Summary Plan Descriptions for HCA Benefits Plans

Transcription

1 Summary Plan Descriptions for HCA Benefits Plans As of February 1, 2011 Includes: HCA Health and Welfare Benefits Plans HCA 401(k) Plan Esta Descripción del Resumen del Plan y el folleto contienen un resumen en inglés de sus derechos y beneficios del plan bajo los planes de beneficio auspiciados por HCA. Si usted tiene dificultades en entender cualquier parte de esta Descripción del Resumen del Plan o folleto, contacte a BConnected al Las horas de oficina son de lunes a viernes, 7 a.m. a 7 p.m. HCA-G21

2 In This Document: Introduction to HCA Total Rewards... 3 HCA Health and Welfare Benefits Summary Plan Description... 5 Overview... 6 Medical Dental Vision HCA Wellness Program Health Reimbursement Accounts (HRAs) Flexible Spending Accounts (FSAs) Life and AD&D Insurance Long-Term Disability Benefits CorePlus Benefits Other Benefits HCA 401(k) Plan Summary Plan Description What to Do If You COBRA Administrative Information Key Terms

3 Introduction to HCA Total Rewards Note: Plan information is updated periodically. The most accurate information is posted at HCArewards.com. The HMO Medical benefit options have separate Summary Plan Descriptions with additional information about the benefit offered under those HMOs. Please read the HMO Summary Plan Descriptions along with this SPD. As an HCA-affiliated employee, you are part of a team that puts patients first and offers best-in-class healthcare at state-ofthe-art facilities. While your focus is on patient care, HCA's focus is on caring for you and your future. One of the ways HCA takes care of its affiliated employees is through the HCA Total Rewards Program. HCA has plans and programs that provide employees with financial and non-financial rewards pay, incentives, benefits, a healthy work environment and a variety of other rewards in an effort to create a valuable employment experience. The HCA Total Rewards program offers a flexible benefits program to eligible employees of its subsidiaries and affiliates. This program allows you to choose the benefits that best fit the needs of you and your family. This document includes summary plan descriptions (SPD) that describe the Health and Welfare Benefits Plan and the HCA 401(k) Plan. It is intended to satisfy the summary plan description requirements of ERISA. This SPD explains the plans and benefits that apply to eligible employees who are not at an HCA-affiliated facility where there is union representation or at a facility that mirrors the benefits of a facility with union representation. Other groups of employees are eligible for the HCA Health and Welfare Benefits Plan and the HCA 401(k) Plan, but the plan provisions that apply to those groups of employees are described in other SPDs. As of January 1, 2011, the other employee groups who are eligible for these plans are: Good Samaritan Hospital Los Gatos Surgery Center Los Robles Hospital & Medical Center Regional Medical Center of San Jose Research Medical Center (Operating Engineers only) Riverside Community Hospital Southern Hills Hospital & Medical Center (Las Vegas) Sunrise Hospital and Medical Center West Hills Hospital & Medical Center West Hills Surgery Center Other facilities that mirror the benefits of the facilities listed above The HCA Total Rewards program offers the following options: Medical Dental Vision Wellness Health Reimbursement Account Health Care and Day Care Flexible Spending Accounts Life and AD&D Insurance and Dependent Life Insurance Long-Term Disability Employee Assistance Program Voluntary CorePlus Benefits o Auto & Home Insurance (Note: Home insurance not available in all locations) o Legal Benefit o Long-Term Care o Short-Term Disability o Voluntary Permanent Life Insurance HCA 401(k) Plan Enrolling in Benefits: You'll have the opportunity to enroll in Health and Welfare benefits when you begin employment after you complete any applicable eligibility period and again each year during the annual enrollment period. Certain default coverage elections apply if you do not enroll. Specifically, if you do not enroll by your enrollment deadline, you will receive the default coverage listed at BConnected. If you are a full-time employee as designated by your facility, you may receive money back in the form of Cash Out Dollars if you waive certain benefits. Cash Out Dollars are considered taxable income and will be taxed in the same way that your current pay is taxed. You are automatically enrolled in the HCA 401(k) Plan when you become eligible. You can opt out of 401(k) plan participation by logging on to HCArewards.com and clicking on BConnected. Find more information about your benefit options and the cost associated with each by logging on to HCArewards.com and clicking on BConnected. 3

4 Making Changes: The choices you make when you enroll for Health and Welfare benefits remain in effect throughout the plan year. You generally may not make any changes to your Health and Welfare benefit choices until the next annual enrollment period unless you experience a qualifying change in status or qualify for a special enrollment period. See the Making Changes During the Year section for more information. You can change your contribution rate, investment fund or transfer money within the HCA 401(k) Plan at any time. Changes are effective per pay period (as soon as administratively feasible after you submit a change). Benefits Information: Which benefit options are best for you? Only you can decide, but this SPD can help. It contains important information about each of your benefit options. Review the content in this SPD first for a general understanding of the available benefits. Then, when you have a question or need to use your benefits, just turn to the SPD and go to the section that applies. Even if you don t choose to enroll in all your benefit options now, you may decide to enroll in the future. If you do change your mind in the future or even if you just want to reevaluate your options you may want a copy of the Summary Plan Description (SPD). Please Note: Benefit information is updated periodically. You should always check the SPD posted at HCArewards.com for the most up-to-date information. To receive certain benefits materials electronically instead of by mail, sign up for less paper by logging on to HCArewards.com and clicking on BConnected. Where to Find More Plan Information HCArewards.com HCArewards.com is your online resource for information on all of the benefits and rewards you receive as an HCA-affiliated employee. Instances in this SPD that refer you to HCArewards.com typically require that you login. You must login to access online SPDs, benefits provider directories and other customized rewards information. The first time you visit the site as a current employee, you will need to activate your account by following these instructions: 1. Go to HCArewards.com 2. Enter your HCA 3-4 ID 3. Enter the last four digits of your Social Security number and your birth date (####MM/DD/YYYY) 4. Create and confirm a new password 5. Answer security questions 6. You will be taken back to the login screen 7. Enter your HCA 3-4 ID and the new password you created BConnected BConnected is your resource to personalized benefits account information. You can use BConnected to: Enroll in the HCA 401(k) Plan when you are eligible Add, review or change your life insurance and 401(k) beneficiary information View your balances and rates of return for the HCA 401(k) Plan Change your contribution rate or investments for future contributions to your HCA 401(k) Plan account Change your current investment fund(s) or transfer money within the HCA 401(k) Plan Get answers to general benefits questions Online Access: You can access BConnected by logging on to HCArewards.com and clicking on BConnected. By Phone: You can also obtain information about your benefits 24 hours a day through the automated phone system at If you need to speak directly with a Benefits Center Representative, they are available Monday through Friday, from 7 a.m. to 7 p.m. (Central Time). 4

