Swarthmore College. Benefit Enrollment Guide

Transcription

1 Swarthmore College Benefit Enrollment Guide November 1, 2013 to October 31, 2014

2 Your Coverage Choices Keystone HMO and POS Plans: Both are considered Health Maintenance Organization plans that require you to select a primary care physician (PCP) who coordinates your care and authorizes visits to specialist or other providers for in-network services. Generally, you are charged a copayment when you visit your PCP or a specialist, or receive a service from an innetwork provider. For certain services, x-ray, lab, podiatry, and physical/occupational therapy, your PCP is contractually required to refer you to a designated network location. Please Note: referrals can be sent electronically and can be written for up to 90 days. You may change your PCP at any time. The Keystone POS plan allows you the additional feature of visiting doctors and providers outside the network without referral (self-referral). However, there is a deductible, co-insurance and balance billing. Out-of-Network expenses are paid at the stated percentage of the standards established by the Health Insurance Association of America (HIAA). Personal Choice PPO: This is a Preferred Provider Organization plan that allows direct access to medical care including specialists without a referral. Copayments are required. The plan allows out-of-network care, however, there is a deductible, co-insurance and balance billing. Out-of-Network expenses are paid at the stated percentage of Independence Blue Cross allowance. High Deductible Health Plan: This is also a Preferred Provider Organization plan that allows direct access to medical care including specialist without a referral. The plan allows out-of-network care. However, this plan has a front-end deductible, which must be met prior to benefits being paid by the plan. After the deductible is met, the plan pays 100% for innetwork services and reverts to copays for prescription coverage. Employees enrolled in the High Deductible Health Plan have the option to set up a Health Savings Account ( HSA ). An HSA is a tax advantaged account you can use to pay for Qualified Medical Expenses, which includes the deductible under the High Deductible Health Plan. The HSA is owned by you and is separate from the High Deductible Health insurance plan. Independence Blue Cross has a preferred relationship with The Bancorp Bank. Health Savings Account ( HSA ) An HSA is a tax-advantaged medical savings account available to taxpayers in the United States who are enrolled in a consumer driven health plan such as a High Deductible Health Plan (HDHP). The funds contributed to the account are not subject to federal income tax at the time of deposit. Unlike a Flexible Spending Account, unused funds roll over and accumulate year-to-year if not spent. HSA s are owned by the employee. Funds may be used to pay for Qualified Medical Expenses, including the HDHP deductible, at any time without federal tax. If you choose to enroll in an HSA alongside your HDHP, you have the option to either set up an HSA on your own through your preferred bank or institution, or you can choose to set up an HSA through payroll deductions with Bancorp Bank. Like all HSA accounts, certain fees may apply, however because of Bancorp s relationship with Independence Blue Cross Bancorp s fees may be lower. 2

3 The Internal Revenue Service sets annual limits for minimum deducible amounts and maximum out-of-pocket cost for the HDHP to be considered HSA eligible. These limits can be located on the IRS s web site, Generally, the IRS contribution limits to your HSA for 2014 are $3,300 for Employee Only coverage and $6,550 for all other levels of coverage. If you are over the age of 55 you can make an additional annual $1,000 catch-up contribution. If you discontinue your participation in the HDHP in the first 12 months, such as leave the college or change your enrollment in the next Open Enrollment period, these annual limits may be impacted. Prescription Coverage All of our health plans provide prescriptions coverage through FutureScripts. This includes both retail pharmacy and mail order prescriptions. Definitions: Generic: A drug whose formula is equivalent to that of a brand-name drug. Brand Name: An original formula drug with no generic equivalent. Non-Formulary: Typically brand name medication that have no available generic equivalent. In some cases, medications in this category may require prior authorization by Independence Blue Cross. Save using the Mail Order program: If you have medicine you take regularly, pay two co-payments, rather than three, for a 90-day supply when you use the mail order through FutureScripts. Prescription Overrides: If you are travelling outside the United States for an extended period of time and need an override to obtain access to your prescriptions, contact either Human Resources by phone or humanresources@swarthmore.edu at least three (3) weeks prior to your departure date. Dental Delta Dental of Pennsylvania is a national insurer of dental benefits that provide customer service, claims processing, and an extensive network of providers. You have the option to buy up to Enhanced Delta Dental (or Buy Up Plan), which provides greater reimbursement rates and the same extensive network. These plans are dental Preferred Provider Organizations (PPOs) so there is also an out-of-network reimbursement. You can use this option to go to any provider whether they are a participating Delta Dental PPO provider or not. However, in the case of providers who do not participate in the network they may reserve the right to balance bill you for services not reimbursed by Delta Dental. Vision Coverage You have the option to buy up to the enhanced Davis Vision Plan (or Buy Up Plan) which provides more coverage. Both the basic and enhanced plans give you flexibility to use in-network and out-of-network providers. 3

