Benefits Plan Updates

Transcription

1 Teachers Health Trust 2015 Health Care Benefits Plan Updates 2015 Trust Universal ID Cards Page 2 Grandfathered Status Updates Page 4 Retiree Health Plan Merger Page 5 Summaries of Coverage Pages IMPORTANT UPDATE INFORMATION ABOUT YOUR HEALTH CARE PLAN ENCLOSED

2 Health Plan Updates 2015 Health Plan Updates PAGE CONTENT 2015 Health Care Benefits Updates Overview 2015 Trust Universal ID Card Prescription Drug Coverage Update Trust Transitioning from Grandfathered Status Influenza Vaccinations Retiree Health Plan Merger Notification The Women s Health and Cancer Rights Act of 1998 Routine & Preventive Care Coverage Notice Important Notice About Prescription Drug Coverage and Medicare Notice of Privacy Practices for the Use and Disclosure of Private Health Info. Notice of COBRA Continuation Rights Summary of Coverage: Diamond PPO Plan Summary of Coverage: Platinum PPO Plan Summary of Coverage: Retiree PPO Plan Excluded Services and Other Covered Services Coverage Examples Premium Rate Sheet: Active Participants Premium Rate Sheet: Retiree Participants Contact Information 2015 Health Care Benefits Updates Overview The Teachers Health Trust continuously works to ensure that a proper balance between the benefits offered and their cost is maintained. Additionally, the Trust considers it pivotal that all of our participants receive information about the annual updates and adjustments that are important to managing the health care for themselves as well as their families. For this reason, the Trust has included information about updates to your benefits that are pertinent to you and your family. Please carefully review the following pages for the effective dates of any changes that may require action by you to ensure a smooth transition for you and your dependents. If you have any questions or require additional information, please contact the Service Department at or between 7:00 a.m. and 5:45 p.m., Monday through Thursday, and 9:00 a.m. and 11:45 a.m., Friday. You may also the Service Team at serviceteam@teachershealthtrust.org Trust Universal ID Card Your new Universal ID Card will be sent to you prior to the end of the year. This card will be needed for appointments related to: ¾ Medical ¾ Dental ¾ Prescription ¾ Vision This new card will not impact your coverage or in-network pharmacies. Please show this card to your pharmacist in order to assist in filling your prescription. The pharmacy will be unable to fill your prescription without you first providing them with your new insurance card. RxBIN: RxPCN: RxGrp: Issuer (80840): ID: Name: Medical Network: Teachers Health Trust Plan Name: Diamond Plan For additional cards or prescription ADV drug information, please contact RX0000 MedImpact at Johnathon S Doe TEACHERS HEALTH TRUST Medical and Prescription Drug Card

3 2015 Health Plan Updates 3 The Teachers Health Trust (Trust) has partnered with MedImpact to provide your prescription benefits beginning January 1, Your new 2015 Trust Universal Card will be sent to you prior to the end of the year (see previous page). This program is designed to provide high quality care while simultaneously helping to manage the increasing costs of prescription drugs. How to Use Your New Pharmacy Benefit Plan 1. Visiting Your Local Retail Pharmacy The 2015 Trust Universal Card will include the information your pharmacy needs to process prescriptions with MedImpact. Please show this card to your pharmacist in order to assist in filling your prescription. The pharmacy will be unable to fill your prescription without you first providing them with your new insurance card. Your network pharmacies are CVS, Lin s Supermarket (Overton, NV), Sam s Club, Vons and Wal-Mart. If you choose to use MedImpact pharmacies other than those listed above, you will have a $10 Pharmacy Choice Fee in addition to the regular co-pay or co-insurance for covered drugs. For a complete listing of MedImpact pharmacies, visit mp.medimpact.com. 2. Filling Mail-Order Prescriptions You can obtain a 90-day supply for maintenance medication(s) through CVS/Caremark. If you use mail-order, you can save money and time by having prescriptions for maintenance medication(s) delivered right to your home. To learn more about the mail-order program, you may visit the CVS/Caremark website at or speak to a representative by phone at Filling Specialty Prescriptions Your specialty pharmacy is CVS/Caremark. This program supports patients with complex health conditions who need injectable medications, or medications with strict compliance requirements and/or special storage needs. CVS/Caremark allows you to receive your specialty medications via delivery to your home, workplace, physician's office or other designated location. For more information about this service, you may visit the CVS/Caremark website at or speak to a representative by phone at Using the MedImpact Member Website and/or Mobile Patient Applications Information to help you understand your prescription benefit and drug coverage details, along with formulary and pharmacy information, is available online through the MedImpact Member website and mobile applications. Go to the Member link at mp.medimpact.com and follow the registration prompts. Be sure to have your insurance card available during registration. 5. A Few Money-Saving Tips ¾ If the Dispense as Written (DAW) box on your prescription is marked, it will automatically be filled with a brand-name drug and you will be responsible for a higher cost. Ask your physician if a generic medication is available, if appropriate, as they will generally save you money. ¾ If a generic is not available and if appropriate, ask your physician to prescribe a drug on the preferred drug list. Preferred medications are generally less expensive than non-preferred medications. The preferred drug list can be found on either the Trust website ( or the MedImpact website (mp.medimpact.com). Questions? Prescription Drug Coverage Update If you have a question about your pharmacy coverage, please contact a MedImpact Customer Representative by phone at MedImpact is available 24 hours a day, 7 days a week. You may also visit MedImpact online at mp.medimpact. com. For TDD assistance, please call 711, reference and you will be connected with an agent who can assist you. MedImpact is here to help you.