5 HCA Health and Welfare Benefits Plan Summary Plan Description As of February 1,

6 HCA Health and Welfare Benefits Plan Overview Eligibility... 7 Employee... 7 Dependent... 7 Eligible Dependent Children... 7 Eligible Spouse... 8 Eligible Domestic Partner Dependents... 8 Dependent Verification... 9 Special Note for Dependent Coverage... 9 Coverage for Disabled Dependents... 9 No Double Coverage Qualified Medical Child Support Order Other Coverage Participation Enrollment Annual Enrollment Special Enrollment Rights Making Changes During the Year Cost of Coverage When Coverage Begins When Coverage Ends Flexible Spending Accounts Long-Term Disability Removing Dependents from Coverage Naming a Beneficiary If You Take a Leave of Absence

7 Eligibility Employee Generally, you are eligible for the HCA Health and Welfare Benefits Plan if you are classified by HCA or an HCA-Affiliated Facility as a full-time or part-time employee. Temporary employees, seasonal employees, leased employees, P.R.N.s and independent contractors are not eligible. If you are an independent contractor, you are not eligible for the HCA Health and Welfare Benefits Plan, even if you are later determined to be an employee as a result of a judicial or administrative determination. You are eligible for Long-Term Disability coverage if you are a full-time employee and are classified by HCA or an HCA-Affiliated Facility as regularly scheduled to work at least 32 hours per week. For the Life and AD&D, Long-Term Disability and Short-Term Disability benefits, you will need to be actively at work, which means you are performing all of the material and substantial duties of your occupation. Generally, coverage begins the first of the month following two months of service. In some facilities, coverage may begin sooner. When you are eligible for benefits enrollment, view your actual Benefit Effective Date by logging on to HCArewards.com and clicking on BConnected, calling or reviewing your enrollment materials. The eligibility for the CorePlus Benefits program is described in that section of the SPD. It is important for all eligible employees to understand that if you do not elect coverage, you will be assigned default coverage. For information about how full-time and part-time status is determined at your facility, please contact your facility s Human Resources office. Dependents When you become eligible to participate in the following benefit programs, you may enroll your eligible dependents in these programs: Medical Dental Vision Dependent Life Insurance Your eligible dependents include: Your legal spouse, unless you and your spouse are legally separated or divorced Your common law spouse, in states that recognize those unions Your eligible domestic partner (see additional requirements below) Your eligible dependent children For the Life and AD&D Insurance benefit option, your child must be at least 14 days old Your eligible dependent children who satisfy the eligibility requirements for the insured benefit options The dependent eligibility in this section also applies for eligible expenses submitted for reimbursement under the Health Care FSA and HRA, except that domestic partners and children of domestic partners are not eligible dependents for purposes of the Health Care FSA and HRA. Refer to the Day Care FSA section for more information regarding expenses for eligible dependents under the Day Care FSA. The dependent eligibility for the CorePlus Benefits is described under that section of the SPD. For Dependent Life Insurance, if your dependent is totally disabled, your disabled dependent s coverage will begin on the date your dependent is no longer totally disabled. Please refer to the Dependent Life section for more information about disabled or incapacitated dependents. Eligible Dependent Children Your eligible dependent children are your children, as defined below, who fall into one of the dependent categories outlined below: Dependent Categories: Required Documentation: Children until they reach age 26. A birth certificate will be required when adding a dependent to coverage. Children until they reach age 26 who are children of an eligible domestic A birth certificate will be required when partner. adding a dependent to coverage. Individuals under your permanent legal guardianship who are under age 26. Call BConnected at (800) Children who become physically or mentally disabled while covered under a Call BConnected at (800) medical benefit option offered under the HCA Health and Welfare Benefits Plan, and who remain disabled after age 26, are not capable of self-support, and depend upon you for his or her support regardless of their current age. 7