4 If you enroll in either the Keystone HMO or Keystone POS plan, routine vision exams at the specialist copay are included on a bi-annual (every two years) basis. This means you can use the Davis and Keystone plans on alternating years for routine vision exams. You can also receive discounts for vision care products and services through our life insurance company, Aetna. Go to click the Individual & Families tab on the top navigation bar, then click on Products and Services on the left navigation bar and Vision. You will need to register; reference plan number Waive Coverage We offer the option to waive medical, dental and vision coverage if you have coverage elsewhere. Full-time benefits eligible employees that choose to waive medical coverage, including the base dental and vision coverage, will receive a credit of $60 per month. If you wish to waive only medical coverage and enroll in employee only coverage for the base dental and vision plans you will receive a credit of $40 per month. If you wish to waive only medical coverage and enroll in employee plus child/children/spouse or family coverage for the base dental and vision plans you will receive a credit of $20 per month. College Contributions The College uses the Keystone HMO plan to set the level of College contribution. Election of the Keystone POS, Personal Choice PPO, High Deductible Health plans will result in you contributing the difference between the College contribution and the premium cost of these plans. Participants that choose the Keystone HMO employee only or employee plus child coverage will receive a monthly credit (formerly the Benefit Bank) of $35 and $15, respectively, for the benefit year. This monthly credit amount will decrease over the coming years and will be eliminated by Participants who receive the monthly credit and choose to contribute to one or both of the Flexible Spending Accounts must place any excess College contributions into the Flexible Spending Accounts before contributing money out of their own pay. 4

5 Full-Time Medical Employee Monthly Rates for FULL-TIME EMPLOYEE PLAN COVERAGE MONTHLY COLLEGE CREDIT (if applicable) Keystone HMO Plan Employee Only $ $0.00 $35.00 Employee & Child $ $0.00 $15.00 Employee & Children $ $79.85 $0.00 Employee & Spouse $ $ $0.00 Family $ $ $0.00 Keystone POS Plan Employee Only $ $25.92 $0.00 Employee & Child $ $45.90 $0.00 Employee & Children $ $ $0.00 Employee & Spouse $ $ $0.00 Family $ $ $0.00 Personal Choice Plan Employee Only $ $ $0.00 Employee & Child $ $ $0.00 Employee & Children $ $ $0.00 Employee & Spouse $ $ $0.00 Family $ $ $0.00 High Deductible Health Plan Employee Only $ $0.00 $62.50 Employee & Child $ $0.00 $7.75 Employee & Children $ $68.53 $0.00 Employee & Spouse $ $33.47 $0.00 Family $ $0.00 $37.96 *Employee Credit for the High Deductible Health Plan must be contributed to a Health Saving Account. It will not be paid to the employee as cash. 5

6 Dental Rates Employee Monthly Rates for FULL TIME EMPLOYEE PLAN COVERAGE MONTHLY COLLEGE CREDIT (if applicable) Dental Employee Only $17.00 $0.00 $0.00 Employee & Child $45.00 $0.00 $0.00 Employee & Children $45.00 $0.00 $0.00 Employee & Spouse $45.00 $0.00 $0.00 Family $45.00 $0.00 $0.00 Vision Rates Employee Monthly Rates for FULL TIME EMPLOYEE PLAN COVERAGE MONTHLY COLLEGE CREDIT (if applicable) Vision Employee Only $2.93 $0.00 $0.00 Employee & Child $7.63 $0.00 $0.00 Employee & Children $7.63 $0.00 $0.00 Employee & Spouse $7.63 $0.00 $0.00 Family $7.63 $0.00 $0.00 Waiver of Coverage Full-Time Employee Rates for FULL-TIME EMPLOYEE PLAN COVERAGE Waive Medical, Dental and Vision FULL-TIME EMPLOYEE PLAN COVERAGE Waive Medical Only; Employee only Basic Dental & Vision Waive Medical Only; Employee only Plus Child(ren), Spouse or Family Basic Dental & Vision 6 CREDIT (if applicable) $60.00 CREDIT (if applicable) $40.00 $20.00