4 Health Plan Updates Trust Transitioning from Grandfathered Status Since its inception, the Teachers Health Trust has always been able to administer and sustain our plans as grandfathered health plans. Recently, due to the passing of the Patient Protection and Affordable Care Act (Affordable Care Act), the Trust has had to implement some minor changes to our existing plans in order to remain compliant. What is Grandfathered Status? Health care plans established prior to March 23, 2010 are eligible for grandfathered status and, therefore, do not have to meet all the requirements of the Affordable Care Act. However, if an insurer makes significant changes to plan benefits, premiums, copayments and/or deductibles; then the plan ceases to be a grandfathered plan. Grandfathered plans are those that were in existence during this time period and have not been changed in any way that substantially cuts benefits or increases costs to the consumers. How does the Patient Protection and Affordable Care (PPAC) Act affect my existing plan? There are several benefit changes that are required to take effect for new and renewing plans on or after September 23, 2010, including, but not limited to: ¾ Removal of lifetime dollar limits on essential health benefits ¾ Removal of annual dollar limits on essential health benefits ¾ End arbitrary cancellations of health coverage ¾ Coverage for dependents up to age 26, regardless of standard eligibility criteria ¾ No pre-existing condition limitations for members under age 19 ¾ Provide Summary of Benefits and Coverage ¾ In 2014, coverage waiting periods must not exceed 90 days ¾ No prior authorization for emergency room services ¾ Copay and coinsurance rates for emergency room services performed in- or out-of-network will be the same ¾ Additional appeal rights and notice requirements may apply NOTE: Most requirements mandated by the ACA, as noted above, will not impact the Trust s benefit plans since the majority were already covered. For example, since the Trust has never instituted pre-existing conditions limitations within any plans, this change will not impact any of its offered plans. The Teachers Health Trust and MedImpact have partnered to provide eligible participants and dependents influenza vaccinations at select CVS Pharmacy locations that offer flu vaccination services. All participants and dependents who have Teachers Health Trust as their primary medical coverage are eligible. If your spouse, domestic partner and/or dependents have primary coverage through another plan, please review their benefits under that plan for coverage information. Important Reminders Influenza Vaccinations ¾ Vaccinations are available now. ¾ Injectable seasonal flu vaccination will be administered (Trivalent). ¾ A copayment of $5.00 per vaccination will be charged through December 31, ¾ No copayment is charged per vaccination beginning January 1, ¾ Vaccinations are available through April 30, ¾ The listed vaccination copayment does not include administration of high dose or Flu-Mist. ¾ CVS reserves the right to not provide vaccinations to minors as determined by state law or clinical considerations. Through this program, influenza vaccinations may be acquired in-network through your prescription card at participating CVS Pharmacy locations. Services obtained through a CVS Minute Clinic will be considered and processed as out-of-network. Visit to find contact information for your local CVS Pharmacy location.

5 2015 Health Plan Updates 5 The Retiree Health Trust has merged with the Teachers Health Trust. Effective as of November 1, 2014, the Retiree Health Plan will be administered by the Teachers Health Trust. The Board of Trustees have been combined and now consists of nine (9) members; four (4) members from the previous Teachers Health Trust Board, four (4) members of the previous Retiree Health Trust Board and the President of CCEA. Your Retiree Health Plan medical, dental, vision and prescription benefits have not changed. We realize you may have some questions about the transition and have provided some of the most common below: Q & A Retiree Health Plan Merger Notification 1. As a retiree, will I have to re-enroll in the Retiree Health Plan? No, you will not be required to re-enroll; your status as a participant is unchanged. 2. Have my Retiree benefits changed? Your Retiree Health Plan benefits will remain the same as your current retiree plan benefits at this time. 3. Will I have the same insurance card? You may continue to use your current ID card through December 31, As of January, , however, you will be mailed your new Trust Identification Card to replace your current one. 4. Will my premium increase? No, your premium will remain the same at this time. 5. Who do I call if I have any questions about my plan benefits? You may contact the Teachers Health Trust during our regular business hours. You may also refer to the Retiree Health Plan Document, available online at the Trust s website ( 6. Will my prescription drug plan remain the same? Yes, please refer to the formulary list, available online at the Trust s website ( 7. Will I have to change my provider? No, if you are currently receiving services from a Trust in-network provider, you may continue to do so. 8. Can I make any plan changes at this time? No, you may make plan changes during open enrollment or after a life event. For detailed information on life events, please refer to the Retiree Health Plan Document available online at the Trust s website ( Please visit our website at for a list of current Trust in-network-providers, prescription formulary and/or to view a detailed Retiree Health Plan Document. If you have any questions, please contact the Teachers Health Trust at ( outside of Nevada) 7:00 a.m. to 5:45 p.m. PST Monday through Thursday and 9:00 a.m. to 11:45 a.m. PST on Fridays. You may also reach the Customer Service Department by at serviceteam@ teachershealthtrust.org. The Women s Health and Cancer Rights Act of 1998 Under federal law, group health plans and health insurance issuers providing benefits for a mastectomy must also provide, in connection with the mastectomy for which the Participant or Qualified Beneficiary is receiving benefits, coverage for: ¾ All states of reconstruction of the breast on which the mastectomy has been performed; ¾ Surgery and reconstruction of the other breast to produce a symmetrical appearance; and ¾ Prostheses and treatment of physical complications of mastectomy, including lymphedema; in a manner determined in consultation between the attending Physician and the patient. These benefits may be subject to Annual Deductible, Copayment, and Coinsurance provisions that are appropriate and consistent with other benefits under the Trust. If you have any questions regarding this coverage under the Teachers Health Trust, please contact: Teachers Health Trust 2950 E. Rochelle Avenue Las Vegas, NV or

