OAKLAND COMMUNITY COLLEGE

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1 OAKLAND COMMUNITY COLLEGE Flexible Compensation Plan Flex Comp Exempt Administration and Management Staff Plan Year January 1, - December 31,

2 The benefits described in this booklet do not constitute a guarantee of such benefits and are subject to change by the Board of Trustees, provided however, that all such benefits and other conditions of employment may be subject to a collective bargaining agreement. Any conflict between the terms and conditions of benefits provided in this booklet and those provided in an applicable collective bargaining agreement will be resolved with reference to the collective bargaining agreement. Please note when selecting your benefits during open enrollment in Oct/Nov, you are electing benefits for the calendar year January-December. 1

3 Contents Introduction 3 Plan Overview 4 Considerations 5 Benefits Summary 7 Flexible Benefits at a Glance 8 Medical Coverage 9 Dental Coverage 27 Vision Coverage 29 Group Term Life and AD and D Insurance 30 Optional Term Life and AD and D Insurance 31 Dependent Term Life Insurance 32 Short Term Disability 33 Long Term Disability 34 Flexible Spending/Reimbursement Accounts 35 Health Care expenses 39 Dependent Care expenses 42 Adoption Care expenses (b) Plan Highlights 46 Tax Deferred Retirement Plans 47 Other Benefits 48 Direct Deposit 48 Personal Accident Insurance 48 Portable Whole Life Insurance 48 Long-Term Care Insurance 48 Employee Assistance Program 48 Long Service Awards 48 Retirement 49 Tuition Grants 52 Tuition Reimbursement 53 COBRA Continuation 54 Workers Compensation 55 Glossary of Terms 57 Carrier Directory 60 2

4 Every effort has been made to ensure the accuracy and completeness of these benefit descriptions. However, if statements in this booklet differ from the applicable contracts, certificates and riders, then the terms of those contracts, certificates and riders will prevail. Introduction It is inconceivable to think a single person, a family with children or a couple approaching retirement would all want the same benefits. That is why OCC created the Oakland Community College Flexible Compensation Plan (FlexComp). FlexComp is based on the concept that you are the best judge of your benefit needs. Therefore, the program provides you with a Core of essential coverage then gives you the option of either electing additional coverage, less coverage or declining coverage altogether. Should you decide to take less comprehensive coverage or no coverage at all, you will receive a cash payment. That cash payment will be added to your earnings and received over your normal pay schedule. FlexComp also gives you the opportunity to pay health and dependent care expenses with pre-tax dollars. Through the College's Flexible Spending/Reimbursement Account, you can use pre-tax rather than aftertax dollars to pay your out-of-pocket expenses. This approach may reduce your current tax liability and could result in greater take home pay. That s what FlexComp is all about receiving the most value from your pay and benefits by choosing what best fits your personal needs. And, because you will have the opportunity to make your selections once each year, you can impact your total compensation as your needs change. The opportunity to choose is accompanied by the responsibility of understanding your choices. This booklet provides extensive information about FlexComp and the options that are available to you. Prior to January 1 of each year, you will be offered the opportunity to add or drop coverage for the following 12 months. If you do not enroll in the benefit online program established by the College, you will continue the coverage in effect, including any deductions for your health care reimbursement and/or dependent care reimbursement account(s) for the next 12 months. 3

5 Plan Overview Core Program Employee Options Oakland Community College s Flexible Compensation Program is made up of two components. The Core Program and Employee Options. includes all the current levels of coverage provided by the College. Medical Coverage for you and your eligible dependents, cost-sharing required Dental Coverage for you and your eligible dependents Vision Coverage for you and your eligible dependents Group Term Life/Accidental Death and Dismemberment Insurance Short Term Disability Long Term Disability allow you to modify the Core Program, as you wish. Cost for enhanced benefits is conveniently made through payroll deduction. Included among your Employee Options are a number of different alternatives: Enhanced Dental Coverage (nominal cost to employee) Decline Dental Coverage in exchange for cash Enhanced Vision coverage (nominal cost to employee) Less Comprehensive Vision Coverage in exchange for cash Decline Vision Coverage in exchange for cash Less Comprehensive Group Life and AD and D in exchange for cash Enhanced Options Short Term Disability (nominal cost to employee) Additional Group Term Life and Accidental Death and Dismemberment Insurance An Employee Flexible Spending/Reimbursement Account for Health Care, Adoption and/or Dependent Care Expenses (using pre-tax dollars) In addition to the Flexible Compensation menu, you will also have the opportunity to participate in other benefit programs through payroll deduction. Those programs include: Portable Whole Life Insurance Tax-Deferred Annuities Personal Accident Insurance Long-Term Care Insurance It is up to you to decide which of these options you would like for the plan year. 4

