Welcome Eligibility Eligible Employees Eligible Dependents Child Support Orders Enrollment How to Enroll If You Do Not Enroll After You Enroll Late Enrollment for Life Insurance Beneficiaries When Coverage Begins Full-Time Employees Part-Time or Seasonal Employees Actively-at-Work Requirements Mandated Coverage for Hawaii Employees Making Changes Changing Your Benefit Elections Welcome to Benefits Lifestyle Benefits and Programs This is your guide to benefits for full-time benefit-eligible U. S. employees (including Puerto Rico). It is designed to be easy to read and understand and there are lots of ways to help you find the information you need. As a employee, you have a variety of lifestyle benefits and programs available to you. Find information on all your benefits on Gapweb. In addition to discounts and deals in your local community, offers several programs to make your life a little easier, such as: This guide covers the topics/plans shown here. Click on any section and you will go straight there. Once there, a table of contents will appear on the left to help you navigate to any item in the section. PTO / Holidays / Leaves of Absence* Weight Watchers Financial Planning You can also use the buttons here to find your way around the document as well as look up for a specific plan, go to the, for terms and more. Employee Merchandise Discount GapShare 401(k) If you have any questions or need support, please contact Employee Services at 866.411.2772, ext. 20600. The plans outlined in this summary plan description (SPD) may be updated or amended at any time. You can find the most up-todate information on Gapweb (https://portal.gap.com)> benefits > select U.S. Full-Time Benefits. Employee Stock Purchase Program (ESPP) Commuter Benefits Smoking Cessation Travel Assistance Adoption Assistance Reimbursement Your HealthCare Advocate * For additional information on leaves of absence at, see the Employee Leave of Absence Guide on Gapweb or call the Leave of Absence and Administrator at 800.GAP.9680. When Coverage Ends Health Care, EAP, Health Care FSA Dependent (Day) Care FSA Life Insurance and AD&D and Business Travel Accident This guide also incorporates other materials by reference, such as enrollment materials, benefit summaries and plan-related communications you may receive from time to time. These materials are also a part of this summary plan description. This summary plan description (SPD) summarizes information about certain benefits. Although every effort has been made to ensure the accuracy of this information, this SPD is not a legal contract. The plan documents and contracts govern the terms, conditions, and provisions of the benefits. If there are differences between the information in this SPD and the provisions of the plan, the official plan document or contract will generally govern unless otherwise provided by law. Plan benefits are available only if provided for in the official plan documents or contracts. intends to continue this plan, but reserves the right, in its sole discretion, to modify, change, revise, amend, or terminate the plan and any health benefit program sponsored under the plan at any time, for any reason, and without prior notice as it relates to the provision of benefits for any active or former employee, including any beneficiary or dependent of such active or former employee. This SPD is not to be construed as a contract of or for employment. 1
Welcome The following dependents are eligible for coverage: Eligible Employees Eligibility Your legal opposite or same-sex spouse, if you are not legally separated or divorced and have not had your marriage annulled. Eligible Dependents Eligible Employees Your partner (see Eligible Partners below). Employees classified as full-time in the U.S. and Puerto Rico are eligible to participate in the benefit programs. Employees classified as part-time or seasonal are not eligible. Your or your spouse s/partner s eligible children (see Eligible Children on page 3). Eligibility Child Support Orders Enrollment How to Enroll If You Do Not Enroll After You Enroll Late Enrollment for Life Insurance Beneficiaries When Coverage Begins Full-Time Employees Part-Time or Seasonal Employees Actively-at-Work Requirements Mandated Coverage for Hawaii Employees Making Changes Changing Your Benefit Elections When Coverage Ends Health Care, EAP, Health Care FSA Dependent (Day) Care FSA Life Insurance and AD&D and Business Travel Accident Some benefits may have additional eligibility requirements, which are outlined in the benefits summaries on Gapweb (https://portal.gap.com)> benefits > select U.S. Full-Time Benefits. The plans outlined in this summary plan description (SPD) may be updated or amended at any time. Important: Due to tax laws, Puerto Rico employees are not eligible to participate in certain benefit programs, including Flexible Spending Accounts. When you enroll, you may elect to cover your eligible dependents under the, Dental, Vision Plus, Dependent Life Insurance, and Accidental Death & Dismemberment plans. If you and your eligible dependents work for, you may not be covered as both an employee and as a dependent on the Gap Inc. medical plans or the Dependent Life Insurance plan. If you and your spouse/partner have children, they may not be covered on more than one employee s medical or Dependent Life Insurance plan. 1. A domestic partnership or civil union that is legally established under state law, or 2. A domestic partnership of the same or opposite sex, and you: Are in an exclusive, committed relationship that is expected to last indefinitely Are jointly responsible for each other s financial obligations and common welfare Share the same principal residence(s) with each other Eligible Dependents 2 Eligible Partners Partner means domestic partners and civil union partners. Your partner is eligible for coverage if you and your partner have: Are at least 18 years of age Are not legally married to another person, and Are not related by blood in a way that would prevent you from being legally married.