6 Health Plan Updates Routine & Preventive Care Coverage Notice Beginning January 1, 2015, the Trust will no longer have a $600 calendar year maximum for benefits covered as Preventive/ Routine care. Additionally, an office copayment will no longer be required for Preventive/Routine care. The services listed below are covered under the Preventive/Routine Care Benefit when no diagnosis is present. Prior authorization requirements established throughout the Teachers Health Trust Plan Document apply to all Preventive/Routine Care. Preventive Health Services for Adults Essential Health Benefits ¾ Abdominal Aortic Aneurysm Screening ¾ Alcohol Misuse Screening/Counseling ¾ Aspirin Use (to prevent cardiovascular disease) ¾ Blood Pressure screening for all adults ¾ Cholesterol Screening ¾ Colorectal Cancer Screening ¾ Depression Screening ¾ Diabetes (Type 2) Screening ¾ Diet Counseling ¾ HIV Screening ¾ Immunization Vaccines ¾ Obesity Screening/Counseling ¾ Sexually Transmitted Infection (STI) Prevention Counseling ¾ Syphilis Screening ¾ Tobacco Use screening/cessation Interventions Preventive Health Services for Women ¾ Anemia Screening for Pregnant Women ¾ Breast Cancer Genetic Test Counseling (BRCA) ¾ Breast Cancer Mammography Screenings ¾ Breast Cancer Chemoprevention Counseling ¾ Breastfeeding Comprehensive Support/Counseling ¾ Cervical Cancer Screening ¾ Chlamydia Infection Screening ¾ Contraception: FDA-approved contraceptive methods, sterilization procedures, and patient education and counseling ¾ Domestic and Interpersonal Violence Screening/ Counseling ¾ Folic Acid Supplements ¾ Gestational Diabetes Screening ¾ Gonorrhea Screening ¾ Hepatitis B Screening (Pregnant at 1 st prenatal visit) ¾ HIV Screening/Counseling ¾ Human Papillomavirus (HPV) DNA Test ¾ Osteoporosis Screening ¾ Rh Incompatibility Screening ¾ Sexually Transmitted Infections Counseling ¾ Syphilis Screening ¾ Tobacco Use Screening and Interventions ¾ Urinary Tract/Other Infection Screening ¾ Well-woman Visits for recommended services for women under 65 Preventive Health Services for Children ¾ Alcohol and Drug Use Assessments for Adolescents ¾ Autism Screening for Children at 18 and 24 Months ¾ Behavioral Assessments ¾ Blood Pressure Screening ¾ Cervical Dysplasia Screening ¾ Depression Screening for Adolescents ¾ Developmental screening for children under age 3 ¾ Dyslipidemia Screening ¾ Fluoride Chemoprevention Supplements ¾ Gonorrhea Preventive Medication (Newborns) ¾ Hearing Screening (Newborns) ¾ Height, Weight and Body Mass Index Measurements ¾ Hematocrit or Hemoglobin Screening ¾ Hemoglobinopathies or Sickle Cell Screening (Newborns) ¾ HIV Screening ¾ Hypothyroidism Screening (Newborns) ¾ Immunization Vaccines ¾ Iron Supplements (Ages 6-12 mos. at risk for anemia) ¾ Lead screening for Children at Risk of Exposure ¾ Medical History Throughout Development ¾ Obesity Screening/Counseling ¾ Oral Health Risk Assessment ¾ Phenylketonuria (PKU) Screening (Newborns) ¾ Sexually Transmitted Infection (STI) Prevention Counseling and Screening ¾ Tuberculin Testing ¾ Vision screening for all children Many of the screenings listed above are inclusive as part of a single preventive care office visit. To review complete and detailed descriptions of screening/counseling requirements, age groups and vaccine types in respect to all preventive health services, please visit