8 Your Children are defined as your: Biological children Adopted children Children placed with you for adoption Stepchildren Children who must be provided health coverage under a Medical benefit option as required by a Qualified Medical Child Support Order (QMCSO) Note: If you are in the state of Florida, different dependent eligibility rules may apply to you. Call BConnected at (800) for more information. Eligible Dependent Spouse Your spouse is that one person of the opposite sex to whom you are legally married pursuant to state law. Eligible Domestic Partner Dependents You may also enroll your domestic partner and the children of the domestic partner provided you and your domestic partner reside in a state that recognizes same sex marriage and are married or you and your domestic partner: Both are members of the same sex in a committed relationship or both are opposite sex in a committed relationship and one or both are age 62 or older and one or both meet the criteria for Social Security benefits for old-age or aged individuals; and Share a common residence; and Agree to be jointly responsible for each other s basic living expenses incurred during your domestic relationship; and Neither is married to another person or a member of another domestic partner relationship; and Both are at least 18 years of age and capable of consenting to a domestic partner relationship; and Neither is related by blood that would prevent either from being married to each other; and Neither has previously filed a Declaration of Domestic Partnership that has not been revoked. Basic Living Expenses means shelter, utilities and all other costs directly related to the maintenance of the common household of the shared residence of the domestic partners. It also means any other cost, such as medical care, if some or all of the cost is paid as a benefit because a person is another person s domestic partner. Jointly responsible means that each partner agrees to provide for the other partner s basic living expenses if the partner is unable to provide for him/herself. Persons to whom these expenses are owed may enforce this responsibility if, in extending credit or providing goods or services, they relied on the existence of the domestic partnership and the agreement of both partners to be jointly responsible for those specific expenses. To enroll the domestic partner, you and your domestic partner must sign and have notarized the Declaration of Domestic Partnership affidavit (Or, for those states that recognize same sex marriage, provide a valid marriage license). You may call BConnected at to obtain the affidavit. (For California, you may use the state affidavit.) The affidavit must be executed and notarized within 31 days of the establishment of the domestic partner relationship and fulfillment of the requirements above. You must mail the affidavit to BConnected, P.O. Box , Dallas, TX You may also add your domestic partner at annual enrollment provided the affidavit is submitted during the annual enrollment period. When the affidavit is executed, notarized and submitted to BConnected, both of you agree: To notify BConnected immediately if the domestic partner relationship terminates; The value of domestic partner (including children of the domestic partner) coverage will be treated as income to the HCA- Affiliated Facility plan participant; Any misrepresentation may result in loss of benefits and/or termination of employment; Any person or company which suffers a loss as a result of a misrepresentation in the affidavit, or because of any misrepresentation of eligibility for domestic partner status, may bring a legal action against both of you, jointly or separately, to recover any loss, including reasonable attorney fees and other expenses of a suit; Proof of a domestic partner relationship will be provided when requested; and The implementation or termination of this domestic partner relationship may affect the insurance coverage and other benefits of both parties. If you only wish to enroll the child(ren) of the domestic partner, both of you will still need to execute, notarize and submit the Declaration of Domestic Partnership affidavit to BConnected before such child(ren) may be added. The rules regarding No Double Coverage also apply to domestic partner relationships where both parties work for HCA-Affiliated Facilities. Local HMO coverage provisions may apply concerning coverage for domestic partners and the child(ren) of the domestic partner; check with your local HMO to determine coverage provisions for domestic partners and their dependents. 8

9 Dependent Verification Process The purpose of the Dependent Verification Process is to make sure we provide high-quality, cost-effective healthcare coverage to eligible employees and their dependents. Documentation Required When Enrolling a New Dependent Dependents added to coverage must complete an eligibility verification process. When an employee enrolls a new dependent, they will receive a notice from BConnected and will be required to submit appropriate documentation. Participants have 31 days from the date they elect dependent coverage to return the appropriate documentation. If verification is not completed by the deadline, BConnected will retroactively drop the dependent as of the coverage effective date. Enrolling an ineligible dependent is considered intentional misrepresentation. Random Dependent Eligibility Audits BConnected conducts random checks to make sure only eligible dependents are covered. Severe penalties, including the loss of coverage and liability for repayment, could apply if you knowingly attempt to cover or continue to cover anyone who is not eligible. During the random check process, BConnected will select a percentage of participants covering any type of dependent and require them to submit documentation of eligibility (including spouse, common law spouse, dependent child, domestic partner, domestic partner child). If a participant was previously selected for the audit but did not provide appropriate documentation and was dropped from coverage, they must provide the documentation before adding the dependent to coverage during annual enrollment. Participants must submit the required documentation by the deadline indicated by BConnected. If you do not respond by the date indicated, the dependent will be dropped from all coverages. Coverage may be reinstated once the participant submits the required documentation. Enrolling an ineligible dependent will be considered an intentional misrepresentation of material fact and the plan may rescind coverage for that ineligible dependent. Special Note for Dependent Coverage Please be sure your dependents are eligible if you choose a Medical or Dental HMO under the rules of that organization. These additional eligibility terms can be found in the document provided by the HMO. Severe penalties, including loss of coverage, and liability for repayment, could apply if you knowingly attempt to cover or continue to cover anyone who is not eligible. HCA reserves the right to request proof of dependent status. If you elect a Medical or Dental HMO that has different dependent eligibility rules or definitions than stated in this SPD and you later elect a medical or dental PPO option that follows the rules stated above, a dependent may lose coverage. If you are considering changing coverage options, you should pay close attention to the dependent eligibility provisions to be aware of whether your new plan election has the same dependent eligibility provisions. If you have any questions, call BConnected at Coverage for Disabled Dependents You may continue to cover under the Medical, Dental, Vision or Dependent Life Insurance benefit options dependent children who become physically or mentally disabled while covered under a medical benefit option offered under the HCA Health and Welfare Benefits Plan, and who remain disabled after age 26, are not capable of self-support, and depend upon you for his or her support regardless of their current age. A child with a learning disability is not considered physically or mentally disabled. You may continue coverage for a disabled child until one of the following events occurs: Your coverage under the benefit option ends; The child s disability ends; The child marries; You fail to provide proof when requested that the disability continues; or Your disabled child fails to undergo any physical examination required as proof of continuing disability Contact BConnected at for specific rules for Medical, Dental and Vision benefits. 9

