reasonably expect that failure to receive immediate medical attention would: Result in serious impairment to bodily functions Result in serious dysfunction of any bodily organ or part; or With respect to a pregnant woman who is having contractions, for which there is inadequate time to effect a safe transfer to another hospital before delivery of for which transfer may pose a threat to the health or safety of the woman or the unborn child. Emergency services means, with respect to an emergency medical condition: An emergency medical screening exam that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department to evaluate such emergency medical condition; and. Such further medical examination and treatment as are required under 42 U.S.C. 1395dd, the Emergency Medical Treatment and Active Labor Act (EMTALA), to stabilize a patient, to the extent the examination and treatment are within the capability of the staff and facilities available at the hospital. Experimental/Investigational Experimental/investigational means those services that are determined by the claims administrator (Providence Health Plan) not to be medically necessary or accepted medical practice in the service area, including services performed for research purposes. In determining whether services are experimental/investigational, the claims administrator will consider whether the services are in general use in the medical community in the U.S.; whether the services are under continued scientific testing and research; whether the services show a demonstrable benefit for a particular illness or disease; whether they are proven to be safe and efficacious; and whether they are approved for use by appropriate governmental agencies. The claims administrator determines on a caseby-case basis whether the requested services will result in greater benefits than other generally 2-48 Medical

73 available services, and will not approve such a request if the service poses a significant risk to the health and safety of the covered person. The claims administrator will retain documentation of the criteria used to define a service deemed to be experimental/investigational and will make this available for review upon request. Generic Drugs When a brand name drug s patent expires, generic versions of the drug can be approved for sale. A generic drug works like a brand name drug in dosage, strength, performance and use and must meet the same quality and safety standards. All generic drugs must be reviewed and approved by the Food and Drug Administration (FDA). Health Care Provider A physician, practitioner, nurse, hospital, or specialized facility as those terms are specifically defined in this section. Home Health Care Agency A public or private agency or organization, licensed and operated according to the law that specializes in providing medical care and treatment in the home. The agency must have policies established by a professional group and at least one physician and one registered graduate nurse to supervise the services provided. Hospice Treatment Plan A program approved by the attending physician for care rendered to a terminally ill covered person with a medical prognosis that life expectancy is six months or less. Hospice Facility A public or private facility, licensed and operated according to the law, primarily engaged in providing palliative, supportive, and other related care for a covered person diagnosed as terminally ill with a medical prognosis that life expectancy is six months or less. The facility must have an interdisciplinary medical team consisting of at least one physician, one registered nurse, one social worker, one volunteer, and a volunteer program. It must be approved by Medicare or accredited by the Joint Commission on Accreditation of Health Care Organizations. A hospice facility is not a facility or part of a facility which is primarily a place for rest, custodial care, the aged, drug addicts, alcoholics, or a hotel or similar institution. Hospital An institution operated as required by law, which: is primarily engaged in providing health services on an inpatient basis for the acute care of sick or injured patients. Care is provided through medical, mental health, substance abuse, diagnostic, and surgical facilities, by or under the supervision of a staff of physicians; and has 24-hour nursing services. In-network An in-network provider (also referred to as participating or preferred) is one contracted with a network contracted by the claims administrator to provide services to plan members for specific prenegotiated rates. Typically, if you visit a physician or other provider within the network, the amount you will be responsible for paying will be less than if you go to an out-of-network provider. Injury Under the medical plan, a condition which results independently of an illness and all other causes and is a result of an externally violent force or accident. Inpatient Treatment in an approved facility during the period when charges are made for room and board. Intensive Care Unit A section, ward, or wing within a hospital which is operated exclusively for critically ill patients and provides special supplies, equipment, and constant observation and care by registered graduate nurses or other highly trained personnel. This excludes, 2-49 Medical

74 however, any hospital facility maintained for the purpose of providing normal post-operative recovery treatment or service. Maintenance Care Services and supplies primarily to maintain a level of physical or mental function. The qualified practitioner recommends the service. The service is rendered in the most costefficient manner and type of setting consistent with nationally recognized standards of care, with consideration for potential benefits and harms to the patient. Medical Emergency A sudden and unexpected illness and/or injury that you believe would place you in danger or cause serious damage to your health if you don t seek immediate care. Such conditions include but are not limited to: suspected heart attack, stroke, loss of consciousness, respiration problems, actual or suspected poisoning, serious burn, heat exhaustion, convulsions, bleeding that does not stop, and acute chest pain or abdominal pain. Medically Necessary (Medical Necessity) Medically necessary means services that are in the reasonable opinion of the claims administrator, Providence Health Plan, consistent with the written criteria regarding medically indicated services that are maintained by them. The criteria are based on the following principles: The service is medically indicated according to the following factors: The service is necessary to diagnose or to meet the reasonable health needs of the covered person; The expected health benefits from the service are clinically significant and exceed the expected health risks by a significant margin; The service is of demonstrable value and that value is superior to other services and to the provision of no services; and Expected health benefits can include: Increased life expectancy; Improved functional capacity; Prevention of complications; or Relief of pain. The service is consistent in type, frequency and duration with scientifically based guidelines of national medical, research, or health care coverage organizations or governmental agencies that are accepted by Providence Health Plan. In the case of a life-threatening illness, a service that would not meet the criteria above may be considered medically necessary for purposes of reimbursement, if: It is considered to be safe and effective, as demonstrated by accepted clinical evidence reported by generally-recognized medical professionals or publications; and The treatment is provided in a clinically controlled research setting using a specific research protocol that meets standards equivalent to those defined by the National Institutes of Health for a life-threatening condition. For the purpose of this exception, the term lifethreatening means more likely than not to cause death within one year of the date of the request for diagnosis or treatment. Any service or supply that is not experimental or investigational and that is required for the diagnosis or treatment of an active illness or injury, is rendered by or under the direct supervision of the attending physician, is appropriate and consistent with the diagnosis, is generally accepted by medical professionals in the United States, and which could not be omitted without adversely affecting the patient s medical condition or quality of medical care. Drugs, procedures, treatments, services, supplies, and/or devices which are primarily for research or data accumulation, for custodial care, or for the convenience of the 2-50 Medical

75 patient, the patient s family, or of the provider of services or supplies and/or which are experimental and/or investigational in nature are not covered. Mental Health Treatment Facility A public or private facility, licensed and operated according to the law, which provides a program for diagnosis, evaluation, and effective treatment of mental health disorders; infirmary-level medical services; supervision by a staff of physicians; and skilled nursing care by licensed registered nurses or by licensed practical nurses who are directed by a full-time R.N. It must be accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The facility must also prepare and maintain a written plan of treatment for each patient. The plan must be based on medical, psychological, and social needs. plan year. After you have spent the out-of-pocket maximum and the deductible, the medical option pays 100% of any additional covered expenses in that year. Outpatient Treatment either outside of a hospital setting or at a hospital when room and board charges are not incurred. Outpatient Mental Health or Substance Abuse Service Outpatient service means diagnosis or treatment of a person who is not an inpatient of a health facility or participating in a residential facility program. Outpatient service must be provided as part of a program approved by the State Mental Health Division or by one of the following: Physician; Naturopathic Medicine (Naturopathy) A school of medical philosophy and practice that seeks to improve health and treat disease chiefly by assisting the body s innate capacity to recover from illness and injury. Naturopathic practice may include a broad array of different modalities. Practitioners tend to emphasize a holistic approach to patient care. Psychologist; Psychiatrist; Nurse practitioner; Licensed Clinical Social Worker (L.C.S.W.) upon the written referral of a physician or psychologist; Certified Mental Health Counselor; or Nurse Registered Graduate Nurse (R.N.), Licensed Vocational Nurse (L.V.N.), or Licensed Practical Nurse (L.P.N.). Out-of-network An out-of-network provider is one which has not contracted with a network contracted by the claims administrator to provide services to plan members for specific pre-negotiated rates. Health plans may offer coverage for out-of-network providers, but your patient responsibility would be higher than it would be if you were seeing an in-network provider. Out-of-Pocket Maximum The maximum amount (including deductible) you must pay toward covered medical expenses in any Social Worker (M.S.W.) Participating Pharmacy Participating pharmacy means pharmacy that has a signed contract with Providence Health Plan to provide medications and other services at special rates. There are four types of participating pharmacies: Retail: a participating pharmacy that allows up to a 30-day supply of short-term and maintenance prescriptions. Preferred Retail: a participating pharmacy that allows up to a 90-day supply of maintenance prescriptions and access to up to a 30-day supply of short-term prescriptions. Specialty: a participating pharmacy that allows up to a 30-day supply of specialty and self Medical

76 administered chemotherapy prescriptions. These prescriptions require special delivery, handling, administration and monitoring by your pharmacist. Mail Order: a participating pharmacy that allows up to a 90-day supply of maintenance prescriptions and specializes in direct delivery to your home. Prior Authorization Prior authorization or prior authorized means a request to Providence Health Plan (PHP) or its authorizing agent by you or by a qualified practitioner regarding a proposed service, for which prior approval is required. Prior suthorization review will determine if the proposed service is eligible as a covered service or if an individual is a covered person at the time of the proposed service. To facilitate review of the prior authorization request, PHP may require additional information about the covered person s condition and/or the services requested. They may also require that a covered person receives further evaluation from a qualified practitioner of their choosing. Services that require prior authorization are shown on pages 2-34 to Prior authorized determinations are not a guarantee of benefit payment unless: A determination that relates to benefit coverage and medical necessity is obtained no more than 30 days prior to the date of the Service; or A determination that relates to eligibility is obtained no more than five business days prior to the date of the service. Residential Mental Health or Substance Abuse Facility A residential facility is a program or facility approved by the State Mental Health Division or accredited by the Joint Commission on Accreditation of Healthcare Organizations which provides an organized full-day or part-day program of treatment for alcoholism, drug addiction, or mental illness, but is not licensed to admit patients who require 24-hour skilled nursing care. Physically or Mentally Disabled The inability of a person to be self-sufficient as the result of a condition such as mental retardation, cerebral palsy, epilepsy, or another neurological disorder which is diagnosed by a physician as a permanent and continuing condition. Physicians, Surgeons, and Dentists Under the medical or dental plans, a person acting within the scope of his/her license and holding one of the following degrees, and who is legally entitled to practice medicine in all its branches under the laws of the state or jurisdiction where the services are rendered. Doctor of Medicine (M.D.) Doctor of Osteopathy (D.O.) Doctor of Optometry (O.D.) Doctor of Dental Surgery (D.D.S.) Doctor of Dental Medicine (D.M.D.) Doctor of Podiatry (D.P.M. or D.S.C.) Doctor of Naturopathy (N.D.) Doctor of Chiropractic (D.C.) For the purposes of the Plan, the term does not include you, your spouse, the immediate family of either you or your spouse, or a person living in your household, including an Adult Benefit Recipient. Physician Services Refers to covered services provided by a physician in a hospital or other setting or in his/her office other than those services specifically identified as having specific copayments or limitations within the Plan. Plan Year The 12-month period beginning January 1 and ending December 31. Qualified Practitioner A physician, Women s Health Care Provider, nurse practitioner, nurse practitioner midwife, clinical social worker, physician assistant, psychologist, dentist, or other practitioner who is professionally 2-52 Medical

77 licensed by the appropriate governmental agency to diagnose or treat an injury or illness and who provides covered services within the scope of that license or person acting within the scope of applicable state licensure/ certification requirements and holding the degree of Doctor of Optometry (O.D.), Certified Nurse Midwife (C.N.M.), Certified Registered Nurse Anesthetist (C.R.N.A.), Registered Physical Therapist (R.P.T.), Psychologist (Ph.D., Ed.D., Psy.D.),Advanced Registered First Assistant (A.R.F.A.), Certified First Assistant (C.F.A.), Certified Registered Nurse Assistant (C.R.N.A.), Advanced Registered Nurse Practitioner (A.R.N.P.), Licensed Clinical Social Worker (L.C.S.W.), Certified Mental Health Counselor, Social Worker (M.S.W.), Speech Therapist (M.S. or M.A.), Occupational Therapist, Physician s Assistant (if working under the supervision of an M.D.), Registered Respiratory Therapist, Certified Nurse Practitioner, Certified Audiologist, Licensed Acupuncturist or Radiation Therapist. Primary Care Physician(PCP)/Personal Physician/Provider (PPP) Qualified practitioner who specializes in family practice, general practice, internal medicine or pediatrics; a nurse practitioner; or a physician assistant, when providing services under the supervision of a physician; who agrees to be responsible for the continuing medical care by serving as case manager. Enrolled adult females also may choose a physician specializing in obstetrics or gynecology; a nurse practitioner; a certified nurse midwife; or a physician assistant specializing in women s health care as their Personal Physician/Provider. These practitioners provide preventive care and health screening, medical management of many chronic conditions, allergy shots, treatment of some breaks and sprains, and care for many major illnesses and nearly all minor illnesses and conditions. Many may offer maternity care and minor outpatient surgery as well. IMPORTANT NOTE: Participating PCP/PPP/Providers have a special agreement with Providence Health Plan to serve as a case manager for your care. This means not all of our Participating Providers with the specialties listed above are Participating PCPs/PPPs/Providers. Please refer to the Provider Directory, available online, for a listing or call your Customer Service team to request a hard copy. For the purposes of the Providence non-hmo plans, you are not required to select a PCP/PPP, however, to receive the reimbursement rates only available for PCP/PPP care you will need to receive care from one of the five areas of practices listed above. Reasonable and Customary Charge/Fee The prevailing charge made to the majority of patients for the same service or procedure. The charge must be within the range of the charges most frequently made in the same or similar medical service area for the service or procedure as billed by other physicians. For services provided by non-physicians, the charge must be within the range of the charges most frequently made in the same or similar medical service area for the service or procedure as billed by other registered or licensed health care providers. Second Surgical Opinion Examination by a physician who is certified by the American Board of Medical Specialists in a field related to the proposed surgery to evaluate the medical advisability of undergoing a surgical procedure. Service Service means a health care related procedure, surgery, consultation, advice, diagnosis, referral, treatment, supply, medication, prescription drug, device or technology that is provided to a covered person by a participating provider or a nonparticipating provider. Skilled Nursing Facility A public or private facility, licensed and operated according to the law, which maintains permanent and full-time facilities for 10 or more resident patients; has a nurse or physician on full-time 2-53 Medical

78 duty in charge of patient care; has at least one Registered Nurse or Licensed Practical Nurse on duty at all times; maintains a daily medical record for each patient; and has transfer arrangements with a hospital and a medical review plan in effect. The facility must be primarily engaged in providing continuous skilled nursing care for persons during the convalescent stage of their illness or injury, and is not, other than by coincidence, a rest home for custodial care for the aged. Substance Abuse Treatment Facility A public or private facility, licensed and operated according to the law, which provides a program for diagnosis, evaluation, and effective treatment of substance abuse; detoxification services; infirmarylevel medical services; supervision by a staff of physicians; and skilled nursing care by licensed nurses who are directed by a full-time R.N. The facility must also prepare and maintain a written plan of treatment for each patient based on medical, psychological, and social needs. Surgery Any operative or diagnostic procedure performed in the treatment of an injury or illness by instrument or cutting procedure through any natural body opening or incision. Urgent/Immediate Care Urgent/immediate care means services that are provided for unforeseen, non-life threatening, minor illnesses and injuries which require immediate attention, such as ear, nose and throat infections and minor sprains and lacerations. Usual, Customary and Reasonable (UCR) When a service is provided by a participating provider, UCR means charges based on the fee that Providence Health Plan has negotiated with participating providers for that service. UCR charges will never be less than the negotiated fees. When a service is provided by a non-participating provider, UCR charges will be based on the lesser of: The fee a professional provider usually charges for a given Service; A fee which falls within the range of usual charges for a given service billed by most professional providers in the same locality who have similar training and experience; A fee which is prevalent or which would not be considered excessive in a particular case because of unusual circumstances; or The fee determined by comparing charges for similar services to a national database adjusted to the geographical area where the Service was performed. UCR charges do not include sales taxes, handling fees and similar surcharges, and such taxes, fees and surcharges are not covered expenses. Women s Health Care Provider Women s Health Care Provider means an obstetrician, gynecologist or physician assistant specializing in women s health, advanced registered nurse practitioner specialist in women s health, or certified nurse midwife, practicing within the applicable lawful scope of practice. Urgent/immediate care Covered Services are provided when your medical condition meets the guidelines for urgent/immediate care that have been established by us. Covered services do NOT include services for the inappropriate use of an urgent/immediate care facility, such as: services that do not require immediate attention, routine check-ups, follow-up care, and prescription drug requests Medical

79 III. Dental Your Dental Options Your Dental options are: Delta Dental PPO 2000 Plan (with Orthodontia for adults and children) The charts below illustrate the Delta Dental PPO 1500 and Delta Dental PPO 2000 Plan coverage. Delta Dental PPO 1500 Plan No Coverage Both plans are administered by Delta Dental/ Washington Dental Service (WDS), a member of the Delta Dental Plans Association. Dental Coverage Services are paid at the Plan percentages listed below and are subject to the maximum allowable fee. Delta Dental PPO 1500 Plan Deductible Coinsurance In Network (PPO) Out of Network (Premier and Non-PPO) Diagnostic & Preventive $0 100% 80% Restorative $50 per person 80% 70% $150 per family Major Combined with Restorative 50% 50% Annual Maximum Dental Benefits Orthodontia Benefit $1,500 per person Not covered Delta Dental PPO 2000 Plan Deductible In Network (PPO) Coinsurance Out of Network (Premier and Non-PPO) Diagnostic & Preventive $0 100% 80% Restorative $50 per person 80% 70% $150 per family Major Combined with Restorative 50% 50% Orthodontia Annual Maximum Dental Benefits $50 lifetime maximum 50% 50% $2,000 per person Orthodontia Benefit $2,000 lifetime maximum 3-1 Dental

80 Check the Coordination of Benefits section (Chapter 5, page 5-5) to see how the Plans work with any other medical, vision and/or dental coverage you may have. 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 offered the legacy DeltaCare USA (DHMO) and the Delta Dental PPO Please see the 2012 Summary Plan Description/California for information on the legacy plan. Choosing Dental Coverage How do you decide which Dental option is best for you? You may want to consider the following: What do you expect your dental expenses will be for the coming plan year? What will the Dental options pay for your expected level of expense? What is the cost of purchasing the Dental options? Do you have any other sources of coverage? If the cost of Dental coverage is more than you expect your expenses will be, you may want to consider covering your dental costs through the Health Care Flexible Spending Account outlined in Chapter 14 of this Summary Plan Description or your Health Savings Account if you are enrolled in the Health Savings Medical Plan. With the Providence Health and Welfare Benefit Plan, you choose your Dental coverage separately from your Medical or Vision coverage. Your Family Category for Dental coverage does not have to be the same as for Medical or Vision. Family Categories You may choose any one of the following Family Categories for Dental coverage: Employee Only Employee Plus Child(ren) Employee Plus One Adult Employee Plus One Adult Plus Child(ren) About Your Dental Benefits All benefits under this Plan must satisfy some basic provisions. The provisions on the following pages are commonly included in dental benefit plans but are often overlooked or misunderstood. Maximum Allowable Fee The maximum dollar amount that will be allowed toward the reimbursement for any service provided for a covered dental benefit. Dental Care Providers Choosing a Dentist With Delta Dental/Washington Dental Service, you may select any licensed dentist; however, your benefits may be paid at a higher level and your out-of-pocket expenses may be lower if you choose a participating Delta Dental dentist. Tell your dentist that you are covered by a Delta Dental plan and provide your identification number, the plan name and the group number. There are advantages to selecting a Delta Dental member dentist. If you select a dentist who is a participant with Delta Dental: The dentist has agreed to provide treatment according to the provisions of his or her member dentist contract. Participating dentists complete claim forms and submit them to Washington Dental Service/ Delta Dental. Payment will be based on the pre-approved fees your dentist has filed with the local Delta Dental plan and will be sent directly to your dentist. You will be responsible only for stated coinsurance, deductibles, any amount over the plan maximum and for any elective care you choose to receive outside the covered dental benefits. You can find a participating dentist in your area by visiting the WDS Web site at com. Go to Looking for a Dentist and click on Read More. This will bring up the WDS Dentist Directory and the Delta Dental Plans Association National Provider Directory. 3-2 Dental

81 Delta Dental PPO Dentists Delta Dental PPO dentists must be Delta Dental member dentists in order to participate in the PPO network. You can choose any dentist in or out of the PPO network. However, if you select a dentist who is part of the Delta Dental PPO network, your benefits will be paid at a higher level and your outof-pocket expenses may be lower. PPO dentists receive payment based on their preapproved PPO fees and they cannot charge you more than these fees. You will be responsible only for your stated deductibles, coinsurance and/or amounts in excess of the plan maximums. Note: Employees who work in Alaska and Montana, and their covered dependents, will receive the PPO level of benefits for any dentist they use due to the limited network availability in these states. Delta Dental Premier Dentists (non-ppo) Delta Dental Premier dentists also have contracts with Delta Dental, but they are not necessarily part of the PPO network. Their payments will be based on their pre-approved fees with Delta Dental. They also cannot charge you more than these fees. You will be responsible only for stated deductibles, coinsurance and/or amounts in excess of the plan maximums. Nonparticipating Dentists You are not limited to visiting a Delta Dental dentist. However, if you choose a nonparticipating dentist: You will be responsible for having the dentist complete and sign claim forms. You will need to ensure that the claims are sent to Delta Dental/Washington Dental Service in Seattle, Washington. Claim payments will be based on actual charges or Delta Dental/Washington Dental Service s maximum allowable fees for nonparticipating dentists in the state in which services are performed, whichever is less. You will be responsible for any balance remaining. Please be aware that Delta Dental has no control over nonparticipating dentists charges or billing practices. Benefit Year/Benefit Period The words year or period, as used in this document, refer to the benefit year, which is the 12-month period beginning January 1 and ending December 31. All annual benefit maximums and deductibles accumulate during the benefit year. Covered Procedures Covered Diagnostic & Preventive Expenses (Class I) The Plan will pay 100% in-network, and 80% out of network of the maximum allowable fee or the actual charge, whichever is less, with no deductible for expenses considered preventive services according to all provisions, requirements, and limitations of the Plan. Diagnostic Diagnostic evaluation for routine or emergency purposes X-rays Study models Detail of Covered Benefits, with Limitations Routine examination (periodic oral evaluation) is covered twice in a benefit period. Comprehensive or detailed and extensive oral evaluation is covered once in the patient s lifetime by the same dentist. Additional comprehensive or detailed and extensive oral evaluations by the same dentist will be allowed as periodic oral examinations. Limited problem-focused evaluations are covered twice in a benefit period. Complete series or panorex x-rays are covered once in a three-year period from the date of service. Any number or combination of X-rays billed for same date of service that equals or exceeds the allowed fee for a complete series will be paid as a complete series. Supplementary bitewing x-rays are covered twice in a benefit period. Study models (diagnostic casts) are covered once per lifetime. Not Covered: Consultations 3-3 Dental

82 Preventive Prophylaxis (cleaning) Periodontal maintenance Fissure sealants Topical application of fluoride including fluoridated varnishes Space maintainers Preventive resin restoration Detail of Covered Benefits, with Limitations Any combination of prophylaxis and periodontal maintenance is covered twice in a benefit period. Periodontal maintenance procedures are covered only if a patient has completed active periodontal treatment. Topical application of fluoride, including fluoride varnishes, is limited to two covered procedures in a benefit period through age 18. Application of fissure sealants will be covered for permanent molars with no restoration on the occlusal (biting) surface once in a lifetime per tooth from the date of service through age 15. If eruption of permanent molars is delayed, sealants will be allowed if applied within 12 months of eruption with documentation from the attending Dentist. Space maintainers are covered once in a patient s lifetime through age 13 for the same missing tooth or teeth. Application of preventive resin restorations will be covered for permanent molars with no restorations on the occlusal (biting) surface. Limited to once in a three-year period per tooth from the date of service for either fissure sealant or preventive resin restoration (but not both) through age 15. If eruption of permanent molars is delayed, preventive resin restorations will be allowed if applied within 12 months of eruption with documentation from the attending dentist. Not Covered: Plaque control program (oral hygiene instruction, dietary instruction and home fluoride kits) Covered Restorative Expenses (Class II) If you elect either the Delta Dental PPO 2000 Plan option or the Delta Dental PPO 1500 Plan option, the Plan will pay 80% in-network and 70% out of network of the maximum allowable fee or the actual charges, whichever is less, after payment of the combined Restorative and Major deductible for expenses considered basic services according to all provisions, requirements, and limitations of the Plan. Restorative Restorations (fillings) Stainless steel crowns Refer to Major Expenses (Class III) for crowns, veneers or onlays Detail of Covered Benefits, with Limitations Restorations (fillings) to treat carious lesions (visible destruction resulting from dental decay) or to treat a fracture resulting in significant damage to tooth structure (missing cusp) or existing restoration on the same surface(s) of the same tooth are covered once in a two-year period from the date of service. Restorations on a posterior tooth, (including a white filling) will receive an amalgam allowance will be made, with any difference in cost being the responsibility of the eligible person. An inlay (as a single tooth restoration) will be considered as elective treatment and an amalgam allowance will be made, with any difference in cost being the responsibility of the eligible person. Stainless steel crowns are covered once in a two-year period from the seat date. Not Covered: Overhang removal, re-contouring or polishing of a restoration, and restorations necessary to correct vertical dimension or to alter the morphology (shape) or occlusion are not a paid covered benefit. 3-4 Dental

83 Oral Surgery Not covered: Removal of teeth Preparation of the mouth for the insertion of dentures Treatment of pathological conditions and traumatic injuries of the mouth Bone replacement graft for ridge preservation Bone grafts, of any kind, to the upper or lower jaws not associated with periodontal treatment of teeth. Tooth transplants. Sedation General anesthesia Intravenous sedation Detail of Covered Benefits, with Limitations Either general anesthesia or intravenous sedation (but not both) is covered when performed on the same day when administered by a licensed dentist or other Delta Dental/ Washington Dental Service-approved licensed professional who meets the educational, credentialing and privileging guidelines established by the Dental Quality Assurance Commission of the state of Washington or as determined by the state in which the services are delivered. Predeterminations are required. General anesthesia is covered in conjunction with certain covered endodontic, periodontic and oral surgery procedures, as determined by Delta Dental/Washington Dental Service or when medically necessary, for children through age six or a physically or developmentally disabled person, when in conjunction with Diagnostic & Preventive, Restorative, Major, and Orthodontic covered dental procedures. Pre-determinations are required. Periodontics Some benefits are available only under certain conditions of oral health. It is strongly recommended that you have your dentist submit a predetermination of benefits to determine if the treatment will be covered. A predetermination is not a guarantee of payment. Surgical and nonsurgical procedures for treatment of the tissues supporting the teeth, including Periodontal scaling/root planing Gingivectomy Limited adjustments to occlusion (eight teeth or fewer) Refer to Preventive for periodontal maintenance benefits Detail of Covered Benefits, with Limitations Periodontal scaling/root planing for 4 teeth per quad is covered once in a two-year period from the date of service. Gingivectomy or gingioplasty for 4 teeth per quad is covered once in a three-year period from date of service. Limited adjustments to occlusion are covered once in a 12-month period from date of service. Periodontal maintenance procedures are covered twice in a benefit period, and only if a patient has completed active periodontal treatment. Under certain conditions of oral health, any combination of prophylaxis or periodontal maintenance may be covered up to a total of four times in a benefit period. Endodontics Procedures for pulpal and root canal treatment, services, including Pulp exposure treatment Pulpotomy Apicoectomy 3-5 Dental

84 Detail of Covered Benefits, with Limitations Root canal treatment on the same tooth is covered only once in a two-year period from the date of service. Re-treatment of the same tooth is allowed when performed by a different dental office Not covered: Bleaching of teeth Covered Major Expenses (Class III) If you elect dental coverage, the Plan will pay 50% of the maximum allowable fee or the actual charges, whichever is less after payment of the combined Restorative and Major deductible for expenses considered major services according to all provisions, requirements, and limitations of the Plan. Restorative Crowns, veneers or onlays Crown buildups Post and core on endodontically treated teeth Detail of Covered Benefits, with Limitations Crowns or onlays for treatment of carious lesions (visible destruction of hard tooth structure resulting from the process of dental decay) or fracture resulting in significant loss of tooth structure (missing cusp), when teeth cannot reasonably be restored with filling materials such as amalgam or resin-based composites. Crowns or onlays on the same teeth are covered only once in a five-year period. If a tooth can be restored with a filling material such as amalgam or filled resin, an allowance will be made for such a procedure toward the cost of any other type of restoration that may be provided. Delta Dental/Washington Dental Service will allow the appropriate amount for an amalgam restoration (posterior tooth) or composite restoration (anterior tooth) toward the cost of processed filled resin or processed composite restorations. A crown buildup or a post and core are covered once in a five-year period on the same tooth from the date of service. Under certain conditions of oral health, services covered are occlusal guard (nightguard) (once in three years), repair and relines of occlusal guard (nightguard) more than six months after the initial placement. Note: These benefits are available only under certain conditions of oral health. It is strongly recommended that you have your dentist submit a predetermination of benefits to determine if the treatment will be covered. Not covered: Crowns in conjunction with overdentures. Prosthodontics Dentures Fixed partial dentures (fixed bridges) Inlays when used as a retainer for a fixed partial denture (fixed bridge) Removable partial dentures Adjustment or repair of an existing prosthetic appliance Surgical placement or removal of implants or attachments to implants Detail of Covered Benefits, with Limitations Surgical placement or removal of implants or attachments to implants. Initial installation of dentures. Dentures, fixed partial dentures (fixed bridges), removable partial dentures, and the adjustment or repair of an existing prosthetic device. Replacement of an existing prosthetic appliance is covered only once every five years and only then if it is unserviceable and cannot be made serviceable. Replacement of implants and superstructures is covered only after five years have elapsed from any prior provision of the implant. 3-6 Dental

85 Full, immediate, and overdentures the appropriate amount for a full, immediate, or overdenture toward the cost of any other procedure that may be provided, such as personalized restorations or specialized treatment is allowed. Root canal treatment performed in conjunction with overdentures is limited to two teeth per arch and is paid at the Major expense payment level. Temporary/interim dentures - the amount of a reline toward the cost of an interim partial or full denture. After placement of the permanent prosthesis, an initial reline will be a benefit after six months. Partial dentures - if a more elaborate or precision device is used to restore the case, the cost of a cast chrome and acrylic partial denture will be allowed toward the cost of any other procedure provided. Covered Orthodontic Expenses Delta Dental PPO 2000 Plan The Plan will pay 50% of the maximum allowable fee or the actual charges, whichever is less up to the lifetime orthodontic maximum, after payment of the $50 lifetime orthodontic deductible for expenses related to orthodontic services according to all provisions, requirements, and limitations of the Plan. Orthodontia benefits are paid according to a schedule; not as a single sum. Not more than $1,000 of the maximum, or one-half of WDS s total responsibility shall be payable at the time of initial banding. Subsequent payments of the plan benefits will be made quarterly following the initial banding as long as you, and your child if the child is the patient, are covered under this option. It is strongly suggested that an orthodontic treatment plan be submitted to, and a predetermination be made by, WDS prior to commencement of treatment. A predetermination is not a guarantee of payment. Additionally, payment for orthodontic benefits is based upon eligibility. If individuals become ineligible prior to the payment of benefits, subsequent payment is not covered. Detail of Covered Benefits, with Limitations Treatment of malalignment of teeth and/ or jaws. Orthodontic records: exams (initial, periodic, comprehensive, detailed and extensive), X-rays (intraoral, extraoral, diagnostic radiographs, panoramic), diagnostic photographs, diagnostic casts (study models) or cephalometric films. Payment is limited to: Completion, or through when the patient is no longer covered under the Delta Dental PPO 2000 Plan, whichever occurs first Treatment received after coverage begins (claims must be submitted to WDS within 180 days of the treatment date). For orthodontia claims, the initial banding date is the treatment date. Treatment that began prior to the start of coverage will be prorated: Payment is made based on the balance remaining after the down payment and charges prior to the date of coverage are deducted. WDS will issue payments based on the Plan s responsibility for the length of the treatment. The payments are issued providing the employee is eligible and the dependent is in compliance with the age limitation. Not covered: charges for replacement or repair of an appliance; services considered inappropriate and unnecessary, as determined by WDS. Maximum Payments Delta Dental PPO 2000 Plan: The maximum plan payment for all services is $2,000 per calendar year for you and each eligible family member. In addition, there is a $2,000 lifetime Orthodontic benefit. 3-7 Dental

86 Delta Dental PPO 1500 Plan: The maximum plan payment for all services is $1,500 per calendar year for you and each eligible family member. Predetermination of Dental Benefits If you or your dependent is considering a course of treatment which will result in dental expenses in excess of $250, it is advisable to submit a request to Delta Dental/Washington Dental Service to determine what portion of the cost will be covered by the Plan. Ask your Delta Dental/ Washington Dental Service member dentist to complete a predetermination for you. If your dentist is not a member of Washington Dental Service, you will need to obtain a dental claim form from the Delta Dental/Washington Dental Service Web site at com. Ask your non-member dentist to complete the dentist section and return it to the address indicated. Delta Dental/ Washington Dental Service will notify you and your dentist of the estimated benefit payments you may receive based on what was submitted for approval. A course of treatment is a planned program of one or more dental services or supplies which may be rendered by one or more dentists. This program is for the correction of a dental condition diagnosed by the attending dentist as a result of an oral examination. The course of treatment begins on the date the dentist first renders treatment to correct the diagnosed dental condition. Predeterminations are required for general anesthesia or intravenous sedation. A predetermination is not an authorization for services but a notification of Covered Dental Benefits available at the time the predetermination is made and is not a guarantee of payment. WDS will make payments based on your available benefits (maximum, deductible and other limitations as described in your benefits booklet) and the current plan provisions when the treatment is provided. In the event your benefits are terminated and you are no longer eligible, the predetermination is voided. Urgent Predetermination Requests Should a predetermination request be of an urgent nature, whereby a delay in the standard process may seriously jeopardize life, health, the ability to regain maximum function, or could cause severe pain in the opinion of a physician or dentist who has knowledge of the medical condition, WDS will review the request within 72-hours from receipt of the request and all supporting documentation. When practical, WDS may provide notice of determination orally with written or electronic confirmation to follow within 72 hours. Immediate treatment is allowed without a requirement to obtain a predetermination in an emergency situation subject to the contract provisions. Dental Expenses Not Covered In addition to exclusions noted previously, the Plan will not provide benefits for any of the items listed in this section. This list is intended to give you a general description of expenses for services and supplies not covered by the Plan. Any portion of a charge which exceeds the maximum allowable fee or the filed fee, whichever is less, for the geographic area in which services are rendered. Any service, supply, or treatment which does not meet the standards accepted by the American Dental Association (ADA). Services or supplies for which there is no legal obligation to pay or charges which would not be made except for the availability of benefits under the Plan. Services furnished by or for the U.S. government or any other government, unless payment is legally required. Any condition, disability or expense sustained as a result of being engaged in: an illegal occupation, commission or attempted 3-8 Dental