7 2015 Health Plan Updates 7 Important Notice About Prescription Drug Coverage and Medicare Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Teachers Health Trust and about your options under Medicare s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. There are two important things you need to know about your current coverage and Medicare s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2. Teachers Health Trust has determined that the prescription drug coverage offered by the Teachers Health Trust is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15 to December 7. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What Happens to Your Current Coverage If You Decide to Join A Medicare Drug Plan If you decide to join a Medicare drug plan, your current Teachers Health Trust coverage will be affected. If you do decide to join a Medicare drug plan and drop your current Teachers Health Trust coverage, be aware that you and your dependents will not be able to get this coverage back. When Will You Pay A Higher Premium (Penalty) to Join A Medicare Drug Plan? Because your existing coverage is on average at least as good as standard Medicare prescription drug coverage, you can keep this coverage and not pay extra if you later decide to enroll in Medicare prescription drug coverage. Individuals can enroll in a Medicare prescription drug plan when they first become eligible for Medicare and each year from October 15 through December 7. Beneficiaries terminating Trust active coverage may be eligible for a special enrollment period during which they may sign up for a Medicare prescription drug plan. You should compare your current coverage, including which drugs are covered, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area. If you drop or lose your coverage with Teachers Health Trust and do not enroll in Medicare prescription drug coverage after your current coverage ends, you may pay more (a penalty) to enroll in Medicare prescription drug coverage later. Please contact us for more information about what happens to your coverage if you enroll in a Medicare prescription drug plan. If you go 63 days or longer without prescription drug coverage that is at least as good as Medicare s prescription drug coverage, your monthly premium will go up at least 1% per month for every month that you did not have that coverage. For example, if you go 19 months without coverage, your premium will always be at least 19% higher than what many other people pay. You will have to pay this higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following November to enroll.

8 Health Plan Updates Notice of Privacy Practices for the Use and Disclosure of Private Health Information This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Effective Date: March 26, 2013 Teachers Health Trust (Trust) is required by law to maintain the privacy of Protected Health Information (PHI) and to provide individuals with notice of our legal duties and privacy practices with respect to PHI. PHI is information that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. This Notice of Privacy Practices (Notice) describes how we may use and disclose PHI to carry out treatment, payment or health care operations and for other specified purposes that are permitted or required by law. This Notice also describes your rights with respect to PHI about you. The Trust is required to follow the terms of this Notice. We will not use or disclose PHI about you without your written authorization, except as described in this Notice. We reserve the right to change our practices and this Notice, and to make the new Notice effective for all PHI we maintain. Upon request, we will provide any revised Notice to you. Notice of PHI USES and Disclosures Required PHI Uses and Disclosures. Upon your request, the Trust is required to give you access to certain PHI in order to inspect and copy it. Use and disclosure of your PHI may be required by the Secretary of the Department of Health and Human Services to investigate or determine the Trust s compliance with the privacy regulations. Uses and disclosures to carry out treatment, payment, and health care operations. The Trust and its business associates will use PHI without your consent, authorization or opportunity to agree or object to carry out treatment, payment and health care operations. The Trust also will disclose PHI to the Teachers Health Trust for purposes related to treatment, payment and health care operations. The Trust Sponsor has amended its plan documents to protect your PHI as required by federal law. Treatment is the provision, coordination or management of health care and related services. It also includes but is not limited to consultations and referrals between one or more of your providers. For example, the Trust may disclose to a treating orthodontist the name of your treating dentist so that the orthodontist may ask for your dental X-rays from the treating dentist. Payment includes but is not limited to actions to make coverage determinations and payment (including billing, claims management, subrogation, Trust reimbursement, reviews for medical necessity and appropriateness of care and utilization review and preauthorizations). For example, Teachers Health Trust may tell a doctor whether you are eligible for coverage or what percentage of the bill will be paid by the Trust. Health care operations include but are not limited to quality assessment and improvement, reviewing competence or qualifications of health care professionals, underwriting, premium rating and other insurance activities relating to creating or renewing insurance contracts. It also includes disease management, case management, conducting or arranging for medical review, legal services and auditing functions including fraud and abuse compliance programs, business planning and development, business management and general administrative activities. For example, Teachers Health Trust may use information about your claims to refer you to a disease management program, project future benefit costs or audit the accuracy of its claims processing functions.

9 2015 Health Plan Updates 9 Notice of COBRA Continuation Coverage Rights The Department of Labor has developed a model Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) continuation coverage general notice that plans may use to provide the general notice. To use this model general notice properly, the Plan Administrator must fill in the blanks with the appropriate plan information. The Department considers use of the model general notice, to be good faith compliance with the general notice content requirements of COBRA. The use of the model notices isn t required. The model notices are provided to help facilitate compliance with the applicable notice requirements. NOTE: Plans do not need to include this instruction page with the model general notice. Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub. L ) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C The public reporting burden for this collection of information is estimated to average approximately four minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC or ebsa.opr@ dol.gov and reference the OMB Control Number OMB Control Number (expires 10/31/2016) Continuation Coverage Rights Under COBRA Introduction You re getting this notice because you recently gained coverage under a group health plan (Teachers Health Trust). This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage. The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan s Summary Plan Description or contact the Plan Administrator. You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse s plan), even if that plan generally doesn t accept late enrollees.