10 No Double Coverage If you are eligible, you may choose coverage as an employee or as a dependent of another employee, but not both. In addition, children can be covered as dependents of only one employee. So, for example, if you and your spouse both work for HCA-Affiliated Facilities, you would have the following options: Each of you may be covered separately as employees and one of you may elect to cover any dependent children; One of you may waive coverage and be covered as a dependent, along with any eligible children, under the other spouse s coverage; or Each of you may waive coverage, provided you have coverage elsewhere. You cannot be eligible for coverage at more than one HCA-Affiliated Facility at the same time. If you double cover yourself or your dependents, double benefits will not be provided under any of the Health and Welfare benefits. Qualified Medical Child Support Order The health benefit options will comply with the terms of a Qualified Medical Child Support Order (QMCSO). A QMCSO is a judgment, decree, order (including approval of a settlement agreement) or administrative notice issued pursuant to a state domestic relations law or a national medical support notice (as defined by ERISA) from a court or administrative body directing a health plan to cover a child of a participant under the group health plan(s). Federal law provides that a medical child support order must meet certain form and content requirements in order to be a QMCSO. When an order is received, each affected participant and each child (or the child s representative) covered by the order will be given notice of the receipt of the order and a copy of the plan s procedures for determining if the order is valid. Coverage under the plan pursuant to a QMCSO will not become effective until the Plan Administrator determines that the order is a QMCSO. If you, your children or their authorized representatives have any questions or would like to receive a free copy of the written procedures for determining whether a QMCSO is valid, please contact BConnected. Other Coverage If you have coverage available under another health plan (for example, coverage under your spouse s employer plan), you should consider whether you or your dependents should be covered under the HCA Medical benefit options and the other health plan. If the other health plan is the primary plan, it is unlikely that the HCA Medical benefit options will pay benefits as the secondary carrier. Refer to the Coordination of Benefits section for more information. Participation Enrollment New Hire Enrollment After you begin working and become eligible for benefits, you will receive enrollment information in the mail. Access additional information about your benefits options and the cost associated with each, along with this SPD by logging on to HCArewards.com and clicking on BConnected. You should keep this SPD even if you elect no coverage, so you'll have the information if you elect coverage at a later date. To enroll in or decline coverage for yourself or your dependents by the date shown on your enrollment materials, log in to HCArewards.com and click on BConnected or call BConnected at Once you enroll, you generally cannot change your choices until the next annual enrollment period unless you have a qualifying change in status or qualify for a special enrollment period. If you do not enroll by the date shown in your enrollment materials and on the BConnected Web site, you will automatically be enrolled in and pay for - the default coverages shown below. The cost of this coverage will be deducted from your paycheck on a before-tax basis. 10

11 Full-Time Employees If you are a full-time employee and you do not enroll, your default coverage is the HCA Well Care Level 2 Plan and employee basic Life and AD&D insurance benefits, employee-only coverage. If this default applies to you, it appears on your list of benefits options when you log on to HCArewards.com and click on BConnected. Benefits: Medical (including prescription drugs) Employee Life and AD&D EAP Dental Vision Wellness and Health Reimbursement Account Flexible Spending Accounts Supplemental Life Dependent Life Long-Term Disability CorePlus Voluntary Benefits Default Coverage: HCA Well Care Level 2 (employee only) One times base pay Coverage No Coverage No Coverage No Coverage No Coverage No Coverage No Coverage No Coverage No Coverage Part-Time Employees If you are a part-time employee and you do not enroll, your default coverage is the no coverage option for all benefits, except the Employee Assistance Program. Annual Enrollment You have the opportunity to change your benefit elections each year during annual enrollment. The annual enrollment period typically occurs in the fall for coverage that will be effective the following January. Before the annual enrollment period begins, you will receive materials to help you make your benefit choices and complete the enrollment process. During your annual enrollment period, you will need to log on to HCArewards.com and click on BConnected to view your complete list of benefit options and the cost of each item. The portion of the information online that includes the contribution amounts for the benefits you select are considered part of this SPD. Please review this information and contact BConnected for answers to your questions. You must contact BConnected, online or by phone, before the annual enrollment deadline to make any changes to your coverage for the upcoming plan year. Otherwise except for your participation in a Flexible Spending Account the coverage options you had in effect during the current plan year will automatically continue, including default elections, throughout the upcoming plan year (if those options are still available). Any benefit contributions from your pay (including any applicable increase in those contributions) for those benefits will continue as well. If the Medical benefit option is not available (such as a change in HMO option) and you do not make an annual enrollment election, you will default to the HCA Well Care Level 2 Plan. If you want to participate in a Flexible Spending Account, you must enroll each year and specify your contributions for the upcoming year. Your benefit choices made during the annual enrollment will take effect on January 1 and remain in effect until December 31. Once you make your choices for the upcoming plan year, you will not be able to make any changes to your coverage until the next annual enrollment period unless you have a qualifying change in status or qualify for a special enrollment period. For more information, refer to the Making Changes During the Year section. Evidence of Insurability If you decline Employee Life Insurance, Dependent Life Insurance or Long-Term Disability coverage when you are first eligible for these benefits but decide during a subsequent annual enrollment that you want to add one or more of these options or increase your level of coverage, you will be required to provide evidence of insurability. You may also be required to provide evidence of insurability if the change is due to a qualifying change in status. To provide evidence of insurability, you ll need to complete a form that contains questions about your or your dependent s health and medical history. The form will be mailed directly to you if evidence is required. Once you complete the evidence of insurability form, send it to the carrier providing coverage in the envelope provided. If approved, your new coverage will become effective on the first of the month following the carrier s approval or on January 1, whichever date is later. Special Enrollment Rights Special enrollment rights allow you and/or your dependents to enroll in a Medical benefit option or change from one Medical benefit option to another without waiting until annual enrollment, if certain events occur. Special enrollment applies only to the Medical benefit options. You only have a certain period of time listed below to make changes to your election by contacting BConnected. 11