87 commission of an assault or other illegal act, participation in a civil revolution or a riot, duty as a member of the armed forces of any state or country, or a war or act which is declared or undeclared. Services for injuries or conditions that are compensable under Worker s Compensation or Employers Liability laws, and services that are provided to the eligible person by any federal or state or provincial government agency or provided without cost to the eligible person by any municipality, county, or other political subdivision, other than medical assistance in this state, under medical assistance RCW , or any other state, under 42 U.S.C., Section 1396a, section 1902 of the Social Security Act. Materials placed in tooth extraction sockets for the purpose of generating osseous filling. Experimental services or supplies. Experimental services or supplies are those whose use and acceptance as a course of dental treatment for a specific condition is still under investigation/ observation. In determining whether services are experimental, Delta Dental/ Washington Dental Service, in conjunction with the American Dental Association, will consider if: Dental Service must respond to such appeal within 20 working days after receipt of all documentation reasonably required to make a decision. The 20-day period may be extended only with written consent of the covered individual. Expenses for preparing dental reports, itemized bills, or claim forms. Mailing and/or shipping and handling charges. Patient management problems. Habit-breaking appliances. Charges for broken appointments or telephone calls. Services or supplies furnished, paid for or for which benefits are provided or required by reason of past or present service of any covered family member in the armed forces of a government. Professional services performed by a person who ordinarily resides in your household or who is related to the covered person, such as a spouse/adult Benefit Recipient, parent, child, brother, sister, or in-law. Expenses eligible for consideration under any other plan of the employer. the services are in general use in the dental community in the State of Washington; the services are under continued scientific testing and research; the services show a demonstrable benefit for a particular dental condition; and they are proven to be safe and effective. Any individual whose claim is denied due to this experimental exclusion clause will be notified of the denial within 20 working days of receipt of a fully documented request. Any denial of benefits by Delta Dental/ Washington Dental Service on the grounds that a given procedure is deemed experimental, may be appealed to Delta Dental/Washington Dental Service. By law, Delta Dental/Washington Expenses incurred for services rendered or devices ordered before the date of coverage under this Plan. Training, educational instruction, or materials relating to dietary counseling, personal oral hygiene, or dental plaque control. The replacement of a lost, stolen or missing prosthetic device. Services and supplies for personalization or characterization of prosthetic devices. Restorations or appliances necessary to correct vertical dimension or to restore the occlusion; such procedures include restoration of tooth structure lost from attrition, abrasion or erosion, and restorations for malalignment of teeth. 3-9 Dental

88 General anesthesia/intravenous (deep) sedation, except as specified for certain covered endodontic, periodontic, and oral surgery procedures. General anesthesia except when medically necessary, for children through age six or a physically or developmentally disabled person, when in conjunction with covered dental procedures. Athletic mouth guards. Duplicate prosthetic devices or appliances. Treatment, by any means, of jaw joint problems including temporomandibular joint dysfunction syndrome (TMJ) and other craniomandibular disorders or other conditions of the joint linking the jawbone and skull, and the muscles, nerves, and other tissues related to that joint. Procedures or appliances to stabilize periodontally involved teeth. Precision or semi-precision attachments. Expenses for services performed after the date coverage ends under this Plan. However, if performed within 90 days of the date coverage ends, the following services will be provided: Installation or adjustment of dentures or fixed bridgework if the impressions were taken before coverage ended. Crowns, inlay, or onlay restorations if the tooth or teeth were prepared before coverage ended. Root canal therapy if the pulp chamber was opened before coverage ended. Any charge for dental services or supplies included in your selected Medical option, including surgery; hospitalization charges and any additional fees charged by the dentist for hospital treatment Application of desensitizing agents Analgesics such as nitrous oxide, conscious sedation, euphoric drugs, injections, or prescription drugs Charges for treatment not given by a legally qualified dentist, except for scaling or cleaning of teeth by a licensed dental hygienist, which is covered if rendered under the supervision and direction of the dentist. Charges for cosmetic dentistry. Charges for replacement of dentures or bridgework if less than five years from the last denture or bridgework replacement. Services that are payable under any automobile medical, personal injury protection ( PIP ), automobile no-fault, homeowner, commercial premises coverage, or similar contract or insurance, when such contract or insurance makes benefits or services available to you whether or not you make application for such benefits or services. Any benefits or services provided under this plan that are subject to this exclusion are provided solely to assist you and such assistance does not waive the Plan s right to reimbursement or subrogation as specified under Third-Party Liability, page 5-7. This exclusion also applies to services and supplies after you have received proceeds from a settlement as specified in the Benefits From Other Sources section, pages 5-7 to Copings Under the Delta Dental PPO 1500 Plan, orthodontic services and supplies Glossary of Terms From Chapter 3 Words or phrases used in this chapter of the Summary Plan Description for which the following definitions are available. Benefit Year The 12-month period beginning January 1 and ending December 31. All annual deductibles and benefit maximums accumulate during the benefit year Dental

89 Coinsurance Coinsurance is the percent of eligible medical expenses you pay after the deductible has been satisfied. These percentages apply only to covered expenses which do not exceed usual and customary charges. In addition to coinsurance, you pay any amount which exceeds the usual and customary charge for covered expenses. Deductible The deductible is the amount you must pay before the Plan pays any benefits. Dental Hygienist A person trained and licensed to perform dental hygiene services, such as prophylaxis (cleaning of teeth), under the direction of a licensed dentist. Dentist A person acting within the scope of his/her license, holding the degree of Doctor of Medicine (M.D.), Doctor of Dental Surgery (D.D.S.), or Doctor of Dental Medicine (D.M.D.), and who is legally entitled to practice dentistry in all its branches under the laws of the state or jurisdiction where the services are rendered. Eligible Expenses Charges for health care services or supplies that are covered under the Medical, Dental, and Vision options or expenses which can be reimbursed through the Health Care Flexible Spending Accounts. Filed Fees Approved fees that participating Delta Dental/ Washington Dental Service member dentists have agreed to accept as the total fees for the specific services performed. Maximum Allowable Fees The maximum dollar amount that will be allowed by Delta Dental/ Washington Dental Service toward the reimbursement for any service provided for a covered dental benefit Dental

90 IV. Vision Choosing Vision Coverage To decide whether or not to participate in the Vision Service Plan (VSP), estimate your eyewear/ vision needs for the year and compare your estimated cost with the VSP premium amount. If your estimated expenses are less than the premium amount, consider contributing to the Health Care Flexible Spending Account or your Health Savings Account, if enrolled in the Health Savings Medical Plan, to cover the expenses on a pre-tax basis. What Is Covered? Eye Exam 100% after $15 copay once every 12 months Prescription Glasses Lenses Single vision, lined, bifocal and lined trifocal lenses, lenticular lenses, or Progressive, photochromic, tints, ultraviolet coating, scratch coating, and antireflective coating, or Polycarbonate lenses for dependent children Frame of your choice Contact Lens Care includes cost of your contacts and the contact lens fitting and evaluation (in addition to vision exam) 4-1 Vision You may choose any one of the following family categories or you may elect no coverage. Employee Only Employee Plus Child(ren) Employee Plus One Adult Employee Plus One Adult Plus Child(ren) Your Family Category for VSP may be different from your Medical and Dental categories. VSP Member Provider Affiliate Provider Non-member Provider 100% once every 12 months 100% once every 24 months up to $120 plus 20% discount on any out-of-pocket costs 100% once every 12 months up to $200 allowance for elective contact lenses Visually necessary contact lenses at 100% with pre-authorization, once every 12 months Extra Discounts and Savings Using a VSP Network Provider Glasses and Sunglasses Average 35-40% savings on all non-covered lens options 30% off additional glasses and sunglasses, including lens options, from the same VSP doctor on the same day as your WellVision Exam. Or get 20% off from any VSP doctor within 12 months of your last WellVision Exam Contacts 15% off cost of contact lens exam (fitting and evaluation) Laser Vision Correction Discounts only available from contracted facilities. 100% after $15 copay once every 12 months 100% once every 12 months 100% once every 24 months up to $120 plus 20% discount on any out-of-pocket costs OR 100% once every 12 months up to $200 allowance for elective contact lenses Up to $210 for visually necessary contact lenses at 100%, once every 12 months Costco Costco pricing applies; there are no additional discounts All Other Affiliate Provider Locations 20% off additional glasses and 15% off contact lens services within one year Up to $50 once every 12 months after $15 copay Up to $40 for single vision, or Up to $60 for lined bifocal, or Up to $80 for lined trifocal, or Up to $125 for lenticular, and Up to $5 for tinting (total) Once up to every 12 months Up to $45 once every 24 months Up to $200 once every 12 months for elective contact lenses Up to $210 for visually necessary contact lenses with pre-authorization, once every 12 months Not Available

91 How Does it Work? Vision Service Plan covers eye exams, prescription eyeglasses, and/or prescription contact lenses. You can go to any provider you wish, but you ll receive a higher level of benefits if you choose a doctor who participates in the VSP network. When you use a VSP doctor, most services are covered in full after the copay and you will also receive discounts and preferred member pricing. Best of all, there are no claim forms to file. Simply make an appointment with a participating VSP doctor and identify yourself as a VSP member. To determine if your doctor is part of VSP s network, or to find a new vision care provider, contact VSP Customer Service at or visit VSP s website At the time of your appointment, you pay the copay (if any) to the Member Doctor for covered services, plus any charges in excess of the plan benefits. The Member Doctor will handle the paperwork for receiving payment of the VSP benefits. Affiliate providers are providers of covered services and materials who are not contracted as Member Doctors but who have agreed to bill VSP directly for covered services and to receive the scheduled benefit. Some affiliate providers may not be able to provide all the services included in this plan; please discuss requested services with your provider or contact VSP Customer Service. If you are enrolled and obtain vision services from a Non-member Doctor, you pay the full cost of care. You will need to submit a claim to VSP within one year of the date of service to receive reimbursement as shown on the schedule on the previous page. Visit for forms. The scheduled benefit is only available once per 12 or 24 month period, depending on service, whether provided by Member Doctor, Affiliate Provider or Non-member Doctor. Low Vision Benefit If you or a covered family member have severe visual problems that cannot be corrected with regular lenses, you may be eligible for additional benefits. The VSP doctor will determine if a patient meets the benefit criteria for low vision benefits at the time of service. If the patient does the VSP doctor will submit a verification form and obtains a Benefit Authorization Notice from VSP. Complete low vision analysis/diagnosis includes a comprehensive exam and subsequent low vision aids as Visually Necessary or Appropriate. What is Covered VSP Provider Affiliate and Non-member Provider Supplemental 100% Up to $125 Testing Supplemental 75% 75% Care Aids Benefit Maximum $1,000 every two years Maximum of two supplemental tests in a two year period Vision Expenses Not Covered or Limited Benefits The VSP plan is designed to cover visual needs rather than cosmetic materials. If you choose any of the following extras, the plan will pay the basic cost of the allowed lenses, and you pay the additional cost for the options. Discounts may be available. See the previous schedule. optional cosmetic processes color coating mirror coating cosmetic lenses laminated lenses polycarbonate lenses oversize lenses certain limitations on low vision care a frame that costs more than the Plan allowance contact lenses (except as noted) 4-2 Vision

92 No benefits will be payable for the following: care, treatment or supplies received prior to or after coverage under this Plan orthoptics or vision training and any associated supplemental testing plano lenses (less than ±.50 diopter power) two pair of glasses in lieu of bifocals replacement of lenses and frames furnished under this Plan which are lost or broken, except at the normal intervals when services otherwise available medical or surgical treatment of the eyes corrective vision of an experimental nature costs for services and/or materials above Plan Benefit allowances services and/or materials not indicated as covered Plan benefits in the schedule shown on page Vision

93 V. General Medical, Dental, and Vision Information Claims Paid Based on Date of Service When you submit a claim for payment for medical, dental, or vision services, it is paid based on your elected option in effect at the time you incurred the expense, not when you submit it. This is an important point. You incur an expense when you receive the medical treatment or service or when you purchase medical supplies covered by the Plans. You must submit claims within 12 months of the time you receive the services or supplies for the claim to be considered. When you submit a claim for payment, you can expect to have it processed promptly and accurately as long as it is submitted fully and accurately. Any claims not submitted within 12 months from when they were incurred will not be paid by the Plan. Filing Claims for the Providence Health and Welfare Benefit Plan Options All Health Reimbursement and Health Savings Medical Plan claims should be sent to: Providence Health Plan P.O. Box 4447 Portland, OR If the claim is from a Preferred Provider (PPO) the discounts will be applied by the Plan and the claim will then be processed. To ensure timely processing of claims, you are encouraged to submit your claim within 60 days of the date of services. The Plan will not pay claims received more than 365 days after the date of service, unless you can provide proof that you were legally incapacitated. You will receive an explanation of benefits (EOB) from the Plan after your claim is processed. The EOB explains how the Plan processed your claim, and will help you pay your share of the bill to your Provider, if necessary. Copayment or coinsurance amounts, services, or amounts not covered and general information about the Plan s processing of the claim are explained on the EOB. For other medical plan options, please see the appendix for information. Questions about Claims, Eligibility and Benefits for Medical Plans Administered by Providence Health Plan If you have questions about the status of your claim or if your provider would like to check either eligibility or benefits, call the Providence Health Plan Customer Services Team Representative directly at: Providence Health Plan s Customer Services Team Representatives are located in Beaverton, Oregon, and are available to take your call Monday through Friday, from 8:00 A.M. through 5:00 P.M. Pacific Standard Time/Pacific Daylight Time. In-network Claims (see pages 2-3 to 2-6) If you obtain services from a Preferred Provider or facility, your Preferred Provider will submit your claim for you. Please identify yourself as a member of the First Choice network by presenting your ID card to the provider at the time of services. Your Preferred Provider will send your claim directly for claims administration. Providence Health Plan, as the claims administrator, will adjust the bill to reflect the PPO discount and process the claim. If your claim is a hospital claim at an in-network facility other than a Providence Health & Services facility, your provider will send the bill to the network administrator for pre-pricing and then to Providence Health Plan for processing. Always present your Medical Identification Card to the provider and be sure the provider has the correct billing address for Providence Health Plan. Copays, if any, will generally be collected by the provider. 5-1 General Medical, Dental, and Vision Information

94 Non-Preferred Provider/Out-of-network Claims If you go to a non-preferred Provider, you will need verify whether your provider will submit your claim directly to Providence Health Plan. If in an emergency, you go to a non-preferred Pharmacy, you will need to submit your claim directly to Providence Health Plan at the address listed on page 5-1. Claim forms are available from the HR Service Center. Please be sure that you complete all sections of the claim form except the Provider section; and sign and date it. A separate claim form must be completed for each family member for whom a claim is filed. Instead of having the provider complete the provider section of the claim form, an itemized bill may be attached. The itemized bill must include the following information: identification number as shown on your medical ID card Employee name Patient name Type of service Description of the service (CPT or procedure code) Date of each service Diagnosis Charge for each service Provider s Tax Identification Number (TIN#) Provider s billing address National Provider Identifier (NPI) Please make copies of all itemized bills and claim forms. They cannot be returned. Canceled checks and balance due bills are not acceptable substitutes for itemized bills. Claims for Other Medical Options Please see the appendix for referral to the summary of the other medical options. Flexible Spending Accounts Questions about Health Care and Dependent Care Flexible Spending Accounts processed by the administrator, HealthEquity, can be answered by a Customer Service Representative. Call and ask to speak directly to a service representative. Health Care and Dependent Care Flexible Spending Account claims should be sent to the address on your claim forms. Web site: Dental Claims Dental claims should be sent to: Delta Dental/Washington Dental Service P.O. Box Seattle, WA For questions about claims, eligibility, and benefits, please call your customer services team representative at: Customer Service Toll-free: Customer service representatives are available: Monday Friday 8 A.M. to 5 P.M., Pacific Standard Time Web site: Vision Claims Vision claims should be sent to: Vision Service Plan (VSP) P.O. Box Sacramento, CA For vision questions about claims, eligibility, and benefits, please call your Member Services representative at: Member Services Toll-free: Customer service representatives are available: Monday Friday 5 A.M. to 7 P.M., Pacific Time Web site: General Medical, Dental, and Vision Information

95 Claim Review and Appeal The chart below summarizes the claims and appeals procedures for each of the listed plans. However, you must follow the specific claims and appeals procedures established by the appropriate insurance carrier. See page 16-1 for more information. Type of Plan Medical (PHP) Dental (WDS) Vision Plans (VSP) Health Care Flexible Spending Account (HealthEquity) (Group Health and Blue Shield resource information supplied in appendix) When Claim Decisions Will Be Made (in calendar days) The claims administrator will provide you with oral or written notification. If oral, a written or electronic notification will be given not later than three days after the oral notification. For a pre-service claim, within 15 days of receipt of your request for review (which may be extended up to a total of 30 days if they need more time to process your claim for reasons beyond their control. If this applies, you will be notified before the end of the original 15-day period.) If your claim is incomplete, you will be notified within five days, and you will have at least 45 days to provide the necessary information. Your Deadline for Initial Appeal You have 180 days after receiving notice that your claim is denied to file an appeal, in writing, to the claims administrator. When Appeal Decisions Will Be Made For a pre-service claim (medical, dental), within 15 calendar days of receipt of your request for review. For a pre-service, urgent care claim (medical), within 72 hours of receipt of your request for review. If additional information is needed, you shall be notified and shall have at least 48 hours from receipt of the notice within which to provide the requested information. For a pre-service, urgent care medical claim, within 72 hours of receipt of your request for review. If your claim is incomplete you will be notified within 24 hours after it receives your claim, and you will have at least 48 hours to respond. In such case, a decision will be made within 48 hours of the earlier of the receipt of the information or the end of the period given to furnish the additional information. For a post-service claim, within 30 days of receipt of your request for review (which may be extended up to a total of 45 days if they need more time to process your claim for reasons beyond their control. If this applies, you will be notified before the end of the original 30-day period.) If your claim is incomplete, you will have at least 45 days to provide the necessary information. For a post-service claim, within 30 calendar days of receipt of your request for review. Extension: If the claims administrator determines that special circumstances require an extension of time for processing the claim or appeal, you will be notified of that extension. Urgent Care Claims An urgent care claim is any claim for medical care or treatment where the application of the time periods for making non-urgent care determinations could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain maximum function or, in the opinion of a physician with knowledge of the claimant s medical condition, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. Ongoing Care Claims Special rules apply where the Plan has approved an ongoing course of health care treatment either for a specific period of time or for a specific number of treatments. 5-3 General Medical, Dental, and Vision Information

96 A reduction or termination of the course of treatment before the approved time period or number of treatments will be considered a claim denial (except for plan amendment or termination). In this case, the claims administrator will notify you in advance so you can appeal the decision before the benefit is reduced or terminated. You may request to extend the course of treatment beyond the approved time period or number of treatments. If this involves an urgent care claim, the claims administrator will notify you whether your request has been approved or rejected within 24 hours of receiving your request, as long as you make your request at least 24 hours before the approved time period or number of treatments expires. Pre-Service Claims The Plan can require approval of a service before you receive care (for example, preauthorization of a hospital stay). This is a pre-service claim. See the medical and vision sections of the SPD for more information on any services which require preapproval. Post-Service Claims Post-service claims are all other claims that are not urgent care or pre-service claims. If you failed to provide the information needed to process the claim, you will receive a notice from the claims administrator. The notice will identify the additional necessary information. You will have 45 days from the notice date to provide the additional information. Claims Denial Notice for Benefits You will receive a written or electronic notice of the claims decision from the claims administrator within the time prescribed in the chart on page 5-3. If your claim is denied, the notification will include: specific reasons for the denial; reference to the specific plan provisions on which the decision is based; a description of any additional material or information necessary for the claim to be completed and an explanation of why the material or information is necessary; a description of the Plan s review procedures and their time limits, including your right to bring a civil action in court under Section 502(a) of ERISA following a claims denial on review; if an internal rule, guideline, protocol or other similar criterion was relied upon in the denial of the claim, you will be notified that the decision was based on the applicable items mentioned above, and that copies of the applicable material will be provided upon request (free of charge); if the denial is based on a medical necessity or experimental treatment or similar exclusion or limit, you will be given an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to your medical circumstances, or notified that such explanation will be provided free of charge upon request; and for a claims denial involving an urgent care claim, a description of the expedited review process applicable to such claims. If a medical judgment is involved, including denials based on a medical necessity or experimental treatment, the person reviewing your appeal will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment, who was not consulted in connection with the initial claim denial, and who is not the subordinate of anyone consulted in the claim denial. The medical or vocational experts whose advice was obtained will be identified. If your claim is denied, and you disagree with the decision, your deadline to appeal is the same time limits specified in the chart on page 5-3. If you fail to appeal within the applicable time limit, then you lose your right to appeal and your right to file suit. Termination of Coverage Due to Fraud or Abuse Coverage under this Plan, either for you or for your covered dependent(s) may be rescinded retroactively (deemed from the beginning as 5-4 General Medical, Dental, and Vision Information

97 never effective) or terminated in case of fraud or intentional misrepresentation of material fact by you or by your covered dependent in obtaining, or attempting to obtain, benefits under this Plan. If coverage is rescinded, the Plan will retain any money you paid for coverage as liquidated damages and reserves the right to recover to from you or from your covered dependents the benefits paid as a result of such wrongful activity. In addition, the Plan may deny future enrollment to you and to your dependents under any Providence medical plan for a period of five years from such rescission or termination. Recovery/Reimbursement By enrolling on a health plan, you agree to the provisions of the recovery, reimbursement and coordination of benefits provisions, including subrogation, as a condition of receiving benefits under the plan. If you, or your covered dependent, fail to comply with the requirements payment of benefits may be suspended as a result. Recovery Whenever payments have been made in excess of the amount necessary to satisfy the provisions of this Plan, including coordination of benefits, the Plan has the right to recover the amount of the payments from any individual, insurance company, health care provider, or other organization to whom the excess payments were made. Whenever payments have been based on the insured s fraudulent act or intentional misrepresentation of material fact, the Plan has the right to withhold payment of benefits under the Plan until the overpayment is recovered. Reimbursement The Plan s right to reimbursement is separate from and in addition to the Plan s right of subrogation. Coordination of Benefits Sometimes you or your covered dependents are eligible for benefits under another medical, dental and/or vision insurance plan. If so, benefits for covered services under this Plan will be coordinated with those from the other insurance plan, including Medicare. This is called coordination of benefits (COB). 5-5 General Medical, Dental, and Vision Information COB is a way to figure out how much each health plan will pay when you have a claim. One group plan always pays first (primary plan) and the other plan always pays second (secondary plan). Your primary plan will pay for your services under its policy s terms first, and your secondary plan will pay any out-of-pocket costs according to its terms. Remember, insurance carriers will pay only for those services which are covered in their plans. When this Plan is the secondary payor, the Medical, Dental, and Vision Plans will coordinate payment with the primary plan in such a way that when this plan s payment is combined with the primary plan s payment, the total does not exceed the maximum amount this Plan would have paid if it were primary. For dental plans, if you are covered by two or more Plans that compute their benefit payments on the basis of a maximum allowable amount, relative value schedule reimbursement method or other similar reimbursement method, any amount charged by the provider in excess of the highest reimbursement amount for a specific benefit is not an Allowable Expense. If you are covered by two or more Plans that provide benefits or services on the basis of negotiated fees, an amount in excess of this plan s negotiated fee is not an Allowable Expense. Vision coverage will be coordinated based on the Plan s schedule of benefits. No benefits will be paid for services not covered by your Providence plan. When Both Work for Providence Spouses, or a parent and an adult child, who both work for Providence may not have double medical, dental or vision coverage. An employee can be covered as an employee or a dependent, but not both. Likewise, dependent children may not have double coverage under the Providence offered plans. Only one parent may cover the children at any given time. There will be no coordination of benefits between two Providence offered plans for coverage.

98 The HR Service Center audits enrollment records in administering this provision. Before changing any enrollment record, the HR Service Center will attempt to contact the involved employees to discuss available enrollment options. When both employees are covered on the others plans, elections will be updated to reflect Employee Only coverage for each; likewise, if the dependent children are covered under both parents (employees), the coverage record will be updated so that the employee whose plan is considered secondary will be updated with Employee Only coverage. These changes can be processed mid-year, but no refund to previous employee contributions for premium coverage will be made. Medicare and End Stage Renal Disease If you are covered by Medicare or if you or a dependent are diagnosed with End Stage Renal Disease, you may be eligible for Medicare coverage. Once covered by Medicare, Providence will coordinate benefits according to the rules set forth by Medicare, which can result in Providence being the secondary payor. Pharmacy Benefit Coordination Effective April 15, If you are covered by more than one plan for prescription drugs and: the Health Reimbursement Medical Plan is the secondary plan Coordination of benefits will occur when your pharmacist enters the insurance information. If your pharmacy can not bill secondary insurance, Submission of a Prescription Drug Reimbursement Request Form and your itemized pharmacy receipts is required to for consideration of your claim. This form is available online at providence.org/phs-employees or by calling your Customer Service Team at Providence Health Plan will coordinate payment with the primary plan in such a way that when this plan s payment is combined with the primary plan s payment, the total does not exceed 100% of the covered cost of the drug. the Health Savings Medical Plan is the secondary plan Submission of a Prescription Drug Reimbursement Request Form and your itemized pharmacy receipts is required to for consideration of your claim. This form is available online at providence.org/phs-employees or by calling your Customer Service Team at Coordination with the primary plan s payment will be subject to the deductible. Once the deductible is met, this plan s payment in combination with the primary plan s payment will not exceed 100% of the covered cost of the drug. Other Group Plans If a group health plan does not contain a coordination of benefits provision it is always considered the primary plan. When plans covering you and/or your dependents contain a coordination of benefits provision order of payment will be as follows: First The plan in which you are a subscriber. Second The plan in which you are a dependent. If the rules above do not apply, the plan that has covered you longest is the primary plan. However, this rule does not apply if you are covered as an employee who has been laid off or has retired or as a dependent of that employee. In these cases, the plan covering you as an employee who has been laid off or has retired or as a dependent of that employee, is the secondary plan. Both plans must follow this rule for it to apply. If none of the above rules apply, the plan that has covered you longest is the primary plan. 5-6 General Medical, Dental, and Vision Information

99 The following rules apply to dependent children: If parents are not separated or divorced: The birthday rule applies. This rule states that the plan of the parent whose birthday comes first during the year is primary, not taking into account the year. If both parents have the same birthday, the plan that has covered the parent longest is the primary plan. However, some plans do not follow the birthday rule. In these cases, the rule of the other plan applies. If parents are separated or divorced: If a court order makes one parent responsible for paying the child s health care costs, that parent s plan is primary. If not, the plan of the parent with custody is primary. If the parent with custody remarries, the secondary plan will then be that of the stepparent. And the plan of the parent who does not have custody will pay third. Right to Make Payments to Other Organizations Whenever payments which should have been made by this Plan have been made by any other plan(s), this Plan has the right to pay the other plan(s) any amount necessary to satisfy the terms of this coordination of benefits provision. Amounts paid will be considered benefits paid under this Plan and, to the extent of such payments, the Plan will be fully released from any liability regarding the person for whom payment was made. Benefits to Be Paid by Other Sources Situations may arise in which health care expenses are also covered by a source other than the Plan. If so, the Plan won t provide benefits that duplicate the other coverage. For example, the Plan won t provide benefits that duplicate those available to a covered person under no-fault motor vehicle or similar insurance or through a state-sponsored program such as DSHS. If another plan is the primary payor, a copy of the other plan s Explanation of Benefits (EOB) should be included with the claim you submit to Providence Health Plan. Third-Party Liability If someone else is legally responsible or agrees to compensate you for injuries suffered by you or a family member, you will need to reimburse the Plan for any benefits the Plan paid in connection with those injuries, whether or not you have been made whole by such compensation. If a subrogation statement or other repayment agreement is requested to be signed, the Plan s right to recovery through Reimbursement and/or Subrogation remains in effect regardless of whether the statement or agreement is actually signed. Failure to Refund Full Amount. If you or your Dependent, and in the event of a Dependent who is a minor, the Dependent s representative, does not promptly refund the full amount to the Plan due to the Plan under this provision, the Plan may reduce the amount of any future benefits that are payable to you or your Dependent. The reductions will equal the amount the Plan paid in excess of the amount it should have paid. The Plan may have other rights in addition to the right to reduce future benefits. Subrogation and Recovery This provision applies when you or your Dependent, referred to in this section as Covered Person, may incur medical charges due to injuries which may be caused by the act or omission of a Third Party or a Third Party may be responsible for payment. In these circumstances, the Covered Person or the Covered Person s beneficiary may have a claim against that Third Party, or insurer, for payment of the medical charges. Accepting benefits under the Providence Health & Services health plan(s) (the Plan ) for those incurred medical expenses automatically assigns to the Plan any rights the Covered Person may have to recover payments from any Third Party or insurer. The Plan s share of the Recovery shall not be reduced because you, your dependent, or your beneficiary has not received the full damages claimed, unless the Plan agrees in writing to a reduction. 5-7 General Medical, Dental, and Vision Information

100 Further, this subrogation right allows the Plan to pursue any claim which the Covered Person has against any Third Party, or insurer, whether or not the Covered Person chooses to pursue that claim. The Plan may make a claim directly against the Third Party or insurer, but in any event, the Plan has a lien on any amount recovered by the Covered Person whether or not designated as payment for medical expenses. This lien shall remain in effect until the Plan is repaid in full. The Covered Person: automatically assigns to the Plan his or her rights against any Third Party or insurer when this provision applies; and must repay to the Plan the benefits paid on his or her behalf out of the Recovery made from the Third Party or insurer or the Plan may recover from the Covered Person or his or her legal representative any benefits paid under the Plan from any payment the Covered Person receives or is entitled to receive from the Third Party. Amount subject to subrogation or refund. The Covered Person agrees to recognize the Plan s right to subrogation and reimbursement. These rights provide the Plan with a 100%, first dollar priority over any and all Recoveries and funds paid by a Third Party to a Covered Person relative to the injury or sickness, including a priority over any claim for non medical or dental charges, or other costs and expenses. The Plan s priority amount is not to be reduced by attorney fees related to Recovery, unless in the Plan Administrator s sole discretion it is determined that not sharing a portion of such fees or costs would be inequitable given the facts of a particular case. Accepting benefits under the Plan for those incurred medical expenses automatically assigns to the Plan any and all rights the Covered Person may have to recover payments from any Third Party. Further, accepting benefits under this Plan for those incurred medical expenses automatically assigns to the Plan the Covered Person s Third Party Claims. Notwithstanding its priority to funds, the Plan s subrogation and refund rights, as well as the rights assigned to it, are limited to the extent to which the Plan has made, or will make, payments for medical charges as well as any costs and fees associated with the enforcement of its rights under the Plan. The Plan reserves the right to be reimbursed for its court costs and attorneys fees if the Plan needs to file suit in order to recover payment for medical expenses from the Covered Person. Also, the Plan s right to subrogation still applies if the Recovery received by the Covered Person is less than the claimed damage, and, as a result, the claimant is not made whole. When a right of recovery exists, the Covered Person will execute and deliver all required instruments and papers as well as doing whatever else is needed to secure the Plan s right of subrogation as a condition to having the Plan make payments. In addition, the Covered Person will do nothing to prejudice the right of the Plan to subrogate. Conditions Precedent to Coverage. The Plan shall have no obligation whatsoever to pay medical/dental benefits to a Covered Person (Suspension of Benefits) if a Covered Person refuses to cooperate with the Plan s reimbursement and subrogation rights or refuses to execute and deliver such papers as the Plan may require in furtherance of its reimbursement and subrogation rights. Further, in the event the Covered Person is a minor, the Plan shall have no obligation to pay any medical benefits incurred on account of injury or sickness caused by a Third Party until after the Covered Person or his authorized legal representative obtains valid court recognition and approval of the Plan s 100%, first dollar reimbursement and subrogation rights on all Recoveries, as well as approval for the execution of any papers necessary for the enforcement thereof, as described herein. 5-8 General Medical, Dental, and Vision Information

101 Defined terms under this section. Recoveries means all monies paid to the Covered Person by way of judgment, settlement, or otherwise to compensate for all losses caused by the Injury or Sickness, whether or not said losses reflect medical charges covered by the Plan. Recoveries further includes, but is not limited to, recoveries for medical or dental expenses, attorneys fees, costs and expenses, pain and suffering, loss of consortium, wrongful death, lost wages and any other recovery of any form of damages or compensation whatsoever. Refund means repayment to the Plan for medical benefits that it has paid toward care and treatment of the injury or sickness. Suspension of Benefits means: After the Covered Person has received proceeds of a settlement or recovery from the Third Party, the Covered Person is responsible for payment of all medical expenses for the continuing treatment of the illness or injury that the Plan would otherwise be required to pay, until all proceeds from the settlement or recovery have been exhausted. If the Covered Person has failed to reimburse the Plan as required by this section, the Plan is entitled to offset future benefits otherwise payable under this Plan, or under any future plan offered by Providence Health & Services, to the extent of the value of the benefits advanced under this section. If the Covered Person continues to receive medical treatment for the condition after obtaining a settlement or recovery from one or more third parties, the Plan is not required to provide coverage for continuing treatment until the Covered Person proves to the Plan s satisfaction that the total cost of the treatment is more than the amount received in settlement or recovered from the third party, after deducting the cost of obtaining the settlement or recovery. The Plan will only cover the amount by which the total cost of benefits that would otherwise be covered under the Plan exceeds the amount received in settlement or recovery from the third party. The Plan is entitled to suspend such benefits even if the total amount of such settlement or recovery does not fully compensate the Covered Person for other damages, particularly including lost wages or pain and suffering. Any settlement arising out of an injury or illness covered by the Plan will be deemed first to compensate the Covered Person for medical expenses, regardless of any allocation of proceeds in any settlement document that the Plan has not approved in advance. In no event shall the amount reimbursed to the Plan be less than the maximum permitted by law. Third Party means any Third Party including another person or a business entity. The Third Party is defined to include, but is not limited to, any of the following: The party or parties who caused the illness, sickness, or bodily injury. The insurer or other indemnifier of the party or parties who caused the illness, sickness, or bodily injury. A guarantor of the party or parties who caused the illness, sickness, or bodily injury. The Covered Person s own insurer (for example, in the case of uninsured, underinsured, medical payments or no fault coverage). A Workers Compensation insurer. Any other person, entity, policy or plan that is liable or legally responsible in relation to the act or omission to act, illness, sickness or bodily injury, including, but not limited to, premises medical payments coverage, liability insurance coverage, automobile no-fault or medical payments coverage, uninsured or underinsured motorist coverage. Recovery from another plan under which the Covered Person is covered. This right of Refund also applies when a Covered Person 5-9 General Medical, Dental, and Vision Information