10 Health Plan Updates What is COBRA Continuation Coverage? COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a qualifying event. Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a qualified beneficiary. You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. If you re an employee, you ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: ¾ Your hours of employment are reduced, or ¾ Your employment ends for any reason other than your gross misconduct. If you re the spouse of an employee, you ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events: ¾ Your spouse dies; ¾ Your spouse s hours of employment are reduced; ¾ Your spouse s employment ends for any reason other than his or her gross misconduct; ¾ Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or ¾ You become divorced or legally separated from your spouse. Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events: ¾ The parent-employee dies; ¾ The parent-employee s hours of employment are reduced; ¾ The parent-employee s employment ends for any reason other than his or her gross misconduct; ¾ The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both); ¾ The parents become divorced or legally separated; or ¾ The child stops being eligible for coverage under the Plan as a dependent child. Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event. If a proceeding in bankruptcy is filed with respect to the Teachers Health Trust s Retiree Health Plan, and that bankruptcy results in the loss of coverage of any retired employee covered under the Plan, the retired employee will become a qualified beneficiary. The retired employee s spouse, surviving spouse, and dependent children will also become qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan. When is COBRA Continuation Coverage Available? The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events: ¾ The end of employment or reduction of hours of employment; ¾ Death of the employee; ¾ Teachers Health Trust Retiree Health Plan: Commencement of a proceeding in bankruptcy with respect to the employer; or ¾ The employee s becoming entitled to Medicare benefits (under Part A, Part B, or both). For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 60 days after the qualifying event occurs. You must provide this notice to: Teachers Health Trust. COBRA coverage will not be effective until all COBRA premium payments are current. Failure to complete the election form within 60 calendar days will result in forfeiture of COBRA rights.

11 2015 Health Plan Updates 11 How is COBRA Continuation Coverage Provided? Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children. COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage. There are also ways in which this 18-month period of COBRA continuation coverage can be extended. Disability Extension of 18-Month Period of COBRA Continuation Coverage If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage. ¾ The qualified beneficiary must be deemed disabled according to Title II or XVI of the Security Act by the Social Security Administration. ¾ The Social Security Administration must determine a qualified beneficiary was disabled at the time of the qualifying event or any time during the first 60 days of COBRA continuation coverage and within 18 months of initial coverage. ¾ The extension is not limited to the disabled qualified beneficiary. It applies to all qualified beneficiaries. ¾ It is the qualified beneficiary s responsibility to obtain and submit the disability determination from the Social Security Administration within 60 days of the determination and within 18 months of initial coverage. ¾ The Teachers Health Trust can charge up to 150% of the applicable premium during the extended 11-month COBRA period, as long as the disabled qualified beneficiary extends the COBRA coverage. ¾ A qualified beneficiary who has qualified for the extension must notify the Teachers Health Trust within 31 calendar days if a final determination is made that they are no longer disabled. NOTE: It can sometimes take several months for a Determination of Disability to be made by the Social Security Administration. Remember, it is the qualified beneficiary s responsibility to secure the Determination of Disability from the Social Security Administration. Second Qualifying Event Extension of 18-Month Period of COBRA Continuation Coverage If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to: 1. Death of an employee. 2. Medicare entitlement. (If an employee becomes entitled to Medicare,and if the Medicare entitlement causes a loss of coverage under the plan, then the Medicare entitlement is a COBRA qualifying event for covered dependents.) Entitlement to Medicare means the qualified beneficiary is actually covered under Medicare Parts A and B. 3. Divorce or legal separation. 4. Dependent ceases to qualify as a dependent under the plan; e.g., a dependent over age 19 is no longer a full-time student. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. The 36 months of coverage is measured from the date of the qualifying event. It is the participant s responsibility to notify the Teachers Health Trust when divorce or legal separation occurs or when a dependent has ceased to be a dependent under the plan.