12 Losing Other Medical Coverage If you declined coverage under the Medical benefit options when it was first available because of other medical coverage and that coverage is later lost on account of (a) exhaustion of COBRA continuation coverage, (b) lost eligibility for other coverage, or (c) termination of employer contributions towards the other coverage, then you and your eligible dependents may enroll in a Medical benefit option under the HCA Health and Welfare Benefits Plan on or before the date that is 30 days after the date you lost that other coverage. Lost eligibility for other coverage includes: a loss of other medical coverage as a result of your legal separation or divorce, a dependent s loss of dependent status, death, termination of employment or reduction in number of hours of employment, or you no longer reside, live or work in the service area of a health maintenance organization in which you participated. Your enrollment will take effect on the first day of the month following your loss of coverage and your timely request to enroll by contacting BConnected. New Eligible Dependents If you initially declined enrollment for yourself or your eligible dependents and you later have a new eligible dependent because of marriage, birth, adoption, placement for adoption, or legal guardianship, you may enroll yourself and your new eligible dependents (including an eligible dependent spouse if you have a new eligible dependent child), if you request enrollment by contacting BConnected on or before the date that is 30 days after the marriage, birth, adoption, placement for adoption, or legal guardianship. For example, if you and your eligible dependent spouse have a child, you may enroll yourself, your eligible dependent spouse and your new child in a Medical benefit option, even if you were not previously enrolled. You will not, however, be able to enroll existing eligible dependent children for whom coverage has been waived in the past. For birth, adoption or placement for adoption, you or your eligible dependent s participation will start as of the date of the birth, adoption or placement for adoption, as long as you timely requested enrollment by contacting BConnected. For marriage, your participation or your eligible dependent s participation will start no later than the first of the month following the date of the marriage, provided you request enrollment by contacting BConnected on or before the date that is 30 days after the marriage. You will need to enroll your new eligible dependents on or before the date that is 30 days after the event by which they became your eligible dependent (for example, a new spouse after your marriage or your baby is born). If you do not add new eligible dependents within this 31-day period, you cannot enroll them until the next annual enrollment, special enrollment or unless a change in status event occurs. Medicaid and CHIP If you or your eligible dependents are eligible for, but not enrolled in a Medical benefit option and you or your eligible dependents (a) lose coverage under Medicaid or a State child health plan (CHIP), or (b) become eligible for a premium assistance subsidy for a Medical benefit option through Medicaid or CHIP, then you and your eligible dependents may enroll in a Medical benefit option, as long as you request enrollment by contacting BConnected on or before the date that is 60 days after the loss of coverage or the date you or your eligible dependents became eligible for the premium subsidy. Making Changes During the Year Generally, once you make your benefit choices, you may not change them until the next annual enrollment period. But there are some limited exceptions, described in the following sections. The general rule is that you cannot change your elections until the next annual enrollment so choose carefully. These exceptions may or may not apply to all benefit options elections and these election changes do not apply to the CorePlus Benefits. If you believe you may fall within one of the limited exceptions, and you need to change your election during the year, you must do so within 31 days of the event that causes the exception to occur. The Plan Administrator determines eligibility for any change discussed in this section. Contact BConnected at as soon as possible to make the appropriate changes. Family Events You may change your HCA Health and Welfare Benefit Plan elections during the year if one of the following family events affects your, your spouse s or your dependent child s eligibility with respect to that coverage. Any election change must be consistent with the family event allowing the change. Remember, it is not enough just to have an event occur. You or your eligible dependent will need to become eligible for or ineligible for coverage on account of the event, and the election change must be consistent with that event. Family events are: 12

13 Your marriage, divorce, legal separation or legal annulment, or the death of your spouse Dissolution of common law marriage through court proceeding Your dependent child s birth, death, adoption or placement with you for adoption Your dependent child becomes eligible or ineligible for coverage due to his or her age, or any similar circumstance A change in your, your spouse s residence that affects that person s eligibility Job Events You may change your HCA Health and Welfare Benefits Plan elections during the year if one of the following job events affects your, your spouse s or your dependent child s eligibility with respect to that coverage. Any election change must be consistent with the job event allowing the change. Remember, it is not enough just to have an event occur. You or your eligible dependent will need to become eligible or ineligible for coverage on account of the event, and the election change must be consistent with that event. Job events are: A termination or commencement of employment A strike or lockout A commencement of or return from an unpaid leave of absence A change in worksite Any other change in employment status with the consequence that the person becomes or ceases to be eligible for a benefit Qualified Medical Child Support Order You may change your Medical, Dental, and Vision benefits or Health Care Flexible Spending Account if a judgment, decree, or order, resulting from a divorce, legal separation, annulment, or change in legal custody (including a Qualified Medical Child Support Order), is entered by a court of competent jurisdiction that requires accident or health coverage for your Child under the HCA Health and Welfare Benefits Plan. Coverage for a child may not be terminated unless other healthcare coverage is actually provided. Family and Medical Leave Act (FMLA) If you take FMLA leave, you may change your election with respect to Medical, Dental, Vision and Health Care Flexible Spending Account coverage. For more information, see If You Take a Leave of Absence. Day Care Flexible Spending Account Changes For your Day Care Flexible Spending Account, significant cost changes that may allow you to change your contributions include: 1. Selecting a different dependent care provider 2. Increasing the cost of your provider 3. Increasing or decreasing the hours (and thus the cost) of the provider 4. You take or return from a leave of absence that lasts longer than two weeks The information described above does not apply to your Health Care Flexible Spending Account. Other Cafeteria Plans If the employer of your spouse, former spouse or dependent child offers a cafeteria or Section 125 plan that has a period of coverage different from the calendar year (for example, a different annual enrollment period) or that allows the same election changes as listed above, you may change your benefit election to correspond with an election or election change made under that other cafeteria plan. Your election change must be on account of and must correspond with that other election. Also, the other cafeteria plan must allow this type of change. The information described above does not apply to your Health Care Flexible Spending Account. Significant Cost or Benefit Option Changes If there is a change in the availability of benefits option or coverage (addition or removal) under the HCA Health and Welfare Benefits Plan or under your spouse s or dependent child s employer s benefit plan (for example, a new HMO or PPO option is added), you may change your benefit elections consistent with the availability or removal of the benefit option. You may also change your elections if there is a significant increase or decrease in the cost of a benefit option during the plan year. The Plan Administrator determines whether there is a significant change in the cost. The information described above does not apply to your Health Care Flexible Spending Account. Automatic Changes If the cost of your underlying coverage increases or decreases, the plan may automatically change the amount of your beforetax premium contribution that is withheld. Likewise, the plan may automatically change the amount of your deduction if it is required to do so by the terms of a QMCSO or by the terms of another judgment, decree or order that requires the plan to provide coverage for your dependents. 13