102 recovers under an uninsured or underinsured motorist plan (which will be treated as Third Party coverage when reimbursement or subrogation is in order), homeowner s plan, renter s plan, medical malpractice plan or any liability plan. Rights of Plan Administrator. The Plan Administrator has a right to request reports on and approve of all settlements. Federal Programs The term group health plan includes the federal programs Medicare, Medicaid, and Champus TriCare. The regulations governing these programs take precedence over the order of determination of this plan. In general, employer health plan benefits are primary to Medicare benefits for all Medicare beneficiaries, including disabled employees, unless employer plan coverage is rejected. Rights to Receive and Release Necessary Information The Plan may, without consent of or notice to any person, release to or obtain from any organization or person, information needed to implement plan provisions. When you request benefits, you must furnish all the information required to implement plan provisions. Assignment of Benefits Benefits payable by the Plan may be assigned to the provider of services or supplies at your option. Payments made in accordance with an assignment are made in good faith and discharge the Plan s obligation to the extent of payment. Coverage During a Leave of Absence Contact the HR Service Center for information regarding continuation of Medical, Dental, and Vision coverage during an approved leave of absence, including leaves provided under the Family Medical Leave Act of 1993 and military leaves. Optional Continuation of Coverage (COBRA) Coverage under the Medical, Dental, and Vision Plans for individuals ceases on the last day of the month in which: employment terminates, an individual is no longer in an eligible class, required contributions are not made, or the group policy is discontinued. Continuation of Coverage under Federal Law Federal law (COBRA) requires the Plan to offer to you and/or your dependent(s) continued Medical, Dental, and Vision coverage if the coverage would other end due to one of the following qualifying event : termination of your employment with Providence Health & Services for any reason except gross misconduct. Coverage may be continued for you and your eligible dependents. a reduction in the hours you work which results in loss of plan eligibility or a premium increase. Coverage may be continued for you and your eligible dependents. your death. Coverage may be continued for your eligible dependents. divorce or legal separation from your spouse. Coverage may be continued for that spouse and your eligible dependents. your entitlement to Medicare. Coverage may be continued for your eligible dependents. loss of eligibility by a covered dependent child because the child no longer qualifies as a dependent. Coverage may be continued for that child. Individuals who are eligible to continue coverage under the Medical, Dental or Vision benefits due to the above COBRA provisions are called Qualified Beneficiaries General Medical, Dental, and Vision Information

103 NOTE: In order to choose this continuation coverage, an individual must be a covered person under the Plan on the day before the qualifying event. A child born to or adopted by a person on COBRA may be enrolled in the Plan so long as they are added to coverage within 60 days of birth or adoption. The dependent s COBRA coverage ends when the original qualified beneficiary s coverage ends, however, the dependen then becomes a qualified beneficiary with independent rights to elect COBRA. COBRA notifications are sent to the last known address on file in the payroll system. If you have a COBRA qualifying event, it is important that you ensure your address is up to date. To update your address please log in to ProvConnect; If you re on the Providence network, go to org. From outside the Providence network, go to provconnect.providence.org. Maximum Period of Continuation Coverage The maximum period of continuation coverage for individuals who qualify due to termination of employment or reduction in hours worked is 18 months from the date of the qualifying event unless you or your eligible dependent is disabled (as determined by the Social Security Administration) at some point before thje 60th day of COBRA coverage. In the case of such disability, coverage for the disabled person and/or family members who are also Qualified Beneficiaries, may be extended an additional 11 months for up to a total of 29 months. For the 11-month extension to apply, notice of the determination of disability under the Social Security Act must be provided by the disabled individual to the Plan Administrator or COBRA administrator within 60 days of the later of the date on which the Social Security Administration issues the disability determination or the date on which you lose coverage as a result of the qualifying event. The maximum period of continuation coverage for individuals who qualify due to any other described qualifying event is 36 months from the date of the qualifying event. If an individual experiences more than one qualifying event, the maximum period of coverage will be computed from the date of the earliest qualifying event; in no event will more than 36 months of continuation coverage be available. If you become covered by Medicare before a reduction in hours/termination of employment, coverage for your covered dependents may be continued for up to 18 months from termination/ reduction or for up to 36 months from the date you became covered by Medicare, whichever is longer. Notification Requirement You or your dependent has the responsibility to inform the HR Service Center in writing of a divorce, legal separation, or a child losing dependent status under the Plan within 60 days from the date of the qualifying event or the date coverage is lost due to the event. Failure to provide this notification within 60 days of the event will result in the loss of continuation rights and your option to purchase COBRA ends. You also have the responsibility of notifying the HR Service Center if you qualify for Social Security disability and of providing documentation. You or your dependents also have the responsibility of keeping the HR Service Center informed of the current address of all participants or beneficiaries under the Plan who are or may become qualified beneficiaries. Cost of Continuation Coverage The cost of continuation coverage is generally 102% of the full cost of the coverage. This cost may differ from the premium rates shown for coverage on your Providence Health and Welfare Benefit Plan enrollment. Rates are established by the Plan and are subject to change when necessary due to plan modifications. In cases of additional coverage due to disability, as described above, the premium for the 19th-29th months of coverage may be 150% of the full cost of coverage. The cost of continuation coverage is computed from the date coverage would normally end due to the qualifying event. Coverage must be continuous. After the initial premium is paid, failure to make payment within 30 days of the due date will result in the permanent cancellation of continuation coverage General Medical, Dental, and Vision Information

104 When Continuation Coverage Ends Continuation of coverage ends for an individual on the earlier of: the date the maximum continuation period expires; the date the covered individual first becomes covered by Medicare, after the date of the COBRA election (although this does not affect dependent eligibility); the date the covered individual first becomes covered under another group health plan (unless that plan contains any exclusion or limitation with respect to a pre-existing condition of the individual who is continuing coverage) after the date of the COBRA election; the last period for which payment was made when coverage is canceled due to non-payment of the required cost; the date Providence Health & Services no longer offers a group health plan to any of its employees; recovery, in case of an extension for Social Security determined disability. You must notify the Plan Administrator within 30 days of the Social Security determination of recovery; or recovery from a Social Security qualified disability during months NOTE: If, as an active employee, you were covered by either Medicare or another employer s plan before your coverage ended for any of the reasons which allow you to apply for COBRA coverage, you may apply for COBRA coverage even though you have other coverage through Medicare or another plan. If you had not been covered by Medicare or the other plan before you lost coverage through Providence Health & Services, you can apply for COBRA coverage. If, however, after the date of your COBRA election, you obtain coverage through Medicare or another group health plan (which did not include any exclusions or limitations with respect to pre-existing conditions), your COBRA coverage will end. If you choose COBRA continuation coverage, the coverage available will be identical to that provided to similarly situated employees or family members (ABRs are not Qualified Beneficiaries under COBRA). If coverage changes for active employees, it will change for you in the same manner. Your COBRA rights are provided as required by law. If the law changes, your rights will change accordingly. If you are covered by an HMO and move out of the area covered by the HMO, you may change to another plan offered by your employer so long as you do so within 31 days of your move and pay the additional premium required, if any. When COBRA coverage ends you may be eligible to convert your coverage to an individual policy. Contact the Plan for more information. Contact the HR Service Center if you wish further information and more details regarding the continuation of coverage (COBRA). Optional Continuation of Coverage for Adult Benefit Recipients Adult Benefit Recipients are not Qualified Beneficiaries under the COBRA regulations; they do not have a right to continuation coverage under COBRA. Coverage under the Medical, Dental, and Vision Plans for an Adult Benefit Recipient ceases on the last day of the month in your coverage ceases. If you elect COBRA coverage for yourself due to a qualifying event, you may elect to continue coverage for your enrolled Adult Benefit Recipient (and the children of your Adult Benefit Recipient Registered Domestic Partner/Domestic Partner). You are also able to add an ABR to your COBRA coverage during the open enrollment period held each fall for the new plan year. If you die, your enrolled Adult Benefit Recipient (including the children of an Adult Benefit Recipient Registered Domestic Partner/Domestic Partner) will be offered continuation coverage for up to 18 months. See When Continuation Coverage Ends on page 5-11 for when the above mentioned continuation coverage ends. Additionally, coverage will cease at the end of the month in which the adult no longer meets the qualifications for coverage as an Adult Benefit 5-12 General Medical, Dental, and Vision Information

105 Recipient, or as the qualifying child of an Adult Benefit Recipient Registered Domestic Partner/ Domestic Partner. Transitional coverage may be offered to your ABR for a period of up to 3 months as a bridge while new coverage is secured. The cost is 102% of the full cost of the plan for this transition coverage. Contact the HR Service Center for more information or to request the transitional coverage General Medical, Dental, and Vision Information

106 VI. Employee Assistance Program (EAP) Overview The Employee Assistance Program (EAP), provided by Providence Health & Services is designed to help employees and their dependents with a wide variety of issues that may have a negative effect on their work or personal life. There are times in most people s lives that they feel unable to resolve all of the decisions, personal problems, family issues, or career difficulties they face. The EAP is designed to be a place to turn for assistance. The EAP s consultants and counselors provide direct services and as needed referrals for further assistance. The goal is to help employees and their family lead healthier and more productive lives. The program is completely voluntary and confidential. The EAP is provided at no cost to active employees and their family members. Coverage is automatic; you don t need to do anything to enroll. There are four EAP providers within the system. You and you family members are to contact the EAP provider designated for your Region as shown. For Alaska Region Employees and PSMS Employees in Alaska Providence Health & Services Alaska Employee Assistance Program (EAP) The Providence Health & Services Alaska Employee Assistance Program ( the EAP ) is a professional, confidential service you can use to get help without charge to you whenever you or an eligible dependent needs assistance in dealing with personal pressures. Counselors are available 24 hours a day, seven days a week at (toll-free) for crisis assistance. The program is provided through a contract with Magellan Behavioral Health, Inc. ( Magellan ). Eligibility and Cost You and your eligible dependents become eligible to participate in the EAP on the first day of employment. Your coverage and coverage of your eligible dependents is automatic; you do not need to take any steps to enroll. Eligible Dependents Eligible dependents: Your spouse/adult Benefit Recipient(ABR) Your unmarried dependent children (whether or not they reside with you) Your child or the child of your spouse will be eligible to participate in the EAP in accordance with the terms of any Qualified Medical Child Support Order (QMCSO). A QMCSO is a medical child support order that meets the requirements set forth in Section 609 of ERISA. Cost The Company pays the full cost of participation in the Employee Assistance Program for you and your eligible dependents (see What Services Are Covered ). If you are on an approved FMLA leave, non-occupational medical leave, or workers compensation leave, your EAP coverage will continue at no cost to you. You have no obligation to pay any premium or fees for EAP coverage or to obtain EAP services; there are no premiums, copayments, co- insurance, or deductible payments applicable to EAP services. Obtaining EAP Services To obtain EAP services, simply call the toll-free number: EAP representatives are available 24 hours a day, 7 days a week, to provide 6-1 Employee Assistance Program (EAP)

107 referral and emergency crisis intervention services. Spanish-speaking representatives and counselors are also available. When you call the EAP, a Magellan representative will: Ask you questions to help identify the problem and how it is affecting you, Find out what solutions you have tried and explore other solutions and resources, and Help you develop a plan to solve the problem. If you desire to work on your problem through in-person sessions with an EAP counselor or if it appears that your problem cannot be adequately addressed in a telephone consultation, the Magellan representative will refer you to an EAP counselor or another resource in your community, as appropriate. You can also visit Magellan s website for confidential, anonymous access to educational materials, self-help tools, a directory of EAP counselors, guidance in preparing for a session with a counselor, and other resources. You can reach this website directly at com/member. The directory can be searched by counselor name or by ZIP Code. To access the directory of EAP counselors: 1. Enter the URL magellanhealth.com/member 2. Click on Find a Provider 3. Follow the online directions 4. Under Provider, select Employee Assistance Program and Continue 5. Enter search criteria (zip code, etc.) Make sure that the box for Employee Assistance Providers is selected. At your request, Magellan will send you a hard copy of the directory information; contact Magellan at Covered Services Personal Consultation Services The EAP provides confidential assessment, counseling, and referral services to help with issues or problems that could potentially affect your health, relationships, and job performance. You and each of your eligible dependents are eligible to participate in up to five (5) in-person sessions per problem each calendar year (as considered clinically necessary by the EAP). If you obtain in-person counseling for a problem together with an eligible dependent, such as your spouse, the total number of in-person sessions for which you and the other person are eligible for that problem is still five (5). The number of sessions does not double simply because two persons participate in counseling or triple because three persons participate. There is no lifetime maximum on the number of sessions. The EAP will help you develop solutions for problems such as: Marital and family problems (marital tension, parental concerns, etc.) Emotional concerns (anxiety, depression, stress, etc.) Substance abuse or misuse (drug, alcohol, etc.) Emotional stress Conflicts at work or home Other personal problems. In-person EAP services are available only through the network of independent EAP counselors with whom Magellan contracts. You may select an EAP counselor by calling Magellan at The EAP counselor will help you evaluate and work through your problem. In many cases, the problem is resolved within the five (5) in-person sessions available through the EAP. However, if more sessions or other health care services are needed, you may be referred to an outside source for assistance; such referral may take place as soon as the EAP counselor recognizes that handling your problem through the EAP is not appropriate. 6-2 Employee Assistance Program (EAP)

108 If you have questions or concerns about your EAP services, please call Magellan at Legal and Financial Consultation Services The EAP also provides you and your eligible dependents with free initial legal and financial consultations for such matters as: Wills and inheritance concerns Divorce, custody, adoption matters Consumer issues Real estate questions Criminal matters Debt management Basic financial planning/retirement, savings, investments insurance, Budgeting/family financial issues Identity theft You may access the legal or financial consultation services through the EAP toll-free number, Legal consultation services are available telephonically and in-person; financial consultation services are available only telephonically. If you need continued legal assistance after the initial consultation, you can choose whether to retain the attorney at your expense, seek alternative counsel, or adopt an alternative plan of action. If you retain the consulting attorney, you will be entitled to a twenty-five percent (25%) reduction in fees from the consulting attorney s normal fees. You are fully responsible for payment of these fees. You may also access an online library of articles on legal issues, legal forms that can be downloaded for your use, and other resources for legal and financial guidance through Magellan s website, which may be accessed as described above under Personal Consultation services. There is no restriction on the number of times you may use the legal and financial consultation services. However, you may not access legal consultation services on a continuing basis in order to undertake your own representation. Services Not Covered by the EAP The EAP does not include any of the services or charges listed below. Some of these services may be covered by your medical plan. Services by providers who are not part of Magellan s EAP counselor network EAP sessions that were not accessed through Magellan (either through the toll-free telephone access line or the on- line selfreferral service) for the particular problem More than five (5) in-person EAP sessions per problem per year Treatment for any problem or condition that cannot be resolved in brief counseling (for example, any condition that requires inpatient treatment or more than five (5) outpatient sessions) Psychiatric services or other medical care, including services for a condition that requires psychiatric treatment (for example, a psychosis) and prescription drugs Inpatient treatment Counseling; evaluation or preparation of recommendations for use in child custody proceedings, child abuse proceedings, criminal proceedings, workers compensation proceedings, or any legal actions of any kind or otherwise required by any state or federal judicial officer or other governmental official or agency Evaluations for fitness for duty determinations or excuses for leaves of absence or time off Psychological, psychiatric, neurological, educational, or IQ testing Remedial and social skills education services, such as evaluation or treatment of learning disabilities, learning disorders, academic skill disorders, language disorders, mental retardation, motor skill disorders, or communication disorders; behavioral training; cognitive rehabilitation 6-3 Employee Assistance Program (EAP)

109 Medication or medication management or treatment of any condition for which medication is required, unless you are seeing a doctor who prescribes medication for that condition and oversees your use of the medication Examinations and diagnostic services in connection with obtaining employment or a particular employment assignment, admission to or continuing in school, securing any kind of license (including professional licenses), or obtaining any kind of insurance coverage Testimony in legal proceedings or creation of records for legal proceedings or other preparation for legal proceedings Services or supplies rendered by a family member Services rendered before coverage became effective or after coverage ends Guidance on workplace issues when you sue, or threatens to sue, the Company Acupuncture Biofeedback or hypnotherapy Direct treatment for metal retardation, learning disabilities, or autism Aversion therapy Sleep therapy Charges for failure to keep a scheduled visit Legal assistance for employment issues, commercial enterprise, second opinions or third-party advice, such as a relative s legal problem, matters considered frivolous or harassing by the consulting attorney, matters involving Magellan, the Company, the legal services vendors or its plan attorneys, or any matter that would involve a violation of ethical rules Recommendation or endorsement of a specific attorney to represent you; the final decision regarding whether a particular attorney is suitable for your needs can only be made by you Financial advice or instruction as to any course of action. The financial consultants are not responsible for any decisions you make about your financial planning. Reimbursement of Claims Magellan pays EAP counselors directly. You do not have to file EAP claims. There are no copays, coinsurance, or deductibles. You should not make any payment to a provider for EAP services. You should not make any agreement with an EAP counselor to pay the counselor for EAP services. However, you will be responsible to pay for services that you obtain without having Magellan open an EAP case with a particular EAP counselor. Claim Determinations Magellan will generally make a determination on your request for personal consultation services and inform you of its determination in your initial telephone call to request services. If Magellan cannot decide while on the initial call, Magellan will decide within five (5) calendar days of your request for personal consultation services or of notice to Magellan of a circumstance that affects the availability of further EAP services. Magellan will inform you by telephone of its determination within one (1) business day after it decides. If you consent to written notice, Magellan will also send you written notice of its determination within one (1) business day of the telephonic notice. If additional information is needed to process the request, Magellan will notify you within 24 hours of receipt of your request. You will be given at least 48 hours to submit the information, and you will be notified of the decision no later than 48 hours after the end of that additional time period (or after Magellan s receipt of the information, if earlier). If you are receiving an ongoing course of EAP counseling, Magellan will notify you in advance if it intends to terminate or reduce the number of EAP sessions that can be provided so that you will have an opportunity to appeal the decision before the termination or reduction takes effect. If Magellan determines that you need urgent care, Magellan 6-4 Employee Assistance Program (EAP)

110 will provide telephonic crisis counseling and make an appropriate referral to your benefit plan and/or emergency resources in the community. Magellan does not make claim determinations relating to urgent care. Because Magellan pays all EAP counselors directly, you should not make any payment to a counselor for EAP services. In the event that you mistakenly pay a counselor for EAP services, Magellan will make a determination on your request for reimbursement within 15 days after receipt of the claim (if EAP services have not yet been received) or within 30 days after receipt of the claim (if the EAP services have already been received). Magellan will notify you of its determination telephonically, and, if you consent to written notice, in writing, within the 15 day or 30 day period, as applicable. EAP services do not include urgent care services. Therefore, if Magellan determines that you need urgent care, Magellan will make an appropriate referral to your benefit plan and/or emergency resources in the community. Magellan does not make determinations relating to urgent care under the EAP. Adverse Determinations of a Claim for EAP Benefits If a claim for EAP benefits is wholly or partially denied, and you authorize written communication to you, Magellan will provide written notice of the denial to you or your authorized representative. This notice of the decision will: give the specific reason or reasons for the denial decision; identify Plan provisions on which the decision is based; describe any additional material or information necessary for an appeal review and an explanation of why it is necessary; explain the review procedure, including time limits for appealing the decision and to sue in federal court; identify your right to receive, free of charge, upon your request, any internal rule, guidelines, protocol or similar criterion relied on in making the decision; identify your right to receive, free of charge, upon your request, an explanation of the clinical judgment on which the decision is based (if the denial is based on exclusion of experimental treatment services or because EAP services are not clinically appropriate). If you do not authorize written notice, Magellan will furnish this information to you or your authorized representative by telephone. Appeals of Adverse Determinations If you believe your claim for EAP benefits was denied in error, you may appeal the decision. Your appeal must be submitted in writing within 180 days following your receipt of a denial notice to: Magellan Behavioral Health P.O. Box 2128 Maryland Heights, MO Your appeal should state the reasons why you feel your claim for EAP benefits is valid and include any additional documentation that you feel supports your claim for EAP benefits. You can also include any additional questions or comments. You may submit written comments, documents, records and other information relating to your appeal, whether or not the comments, documents, records or information were submitted in connection with the initial claim for EAP benefits. On your request, Magellan will make relevant documents available to you. The review of the initial decision will consider all new information, whether or not it was presented or available for the initial decision. The person who conducts the appeal review will be different from the person(s) who originally denied your claim for EAP benefits and will not report directly to the original decision maker or prior reviewer. You or your authorized representative will be notified of the appeal decision within the following time frames: 6-5 Employee Assistance Program (EAP)

111 If the appeal involves an adverse determination on a request for EAP services or a pre-service adverse determination relating to reimbursement, within thirty (30) days of Magellan s receipt of the request for appeal. If the appeal involves a post-service adverse determination relating to reimbursement, within sixty (60) days of Magellan s receipt of the request for appeal. Appeal Decisions If you authorize written communication, Magellan will give you or your authorized representative the decision on the appeal in writing. If the denial is upheld on appeal, the notice will include the following information: the specific reason or reasons for the denial decision; identification of Plan provisions on which the decision is based; notice of your right to receive, free of charge, upon your request, any internal rule, guidelines, protocol or similar criterion relied on in making the decision; notice of your right to receive, free of charge, upon your request, an explanation of the clinical judgment on which the decision is based (if the denial is based on exclusion of experimental treatment services or because EAP services are not clinically appropriate); notice of your right to receive, free of charge, upon your request, reasonable access to, and copies of, all documents, records and other information relevant to the appeal; and notice of your right to bring a civil lawsuit under ERISA 502(a). If you do not authorize written notification, Magellan will furnish this information to you or your authorized representative by telephone. If you do not agree with the final decision of Magellan, you may bring a lawsuit in federal district court. You may not initiate a legal action for the benefits unless you utilize all available appeal processes, as described above. Continued Coverage under the EAP You and your eligible dependents may choose to have EAP coverage continued in a number of situations that ordinarily end your coverage. This coverage is provided according to the Consolidated Omnibus Budget Reconciliation Act and is often referred to as COBRA coverage. You will have to pay the cost of any continued coverage. The Company s benefits department will bill you directly for this coverage on a monthly basis. Events That Qualify for Continued Coverage If your employment status changes to part-time or if you fail to return to work after the maximum time allowed for an approved leave of absence, coverage for you and your eligible dependents may continue for up to 18 months. The Company s benefits department will contact you with instructions for continuing your coverage if your employment ends or your employment status changes to part-time. However, termination due to gross misconduct cancels eligibility for this benefit for you and your eligible dependents. In addition, if you or your eligible dependents are determined to be disabled (as defined by the Social Security Act) prior to the qualifying event or during the first 60 days of your COBRA coverage, up to a total of 29 months of COBRA coverage may be available for you and/or your family. You may be charged a higher premium after the first 18 months. To be eligible, the disabled dependent must notify the Company s benefits department within 60 days after receiving a determination of disability by the Social Security Administration. In addition, the determination must be made before the end of that individual s 18 months of COBRA coverage. The disabled dependent must also notify the Company s benefits department within 30 days of the date the disability ends. Your eligible dependents may continue coverage for up to 36 months if they lose coverage due to one of the following events. Also, if any of the 6-6 Employee Assistance Program (EAP)

112 events listed below occur during the 18-month period, your eligible dependents may continue coverage for up to a total of 36 months. Your death Your divorce or legal separation Your child s loss of eligibility as a dependent for coverage provided under the Providence Health & Services EAP For the first event, the Company s benefits department will provide instructions for continuing coverage. For all other events, you or your eligible dependents must notify the Company s benefits department within 60 days after the later of the date coverage is lost or the date the second or third event occurs. You or your eligible dependents must elect to continue coverage within 60 days after you are notified of your right to do so. You, your covered spouse or your eligible dependents will be charged for the continued coverage. Payment for the coverage is due on the first day of each month. Events That May Affect Continued Coverage Extended coverage may be modified based on Plan rules if you experience a qualified change in status. See Participation for detailed information on allowable status changes. Extended coverage may also be modified if, during the 18-, 29- or 36-month continuation period, a child is born to the covered participant or placed for adoption with the covered participant. In such case, you must notify the Company s benefits department within 30 days of the birth or placement if you wish to cover the new dependent as a qualified beneficiary under COBRA. There may be a higher premium for this additional coverage. The Company s benefits department will bill you directly for this coverage on a monthly basis. Events That End Continued Coverage Extended coverage will end automatically upon the expiration of the 18-, 29- or 36-month continuation periods described earlier. In addition, extended coverage will end automatically if any of the situations listed below occurs: The Company ends the EAP. The initial premiums are not paid within 45 days of your election date. Premiums for subsequent months are not paid within 30 days of the due date. A person eligible for continued benefits becomes covered under any other EAP (unless the EAP has an enforceable preexisting condition clause). In addition to the events described above, if you are a retiree and you, your eligible dependents lose retiree EAP coverage or have retiree EAP coverage substantially reduced due to Chapter 11 bankruptcy filing by the Company, you and your eligible dependents will be entitled to continue retiree EAP coverage through COBRA by electing to pay for continued coverage. In the event of such a loss or substantial reduction, the Company s benefits department will contact you with instructions for continuing coverage and additional information regarding the length of your continuation rights. Additional Information about the EAP You should be aware of the following additional information about the EAP. When Coverage Ends Your coverage and your eligible dependents coverage under the EAP will end in the following circumstances: Your Employment with the Company Terminates. Coverage will end on the last day of the pay period in which your employment ends (except as provided under any applicable law). Failure to Make Any Required Contributions. Coverage continues to the end of the period covered by your last required contribution (for example, for coverage under COBRA). Death. Your eligible dependents will be covered through the end of the month following your death. Change in Employment Status That Affects Your Eligibility to Participate in the EAP. Coverage ends on the last day of the pay period in which your employment status changes. 6-7 Employee Assistance Program (EAP)

113 Retirement. Coverage continues through the end of the month in which you retire. Divorce. Coverage for your ex-spouse continues through the last day of the month in which the divorce is final. End of Principal Support for Children. Coverage continues through the last day of the month in which you are no longer responsible for principal support. The Plan Ends. Coverage for you and your eligible dependents ends on the date the EAP is terminated. Assignment of Benefits You may not assign, transfer, or convey any of the benefits provided by the EAP. Implied Promises Nothing in this booklet says or implies that participation in the EAP guarantees your continued employment with the Company. There is also no guarantee that the EAP will continue indefinitely. The Company reserves the right to change the EAP Administrator at any time. If this happens, you will be notified. Plan Termination or Amendment While the Company intends to continue offering this EAP, the Company does reserve the right to terminate, discontinue, change or amend the EAP at any time, for any reason. Confidentiality Discussions with the EAP counselor are confidential. The EAP will not share information identifying your use of the EAP without your permission, except as required or permitted by law. You will have an opportunity to evaluate the services provided by the EAP by completing a confidential survey. Administrative Information Plan Name The name of the Plan is the Providence Health & Services Alaska Employee Assistance Program. Plan Sponsor Providence Health & Services is the sponsor of the Plan. Most of your questions can be answered by contacting the HR Service Center at Plan Type The Plan is a welfare benefit plan established for the benefit of the Company s employees. Plan Administrator The Employee Assistance Program is administered by the Company under the provisions of a service contract between the Company and Magellan Behavioral Health. The Board of Directors of the Company or any person or persons appointed by the Board of Directors may, from time to time, establish rules for the interpretation, application and administration of the EAP, and also may determine the interpretation and application of the Plan in particular cases. In all cases, uniform policies will be followed. Administration of the EAP will not discriminate against any individual or group of individuals. To the extent that a responsibility has not been delegated to another party including Magellan the Plan Administrator has the full and exclusive right and discretionary authority to construe the terms of the Plan to resolve any ambiguities and to decide any question that may arise with the Plan s application or administration, including the determination of eligibility for benefits. Decisions of the Plan Administrator are final and binding upon all parties. You can reach the Plan Administrator at: Senior Vice President, Chief Human Resources Officer, Providence Strategic and Management Services (or his/her designee) Providence Health & Services 1810 Lind Avenue SW #9016 Renton WA (425) Employer Identification Number (EIN) The Employer Identification Number assigned to the Company by the Internal Revenue Service is Plan Number The Plan Number assigned for the EAP is PN 501. Plan Year The Plan Year is January 1 through December Employee Assistance Program (EAP)

114 Plan Funding and Sources of Financing The Company pays the entire cost of the EAP from its general assets. There is no specific trust fund from which benefits or services under The Plan are paid. Active employees do not pay any contribution. However, if you are referred for treatment outside the EAP, you, together with your health care benefit plan, are responsible for paying for such treatment. EAP Administrator The EAP administrator is Magellan Behavioral Health, Magellan Plaza, Maryland Heights, Missouri 63043, Agent for Service of Legal Process You can reach the Agent for Service of Legal Process at: Business Filings Incorporated 1801 West Bay Drive NW, Suite 206 Olympia, Washington Definitions Certain terms and phrases used to describe the Employee Assistance Program ( EAP ) may not be familiar to you. It is important that you understand how the EAP works and your rights as a participant, so some important terms are defined below. The defined terms will be capitalized throughout the document for your convenience. Authorized Representative: An authorized representative is a person you authorize, in writing, to act on your behalf or a person given authority by court order to request treatment or submit claims on your behalf. Brief Counseling: Brief counseling is outpatient counseling that is problem-focused, that emphasizes skills and strengths, and encourages practicing new behaviors; that involves setting goals achievable in a one to five month period; that involves interpretation, suggestions, and a framework provided by the counselor; that you may utilize alone or together with others who are important to resolution of your problem. Claim: A claim is a request for benefits made in accordance with the Plan s procedures. A claim may be either a request for personal consultation services or a request for reimbursement of the cost of EAP counseling. Company: Providence Health & Services Alaska Employee Assistance Program (EAP) Administrator: The EAP Administrator is Magellan Behavioral Health, the organization that has been engaged by the Company to provide the EAP. Employee Assistance Program (EAP) Counselor: An EAP Counselor is a psychologist, clinical social worker, marriage, family, and child counselor or other behavioral health professional who is licensed under state law to deliver counseling services and who is contracted with the EAP Administrator to provide EAP services. Employee Assistance Program (EAP): An EAP is a systematic program to help employees resolve personal problems, such as family conflict, drug or alcohol abuse, stress, marital discord, personal finances, and other personal problems, and to provide training, consultation, and other management services relating to the effective utilization of the EAP by an employer and its employees. ERISA: The Employee Retirement Income Security Act of 1974, the federal law that regulates group health plans and other employee plans. Plan: Unless otherwise stated, the term Plan refers to the Providence Health & Services Alaska Employee Assistance Program (EAP). Urgent Care: Care needed to avoid serious jeopardy to your life or health or to regain maximum function (or require to avoid severe pain), as determined by Magellan or your treating physician. Your Rights Under ERISA As a participant in the Providence Health & Services Alaska Employee Assistance Program, you are entitled to certain rights and protections under ERISA. ERISA provides that all Plan participants are entitled to the following rights: 6-9 Employee Assistance Program (EAP)

115 Receive Information about Your Plan and Benefits You may examine, free of charge, all documents governing the Plan, including insurance contracts, collective bargaining agreements and the latest annual report (Form 5500 Series). These documents are available at the Plan Administrator s office and at other specified locations. The annual report is also filed with the U.S. Department of Labor and is available at the Public Disclosure Room of the Employee Benefits Security Administration. You may obtain copies of all documents governing the operation of the Plan, including insurance contracts, copies of the latest annual report (Form 5500 series) and updated Summary Plan Descriptions, by writing to the Plan Administrator. The Plan Administrator may make a reasonable charge for the copies. You also may receive a summary of the Plan s annual financial report. The Plan Administrator is required by law to furnish each participant with a copy of this Summary Annual Report (SAR). Continue EAP Coverage You may continue EAP coverage for yourself or your eligible dependents if there is a loss of coverage under the EAP as a result of a qualifying event. You or your eligible dependents may have to pay for such coverage. Review this Summary Plan Description and the documents governing the EAP for the rules governing your COBRA continuation coverage rights. Prudent Actions by Plan Fiduciaries In addition to creating rights for Plan participants, ERISA imposes duties upon the people who are responsible for operating the Plan. These people are called fiduciaries of the Plan. They have a duty to act prudently and in the interest of you and other Plan participants and beneficiaries. No one, including your employer or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a benefit to which you are otherwise entitled, or from exercising your rights under ERISA. Enforcement of Your Rights If your claim is denied, in whole or in part, the Plan Administrator must give you a written explanation of the reason for denial, and you can obtain copies of documents relating to the decision without charge. You also have the right to have the Plan Administrator review and reconsider your claim within certain defined time schedules. Under ERISA, there are steps you can take to ensure the above rights. For instance, if you request a copy of Plan documents or the latest annual report from the Plan Administrator and do not receive them within 30 days, you may file suit in a federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the Plan Administrator. If your request for benefits is denied or ignored, in whole or in part, you may file suit in a state or federal court. You may also file suit in a federal court if you disagree with a decision, or the lack of a decision, concerning the qualified status of a medical child support order. If Plan fiduciaries misuse the Plan s money or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a federal court. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose (for example, if the court finds your claim is frivolous), it may order you to pay these costs and fees. Assistance with Your Questions If you have any questions about the Plan, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory, or at the following address: 6-10 Employee Assistance Program (EAP)

116 Division of Technical Assistance and Inquiries Employee Benefits Security Administration U.S. Department of Labor, 200 Constitution Avenue, NW Washington, D.C You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration. About This Booklet This booklet, called a Summary Plan Description (SPD), highlights key features of the Providence Health & Services Alaska Employee Assistance Program. The Plan is governed by this SPD and a legal contract with Magellan. If there is a conflict between this SPD and the contract, the contract will always govern. This SPD will govern in the event of a conflict between it and any written or verbal explanation from Company or Plan representatives. Alaska. There is also no guarantee that the number of EAP session will not be changed in the future, or that the EAP will continue indefinitely. While the Company intends to continue offering this EAP, the Company reserves the right to terminate, discontinue, change or amend the EAP at any time, for any reason. If you have any questions about the Company s benefits, contact the HR Service Center. Please note: the Alaska EAP SPD was written by Magellan in For this document, the Plan Administrator contact, the EIN, the Agent for Legal Process and a reference to call the Alaska Benefits department were updated. Nothing in this booklet says or implies that participation in the EAP guarantees continued employment with Providence Health & Services For California Region Employees and PSMS Employees in California Providence Health & Services California Employee Assistance Program (EAP) Eligibility / Coverage All employees and their immediate family members are eligible. Immediate family members or dependents are defined as those residing in your household and eligible dependents away at school. Eligible employees include full time, part time, per diem and on-call employees. You do not have to enroll for coverage. Eligible employees and dependents are automatically covered. You are automatically covered on your date of hire. EAP Services Available Depending on your situation, the EAP counselor may do the following: Refer you to a licensed network EAP provider in your community for up to three (3) in-person visits at no cost to you, per issue, per year; Link you to available resources in your community; or Offer you support over the telephone. Additionally, if the counselor determines the situation requires it, you may be referred for additional assistance through the mental health or substance abuse coverage offered through your medical Plan. Any information about your call or treatment is confidential and may only be disclosed as permitted or required by law. Additional Services Available Achieve Solutions is ValueOptions on-line tool and offers information, and other resources on more than 200 behavioral health and wellness topics, 6-11 Employee Assistance Program (EAP)