12 Health Plan Updates COBRA Coverages Qualified beneficiaries will receive the same selection of plans available to active participants. The Term Life benefit is not available under COBRA. You may continue Term Life on an individual basis. COBRA Premiums The qualified beneficiaries are responsible for the entire cost of COBRA coverage. There is no contribution received from the CCSD. Monthly premiums are fixed for a 12-month period of time, called the determination period. The determination period for the Teachers Health Trust is January 1 through December 31. COBRA premium rates may be adjusted at the beginning of each determination period. If you elect to continue coverage through COBRA, you have 45 calendar days from your election date to pay the premium for the initial coverage period. Thereafter, premiums are due no later than the 20th of the month prior to the month of coverage, with a maximum 31-day grace period. COBRA payments must be postmarked on or before the last day of the 31-day grace period to be considered timely. Failure to pay your premiums within the 31-day grace period will result in termination of COBRA rights. Cancellation of COBRA COBRA continuation coverage will end prior to the maximum continuation period for any of the following reasons: ¾ The Teachers Health Trust ceases to provide any group health plan to any of its employees. ¾ Any required premium for continuation coverage is not paid in a timely manner. ¾ A qualified beneficiary becomes covered under another group health plan that does not contain any exclusion or limitation with respect to any pre-existing condition of such beneficiary other than such an exclusion or limitation which does not apply to or is satisfied by such beneficiary by reason of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). ¾ A qualified beneficiary becomes entitled to Medicare. ¾ A qualified beneficiary extended continuation coverage to 29 months due to a Social Security disability, and a final determination has been made that the qualified beneficiary is no longer disabled. ¾ A qualified beneficiary notifies the Teachers Health Trust he/she wishes to cancel COBRA continuation coverage. Payments All COBRA premium payments should be sent to: Teachers Health Trust P.O. Box Las Vegas, NV Premium contributions must be made by personal check or money order payable to the Teachers Health Trust and received from you no later than the 20th of each month prior to the month of coverage. Neither you nor your dependents will be eligible for benefits unless you are current with your premium payments. All COBRA participants should direct questions concerning continuation coverage to the Trust at or The Trust Service Department can also be reached by at serviceteam@teachershealthtrust.org. If a due date mentioned in this notice falls on a Saturday, Sunday or holiday; the due date extends to the next business day.

13 2015 Health Plan Updates 13 Are There Other Coverage Options Besides COBRA Continuation Coverage? Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse s plan) through what is called a special enrollment period. Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at If you have questions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor s Employee Benefits Security Administration (EBSA) in your area or visit (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA s website.) For more information about the Marketplace, visit Keep your Plan informed of address changes To protect your family s rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. Certificate of Health Insurance Portability If your COBRA coverage ends after June 1, 1997, a Certificate of Health Insurance Portability will automatically be sent to you. The new Certificate of Health Insurance Portability will detail the total time covered under the Teachers Health Trust group health plan and the type of health care plan you were covered under. The time covered under the Teachers Health Trust group health plan (including COBRA coverage) will be used to offset a new employer s pre-existing condition period. Questions regarding a new employer s pre-existing condition period should be directed to the new employer.

14 Health Plan Updates Summaries of Coverage What These Plans Cover and What They Cost This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling Copayments are fixed dollar amounts (for example $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference, (This is called balance billing.) This plan encourages you to use in-network providers by charging you lower deductibles, copayments and coinsurance amounts. Summary of Coverage: Diamond PPO Plan Important Questions Answers Why this Matters: What is the premium? $35.00 per paycheck for the employee only. To determine total cost, a rate sheet is available online at www. teachershealthtrust.org The premium is the amount paid for health insurance. This amount is determined by your plan choice and the number of dependents you have on the plan. What is the overall deductible? Are there other deductibles for specific services? $1,500 for Out-Of-Network Services This is applied to services rendered by doctors that are not contracted with the Teachers Health Trust. NO Is there an out-of-pocket limit on my expenses? What is not included in the out-of-pocket limit? Is there an overall annual limit on what the insurer pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn't cover? $6, per individual or $13,2000 per family for in-network services family Services rendered by out-of-network providers NO Yes. See org or call (702) for a list of participating providers. NO Yes. Examples are: Infertility treatment, cosmetic services, any non-medically necessary services This is the maximum amount you will have to pay for co-payments and co-insurance for all innetwork services in a calendar year. There is not an out-of-pocket maximum for services rendered by out-of-network providers. There are limits for some individual services. A complete listing of limitations is available in the plan document located at www. teachershealthtrust.org. The Teachers Health Trust contracts with different providers who agree to specific allowables for specific services. Any amount the in-network provider bills in excess of the contracted amount will be written off. You may make an appointment directly with a specialist without seeing a primary care provider first. A complete list of exclusions and limitations can be found in the complete plan document located at

15 2015 Health Plan Updates 15 Common Medical Event If you visit a health care provider's office or clinic Services You May Need Primary care visit to treat an injury or illness Your cost if you use a provider Limitations and In-Network Out-of-Network Exceptions $20 After CYD 30% Specialist visit $20 After CYD 30% Other practitioner office visit $20 After CYD 30% Preventive care/screening/ immunization $0 After CYD 30% Completed by Lab $0 After CYD 30% Prior Authorization Required - Out of Network If you have a test Completed by doctor s office $10 After CYD 30% Prior Authorization Required - Out of Network Diagnostic test (x-ray) $10 After CYD 30% Imaging (MRI/CT Scan) $50 After CYD 30% Prior Authorization Required Imaging (PET scans) $200 After CYD 30% Prior Authorization Required Generic Drugs Under $25 $0 After CYD 30% Generic Drugs Over $25 $25% Up to $20 After CYD 30% Preferred Brand Drugs 25% ($25-$50) After CYD 30% If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www. teachershealthtrust. org Non-Preferred Brand Drugs 40% ($40-$80) After CYD 30% Pharmacy Choice Fee $10 per Rx N/A PCF if other than CVS, Wal-Mart or Sam s Club Generic Drugs Under $75 (Mail Order) Generic Drugs Over $75 (Mail Order) Preferred Brand Drugs (Mail Order) $0 N/A $25 N/A $70 N/A Non-Preferred Brand Drugs (Mail Order) $105 N/A Specialty drugs Prorated N/A 30-day increments, copayment is prorated If you have outpatient surgery Facility fee (e.g., ambulatory surgery center $150 After CYD 30% Physician/Surgeon Fee $125 After CYD 30% Anesthesia Fee $100 After CYD 30%