14 Medicare or Medicaid If you, your spouse or your dependent child is enrolled in group healthcare coverage and also becomes entitled to Medicare or Medicaid coverage (other than Medicaid coverage solely for pediatric vaccines), you may change your election to cancel or reduce group healthcare coverage of that person. Similarly, if that person loses entitlement to Medicare or Medicaid (other than Medicaid coverage solely for pediatric vaccines), then you may change your election to begin or increase group healthcare coverage of that person. Loss of Certain Governmental Healthcare Coverage You may change your election to add group healthcare coverage for yourself, your spouse or your dependents if you or they lose group healthcare coverage sponsored by a governmental or educational institution, including a state children s health insurance program (CHIP) under Title XXI of the Social Security Act, certain Native American health insurance programs, a state health benefits risk pool or a foreign government group health plan. However, you may not drop group healthcare coverage during the year in favor of these governmental health programs. The information described above does not apply to your Health Care Flexible Spending Account. Special Rules for Flexible Spending Accounts You may not reduce your benefit elections for the Flexible Spending Accounts below the amount already reimbursed to you before the change in status event. Cost of Coverage Regular deductions for certain qualified benefits under the HCA Health and Welfare Benefits Plan occur with before-tax dollars. This means that you do not pay Social Security tax, federal income tax and most state taxes on the amount deducted for these coverages. Some benefit contributions must be made with after-tax dollars (like dependent life insurance and supplemental employee life insurance). In addition, HCA and HCA-Affiliated entities may also contribute to the cost of certain benefits. Although the use of before-tax dollars reduces your taxable pay, benefits that are based on your pay such as Life Insurance and Long-Term Disability (LTD) coverage are not reduced by these regular deductions. These benefits will continue to be based on your pay as determined by these plans. You may be required to contribute for your coverage. Log on to HCArewards.com and click on BConnected for your cost information. When Coverage Begins Generally, if you are eligible, your coverage begins on the first day of the month after you complete two calendar months of service, as long as you are actively at work on that day. (In some facilities, you may be eligible sooner. Log on to HCArewards.com and click on BConnected or review your enrollment materials for your actual Benefit Effective Date.) You will be considered to be actively at work if your effective date falls on a non-scheduled weekday, weekend or holiday. If you are away from work on your effective date because of a health status-related factor, your Health benefit options and Health Care FSA coverage will begin on the same day that it would have begun if you were actively at work. But LTD, Life and AD&D Insurance coverage will not begin until you return to work for one full day. Likewise, any days you are absent from work because of your own health status, medical condition or disability will still count toward your eligibility waiting period as if you had been actively at work, but only for the Health benefit options. Generally, your dependents coverage begins on the same day your coverage begins. For Dependent Life Insurance, if your dependent is totally disabled on the date coverage should begin, it is delayed until the dependent is no longer totally disabled. This delayed effective date rule also applies to any increase in LTD, your Life and AD&D insurance or Dependent Life Insurance coverage due to a change in annual pay, qualified change in status event or an annual enrollment election. If evidence of insurability is required, Life and AD&D Insurance and LTD coverage for you and your dependents will begin once the carrier approves the evidence of insurability. (Evidence of insurability may not be required when you first become eligible.) Rehire If you are a participant in the HCA Health and Welfare Benefits Plan and you terminate employment, and later you are rehired within six months, coverage will begin on the first day you return to work, unless the delayed effective date rule above applies. If you are rehired within 30 days within the same calendar year, your previous elections will be reinstated and no changes are allowed. If you are rehired after 30 days but within six months and within the same calendar year, then changes to your elections may be made under the qualifying change in status rules above or special enrollment rights section. If you are rehired in the following calendar year, your previous elections will apply (if the option is no longer available, default options apply). You will have 30 days from your rehire date to make changes, subject to evidence of insurability rules for Life and AD&D and LTD coverages. If you are rehired after six months, you are treated as a new hire. 14

15 When Coverage Ends Medical, Dental, Vision, Wellness and HRA, EAP and Life and AD&D Insurance Coverage Medical, Dental, Vision, Wellness and HRA, EAP, Life and AD&D Insurance coverage ends as shown in the following table. In certain circumstances, Medical, Dental, Vision, Wellness and HRA, EAP and Health Care Flexible Spending Account coverage may be continued under COBRA. If You stop working for your facility or retire* You no longer meet the eligibility rules Your dependent no longer meets the eligibility rules You stop coverage for yourself and/or your dependents because of a qualifying change in status You choose to stop coverage for yourself and/or your dependents during the annual enrollment period HCA no longer provides the coverage You don't make the required contributions You are not at work due to disease, injury or approved paid or unpaid leave of absence and you stop making contributions You have continued coverage during a paid leave that continues beyond six months You die Coverage ends The last day of the month following your last day at work (not the last day you are paid) The last day of the month The date eligibility is lost. For example, your child's coverage ends on his or her 26th birthday The date the qualifying change in status occurs. For example, your spouse's coverage would end at midnight on the date of the divorce The last day of the current calendar year The last day the coverage is in effect The end of the month in which premiums were paid The last day before leave starts unless contributions continue. Benefits cannot continue longer than six months from the day you begin your paid or unpaid leave The last day of the six months following the start of you leave of absence All coverage for you ends on the date of death; however, coverage for your covered dependents terminates at the end of the month *If you are eligible for early retirement under the HCA 401(k) Plan, you may continue to receive reimbursements for eligible claims incurred up to the value of your HRA account balance as of your early retirement date. Note: For details about when CorePlus Benefits coverage ends, refer to the CorePlus Benefits section. Flexible Spending Accounts Special participation rules apply to the Flexible Spending Accounts. You may submit claims for reimbursement from the Health Care Flexible Spending Account only for expenses or services that were incurred before the date coverage ended (unless you elect to continue coverage under COBRA). You may submit claims for reimbursement from the Day Care Flexible Spending Account for eligible expenses incurred through the end of the calendar year, even though you stop contributing when coverage ends. Expenses are treated as having been incurred when the participant is provided care that gives rise to the expense, and not when the participant is formally billed or charged, or pays for care. Long-Term Disability Long-Term Disability (LTD) coverage follows rules that are different from other coverage options. LTD coverage will end on the day: You actively stop working for your facility or retire You no longer meet the eligibility rules, unless you are receiving LTD benefits HCA no longer provides the coverage You no longer qualify for disability income benefits and you do not return to active work You fail to pay the required premium Removing Dependents from Coverage It is your responsibility to call BConnected at to remove ineligible dependents from coverage as soon as they become ineligible, or at least within 31 days of the date they become ineligible. Until you do so, you will continue to pay for coverage, but the HCA Health and Welfare Benefits Plan may cancel coverage for that dependent immediately upon learning of the dependent s ineligibility. Keeping ineligible dependents on the HCA Health and Welfare Benefits Plan is considered intentional misrepresentation. The HCA Health and Welfare Benefits Plan may make that cancellation effective to the date of ineligibility. Any amounts you pay for coverage for an ineligible dependent may not be refunded. 15