6 Considerations FlexComp increases the value of your compensation by allowing you to choose the benefits that are best for your personal situation from a range of options. The enrollment process is designed to make sure you have all the information you need to make good FlexComp decisions. Full-time employees can enroll in the FlexComp program immediately following hire. Refer to the appropriate Master Agreement/Board Policy for effective dates of coverage. After your initial enrollment, FlexComp elections can be made once each year, giving you the opportunity to change your benefits as your personal needs change. Making Your FlexComp Decisions Your personal situation, your financial position, and FlexComp s flexibility are among the factors to consider in deciding on your FlexComp program. The following list of factors may help you in considering the choices available to you. These observations should not be viewed in any way as recommendations or advice. Especially for your first enrollment the College strongly recommends that you discuss your program options with your family and a tax advisor, if you use one. Your need for benefit coverage and the kind of coverage you want are likely to vary, depending on your family situation and lifestyle: Age Your health and financial responsibilities, which affect the coverage you need, tend to vary with age. Children Your medical bills may be higher; thus the need to replace your income in the event of death or disability may be greater if you have children. Spouse's job Coordination with your spouse s benefit plans may be a consideration. Your Personal Situation Retirement plans Your savings decisions very early in your career can significantly affect the funds available for your retirement. Flexible Spending/Reimbursement Account You can use Flexible Spending/ Reimbursement Account funds to pay dependent care expenses, as well as medical, adoption, vision and dental expenses not covered by the carrier. Dollars/Cost If you were to choose the highest level of coverage in each benefit area, you 5

7 may have a deduction from your pay. If you choose lower levels of coverage, you may have cash payments included in your pay. Cash payments are subject to ordinary taxes. Making Flexible Compensation Decisions Do I have duplicate coverage? How can I coordinate coverage? If I leave my employer for whatever reason, does the employer-provided life insurance coverage stop? If so, have I provided for coverage elsewhere? If I become disabled, would my disability benefit check be enough to maintain my current lifestyle? Enrollment Period To take advantage of FlexComp choices, you need to understand the differences among the options. This summary booklet which describes each plan, and suggests factors you may wish to consider in making FlexComp decisions. An enrollment form and instructions for completing the form, are available on Infomart Each year you will have an opportunity to change your selections during the annual open enrollment process. Should any costs or levels of coverage be changed, the re-enrollment period allows you to assess those changes as they pertain to your own personal situation. Therefore, it is in your best interest to participate in the annual open enrollments to make certain that your benefit choices remain up-to-date and consistent with your objectives. If you have questions relative to your own particular situation, you can get answers to these by calling your Human Resources Specialist. Payment of any benefit is subject to the terms and conditions of the Summary Plan Document rather than any information given here. This description does not change in any way the provisions set forth in the plan document. 6

8 Benefits Summary Employees, their spouses, and dependent children, are eligible for medical coverage. These benefits are effective the first day of the month following official hire date. Medical Coverage Employees, their spouses, and dependent children, are eligible for dental and vision coverage. Employees have the option to increase their benefit levels through payroll deduction, or they may reduce their benefit levels and receive a cash payment. Dental and Vision Coverage The College provides life insurance coverage for all full-time employees. Employees may have option(s) to reduce their life insurance coverage in exchange for a cash payment. Optional life insurance coverage is paid fully by the employee and requires proof of good health. Group Life Insurance and Accidental Death and Dismemberment Employees are entitled to a weekly benefit based on a percentage of their gross wages. Benefits commence after satisfying the applicable elimination period. Employees may have the option to increase their weekly benefit. Cost for the increased coverage is made through payroll deduction. Short-Term Disability Employees are entitled to a monthly benefit based on a percentage of their gross wages. Benefits commence after the qualifying period which is the greater of 90 days or the applicable period of paid leave. Long-Term Disability Employees have the option to utilize pre-tax dollars for either health care or dependent care or adoption expenses. Maximum amount of money for health care is $2,500, and the maximum amount for dependent care is $5,000. The maximum amount for adoption is $12,650. Flexible Spending/ Reimbursement Account Other benefits available through payroll deduction include: tax deferred annuities, direct deposit, personal accident insurance, whole life portable life insurance. Other Benefits 7

9 Exempt Administrative and Management Staff "Flexible Benefits at a Glance" Benefits Core Option I Option II Option III Comments/Carrier HMO Medical Coverage In Network Deductible In Network Office Prescription Co-pay Out-of-Network Deductible Out-of-Network Cost Sharing Aetna PPO A $500/1000 $15 $10/$20/$40 $1000/$2000 See plan for details Aetna PPO B $100/200 $15 $10/$20/$40 $200/250 See plan for details Aetna Select Choice 0 $10 $5/$10 n/a See plan for details OPT OUT Opt Out (Option III) Requires proof of medical coverage other than OCC coverage Cost Sharing Required Cost sharing required Cost-sharing required No Refund Dental Coverage Year Benefit Cost Sharing Ortho Life Benefit Cost Sharing Cash Cost / Refund $ /20% $2,000 60/40% No Refund $ /20% $3,000 60/40% $48 Cost $1,200 90/10% $2,000 60/40% $96 Cost OPT OUT $150 Refund ADN Vision Coverage Exam Frames Lenses Contacts Cash Cost / Refund $45 $55 $42/70/84 $115 No Refund $45 $60 $45/75/85 $125 $24 Cost $45 $25 $21/30/40 $75 $12 Refund OPT OUT $24 Refund ADN Group Term Life and ADandD Coverage Cash Refund $120,000 No Refund $50,000 $48 refund $25,000 $96 refund Not Available Metlife Optional Term Life/AD and D Maximum Coverage Cash Cost $120,000 * Cost Varies $50,000 * Cost Varies $25,000 * Cost Varies Not Available Optional coverage, paid for by the employee, requires proof of good health. Cost based on age. Metlife Short Term Disability Base Salary Maximum Benefit Cash Cost / Refund 60% No Refund 65% $24 Cost 70% $48 Cost Not Available The Standard Long Term Disability Base Salary Cash Cost / Refund 70% No Refund Not Available Not Available Not Available The Standard Flexible Spending / Reimbursement Account Health Care Minimum Maximum Dependent Care Minimum Maximum Adoption Expense Minimum Maximum Not Available $120 $5,000 $520 $5,000 0 $12,650 Not Available Not Available Pre-Tax Payroll Deduction available for Health and Dependent Care Expenses Adoption Claims Administered by E.B.C. Inc. The menu should be read across not vertically. You may select only one option for each benefit category. Cash cost represents annual cost to employee of enhanced benefits. Cash payment represents annual refund paid to employee. Annual open enrollment period will be during Oct/Nov with an effective date of January 1. Selection of carrier is subject to change. 8