117 including depression, stress, anxiety, alcohol, marriage, grief and loss, child/elder care, and work/ life balance. Providence Health & Services Southern California members may navigate the Web site anonymously or may choose to initiate an anonymous Call Back Request, whereby a clinically trained professional will respond via phone to provide added guidance or assistance. The Achieve Solutions website covers a variety of services for any circumstance. includes (but is not limited to): Adoption Parenting and child development Child care Emergency dependent care Education Children and adults with special needs Convenience services Moving and relocation Pet care Health and wellness Older adult care Aging Retirement End-of-life issues Balancing work and family Other EAP services include educational materials that are provided to supplement referrals and include articles, checklists, booklets and pamphlets written by specialists and renowned experts and organizations. Legal and Financial Solutions EAP also provides access to a national network of independent attorneys who have experience in a variety of legal areas including bankruptcy, estate planning, taxes, family law, consumer and financial matters and traffic violations. For financial concerns, EAP provides telephonic information and advisory services utilizing independent professionals with experience in financial matters, such as financial planners, certified public accountants and insurance specialists. If legal representation is needed, EAP will provide a referral to a local network attorney who will provide an initial one-half (1/2) hour face-toface consultation at no charge and will provide additional legal services at a 25 percent reduction of their customary fees. You are responsible for all fees beyond the free initial consultation. The attorneys and financial professionals will assist you with most situations, but some restrictions do apply. Identity Theft Program component allows members a free, 30-minute consultation with a Fraud Resolution Specialist, which includes emergency response activities for the member s protection. Providence Health & Services provides no warranties or representations regarding the quality of services provided by each individual attorney or financial professional. Accessing Services You can reach the EAP by phone at , 24 hours a day, seven days a week. You will need to provide sufficient information, as determined by the plan administrator, to prove eligibility when contacting your EAP. Licensed, clinical care managers are available 24 hours a day, seven days a week. If you choose to research issues or get help using the Internet, you can access ValueOptions at The site provides information on a variety of topics such as mental health and substance abuse, child and elder care referrals and more. You can access the site 24 hours a day, seven days a week. Filing and Processing of Claims Employees are not required to file a claim for services provided through the EAP. Call ValueOptions at at any time to access services. If additional sessions beyond the three EAP sessions are needed, the EAP counselor may make a referral per issue to a resource such as 6-12 Employee Assistance Program (EAP)

118 a local behavioral health care or medical provider. If the employee or immediate family member elects to use those resources, there may be a charge associated with that resource. Individuals who are eligible to continue coverage under EAP benefits due to the COBRA provisions are called Qualified Beneficiaries. Reimbursement of Claims You do not have to file EAP claims. There are no copays, coinsurance, or deductibles. You should not make any payment to a provider for EAP services. You should not make any agreement with an EAP counselor to pay the counselor for EAP services. However, you will be responsible to pay for services that you obtain without receiving prior authorization for an EAP case with a particular EAP counselor. When Coverage Ends Your coverage and your eligible dependents coverage under the EAP will end in the following circumstances: Your Employment with the Company Terminates, including Death & Retirement. Coverage will end on the last day of the month iin which your employment ends (except as provided under any applicable law). Divorce. Coverage for your ex-spouse continues through the last day of the month in which the divorce is final. Children No Longer Qualify as Eligible dependents. Coverage continues through the last day of the month in which the dependent ceases to be an eligible dependent. The Plan Ends. Coverage for you and your eligible dependents ends on the date the EAP is terminated. Exclusions The following services are specifically excluded from the Scope of Services provided under this plan. These restrictions include, but are not limited to: (1) Employment issues no advice will be offered on disputes between employee and employers; (2) Corporate law questions pertaining to corporate law, including those generated from employee or spousal owned businesses will not be answered; (3) Second opinions advice will not be given on how another attorney is handling a legal situation or rendering a subsequent opinion in case law; (4) Third-party callers participants cannot seek advice to help with someone else s legal problems; (5) Investments financial professionals will not provide advice regarding specific investments vehicles such as stocks, bonds, or mutual funds. They can, however, provide advice on investment strategies. Your Grievance and Appeal Rights If a claim for EAP benefits is wholly or partially denied, and you authorize written communication to you, Value Options will provide written notice of the denial to you or your authorized representative. This notice of the decision will: give the specific reason or reasons for the denial decision; identify Plan provisions on which the decision is based; describe any additional material or information necessary for an appeal review and an explanation of why it is necessary; explain the review procedure, including time limits for appealing the decision and to sue in federal court; identify your right to receive, free of charge, upon your request, any internal rule, guidelines, protocol or similar criterion relied on in making the decision; identify your right to receive, free of charge, upon your request, an explanation of the clinical judgment on which the decision is based (if the denial is based on exclusion of experimental treatment services or because EAP services are not clinically appropriate). If you do not authorize written notice, ValueOptions will furnish this information to you or your authorized representative by telephone Employee Assistance Program (EAP)

119 Appeals of Adverse Determinations If you believe your claim for EAP benefits was denied in error, you may appeal the decision. Your appeal must be submitted in writing within 180 days following your receipt of a denial notice to ValueOptions, P.O. Box 1860, Latham, NY Your appeal should state the reasons why you feel your claim for EAP benefits is valid and include any additional documentation that you feel supports your claim for EAP benefits. You can also include any additional questions or comments. You may submit written comments, documents, records and other information relating to your appeal, whether or not the comments, documents, records or information were submitted in connection with the initial claim for EAP benefits. On your request, ValueOptions will make relevant documents available to you. The review of the initial decision will consider all new information, whether or not it was presented or available for the initial decision. Value Options will conduct the appeal review. You or your authorized representative will be notified of the appeal decision within the following time frames: If the appeal involves an adverse determination on a request for EAP services or a preservice adverse determination relating to reimbursement, within 30 days of ValueOptions receipt of the request for appeal. If the appeal involves a post-service adverse determination relating to reimbursement, within 30 days of Value Options receipt of the request for appeal. Appeal Decisions If you authorize written communication, ValueOptions will give you or your authorized representative the decision on the appeal in writing. If the denial is upheld on appeal, the notice will include the following information: the specific reason or reasons for the denial decision; notice of your right to receive, free of charge, upon your request, any internal rule, guidelines, protocol or similar criterion relied on in making the decision; notice of your right to receive, free of charge, upon your request, an explanation of the clinical judgment on which the decision is based (if the denial is based on exclusion of experimental treatment services or because EAP services are not clinically appropriate); notice of your right to receive, free of charge, upon your request, reasonable access to, and copies of, all documents, records and other information relevant to the appeal; and notice of your right to bring a civil lawsuit under ERISA 502(a). If you do not authorize written notification, ValueOptions will furnish this information to you or your authorized representative by telephone. If you do not agree with the final decision of ValueOptions, you may bring a lawsuit in federal district court. You may not initiate a legal action for the benefits unless you utilize all available appeal processes, as described above. Additional Information about the EAP Assignment of Benefits You may not assign, transfer, or convey any of the benefits provided by the EAP. Implied Promises Nothing in this booklet says or implies that participation in the EAP guarantees your continued employment with the Company. There is also no guarantee that the EAP will continue indefinitely. The Company reserves the right to change the EAP Administrator at any time. If this happens, you will be notified. Plan Termination or Amendment While the Company intends to continue offering this EAP, the Company does reserve the right to terminate, discontinue, change or amend the EAP at any time, for any reason. identification of Plan provisions on which the decision is based; 6-14 Employee Assistance Program (EAP)

120 Confidentiality Discussions with the EAP counselor are confidential. The EAP will not share information identifying your use of the EAP without your permission, except as required or permitted by law Leave of Absence Contact the HR Service Center for information about continuing your EAP coverage while on a leave of absence. Conversion of Coverage You cannot convert coverage under the EAP to an individual policy. Optional Continuation of Coverage (COBRA) Federal Law (COBRA) requires that you and your dependents are offered continued EAP coverage for quaifying events. See page 5-11 for information on COBRA. Because this document is intended as a summary of the EAP benefits plan, it is not intended to describe each plan provision in full detail. More complete rules are contained in the governing agreement between ValueOptions and Providence Health & Services Southern California. Differences between this summary and the applicable agreement are not intended. If, however, any differences are found to exist, the relevant provisions of the agreement and not the summary will govern. Please note: the California EAP summary was written by ValueOptions in For Western Montana and the Washington Regions Employees, and PSMS Employees in Western Montana and Washington Providence Health & Services Montana/Washington Employee Assistance Program (EAP) Eligibility / Coverage All employees and their immediate family members are eligible. Immediate family members or dependents are defined as anyone living in the employee s household, including significant others and any dependents living outside of the home. Eligible employees include full time, part time, per diem and on-call employees. You do not have to enroll for coverage. You and your eligible dependents are automatically covered on your date of hire. Services Available Services are available through APS Healthcare (APS). A plan of assistance which includes problem assessment, education, information, and assistance with initial crisis management is provided. Such personal problems may include, but are not limited to, family or relationship problems, parenting difficulties, work related problems, substance use and abuse, grief and loss, emotional and physical abuse, and anxiety and depression. The plan of assistance may include a referral to an outside agency for further support or assistance. Fees incurred by any employee or family member at agencies other than APS are not included in the EAP coverage and are the full responsibility of the employee or eligible family member. Counseling sessions including an initial evaluation to identify problems, with followup contact as deemed appropriate by the counselor. APS agrees to provide a maximum of three (3) counseling sessions (hours) per incident per year for each eligible employee and their family members. APS shall determine what constitutes a separate incident. A 6-15 Employee Assistance Program (EAP)

121 counselor may deem it necessary to hold longer sessions to facilitate the needs of the client. If session length is extended, the number of sessions is reduced to equal a maximum of counseling hours. APS shall make EAP masters or doctoral level consultants available telephonically 24 X 7. As appropriate, the EAP telephonic consultant will facilitate an in-person EAP assessment. Legal and Financial Resources: APS shall provide access for non employer-related legal issues via telephonic and face-to-face consultation by legal and financial specialists. Intake/requests for services shall be made via toll-free number through an APS EAP counselor. Services shall include: Free 30 minute telephonic or face-to-face consultation with local attorney. Topics of assistance include, among others: civil/ consumer issues, personal/family issues, financial matters, real estate, criminal matters, IRS issues, consumer credit services, and estate planning. Twenty-five percent (25%) reduction in fees if network attorney is retained. Free 30-minute telephone consultation with a financial representative for the following issues, among others: retirement planning, college funding, life insurance needs, charitable giving, deferred compensation, or debt. Consultations are provided at no cost to the employee or household member by certified and/or licensed, as applicable, financial organizations or independent agents. Following consultation, any services purchased from the organization or agent, if any, would be the responsibility of the employee or household member. Upon Employer request, APS shall coordinate Critical Incident Stress Debriefing (CISD) services in the event Employer suffers a catastrophic event, including but not limited to violence in the workplace, injury or death of an employee, or natural disaster. Services may include telephonic assessment, group debriefing or defusing of affected employees and follow up. Up to seven (7) hour(s) of on-site CISD services per year are included in the contracted rate with additional hours available on a fee for service basis. Management Consultation Services are available to Employers Managers, Supervisors and Human Resource professionals for issues impacting the overall well-being of the workplace included but not limited to, performance problems, an employee s personal problems, team building and communication problems. Helping Hands Fund Program is coordinated through APS. The program provides financial assistance to employees who are experiencing financial emergencies. The following services will be offered for Marionwood and Providence Regional Services. When an employee calls APS to access the Helping Hands Fund, an EAP consultant will complete a full clinical assessment. APS will or fax the Helping Hands Fund Application to the employee who will return the completed application and any documentation that supports the hardship back to APS. The Lead EAP Consultant will contact the employee to complete the Helping Hands Score Sheet and complete the financial assessment / evaluation. At the completion of the session, APS will present recommendations to an approved Providence Health & Services representative who will make the final decision on the approval of the grant request. APS will be notified within one week of the Providence Health & Services decision and APS will notify the employee with the determination. Accessing Services You can reach the EAP by phone at EAP Consultants are available 24 hours a day, seven days a week Employee Assistance Program (EAP)

122 Accessing On-Line EAP Resources If you choose to research issues or get help using the Internet, you can access APS HelpLink the online resource available through the EAP at www. apshelplink.com. The site provides information on a variety of topics such as mental health and substance abuse, child and elder care referrals and more. You can access the site 24 hours a day, seven days a week. Much of the information on the site is also available in Spanish. The APS web site also provides quick links to the following tools in the right navigation, click on: Locate Resources to find help in your area, for example, to locate available day care, schools and volunteer opportunities. Savings Center to find discounts on namebrand, everyday and luxury items. Fees incurred by any employee or family member at agencies other than APS or with APS contracted providers if a referral is not obtained from APS in advance of the initial session are not included in the EAP coverage and are the full responsibility of the employee or eligible family member. Biofeedback and hypnotherapy. Services required by court order, or as a condition of parole or probation, not, however, to the exclusion of services to which the Member would otherwise be entitled. Services for remedial education including evaluation or medical treatment of learning disabilities or minimal brain dysfunction; developmental and learning disorders; behavioral training; or cognitive rehabilitation. Learning Center to access lessons to improve your mental and physical health; and relationships at work and at home. Medical treatment or diagnostic testing related to learning disabilities, developmental delays, or educational testing or training. Relocation Center to get inside information on a community. Lists the schools, hospitals and places of worship near you. Provides statistics on crime rates, cost and types of housing, age and more. Filing and Processing of Claims Employees are not required to file a claim for services provided through the EAP. Call APS Healthcare at at any time to access services. If additional sessions beyond the three EAP sessions are needed, the EAP counselor may make a referral to a resource such as a local behavioral health care or medical provider. If the employee or immediate family member elects to use those resources, the resulting fees and copayments, if any, would be the responsibility of the employee or immediate family member. Exclusions The following services are specifically excluded from the Scope of Services provided under this plan. Services not listed as EAP General Program Services Employee Assistance Program (EAP) Services received from a non-network Provider, unless pre-approved by APS. Psychological testing. (psychological testing is not necessary to determine an appropriate referral to a Network Provider to receive Covered Services, or alternatively, to determine appropriate referrals to community resources for non-covered services) Sleep therapy. Medical treatment of congenital and/or organic disorders associated with permanent brain dysfunction, including without limitation, organic brain disease, Alzheimer s disease and autism. IQ testing. (IQ testing is not necessary to determine an appropriate referral to a Plan Provider to receive Covered Services, or alternatively, to determine appropriate referral to community resources for non-covered services.) Medical treatment for chronic pain. Services involving medication management or medication consultation with a psychiatrist.

123 Fitness for Duty Evaluations (FFDE). Any form of therapy or counseling considered experimental, investigational or unproven. Medical treatment of any kind. Informal Member Problem Resolution under the EAP Plan A member may call APS at any time via the dedicated toll free number to seek resolution to a problem. Your Grievance and Appeal Rights If you disagree with APS s decision about your services, you have the right to appeal. You may appeal if you believe that the Plan has not paid a bill, has paid a bill incorrectly, or is stopping care you believe you still need. You may also file a quality of care or general complaint. Please include as much information as possible including the date of the incident, the names of the individual involved, and the specific circumstances. You must file your grievance or appeal within 30 days of the date of service. To the extent possible, complaints filed will be resolved within 30 days. If the matter is still unresolved following the appeal process you may submit the matter to arbitration conducted pursuant to arbitration rules of the American Arbitration Association Written grievances or appeals should be sent to: APS Healthcare Att: EAP Complaint and Appeal 21 Governors Court, Suite 100 Windsor Mill, MD You may file a grievance by phone by calling the EAP dedicated toll free number for Providence Health and Services. You may fax your grievance or appeal to: When coverage ends Your coverage ends as of the earliest of the following events: 30 days after your employment ends for any reason. The last day of the month in which your dependent no longer qualifies as an eligible dependent. The date Providence terminates the agreement. Leave of Absence Contact the HR Service Center for information about continuing your EAP coverage while on a leave of absence. Conversion of Coverage You cannot convert coverage under the EAP to an individual policy. Optional Continuation of Coverage (COBRA) Federal Law (COBRA) requires that you and your dependents are offered continued EAP coverage if the coverage would otherwise end due to one of the following qualifying event : Termination of your employment with Providence Health & Services for any reason except gross misconduct. Coverage may be continued for you and your eligible dependents. Your death. Coverage may be continued for your eligible dependents. Divorce or legal separation from your spouse. Coverage may be continued for the spouse and your eligible dependents. Your entitlement to Medicare. Coverage may be continued for your eligible dependents. Loss of eligibility by a covered dependent child because the child no longer qualifies as a dependent. Coverage may be continued for that child. Individuals who are eligible to continue coverage under the EAP benefit due to the above COBRA provisions are called Qualified Beneficiaries. See page 5-10 for more information on COBRA continuation of coverage Employee Assistance Program (EAP)

124 Because this document is intended as a summary of the EAP benefits plan, it is not intended to describe each plan provision in full detail. More complete rules are contained in the governing agreement between APS Healthcare and Providence Health & Services. Differences between this summary and the applicable agreement are not intended. If, however, any differences are found to exist, the relevant provisions of the agreement and not the summary will govern. Please note: the Washington EAP summary was written by APS in 2010 For Oregon Region Employees and PSMS Employees in Oregon Providence Health & Services Oregon and SW Washington* Employee Assistance Program (EAP) 1. Enrollment/Eligibility As an eligible employee you are automatically enrolled - as are the members of your family - for the Employee Assistance Program when you are hired or re-hired/reinstated. No enrollment action is needed from you. Eligibility (a) Employees. All active employees of Providence Health & Services - Oregon Region entities are eligible to participate in the Plan, except leased employees as defined in the Internal Revenue Code and individuals who are not treated as employees for payroll tax purposes (even if the individual is subsequently determined to be an employee). (b) Family Members. The immediate family members of eligible employees are eligible to participate in the Plan. For this purpose, an immediate family member includes your legal spouse as defined by applicable law or your domestic partner as defined in (ii) below, and your unmarried children as defined in (i) below if they are under age 26. *Services available to Oregon Region employees and PSMS employees based in Oregon, and their family members, who reside in southwest Washington state (i) The following are all considered children : (A) Your natural child, when it is your legal obligation for contribution of ongoing support and there is no court order to the contrary; (B) Your stepchild, grandchild, adopted child, domestic partner s child, or foster child, when legal proof of dependency or guardianship is provided; (C) A child under age 18 who is placed in your home pending adoption by you; and (D) Any other child related to you by blood or marriage for whom you are the legal guardian, when a court order showing legal guardianship is provided. (ii) Domestic partners are two people of the same sex who are in a committed relationship and who meet the following requirements: (A) Share a common residence and the common necessities of life; (B) Have joint responsibility for each other s welfare; (C) Are not legally married to, separated from, or in a domestic partnership with any other person; (C) Are not blood relatives; and (D) Are both at least age Employee Assistance Program (EAP)

125 If you have a child who is incapable of selfsupport because of a physical handicap or mental retardation, that child may be eligible for coverage even though he or she is age 26 or older. To be eligible for coverage, (1) the child must be unmarried, reside with you, and be principally dependent on you for support, (2) the disability must have arisen before the child s 26th birthday, and (3) you must certify that these conditions have been met. Please contact your Human Resources Department at least 31 days before your child s 26th birthday for certification information. The Plan Administrator reserves the right to verify the eligibility of any immediate family member. dependent. If you acquire a new immediate family member during the period of continuation coverage (see Section 4), the new family member will be covered under the Plan. Coverage for those family members will end in accordance with Section 3(b)(iii). However, if a child is born to you or your domestic partner or placed for adoption with you during the period of continuation coverage, the child will be covered under the Plan and coverage for the child will end in accordance with Section 3(b)(ii). 2. Plan Benefits Benefits under the Plan are provided by Providence Health & Services Employee Assistance Program ( EAP ), a department of Providence Ambulatory Services Division in Oregon. Plan benefits include General assessment, short-term counseling, resource exploration and referral, Legal and Financial Services, Career planning services, Elder & Child care resources & referral, and Critical Incident Stress Debriefing (CISD) These services are available to help Plan participants resolve a variety of personal problems such as family conflicts, problems with business relationships, chemical dependency, stress, depression, anxiety, grief, trauma, and other kinds of personal and emotional issues. If you have a legal or financial concern, you will receive a referral through the EAP and its vendor partner, CLC, which provides free legal and financial consultation and assistance when you have questions about topics such as: housing and real estate matters; estate planning; family law, such as divorce, child custody and child support; car accidents and related matters; financial problems such as debt; consumer concerns; and criminal and government matters. The initial telephone consultation or face-to-face meeting (up to one-half hour) with a network attorney or financial professional is free. Additional visits or services are available at a discount of 25% off of the attorney or financial professional s regular rates, depending on the type of legal or financial issue you have. To obtain assistance with a personal problem, you can make an appointment with an EAP counselor by calling or ; A counselor will meet with you, evaluate your problem, and help you develop a personal action plan to resolve the problem. If the counselor determines that your problem can be resolved through short-term counseling, the EAP will provide those services at no cost to you. Benefits under the Plan are limited to six (6) visits to an EAP counselor per each separate issue or event. If you and your EAP counselor agree that you need additional care that goes beyond the scope of the EAP, the additional care you receive may be covered by your medical option under your medical plan. Providence EAP can assist you in arranging your continued treatment through your medical benefits option. All services you receive through the Employee Assistance Program are confidential. If you call the EAP or visit an EAP counselor, your name and the fact that you used the Plan s services will not be disclosed without your prior written consent. All calls and counseling sessions are confidential, except as required by law (e.g., when a person s emotional condition is a threat to himself/herself or others, or there is suspected abuse of a minor child, or elder abuse). All Plan counselors are experienced professionals who hold a master s degree in behavioral sciences, counseling, social work, or 6-20 Employee Assistance Program (EAP)

126 a related field; have a minimum of five years of postgraduate supervised clinical experience; are trained in assessment, referrals, and short-term therapy. Exclusions The Plan will not cover the cost of any services you receive through the referral. Benefits under the Plan are limited to six (6) visits to an EAP counselor per issue or event. 3. Coverage (a) Commencement of Coverage. Coverage begins on the first day on which you become eligible. (b) Termination of Coverage. (i) Employees. If you are covered under the Plan as an eligible employee, your coverage will end on the last day of any applicable period of continuation coverage, if elected (as described in Sections 4 and 5), after your employment ends. (ii) Spouses, Domestic Partners, and Dependent Children. Coverage of your spouse or domestic partner and your dependent children will end on the last day of any applicable period of continuation coverage, if elected (as described in Sections 4 and 5), after your employment ends or a spouse, domestic partner, or dependent child ceases to be your immediate family member. (iii) Family Members Acquired During Continuation Coverage. Note: Coverage will also end if the Plan is terminated or, in the case of immediate family members, the Plan is amended to eliminate coverage for immediate family members. However, a Plan amendment that eliminates coverage for immediate family members will not terminate coverage for a spouse, domestic partner, or dependent child whose period of continuation coverage began before the effective date of the amendment. 4. Continuation Coverage You, your spouse or domestic partner, and your dependent children are permitted to separately elect to continue coverage under the Plan if it would otherwise terminate because of your termination of employment (other than by reason of your gross misconduct). If you, your spouse or domestic partner, or your dependent child elect to continue coverage, all immediate family members, as described in Section 1(b), are eligible for coverage. Your spouse or domestic partner and your dependent children may also elect to continue coverage under the Plan if they lose coverage because of your death, your divorce or legal separation, or the end of your domestic partnership. In addition, your dependent child may elect to continue coverage under the Plan if coverage terminates because of your child s ceasing to be an immediate family member. These circumstances are referred to as qualifying events, and individuals eligible for continuation coverage are referred to as qualified beneficiaries. Coverage of a family member acquired during your continuation coverage (other than a newborn or adopted child) will end when the earlier of the following events occurs: (A) Your coverage ends; or (B) The family member no longer qualifies as your immediate family member. For purposes of continuation coverage, dependents are your immediate family members as described in Section 1(b). Your rights to continuation coverage are the same as required by federal law, except that you may not be required to pay premiums for the continuation coverage. The Plan and this summary plan description do not grant you more rights than the law requires for similarly situated qualified beneficiaries who make timely premium payments for continuation coverage Employee Assistance Program (EAP)

127 (a) Election Period. To receive continuation coverage, qualified beneficiaries must elect continuation coverage within 60 days after the later of the date coverage terminates because of the occurrence of a qualifying event or notification by the Plan Administrator of a loss of coverage. Failure to elect continuation coverage within that period eliminates the right to continuation coverage by reason of that event. (b) Newly Acquired Immediate Family Members. If you or your dependents elect continuation coverage, any newly acquired immediate family member will be covered under the Plan. If a child is born to or placed for adoption with you during the period of continuation coverage, the child is considered a qualified beneficiary as long as, if you are a qualified beneficiary, you elect continuation coverage for yourself. If the child is added as a dependent, the child will have independent election rights and second qualifying event rights. (c) Length of Continuation Coverage. You or your dependents can extend coverage for up to 18 months if you lose coverage because you terminate employment. Your dependents can extend coverage for up to 36 months if they lose coverage because of your death, your legal separation or divorce, the end of your domestic partnership, or your child s loss of dependent status. If one of these 36-month qualifying events occurs during the 18-month period after the loss of coverage as a result of your termination of employment (or during the 29-month period if continuation coverage is extended due to disability, as described below), the total continuation period may be extended to a total of 36 months after the initial loss of coverage. If you have a termination of employment within 18 months after the date you become entitled to Medicare, the period of continuation coverage available to your dependents will be 36 months after the date on which you became entitled to Medicare, or 18 months (29 months or 36 months if coverage is extended due to disability or a 36-month qualifying event) after the date of loss of coverage, whichever period is longer. (d) Notice to Plan Administrator. You or a dependent must notify the Plan Administrator in writing or electronically within 60 days after the later of the date of a qualifying change in status or the date of loss of coverage. (e) Notice by Plan Administrator. Once the Plan Administrator has received notice of a qualifying event, you or your dependents will be notified by the Plan Administrator of a termination of coverage that entitles you or your dependents to elect continuation coverage. Notice to your spouse or domestic partner constitutes notification to any dependent child residing with your spouse or domestic partner. If your spouse or domestic partner has a different address, you and any dependent living with you will be separately notified. In order to protect your family s rights, you should keep the Plan Administrator informed of any changes in the address of family members. (f) Further Information. Contact the Plan Administrator for further information and details regarding continuation coverage. 5. Military Service If you are absent from employment because of military service, you may elect to continue a nd reinstate coverage for you and your dependents in the Plan under the Uniformed Services Employment and Reemployment Rights Act of 1994 ( USERRA ). Contact the HR Service Center for more information. 6. Additional Legal Requirements (a) Medical Child Support Orders. The Plan will comply with medical child support orders, as defined in Section 609(a) of the Employee Retirement Income Security Act of 1974, as amended ( ERISA ). You or your dependents may obtain, without charge, a copy of the procedures governing medical child support order determinations from the Plan Administrator. (b) Medicaid Recipients. The following rules will apply with respect toany eligible employee or immediate family member who is eligible for Medicaid benefits: 6-22 Employee Assistance Program (EAP)

128 (i) Benefit payments under the Plan will be made in accordance with any assignment of rights made by or on behalf of the eligible employee or immediate family member, to the extent that the assignment is required by a state Medicaid program. (ii) In enrolling any individual as an eligible employee or immediate family member, or in determining or making any benefit payments to or on behalf of any individual, the Plan will not take into account the fact that the individual is eligible for or provided medical assistance under a state Medicaid program. (iii) To the extent that a state Medicaid program has made payments that the Plan is legally responsible for, the Plan s benefit payments will be made in accordance with any state law, provided that the state has acquired the rights of the eligible employee or immediate family member with respect to those benefit payments. 7. Claims Procedure (a) Filing of Claim. As described in Section 2, you can receive services under the Plan by calling the EAP directly. If your request for an appointment is denied, or if you are otherwise denied services under the Plan, you have the right to make a written claim for benefits. This section describes the procedures for making written benefit claims and for requesting information, interpretations, or rulings under the Plan. If you have a benefit claim, a request for information under the Plan, or a request for an interpretation or ruling under the Plan, the claim or request must be presented in writing to the Plan Administrator (see Section 10) in care of the Benefits Manager. Special rules apply to urgent care claims, as defined below. Urgent care claims may be made by telephone, facsimile, or other similar method. In addition, a health care professional with knowledge of your medical condition may act as your authorized representative with respect to urgent care claims. An urgent care claim is a claim for medical care where the application of the time periods for deciding non-urgent care claims could seriously jeopardize your life, health, or ability to regain maximum function, or, in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without the claimed care. (b) Initial Review. (i) Time Period for Notice of Decision. If your claim is wholly or partially denied, you will be given a written or electronic notice of the decision on the claim within the time periods described below, depending on the type of claim. (A) Post-Service Claims. If your claim is a post-service claim, as defined below, you will be notified of the decision on the claim within 30 days after receipt of the claim, unless an extension is necessary due to matters beyond the control of the Plan. If there is an extension, you will be notified of the extension, the reason for the extension, and the date by which a decision is expected, before the end of the initial 30-day period. If an extension is required because you failed to submit necessary information, the extension notice will describe the required information and you will have at least 45 days from receipt of that notice to provide the information. The extension will not exceed 15 days from the end of the initial response period (except that, if you are asked to provide additional information, this 15-day extension period will not include the period of time before you respond to the request). A post-service claim is any claim other than a pre-service claim discussed in (B) below. A pre-service claim is any claim for a benefit for which the Plan requires you to obtain authorization before receiving the medical care. (B) Pre-Service Claims. Except as otherwise provided in (C) and (D) below for urgent care claims and concurrent care decisions, if your claim is a pre-service claim, as defined in 6-23 Employee Assistance Program (EAP)

129 (A) above, you will be notified of the decision within 15 days after receipt of the claim unless an extension is necessary due to matters beyond the control of the Plan. If there is an extension, you will be notified of the extension, the reason for the extension, and the date by which a decision is expected, before the end of the initial15- day period. If an extension is required because you failed to submit necessary information, the extension notice will describe the required information and you will have at least 45 days from receipt of that notice to provide the information. The extension will not exceed 15 days from the end of the initial response period (except that, if you are asked to provide additional information, this 15-day extension period will not include the period of time before you respond to the request). If you fail to follow the Plan s procedures for filing a pre-service claim, you will be notified of the failure and the proper procedures within five days after the failure (or 24 hours after the failure, in the case of an urgent care claim). This notification may be oral unless you request written notification. This notification will be required only if the person or organizational unit customarily responsible for handling benefit matters receives a communication by you or your representative that names a specific claimant, a specific medical condition or symptom, and a specific treatment, service, or product for which approval is requested. (C) Claims Involving Urgent Care. Except as otherwise provided in (D) below for concurrent care decisions, you will be notified of the decision on an urgent care claim as soon as possible, taking into account the medical exigencies. The decision will not be given later than 72 hours after receipt of the claim unless you fail to provide necessary information. If additional information is needed, you will be notified within 24 hours after receipt of the claim of the specific information necessary to complete the claim. You will be given at least 48 hours to provide the requested information. If the requested information cannot reasonably be provided within 48 hours, you will be given a reasonable period of time, taking into account the circumstances, to provide the information. If additional information is required, you will be notified of the decision within 48 hours after the earlier of the Plan s receipt of the requested information or the deadline for providing the information. Notice of a denied urgent care claim may be given orally within the time periods described above. If you receive an oral notice, you will also be given a written or electronic notice within three days after you receive the oral notice. (D) Concurrent Care Decisions. If the Plan has approved an ongoing course of treatment to be provided over a period of time or number of treatments, any reduction or termination of the course of treatment (other than by Plan amendment or termination) before the end of the specified period or number of treatments will be treated as a claim denial. You will be notified of such a denial in time to allow you to appeal and obtain a determination on review before the course of treatment is reduced or terminated. If you request that an ongoing course of treatment be extended beyond the previously approved time period or number of treatments, and your request constitutes an urgent care claim, your claim will be decided as soon as possible, taking into account the medical exigencies. If your request was made at least 24 hours before the end of the prescribed period of time or number of treatments, you will be notified of the decision within 24 hours after the Plan received the request Employee Assistance Program (EAP)

130 (ii) Contents of Notice. The notice will indicate the specific reasons for denial, the Plan provisions involved, an explanation of the claims review procedure described below, a description of any additional material or information necessary to complete the claim, and a statement of your right to bring a civil action under ERISA If an internal rule, guideline, protocol, or other similar criterion was relied on in deciding the claim, the notice will either provide a copy of the criterion that was relied on, or it will state that you may obtain a copy of the criterion free of charge on request If the denial was based on a medical necessity, experimental treatment, or similar exclusion, the notice will either explain the scientific or clinical judgment for the decision, or it will state that you may obtain such an explanation free of charge on request If your claim was an urgent care claim, the notice will describe the expedited review process available for such claims. (c) Review of Denied Claim. (i) Request for Review. If your claim is denied in whole or in part, you have the right to request a review of the claim by the Plan Administrator The request, prepared by either you or your representative, must be in writing and must be made by personal delivery or mailing to the Plan Administrator in care of the HR Service Center. Your request for review must be made within 180 days after you are advised of the denial. If the written request is not made within that time period, you waive any right to review. You may also lose the right to sue in state or federal court, as discussed in Section 9. (ii) Review Procedure. The Plan Administrator will conduct a review as a part of which you may present your position. In doing so, you or your representative may review all pertinent documents, if any, supporting the claim and may submit issues and comments in writing. The information you submit will be taken into account in the review process even if it was not considered in deciding the initial claim. You will also be provided, on request and free of charge, reasonable access to, and copies of, all information relevant to your claim. The review will not give any deference to the initial claim decision. It will be conducted by a Plan fiduciary who did not decide the initial claim and who is not a subordinate of the person who decided the initial claim. If the initial claim denial was based in whole or in part on a medical judgment (including determinations with regard to whether a particular treatment is experimental, investigational, or not medically necessary or appropriate), the Plan fiduciary will consult a health care professional with appropriate training and experience. The health care professional must be someone who was not consulted in connection with the initial claim decision, and who is not a subordinate of any health care professional who was consulted on the initial claim. You will be notified of any medical or vocational experts who were consulted in connection with the initial claim decision. If the claim is an urgent care claim, you may request an expedited appeal either orally or in writing. Under the expedited review process, all necessary information, including the decision on review, may be given by telephone, facsimile, or other similar method. (iii) Time Period for Decision on Review. The notice of the decision will be provided within the time periods described below. (A) Post-Service Claims. You will be notified of the decision on review of a post-service claim within 60 days after receipt of the request for review. If the Plan provides for two appeals of a denied claim, you will be notified within 30 days after receipt of the request for review of either appeal. (B) Pre-Service Claims. Except as otherwise provided below for urgent care claims, you will be notified of the decision on review of a pre-service claim within 30 days after 6-25 Employee Assistance Program (EAP)