7 Part-Time Medical Employee Monthly Rates for PART-TIME EMPLOYEE PLAN COVERAGE MONTHLY COLLEGE CREDIT (if applicable) Keystone HMO Plan Employee Only $ $0.00 $0.00 Employee & Child $ $ $0.00 Employee & Children $ $ $0.00 Employee & Spouse $ $ $0.00 Family $ $ $0.00 Keystone POS Plan Employee Only $ $ $0.00 Employee & Child $ $ $0.00 Employee & Children $ $ $0.00 Employee & Spouse $ $ $0.00 Family $ $ $0.00 Personal Choice Plan Employee Only $ $ $0.00 Employee & Child $ $ $0.00 Employee & Children $ $ $0.00 Employee & Spouse $ $ $0.00 Family $ $ $0.00 High Deductible Health Plan Employee Only $ $32.88 $0.00 Employee & Child $ $ $0.00 Employee & Children $ $ $0.00 Employee & Spouse $ $ $0.00 Family $ $ $0.00 7

8 Dental & Vision Buy Up Rates You can enhance your basic dental and vision coverage through our buy-up plan options Full-Time & Part-Time Employee Rates for FULL TIME EMPLOYEE PLAN COVERAGE MONTHLY COLLEGE 8 CREDIT (if applicable) Dental Buy Up Employee Only $17.00 $12.78 $0.00 Employee & Child $45.00 $33.80 $0.00 Employee & Children $45.00 $33.80 $0.00 Employee & Spouse $45.00 $33.80 $0.00 Family $45.00 $33.80 $0.00 Vision Buy Up Employee Only $2.93 $1.79 $0.00 Employee & Child $7.63 $5.58 $0.00 Employee & Children $7.63 $5.58 $0.00 Employee & Spouse $7.63 $5.58 $0.00 Family $7.63 $5.58 $0.00 Qualifying Life Event Generally, you can only make changes to your medical, dental, vision, life and flexible spending accounts once every 12 months during open enrollment. However, you may make certain changes to your coverage if you experience a Qualifying Life Event, such as; - Marriage, divorce or legal separation - Establishment or dissolution of a Qualified Domestic Partner, same sex or opposite sex - Birth or adoption of a child - Death of a spouse or child - Change in residence or work location that affects benefits eligibility for you or your covered dependent(s) - Your child(ren) meets (or fails to meet) the plan s eligibility rules (reaches age 26) - You or one of your covered dependents gain or lose other benefits coverage due to a change in employment status (for example, beginning or ending a job) Changes must be completed within 30 days of the date of the Qualifying Life Event. The above events only apply to adding or dropping dependents outside of the annual benefits enrollment period. Domestic Partner Swarthmore College is committed to the principle of equal employment opportunity for all qualified persons without discrimination. To further this policy and to recognize and support equity to the lesbian/bisexual/gay members and non-married heterosexual couples of the community, Swarthmore College offers a Domestic Partner Benefit Policy. Domestic Partners have the option of coverage under the Employee/Spouse category. To qualify as a Domestic Partner you must complete the Affidavit of Domestic Partner Relationship and submit to Human Resources with any required documentation.

9 Domestic Partner Relationship(s) are not recognized at the federal level; therefore, Swarthmore College is required to impute income and deduct taxes for the portion of the health premium paid by the College on behalf of the employee for the non-employee domestic partner. Please be advised that if you have entered into a valid same sex marriage in any state, Swarthmore College does not impute federal income and deduct taxes on any portion of the benefit at the federal level. However, the College may be required to impute income and deduct taxes for benefits at the state level. For further information about whether state taxes may be applicable to your health premium, please contact Human Resources by phone at or at humanresources@swarthmore.edu. Register with ibx.com Manage your health and your health care benefits by registering on Independence Blue Cross s web site ibx.com. Once you are registered you can view your benefits information, check the status of claims, request an ID Card, print forms, access the database of participating providers, link to the FutureScripts web site and check on prescriptions. We encourage you to review the Welcome Kit materials to better understand the benefits and programs available to you. 9