10 Medical Coverage Fortunately, most of us are in good health most of the time. But illness and accidents are unpredictable. So, it is essential to plan for large and unexpected medical expenses. FlexComp provides a range of plans, so you can choose the protection that s right for you. Several different plans are available. Choices include Aetna Select, Aetna PPO A, and Aetna PPO B. This section gives you a summary of all your health plan options and describes how the health plans work. Plan Year When an employee receives an Explanation of Benefit Statement from the insurance carrier, it is the responsibility of the employee to follow-up with the insurance carrier and/or doctor if appropriate payment is not made. Failure to do so may result in the employee being responsible for the balance of payment. Plan Year 12 months - January 1 through Dec 31 If you choose dependent coverage, your eligible dependents will be covered under the plan you select. Eligible dependents include your spouse and your children to the end of the calendar year in which they reach 26 years of age. Dependents that are totally and permanently disabled by either a physical or mental condition prior to age 19 may be covered beyond the end of the calendar year in which they turn age 26. Dependents Eligible children include: Stepchildren who reside with the employee, legally adopted children and children over whom the employee has legal guardianship. The eligible children may be included the same as your own children provided they depend upon you for support and maintenance. An OCC employee cannot be enrolled in any OCC benefit both as the subscriber and as a spouse. In the case of both parents being eligible for OCC benefits, dependents are only eligible for coverage under one parent. The cost-sharing payment shall be made through pre-tax payroll deductions. If a change in family status occurs during the year (birth, death, marriage, divorce, adoption or loss of coverage due to loss of a Spouse's employment) coverage may be added or deleted, to the extent such addition or deletion is consistent with and on account of the family status change. The employee must notify Human Resources within 31 days of the event. Coverage becomes effective on the date of the event. Important An employee participating in Aetna will receive an Aetna identification card, to be used for health services. 9

11 Oakland Community College Aetna Select SM - Open Access ASC $5/$10 RX Prescription Co-Pay $10 Office Co-pay PLAN DESIGN & BENEFITS ADMINISTERED BY AETNA LIFE INSURANCE COMPANY PLAN FEATURES PREFERRED CARE Deductible (per calendar year) None Once Family Deductible is met, all family members will be considered as having met their Deductible for the remainder of the calendar year. Member Coinsurance Covered 100% Applies to all expenses unless otherwise stated. Payment Limit (per calendar year) None Individual None Family Certain member cost sharing elements may not apply toward the Payment Limit. Only those preferred expenses resulting from the application of coinsurance percentage (except any deductibles, copays, and penalty amounts) may be used to satisfy the Payment Limit. Once Family Payment Limit is met, all family members will be considered as having met their Payment Limit for the remainder of the calendar year. Lifetime Maximum Unlimited except where otherwise indicated. Primary Care Physician Selection No. Must see Network Providers. Referral Requirement No. Must see Network Providers. PREVENTIVE CARE PREFERRED CARE Routine Adult Physical Exams/ Immunizations Covered 100% 1 exam per 12 months Routine Well Child Exams/Immunizations Covered 100% 7 exams in the first 12 months of life, 3 exams in the 13th-24th months of life; 1 exam per 12 months thereafter to age 18. Routine Gynecological Care Exams Covered 100% Includes routine tests and related lab fees Routine Mammograms Covered 100% One baseline mammogram for covered females age 35-39, one mammogram per calendar year for covered females females age 40 and over. Routine Digital Rectal Exam Covered 100% Prostate-specific Antigen Test Covered 100% Colorectal Cancer Screening For all members age 50 and over. Covered 100% Routine Eye Exams $10 office visit copay 1 exam every 12 months 1 exam every 12 months. Routine Hearing Exams Covered 100% 1 exam every 24 months Limited to $1000 within a 24 month Hearing Aids period PHYSICIAN SERVICES PREFERRED CARE Office Visits to PCP $10 office visit copay Includes services of an internist, general physician, family practitioner or pediatrician. 10