131 receipt of the request for review. If the Plan provides for two appeals of a denied claim, you will be notified within 15 days after receipt of the request for review of either appeal. (C) Claims Involving Urgent Care. You will be notified of the decision on review of an urgent care claim within 72 hours after receipt of the request for review. (iv) Contents of Review Decision. The decision will be provided to you in writing or by electronic notice. It will include the reasons and the Plan provision(s) on which it is based. The decision will also inform you of your right to request information relevant to the claim and to bring a civil action under ERISA. If an internal rule, guideline, protocol, or other similar criterion was relied on in deciding the claim, the notice will either provide the criterion that was relied on, or it will state that you may obtain a copy of the criterion free of charge on request. If the denial was based on a medical necessity, experimental treatment, or similar exclusion, the notice will either explain the scientific or clinical judgment for the decision, or it will inform you that such an explanation will be provided free of charge on request. The decision will include a statement regarding voluntary alternative dispute resolution options. (v) Effect of Review. The decision is final and binding upon you, the Plan Administrator, and all other persons involved. (d) Subsequent Review. Any further review, judicial or otherwise, will be based on the record considered by the Plan Administrator and is limited to whether the Plan Administrator acted arbitrarily or capriciously in the exercise of its discretion. 8. Statement Of ERISA Rights As a participant in the Plan, you are entitled to certain rights and protections under ERISA. ERISA provides that all Plan participants are entitled to: (a) Examine, without charge, at your Human Resources Department or the Plan Administrator s office, all Plan documents, including a copy of the latest annual report (Form 5500 Series) filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration. (b) Obtain copies of all Plan documents and other Plan information (including copies of the latest annual report (Form 5500 Series) and updated summary plan description) upon written request to the Plan Administrator. The Plan Administrator may make a reasonable charge for the copies. (c) Continue health care coverage for yourself, spouse, or dependents if there is a loss of coverage under the Plan as a result of a qualifying event. Review this summary plan description and the documents governing the Plan on the rules governing your COBRA continuation coverage rights. In addition to creating rights for Plan participants, ERISA imposes duties upon the persons who are responsible for the operation of the Plan. These persons (called fiduciaries ) have a duty to operate the Plan prudently and must act solely in the interest of you and other Plan participants and beneficiaries. No one, including your entity or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit from the Plan or exercising your rights under ERISA. If your claim for a welfare benefit is denied or ignored, in whole or in part, youhave a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules. Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request copies of Plan documents or the latest annual report from the Plan and do not receive them within 30 days, you may file suit in a federal 6-26 Employee Assistance Program (EAP)

132 court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the Plan Administrator. If your claim for a welfare benefit is denied or is ignored in whole or in part, you may file suit in a state or federal court. If your claim for benefits is denied, however, you must appeal the decision and follow the claims procedure described in Section 7 before you may file suit. If you disagree with the Plan s decision or lack thereof concerning the qualified status of a medical child support order, you may file suit in federal court. If it should happen that Plan fiduciaries misuse the Plan s money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a federal court. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the party you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous. If you have any questions about the Plan, you should contact the Plan Administrator. If you have any questions about this statement or your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries,Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration. Plan Sponsor/Plan Administrator: Senior Vice President, Chief Human Resources Officer, Providence Strategic and Management Services (or his/her designee) Providence Health & Services - Washington 1801 Lind Avenue SW, #9016 Renton WA (425) EIN # Plan Number The Plan Number is PN 501. Plan Year The Plan Year is January 1 through December 31. Plan Funding and Sources of Financing The Company pays the entire cost of the EAP from its general assets. There is no specific trust fund from which benefits or services under The Plan are paid. Active employees do not pay any contribution. However, if you are referred for treatment outside the EAP, you, together with your health care benefit plan, are responsible for paying for such treatment. EAP Administrator The EAP administrator is Providence Health & Services - Oregon dba Providence EAP 4900 NE Glisan St. Portland, OR Agent for Service of Legal Process You can reach the Agent for Service of Legal Process at: Business Filings Incorporated 1801 West Bay Drive NW, Suite 206 Olympia, Washington ` This document is intended as a summary of the EAP benefits plan. Differences between this summary and the applicable Plan Document/agreement are not intended. If, however, any differences are found to exist, the relevant provisions of the agreement and not the summary will govern. Please note: the Oregon EAP Plan Document was amended and restated in This summary was modified to update for references to the HR Service Center and the Plan Administration information Employee Assistance Program (EAP)

133 VII. Basic Employee Life and AD&D Insurance If you are a benefits-eligible employee, you are automatically provided with life and accidental death & dismemberment (AD&D) insurance at no cost to you. To find out the level of your Basic Life Insurance and AD&D coverage, log on to ProvConnect Employee Self-Service. Under My Benefits, click on Life & Disability to review your Basic Life Insurance and Basic AD&D Coverage. Alternatively, you may contact the HR Service Center for your coverage amounts. Note: If the amount of your Basic Life Insurance exceeds $50,000, you will be subject to imputed income on amounts above $50,000 in accordance with Internal Revenue Service regulations. Life Benefit Reductions: At age 70, benefits are reduced to 65% of the original coverage amount. At age 75, benefits are reduced to 45% of the original coverage amount, and to 30% at age 80. The age reduction will go into effect January 1 of the year in which you will reach the listed ages. How the Plan Works Designation of Beneficiary When you enroll for coverage through ProvConnect you will see a space for naming a beneficiary(ies) for your Basic Employee Life and AD&D Insurance coverage. You may change your beneficiary(ies) at any time by updating ProvConnect. The beneficiary may be one person or several people or your estate. If you are married, a spousal consent form may be required as part of your beneficiary designation. Before deciding on beneficiaries, you may wish to contact your attorney for advice. If you do not name a beneficiary, any Basic Employee Life and AD&D benefit payable would be made in accordance with a line of succession specified in the insurance contract. You may contact the HR Service Center for an insurance certificate containing additional details. The insurance contract governs the terms of coverage. 7-1 Basic Employee Life and AD&D Insurance Benefits Your Basic Employee Life and AD&D Insurance death benefit will be payable to your designated beneficiary upon satisfactory proof that your death occurred while you were insured. (Payment for AD&D benefits if you are injured are payable to you.) Your beneficiary will receive details about payment options when you die. If death or dismemberment due to a covered accident (see page 10-1 for exclusions) occurs within 365 days of an accident to an insured individual, the Plan pays benefits as follows: Loss Life Loss of speech and hearing Brain damage Loss of any combination of hand, foot, or sight of one eye Loss of hand Loss of foot Loss of sight in one eye Loss of an arm Loss of a leg Paralysis of both upper and lower limbs (quadriplegia) Paralaysis of both lower limbs (paraplegia) Paralysis of both upper & lower limbs on one side (hemiplegia) Paralysis of one arm or leg Loss of speech or loss of hearing Loss of thumb & index finger of same hand Coma Benefit Payable 100% of Coverage Amount 100% of Coverage Amount 100% of Coverage Amount 100% of Coverage Amount 50% of Coverage Amount 75% of Coverage Amount 100% of Coverage Amount 50% of Coverage Amount 50% of Coverage Amount 25% of Coverage Amount 50% of Coverage Amount 25% of Coverage Amount 1% of Coverage Amount per month to a maximum of 60 months No more than the elected amount will be paid for all losses sustained by an insured individual while the group policy is in effect.

134 Coverage If Totally Disabled If you become totally and permanently disabled while insured before age 60, the amount of your Basic Employee Life Insurance in force at that time will be continued by your employer until age 65. When you turn 65, you may convert your coverage. Filing Claims To file a claim, your beneficiary should contact the HR Service Center. Termination of Insurance Your Insurance will cease at the end of the month in which you are no longer benefits-eligible, terminate employment or are no longer a member of eligible group, serve more than 30 days full-time active duty in any armed forces, the premium is not paid when due, or the group policy is terminated. Conversion If your group coverage stops for any reason other than non-payment of the premiums when due, you have 31 days to convert your group coverage to an individual policy. This conversion benefit allows you to convert coverage to an individual policy (any permanent life insurance policy that the insurance company is then offering) up to the current certificate amount without having to give evidence of insurability. The permanent policy you receive will not include waiver of premium benefits or other supplementary benefits available under the group policy. If the Master Group policy or the employer s participation terminates, only a limited conversion benefit will be available. 7-2 Supplemental Employee Life Insurance

135 Glossary of Terms From Life and Accidental Death & Dismember Chapters Accident An unforeseen and unavoidable event resulting in an injury which is not due to any fault of the covered person. Loss For the Accidental Death & Dismemberment coverage, loss means: with regard to hand or foot, complete severance through or above the wrist or ankle joint; loss of an eye means total and irrecoverable loss of sight; Adult Benefit Recipient See page 1-1 Beneficiary The person(s) or other entity you designate to receive your life insurance, accidental death & dismemberment insurance, and Business Travel Accident insurance benefits if you die. loss of speech means complete inability to communicate audibly in any degree; loss of hearing which cannot be corrected by any hearing aid or device; loss of thumb and index finger means severance of each through or above the joint closest to the wrist. Dependent See page 1-1 and page 9-1 Hemiplegia Total or partial paralysis of one side of the body. Imputed Income The assessed value of your Basic Life Insurance which is subject to tax, based on your age and amount of coverage, is called imputed income. Your employer is required to calculate your imputed income for Basic employee coverage over $50,000 using an IRS table. (The value of Supplemental Life Insurance price tags is not considered imputed income because premiums are paid on an after-tax basis.) Taxable amounts will be shown annually on your W-2 statement. Limb An arm or leg. Paralysis Paralysis means loss of use, without severance of a limb. This loss must be determined by a physician to be complete and not reversible. Paraplegia Paralysis of the lower half of the body. Plan Year The 12-month period beginning January 1 and ending December 31. Quadriplegia Paralysis of all four limbs. Severance Severance means complete separation and dismemberment of the limb from the body. 7-3 Supplemental Employee Life Insurance

136 VIII. Supplemental Employee Life Insurance Your Supplemental Employee Life Options The Plan offers Supplemental Employee Life Insurance in amounts from $10,000 to $1,000,000, in $10,000 increments. The amount you choose cannot exceed six times your pay. Or, you may choose to waive coverage. Benefit Reductions: At age 70, benefits are reduced to 65% of the original coverage amount. At age 75, benefits are reduced to 45% of the original coverage amount, and to 30% at age 80. The age reduction will go into effect January 1 of the year in which you will reach the listed ages. Actively at Work Provision If you are absent from work due to sickness or injury on the date of eligibility or the effective date of coverage, then your eligibility date or the date on which your coverage would otherwise become effective, will be deferred until the first day of the policy month following the date you return to active full-time work. This will also apply to any increase in your coverage. This is the actively at work provision. Dual Coverage If you and your spouse/domestic partner are both employed by Providence Health & Services, only employee coverage is available to each person. Should an employee recognize an error in election, they should contact the HR Service Center immediately to cancel the election. This change can be processed mid-year, but no refund to previous premium paid may be returned. Note: Employee Supplement Life Insurance is available as part of your benefits as an employee of Providence Health & Services. However, as the premiums are collected on an after-tax basis, it is not treated as part of a Section 125 plan under Internal Revenue Service code. 8-1 Supplemental Employee Life Insurance * 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. Qualified 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. Choosing Supplemental Employee Life Insurance Group Life Insurance can be an important resource for your family or estate in the event of your death. With the Providence Health and Welfare Benefit Plan, you have the opportunity to purchase life insurance underwritten by Metropolitan Life Insurance Company (MetLife). You may contact the HR Service Center for an insurance certificate containing additional details. The insurance contract governs the terms of coverage. How the Plan Works In your first enrollment, you may choose any coverage level up to: If you earn $25,000 or less per year the lesser of six times pay or $150,000 of coverage. Options above $100,000 require evidence of insurability (statement of health) If you earn more than $25,000 per year any coverage level up to and including $1,000,000, subject to the six times pay limit. Options above $500,000 or four times pay, whichever is less, will always require evidence of insurability (statement of health). Each fall thereafter you can choose your Supplemental Employee Life Insurance option to be effective for the coming calendar year. You may elect a one- level ($10,000) or two-level ($20,000) increase during the annual Open Enrollment period without having to submit evidence of your insurability.

137 However, you will be required to provide evidence of insurability each time you elect more than a two-level ($20,000) increase in your insurance amount or if your selected option amount is greater than $500,000 or four times pay, whichever is less. You will also be required to provide evidence of insurability (statement of health). If you waive coverage one year and wish to enroll in a subsequent year for more than $20,000 in coverage. If you are disabled and away from work, you cannot make any changes in your coverage levels for you or your dependents until the annual Open Enrollment after you return to work on a regular basis. Designation of Beneficiary Employee Self-Service on ProvConnect provides space for naming a bene ficiary(ies) for your Supplemental Employee Life Insurance coverage. You may change your beneficiary(ies) at any time on-line through Employee Self-Service through ProvConnect. The beneficiary may be one person several people or your estate. If you are married, a spousal consent form may be required as part of your beneficiary designation. Before deciding on beneficiaries, you may wish to contact your attorney for advice. If you do not name a beneficiary, any Supplemental Employee Life benefit payable would be made in accordance with a line of succession specified in the insurance contract. Benefits Your Supplemental Employee Life Insurance benefit will be payable to your designated beneficiary upon satisfactory proof that your death occurred while you were insured. Payment will be made in one sum, unless you have previously elected an optional method of settlement by agreement in writing with the insurance carrier. If you do not select an optional method of settlement before your death, your beneficiary may do so before the benefit is paid. Your beneficiary will receive details about these options when you die. Coverage If Totally Disabled If you become totally and permanently disabled with at least 12 continuous months of coverage, before age 60, and are approved by the insurance company, the amount of your Supplemental Employee Life Insurance in force at the time of your disability can be continued without cost to you until age 70. There is a 9-month waiting period from the date of disability before the approved waiver takes effect. When your coverage terminates, you may convert your coverage (see below). You are responsible for paying the premium during the 9-month waiting period. A request for a waiver of premium is to be filed at the same time as you apply for long term disability to be considered by the insurance company. Requests for waivers filed after 12 months from when your service ends will not be accepted. Filing Claims To file a claim, your beneficiary should contact the HR Service Center. Leave of Absence Contact the HR Service Center for information about continuing your Supplemental Employee Life Insurance while on an approved leave of absence. Termination of Coverage Your Supplemental Employee Life Insurance coverage will end at the end of the month in which you are no longer in an eligible group, the premium is not paid, or the group policy is terminated. Portability and Conversion of Supplemental Employee Life Insurance Portability Your Supplemental Group Life Insurance is portable at group rates until age 70 if you: terminate, or become ineligible for benefits. 8-2 Supplemental Employee Life Insurance

138 If you are age 70 or older, portability is still available but the amount of coverage is subject to the age reductions. You must apply for portability and for conversion within 31 days after coverage ends. Your policy under the portability option will be an individual certificate issued under a new group policy and will differ in some ways from your policy with Providence Health & Services. You may continue coverage at your current level or reduce it as specified in the policy without taking the medical examination that would normally be required for new insurance. Application forms are available from the HR Service Center. You may also be contacted by a representative of MetLife regarding portability and conversion of your group life coverage. For those employees and dependents who are covered under the portability option, there is no impact if the Master Contract is terminated. However, if the Master Contract is terminated, active employees and dependents who are covered under the supplemental employee and dependent life insurance coverages are not eligible for portability. The conversion option is still available. Conversion If your or your dependents group coverage stops for any reason other than non-payment of the premiums when due, you have 31 days to convert your group coverage to an individual policy. This conversion benefit allows you to convert coverage to an individual policy (any permanent life insurance policy that the insurance company is then offering) up to the current certificate amount without having to give evidence of insurability. The permanent policy you receive will not include waiver of premium benefits or other supplementary benefits available under the group policy. If the Master Group policy or the employer s participation terminates, only a limited conversion benefit will be available. Accelerated Death Benefit If you are diagnosed by two unaffiliated physicians as terminally ill (with a life expectancy of 24 months or less), you may apply for an accelerated benefit payment of up to 50% of the coverage amount in force or $500,000, whichever is less. (If you are earning less than $25,000 per year, the maximum is $75,000.) Forms are available from the HR Service Center. This benefit is payable only once in your lifetime, and will reduce the life insurance death benefit. The terminal illness benefit may be taxable. As with all tax matters, you should consult with a personal tax advisor to assess the impact of this benefit. 8-3 Supplemental Employee Life Insurance

139 IX. Dependent Life Insurance Your Dependent Life Insurance Options You may choose among the following Dependent Life options: Spouse/Adult Benefit Recipient Domestic Partner* Coverage: The Plan offers Spouse/Adult Benefit Recipient* Domestic Partner Life Insurance in amounts from $10,000 to $500,000, in $10,000 increments. You may elect coverage equal to 100% of the total amount of your life insurance coverage (Basic plus Supplemental) or $500,000, whichever is less. Or, you may choose to waive coverage. Evidence of Insurability is required for any amount elected over $50,000. * 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. Qualified 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. Benefit Reductions: At age 70, benefits are reduced to 65% of the original coverage amount. At age 75, benefits are reduced to 45% of the original coverage amount, and to 30% at age 80. The age reduction will go into effect January 1 of the year in which your spouse/domestic partner will reach the listed ages. NOTE: For purposes of calculating premium and for benefit reduction, the spouse/domestic partner s age is based on the age achieved during the plan year. Note: Dependent Life Insurance is available as part of your benefits as an employee of Providence Health & Services. However, it is not treated as part of a Section 125 plan under Internal Revenue Service code. Qualified Domestic Partner For dependent life insurance and Accidental Death & Dismemberment, your Adult Benefit Recipient domestic partner* means one of two people of the same or opposite sex, who with the employee represent themselves publicly as each other s domestic partner and have have registered as domestic partners or members of a civil union with a government agency or office where such registration is available, or submitted a declaration to Providence establishing that the employee and partner: are each 18 years of age or older; and have shared the same residence for at least 12 months prior to the date they enroll for insurance for the Domestic Partner under the Group Policy*; and are not married; and have not had another domestic partner within 12 months prior to the date they enrolled for insurance for the Domestic Partner under the Group Policy; and are not related by blood in a manner that would bar their marriage in the jurisdiction in which they reside; and have an exclusive mutual commitment to share the responsibility for each other s welfare; and financial obligations** which commitment existed for at least 12 months prior to the date they enroll for insurance for the Domestic Partner under the Group Policy, and such commitment is expected to last indefinitely. * they are a member of your household, i.e. a person who is part of the 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 both are committed to a relationship of 9-1 Dependent Life Insurance

140 mutual caring. This does not include a renter, roommate or other person living in the home on a casual basis. ** 2 or more of the following exist as evidence of joint responsibility for basic financial obligations: a joint mortgage or lease; designation of the Domestic Partner as beneficiary for life insurance or retirement benefits; joint wills or designation of the Domestic Partner as executor and/or primary beneficiary; designation of the Domestic Partner as durable power of attorney or health care proxy; ownership of a joint bank account, joint credit cards or other evidence of joint financial responsibility; or other evidence of economic interdependence. You may enroll your domestic partner for dependent life insurance and Accidental Death & Dismemberment insurance even if he/she has access to other group medical coverage. Note: the children of qualifying domestic partners are also eligible for dependent life and Accidental Death & Dismemberment. Child(ren) Coverage: See page 1-1 for dependent eligibility for life insurance. $10,000 per child 6 months and older; $500 per child less than 6 months of age* No Coverage *Children must be at least 15 days old for coverage to be in effect. You may contact the HR Service Center for an insurance certificate containing additional details. The insurance contract governs the terms of coverage. Choosing Dependent Life Coverage The Dependent Life Insurance Plan, underwritten by the Metropolitan Life Insurance Company (MetLife), is designed to help you with the unexpected expenses you would face if another member of your family should die. Coverage of $10,000 for your children is available without the purchase of Supplemental Employee Life Insurance and without evidence of insurability. Dual Coverage If you and your spouse/domestic partner are both employed by Providence Health & Services, only employee coverage is available to each person. Children may only be covered by one employee. Should an employee recognize an error in election, they should contact the HR Service Center immediately to cancel the election. This change can be processed mid-year, but no refund to previous premium paid may be returned. How the Plan Works Each fall, you elect your Dependent Life benefit options to be effective for the next calendar year. During your first enrollment as newly benefits eligible employee, you may select any amount of spouse/adult Benefit Recipient domestic partner coverage up to $50,000 without evidence of insurability (statement of health). After the first year, spouse/adult Benefit Recipient domestic partner coverage amounts may be increased by one level per year for coverage levels up to and including $50,000. No evidence of insurability is required for this increase. Evidence of insurability is required for any coverage amount above $50,000 or for any increase of more than one benefit level. Your contributions for this plan are made on an after-tax basis. Late entrants: If you could have covered your spouse/domestic partner when you were first eligible to do so and decided not to enroll him or her, you must provide evidence of insurability (statement of health) for your spouse/domestic partner if you apply for any amounts of coverage above $10, Dependent Life Insurance

141 Designation of a Beneficiary The Dependent Life Insurance benefit will be paid to you if your spouse/domestic partner or children die, unless you tell us otherwise in writing. If you are not living at the time of their death, the benefit will be paid in accordance with contract provisions. Benefits Dependent Life Insurance benefits will be payable upon satisfactory proof of your dependent s death while he or she is insured. Payment will be made in one sum. Filing Claims To file a claim, contact the HR Service Center. Leave of Absence Contact the HR Service Center for information about continuing your Dependent Life coverage while on a leave of absence. Termination of Coverage Dependent Life coverage will end on the last day of the month in which you terminate employment, are no longer a member of an eligible group or become disabled or at the end of the month in which you stop making required contributions for coverage or the date the group policy is terminated, whichever occurs first. Portability and Conversion of Dependent Life Coverage Portability When you terminate, are no longer a member of an eligible group, or become disabled, spouse/ Adult Benefit Recipient domestic partner coverage at group rates is portable, if you are under age 70. If your spouse/domestic partner is age 70 or older on the date you terminate, portability is still available but the amount of coverage is subject to the age reductions. Child coverage is also portable at $10,000. Applications for portability, conversion, and child continuation must take place within 31 days after the date coverage ends. Your policy under the portability option will be issued under a new group policy and will differ in some ways from your policy with Providence Health & Services. You may continue coverage at your current level or reduce it as specified in the policy without taking the medical examination that would normally be required for new insurance. Application forms are available from the HR Service Center. You may also be contacted by a representative of MetLife regarding portability and conversion of your group life coverage. For those employees and dependents who have chosen the portability option, there is no impact if the Master Contract is terminated. However, if the Master Contract is terminated, active employees and dependents who are covered under the supplemental employee and dependent life insurance coverages are not eligible for portability. The conversion option is still available. Conversion If your or your dependents group coverage stops for any reason other than non-payment of the premiums, you have 31 days to convert your group coverage to an individual policy. You may convert coverage to an individual policy (any permanent life insurance policy that the insurance company is then offering) up to the current certificate amount without having to give evidence of insurability. The permanent policy you receive will not include waiver of premium benefits or other supplementary benefits you may have enjoyed under the group policy. If the Master Group policy or the employer s participation terminates, only a limited conversion benefit will be available. 9-3 Dependent Life Insurance

142 Accelerated Death Benefit If your spouse/domestic partner is diagnosed by two unaffiliated physicians as terminally ill (with a life expectancy of 24 months or less) you may apply for an accelerated benefits payment of up to 50% of the coverage amount in force or $250,000, whichever is less. Benefits are payable to the insured (i.e., your spouse/domestic partner). This benefit is payable only once in the insured s lifetime, and will reduce the life insurance death benefit. This benefit is not available for child coverage. The terminal illness benefit may be taxable. As with all tax matters, you should consult with a personal tax advisor to assess the impact of this benefit. 9-4 Dependent Life Insurance

143 X. Supplemental Accidental Death and Dismemberment Your Supplemental AD&D Options The Providence Health and Welfare Benefit Plan offers Supplemental Employee Accidental Death & Dismemberment (AD&D) Insurance in amounts from $10,000 to $1,000,000, in $10,000 increments. The amount you choose cannot exceed ten times your pay. Designation of Beneficiary You may name a beneficiary by using Employee Self-Service (ESS) on ProvConnect. If you do not name a beneficiary, any death benefit payable would be paid in accordance with the line of succession specified in the insurance contract. Benefits for loss other than life will be paid to you. Filing Claims To file a claim, contact the HR Service Center. Benefits If death or dismemberment due to a covered accident occurs within 365 days of an accident to an insured individual, the Plan pays benefits as follows: Loss Life Loss of speech and hearing Brain damage Loss of any combination of hand, foot, or sight of one eye Loss of hand Loss of foot Loss of sight in one eye Loss of an arm Loss of a leg Paralysis of both upper and lower limbs (quadriplegia) Paralaysis of both lower limbs (paraplegia) Paralysis of both upper & lower limbs on one side (hemiplegia) Paralysis of one arm or leg Loss of speech or loss of hearing Loss of thumb & index finger of same hand Coma Benefit Payable 100% of Coverage Amount 100% of Coverage Amount 100% of Coverage Amount 100% of Coverage Amount 50% of Coverage Amount 75% of Coverage Amount 100% of Coverage Amount 50% of Coverage Amount 50% of Coverage Amount 25% of Coverage Amount 50% of Coverage Amount 25% of Coverage Amount 1% of Coverage Amount per month to a maximum of 60 months No more than the elected amount will be paid for all losses sustained by an insured individual while the group policy is in effect. Exclusions AD&D benefits will not be paid for loss directly caused by any of the following: physical or mental illness or infirmity, or the diagnosis or treatment of such illness or infirmity; infection, other than infection occurring in an external accidental wound; suicide or attempted suicide intentionally self-inflicted injury; service in the armed forces of any country or international authority, except the United States National Guard; 10-1 Supplemental Accidental Death and Dismemberment

144 any incident related to: travel in an aircraft as a pilot, crew member, flight student or while acting in any capacity other than as a passenger; travel in an aircraft for the purpose of parachuting or otherwise exiting from such aircraft while it is in flight; parachuting or otherwise exiting from an aircraft while such aircraft is in flight, except for self-preservation; Termination of Insurance Your Supplemental Accidental Death and Dismemberment Insurance will cease at the end of the month in which you are no longer benefitseligible, terminate employment or are no longer a member of eligible of class, do not pay your premium when due, serve more than 30 days fulltime active duty in any armed forces or the group policy is terminated. This coverage is portable. travel in an aircraft or device used; for testing or experimental purposes; by or for any military authority; or for travel or designed for travel beyond the earth s atmosphere; committing or attempting to commit a felony; the voluntary intake or use by any means of: any drug, medication or sedative, unless it is: taken or used as prescribed by a Physician, or an over the counter drug, medication or sedative taken as directed; alcohol in combination with any drug, medication, or sedative; or poison, gas, or fumes; or war, whether declared or undeclared; or act of war, insurrection, rebellion or riot. Exclusion for Intoxication AD&D benefits will not be paid for any loss if the injured party is legally intoxicated at the time of the incident and is the operator of a vehicle or other device involved in the incident. Leave of Absence Contact the HR Service Center for information regarding continuation of your Supplemental AD&D coverage while on an approved leave of absence Supplemental Accidental Death and Dismemberment

145 XI. Dependent Accidental Death and Dismemberment Your Dependent AD&D Insurance Options You may choose among the following Dependent Accidental Death & Dismemberment (AD&D) insurance options: Spouse/Adult Benefit Recipient Domestic Partner* Coverage: The Plan offers Spouse/Adult Benefit Recipient Domestic Partner AD&D Insurance in amounts from $10,000 to $500,000, in $10,000 increments. Or, you may choose to waive coverage. 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. Qualified 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. Qualified Domestic Partner Please see page 9-1 for a definition of a qualified ABR domestic partner under the terms of the dependent life insurance and Accidental Death & Dismemberment insurance. You may enroll your qualifying domestic partner for dependent life and Accidental Death & Dismemberment insurance even if he/she has access to other group medical coverage. Note: the children of qualifying domestic partners are also eligible for dependent life and Accidental Death & Dismemberment. Child(ren) Coverage: $10,000 per child 6 months and older; $500 per child less than 6 months of age; or waive coverage. *Children must be at least 15 days old for coverage to be in effect. (See page 1-1 for who is eligible for child(ren) coverage.) Dual Coverage If you and your spouse/domestic partner are both employed by Providence Health & Services, only employee coverage is available to each person. Children may only be covered by one employee. Designation of Beneficiary Benefits payable from the Dependent AD&D insurance will be paid to you unless you tell us otherwise. If you are not living at the time of their death, the benefit payable would be paid in accordance with the line of succession specified in the insurance contract. You may contact the HR Service Center for an insurance certificate containing additional details. The insurance contract governs the terms of coverage. Benefits Life Loss Loss of speech and hearing Brain damage Loss of any combination of hand, foot, or sight of one eye Loss of hand Loss of foot Loss of sight in one eye Loss of an arm Loss of a leg Paralysis of both upper and lower limbs (quadriplegia) Paralaysis of both lower limbs (paraplegia) Paralysis of both upper & lower limbs on one side (hemiplegia) Paralysis of one arm or leg Loss of speech or loss of hearing Loss of thumb & index finger of same hand Coma Benefit Payable 100% of Coverage Amount 100% of Coverage Amount 100% of Coverage Amount 100% of Coverage Amount 50% of Coverage Amount 75% of Coverage Amount 100% of Coverage Amount 50% of Coverage Amount 50% of Coverage Amount 25% of Coverage Amount 50% of Coverage Amount 25% of Coverage Amount 1% of Coverage Amount per month to a maximum of 60 months 11-1 Dependent Accidental Death and Dismemberment

146 If death or dismemberment due to a covered accident occurs within 365 days of an accident to an insured individual, the Plan pays benefits as listed on page No more than the elected amount will be paid for all losses sustained by an insured individual while the group policy is in effect. Filing Claims To file a claim, contact the HR Service Center. Exclusions AD&D benefits will not be paid for loss directly caused by any of the following: physical or mental illness or infirmity, or the diagnosis or treatment of such illness or infirmity; infection, other than infection occurring in an external accidental wound; the voluntary intake or use by any means of: any drug, medication or sedative, unless it is: taken or used as prescribed by a Physician, or an over the counter drug, medication or sedative taken as directed; alcohol in combination with any drug, medication, or sedative; or poison, gas, or fumes; or war, whether declared or undeclared; or act of war, insurrection, rebellion or riot. Exclusion for Intoxication AD&D benefits will not be paid for any loss if the injured party is intoxicated at the time of the incident and is the operator of a vehicle or other device involved in the incident. suicide or attempted suicide intentionally self-inflicted injury; service in the armed forces of any country or international authority, except the United States National Guard; any incident related to: travel in an aircraft as a pilot, crew member, flight student or while acting in any capacity other than as a passenger; travel in an aircraft for the purpose of parachuting or otherwise exiting from such aircraft while it is in flight; parachuting or otherwise exiting from an aircraft while such aircraft is in flight, except for self-preservation; travel in an aircraft or device used; Leave of Absence Contact the HR Service Center for information regarding continuation of your Dependent AD&D coverage while on an approved leave of absence. Termination of Insurance Your Dependent Accidental Death and Dismemberment Insurance will cease at the end of the month in which you are no longer benefitseligible, terminate employment or are no longer a member of eligible of class, do not pay your premium when due, serve more than 30 days fulltime active duty in any armed forces or the group policy is terminated. This coverage is portable. for testing or experimental purposes; by or for any military authority; or for travel or designed for travel beyond the earth s atmosphere; committing or attempting to commit a felony; 11-2 Dependent Accidental Death and Dismemberment

147 XII. Business Travel Accident Eligibility If you are eligible to participate in the Providence Health and Welfare Benefit Plan, or are an active employee regularly scheduled to work at least 16 hours per week, you are eligible for Business Travel Accident coverage. Coverage takes effect on the January 1 after an Open Enrollment (or the first of the month specified by the HR Service Center if newly eligible). Coverage is also available on your spouse or other invited guest of Providence Health & Services who is traveling with you for business reasons. In the remainder of this section, references to you and your includes you as the employee and the person traveling with you for business reasons. Description of Coverage You may contact the Providence Strategic and Management Services Risk Management department for an insurance certificate containing additional details. The insurance contract governs the terms of coverage. This plan provides coverage for any accident that occurs while you are traveling on assignment by or at the direction of Providence Health & Services. The trip is considered to begin when you leave your residence or place of regular employment for the purpose of going on the trip (whichever occurs last). The covered travel ends when you return from the trip to your residence or place of regular employment (whichever occurs first). The covered travel does not include any period of time during which you are on vacation, traveling to and from your place of regular employment, or on an authorized leave of absence. Loss of Life Benefit Amount Eligible employees traveling on Providence business are insured for a loss of life benefit amount of $250,000. Spouses of employees and invited Note: The Business Travel benefit is part of your benefits as an employee of Providence Health & Services. However, it is not treated as part of a Section 125 plan under Internal Revenue Service code, nor as part of the ERISA plan.. guests when traveling with an eligible employee for business reasons are covered for a loss of life benefit amount of $50,000. Total Limit of Liability: The policy will not pay more than $5,000,000 per accident. Schedule of Benefits If you have an accident while traveling on Company business that results, within one year, in any of the following losses, the insurance company will pay the sum indicated below. If the accident results in more than one of these losses, only the loss with the largest sum will be payable. Percent of Loss of Life Loss Benefit Amount Life 100% Speech and Hearing 100% Speech and one of: Hand, Foot or 100% Sight of One Eye Hearing and one of: Hand, Foot or 100% Sight of One Eye Both Hands, Both Feet or Sight of 100% Both Eyes or a Combination of a Hand, a Foot or Sight of One Eye One Hand or One Foot or Sight of 50% One Eye Speech or Hearing 50% Thumb and Index Finger of Same 25% Hand Loss means: for a foot, complete severance through or above an ankle joint; for a hand, complete severance through or above the knuckle joints of at least four fingers on the same hand or at least three fingers and the thumb on the same hand; for sight, permanent loss of sight to no better than 20/200 using corrective aid or device; for hearing, permanent and irrecoverable loss of the entire ability to hear; 12-1 Business Travel Accident