10 Plan Coverage Summary For Keystone HMO & POS Coverage Keystone HMO Keystone POS Referred Self-Referred Deductible Individual/Family None None $200/$600 Annual Copay Maximum Individual/Family $1,000/$2,000 $1,000/$2,000 N/A Co-Insurance Limit Individual/Family Unlimited N/A $1,000/$3,000 Overall Lifetime Maximum Unlimited Unlimited Unlimited Primary Care Office Visit $15 Copay $15 Copay 80% after ded. Specialist Office Visit $25 Copay $25 Copay 80% after ded. Maternity Care $25 Copay, 1 st visit $25 Copay, 1 st visit 80% after ded. Pediatric Immunizations 100% 100% 80% NO ded. Routine GYN Exam 100% 100% 80% NO ded. Routine Mammography 100% 100% 80% NO ded. Hospitalization $100 Copay; $100 Copay; $500 max/adm $500 max/adm 80% after ded. Outpatient Radiology 100% 100% 80% after ded. Outpatient Laboratory 100% 100% 80% after ded. Emergency Room $150 Copay (waived if admitted) $150 Copay (waived if admitted) $150 Copay (waived if admitted) Outpatient Surgery $50 Copay $50 Copay 80% after ded. Spinal Manipulations 100% up to 60 consecutive days per condition Therapy: Physical, Speech, Occupational 100% up to 60 consecutive days per condition 100% up to 60 consecutive days per condition 100% up to 60 consecutive days per condition 80% after ded. ($1,000 max/yr) 80% after ded. ($1,000 max/yr) Durable Medical Equipment 100% 100% 80% after ded. Prescription Drug $15 Generic $15 Generic Covered 30% at a nonparticipating pharmacy $35 Brand $35 Brand $50 Non-Formulary $50 Non-Formulary Vision Inpatient Mental Health $100 Davis Vision Rider once every two cal/yr $100 Copay; $500 max/adm $100 Davis Vision Rider once every two cal/yr $100 Copay; 80% after ded. $500 max/adm Outpatient Mental Health $25 Copay/visit $25 Copay/visit 50% after ded. Inpatient Serious Mental Health $100 Copay; $100 Copay; 80% after ded. $500 max/adm $500 max/adm Outpatient Serious Mental Health $25 Copay/visit $25 Copay/visit 50% after ded. 10

11 Plan Coverage Summary For Personal Choice PPO & HDHP Coverage Personal Choice PPO Personal Choice HDHP In-Network Out-of-Network In-Network Out-of-Network Deductible Individual/Family $0/$0 $500/$1,000 $1,500/$3,000 $5,000/$10,000 Out-of-Pocket Maximum Individual/Family $0/$0 $3,00/$6,000 $5,600/$11,200 $10,000/$20,000 Lifetime Maximum Unlimited Unlimited Unlimited Unlimited Coinsurance 100% 70% 100% after ded. 50% after ded. Coinsurance Individual/Family N/A N/A 100% after ded. 50% after ded. Primary Care Office Visit $20 Copay 70% after ded. 100% after ded. 50% after ded. Specialist Office Visit $30 Copay 70% after ded. 100% after ded. 50% after ded. Maternity Care $20 Copay, 1 st visit 70% after ded. 100% after ded. 50% after ded. Pediatric Immunizations 100% 70% NO ded. 100% NO ded. 50% NO ded. Routine GYN Exam (1 per year for any age women) 100% 70% NO ded. 100% NO ded. 50% NO ded. Routine Mammogram 100% 70% NO ded. 100% NO ded. 50% NO ded. Hospitalization $150 Copay/day, $750 max/adm 70% NO ded. 100% after ded. 50% after ded. Outpatient Radiology $30 Copay 70% after ded. 100% after ded. 50% after ded. Outpatient Laboratory 100% 70% after ded. 100% after ded. 50% after ded. Emergency Room $150 Copay (waived if admitted) $150 Copay (waived if admitted) % after ded. Covered at in-network level Outpatient Surgery $150 Copay 70% after ded. 100% after ded. 50% after ded. Restorative Services $30 Copay 70% after ded. 100% after ded. 50% after ded. (30 visits per year) (30 visits per year) (20 visits/benefit period) (20 visits/benefit period) Therapy: Physical, Speech, Occupational Durable Medical Equipment & Prosthetics Prescription Drug $20 Copay (1-30 visits) $30 Copay (31-60 visits) 70% after ded. 100% after ded. 50% after ded. 60 visits total per yr. for PT/ST/OT combined 60 visits total per yr. for PT/OT combined 60 visits per yr. for ST $30 Copay 50% after ded. Copay/per rental period 70% after ded. 100% after ded. or purchase $2,500 ben.max./cal.yr. $15 Generic $5 Generic Covered 30% at a nonparticipating pharmacy 50% after ded. $35 Brand $20 Brand $50 Non-Formulary $45 Non-Formulary after ded. Inpatient Mental Health $150 Copay/day,$750 max/adm 70% after ded. 100% after ded. 50% after ded. Outpatient Mental Health $30 Copay/visit 50% after ded. 100% after ded. 50% after ded. Inpatient Serious Mental Health Outpatient Serious Mental Health $150 Copay/day,$750 max/adm 70% after ded. 100% after ded. 50% after ded. $30 Copay/day 50% after ded. 100% after ded. 50% after ded.