12 Specialist Office Visits E-visit to Specialist or non-specialist Walk-in Clinics Allergy Testing Allergy Injections (Copay waived when an office visit charge is not made) DIAGNOSTIC PROCEDURES $10 office visit copay Not Covered Not Covered Covered as either PCP or specialist office visit Covered as either PCP or specialist office visit PREFERRED CARE Diagnostic Laboratory and X-ray $10 copay If performed as a part of a physician office visit and billed by the physician, expenses are covered subject to the applicable physician's office visit member cost sharing EMERGENCY MEDICAL CARE PREFERRED CARE Urgent Care Provider $25 copay (benefit availability may vary by location) Non-Urgent Use of Urgent Care Provider Not Covered Emergency Room $25 copay Non-Emergency care in an Emergency Room Not Covered Ambulance Covered 100% HOSPITAL CARE PREFERRED CARE Inpatient Coverage Covered 100% The member cost sharing applies to all covered benefits incurred during a member's inpatient stay Inpatient Maternity Coverage Covered 100% The member cost sharing applies to all covered benefits incurred during a member's inpatient stay Outpatient Surgery Covered 100% Outpatient Hospital Expenses (excluding surgery) Covered 100% The member cost sharing applies to all Covered Benefits incurred during a member's outpatient visit MENTAL HEALTH SERVICES PREFERRED CARE Inpatient Covered same as Inpatient Hospital services. The member cost sharing applies to all covered benefits incurred during a member's inpatient stay Outpatient $10 copay The member cost sharing applies to all covered benefits incurred during a member's outpatient visit ALCOHOL/DRUG ABUSE SERVICES PREFERRED CARE Inpatient Covered same as Inpatient Hospital services. The member cost sharing applies to all covered benefits incurred during a member's inpatient stay Residential Treatment Facility Covered same as Inpatient Hospital services. Outpatient $10 copay The member cost sharing applies to all Covered Benefits incurred during a member's outpatient visit OTHER SERVICES PREFERRED CARE Convalescent Facility Covered 100% Limited to 120 days per calendar year. The member cost sharing applies to all covered benefits incurring during a member's inpatient stay Home Health Care Covered 100% Limited to 120 visits per calendar year. Each visit by a nurse or therapist is one visit. Each visit up to 4 hours by a home health care aide is one visit. Private Duty Nursing Covered 100% Limited to 70 eight hour shifts per calendar year. Each visit by a nurse or therapist is one visit. Each visit up to 4 hours by a home health care aide is one visit. Autism Member cost sharing is based on the type of service performed and the place of service where it is rendered. Applied Behavioral Health Analysis (ABA) and behavioral therapy for children to age 15 covered on the same basis as 11

13 any other. Hospice Care - Inpatient Covered 100% The member cost sharing applies to all covered benefits incurred during a member's inpatient stay Hospice Care - Outpatient Covered 100% The member cost sharing applies to all covered benefits incurred during a member's outpatient visit Outpatient Short-Term Rehabilitation Covered 100% after $10 copay Includes Speech, Physical, Occupational, and Spinal Manipulation Therapy, limited to 60 visits per calendar year. Durable Medical Equipment Covered 100% Maximum annual benefit of $10,000 per member per calendar year Early Intervention Services Member cost sharing is based on the type of service performed and the place of service where it is rendered Diabetic Supplies Covered same as any other medical expense. Contraceptive drugs and devices not obtainable at a Covered 100% (payable as any other covered expense) pharmacy (includes coverage for contraceptive visits) Transplants Coverage is provided at an IOE contracted facility only. Covered 100% Bariatric Surgery ($10,000 Per Life Time) Covered 100% Mouth, Jaws and Teeth Member cost sharing is based on the type of service (oral surgery procedures, whether medical or dental in performed and the place of service where it is rendered nature) Out of Area Dependents No coverage for non-emergency care received outside the service area. FAMILY PLANNING PREFERRED CARE Infertility Treatment Member cost sharing is based on the type of service performed and the place of service where it is rendered Diagnosis and treatment of the underlying medical condition. Comprehensive Infertility Services Advanced Reproductive Technology (ART) Voluntary Sterilization Including tubal ligation and vasectomy. Not Covered Not Covered Member cost sharing is based on the type of service performed and the place of service where it is rendered GENERAL PROVISIONS Dependents Eligibility Spouse, children from birth to age 26 Pre-existing Conditions Exclusion On effective date: Waived if enrolled within 31 days After effective date: Full Postponement For members age 19 or over this plan imposes a pre-existing condition exclusion, which may be waived in some circumstances and may not be applicable to you. A pre-existing condition exclusion means that if you have a medical condition before coming to this plan, you may have to wait a certain period of time before the plan will provide coverage for that condition. This exclusion applies only to conditions for which medical advice, diagnosis, care, or treatment was recommended or received or for which the individual took prescribed drugs within 90 days.generally, this period ends the day before your coverage becomes effective. However, if you were in a waiting period for coverage, 90 days ends on the day before the waiting period begins. The exclusion period, if applicable, may last up to 365 days from your first day of coverage, or, if you were in a waiting period, from the first day of your waiting period. If you had prior creditable coverage within 90 days immediately before the date you enrolled under this plan, then the pre-existing conditions exclusion in your plan, if any, will be waived. 12