148 for speech, permanent and irrecoverable loss of the entire ability to speak without the aid of mechanical devices for thumb and index finger, complete severance through or above the knuckle joints of the thumb and index finger of the same hand. Psychological Therapy If as a result of a covered accident psychological therapy is needed, the Plan will pay up to 10% of the Loss of Life Benefit Amount within two years of the covered accident. Such therapy must: Percent of Loss of Life Loss of Use Benefit Amount One Hand or One Foot 25% Both Hands or Both Feet or a 50% Combination of a Hand and a Foot One Arm or One Leg 50% Both Arms or Both Legs or a 75% Combination of an Arm and a Leg Both Arms and Both Legs 100% Loss of Use (permanent and total inability of the body part to function) for hand, loss of use at or above the knuckle joints of at least four fingers on the same hand or at least three fingers and the thumb on the same hand for foot, loss of use at or above the ankle joint for arm, loss of use at or above the elbow joint for leg, loss of use at or above the knee joint Only one amount, the largest to which you are entitled, is paid for all losses resulting from one accident. Exposure and Disappearance If as the result of a covered accident, you are unavoidably exposed to the elements which causes a loss for which a benefit is otherwise payable, the loss will be covered by the Plan. If your body has not been found within one year of disappearance, break down, stranding, sinking or wrecking of the vehicle in which you were an occupant, then you will be considered to have suffered accidental death within the terms of the Plan. be provided under the care, supervision, or order of a physician; be essential to help cope with the loss; meet generally accepted standards of medical practice and not exceed the usual level of cost for similar counseling sessions in your geographic location. Rehabilitation Benefit If you need to participate in a formal rehabilitation program in order to return to work after suffering injuries in a covered accident, the Plan will reimburse you for up to a maximum of 10% of the Loss of Life Benefit Amount. The expenses must not exceed the usual charges for similar treatment, supplies, or services in your area and they must be incurred within two years of the accident. Seatbelt Benefit If you die as the result of injuries sustained in a covered accident while driving or riding in a private passenger car equipped with seatbelts, and you were wearing a properly fastened original, factoryinstalled seatbelt the amount payable will be the lesser of $50,000; or 10% of the Loss of Life Benefit Amount. Exclusions Covered travel does not include any period of time: while you are working at your regular place of employment; during the course of everyday travel to and from work; or during an authorized leave of absence or vacation. This Plan does not cover a loss resulting from the following events: suicide or intentionally self-inflicted injury; 12-2 Business Travel Accident

149 traveling in an aircraft, leased or operated by you or Providence Health & Services; flying as a pilot or crew member of any aircraft except when temporarily performing in a life threatening emergency; caused by or resulting from emotional trauma, mental or physical illness, disease, pregnancy, childbirth or miscarriage, or viral infection or bodily malfunctions; bacterial infections unless caused by a covered accident or from accidental consumption of a substance contaminated by bacteria; or any act of war, declared or undeclared, except to the extent that it is provided for under the War Risk endorsement. Filing Claims To file a claim, your or your beneficiary should contact the Providence Strategic and Management Services Risk Management department for information on the claims process. Termination of Coverage All coverage under this Plan terminates when you leave the employment of the Company, the date the policy terminates, or the date you are no longer in an eligible class, whichever occurs first Business Travel Accident

150 Emergency Assistance Program Providence Health & Services has arranged for emergency assistance 24 hours a day, seven days a week if you are traveling on company business. Contact Access Services Travel within the United States and Internationally MEDEX Within US, Canada, Puerto Rico or US Virgin Islands: Within the United Kingdom, From anywhere else call collect to: Baltimore, MD United Kingdom hours a day, seven days a week Includes: special assistance in replacing lost or stolen travel documents, including passports emergency funds transfer special assistance in locating the nearest, most appropriate medical care verification of insurance coverages, facilitating entry and admissions into hospitals and other medical care providers assistance in establishing contact with family, personal physician and employer as appropriate special assistance in the coordination of direct claims payment management, arrangement and coordination of emergency medical transportation and evacuation as necessary translation services and referrals to local interpreters as necessary knowledgeable legal referral assistance courtesy assistance in securing incidental aid and other travel-related services coordination of securing bail bonds and other legal instruments. Medical Evacuation and Repatriation If during the course of your covered travel, you become ill or injured resulting in a necessary medical evacuation and/or repatriation, the plan may pay up to $250,000 in benefits. The medical evacuation and repatriation must be ordered by a physician who certifies the transportation and medical treatment are necessary and appropriate, and approved by the Assistance Services Administrator. Medical Evacuation: emergency transportation of the insured person from the location where injured or becomes ill to the nearest hospital where appropriate medical treatment can be obtained. Repatriation: the transfer of the insured person from the local hospital where emergency care initially given to the insured s country of domicile or residence to obtain further medical treatment or recover. Repatriation also includes necessary arrangements for the return of the insured person s remains in the event of loss of life. Covered expenses include the transportation by the most direct and economical route, and best suited to the seriousness of the person s condition. Special transportation must be recommended by the attending physician or by the standard regulations of the conveyance transporting the person. Necessary medical supplies ordered or prescribed by the attending physician are included. Covered expenses do not include expenses incurred while you are traveling against the advice of a physician or traveling for the purpose of obtaining medical treatment. Providence Strategic and Management Services (PSMS) Risk Management department may offer other international travel coverage. Please contact PSMS Risk Management for more information Business Travel Accident

151 XIII. Disability Your Long Term Disability Options You are provided with a level of long term disability (LTD) coverage which offers income replacement up five years, age 65 or to your normal Social Security Retirement age, after a 180- day benefit waiting period. To find out the level of coverage provided to you, log on to ProvConnect Employee Self-Service. Under My Benefits, click on Life & Disability. Depending on the ministry at which you work you may also be given the choice of electing a buy up or buy down LTD coverage option. Your buy up or buy down LTD coverage may include a different level of income replacement and/or benefit waiting period. Please review your enrollment information or contact the HR Service Center for the LTD coverage options available to you. The maximum monthly benefit is generally $10,000 (see page 13-2). Your price tag for LTD options represents the per pay period cost of providing you with that coverage for the plan year. Note: The LTD plan provided to physicians and eligible advanced practice practitioners of Providence St. Mary Medical Center and Providence Medical Group - Southwest Washington is administered under a separate policy with The Standard and is not subject to the provisions of the Unum policy. LTD Benefits will be reduced by any amounts payable to you by any of the sources listed under Deductible Income (Effects of Other Income Benefits) on page Active Employment Requirement If you are not actively at work on the date insurance would otherwise be effective, it will take effect on the date you return to active service. This requirement also applies to increases you make to any existing coverage amounts. Active Employment You are actively employed when you are performing the material and substantial duties of your regular occupation and receiving pay from Providence, as your employer, on a regular basis. You must be working the minimum number of hours to be eligible for the Plan. Your work site must be either one of Providence Health & Services usual places of business; an alternative work site at Providence s direction, including your home; or at a location to which Providence business requires you to travel. A scheduled holiday or vacation is considered active employment. Maximum Benefit Period If you become disabled and you are covered under the For Five Years Plan, benefits are payable until: Age at Disability Maximum Benefit Period 64 or younger 5 years 65 through 68 Age 70, but not less than 1 year 69 and over 1 year Note: Eligible employees of Providence Sacred Heart Medical Center may be covered under a core plan that has a maximum duration of 5 years (union) or is payable up to age 70 (physicians) and is not impacted by the Social Security Normal Retirement Age table. If you become disabled and you are covered under a To Social Security Normal Retirement Age Plan, benefits are payable until: Age at Disability Maximum Benefit Period 61 or younger To SSNRA (Social Security Normal Retirement Age), whichever is longest months months months months months months months 69 or older 12 months Note: The above Social Security Normal Retirement Age table applies to all groups, including physicians, except Providence Sacred Heart Medical Center Union Employees, Providence Sacred Heart Medical Care Physicians and Providence Strategic and Management Services. Eligible Alaska Resident Physicians are also covered under a core plan that is payable according to the above Social Security Retirement Age table. Additional Physician specific coverage elements throughout this chapter Disability

152 If you become disabled and you are covered under a To Age 65 Plan, benefits are payable until: Age at Disability Maximum Benefit Period 59 or younger To Age 65, but no less than 5 years months months months months months months months months months 69 and over 12 months Note: Eligible employees of Providence Strategic and Management Services are covered under a To Age 65 Plan. If you are a Providence Sacred Heart Medical Center Physician and become disabled and your Maximum Benefit Period is: Age at Disability Maximum Benefit Period Less than 70 To Age 70, but not less than 1 year 70 and over 1 year You may contact the HR Service Center for an insurance certificate containing additional details. The insurance contract governs the terms of coverage. Temporary Recovery (Successive Periods of Disability) If you temporarily recover from your disability, and then become disabled again from the same cause or causes, you do not have to serve a new elimination period as long as you remained continuously insured under the plan. A separate period of disability will be considered continuous if it results from the same or related causes as a prior disability for which monthly benefits were payable, and after receiving disability benefits, you return to work in your regular occupation or a qualified alternative for less than six consecutive months. Your recurrent disability will be subject to the same terms of the plan as your prior claim and be treated as a continuation. Any later period of disability, regardless of cause, that begins when you are eligible for coverage under any other group disability plan provided by any employer will not be eligible for payments under this plan. A period of disability is not continuous if separate periods of disability result from unrelated causes. How the Plan Works Benefits If you become disabled due to a covered injury or sickness, you will receive a total monthly income from all sources that is at least equal to the selected percentage of your monthly earnings at the time of disability, to a maximum of $10,000; $5,000 for union represented employees at Providence Sacred Heart Medical Center; $12,500 for physicians at Providence Sacred Heart Medical Center; or $15,000 for physicians and eligible advance practice practitioners in the Oregon Region. Monthly Earnings see the next page for the definition of monthly earnings which may apply to you based on your employee group. Indexed Covered Earnings Indexed covered earnings means your monthly earnings adjusted on each anniversary of benefit payments by the lesser of 10% or the current annual percentage increase in the Consumer Price Index. Your indexed covered earnings may increase or remain the same, but will never decrease. The Consumer Price Index (CPI-U) is published by the U.S. Department of Labor. Unum reserves the right to use some other similar measurement if the Department of Labor changes or stops publishing the CPI-U. Indexing is only used as a factory to determine your percentage of lost earnings while you are disabled and working Disability

153 Monthly Earnings Monthly Earnings as Defined in the Unum Certificate For all employees other than those in the listed groups below Providence Holy Cross Medical Center (CA), Providence Saint Joseph Medical Center (CA), Providence St. Elizabeth Care Center (CA) and Providence Tarzana Medical Center (CA) Providence Little Company of Mary Hospital, Medical Institute and San Pedro Hospital (CA) Providence High School (CA), Alaska resident physicians, Physician and union employee s of Providence Sacred Heart Medical Center (WA) Physicians working at an Alaska Region ministry Physicians working at a ministry located in Washington state (except physicians at Providence Sacred Heart Medical Center) Advance practice practitioners working at Providence Medical Group - Northwest Washington or Providence Health Care - Western Montana Oregon Region physicians and eligible advance practice practitioners 13-3 Disability Your gross monthly income from Providence in effect just prior to your date of disability. It includes your total income before taxes. It is prior to any deductions made for pre-tax contributions to a qualified deferred compensation plan, Section 125 plan, or flexible spending account. It includes income from any shift differential and Top of the Range Base Pay Lump Sum and other income included in Benefits Salary, but it does not include income received from commissions, bonuses, overtime pay or any other extra compensation, or income received from sources other than Providence. Top of the Range Base Pay Lump Sum: Amounts paid during the preceding 12 months, divided by 12 Your gross monthly income from Providence in effect just prior to your date of disability. It includes your total income before taxes. It is prior to any deductions made for pre-tax contributions to a qualified deferred compensation plan, Section 125 plan, or flexible spending account. It includes income from any shift differential, Top of the Range Base Pay Lump Sum and adjusted base pay, 12 hour shift overtime pay for Employees in California regularly scheduled to work 12 hour shifts and other income included in Benefits Salary. It does not include income received from commissions, bonuses, overtime pay or any other extra compensation, or income received from sources other than Providence. Top of the Range Base Pay Lump Sum:acility Charges: Amounts paid during the preceding 12 months, divided by 12 Your gross monthly income from Providence in effect just prior to your date of disability. It includes your total income before taxes. It is prior to any deductions made for pre-tax contributions to a qualified deferred compensation plan, Section 125 plan, or flexible spending account. It includes income from any shift differential and other income included in Benefits Salary, but does not include income received from commissions, bonuses, overtime pay or any other extra compensation, or income received from sources other than Providence. Your gross monthly income from Providence in effect just prior to your date of disability. It includes your total income before taxes. It is prior to any deductions made for pre-tax contributions to a qualified deferred compensation plan, Section 125 plan, or flexible spending account. It includes income actually received from any shift differential, Incentive arrangement or productivity bonus (if any) and other income included in Benefits Salary as defined by Providence. It does not include commissions, overtime pay or any other extra compensation, or income received from sources other than Providence. With respect to physicians, Covered Earnings means an Employee s annual wage or salary in effect 12 months prior to the date Disability begins. However, if the physician s Disability begins within the first year of employment, his or her Covered Earnings will be based on contracted annual earnings. Bonuses will be averaged for the lesser of: - the prior calendar year s 12 month period of your employment with Providence just prior to the date disability begins; or - the period of actual employment with Providence. Your gross monthly income from Providence in effect just prior to your date of disability. It includes your total income before taxes. It is prior to any deductions made for pre-tax contributions to a qualified deferred compensation plan, Section 125 plan, or flexible spending account. It includes income actually received from any shift differential, Incentive Arrangement, President of Medical Staff work stipend, Productivity Bonus (if any) and other income included in Benefits Salary as defined by Providence. It does not include commissions, overtime pay or any other extra compensation, or income received from sources other than your Employer. Incentive arrangement and productivity bonuses will be averaged for the lesser of: - the prior calendar year s 12 month period of your employment with Providence just prior to the date disability begins; or - the period of actual employment with Providence.

154 Deductible Income (Effect of Other Income Benefits) If you receive disability benefits from sources other than this Plan, Plan benefits are reduced by the amount of such other income benefits. Other income benefits include the: Amount you receive or are entitled to receive under a workers compensation law, an occupational disease law, and/or any other act or law with similar intent. Amount you receive or are entitled to receive as disability payments under any state compulsory benefit act or law, automobile liability insurance policy, other group insurance plan, and/or governmental retirement system as a result of your job with Providence. Amount you, your spouse and your children receive or are entitled to receive as disability payments because of your disability under the United States Social Security Act, the Canada Pension Plan, the Quebec Pension Plan and/or any similar plan or act. For physicians of Providence Sacred Heart Medical Center, family social security benefits are not included for purposes of benefit reduction Amount you receive as retirement payments or the amount your spouse and children receive as retirement payments because you are receiving retirement payments under the United States Social Security Act, the Canada Pension Plan, the Quebec Pension Plan and/or any similar plan or act. For physicians of Providence Sacred Heart Medical Center, family retirement benefits are not included for purposes of benefit reduction Amount you receive under the Providence s retirement plan, including any distribution, lump sum, or annuity from the Core cash balance plan and/or the 401(a) Service Plan. Regardless of how the retirement funds are distributed, Unum will consider your and Providence s contributions to be distributed simultaneously throughout your lifetime. Amounts received do not include amounts rolled over or transferred to any eligible retirement plan. Unum uses the definition of eligible retirement plan as defined in Section 402 of the Internal Revenue Code including any future amendments affecting the definition. The amount you receive under Title 46, United States Code Section 688 (The Jones Act). The amount you receive from a third party (after subtracting attorney s fees) by judgment, settlement or otherwise. With the exception of retirement payments, Unum will only subtract deductible sources of income payable as a result of the same disability. Benefits will not be reduced by your Social Security Income if your disability begins after age 65 and you were already receiving Social Security retirement payments. Exceptions to Deductible Income (Exceptions to Other Income Benefits) Your benefits will not be reduced by: 403(b) plans profit sharing plans thrift plans tax sheltered annuities stock ownership plans non-qualified plans of deferred compensation pension plans for partners military pension and disability income plans credit disability insurance franchise disability income plans a retirement plan from another employer individual retirement accounts (IRA) individual disability income plans salary continuation or accumulated sick leave plans 13-4 Disability

155 Definition of Disability To receive benefits under this Plan, you must be disabled (as defined below) as a result of a covered injury or sickness, and you must be under the appropriate care of a licensed, practicing physician who is qualified to treat your disability. Unum may require you to be examined by a physician, other medical practitioner and/or vocational expert of our choice. Unum will pay for this examination and can require an examination as often as it is reasonable to do so. Unum may also require you to be interviewed by an authorized Unum Representative. The loss of a professional or occupational license or certification does not, in itself, constitute disability. As Defined in the Unum Certificate For all employees other than those in the listed groups below You are disabled when Unum determines that: - you are limited from performing the material and substantial duties of your regular occupation due to your sickness or injury; and - you have a 20% or more loss in your indexed monthly earnings due to the same sickness or injury. After 24 months of payments, you are disabled when Unum determines that due to the same sickness or injury, you are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience. You must be under the regular care of a physician in order to be considered disabled. To be considered disabled: - you must visit a physician as frequently as is medically required, according to generally accepted medical standards, to effectively manage and treat your disabling condition(s); and - you must be receiving the most appropriate treatment and care, which conforms with generally accepted medical standards, for your disabling condition(s) by a physician whose specialty or experience is the most appropriate for your disabling condition(s), according to generally accepted medical standards. Physicians and medical resident physicians working at an Alaska Region ministry Physicians working at a ministry located in Washington state (except Providence Sacred Heart Medical Center) Advance practice practitioners working at Providence Medical Group - Northwest Washington or Providence Health Care Physicians and advance practice practitioners working at a Western Montana Region ministry You are disabled when Unum determines that: - you are limited from performing the material and substantial duties of your regular occupation due to your sickness or injury; and - you have a 20% or more loss in your indexed monthly earnings due to the same sickness or injury. You must be under the regular care of a physician in order to be considered disabled. To be considered disabled: - you must visit a physician as frequently as is medically required, according to generally accepted medical standards, to effectively manage and treat your disabling condition(s); and - you must be receiving the most appropriate treatment and care, which conforms with generally accepted medical standards, for your disabling condition(s) by a physician whose specialty or experience is the most appropriate for your disabling condition(s), according to generally accepted medical standards Disability

156 Physicians and eligible advance practice practitioners working at an Oregon Region ministry Providence Sacred Heart Medical Center Physicians You are disabled when Unum determines that: - you are limited from performing the material and substantial duties of your regular occupation due to your sickness or injury; and - you have a 20% or more loss in your indexed monthly earnings due to the same sickness or injury. Regular occupation means your specialty in the practice of medicine which you are routinely performing when your disability begins. Unum will look at your occupation as it is normally performed in the national economy, instead of how the work tasks are performed for a specific employer or at a specific location You must be under the regular care of a physician in order to be considered disabled. To be considered disabled: - you must visit a physician as frequently as is medically required, according to generally accepted medical standards, to effectively manage and treat your disabling condition(s); and - you must be receiving the most appropriate treatment and care, which conforms with generally accepted medical standards, for your disabling condition(s) by a physician whose specialty or experience is the most appropriate for your disabling condition(s), according to generally accepted medical standards. Providence High School employees You are disabled when Unum determines that: - you are limited from performing the material and substantial duties of your regular occupation due to your sickness or injury; and - you have a 20% or more loss in your indexed monthly earnings due to the same sickness or injury. After 30 months of payments, you are disabled when Unum determines that due to the same sickness or injury, you are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience. You must be under the regular care of a physician in order to be considered disabled. To be considered disabled: - you must visit a physician as frequently as is medically required, according to generally accepted medical standards, to effectively manage and treat your disabling condition(s); and - you must be receiving the most appropriate treatment and care, which conforms with generally accepted medical standards, for your disabling condition(s) by a physician whose specialty or experience is the most appropriate for your disabling condition(s), according to generally accepted medical standards Disability

157 When Benefits Begin Payments begin after the end of the elimination period (Benefit Waiting Period). The elimination period is the first 90 or 180 days of continuous disability, depending on your coverage option. Your disability will be treated as continuous if your disability stops for 30 days or less during the elimination period. The days you are not disabled will not count toward your elimination period. Minimum Benefit The minimum monthly benefit payment is the greater of $100 or 10% of your gross disability payment, regardless of income you receive from other sources while disabled. If there is an overpayment due, this benefit may be reduced to recover the overpayment. Return to Work Incentives (Work Incentive Benefit) To encourage you to return to work as soon as medically possible, the Plan offers return-to-work incentives. You may continue to receive benefits if you return to work but continue to meet the definition of disability. During the 12 months that monthly benefits are payable, benefits will be reduced so that the combination of this Plan s benefit and your disability earnings do not exceed 100% of your indexed covered earnings. After the first 12 months, benefits payable under this Plan will be based on the percentage of income you are losing due to your disability. Your percent of lost earnings is calculated by subtracting your work earnings from your indexed covered earnings, then dividing that amount by you indexed covered earnings. Then multiply your percent of lost earnings by your monthly disability benefit for the amount Unum will pay you each month. Limitations Pre-existing Conditions Limitation Benefits will not be paid for any period of disability caused by or contributed to or resulting from, a pre-existing condition until you have been continuously insured and actively at work for 12 months. Pre-existing condition means an injury or sickness for which you received medical treatment, consultation, care, or services including diagnostic measures, or took prescribed drugs or medicines during the three months just prior to your effective date of coverage. the disability begins in the first 12 months after your effective date of coverage. If you increase your coverage from one year to the next, and you become disabled within 12 months of the increase from a condition for which you were treated within three months before the change in coverage took effect, your benefits will be paid based on your prior coverage level. Mental Illness, Alcoholism, and Drug Abuse Limitation The lifetime cumulative maximum benefit period for all disabilities due to mental illness and alcoholism or drug abuse is 24 months. Only 24 months of benefit will be paid for any combination of such disabilities even if the disabilities: are not continuous; and are not related. You will continue to receive payments beyond the 24 month period if you meet one or both of these conditions: If you are confined to a hospital or institution at the end of the 24 month period, you will receive payments during your confinement. If you are still disabled when you are discharged, you will receive payments for a recovery period of up to 90 days. If you become reconfined at any time during the recovery period and remain confined for at least 14 days in a row, you will receive payments during that additional confinement and for one additional recovery period up to 90 more days. Additionally, if you continue to be disabled by mental illness and alcoholism or drug abuse after reaching the maximum payment period and subsequently become confined to a hospital or 13-7 Disability

158 institution for at least 14 days in a row, benefit payments may resume during the length of the reconfinement. You will not receive benefit payments beyond the limited pay period as described above, or the maximum period of payment, whichever occurs first. The mental illness limitation will not apply to dementia if it is a result of: stroke; trauma; viral infection; Alzheimer s disease; or other conditions not listed which are not usually treated by a mental health provider or other qualified provider using psychotherapy, psychotropic drugs, or other similar methods of treatment. Exclusions Disabilities caused by, contributed to, or resulting from the following are not covered by the plan: intentionally self-inflicted injuries active participation in a riot loss of a professional license, occupational license, or certification commission of a crime for which you have been convicted pre-existing condition war, declared or undeclared any period of incarceration while disabled Survivor Benefits A Survivor Benefit will be paid if you die while you are receiving disability benefits. The Survivor Benefit equals three times your gross disability payment provided your disability continued for 180 consecutive days or more and you were entitled to receive payments under the Plan. Benefits will be paid to your spouse/domestic partner. If there is no spouse/domestic partner, benefits will be paid in equal shares to your surviving children. If there are no spouse/domestic partner and children, benefits will be paid to your estate. Spouse/domestic partner as used in the paragraph above means your lawful spouse or qualifying same or opposite gender domestic partner. Children means your unmarried children under age 25. Filing Claims To file a claim, contact the HR Service Center. Proof of loss must be filed with the insurance company no later than 90 days after the date of the disability for which the claim is filed. It is preferred that claims be filed within 45 to 60 days before the end of the elimination period. If you have short term disability coverage through Unum, whether voluntary individual coverage or group coverage, Unum will initiate the long term disability filing for you if it appears you will be disabled fpr the maximum period of short term disability benefits. Termination of Disability Benefits Benefits will end on the earliest of: regular occupations/gainful occupation Alaska, Oregon and Washington physicians when you are able to work in your regular occupation on a part-time basis but choose not to when you are able to work in any gainful occupation on a part-time basis but choose not to Providence High School during the first 30 months of payments, when you are able to work in your regular occupation on a part-time basis but you choose not to; after 30 months of payments, when you are able to work in any gainful occupation on a part-time basis but you choose not to Disability

159 All other employee groups during the first 24 months of payments, when you are able to work in your regular occupation on a part-time basis but you choose not to; after 24 months of payments, when you are able to work in any gainful occupation on a part-time basis but you choose not to. if you are working and your monthly disabilty earnings exceed 80% of your indexed covered earnings. the date you are determined not to be disabled. the date you are determined to not be disabled under the terms of the plan, unless you are able to receive benefits under Unum s rehabilitation and return to work assistance program. the end of the maximum benefit period. the date you fail to submit proof of continuing disability. after 12 months of payments if you are considered to reside outside the United States or Canada. Your will be considered to reside outside these countries when you have been outside the U.S. or Canada or a total period of six months or more during any 12 consecutive months of benefits. the date you die. Conversion If your Long Term Disability Insurance is terminated due to your employment ending, you may buy LTD conversion insurance without submitting evidence of insurability. You must: have been insured under the Plan for at least one year, not be disabled on the date your insurance ends, not be covered under another group long term disability plan within 31 days after your employment ends, not recover from a disability and do not return to work for Providence, and not be on a leave. You must apply in writing and pay the first premium for LTD conversion insurance within 31 days of termination. You will not be able to convert if your insurance under the Plan is terminated because: the Group Policy is amended or terminated, you fail to pay, when due, any required contributions for the cost of insurance under the Plan, the group policy is amended to exclude the group of employees to which you belong, the plan is terminated, you are no longer in an eligible group, or you end your working career or retire and receive payment from any employer retirement plan. The benefits, terms, and conditions of the conversion policy will be those which are offered for conversion at the time you apply. The effective date of coverage under the conversion policy will be the day following the date your insurance under the Plan terminates. Physician Plans Alaska Resident Physicians Providence provides you with coverage of 60% of monthly earnings to Social Security Normal Retirement Age, after 90-day elimination period (Benefit Waiting Period), with a maximum monthly benefit of $2,000. You may choose to buy up to 60% of monthly earnings to Social Security Normal Retirement Age, after 90-day elimination period (Benefit Waiting Period), with a maximum monthly benefit of $3,500. Your price tag for the buy up option represents the per pay period cost of providing you with that coverage for the plan year Disability

160 Alaska Physicians Plan Eligible physicians are provided with Long Term Disability coverage of 60% of covered monthly earnings to Social Security Normal Retirement Age with a maximum monthly benefit of $10,000. Benefits may begin after a 90-day elimination period (Benefit Waiting Period). Oregon Providers Plan Eligible physicians and advance practice practitioners are provided with Long Term Disability coverage of 60% of covered monthly earnings to Social Security Normal Retirement Age with a maximum monthly benefit of $15,000. Benefits may begin after a 90-day elimination period (Benefit Waiting Period). Your payroll is grossed up to cover the taxes for the cost of your LTD premium. Washington and Montana Physicians and Providers Plan Eligibie physicians, and depending on your ministry, advance practice practitioners who are provided with this coverage will have your payroll grossed up to cover the taxes for the cost of your LTD premium. Executive LTD Coverage Providence Health & Services offers a supplemental Long Term Disability insurance policy to eligible executives working for Providence Strategic and Management Services. Copies of the certificate, including eligibility and ERISA information, are provided when an executive employee becomes eligible for coverage. Copies of the certificate may also be obtained by contacting the HR Service Center Disability

161 Providence Hood River Oregon Short Term Disability Plan This short term disability plan provides financial protection for you by paying a portion of your income while you are disabled. The amount you receive is based on the amount you earned before your disability began. In some cases, you can receive disability payments even if you work while you are disabled. You may contact the HR Service Center for an insurance certificate containing additional details. The insurance contract governs the terms of coverage. Who Is Eligible? All benefit-eligible employees working at Providence Hood River Memorial Hospital and Providence Gorge Service Area Housing, except those represented by the Oregon Nurses Association, are eligible the first day of the month following or coincident with 90 days of continuous active employment. Active Employment Requirement If you are not actively at work on the date insurance would otherwise be effective, it will take effect on the date you return to active service. If you are on layoff or leave, including Family and Medical Leave, coverage will commence and continue in accordance with PSMS Human Resource procedures on layoffs and leaves. Active Employment You are actively employed when you are performing the material and substantial duties of your regular occupation and receiving pay from Providence, as your employer, on a regular basis. ` Your work site must be Providence Hood River Memorial Hospital ; Providence Gorge Service Housing; an alternative work site at Providence s direction, including your home; or at a location to which Providence business requires you to travel. A scheduled holiday or vacation is considered active employment. Note: The Short Term Disability Income Protection Plan is part of your benefits as an employee of Providence Hood River. Memorial Hospital or Providence Gorge Service Area Housing. However, it is not treated as part of a Section 125 plan under Internal Revenue Code. Premiums paid by Providence Hood River Memorial Hospital and Providence Gorge Service Area Housing employees (except those represented by Oregon Nurses Association) for Long Term Disability Coverage will be grossed up to cover taxes. How the Plan Works Benefits If you become disabled due to a covered injury or sickness, you will receive a total weekly income from all sources that is at least equal to the Weekly Benefit Amount. Weekly earnings means your gross weekly income from Providence in effect just prior to your date of disability. It includes your total income before taxes and prior to any deductions made for pre-tax contributions to a qualified deferred compensation plan, Section 125 plan, or flexible spending account. It includes income actually received from commissions but does not include renewal commissions, bonuses, overtime pay, or any other extra compensation, or income received from sources other than Providence. Commissions will be averaged for the lesser of: a. the 52 full calendar week period of your employment with your Employer just prior to the date disability begins; or b. the period of actual employment with your Employer. When Benefits Begin Payments begin after the end of the elimination period (Benefit Waiting Period). The elimination period is: 0 continuous calendar days of disability due to injury 3 continuous calendar days of disability due to illness Disability

162 A new elimination period will be applied to each disability unless it is a recurrent claim. Note: For the time your are covered under the STD plan, you will not accrue Paid Time Off (PTO) Nor Extended Illness Benefit (EIB). Weekly Benefit Amount After the elimination period, you are eligible for 60% of weekly earnings up to a weekly maximum of $1,250 for up to 26 weeks. If you are disabled for less than one week after the elimination period, you will receive 1/7th of your payment for each day of disability. Adjustment for Overpayment In the event of an overpayment of benefits, Unum has the right to recover any overpayments due to any error made in processing a claim, you receiving deductible sources of income and any instances of fraud. You are required to repay any overpayment on your claim. Future payments may be reduced or eliminated to recover overpayments. Deductible Income (Effect of Other Income Benefits) If you receive disability benefits from sources other than this Plan, Plan benefits are reduced by the amount of such other income benefits. Other income benefits include the: Amount you receive or are entitled to receive as disability payments under any state compulsory benefit act or law, automobile liability insurance policy, other group insurance plan, and/or governmental retirement system as a result of your job with Providence. Amount you receive under the Providence s retirement plan, including any distribution, lump sum, or annuity from the Core cash balance plan and/or the 401(a) Service Plan. Regardless of how the retirement funds are distributed, Unum will consider your and Providence s contributions to be distributed simultaneously throughout your lifetime. retirement plan. Unum uses the definition of eligible retirement plan as defined in Section 402 of the Internal Revenue Code including any future amendments affecting the definition. The amount you receive under Title 46, United States Code Section 688 (The Jones Act). The amount you receive from a third party (after subtracting attorney s fees) by judgment, settlement or otherwise. With the exception of retirement payments, Unum will only subtract deductible sources of income payable as a result of the same disability. Additionally, if the reduction due to benefits from other sources results in a zero benefit, you will receive a minimum benefit of $25 per week. Exceptions to Deductible Income (Exceptions to Other Income Benefits) Your benefits will not be reduced by: 403(b) plans profit sharing plans thrift plans tax sheltered annuities stock ownership plans non-qualified plans of deferred compensation pension plans for partners military pension and disability income plans credit disability insurance franchise disability income plans a retirement plan from another employer individual retirement accounts (IRA) individual disability income plans salary continuation or accumulated sick leave plans Amounts received do not include amounts rolled over or transferred to any eligible Disability

163 Definition of Disability You are disabled when Unum determines that due to your sickness or injury: you are unable to perform the material and substantial duties of your regular occupation; and you are not working in any occupation. Unum will continue to pay you a disability benefit after you have received benefits under this plan for at least 4 consecutive weeks if: you begin performing at least one of the material and substantial duties of your regular occupation or another occupation; and you have a 20% or more loss in weekly earnings due to the same sickness or injury. You must be under the regular care of a physician in order to be considered disabled. The loss of a professional or occupational license or certification does not, in itself, constitute disability. Unum may require you to be examined by a physician, other medical practitioner and/or vocational expert of our choice. Unum will pay for this examination. Unum can require an examination as often as it is reasonable to do so. Unum may also require you to be interviewed by an authorized Unum Representative. Initiating a Claim Please contact the HR Service Center at to request a claim form. You are encouraged to notify Unum of your claim as soon as possible, so that a claim decision can be made in a timely manner. Written notice of a claim should be sent to Unum within 3 days after the date your disability begins. In addition, you must send Unum written proof of your claim no later than 10 days after your elimination period. If it is not possible to give proof within 10 days, it must be given no later than one year after the time proof is otherwise required except in the absence of legal capacity. You must notify Unum immediately when you return to work in any capacity. Unless a Human Resources representative (e.g. HR business partner, HR Service Center, or Leave of Absence team member) has given you different delivery instructions, you should use the contact information above to notify Unum of your claim. Temporary Recovery (Successive Periods of Disability) If you return to work on a full-time basis for fourteen consecutive days or less, and you again become disabled, then your current disability will be treated as part of your prior claim and you will not have to complete another elimination period. If you return to work full time for 15 or more consecutive days, your current disability will be treated as a new claim. The new claim will be subject to all of the provisions of the Plan and you will be required to satisfy a new elimination period. Return to Work Incentive To encourage you to return to work as soon as medically possible, continuing benefits are available if you return to work but continue to meet the definition of disability and you have received benefits for at least four consecutive weeks. If you receive a physician s release for a limited return to work, and you are earning 80% of your regular earnings or less, you may be eligible to receive STD benefits for those hours you are unable to work. For example, if you meet the definition of disability and are approved to return to work for 15 hours of a 40-hour work week, you would receive regular pay for the time you worked and the lesser of 50% of your weekly benefit or weekly benefit less your regular pay and any deductible sources of income. Exclusions Disabilities caused by, contributed to, or resulting from the following are not covered by the plan and benefits will not be paid: occupational sickness or injury, Disability

164 intentionally self-inflicted injuries, while sane or insane, active participation in a riot, loss of a professional license, occupational license or certification, or commission of a crime for which you have been convicted. The Plan will not cover a disability due to war, declared or undeclared, or any act of war. Unum will not pay a benefit for any period of disability during which you are incarcerated. Termination of Disability Benefits Benefits under the Plan will end on the earliest of: the end of the maximum period of payment which is defined as the earlier of 26 weeks or the beginning of Long Term Disability payments; Termination of Short Term Disability Protection Plan Coverage Your coverage under the Plan ends on the earliest of: the date the Plan is terminated by Providence Health & Services for Providence Hood River Memorial Hospital and Providence Gorge Service Area Housing; the date you are no longer in an eligible group; the date your eligible group is no longer covered; or the last day you are in active employment. the date you are no longer disabled under the terms of the Plan; the date you fail to submit proof of continuing disability; the date you die; when you are able to work in your regular occupation on a part-time basis but choose not to; or after 12 months of payments if you are considered to reside outside of the United States or Canada. You will be considered to reside outside these countries if you have been outside of the United States or Canada for a total period of six months or more during any 12 consecutive months of benefits; the date your disability earnings exceed the amount allowable under the plan Disability