16 Naming a Beneficiary Life and AD&D Insurance You will be asked to name a beneficiary when you enroll for Life and AD&D Insurance coverage. The beneficiary you name will receive benefits from the Life and AD&D Insurance benefit option if you die. If you name more than one beneficiary, you should include how benefits should be divided among them. Otherwise, the benefit will be divided equally among the beneficiaries. If a beneficiary dies before you, his or her share will pass to any surviving beneficiaries in the order you designated. Changing Your Beneficiary: You may change your beneficiary designation at any time by submitting a new Beneficiary Designation Change Form. Log on to HCArewards.com and click on BConnected or call to request a form or ask questions about naming a beneficiary. Your new designation will take effect on the date you sign the form. However, the change in beneficiary will not go into effect if the insurance company has taken any action or made any payment before BConnected receives the completed Beneficiary Designation Change Form. Note: If you make a beneficiary change for Life and AD&D Insurance, it will only be changed for Life and AD&D and will not apply to the HCA 401(k) Plan. You must make changes separately for each of those benefits. If You Do Not Name a Beneficiary If you do not have a beneficiary for Life and AD&D Insurance on file with BConnected, or if your beneficiary dies before you or your beneficiary is disqualified, the insurance company may pay death benefits to your estate. However, Prudential has the right to make payments to one or more of your surviving family members in the following order: Your spouse Your child or children Your mother or father Your brothers or sisters If You Take a Leave of Absence You may continue the following HCA Health and Welfare benefits elections during a leave of absence: Medical Dental Vision Wellness and Health Reimbursement Account (HRA) Employee Assistance Program Health Care Flexible Spending Account (You may not continue participating in the Day Care Flexible Spending Account during a leave of absence that extends beyond two weeks.) Life and Accidental Death and Dismemberment (AD&D) Long-Term Disability If you are on a paid leave, your contributions continue (except for the Day Care Flexible Spending Account) unless you notify BConnected otherwise. If you are on an unpaid leave of absence, you must pay the full cost of your coverage (including Basic Life and AD&D) directly to BConnected after your paid leave ends and your unpaid leave begins. If your unpaid leave is covered under the Family and Medical Leave Act (FMLA), you will continue to pay the employee cost of coverage directly to BConnected throughout your FMLA leave. If your leave is due to Workers Compensation, you will continue to pay the employee cost of coverage directly to BConnected for the leave period, but not more than six months. No matter what type of leave of absence you take (including FMLA or Workers Compensation), the maximum amount of time you can continue benefits is six months from the date you began your leave of absence. If you are still on a leave of absence after six months, your active participation in all welfare benefits ends at the end of the month. For Long-Term Disability, you must continue premium payments whether on a paid or unpaid leave to be eligible to receive benefits at the end of the elimination period. However, you will become eligible to continue your Medical, Dental, Vision, Wellness and Health Reimbursement Account (HRA) benefit options and the EAP (Health benefit options) and your participation in the Health Care Flexible Spending Account through COBRA. If you elect to drop coverage during an unpaid leave of absence, according to the change in status rules, your coverage ends as of the date your unpaid leave of absence begins. If you do not elect to drop coverage, you will be required to pay the cost of your coverage. If you fail to make the required payments, your coverage ends the last day before the leave in which your unpaid leave of absence began or the last day of the month in which you paid your premiums in full, whichever is later. 16