14 If you had no prior creditable coverage within the 90 days prior to your enrollment date (either because you had no prior coverage or because there was more than a 90 day gap from the date your prior coverage terminated to your enrollment date), we will apply your plan's pre-existing conditions exclusion. In order to reduce or possibly eliminate your exclusion period based on your creditable coverage, you should provide us a copy of any certificates of creditable coverage you have.please contact Aetna Member Services at if you need assistance in obtaining a certificate of creditable coverage from your prior carrier or if you have any questions on the information noted above. The pre-existing condition exclusion does not apply to pregnancy nor to a child who is enrolled in the plan within 31 days of birth, adoption, or placement for adoption. Note: For late enrollees, coverage will be delayed until the plan's next open enrollment, and the pre-existing condition exclusion will be applied from the individual's effective date of coverage. This plan does not cover all health care expenses and includes exclusions and limitations. Members should refer to their plan documents to determine which health care services are covered and to what extent. The following is a partial list of services and supplies that are generally not covered. However, your plan documents may contain exceptions to this list based on state mandates or the plan design or rider(s) purchased by your employer. All medical or hospital services not specifically covered in, or which are limited or excluded in the plan documents; Charges related to any eye surgery mainly to correct refractive errors; Cosmetic surgery, including breast reduction; Custodial care; Dental care and X-rays; Donor egg retrieval; Experimental and investigational procedures; Hearing aids; Immunizations for travel or work; Infertility services, including, but not limited to, artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI and other related services, unless specifically listed as covered in your plan documents; Nonmedically necessary services or supplies; Orthotics; Over-the-counter medications and supplies; Reversal of sterilization; Services for the treatment of sexual dysfunction or inadequacies, including therapy, supplies, or counseling; and special duty nursing. Weight control services including surgical procedures, medical treatments, weight control/loss programs, dietary regimens and supplements, appetite suppressants and other medications; food or food supplements, exercise programs, exercise or other equipment; and other services and supplies that are primarily intended to control weight or treat obesity, including Morbid Obesity, or for the purpose of weight reduction, regardless of the existence of comorbid conditions. This material is for informational purposes only and is neither an offer of coverage nor medical advice. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee results or outcomes. Consult the plan documents (i.e. Group Insurance Certificate and/or Group Policy) to determine governing contractual provisions, including procedures, exclusions and limitation relating to the plan. With the exception of Aetna Rx Home Delivery, all preferred providers and vendors are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Aetna Rx Home Delivery, LLC, is a subsidiary of Aetna Inc. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change without notice. Some benefits are subject to limitations or visit maximums. Certain services require precertification, or prior approval of coverage. Failure to precertify for these services may lead to substantially reduced benefits or denial of coverage. Some of the benefits requiring precertification may include, but are not limited to, inpatient hospital, inpatient mental health, inpatient skilled nursing, outpatient surgery, substance abuse (detoxification, inpatient and outpatient rehabilitation). When the Member s preferred provider is coordinating care, the preferred provider will obtain the precertification. When the member utilizes a non-preferred provider, Member must obtain the precertification. Precertification requirements may vary. Depending on the plan selected, new prescription drugs not yet reviewed by our medication review committee are either available under plans with an open formulary or excluded from coverage unless a medical exception is obtained under plans that use a closed formulary. They may also be subject to precertification or step-therapy. Non-prescription drugs and drugs in the Limitations and Exclusions section of the plan documents (received after open enrollment) are not covered, and medical exceptions are not available for them. While this information is believed to be accurate as of the print date, it is subject to change. Plans are administered by Aetna Life Insurance Company. 13

15 PLAN DESIGN & BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY Oakland Community College AETNA PPO A $10/$20/$40 RX Prescription Co-pay $15 office visit Co-Pay PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $500 Individual $1,000 Individual $1,000 Family $2,000 Family All covered expenses, excluding prescription drugs, accumulate separately toward the preferred or non-preferred Deductible. Unless otherwise indicated, the deductible must be met prior to benefits being payable. The family Deductible is a cumulative Deductible for all family members. The family Deductible can be met by a combination of family members; however no single individual within the family will be subject to more than the individual Deductible amount. Member Coinsurance 10% 40% Applies to all expenses unless otherwise stated. Payment Limit (per calendar year) $1,000 Individual $2,000 Individual $2,000 Family $4,000 Family All covered expenses, excluding prescription drugs, accumulate separately toward the preferred or non-preferred Payment Limit. Certain member cost sharing elements may not apply toward the Payment Limit. Only those preferred/non-preferred out-of-pocket expenses resulting from the application of coinsurance percentage, deductibles, and copays (except any penalty amounts) may be used to satisfy the Payment Limit. Once Family Payment Limit is met, all family members will be considered as having met their Payment Limit for the remainder of the calendar year. Lifetime Maximum Unlimited except where otherwise indicated. Payment for Non-Preferred Care** Not Applicable Professional: Prevailing Charges Facility: Prevailing Charges Primary Care Physician Selection Not Applicable Not Applicable Certification Requirements - Certification for certain types of Non-Preferred care must be obtained to avoid a reduction in benefits paid for that care. Certification for Hospital Admissions, Treatment Facility Admissions, Convalescent Facility Admissions, Home Health Care, Hospice Care and Private Duty Nursing is required - excluded amount applied separately to each type of expense is $500 or 50% of the scheduled benefit amount per occurrence. Referral Requirement None None PREVENTIVE CARE IN-NETWORK OUT-OF-NETWORK Routine Adult Physical Exams/ Covered 100%; deductible waived 40%; after deductible Immunizations 1 exam every 12 months for members age 18 and older. Routine Well Child Covered 100%; deductible waived 40%; after deductible Exams/Immunizations 7 exams first 12 months; 3 exams 13 th -24 th months; 3 exams 25 th -36 th months; 1 exam per 12 months thereafter to age 18. Routine Gynecological Care Covered 100%; deductible waived 40%; after deductible Exams Includes routine tests and related lab fees. Routine Mammograms Covered 100%; deductible waived 40%; after deductible One baseline mammogram for covered females age 35-39, one mammogram per calendar year for covered females age 40 and over. 14