165 Glossary of Terms from the Disability Chapter Dependent Your child(ren) under the age of 15; and your child(ren) age 15 or over or a family member who requires personal care assistance. Disability Earnings The earnings which you receive while you are disabled and working, plus the earnings you could receive if you were working to your maximum capacity. Elimination Period Ta period of continuous disability which must be satisfied before you are eligible to receive benefits from Unum. Evidence of Insurability A statement of your medical history which Unum will use to determine if you are approved for coverage. Evidence of insurability will be at Unum s expense. Gainful Occupation An occupation that is or can be expected to provide you with an income at least equal to 80% of your indexed monthly earnings within 12 months of your return to work. Gross Disability Payment The benefit amount before Unum subtracts deductible sources of income and disability earnings. Injury A bodily injury that is the direct result of an accident and not related to any other cause. Layoff or Leave of Absence You are temporarily absent from active employment for a period of time that has been agreed to in advance in writing by your Employer. Your normal vacation time or any period of disability is not considered a temporary layoff or leave of absence. Limited What you cannot or are unable to do. Material and Substantial Duties Duties that are normally required for the performance of your regular occupation; and cannot be reasonably omitted or modified. Maximum Capacity Based on your restrictions and limitations, the greatest extent of work you are able to do in your regular occupation, that is reasonably available. Mental Illness Psychiatric or psychological condition classified in the Diagnostic and Statistical Manual of Mental Health Disorders (DSM), published by the American Psychiatric Association, most current as of the start of a disability. Such disorders include, but are not limited to, psychotic, emotional or behavioral disorders, or disorders relatable to stress or to substance abuse or dependency. If the DSM is discontinued or replaced, these disorders will be those classified in the diagnostic manual then used by the American Psychiatric Association as of the start of a disability. National Consumer Price Index (CPI-U) The National Consumer Price Index for Urban Wage Earners and Clerical Workers published by the U.S. Department of Labor. If the index is discontinued or changed, another nationally published index that is compatible to the CPI-U will be used. Pre-existing Condition Exclusion The Long Term Disability options have a preexisting condition exclusion which stipulates that no benefits will be paid for new hires during the first 12 months of coverage for disabilities caused by a pre-existing condition. In addition, if you increase your coverage from one year to the next, your prior coverage will remain in effect in the event of disability within the plan year resulting from a pre-existing condition Disability

166 A pre-existing condition means an injury to sickness for which you received medical treatment, consultation, care or services including diagnostic measures, took prescribed drugs or medicines during the three months just prior to your effective date of coverage, and the disability begins in the first 12 months after your effective date of coverage. Recurrent Disability A disability which is caused by a worsening in your condition; and due to the same cause(s) as your prior disability for which Unum made a Long Term Disability payment. Regular Care You personally visit a physician as frequently as is medically required, according to generally accepted medical standards, to effectively manage and treat your disabling condition(s); and you are receiving the most appropriate treatment and care which conforms with generally accepted medical standards, for your disabling condition(s) by a physician whose specialty or experience is the most appropriate for your disabling condition(s), according to generally accepted medical standards. Regular Occupation The occupation you are routinely performing when your disability begins. Unum will look at your occupation as it is normally performed in the national economy, instead of how the work tasked are performed for Providence or at a specific location. Survivor, Eligible Your spouse, if living; otherwise your children under age 25 equally Disability

167 XIV. Health Care Flexible Spending Account Deciding on Participation The Health Care Flexible Spending Account enables you to pay for health care services not covered by the Medical, Dental, and Vision Plans on a pre-tax basis. After you have decided on the best Medical, Dental, and Vision options for your situation, you should have a pretty good idea of how much you may be paying out-of-pocket for health care services your deductibles, coinsurance, etc. You can save money on taxes by setting this amount aside, on a pre-tax basis. You then fund your Flexible Spending Account each pay period. The account will then reimburse you for eligible health care expenses having a date of service during the plan year in which contributions were made. Participation in the Health Care Flexible Spending Account is completely optional. If you want to participate, you can contribute whatever amount you choose. The minimum contribution is $120; the maximum contribution is $2,500 per year (prorated if you are newly eligible mid-year). When deciding on your level of participation, keep in mind that you may include eligible out-of-pocket expenses for yourself, your spouse, any federal tax dependents regardless of their insurance coverage, and your adult child up to reaching the age of 26. In essence, think of your Health Care Flexible Spending Account as a family account. When deciding how much to contribute to the account, keep in mind that IRS regulations require any amounts left over at the end of the plan year to be forfeited. And, you cannot change your contribution amount during the plan year unless you have a qualifying event (see page 1-13) If You Are Enrolled on the Health Reimbursement Medical Plan: Order of Reimbursement Between Accounts for Medical Expenses If you are enrolled in the Health Reimbursement Medical Plan and have funds available in your health reimbursement account (HRA), the funds in your HRA will be used first to pay your out of pocket medical and prescription expenses covered by the plan. Once the funds in your HRA have been spent you may use your Health Care Flexible Spending Account for those out of pocket medical expenses. If You Are Enrolled on the Health Savings Medical Plan: Limited Purpose Health Care Flexible Spending Account Expenses reimbursed by a limited purpose Health Care Flexible Spending Account (Health FSA) are restricted until you reach your plan s deductible. Here s how it works: Before you meet your medical plan deductible, your Health FSA funds are available only for certain expenses, including: Dental care and orthodontia, such as fillings, X-rays, braces, caps and mouth guards Vision care, including eyeglasses, contact lenses, solutions and supplies, and LASIK eye surgery Health care not covered under a medical plan Prescriptions and over-the-counter items are reimbursable only for dental, vision and preventive care. After you meet your medical plan deductible: You will get reimbursed for all Health FSA qualified health care expenses, except your deductible. If you elected the Health Savings medical option but are, or become, ineligible to receive contributions to a health care savings account (HSA), your account will not be subject to the restrictions of a Limited Purpose Health Care Flexible Spending Account. Please contact HealthEquity Health Care Flexible Spending Account

168 What Is Covered? Qualifying medical care expenses are defined by the IRS as amounts paid for the diagnosis, cure, medication, treatment, or prevention of disease, or for transportation primarily for and essential to medical care. All expenses must be qualified medical, vision, pharmacy or dental benefit expenses as defined in Section 213(d) of the Internal Revenue Code. Some examples of items that qualify for reimbursement are: Any deductibles and coinsurance you may have to pay under your elected Medical, Dental, or Vision option. Dental expenses not paid by dental insurance. Cost of eyewear and lenses if you waive the Vision Service Plan Any health charges in excess of Medical, Dental and Vision Plan limits, for example: Additional cost to you if a second surgical opinion or hospital pre-admission certification is not obtained when required or HMO guidelines are not followed; Dental expenses in excess of plan payments (such as orthodontia costs in excess of $2,000); and You will only be able to receive reimbursement under the health flexible spending account for your over the counter (OTC) drugs and medicines with a doctor s prescription. You will need to remit your receipt for the OTC drugs and medicine along with your doctor s prescription to receive reimbursement or use your debit card at the pharmacy counter. Weight loss programs prescribed by a physician for treatment of a specific disease or ailment, such as obesity or hypertension; the cost of diet food items in not eligible; Special medical equipment, such as oxygen equipment; Nursing services for care of a specific medical ailment; Cost of a nurse s room and board if paid by the employee where a nurse s services qualify; Services of psychotherapists, psychiatrists, and psychologists; Acupuncture; Reversal of sterilization; Physical therapy; Vision expenses in excess of VSP payments. Any IRS-eligible health care charges not covered by the Medical, Dental and Vision plans, and not specifically excluded by this plan (see page 14-3). Other health care services that would qualify as medical deductions under IRS rules include: Legally obtained, generally accepted over the counter medicine and drugs used for personal medical care to mitigate pain and/ or treat disease or illness or for the purpose of affecting any structure or function of the body. Examples include: antacid, allergy medicine, pain reliever, cold medicine from pharmacy, and over-the-counter Claritin Expenses for services connected with donating an organ; Cost of a guide for a blind person; Cost of a note-taker for a deaf child in school; Prescription drugs or insulin; Cost of Braille books and magazines in excess of the cost of regular editions; Household visual alert system for deaf person; Excess costs of specifically equipping an automobile for a disabled person over the cost of an ordinary automobile; device for lifting disabled person into automobile; 14-2 Health Care Flexible Spending Account

169 Wheelchair or autoette; Crutches; Wigs (where necessary due to mental health of individual who loses hair because of disease); Hearing aids and care; and Cost of fluoridation of home water supply advised by a dentist. The expenses may be incurred for services provided to you, your spouse, any person who would qualify as your dependent under federal income tax rules (even if they are not covered under the Medical, Dental, or Vision option you select), and your adult child up to age 26. You can obtain a complete list of eligible expenses on HealthEquity s web site, com./providence. Some IRS eligible expenses are excluded from this Plan. Exclusions Expenses which do not qualify for reimbursement through the Health Care Flexible Spending Account include: Medical expenses that are eligible for reimbursement from available balances in your health reimbursement account. If you are enrolled on the Health Savings Medical Plan and open an health savings account (HSA), you will not be able to use the Health Care Flexible Spending account for the amounts applied to your plan deductible. (if you have your HSA through HealthEquity this exclusion will be administered for you.) Charges for services obtained before the effective date of your contributions to the account for the plan year Charges for services obtained after the discontinuance of contributions to the account for the plan year Health care insurance premiums Payments to domestic help, companion, babysitter, chauffeur, etc., who primarily renders services of a nonmedical nature Nursemaids or practical nurses who render general care for healthy infants Cosmetic surgery, unless medically necessary and allowed under IRS regulations Tattoos and ear piercing Religious cult deprogramming Fees for exercise, athletic or health club memberships Physical treatments unrelated to a specific health problem (for example, massage for general well-being); Payments for Church of Scientology auditing and processing Marriage counseling provided by clergy member Weight reduction programs for general wellbeing and appearance Any illegal treatment Psychoanalysis undertaken to satisfy a student s curriculum requirement Cost of items for general health or appearance, such as vitamins, dietary supplements, toiletries, cosmetics, and sundry items (for example, soap, tooth brushes) Cost of illegal drugs Cost of nonprescription drugs, except as defined on page 14-2 Abortion or sterilization Drugs which act as, or which under the Ethical and Religious Directives for Catholic Health Care Services Part 4 (fifth edition) are considered to act as, abortifacients Maternity clothes Diaper service Distilled water purchased to avoid drinking fluoridated city water supply 14-3 Health Care Flexible Spending Account

170 Vacuum cleaner purchased by individual with dust allergy Mechanical exercise device not specifically prescribed by doctor Insurance against loss of income; loss of life, limb, or sight Contributions to state disability funds Long Term Care premiums and expenses Over the counter drugs and medicines without a physician s prescription How Does the Account Work? The amount you elect will be deducted from your pay on a per pay period basis, 24 pay periods maximum per plan year, and credited to your Flexible Spending Account. This amount will never be greater than your pay. Debit Card Each participant in the Health Care Flexible Spending Account will be provided with a debit card which may be used at eligible health care merchants and providers that accept the VISA card. Simply present your debit card to pay for the portion of your eligible expenses that are not covered by your insurance plan selections. Using the Debit card eliminates the need for you to pay for out-of-pocket expenses with your own funds, submit a claim, and wait for a reimbursement. The provider will simply swipe your card and be paid for services directly from your account, up to your available balance. The annualized amount of your election is available on the card at the beginning of the plan year, or as of your effective date if you are newly eligible. The available balance will be reduced by any claims paid to date. When using your debit card you are agreeing to the terms of the cardholder agreement. By signing the receipt and authorizing the transaction, you agree: to use the card only at authorized medical, dental, and vision providers; to use the card for eligible medical, dental, and vision expenses as allowed by IRS regulations and eligible under the terms of the plan document; that the transactions have not and will not be reimbursed under any other insurance plan or health care reimbursement plan; to submit any required documentation of a transaction to claims administrator upon request; to return the card at termination or upon demand; and to repay any transactions deemed ineligible under the terms of the Plan. The IRS requires you to obtain a receipt for every debit card transaction and, if necessary, submit the receipt to substantiate the expense. Have your provider give you a detailed receipt at the time of transaction and save it. If a receipt is required, the claims administrator will contact you. If you are unable or unwilling to provide a receipt when requested, the IRS regulations require the claims administrator to deem the transaction ineligible and the amount of the transaction must be repaid to the Plan. Failure to provide a receipt or repay the Plan upon request may result in the cancellation of your debit card. If your card is cancelled you must submit a paper claim form with receipts for any expenses you incur and cannot continue to use the card. Be sure to keep your receipts for documentation. It is also important to keep your receipts for OTC medications in order to be properly reimbursed. The claims administrator is authorized under IRS regulations to deduct any transactions deemed ineligible from your reimbursement request or to request repayment. If you do not repay the administrator for ineligible claims, the amount of the transaction may be deducted from your pay after tax. If You re Unable to Use Your Debit Card If you pay for eligible expenses without using the debit card (i.e., via cash, check, or credit card), you may submit a Claim Form with a detailed 14-4 Health Care Flexible Spending Account

171 receipt. The claims administrator will generally pay your claim within a few business days. The claims administrator will contact you if any additional information is required. The amount of your claim will be deducted from your available balance and reduce the available balance on your debit card. You may mail or fax your claims to the claims administrator, or submit them online. The claims administrator is: HealthEquity Inc. 15 Scenic Point Dr. Ste. 400 Draper, UT Toll-free: Forms are available on the benefits Web site or from the claims administrator. NOTE: FOR PLAN YEAR 2013, You have through March 31 of the following year to file for reimbursement of eligible expenses. Eligible expenses incurred (date of service) through March 15th may count toward any balance left in your account from the previous year. For example, if you set aside $2,000 in your account for 2013, and still have $500 in your account on December 31, any expenses incurred between January 1 and March 15, 2013 can be reimbursed from that $500. FOR PLAN YEAR 2014: When you make your elections for the 2014 plan year, be advised the above grace period will no longer be available. If there is a balance in your account three months after year-end, federal law requires that it be forfeited. Before you decide how much to allocate, you should carefully estimate the expenses that you and your dependents are sure to have. You should not allocate more than you are certain to use. Orthodontia Claims Orthodontia work is often paid in full up front by the patient. If you pay for orthodontic services in advance, you may submit the pre-paid out of pocket amount for reimbursement from a Health Care Flexible Spending Account, whether or not the services are performed in the same plan year as your contributions. No reimbursement is available if actual payment is not made. If you pay for orthodontia care on a payment schedule, the payment date will serve as the treatment date for determining reimbursement from an account during the year. Therefore, only the amount to cover one calendar year of out of pocket payments should be put into the reimbursement account. You will need to submit a separate claim for each treatment payment. Statements You can check your account balance on-line by logging on to or by calling the number on the back of your debit card. Termination of Coverage If you terminate employment with a balance in your Flexible Spending Account, you may continue to submit claims incurred before your termination date (as entered in ProvConnect), or the end of any period during which contributions were made from severance payments, until three months after the end of the plan year or until your balance is zeroed out, whichever comes first. In order to submit claims for services provided to you after your termination, you must elect COBRA continuation coverage for the Health Care Flexible Spending Account. When you elect COBRA coverage for the Health Care Flexible Spending Account, you are required to continue to make contributions to the account on an after-tax basis. If you continue to make the required after- tax contribution through the end of the Plan Year, you will be permitted to continue to submit claims for reimbursement on the same basis as similarly situated active employees. All claims for reimbursement must be submitted by March 31. HEART Act of 2008 Under the Heroes Earnings Assistance and Relief Tax Act of 2008 (HEART Act of 2008), military reservists who are called to active duty for 180 or more days or for an indefinite period may receive a distribution of all or a portion of the unused funds in their Health Care Flexible Spending Account. Unused funds refers to the amount contributed by the participant to the Health Care Flexible Spending Account as of the date of the participant s request for a distribution, minus the participant s claims for reimbursement from 14-5 Health Care Flexible Spending Account

172 the Health Care Flexible Spending Account for the Plan Year for expenses incurred up until and including the same date. If a participant wishes to take a distribution under the HEART Act of 2008, the participant must make the request so that the distribution is made during the period beginning on the date the individual is ordered or called into active duty and ending on the last day reimbursement from the Health Care Flexible Spending Account would otherwise be made for the Plan Year. A participant s distribution request from the Health Care Flexible Spending Account will be processed within thirty (30) days of the date the request is received. Distributions from the Health Care Flexible Spending Account that are permitted under the HEART Act of 2008 will be subject to tax-withholding. However, such distributions are not subject to tax penalties Health Care Flexible Spending Account

173 XV. Dependent Care Flexible Spending Account Deciding on Participation If you are paying for child care or other dependent care services so that you or you and your spouse, can work (or study as a full-time student), you can use the Dependent Care Flexible Spending Account to pay for day care costs in a tax-effective manner. This Plan is completely optional; if you wish to participate, you may contribute whatever amount you choose to the Plan. The minimum annual Dependent Care Flexible Spending Account contribution is $120. Your maximum contribution can be as much as $5,000, subject to the limitations described below. If you are single, you may contribute up to $5,000. If you are married and file a separate federal income tax return, your maximum annual Dependent Care Flexible Spending Account contribution is $2,500. If you are married and file a joint return, the maximum allowable Dependent Care Flexible Spending Account contribution for your household is the lesser of your or your spouse s income (but not more than $5,000). For example, if you earn $25,000 and your spouse earns $4,000, you may not contribute more than $4,000 to your Dependent Care Flexible Spending Account. If your spouse is a full-time student or incapable of self-care, your spouse s earned income is assumed to be at least $250 a month if you have one dependent or $500 a month if you have two or more dependents. In general, your Dependent Care Flexible Spending Account election stays fixed for the entire plan year. However, if your family circumstances change significantly, you may be able to change your election before the next annual enrollment. NOTE: If you and your spouse both work for Providence, you are responsible for electing a contribution amount that complies with the annual IRS limit of $5,000 for couples filing a joint return, or $2,500 per person if filing separately. What Is Covered? You may use the Dependent Care Flexible Spending Account to be reimbursed for eligible dependent care expenses that you currently pay with aftertax dollars. The expense must be incurred after you are participating in the Dependent Care Flexible Spending Account. Eligible expenses include: care at a licensed day care facility private sitter (excluding baby-sitting which allows you and/or your spouse to participate in social or recreational activities whether or not work related) care at a child day care center or adult care center. If the day care center cares for more than six children, the center must comply with all state and local laws and charge a fee for providing care cost of schooling (if your child is under the age of first grade and if the cost of schooling and the cost of care cannot be separated) a housekeeper, au pair, or nanny whose services include providing care for an eligible dependent in-home providers, as long as it is someone other than your spouse/adult Benefit Recipient, a person you list as a dependent on your federal tax return or one of your children under the age of 19 baby-sitting services (work related) day camp (work-related) practical nursing care for an incapacitated spouse or parent Dependent Care Flexible Spending Account

174 Refer to IRS Publication #503 (Child and Dependent Day Care Expenses), available at your local IRS office, by calling TAX-FORM ( ) or by visiting the IRS Web site at ustreas.gov for a complete list of eligible expenses. If Care Is Provided for a Child Services will qualify for reimbursement from the Dependent Care Flexible Spending Account if they are: incurred to enable you or you and your spouse, if you are married, to be employed or study as a full-time student, incurred for a child under 13 years old and who is your dependent under federal tax rules. provided in your home or another location, but not by someone who is your minor child or dependent for income tax purposes (for example, an older child). for the physical care of the child, not for education, meals, lessons such as sailing or photography, etc. If the services are provided by a day care facility that cares for six or more children at the same time, it must be a qualified day care center and have a tax identification number (TIN). If Care Is Provided for Another Dependent The Dependent Care Flexible Spending Account can also be used for a spouse or dependent who is incapable of self-care (for example, an invalid parent). The dependent must regularly spend at least eight hours per day in your home. The same rules that apply to child care apply to the care of other dependents, except that the dependent need not be under age 13. NOTE: You must provide the name, address, and tax-payer identification number (for example, Social Security number) of your day care provider. This is not necessary if your provider is exempt from federal income taxes, such as a church group. If you are unable to provide this information you cannot use this account. Exclusions Expenses which do not qualify for reimbursement through the Dependent Care Flexible Spending Account include: expenses for food and education unless they are provided by the nursery school or day care center as part of its preschool care services tuition, clothes, and entertainment full-time care in a custodial or residential nursing home overnight sleep-away camp expenses for transportation between your home and the place where dependent day care services are provided or to pick up a dependent day care provider expenses claimed on your federal tax return under the federal dependent care tax credit dependent medical and health care expenses services provided before you began participation in the Dependent Care Flexible Spending Account or after your participation ended expenses for dependents who do not meet the eligibility requirements care provided by your spouse/adult Benefit Recipient, a dependent or your child(ren) who are under age 19 at the end of the year care provided by anyone you claim as a dependent on your federal income tax return dependent day care expenses you pay while you are not working or do not otherwise meet the eligibility requirements How Does the Account Work? The amount you elect will be deducted from your pay on a per pay period basis, 24 pay periods maximum per plan year, and credited to your Flexible Spending Account. This amount will never be more than your pay. You pay your day care provider first. When you want to be reimbursed for eligible dependent care expenses, 15-2 Dependent Care Flexible Spending Account

175 you submit a claim for reimbursement along with documentation of your payment To minimize administrative costs, all claims should be at least $25. Paying for Your Eligible Expenses If you pay for dependent care eligible expenses using cash, check, or credit card, you may submit a Claim Form with a detailed receipt. The claims administrator will generally pay your claim within a few business days. The claims administrator will contact you if any additional information is required. The amount of your claim will be deducted from your available Dependent Care balance. You may mail or fax your claims to the claims administrator, or submit them online.the claims administrator is: HealthEquity Inc. 15 Scenic Point Dr. Ste. 400 Draper, UT Toll-free: Forms are available on the benefits Web site or from the claims administrator. You may submit claims at any time during the year. However, your total reimbursements at any time during the year cannot exceed the amount you have contributed through payroll deductions at that time. If there is a balance in your account three months after year-end, federal law requires that it be forfeited. Before you decide how much to contribute, you should carefully estimate the qualifying expenses that you and your dependents are sure to have. You should not allocate more than you are certain to use. Termination of Coverage If you terminate employment with a balance in your Flexible Spending Account, you may continue to submit claims until three months after the end of the plan year or until your balance is zeroed out, whichever comes first. IRS regulations do not allow you to contribute to your Dependent Care Flexible Spending Account after you terminate employment. Which Is Better the Reimbursement or the Tax Credit? Before this plan, you had to pay for day care expenses with after-tax dollars and then apply the federal (and, where applicable, state) tax credits at year-end. By using the Dependent Care Flexible Spending Account, you can use pre-tax contributions to pay for your day care expenses. The result may be lower taxes and, therefore, higher spendable income for you. If you choose to be reimbursed for day care expenses from the Dependent Care Flexible Spending Account, you cannot take advantage of federal and state child care and dependent care income tax credits for the same expenses. You should explore the best alternative considering your personal situation and tax bracket. For some people, the tax credits are preferable to reimbursement; for others, reimbursement from the Dependent Care Flexible Spending Account is best. Your participation in a Dependent Care Flexible Spending Account will reduce your expenses allowed for the tax credit by the amount of your contribution to the Flexible Spending Account. Statements You can check your account balance on-line by logging on to Dependent Care Flexible Spending Account

176 XVI. Problem Resolution, ERISA & HIPAA Information Informal Member Problem Resolution Under the Medical Plan Your Providence Health Plan (PHP) Customer Service Team is available to provide information and assistance at You may call them or set up an appointment with them to discuss your concern. If you have special needs, such as a hearing impairment, call their TTY (telephone device for the hearing impaired) number at Please contact them so they may help you with whatever special needs you may have. If you have coverage through an HMO, please refer to your benefits booklet for contact information. For Western Montana employees, please review your Medical Summary Plan Description from Allegiance. Filing and Processing of Claims Your work location has the necessary claim forms on the benefits Web site. The forms give you the details of how a claim is filed. Your Grievance and Appeal Rights Under the Health Reimbursement and Health Savings Medical Plan If you disagree with the decision about your medical bills or health care services you have the right to two levels of internal review. You may request review if you believe that Providence Health Plan (PHP) has not paid a bill correctly, will not approve care you believe should be covered, or are stopping care you believe you still need. You may also file a quality of care or general complaint with PHP. Please include as much information as possible including the date of the incident, the names of individuals involved, and the specific circumstances. In filing a grievance or appeal: You can submit written comments, documents, records and other information relating to your grievance or appeal and PHP will consider that information in their review process. You can, upon request and free of charge, have reasonable access to and copies of the documents and records held by PHP that relate to your grievance or appeal. To the extent possible, complaints filed by telephone will be resolved at the point of service by a Customer Service representative. All grievances and appeals (except those involving prior authorizations, as noted below) will be acknowledged within seven days of receipt by PHP and resolved within 30 days, or sooner depending on the clinical urgency. Urgent Medical Conditions If you believe your health would be seriously harmed by waiting for PHP s decision on your grievance, or appeal of denied prior authorization request, you may request an expedited review by calling a Customer Service representative at or outside of the Portland area. PHP will let you know by phone and letter if your case qualifies for an expedited review. If it does, PHP will notify you of their decision within 72 hours of receiving your request. If additional information is needed, you shall be notified and shall have at least 48 hours from receipt of the notice within which to provide the requested information. Grievances and Appeals Involving Prior Authorizations (Non-Urgent) If your grievance or appeal involves a prior authorization request for a non-urgent medical condition, PHP will notify you of their decision, (a) within 15 days of receiving your request for a first level appeal, or (b) within 15 days of receiving your request for a second level appeal Problem Resolution, ERISA & HIPAA Information

177 Grievances and Appeals Involving Concurrent Care Decisions (Urgent) If PHP has approved an ongoing course of treatment for you and determine through their medical management procedures to reduce or terminate that course of treatment, they will provide advance notice to you of that decision. You may request reconsideration of their decision by submitting an oral or written request at least 24 hours before the course of treatment is scheduled to end. PHP will then notify you of their reconsideration decision within 24 hours of receiving your request. Grievances and Appeals Involving Post Service Claims If your grievance or appeal involves a post service claim (a claim that does not require prior approval), PHP will notify you of their decision, (a) within 30 days of receiving your request for a first level appeal, or (b) within 30 days of receiving your request for a second level appeal. Extension For pre service and post service claims, the claims administrator shall notify you in writing of the need for an extension, the reason for the extension, and the expected date of decision within the initial period. In no event shall such extension exceed 15 days from the end of such initial period. If an extension is necessary because additional information is needed from you, the notice of extension shall also specifically describe the missing information, and you shall have at least 45 days from receipt of the notice within which to provide the requested information. Exhaustion of Process You must exhaust the applicable first and second levels of appeal under this Appeal Procedure before you initiate any litigation or other legal remedy. First Level Grievance or Appeal You must file your initial grievance or appeal within 180 days of the date on our notice of the initial determination, or that initial determination will become final. Please advise PHP of any additional information that you want considered in the review process. If you are seeing a non-participating provider, you should contact that provider s office and arrange for the necessary records to be forwarded to PHP for the review process. Your grievance or appeal will be reviewed by Providence Health Plan (PHP) staff not involved in the initial determination. You may present your case in writing. Once a final determination is made you will be sent a written explanation of the decision. If the claim is denied on appeal you will receive: The specific reason(s) for the denial, and reference to the pertinent Participating Benefit provisions upon which the denial is based; A description of any additional material or information you need to submit to perfect your claim and the reasons why such material or information is necessary; An explanation of the Plan s claims appeal procedures, including any applicable time limits; In the case of a denial of an urgent care claim, a description of the expedited review procedure applicable to such claims. An urgent care claim decision may be provided orally, so long as written notice is furnished to the claimant within three days of oral notification; Upon request you may also receive: Reasonable access to and copies of all documents, records and other information relevant to the claim for benefits; Any internal rule, guideline, protocol or other similar criterion relied on in the determination, or a statement that a copy of such rule, guideline, protocol or other similar criterion will be provided free of charge; and An explanation of the scientific or clinical judgment relied on in the determination, or a statement that such explanation will be provided free of charge. You and the Plan can also have the right to other voluntary alternative dispute resolution options, such as mediation. Contact your local 16-2 Problem Resolution, ERISA & HIPAA Information

178 U.S. Department of Labor office and your state insurance regulatory agency to find out what resources are available. After you exhausted your internal claim and appeal rights as described above, you may have additional rights to appeal an adverse benefit decision to an independent external review organization. You may contact Providence Health Plan, as claims administrator, for additional information. If the claims administrator fails to follow the claims appeals procedures as outlined, or you are not happy with the decision, you have the right to bring a civil action in Federal court. No lawsuit shall be brought against the Plan Administrator or a Claims Administrator after 120 days from the receipt of the final decision on a claim appeal. Authorized Representative Any eligible person may authorize another person to represent them and with whom they want the claims administrator to communicate regarding specific claims or an appeal. The authorization must be in writing, signed by eligible person, and include all the information required in an appeal. (An assignment of benefits, release of information, or other similar form the eligible person may sign at the request of their health care provider does not make your provider an authorized representative.) You can revoke the authorized representative at any time, and you can authorize only one person as your representative at a time. Second Level Appeal If you are not satisfied with PHP s decision on the first level grievance or appeal, you may request a second level appeal and their Grievance Committee will review your case. The Grievance Committee is made up of individuals not involved in the initial grievance or appeal, and consists of Providence Health Plan (PHP) staff and one or more community representatives. You must submit your written request to the Grievance Committee for review within 60 days of the date of the first level grievance or appeal decision notice, or that first level decision will become final. You may present your case to the Grievance Committee in writing, by telephone conference call, or in person at their Beaverton, Oregon location. The Grievance Committee will review the documentation presented by you and send a written explanation of its decision. Exhaustion of Process You must exhaust the applicable first and second levels of appeal under this Appeal Procedure before you initiate any litigation or other legal proceeding related to your plan benefits. Benefits will be paid under the plan only if the Grievance Committee, or if applicable the Independent Review Organization (IRO), determines in its discretion that you are entitled to them. Any such determination shall be final and binding. After receiving such a determination, you will have exhausted your administrative remedies under the plan, and you will have a right to bring an action for benefits under ERISA Section 502(a)(1) (B). No lawsuit shall be brought against the Plan, the Company, the Plan Administrator or Claims Administrator after 120 days from receipt of the final decision on a claim appeal. External Review If you are not satisfied with the decision of the Grievance Committee and your appeal involves a denial of services because they are not medically necessary, not an active course of treatment for purposes of continuity of care, because they are experimental/investigational, or whether a course of treatment is delivered in an appropriate setting at an appropriate level of care; you may request an external review by an IRO. Your request must be made in writing within 180 days of receipt of the Grievance Committee s final review decision, or that internal decision will become final. When the external review process begins, PHP will forward complete documentation regarding the case to the IRO. The IRO is entirely independent of the Plan Sponsor and Providence Health Plan. There is no cost to you to obtain an external review decision. The IRO will notify you and PHP of its decision. PHP agrees to comply with the IRO decision when the decision involves, (a) medically necessary treatment, (b) experimental/investigational 16-3 Problem Resolution, ERISA & HIPAA Information

179 treatment, (c) an active course of treatment for purposes of continuity of care, or (d) whether a course of treatment is delivered in an appropriate setting at an appropriate level of care. Appeals involving benefit exclusions or non-covered services are not eligible for independent review. How to Submit Grievances or Appeals You may contact a Customer Service representative at or If you are hearing impaired and use a Teletype (TTY) Device, please call our TTY line at or Written grievances or appeals should be sent to: Providence Health Plan Appeals and Grievance Department PO Box 4327 Portland, Oregon You may fax your grievance or appeal to or , or you may hand deliver it (if mailing, use only the post office box address listed above) to the following address: Providence Health Plan The specific reason for the denial or modification Reference to the specific plan provision on which the determination was based Your appeal rights should you wish to dispute the original determination Appeals of Denied Claims Informal Review If your claim for dental benefits has been completely or partially denied, you have the right to request an informal review of the decision. Either you, or your authorized representative (see below), must submit your request for a review within 180 days from the date your claim was denied (please see your explanation of benefits form). A request for a review may be made orally or in writing, and must include the following information: Your name and ID number The group name and number The claim number (from your explanation of benefits form) 3601 SW Murray Blvd. The name of the dentist Beaverton, Oregon Under the PPO 1500 and PPO 2000 Dental Plans Initial Benefit Determinations An initial benefit determination is conducted at the time of claim submission to WDS for payment, modification or denial of services. In accordance with regulatory requirements, WDS processes all clean claims within 30 days from the date of receipt. Clean claims are claims that have no defect or impropriety, including a lack of any required substantiating documentation, or particular circumstances requiring special treatment that prevents timely payments from being made on the claim. Claims not meeting this definition are paid or denied within 60 days of receipt. If a claim is denied, in whole or in part, or is modified, you will be furnished with a written explanation of benefits (EOB) that will include the following information: Please submit your request for a review to: Washington Dental Service Attn: Appeals Coordinator P.O. Box Seattle, WA For oral appeals, please refer to the phone numbers listed on the inside front cover of your benefit booklet. You may include any written comments, documents or other information that you believe supports your claim. WDS will review your claim and make a determination within 30 days of receiving your request and send you a written notification of the review decision. Upon request, you will be granted access to and copies of all relevant information used in making the review decision Problem Resolution, ERISA & HIPAA Information

180 Informal reviews of wholly or partially denied claims are conducted by persons not involved in the initial claim determination. In the event the review decision is based in whole or in part on a dental clinical judgment as to whether a particular treatment, drug or other service is experimental or investigational in nature, WDS will consult with a dental professional advisor. Appeals Committee If you are dissatisfied with the outcome of the informal review, you may request that your claim be reviewed formally by the WDS Appeals Committee. This Committee includes only persons who were not involved in either the original claim decision or the informal review. Your request for a review by the Appeals Committee must be made within 90 days of the post-marked date of the letter notifying you of the informal review decision. Your request should include the information noted above plus a copy of the informal review decision letter. You may also submit any other documentation or information you believe supports your case. The Appeals Committee will review your claim and make a determination within 30 days of receiving your request or within 20 days for experimental/ investigational procedures appeals and sends you a written notification of the review decision. Upon request, you will be granted access to and copies of all relevant information used in making the review decision. In the event the review decision is based in whole or in part on a dental clinical judgment as to whether a particular treatment, drug or other service is experimental or investigational in nature, WDS will consult with a dental professional advisor. The decision of the Appeals Committee is final. If you disagree with this the outcome of your appeal and you have exhausted the appeals process provided by your group plan, there may be other avenues available for further action. If so, these will be provided to you in the final decision letter. Under the Vision Plan Initial Determination: VSP will pay or deny claims within thirty (30) calendar days of the receipt of the claim. In the event that a claim cannot be resolved within the time indicated VSP may, if necessary, extend the time for decision by no more than fifteen (15) calendar days. Request for Appeals: If your, or your family member s, claim for benefits is denied by VSP in whole or in part, VSP will send in writing the reason or reasons for the denial. Within one hundred eighty (180) days after receipt of such notice of denial of a claim, a verbal or written request may be made to VSP for a full review of such denial. The request should contain sufficient information to identify the covered person for whom a claim for benefits was denied, including the name of the enrolled employee, the identification of the enrolled employee, the patient s name and date of birth, the name of the provider of services and the claim number. You may state the reasons you believe that the claim denial was in error. You may also provide any pertinent documents to be reviewed. VSP will review the claim and give you the opportunity to review pertinent documents, submit any statements, documents, or written arguments in support of the claim, and appear personally to present materials or arguments. All requests for appeals should be submitted to: VSP Member Appeals 3333 Quality Drive Rancho Cordova, CA (800) VSP s determination, including specific reasons for the decision, shall be provided and communicated to you or your family member within thirty (30) calendar days after receipt of a request for appeal. If you as the patient disagree with VSP s determination, you may request a second level appeal within sixty (60) calendar days from the date of the determination. VSP shall resolve any second level appeal within thirty (30) calendar days. When you have completed all appeals mandated by the Employee Retirement Income Security Act of 1974 ( ERISA ), additional voluntary 16-5 Problem Resolution, ERISA & HIPAA Information