16 Health Plan Updates Common Medical Event If you need immediate medical attention Services You May Need Emergency Room Services Emergency Room Service (Non-Emergency) Your cost if you use a provider In-Network Out-of-Network Limitations and Exceptions $150 $250 After CYD 30% After CYD 30% If you are on vacation out of the area, the deductible is waived. For emergency services benefits are paid innetwork; for urgent services you pay 30% of EME and any amount in excess of EME. Urgent care $20 After CYD 30% Ambulance 20% 20% If you have a hospital stay Facility fee (e.g., hospital room) $150 per day to $450 max per admission After CYD 30% Authorization Required Physician/surgeon fee $125 After CYD 30% Anesthesia $100 After CYD 30% If you have mental health, behavioral health or substance abuse needs Mental/Behavioral health outpatient services Mental/Behavioral health inpatient services Substance use disorder outpatient services $20 After CYD 30% Authorization required after 24 th visit. $150 per day to $450 max per admission After CYD 30% Annual maximum benefit of 100 days combined for inpatient medical rehabilitation, chemical dependency rehabilitation, long-term acute care, skilled nursing facility or mental health. Authorization required $20 After CYD 30% Authorization required after 24 th visit Substance use disorder inpatient services $150 per day to $450 max per admission After CYD 30% Annual maximum benefit of 100 days combined for inpatient medical rehabilitation, chemical dependency rehabilitation, long-term acute care, skilled nursing facility or mental health. Authorization required If you are pregnant Ultrasounds $10 After CYD 30% Limited to 4 per pregnancy unless done by a perinatologist Delivery $150 After CYD 30% If you need help recovering or have other special health needs Home health care 20% After CYD 30% Authorization required Inpatient Rehabilitation services $150 to $450 max After CYD 30% Annual maximum benefit of 100 days combined for inpatient medical rehabilitation, chemical dependency rehabilitation, long-term acute care, skilled nursing facility or mental health. Authorization required

17 2015 Health Plan Updates 17 Common Medical Event If you need help recovering or have other special health needs Services You May Need Skilled nursing care - facility Durable medical equipment Your cost if you use a provider In-Network $150 to $450 max Out-of-Network After CYD 30% Limitations and Exceptions Annual maximum benefit of 100 days combined for inpatient medical rehabilitation, chemical dependency rehabilitation, long-term acute care, skilled nursing facility or mental health. Authorization required 20% After CYD 30% Authorization required for DME over $500 Hospice service 20% After CYD 30% Authorization required Summary of Coverage: Platinum PPO Plan Important Questions Answers Why this Matters: What is the premium? $0.00 per paycheck for the employee only. To determine total cost, a rate sheet is available online at www. teachershealthtrust.org The premium is the amount paid for health insurance. This amount is determined by your plan choice and the number of dependents you have on the plan. What is the overall deductible? Are there other deductibles for specific services? $2,500 for Out-Of-Network Services This is applied to services rendered by doctors that are not contracted with the Teachers Health Trust. NO Is there an out-of-pocket limit on my expenses? What is not included in the out-of-pocket limit? Is there an overall annual limit on what the insurer pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn't cover? $6, per individual or $13,2000 per family for in-network services family Services rendered by out-of-network providers NO Yes. See org or call (702) for a list of participating providers. NO Yes. Examples are: Infertility treatment, cosmetic services, any non-medically necessary services This is the maximum amount you will have to pay for co-payments and co-insurance for all innetwork services in a calendar year. There is not an out-of-pocket maximum for services rendered by out-of-network providers. There are limits for some individual services. A complete listing of limitations is available in the plan document located at org. The Teachers Health Trust contracts with different providers who agree to specific allowables for specific services. Any amount the in-network provider bills in excess of the contracted amount will be written off. You may make an appointment directly with a specialist without seeing a primary care provider first. A complete list of exclusions and limitations can be found in the complete plan document located at