16 Routine Digital Rectal Exam Covered 100% Member cost sharing is based on the type of service performed and the place of service where it is rendered; after deductible Prostate-specific Antigen Test Covered 100% Member cost sharing is based on the type of service performed and the place of service where it is rendered; after deductible Colorectal Cancer Screening Member cost sharing is based on the type of service performed and the place of service where it is rendered. Member cost sharing is based on the type of service performed and the place of service where it is rendered; after deductible For all members age 50 and over. Routine Eye Exams Not Covered Not Covered Routine Hearing Exams Covered 100%; deductible waived Not Covered Hearing Aids Limited to $5,000 within a 36 month period for both ears. (no age limit) PHYSICIAN SERVICES IN-NETWORK OUT-OF-NETWORK Office Visits to non-specialist 10% after $15 office visit copay; 40%; after deductible deductible waived Includes services of an internist, general physician, family practitioner or pediatrician. Specialist Office Visits 10% after $15 office visit copay; 40%; after deductible deductible waived E-visit to non-specialist Not Covered Not Covered An E-visit is an online internet consultation between a physician and an established patient about a non-emergency healthcare matter. This visit must be conducted through an Aetna authorized internet E-visit service vendor. E-visit to Specialist Not Covered Not Covered An E-visit is an online internet consultation between a physician and an established patient about a non-emergency healthcare matter. This visit must be conducted through an Aetna authorized internet E-visit service vendor. Walk-in Clinics 10% after $15 office visit copay; 40%; after deductible deductible waived Walk-in Clinics are network, free-standing health care facilities. They are an alternative to a physician's office visit for treatment of unscheduled, non-emergency illnesses and injuries and the administration of certain immunizations. It is not an alternative for emergency room services or the ongoing care provided by a physician. Neither an emergency room, nor the outpatient department of a hospital, shall be considered a Walk-in Clinic. Allergy Testing 10%; deductible & copay waived 40%; after deductible Allergy Injections 10%; deductible & copay waived 40%; after deductible DIAGNOSTIC PROCEDURES IN-NETWORK OUT-OF-NETWORK Diagnostic X-ray 10%; deductible & copay waived 40%; after deductible (other than Complex Imaging Services) If performed as a part of a physician office visit and billed by the physician, expenses are covered subject to the applicable physician's office visit member cost sharing. Diagnostic Laboratory 10%; deductible & copay waived 40%; after deductible If performed as a part of a physician office visit and billed by the physician, expenses are covered subject to the applicable physician's office visit member cost sharing. Diagnostic Outpatient Complex 10%; after deductible 40%; after deductible Imaging EMERGENCY MEDICAL CARE IN-NETWORK OUT-OF-NETWORK Urgent Care Provider 10% after $25 copay; deductible 40%; after deductible waived Non-Urgent Use of Urgent Care Provider Not Covered Not Covered 15

17 Emergency Room 10% after $25 copay; deductible waived Not Covered 10% after $25 copay; deductible waived Not Covered Non-Emergency Care in an Emergency Room Emergency Use of Ambulance Covered 100%; after deductible Covered 100%; after deductible Non-Emergency Use of Ambulance Not Covered Not Covered HOSPITAL CARE IN-NETWORK OUT-OF-NETWORK Inpatient Coverage 10%; after deductible 40%; after deductible The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Inpatient Maternity Coverage 10%; after deductible 40%; after deductible The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Outpatient Hospital Expenses 10%; after deductible 40%; after deductible (including surgery) The member cost sharing applies to all covered benefits incurred during a member's outpatient visit. MENTAL HEALTH SERVICES IN-NETWORK OUT-OF-NETWORK Inpatient 10%; after deductible 30%; after deductible The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Outpatient 10% after $15 copay; deductible 40%; after deductible waived The member cost sharing applies to all covered benefits incurred during a member's outpatient visit. All Mental Health and Alcohol/Drug day and visit limits are combined. ALCOHOL/DRUG ABUSE IN-NETWORK OUT-OF-NETWORK SERVICES Inpatient 10%; after deductible 30%; after deductible The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Residential Treatment Facility 10%; after deductible 40%; after deductible Outpatient 10% after $15 copay; deductible 40%; after deductible waived The member cost sharing applies to all covered benefits incurred during a member's outpatient visit. All Mental Health and Alcohol/Drug day and visit limits are combined. OTHER SERVICES IN-NETWORK OUT-OF-NETWORK Convalescent Facility 10%; after deductible 30%; after deductible Limited to 60 days per calendar year. The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Home Health Care 10%; after deductible 40%; after deductible Limited to 120 visits per calendar year. Each visit by a nurse or therapist is one visit. Each visit up to 4 hours by a home health care aide is one visit. Hospice Care - Inpatient 10%; after deductible 40%; after deductible The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Hospice Care - Outpatient 10%; after deductible 40%; after deductible The member cost sharing applies to all covered benefits incurred during a member's outpatient visit. Private Duty Nursing - Outpatient 10%; after deductible 40%; after deductible Each period of private duty nursing of up to 8 hours will be deemed to be one private duty nursing shift. Autism Member cost sharing is based on the type of service performed and the place of service where it is rendered. Member cost sharing is based on the type of service performed and the place of service where it is rendered. Applied Behavioral Analysis (ABA) and behavioral therapy for children to age 15 covered on the same basis as any other expense. Outpatient Short-Term Rehabilitation 10% after $15 copay; deductible 40%; after deductible waived Includes Speech, Physical, and Occupational Therapy, limited to 20 visits per calendar year. 16