17 If you elected to drop coverage during an unpaid leave of absence, you may reinstate your coverage if you call BConnected within 31 days of your return. Different rules apply for Life and AD&D Insurance. Coverage will begin on the date you return. If you do not call within 31 days of your return to work, no coverage will be provided for the remainder of the year. At annual enrollment, you may again elect coverage; however, you may have to submit Evidence of Insurability for Life and AD&D Insurance and Long-Term Disability coverage. The insurance carrier will decide if coverage can again become effective. Please refer to the Health Care FSA for special rules that apply when you take a leave of absence. For more information about a leave of absence, contact your Human Resources department or call BConnected at Continuation of Participation for Employees in the Uniformed Services The Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) guarantees certain rights to eligible employees who enter military service. Upon reemployment, eligible employees may be entitled to the seniority, rights, and benefits associated with the position held at the time employment was interrupted, plus additional seniority, rights, and benefits that would have been attained if employment had not been interrupted. If you take a military leave in accordance with USERRA, you have the right to elect up to 24 months of continuation coverage for yourself and your covered dependents under the Medical, Dental, Vision, Wellness and Health Reimbursement Account (HRA) benefit options and the EAP (Health benefit options). You may also continue coverage under the Health Care Flexible Spending Account through the end of the plan year in which you started your qualified military leave. Your eligible dependents who are covered by these benefit options before the date of your qualified military leave of absence are eligible to elect continuation coverage for these benefits as well. The other welfare benefits may continue for up to six months, however, the insurance contracts may exclude benefits for death, injuries or illness incurred or aggravated during any military service. For the first six months of your qualified military leave, the cost or your coverage will be at the active employee cost. If your leave is for a longer period of time, then after the first six months, the cost of your coverage may increase to 102% of the total cost for coverage under the Health benefit options. The continuation coverage provided pursuant to USERRA runs concurrently with COBRA coverage. If you do not wish to receive some or all of the coverage during your military leave that you were receiving just prior to your leave, you must inform BConnected before the start of your leave. The chart below provides general guidance. Please check with BConnected if you have any specific questions. Coverage: In General: Exceptions: Life and AD&D You will receive a bill and you must make premium payments to continue coverage. Payments must be made to BConnected You may be required to provide evidence of insurability Health LTD Flexible Spending Accounts You will receive a bill and you must make premium payments to continue coverage. Payments must be made to BConnected You will receive a bill and you must make premium payments to continue coverage. Payments must be made to BConnected Refer to the Health Care FSA and Day Care FSA sections of the SPD. To continue coverage for dependents under HCA Well Care Program and/or Dental PPO, your coverage must also be continued. If you think you may be eligible for these special rights under USERRA, please contact BConnected. Day Care FSA contributions end when you are no longer actively at work. Health Care FSA contributions can continue through the end of the year of in which you start your qualified military leave. 17

18 Medical Benefits Medical Highlights Your Choices HCA Well Care Program HCA Well Care Program Details Prescription Drugs Annual Deductible Lifetime Maximum Out-of-Pocket Maximum How to Receive the Highest Level of Benefits Hospital Expenses Non-Hospital Expenses HCA-Affiliated Facilities and the Network Finding Network Providers Benefits at a Glance Inpatient Hospital Services Choosing a Provider Dependents Living Out of the Network Area What to do if You are Traveling What to do if You are Out of the Country Medically Necessary Services Allowable Amounts Precertification When Benefits will be Reduced Continued Stay Review Covered Expenses Hospital Expenses Non-Hospital Expenses Physician Services Network Physician Office Visits Maternity Care Notice of the Women s Health and Cancer Rights Act of Obesity Surgery Nursing Services Home Healthcare Convalescent and Skilled Nursing Facility Care Hospice Care Occupational Therapy Speech Therapy Physical Therapy Treatment of Mouth, Jaws and Teeth Transplants Genetic Testing Clinical Trials Expenses Not Covered General Medical Expenses Not Covered Teeth, Mouth and Jaw Expenses Not Covered

19 Behavioral Health Benefits Precertification Treatment of Mental Disorders Treatment of Substance Abuse Types of Care Eligible Behavioral Health Providers Behavioral Health Expenses Not Covered Prescription Drugs Non-Network Pharmacy (for emergencies only) Limitations on Drugs Specialty Pharmacy Services Mail Order Program Drug Expenses Not Covered How to Use the Benefits Filing HCA Well Care Program or PPO Claims Time Limit to File Claims Filing Medical Claims Filing Behavioral Health Claims Filing Prescription Drug Claims Payment of Benefits What Else You Should Know Case Management Coordination of Benefits Qualified Medical Child Support Order Continuing Coverage (COBRA) Pre-existing Conditions Certificate of Creditable Coverage When the Plan May Recover Payment

20 Medical Highlights The Medical benefit options offered under the HCA Health and Welfare Benefits Plan are designed to help you manage what you pay for medical care. The Medical benefits provide comprehensive healthcare coverage for physician s visits, hospital care, prescription drug and behavioral health expenses. Plan Overview: What coverage categories are available? Who pays the cost? You You plus one dependent You plus two dependents You plus three or more dependents You and your facility share the cost of coverage. Your share of the cost is deducted from your paycheck on a before-tax basis. For more information on what you and your facility pay, log on to HCArewards.com and click on BConnected Your Choices Generally, the following medical options are available: The HCA Well Care Program The HCA Well Care Program is a Preferred Provider Organization (PPO), which offers medical care through a network of providers. You pay less out of pocket if you use HCA-Affiliated Facilities and network providers. The options available are: o HCA Well Care Level 1 o HCA Well Care Level 2 o HCA Well Care Level 3 (not available in all locations) With each HCA Well Care Program option, you automatically have prescription drug coverage, but the amount of coverage depends on the plan option you choose. Health Maintenance Organization (HMO) HMOs are not offered in all areas, and eligibility rules for dependents vary by state. HMOs offer access to healthcare through a network of physicians and facilities. You typically must use an HMO provider to receive benefits except in emergencies. If you choose an HMO, you will receive benefit information in the mail or you can access details at HCArewards.com. The materials will provide any special instructions or steps you must follow, including information regarding claim forms, network providers, copays and dollar limits. Call the Member Services telephone number on your medical ID card for more information about benefits under your plan. No Coverage You should choose No Coverage only if you have coverage elsewhere. Remember, even if you choose the No Coverage option, you can still contribute some of your pay to the Health Care Flexible Spending Account (FSA) and be reimbursed for eligible medical expenses that are not covered by your other medical coverage. When You Have Other Coverage Available Generally, if your spouse has coverage under his or her employer s plan, it does not make sense for you to also cover your spouse or dependents under these Medical benefit options. If the plans pay similar benefit levels for the same covered expenses, you may receive few or no benefits under the secondary plan compared to the extra premiums you would pay. (See the Coordination of Benefits section for more information.) Coverage Categories If you choose to enroll in a Medical benefit option, you may choose coverage for: Yourself Yourself plus one dependent Yourself plus two dependents or Yourself plus three or more dependents If you elect coverage for yourself plus three or more dependents, your cost for coverage will not increase if you add additional dependents. You must contact BConnected at each time you add a dependent to ensure coverage under a Medical benefit option. 20