12 Plan Coverage Summary For Delta Dental Coverage Basic Dental Coverage Buy up Dental Coverage Maximums $1,000 per person per year $1,500 per person per year Diagnostic & Preventive (D&P) Counts toward maximums Counts toward maximums Benefits & Covered Services Diagnostic & Preventive: 100% covered 100% covered exams, cleaning, x-rays, sealants Basic Services: 100% covered 100% covered fillings, denture repair, stainless steel crowns, posterior composites Endodontic (root canal) 100% covered 100% covered Periodontics (gum treatments) 0% covered 50% covered Oral Surgery 0% covered 100% covered Major Services: 0% covered 50% covered crowns, inlays, onlays, cast restoration Prosthodontics: 0% covered 50% covered Bridges and dentures, implants (new) Orthodontics Benefits: N/A 50% covered Dependent children to the end of the calendar year that dependent turns 19 Orthodontics Maximums N/A $1,500 Lifetime Plan Coverage Summary For Davis Vision Coverage Basic Vision Coverage 12 Buy up Vision Coverage In-Network Out-of-Network In-Network Out-of-Network Examination 100% covered $35 allowance 100% covered $35 allowance Exam Frequency Once every two Once every two Once every two Once every two calendar years calendar years calendar years calendar years Frames Hardware Frequency Eyeglass lenses: Standard Lenses, single vision, bifocal, trifocal, lenticular Eyeglass lenses: Specialty Lenses, glass grey #3 prescription, tinting Davis Tower of frames; 100% for Fashion & Designer, $20 for Premier Selection, $60 credit for non-tower Once every two calendar years 100% covered 100% covered $75 allowance for frames and lenses Once every two calendar years $75 allowance for frames and lenses $75 allowance for frames and lenses 100% covered on Davis Tower of frames and $100 credit for non-tower Once every two calendar years 100% covered 100% covered $125 allowance for frames and lenses Once every two calendar years $125 allowance for frames and lenses $125 allowance for frames and lenses

13 Basic Vision Coverage Buy up Vision Coverage Coverage In-Network Out-of-Network In-Network Out-of-Network blended invisible bifocals $10 Copay $10 Copay ultraviolet (uv) coating $12 Copay $12 Copay scratch resistant-single vision $15 Copay $15 Copay scratch resistant-multifocal $25 Copay $25 Copay anti-reflective coating $33 Copay $33 Copay progressive lenses-standard $50 Copay $50 Copay progressive lenses-premium $90 Copay $90 Copay polaroid $60 Copay $60 Copay polycarbonate $30 Copay $30 Copay high index $55 Copay $55 Copay Photochromatic glass-singe $15 Copay $15 Copay Photochromactic glass-multi $25 Copay $25 Copay Photochromatic glass-singe $60 Copay Photochromactic glass-multi $70 Copay Contacts $75 allowance $125 allowance Contact lens evaluation and fitting Lens Options/Vision Care Supplies Included in $75 allowance $75 allowance Included in $75 allowance Included in $125 allowance $125 allowance Included in $125 allowance Additional Eyewear and Exams Warranty Mail Service Membership 1 year unconditional on eyeglasses when selected from the Davis Tower Free Membership in Lens Program 1 year unconditional on eyeglasses when selected from the Davis Tower Free Membership in Lens Program Laser Vision Correction Services Discount at Davis Vision Participating Correction Provider Discount at Davis Vision Participating Correction Provider Flexible Spending Accounts For Health Care and Dependent Care You may make pre-tax contributions to a Flexible Spending Account for either Health Care or Dependent Care expenses incurred by you during the benefit plan year. By saving for these expenses in a Flexible Spending Account you save on taxes and lower your cost for these expenses. While Flexible Spending Accounts offer you a convenient way to pay eligible expenses, and save money on taxes too, it s important to remember that there are some Internal Revenue Service (IRS) restrictions. How do Flexible Spending Accounts Work? If you choose either a Health Care Flexible Spending Account or a Dependent Care Flexible Spending account, or both, you direct part of your pay to one or both of these accounts. 13