18 Early Intervention Services Spinal Manipulation Therapy Member cost sharing is based on the type of service performed and the place of service where it is rendered.; deductible waived 10% after $15 copay; deductible waived Member cost sharing is based on the type of service performed and the place of service where it is rendered; after deductible 40%; after deductible Limited to 20 visits per calendar year. Durable Medical Equipment 10%; after deductible 40%; after deductible Maximum benefit of $2,500 per member per calendar year. Diabetic Supplies -- (if not covered 10%; after deductible 40%; after deductible. under Pharmacy benefit) Transplants 10%; after deductible 40%; after deductible Preferred coverage is provided at an IOE contracted facility only. Non-Preferred coverage is provided at a Non-IOE facility. Bariatric Surgery Not Covered Not Covered The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. "Other" Health Care -- 20% member coinsurance after the preferred (per calendar year) deductible for services that are neither "preferred" nor "non-preferred". FAMILY PLANNING IN-NETWORK OUT-OF-NETWORK Infertility Treatment 10%; after deductible 40%; after deductible Diagnosis and treatment of the underlying medical condition. Comprehensive Infertility Services Not Covered Not Covered Advanced Reproductive Not Covered Not Covered Technology (ART) Vasectomy 10%; after deductible 40%; after deductible Including tubal ligation and vasectomy. GENERAL PROVISIONS Dependents Eligibility Pre-existing Conditions Exclusion Spouse, children from birth to age 26 regardless of student status. On effective date: Waived After effective date: Full postponement For members age 19 or over this plan imposes a pre-existing condition exclusion, which may be waived in some circumstances and may not be applicable to you. A pre-existing condition exclusion means that if you have a medical condition before coming to this plan, you may have to wait a certain period of time before the plan will provide coverage for that condition. This exclusion applies only to conditions for which medical advice, diagnosis, care, or treatment was recommended or received or for which the individual took prescribed drugs within 90 days. Generally, this period ends the day before your coverage becomes effective. However, if you were in a waiting period for coverage, 90 days ends on the day before the waiting period begins. The exclusion period, if applicable, may last up to 365 days from your first day of coverage, or, if you were in a waiting period, from the first day of your waiting period. If you had prior creditable coverage within 150 days immediately before the date you enrolled under this plan, then the pre-existing conditions exclusion in your plan, if any, will be waived. If you had no prior creditable coverage within the 90 days prior to your enrollment date (either because you had no prior coverage or because there was more than a 90 day gap from the date your prior coverage terminated to your enrollment date), we will apply your plan's pre-existing conditions exclusion. In order to reduce or possibly eliminate your exclusion period based on your creditable coverage, you should provide us a copy of any certificates of creditable coverage you have. Please contact Aetna Member Services at if you need assistance in obtaining a certificate of creditable coverage from your prior carrier or if you have any questions on the information noted above. The pre-existing condition exclusion does not apply to pregnancy nor to a child who is enrolled in the plan within 31 days of birth, adoption, or placement for adoption. Note: For late enrollees, coverage will be delayed until the plan's next open enrollment, and the pre-existing condition exclusion will be applied from the individual's effective date of coverage. **We cover the cost of services based on whether doctors are "in network" or "out of network." We want to help you understand how much Aetna pays for your out-of-network care. At the same time, we want to make it clear how much more you will need to pay for this "out-of-network" care. 17

19 You may choose a provider (doctor or hospital) in our network. You may choose to visit an out-of-network provider. If you choose a doctor who is out of network, your Aetna health plan may pay some of that doctor's bill. Most of the time, you will pay a lot more money out of your own pocket if you choose to use an out-of-network doctor or hospital. When you choose out-of-network care, Aetna limits the amount it will pay. This limit is called the "recognized" or "allowed" amount. This amount is based on the out-of-network plan you or your employer picks. For doctors and other professionals the amount is based on the "prevailing" charges. We get this data from an external database. For hospitals and other facilities, the amount is based on "prevailing" charges. We get this data from an external database. Your doctor sets his or her own rate to charge you. It may be higher -- sometimes much higher -- than what your Aetna plan "recognizes." Your doctor may bill you for the dollar amount that Aetna doesn't "recognize." You must also pay any copayments, coinsurance and deductibles under your plan. No dollar amount above the "recognized charge" counts toward your deductible or out-of-pocket maximums. To learn more about how we pay out-of-network benefits visit Aetna.com. Type "how Aetna pays" in the search box. You can avoid these extra costs by getting your care from Aetna's broad network of health care providers. Go to and click on "Find a Doctor" on the left side of the page. If you are already a member, sign on to your Aetna Navigator member site. This applies when you choose to get care out of network. When you have no choice (for example: emergency room visit after a car accident, or for other emergency services), we will pay the bill as if you got care in network. You pay cost sharing and deductibles for your in-network level of benefits. Contact Aetna if your provider asks you to pay more. You are not responsible for any outstanding balance billed by your providers for emergency services beyond your cost sharing and deductibles. This way of paying out-of-network doctors and hospitals applies when you choose to get care out of network. When you have no choice (for example: emergency room visit after a car accident), we will pay the bill as if you got care in network. You pay your plan's copayments, coinsurance and deductibles for your in-network level of benefits. Contact Aetna if your provider asks you to pay more. You are not responsible for any outstanding balance billed by your providers for emergency services beyond your copayments, coinsurance and deductibles. Plans are provided by: Aetna Life Insurance Company. While this material is believed to be accurate as of the production date, it is subject to change. Health benefits and health insurance plans contain exclusions and limitations. Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. You may be responsible for the health care provider's full charges for any non-covered services, including circumstances where you have exceeded a benefit limit contained in the plan. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. The following is a list of services and supplies that are generally not covered. However, your plan documents may contain exceptions to this list based on state mandates or the plan design or rider(s) purchased by your employer. 18