18 Health Plan Updates Common Medical Event If you visit a health care provider's office or clinic Services You May Need Your cost if you use a provider Limitations and In-Network Out-of-Network Exceptions Primary care visit to treat an $30 After CYD 30% injury or illness Specialist visit $30 After CYD 30% Other practitioner office visit $30 After CYD 30% Preventive care/screening/ immunization $0 After CYD 30% Completed by Lab $0 After CYD 30% Prior Authorization Required - Out of Network If you have a test Completed by doctor s office $15 After CYD 30% Prior Authorization Required - Out of Network Diagnostic Test (x-ray) $20 After CYD 30% Imaging (MRI/CT Scan) $75 After CYD 30% Prior Authorization Required Imaging (PET Scan) $400 After CYD 30% Prior Authorization Required Generic Drugs Under $25 $0 After CYD 30% Generic Drugs Over $25 25% up to $25 After CYD 30% Preferred Brand Drugs 25%/$30-$60 After CYD 30% If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www. teachershealthtrust.org Non-Preferred Brand Drugs 40%/$45-$90 After CYD 30% Pharmacy Choice Fee $10 per Rx N/A PCF is other than CVS, Wal-Mart or Sam s Club Generic Drugs Under $75 (Mail Order) Generic Drugs Over $75 (Mail Order) Preferred Brand Drugs (Mail Order) $0 N/A $30 N/A $75 N/A Non-Preferred Brand Drugs (Mail Order) $115 N/A Specialty drugs Prorated N/A 30-day increments, copayment is prorated If you have outpatient surgery Facility fee (e.g., ambulatory surgery center $200 After CYD 30% Physician/Surgeon Fee $250 After CYD 30% Anesthesia Fee $150 After CYD 30%

19 2015 Health Plan Updates 19 Common Medical Event If you need immediate medical attention Your cost if you use a provider Limitations Services You May Need In-Network Out-of-Network and Exceptions Emergency Room Services $350 After CYD 30% If you are on vacation out of the area, the deductible Emergency Room Service $400 After CYD 30% is waived. For emergency (Non-Emergency) services benefits are paid innetwork; Urgent care $30 After CYD 30% for urgent services you pay 30% of EME and Ambulance 30% 30% any amount in excess of EME. If you have a hospital stay Facility fee (e.g., hospital room) $300 per day to $900 max per admission After CYD 30% Authorization Required Physician/surgeon fee $250 After CYD 30% Anesthesia $150 After CYD 30% If you have mental health, behavioral health or substance abuse needs Mental/Behavioral health outpatient services Mental/Behavioral health inpatient services Substance use disorder outpatient services $30 After CYD 30% Authorization required after 24 th visit. $300 per day to $900 max per admission After CYD 30% Annual maximum benefit of 100 days combined for inpatient medical rehabilitation, chemical dependency rehabilitation, long-term acute care, skilled nursing facility or mental health. Authorization required $30 After CYD 30% Authorization required after 24 th visit Substance use disorder inpatient services $300 per day to $900 max per admission After CYD 30% Annual maximum benefit of 100 days combined for inpatient medical rehabilitation, chemical dependency rehabilitation, long-term acute care, skilled nursing facility or mental health. Authorization required If your are pregnant Ultrasounds $20 After CYD 30% Limited to 4 per pregnancy unless done by a perinatologist Delivery $300 After CYD 30% If you need help recovering or have other special health needs Home health care 30% After CYD 30% Authorization required Inpatient Rehabilitation services $300 to $900 max After CYD 30% Annual maximum benefit of 100 days for inpatient medical rehabilitation, chemical dependency rehabilitation, long-term acute care, skilled nursing facility or mental health - Authorization required

20 Health Plan Updates Common Medical Event If you need help recovering or have other special health needs Your cost if you use a provider Limitations Services You May Need In-Network Out-of-Network Skilled nursing care - facility $300 to $900 max After CYD 30% and Exceptions Annual maximum benefit of 100 days combined for inpatient medical rehabilitation, chemical dependency rehabilitation, long-term acute care, skilled nursing facility or mental health. Authorization required Durable medical equipment 30% After CYD 30% Authorization required for DME over $500 Hospice service 30% After CYD 30% Authorization required Summary of Coverage: Retiree PPO Plan Important Questions Answers Why this Matters: What is the premium? $374 - $818, depending upon years of service and unused sick days. To determine total cost, a rate sheet is available on page 27 of this booklet. The premium is the amount paid for health insurance. This amount is determined by your plan choice and the number of dependents you have on the plan. What is the overall deductible? $2,500 for Out-Of-Network Services This is applied to services rendered by doctors that are not contracted with the Teachers Health Trust. Are there other deductibles for specific services? Is there an out-of-pocket limit on my expenses? What is not included in the out-of-pocket limit? Is there an overall annual limit on what the insurer pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn't cover? YES $6, per individual or $13,2000 per family for in-network services family Services rendered by out-of-network providers NO Yes. See org or call (702) for a list of participating providers. NO Yes. Examples are: Infertility treatment, cosmetic services, any non-medically necessary services calendar year deductible for those Retirees living our of the service area. This is the maximum amount you will have to pay for co-payments and co-insurance for all innetwork services in a calendar year. There is not an out-of-pocket maximum for services rendered by out-of-network providers. There are limits for some individual services. A complete listing of limitations is available in the plan document located at org. The Teachers Health Trust contracts with different providers who agree to specific allowables for specific services. Any amount the in-network provider bills in excess of the contracted amount will be written off. You may make an appointment directly with a specialist without seeing a primary care provider first. A complete list of exclusions and limitations can be found in the complete plan document located at