181 alternative dispute resolution options may be available, including mediation and arbitration. You can contact the U. S. Department of Labor or the State insurance regulatory agency for details. Additionally, under ERISA (Section 502(a) (1)(B)) [29 U.S.C. 1132(a)(1)(B)], the covered person has the right to bring a civil (court) action when all available levels of reviews of denied claims, including the appeal process, have been completed, the claims were not approved in whole or in part, and you as the covered person disagrees with the outcome. Under the Employee Assistance Program If your claim under the Employee Assistance Program is denied, you have completed the appeals process described in Chapter VI and the matter is still unresolved to the satisfaction of all parties, you may be able to submit the matter to arbitration conducted pursuant to arbitration rules of the American Arbitration Association. Please see the information for your Employee Assistance Plan provider. Under the Life and Accidental Death & Dismemberment Plan MetLife will review the claims for benefits and notify you or your beneficiary of its non-disability related decision in a period of time not to exceed 90 days from receipt date. Disability related decisions will be decided in accordance with the Claims Involving Disability Determinations in Connection with Life Insurance section. If more than 90 days are needed to make a determination, MetLife will notify you or your beneficiary of the special circumstances beyond the control of the Plan. If MetLife denies the claim, notification of the claims decision will state the reason for denial and reference the specific Plan provision(s) on which the denial is based. If the denial is due to insufficient information, the notification will describe what additional information is needed and why. The notification will also include a description of the Plan review procedures and time limits, including the right to a civil action. In the event a claim has been denied in whole or in part, you or, if applicable, your beneficiary can request a review of your claim by MetLife. This request for review should be sent in writing within 60 days after you or, if applicable, your beneficiary received notice of denial of the claim. The request is to be send to Group Insurance Claims Review at the address of the MetLife office that processed the claim. When requesting a review, in writing, state the reason you or, if applicable, your beneficiary believe the claim was improperly denied and submit any comments, documents, records or other information you or, if applicable, your beneficiary deem appropriate. Upon your written request, MetLife will provide you free of charge with copies of relevant documents, records and other information. MetLife will re-evaluate all the information provided in writing and will conduct a full and fair review of the claim. You or, if applicable, your beneficiary will be notified of the decision within a reasonable period not to exceed 60 days from the date MetLife received your request for review, unless MetLife notifies you within that period that there are special circumstances requiring an extension of time of up to 60 additional days. If MetLife denies the claim on appeal, a final written decision will be sent stating the reason(s) why the claim you or your beneficiary appealed is being denied; reference any specific Plan provision(s) on which the denial is based; any voluntary appeal procedures offered by the Plan; and a statement of your right to bring a civil action if your claim is denied after an appeal. Upon written request, MetLife will provide you free of charge with copies of documents, records and other information relevant to your claim. Claims Involving Disability Determinations in Connection with Life Insurance After MetLife receives your claim involving a disability determination, your claim will be reviewed and you will be notified of the approval or denial within 45 days of the date MetLife received the claim. If more than 45 days are needed, MetLife will notify you of the special 16-6 Problem Resolution, ERISA & HIPAA Information

182 circumstances beyond the control of the Plan. MetLife may have up to two additional extensions of 30 days each to decide your claim. If you do not provide requested information in a timely manner, the period of time pending receipt of your information does not count toward the MetLife s notification period. If MetLife denies your claim, you may appeal the decision in writing within 180 days of receiving the decision. As part of your appeal, you may submit any written comments, documents, records or other information relating to your claim. MetLife will then conduct a full and fair review or your claim taking into account all submitted information. A health care professional with appropriate training and experience will be consulted. You will be notified of MetLife s decision within 45 days of receipt of your written request for review. MetLife may have an additional 45 days under special circumstances. If MetLife denies your appeal, a final written decision stating the reason(s) for denial, reference(s) to any specific Plan provisions on which the denial is based, any voluntary appeal procedures offered by the Plan, and a statement of your right to bring civil action. You may contact the HR Service Center for an insurance certificate containing additional details. The insurance contract governs the terms of coverage. Under the Business Travel Plan Contact Providence Strategic and Management Services Risk Management department for information on the claims process under the Business Travel Plan coverages. Under the Long Term Disability Plan, and Providence Hood River Oregon Short Term Disability Plan Unum will review the claims for benefits and notify you of its decision no later than 45 days after the claim is filed. If more than 45 days are needed to make a determination, the time period may be extended twice by 30 days. Unum will notify you of the extension due to special circumstances beyond the control of the Plan. If you fail to provide all the necessary information, you will have 45 days to provide the information. This period will not count toward Unum decision period. If Unum denies the claim, written or electronic notification of the claims decision will state the specific reason(s) for the determination; reference specific Plan provision(s) on which the determination is based; describe additional material or information necessary to complete the claim and why such information is necessary; describe Plan procedures and time limits for appealing the determination, and your right to obtain information about those procedures and the right to sue in federal court; and disclose any internal rule, guidelines, protocol or similar criterion relied on in making the adverse determination (or state that such information will be provided free of charge upon request). In the event a claim has been denied in whole or in part, you can request a review of your claim by Unum. This request for review should be sent in writing within 180 days after you receive notice of denial of the claim to the address specified in the notice. When requesting a review, in writing, state the reason you believe the claim was improperly denied and submit any comments, documents, records or other information you deem appropriate. Upon your written request, Unum will provide you, free of charge, with copies of relevant documents, records and other information. Unum will re-evaluate all the information provided in writing and will conduct a full and fair review of the claim. You will be notified of the decision within a reasonable period not to exceed 45 days from the date we received your request for review, unless Unum notifies you within that period that there are special circumstances requiring an extension of time of up to 45 additional days Problem Resolution, ERISA & HIPAA Information

183 You may contact the HR Service Center for an insurance certificate containing additional details. The insurance contract governs the terms of coverage and administration. Under the Flexible Spending Accounts If your claim under the Health Care Flexible spending claim account is denied, you may appeal that claim. You will be notified of the decision, (a) within 30 days of receiving your request for a first level appeal, or (b) within 30 days of receiving your request for a second level appeal. If the claim is denied on appeal you will receive The specific reason(s) for the denial, and reference to the pertinent Participating Benefit provisions upon which the denial is based; A description of any additional material or information you need to submit to perfect your claim and the reasons why such material or information is necessary; An explanation of the Plan s claims appeal procedures, including any applicable time limits; Upon request you may also receive: Reasonable access to and copies of all documents, records and other information relevant to the claim for benefits; Any internal rule, guideline, protocol or other similar criterion relied on in the determination, or a statement that a copy of such rule, guideline, protocol or other similar criterion will be provided free of charge; and An explanation of the scientific or clinical judgment relied on in the determination, or a statement that such explanation will be provided free of charge. Once you have completed the appeals process described on page 5-3, and the matter is still unresolved to the satisfaction of all parties, you have the right to bring an action under Section 502(a)(1) (B)of ERISA. No lawsuit shall be brought against the Plan, the Company, the Plan Administrator or a Claims Administrator after 120 days from receipt of the final decision on a claim appeal. For the Dependent Care Reimbursement Account, you will receive a notice of denial within 90 days of denial, unless the Plan needs to extend for up to 90 additional days, which includes the reason for denial, plan reference, what would be needed to appeal and the steps to appeal. You will have 60 days in which to appeal. If, at the end of the full appeal process, you remain unsatisfied, you have the right to bring an action under Section 502(a) of ERISA. Statement of ERISA Rights As a participant in the Providence Health and Welfare Benefit Plan benefit program, you are entitled to certain rights and protection under the Employee Retirement Income Security Act of 1974 (ERISA) and under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). (The Dependent Care Flexible Spending Account and Business Travel Accident Insurance are not ERISAgoverned plans. Therefore, ERISA rights do not apply.) ERISA provides that all plan participants are entitled to: Receive Information About Your Plan and Benefits Examine, without charge, at the Plan Administrator s office and at other specified locations, such as worksites and union halls, all documents governing the Plan, including insurance contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration. Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the Plan, including insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated summary plan description. The Plan Administrator may make a reasonable charge for the copies Problem Resolution, ERISA & HIPAA Information

184 Receive a summary of the Plan s annual financial report. The Plan Administrator is required by law to furnish each participant with a copy of this summary annual report. Continue Group Health Care Coverage Continue health care coverage for yourself, your spouse or dependents if there is a loss of coverage under the Plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review this summary plan description and the documents governing the Plan on the rules governing your COBRA continuation coverage rights. Adult Benefit Recipients experiencing a termination of coverage outside that of the employee are not eligible for COBRA but can choose to continue a transitional coverage for a period of up to 3 months at a cost of 102% of the full cost of the plan. Reduction or elimination of exclusionary periods of coverage for pre-existing conditions under your group health plan, if you have creditable coverage from another plan. You should be provided a certificate of creditable coverage, free of charge, from your group health plan or health insurance issuer when you lose coverage under the Plan, when you become entitled to elect COBRA continuation coverage, when your COBRA continuation coverage ceases, if you request it before losing coverage or if you request it up to 24 months after losing coverage. Without evidence of creditable coverage, you may be subject to a pre-existing condition exclusion for 12 months (18 months for late enrollees) after your enrollment date in your coverage. Prudent Actions by Plan Fiduciaries In addition to creating rights for plan participants ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your Plan, called fiduciaries of the Plan, have a duty to do so prudently and in the interest of you and other plan participants and beneficiaries. No one, including your employer, your union or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a benefit or exercising your rights under ERISA. Enforcement of Your Rights If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules. Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of plan documents or the latest annual report from the Plan and do not receive them within 30 days, you may file suit in a federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the Plan Administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or federal court. In addition, if you disagree with the Plan s decision or lack thereof concerning the qualified status of a domestic relations order or a medical child support order, you may file suit in federal court. If it should happen that plan fiduciaries misuse the Plan s money or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor or you may file suit in a federal court. The court will decide who should pay court costs and legal fees. If you are successful the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous. Assistance with Your Questions If you have any questions about your plan, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA or if you need assistance in obtaining documents from the Plan Administrator, 16-9 Problem Resolution, ERISA & HIPAA Information

185 you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration at Plan Benefits Can Be Changed or Discontinued Providence Health & Services reserves the right to alter, delete, cancel, and otherwise change plan benefits at any time. If any plan is terminated, coverage for you and your eligible family members will end. However, benefits for any legitimate claims incurred before a plan s termination will be provided in accordance with plan provisions. The right to amend, modify, or terminate the Plans at any time and/or in any manner has been delegated to the Senior Vice President, Chief Human Resources Officer for Providence Health & Services (or her/his designee) by the Administrative Committee of Providence Health & Services. The right to make changes in the Providence Health and Welfare Benefit Plan benefit plan provisions, including the right to terminate the Plan, has been delegated to the Senior Vice President, Chief Human Resources Officer for Providence Health & Services (or her/his designee) as the Plan Administrator, by the President/CEO of Providence Health & Services. For information as to when the Plan can rescind your coverage retroactively, please see Chapter 1 and page 5-5.Rescission of coverage and eligibility determinations constitute adverse benefit determinations with appeal rights. Effective Date of Plan Changes Any changes to the Plans will take effect on the date established by the persons making the Plan change. Any material changes to the Plans (that involve terms or conditions discussed in the summary of benefit coverages) will be reported within sixty days prior to when the change takes effect. If any conflicts arise between this Summary Plan Description and the applicable insured contracts, the contracts will govern. Non-Discrimination Testing Federal legislation requires that certain Providence Health and Welfare Benefit Plan benefits pass special non-discrimination tests to ensure that highly compensated employees don t receive a disproportionate share of plan benefits. If the Plan does not meet these tests, highly compensated employees will owe income tax on the value of their benefits. If Providence Health and Welfare Benefit Plan fails to pass the non-discrimination tests, and you are considered to be highly compensated, you will be informed of any additional income to be reported on your W-2 or changes to be made to your benefit elections. HIPAA Health Insurance Portability and Accountability Act of 1996 NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY. If you have any questions about this Notice, please contact the Privacy Contact. Plan Privacy Contact Providence Health and Welfare Benefit Plan Plan Providence Health & Services Group Insurance Plan Providence (PSMS) Integrity Providence Health & Services 1801 Lind Avenue SW #9016 Renton, WA Telephone: As required by the Health Insurance Portability and Accountability Act of 1996, as amended by the Health Information Technology for Economic Problem Resolution, ERISA & HIPAA Information

186 and Clinical Health Act ( HITECH ) and the Modifications to the HIPAA Privacy, Security, Enforcement, and Breach Notification Rules under the Health Information Technology for Economic and Clinical Health Act and the Genetic Information Nondiscrimination Act; Other Modifications to the HIPAA Rules (collectively HIPAA ), this Notice describes the legal obligations of Providence Health & Services ( Providence ) and the Providence Health and Welfare Benefit Plan group health plan (the Plan ) regarding your protected health information ( PHI ) held by the Plan. Among other things, this Notice describes how your PHI may be used or disclosed to carry out treatment, payment, or health care operations, or for any other purposes that are permitted or required by law. PHI means any information, including demographic information, that is created or received by a covered entity or an employer and relates to: the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; and that identifies the individual or for which there is a reasonable basis to believe the information can be used to identify the individual. PHI includes information concerning persons living or deceased and may be written, oral, or electronic. We understand that your PHI is personal. We are committed to protecting your PHI. We create a record of the health care claims reimbursed under the Plan for Plan administrative purposes. This Notice applies to all of the medical records we maintain in connection with the Plan s group health plan benefits. Your personal doctor or health care provider may have different policies or notices regarding the doctor s use and disclosure of your PHI created in the doctor s office or clinic. An insurer that insures group health plan benefits of the Plan may have different policies or notices regarding the insurer s use and disclosure of your PHI created by the insurer Problem Resolution, ERISA & HIPAA Information This Notice tells you about the ways in which we may use and disclose your PHI. It also describes our obligations and your rights regarding the use and disclosure of your PHI. Our Responsibilities We are required by law to: Maintain the privacy of your PHI; Provide you with certain rights with respect to your PHI; Provide you with this Notice of our legal duties and privacy practices with respect to your PHI; and Follow the terms of the Plan s Notice of Privacy Practices that is currently in effect. How We May Use and Disclose Your PHI The following categories describe different ways that we use and disclose PHI. For each category of uses or disclosures we explain what we mean and give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories. For Treatment (as described in the Privacy Regulations). We may use or disclose your PHI to facilitate medical treatment or services by providers. We may disclose your PHI to providers, including doctors, nurses, technicians, medical students, or other hospital personnel, who are involved in taking care of you. For Payment (as described in the Privacy Regulations). We may use and disclose your PHI to determine eligibility for Plan benefits, to facilitate payment for the treatment and services you receive from health care providers, to determine benefit responsibility under the Plan, or to coordinate Plan coverage. For example, we may tell your health care provider about your medical history to determine whether a particular treatment is experimental, investigational, or medically necessary or to determine whether the Plan will cover the treatment. Likewise, we may share your PHI with another entity to assist with the adjudication or subrogation of health claims or to another plan to coordinate benefit payments.

187 For Health Care Operations (as described in the Privacy Regulations). We may use and disclose your PHI for other Plan operations. These uses and disclosures are necessary to run the Plan. For example, we may use your PHI in connection with: conducting quality assessment and improvement activities; underwriting, premium rating, and other activities relating to Plan coverage; submitting claims for stop-loss (or excess loss) coverage; conducting or arranging for medical review, legal services, audit services, and fraud abuse detection programs; business planning and development such as cost management; and business management and general Plan administrative activities. The Plan may not use or disclose PHI that constitutes genetic information for underwriting purposes. Plan Sponsor. For purposes of administering the Plan, we may disclose your PHI to certain employees of Providence. However, those employees will only use or disclose that information to perform Plan administration functions, including payment and health care operations, or as otherwise required by HIPAA or state law, unless you have authorized further disclosures. Your PHI cannot be used for employment purposes without your specific authorization. For a more detailed explanation of the limited ways that we may use or disclose your PHI, please refer to the Plan document and/or any applicable amendments. Business Associates. We contract with service providers called business associates to perform various functions on its behalf. For example, the Plan contracts with a service provider to perform the administrative functions necessary to pay your claims for dental benefits. To perform these functions or to provide the services, business associates will receive, create, maintain, use, or disclose PHI, but only after the Plan and the business associate agree in writing to contract terms requiring the business associate to appropriately safeguard your PHI. The Plan will comply with requirements of HIPAA and its requirements to provide notification to affected individuals, the Department of Health & Human Services, and the media (when required) if the Plan or one of its business associates discovers a breach, as defined under HIPAA, of unsecured PHI. Organized Health Care Arrangement. Providence Health & Services Providence Health and Welfare Benefit Plan Welfare Plan, other group health plans sponsored by Providence and its affiliates and the insurers, if any, of benefits provided under the group health plans are an organized health care arrangement within the meaning of the Privacy Regulations. As such, members of the organized health care arrangement may share your protected health information with each other to carry out payment and health care activities on behalf of the group health plans. Other Covered Entities. We may use or disclose your PHI to assist health care providers in connection with their treatment or payment activities, or to assist other covered entities in connection with certain health care operations. For example, the Plan may disclose your PHI to a health care provider when needed by the provider to render treatment to you. The Plan may disclose PHI to another covered entity to conduct health care operations in the areas of quality assurance and improvement activities, or accreditation, certification, licensing, or credentialing. This also means that the Plan may disclose or share your PHI with other health care programs or insurance carriers in order to coordinate benefits, if you or your family members have other health insurance or coverage. As Required by Law. We will disclose your PHI when required to do so by federal, state, or local law. For example, we may disclose your PHI when required by a court order in a litigation proceeding such as a malpractice action. To Avert a Serious Threat to Health or Safety. We may use and disclose your PHI when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure would only be to someone able to help prevent the threat. For example, we may disclose your PHI in a proceeding regarding the licensure of a physician Problem Resolution, ERISA & HIPAA Information

188 Disclosures to Your Personal Representative and Family Members Your Personal Representative. The Plan will disclose your PHI to an individual who has been designated by you as your personal representative and who has qualified for such designation in accordance with relevant law. Prior to such a disclosure, however, the Plan must be given written documentation that supports and establishes the basis for the personal representation. The Plan may elect not to treat the person as your personal representative if it has a reasonable belief that you have been, or may be, subjected to domestic violence, abuse, or neglect by such person; treating such person as your personal representative could endanger you; or the Plan determines, in the exercise of its professional judgment, that it is not in your best interest to treat the person as your personal representative. Others Involved in Your Care. The Plan may disclose your PHI to a friend or family member who is involved in your health care, unless you object or request a restriction (as provided below). The Plan also may also disclose your information to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location. If you are not present or able to agree to these disclosures of your PHI, then using professional judgment, the Plan may determine whether the disclosure is in your best interest. Mail to Employee. With only limited exceptions, we will send all mail to the employee. This includes mail relating to the employee s spouse and other family members who are covered under the Plan, and it also includes mail with information on the use of Plan benefits by the employee s spouse and other family members and information on the denial of any Plan benefits to the employee s spouse and other family members. If a person covered under the Plan has requested restrictions or confidential communications (as provided below), and if we have agreed to the request, we will send mail as provided by the request. Special Situations When We May Use or Disclose Your Protected Health Care Information Organ and Tissue Donation. If you are an organ donor, we may release your PHI to organizations that handle organ procurement or organ, eye, or tissue procurement or transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation. Military and Veterans. If you are a member of the armed forces, we may release your PHI as required by military command authorities. We may also release PHI about foreign military personnel to the appropriate foreign military authority. Workers Compensation. We may release your PHI for workers compensation or similar programs. These programs provide benefits for work-related injuries or illness. Public Health Risks. We may disclose your PHI for public health activities. These activities generally include the following: To prevent or control disease, injury or disability; To report births and deaths; To report child abuse or neglect; To report reactions to medications or problems with products; To notify people of recalls of products they may be using; To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required or authorized by law. Health Oversight Activities. We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These Problem Resolution, ERISA & HIPAA Information

189 activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws. Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose your PHI in response to a court administrative order. We may also disclose your PHI in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested. Law Enforcement. We may release your PHI if asked to do so by a law enforcement official: In response to a court order, subpoena, warrant, summons, or similar process; To identify or locate a suspect, fugitive, material witness, or missing person; If it pertains to the victim of a crime if, under certain limited circumstances, we are unable to obtain the person s agreement; If it pertains to a death we believe may be the result of criminal conduct; If it pertains to criminal conduct at a hospital, clinic, or treatment facility; In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime. Coroners, Medical Examiners and Funeral Directors. We may release your PHI to a coroner or medical examiner. This may be necessary to identify a deceased person or determine the cause of death. We may also release your PHI to funeral directors as necessary to carry out their duties. National Security and Intelligence Activities. We may release your PHI to authorized federal officials for intelligence, counterintelligence, or other national security activities authorized by law, and for the protection of the President, other authorized persons, or heads of state. Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release your PHI to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution. Required Disclosures Disclosures to the Secretary of the U.S. Department of Health and Human Services. The Plan is required to disclose your PHI to the Secretary of the U.S. Department of Health and Human Services when the Secretary is investigating or determining the Plan s compliance with the Privacy Regulations. Disclosures to You. The Plan is required to disclose to you or your personal representative most of your PHI when you request access to this information. Your Rights Regarding Your PHI You have the following rights regarding PHI we maintain about you: Right to Inspect and Copy. You have the right to inspect and copy PHI that may be used to make decisions about your Plan benefits. To inspect and copy PHI that may be used to make decisions about you, you must submit your request in writing to the Regional Privacy Officer. To the extent that PHI is maintained in an electronic health record, you may request that the Plan provide a copy to you or to a person or entity designated by you in an electronic format. If you request a copy of the information, we may charge a reasonable fee for the costs of copying, mailing, or other supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to PHI, you may request that the denial be reviewed. Right to Request Amendment. If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the Plan Problem Resolution, ERISA & HIPAA Information

190 To request an amendment, your request must be made in writing and submitted to the Regional Privacy Officer. To the extent that PHI is maintained in an electronic health record, you may request that the Plan provide a copy to you or to a person or entity designated by you in an electronic format. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason that supports the request. In addition, we may deny your request if you ask us to amend information that: Is not part of the medical information kept by or for the Plan; Was not created by us, unless the person or entity that created the information is no longer available to make the amendment; Is not part of the information which you would be permitted to inspect or copy; or Is accurate and complete. Right to an Accounting of Disclosures. You have the right to request an accounting of certain disclosures the Plan has made of your PHI. To request an accounting of disclosures, you must submit your request in writing to the Regional Privacy Officer. Your request must state the time period, which may not be longer than six years and may not include disclosures made before April 14, Your request should indicate in what form you want the accounting (for example, paper or electronic). The first accounting you request within a twelve month period will be free. For additional accountings, we may charge you for the costs of providing the accountings. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. Right to Request Restrictions. You have the right to request a restriction or limitation on the PHI we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the PHI we disclose to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not Problem Resolution, ERISA & HIPAA Information use or disclose PHI for payment or health care operations purposes for a surgery you had where the surgery costs have been paid out-of-pocket in full by you (in other words, the Plan is not required to pay for any part of the item or service). Other than where the Plan is not required to pay for the medical services you receive, we are not required to agree to your request. To request restrictions, you must make your request in writing to the Regional Privacy Officer. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse. Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to the Privacy Contact. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how and where you wish to be contacted. Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice. To obtain a paper copy of this Notice, you must request it in writing from the Regional Privacy Officer. Changes to This Notice. We reserve the right to change this Notice. We reserve the right to make the revised or changed notice effective for PHI we already have about you as well as any information we receive in the future. Complaints. If you believe your privacy rights have been violated, there are several ways by which you may lodge a complaint. You may call and make a report using the Providence s Integrity Line ( ), submit an electronic complaint by logging on to Providence s Integrity web-site, contact the Privacy Contact at the above-address

191 and telephone number, or file a complaint with the Secretary of the Department of Health & Human Services. You will not be penalized or retaliated against for filing a complaint. Questions If you have questions about this notice, please contact the HR Service Center at or at [email protected]. Your inquiry will be forward to the Program Director, Benefits Compliance. Other Uses of PHI Other uses and disclosures of PHI not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you provide us with an authorization to use or disclose your PHI, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose your PHI for the reason covered by your initial written authorization. We are unable to take back any disclosures we have already made with your permission. We are required to retain our records of the care that we provided to you. The Plan must always obtain an authorization for use and disclosure of psychotherapy notes, marketing and sale of PHI as added by the 2013 final reguations in 45 CFR Section (b)(1)(ii) (E). Keep the Plan Informed of Address Changes You should keep the Plan informed of any changes in your address. In the event that your PHI has been breached, the Plan will notify you at your address on record in accordance with the Plan s health information privacy policy.. Effective Date This Notice of Privacy Practices becomes effective on January 1, Separation of Providence Health & Services and the Group Health Plan The following classes of employees or other persons under the control of Providence Health & Services shall be given access to protected health information: Senior Vice President, Chief Human Resources Officer VP, Chief Human Resources Operating Officer Administrative Assistant to the CHROO Senior Director, Benefits, PH&S Senior Benefits Coordinator, PH&S, or successor Administrative Assistant position to Senior Director, Benefits Director, Health and Welfare Benefits, PH&S Program Director, Benefit Compliance/ Communication, PH&S Director, Wellness & Absence Management, PH&S Benefits Analyst Wellbeing Manager Benefits, PH&S Senior Benefits Specialist, PH&S Benefits Specialist, PH&S Senior Manager HRSC Operations Manager HRSC Operations HRSC Consultant Senior HR Specialist, Customer Service Specialist and Electronic Files Specialists within the HRSC limited to and pursuant with receiving information from employees Regional and PSMS Privacy Officers Department of Legal Affairs attorneys Risk Management, PSMS Providence Health Plan designated employees pursuant to their role as claims administrator Accountant II Payroll, PSMS, for Health Care Flexible Spending Account financial data Providence Health & Services shall restrict the access to and use of protected health information by such employees and other persons described above to the Plan administration functions that Providence Health & Services performs for the Plan, including payment and health care operations Problem Resolution, ERISA & HIPAA Information

192 XVII. Welfare Plan Information Name of Plan and Plan Number Type of Plan Providence Health & Services Health and Welfare Benefit Plan Welfare Benefit Plan, which includes The Providence Health & Services Group Insurance Plan (PN 501). The Plans are group health welfare plans providing the following types of benefits: Self-Insured Benefits 1. Medical Insurance 2. Dental Insurance 3. Vision Insurance 4. Health Care and Dependent Care Flexible Spending Accounts Insured Benefits 1. Health Maintenance Organization Medical Insurance in Southern California 1. Basic Employee Life Insurance 2. Supplemental Accidental Death and Dismemberment Insurance 3. Supplemental Employee and Dependent Life Insurance 4. Long Term Disability Insurance 5. Short Term Disability Insurance for Hood River Oregon employees 6. Employee Assistance Program 7. Dental Insurance for Specific Employee Group within the Southern California Region Plan Year The plan year is January 1 to December 31. Plan Administrator, Plan Sponsor, and Employer Identification Number for PN 501 Contributions, Funding, and Administration Plan Administrator and Plan Sponsor Senior Vice President, Chief Human Resources Officer, Providence Strategic and Management Services (or his/her designee) Providence Health & Services - Washington 1801 Lind Avenue SW, #9016 Renton WA (425) EIN # Medical, Dental and Vision benefits are self-insured by participating employers. Participating employers include: Providence Strategic and Management Services Providence Alaska Region Providence Southern California Region Providence Oregon Region Providence Washington Regions/Service Areas: Northwest Service Area, Providence Health Care, Senior and Community Services, Southeast Washington, Southwest Service Area Providence Western Montana Region Medical and dental certain benefits offered in the Providence Southern California Region are insured: Health Maintenance Organization Medical Plans Dental Maintenance Organization (legacy) 17-1 Welfare Plan Information

193 Contributions, Funding, and Administration Medical, Dental and Vision benefits are self funded by participating employers. Claims paid under the Plans are paid first from any monies received from plan participants. Medical, Dental and Vision claims are paid from the general assets of participating employers. Two HMO medical plans in the Southern California Region are insured through insurance contracts paid for by employer and employee contributions. For these HMO Plans, the participating employers have delegated authority to the insurance company to administer benefit claims under the Plans. Health Care Spending Accounts is funded by pre-tax participant contributions. Medical claims are paid by: Providence Health Plan P.O. Box 4447 Portland, OR Toll-free: Blue Shield of California (UHW PSJMC legacy plans - see Summary of Material Modification in appendix for California employees) P.O. Box Chico, CA For Group Health HMO (Washington) claims, see Appendix For Montana employees, medical claims are administered by Allegiance Benefit Management, Inc.; information provided in separate medical plans summary. Dental claims are paid by: Delta Dental/Washington Dental Service P.O. Box Seattle, WA Toll-free: For the fully insured DeltaCare HMO: Toll-free Vision claims are paid by: Vision Service Plan 3333 Quality Drive Rancho Cordova, CA Group Number: Toll-free: Health Care and Dependent Care Flexible Spending Account claims are paid by: HealthEquity, Inc. 15 W Scenic Point Dr., Ste 400 Draper, UT As claims administrators for the Plans described above, these entities subject to Providence Health & Services overall authority as Plan Administrator have discretionary authority to interpret plan provisions, to decide questions of eligibility for coverage or benefits under the Plan, to adjudicate claims, and to decide any appeals of denied claims. All other Providence Health and Welfare Benefit Plan benefits are insured through insurance contracts paid for by employer and/or employee contributions. For these Plans, the participating employers have delegated authority to the insurance company to administer benefit claims under the Plans Welfare Plan Information

194 Contributions, Funding, and Administration (cont.) California Health Maintenance Organization Medical insurance benefits are funded, administered, and paid through the purchase of insurance. Benefits are guaranteed in accordance with the provisions of the insurance contract. Blue Shield of California 50 Beale Street, 22nd Floor San Francisco, CA California Dental HMO Program benefits are funded, administered, and paid through the purchase of insurance. Benefits are guaranteed in accordance with the provisions of the insurance contract. Delta Dental of California DeltaCare USA Customer Servcies P.O. Box 1803 Alpharetta, CA Basic Employee Life, Supplemental Employee Life Insurance, Dependent Life Insurance and Supplemental Accidental Death and Dismemberment Insurance benefits are funded, administered, and paid through the purchase of insurance. Benefits are guaranteed in accordance with the provisions of the insurance contract. Metropolitan Life Insurance Company 200 Park Avenue New York, NY Policy Number: G Long Term Disability and Short Term Disability for Hood River OR Insurance benefits are funded, administered, and paid through the purchase of insurance. Benefits are guaranteed in accordance with the provisions of the insurance contract. Unum Life Insurance Company of America 2211 Congress Street Portland, ME Policy Number: (LTD) Employee Assistance Program benefits are funded, administered, and paid through a service agreements. Benefits are guaranteed in accordance with the provisions of the agreement. APS Healthcare Bethesda, Inc. ValueOptions 8403 Colesville Road, Suite Corporate Blvd. Sliver Spring, MD Norfolk, VA Magellan Behavioral Health, Inc. Providence Health & Services - Oregon Magellan Plaza Drive dba Providence EAP Maryland Heights, MO NE Glisan St Portland, OR Agent for Service of Legal Process for PN 501 The registered agent on behalf of the Plan Administrator and Plan Sponsor is: Business Filings Incorporated 1801 West Bay Drive NW, Suite 206 Olympia, Washington Welfare Plan Information

195 Named Fiduciary Providence Health & Services - Washington is the named fiduciary for most of the health and welfare plans as defined in ERISA. The fiduciary acts on your behalf to make sure the Plans are administered fairly, honestly, and in accordance with legal standards and the terms of the plan documents. In exercising fiduciary responsibilities, the Plan Administrator will have discretionary authority (a) to determine whether and to what extent Participants and beneficiaries are entitled to plan benefits, and (b) to construe the Plan terms. The Plan Administrator will be deemed to have properly exercised such discretionary authority unless the Plan Administrator has abused discretion hereunder by acting arbitrarily and capriciously. Blue Shield of California is the named claims fiduciary for the Health Maintence Organization medical plans in California, as defined in ERISA. Blue Shield will administer the Plan in accordance with ERISA and has discretionary authority to make decisions on claim appeals and to interpret the terms of the Health Maintenance Organization plans. Unum is the named claims fiduciary for the Long Term Disability Plan and Short Term Disability Plan for Hood River OR employees, as defined in ERISA. Unum will administer the Plan in accordance with ERISA and has discretionary authority to make decisions on claim appeals and to interpret the terms of the LTD Plan. MetLife is the named claims fiduciary for the Basic and Supplemental Life and Accidental Death & Dismemberment Plans, and Long Term Care insurance, as defined in ERISA. MetLife will administer the Plans in accordance with ERISA and has discretionary authority to make decisions on claim appeals and to interpret the terms of the Plans. Delta Dental of California is the named claims fiduciary for the DeltaCare USA Dental HMO Program, as defined in ERISA. Delta Dental will administer the Plan in accordance with ERISA and has discretionary authority to make decisions on claim appeals and to interpret the terms of the Dental HMO Program. Magellan, ValueOptions, APS Healthcare and Providence Health & Services - Oregon dba Providence EAP, are the named claims fiduciary for the Employee Assistance Program for the state(s) to which they are designated as the provider, as defined in ERISA. Magellan, ValueOptions, APS Healthcare and Providence Health & Services - Oregon dba Providence EAP will administer the Plan in accordance with ERISA and has discretionary authority to make decisions on claim appeals and to interpret the terms of the Employee Assistance Program. Business Travel Accident Insurance (non-erisa) Business Travel Accident Insurance benefits are funded, administered, and paid through the purchase of insurance. Benefits are guaranteed in accordance with the provisions of the insurance contract. CHUBB Group of Insurance Companies Embarcadero Center West 275 Battery Street, Suite 1200 San Francisco, CA Policy Number: Welfare Plan Information

196 This page is intentionally left blank If you are enrolled in a Health Maintenance Organization option or a legacy medical plan, please refer to