14 Separate accounts for Health Care and Dependent Care will be set up in your name. Any money redirected from your pay goes into your account before taxes are withheld. That means your taxable income is lower so you pay less federal income and Social Security taxes. However, depending on where you live you may still be subject to state and/or local city taxes. When you withdraw from your accounts, you are actually using untaxed dollars to pay qualifying expenses, so you lower your net cost. For example, if you paid $100 for new eyeglasses (and this expense was not covered under your Medical or Vision Plan option), you had to earn $133 then pay $33 in federal and Social Security taxes before you got the $100 you needed for the glasses. However, at Swarthmore College, you can deposit $100 to your Health Care Spending Account and pay $100 for the glasses. You won t pay the $33 in taxes. For expenses incurred between November 1, 2013 and October 31, 2014, you have until January 31, 2015 to submit claims for reimbursement. Healthcare Spending Account: This account is designed to help you pay medical, dental and vision care expenses, which are not covered by your medical Plan. For example, you can use the money in your account to pay for such expenses as: - deductible and copayments - expenses for medical services or supplies not covered by your plan - dental, vision and hearing care expenses - transportation expenses related to medical care - nursing care - wheelchairs and other durable medical equipment - capital expenses for a personal residence to accommodate a disabling condition A Health Care Spending Account will not reimburse for insurance premium cost including Medicare. You can deposit as little as you want to your Health Care Spending Account. The maximum contribution to your Health Care Flexible Spending Account is $2,500. Use-it-or-lose-it: Any balance in your account at the end of the plan year, which is not used to pay eligible expenses for that plan year will be forfeited. Dependent Care Spending Account: This account is designed to help you pay dependent care expenses so you can work. A dependent could be a dependent child or a dependent elder parent or grandparent. You will qualify to pay for dependent care expenses through this account if you meet both of these requirements: 1. You are responsible for the care of an eligible dependent such as: - your children under age 13 or, - other adults who are your dependents for federal income tax purposes and who are physically or mentally unable to care for themselves. 2. You must be at work when the eligible dependents receive care. If you are married, you and your spouse must both work to be eligible or your spouse must be a full-time student or disabled. The maximum total contribution to your Dependent Care Account is $5,000. However, there are certain 14

15 restrictions. If you are married, you may not contribute more than the lower of you or your spouse s annual income. If your spouse is disabled or a full-time student, he or she is assumed to earn $200 a month if you claim one eligible dependent and $400 a month if you claim two or more dependents. If your spouse also participates in an employer-sponsored dependent care account, the total contribution for your family cannot be more than $5,000. In addition, if you or your spouse files separate income tax returns, the annual limit is $2,500 instead of $5,000. Use-it-or-lose-it: Any balance in your account at the end of the plan year, which is not used to pay eligible expenses for that plan year, will be forfeited. Life Insurance Coverage For Basic Life Insurance Coverage The College pays the total cost for Basic Life Insurance. The amount of your College provided life insurance is 1.5 times your annual base salary, rounded up to the nearest thousand to a maximum of $150,000 of coverage. IRS tax regulations require that you are liable for taxes on the cost of employer-paid life insurance in excess of $50,000. Additional Life Insurance Coverage You may purchase additional life insurance protection for you, your spouse or domestic partner, or your dependents through Aetna Life Insurance Company. To enroll in Additional Life Insurance for your spouse, domestic partner and/or dependents requires you to enroll in Additional Life Insurance for yourself. Great news! This year only, you will have the option to increase the amount of additional coverage for you and or your family or elect additional coverage for the first time (up to the guaranteed issue amounts and as long as you were not previously denied coverage) without providing medical evidence of insurability. You will have this opportunity during Open Enrollment and later in the year. You will receive notice of the special enrollment period later in the year. Coverage for you Coverage for your spouse/domestic partner For your dependent children 1 to 5 times your salary to a maximum of $750,000; whichever is less $5,000 increments, not to exceed 100% of employee additional life insurance coverage, to a maximum of $100,000 $5,000 or $10,000 increments, not to exceed 100% of employee additional life insurance coverage, to a maximum of $10,000 Coverage for you Evidence of Insurability is required for any level of coverage. Coverage for you Rates per $1,000 of Coverage Under the age of 30 $0.05 Age 30 to 34 $0.06 Age 35 to 39 $0.08 Age 40 to 44 $