20 All medical and hospital services not specifically covered in, or which are limited or excluded by your plan documents. Cosmetic surgery, including breast reduction. Custodial care. Dental care and dental X-rays. Donor egg retrieval. Durable medical Equipment Experimental and investigational procedures, except for coverage for medically necessary routine patient care costs for members participating in a cancer clinical trial. Hearing aids Home births Immunizations for travel or work, except where medically necessary or indicated. Implantable drugs and certain injectable drugs including injectable infertility drugs. Infertility services, including artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI and other related services, unless specifically listed as covered in your plan documents. Long-term rehabilitation therapy. Non-medically necessary services or supplies. Orthotics except diabetic orthotics. Outpatient prescription drugs (except for treatment of diabetes), unless covered by a prescription plan rider and overthe-counter medications (except as provided in a hospital) and supplies. Radial keratotomy or related procedures. Reversal of sterilization. Services for the treatment of sexual dysfunction or inadequacies, including therapy, supplies or counseling or prescription drugs. Special duty nursing. Therapy or rehabilitation other than those listed as covered. Treatment of behavioral disorders. Weight control services including surgical procedures, medical treatments, weight control/loss programs, dietary regimens and supplements, appetite suppressants and other medications; food or food supplements, exercise programs, exercise or other equipment; and other services and supplies that are primarily intended to control weight or treat obesity, including Morbid Obesity, or for the purpose of weight reduction, regardless of the existence of comorbid conditions. Aetna receives rebates from drug manufacturers that may be taken into account in determining Aetna's Preferred Drug List. Rebates do not reduce the amount a member pays the pharmacy for covered prescriptions. Aetna Rx Home Delivery refers to Aetna Rx Home Delivery, LLC, a licensed pharmacy subsidiary of Aetna Inc., that operates through mail order. The charges that Aetna negotiates with Aetna Rx Home Delivery may be higher than the cost they pay for the drugs and the cost of the mail order pharmacy services they provide. For these purposes, the pharmacy's cost of purchasing drugs takes into account discounts, credits and other amounts that they may receive from wholesalers, manufacturers, suppliers and distributors. In case of emergency, call 911 or your local emergency hotline, or go directly to an emergency care facility. Translation of the material into another language may be available. Please call Member Services at AETNA ( ). Puede estar disponible la traduccion de este material en otro idioma. Por favor llame a Servicios al Miembro al AETNA ( ). Plan features and availability may vary by location and group size. For more information about Aetna plans, refer to 19

21 PLAN DESIGN & BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY Oakland Community College Aetna PPO B $10/$20/$40 RX Prescription Co-Pay $15 Office visit Co-Pay PLAN FEATURES IN-NETWORK OUT-OF-NETWORK Deductible (per calendar year) $100 Individual $200 Individual $200 Family $250 Family All covered expenses, excluding prescription drugs, accumulate separately toward the preferred or non-preferred Deductible. Unless otherwise indicated, the deductible must be met prior to benefits being payable. The family Deductible is a cumulative Deductible for all family members. The family Deductible can be met by a combination of family members; however no single individual within the family will be subject to more than the individual Deductible amount. Member Coinsurance None 20% Applies to all expenses unless otherwise stated. Payment Limit (per calendar year) None Individual $750 Individual None Family $750 Family All covered expenses, excluding prescription drugs, accumulate separately toward the preferred or non-preferred Payment Limit. Certain member cost sharing elements may not apply toward the Payment Limit. Only those preferred/non-preferred out-of-pocket expenses resulting from the application of coinsurance percentage, deductibles, and copays (except any penalty amounts) may be used to satisfy the Payment Limit. Once Family Payment Limit is met, all family members will be considered as having met their Payment Limit for the remainder of the calendar year. Lifetime Maximum Unlimited except where otherwise indicated. Payment for Non-Preferred Care** Not Applicable Professional: Prevailing Charges Facility: Prevailing Charges Primary Care Physician Selection Not Applicable Not Applicable Certification Requirements - Certification for certain types of Non-Preferred care must be obtained to avoid a reduction in benefits paid for that care. Certification for Hospital Admissions, Treatment Facility Admissions, Convalescent Facility Admissions, Home Health Care, Hospice Care and Private Duty Nursing is required - excluded amount applied separately to each type of expense is $500 or 50% of the scheduled benefit amount per occurrence. Referral Requirement None None PREVENTIVE CARE IN-NETWORK OUT-OF-NETWORK Routine Adult Physical Exams/ Covered 100%; deductible waived Not Covered Immunizations 1 exam every 12 months for members age 18 and older. Routine Well Child Covered 100%; deductible waived Not Covered Exams/Immunizations 7 exams first 12 months; 3 exams 13 th -24 th months; 3 exams 25 th -36 th months; 1 exam per 12 months thereafter to age 18. Routine Gynecological Care Covered 100%; deductible waived 20%; after deductible Exams Includes routine tests and related lab fees. Routine Mammograms Covered 100%; deductible waived 20%; after deductible One baseline mammogram for covered females age 35-39, one mammogram per calendar year for covered females age 40 and over. 20

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