16 Age 45 to 49 $0.15 Age 50 to 54 $0.23 Age 55 to 59 $0.43 Age 60 to 64 $0.61 Age 65 to 69 $ and over $1.80 Coverage for your Spouse or Domestic Partner Evidence of Insurability level is required for coverage over $25,000; the age of the Employee is used to determine rate. Coverage for your Spouse/Domestic Partner Rates per $1,000 of Coverage Under the age of 25 $0.04 Age 25 to 29 $0.05 Age 30 to 34 $0.07 Age 35 to 39 $0.08 Age 40 to 44 $0.10 Age 45 to 49 $0.14 Age 50 to 54 $0.26 Age 55 to 59 $0.42 Age 60 to 64 $0.73 Age 65 to 69 $ and over $2.00 Coverage for your Dependent Children Evidence of Insurability level is $10,000 Coverage for your dependent Child 15 days to 19 years old; 26 years old if full-time student Rates per $1,000 of Coverage $0.09 Medical Evidence of Insurability To Enroll in Additional life Insurance above the guaranteed issue amount (for employee that is the lessor of 3 times your annual salary or $200,000) requires a completed Statement of Health form that will be sent to Aetna Life Insurance Company for approval. Your Additional Life Insurance coverage will go into effect upon approval of your Statement of Health by Aetna, but not before November 1, Accidental Death and Dismemberment Insurance Coverage For Basic Accidental Death and Dismemberment (AD&D) Insurance The College pays the total cost for Basic Accidental Death and Dismemberment Insurance. The amount of your College provided Accidental Death and Dismemberment Insurance is 1.5 times your annual base salary, rounded up to the nearest thousand to a maximum of $150,000 of coverage. 16

17 Additional AD&D Insurance Coverage You may purchase Additional Accidental Death and Dismemberment insurance protection for you, your spouse or domestic partner, or your dependents through Aetna Life Insurance Company. To enroll in Additional Accidental Death and Dismemberment Insurance you are required to enroll in Additional Life Insurance. Coverage Level Rates per $1,000 of Coverage Employee Only $0.013 All other Coverage Level $0.022 MetLaw Pre-Paid Legal Service for If you opt to enroll, you will have access to an extensive network of attorneys through Hyatt Legal Plans for a number of legal matters. Services include, but are not limited to, estate planning, financial and real estate matters, defense of civil litigation, family law, and traffic offenses. MetLaw provides you with telephone and office consultations for an unlimited number of matters with the attorney of your choice. This plan will also cover matters for you and your dependents at no additional cost. The cost is $19.50 per month Long Term Disability Insurance Long Term Disability Insurance is purchased by the College for all benefit eligible employees of.75 FTE or greater. Long Term Disability insurance provides for a continuation of your base salary in the event you are disabled and unable to return to work after six months. LTD premiums are based upon your salary and your maximum long-term disability benefits available. If an election is made to pay premiums on an after-tax basis, Swarthmore College will add the value of the premium to your paycheck (subject to taxes), then deduct the cost of coverage, thus, allowing you to pay the tax on the value of the premium and collect a tax-free LTD benefit. For more details please see the Taxation Explanation Document found on the Human Resources homepage. Pre-tax Option: This is the College provided coverage in which you pay nothing toward the cost of this insurance. If you ever use the benefit, the income you receive will be federally taxable to you. Post-tax Option: You choose to pay taxes on the premiums the College pays on your behalf. In this case, if you use the benefit, the income you receive will not be federally taxable. The post-tax option is a permanent election. Important Notices for You Women s Health and Cancer Rights Act of 1998: In compliance with the Women s Health and Cancer Rights Act of 1998, Swarthmore College s medical plan coverage provides for the following services in conjunction with a mastectomy: - Reconstruction of the breast on which the mastectomy was performed; - Surgery and reconstruction of the other breast to produce a symmetrical appearance; and - Prosthesis and treatment of physical complications in all stages of mastectomy, including lymph edemas. 17

18 These services will be provided in a manner determined in consultation with the attending physician and patient. Coverage is subject to applicable deductions and co-insurance amounts that apply to other covered services. Newborns and Mothers Health Protection Act of 1996: All of Swarthmore College s medical plans cover no less than a 48-hour inpatient hospital stay for the mother and newborn child following normal delivery and no less than a 96-hour stay following a cesarean section, unless discharged earlier after consulting with the mother, and with the mother s consent, in accordance with the Newborns and Mothers Protection Act. Health Insurance Portability and Accountability Act of 1996 We are required to notify the community of Swarthmore College s duties and obligations under the Health Insurance Portability and Accountability Act of 1996 (HIPPA). HIPAAs goal is to improve administrative efficiency, ensure the confidentiality of information transmitted from health plans to vendors, and protect the privacy of identifiable health care information. Swarthmore College and our health insurance plans are in compliance with HIPAA and fully support its goals and purpose. The HIPAA privacy rules provide individuals who are covered by our plans with certain rights associated with their Protected Health Information (PHI). PHI is individually identifiable health information transmitted or maintained in any form or medium. Your rights regarding PHI include: - Access to inspect, and copy certain PHI; - Ability to request the amendment of your PHI when appropriate; - Ability to request restriction of the use and disclosure of your PHI; - Ability to request the use of alternative means or for receiving communications of your PHI; - Ability to request an account of disclosures of your PHI. The HIPAA s privacy rules apply to any claim processed under Swarthmore College s sponsored medical, prescription, vision or dental plan. We are now prohibited from receiving information to resolve a medical, prescription, vision or dental claim unless you are in the office when a call is made to the insurance provider or you sign an authorization form which allows us to process and resolve insurance claim issues. A more detailed description of the HIPAA legislation, your rights under HIPAA and contact information should you have questions is available at the Human Resources Office. The Mental Health Parity of 1996 The Mental Health Parity Act (MHPA) requires that annual or lifetime dollar limits on mental health benefits be no lower than any such dollar limits for medical or surgical benefits offered by a group health plan. The Mental Health Parity and Addiction Equity Act of 2008 MHPA requires parity with respect to aggregate lifetime and annual dollar limits. However MHPA did not apply to substance use disorder benefits. The Mental Health Parity and Addictions Equity Act (MHPAEA) continued the MHPA parity rules as to limits for mental health benefits, and amended them to extend to substance use disorder benefits. Therefore, our medical plans offer substance use disorder benefits subject to aggregate lifetime and annual dollar limits that comply with the MHPAEA s parity provisions. Medicaid and the Children s Health Insurance Program (CHIP) Offer of Free or Low Cost Health Coverage to Children and Families: If you are eligible for health coverage, but are unable to afford the premium, some states have premium assistance programs that can help pay for coverage. These states use funds from their Medicaid or CHIP programs to help people who are eligible for employersponsored health coverage but need assistance in paying their health premiums. If you or your dependents are already enrolled in Medicaid or CHIP and live in a participating state you can contact your state to find out if premium assistance is available. A list of participating states and contact information is available on the Human 18

19 Resources web site or you can contact the Human Resources Office. If you or your dependents are not currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, you can contact your states Medicaid or CHIP office or dial KIDS NOW or to find out how to apply. If you qualify, you can ask the state if it has a program that might help you pay the premiums for an employer-sponsored plan. Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, you may enroll in Swarthmore College s health plan as long as you and your dependents are eligible but not already enrolled in the plan. This is a Special Enrollment opportunity and you must request coverage within 60 days of being determined eligible for premium assistance. Exchange Notification The Affordable Care Act requires Swarthmore College to notify all employees of the existence of the Health Care Marketplace. When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance: the Health Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic information about the new Marketplace and employment based health coverage offered by Swarthmore College What is the Health Insurance Marketplace? The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, Can I Save Money on my Health Insurance Premiums in the Marketplace? You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on your household income. Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your employer that would cover you (and not any other members of your family) is more than 9.5% of your household income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit. Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer contribution -as well as your employee contribution to employer-offered coverage- is often excluded from income for Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis. How Can I Get More Information? For more information about your coverage offered by Swarthmore College please check your summary plan description or contact Human Resources. The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area. 19