Welcome Eligibility Eligible Employees Eligible Dependents Child Support Orders Enrollment How to Enroll If You Do Not Enroll After You Enroll Late Enrollment for Life Insurance Beneficiaries When Coverage Begins Full-Time Employees Part-Time or Seasonal Employees Actively-at-Work Requirements Mandated Coverage for Hawaii Employees Making Changes Changing Your Benefit Elections When Coverage Ends Health Care, EAP, Health Care FSA Dependent (Day) Care FSA Life Insurance and AD&D and Business Travel Accident Important: reserves the right to request proof of eligibility for any dependent you enroll. Failure to provide sufficient proof of eligibility may result in loss of coverage and denial of claims for your dependent. If it is determined that coverage was obtained through fraud or intentional misrepresentation, coverage may be rescinded retroactively with 30 days advance notice and you may be subject to discipline up to and including termination. Same-sex Spouse and Domestic Partner Benefits and Taxes Health coverage for a same-sex spouse or domestic partner is generally deducted from paychecks on an after-tax basis due to tax laws. You may also be subject to imputed income, which is a tax on the value of the -paid portion of the health coverage provided to your same-sex spouse or partner and his or her children. If your same-sex spouse or partner is your IRS qualifying relative or meets certain state exemptions, you may not have to pay imputed income. For more information, visit Gapweb (https://portal.gap.com)> benefits. See Federal Tax Rules for Tax-Favored Health Benefits on the right for more information about qualifying relatives. Health coverage for legally married same-sex spouses will be deducted from paychecks on a pre-tax basis for federal income tax purposes. Depending on where you live, state taxes may apply. Please contact your tax advisor for more information on the tax consequences of same-sex spouse and domestic partner coverage. Federal Tax Rules for Tax-Favored Health Benefits Benefits are not taxable for employees or their dependents (including partners and their children) who are either Qualifying Children or Qualifying Relatives as defined by the Internal Revenue Code (IRC). However, the plan permits coverage of people (such as partners and certain categories of eligible children) who may not satisfy either of these definitions. This means that the value of benefits provided to such individuals will be reported as taxable income to you (known as imputed income) and that your share of the premiums for that coverage must be paid on an after-tax basis. Consult your own tax advisor or see IRS Publication 502 at www.irs.gov to determine if your dependent is eligible for tax-free health coverage. Contact Employee Services at 866.411.2772, ext. 20600, if you have questions. Eligible Children Eligible children must be under age 26 and include your: Biological or legally adopted children, as well as children placed with you for adoption Stepchildren Children of enrolled partners Children for whom you are responsible to provide health coverage based on a qualified medical child support order (QMCSO), and Foster children, if you are the court-appointed guardian of the child. 3
Welcome Eligibility Eligible Employees Eligible Dependents Child Support Orders Enrollment How to Enroll If You Do Not Enroll After You Enroll Late Enrollment for Life Insurance Beneficiaries When Coverage Begins Full-Time Employees Part-Time or Seasonal Employees Actively-at-Work Requirements Mandated Coverage for Hawaii Employees Making Changes Changing Your Benefit Elections Disabled Children Your child who is disabled or becomes disabled while covered under the plans may continue to be covered at age 26 and beyond. The term disabled means that the child: Is incapable of self-sustaining employment because of intellectual or physical disability Is chiefly dependent upon you for support and maintenance, and Is unmarried. Coverage for a disabled child who has been covered under the plans before age 26 will continue after the child reaches age 26, as long as the above criteria are met. To continue a disabled child s coverage, proof of disability must be given to the insurer or claims administrator within 60 days after the child reaches age 26. The insurer or claims administrator will make the final determination regarding eligibility for coverage. For insurer or claims administrator information, see Claims Administrators and Plan Numbers on page 255. Note that the dependent criteria for the reimbursement of Flexible Spending Account expenses may differ from the dependent eligibility definitions above. When Coverage Ends Health Care, EAP, Health Care FSA Dependent (Day) Care FSA Life Insurance and AD&D and Business Travel Accident Eligibility for the (EAP) Any member of your household can use the Employee Assistance Program (EAP). Coverage is not limited to eligible dependents. EAP coverage is automatic; you do not need to enroll yourself or your household members. 4 Qualified Child Support Orders (QMCSO) A QMCSO is any judgment, decree, or order, including a courtapproved settlement agreement, that is issued by: A domestic relations court or other court of competent jurisdiction, or An administrative process established under state law which has the force and effect of law in that state, and that Assigns to a child the right to receive health benefits for which a participant or beneficiary is eligible under the plan. The plan administrator determines what is qualified under the terms of ERISA and applicable state law. In general, only children who meet the eligibility requirements as dependents can be covered under a QMCSO. However, a QMCSO can also apply to children who: Were born out of wedlock Are not claimed as dependents on your federal income tax return, and Do not live with you. The order will be considered qualified if it meets the following conditions: The order creates or recognizes the child s right to participate in s health plan options as the dependent of an eligible employee. The order includes: 1. The name and last known address of the participant 2. The name and mailing address of each alternate recipient
Welcome 3. A description of the type of coverage to be provided or the manner in which the type of coverage will be determined Eligible Employees 4. The period to which the order applies, and Even if you do not enroll in benefits, you should designate a beneficiary on Gapweb for company-paid Basic Life Insurance benefits. Eligible Dependents 5. Each plan to which the order applies. If You Do Not Enroll Eligibility Child Support Orders Enrollment How to Enroll If You Do Not Enroll After You Enroll Late Enrollment for Life Insurance Beneficiaries When Coverage Begins Full-Time Employees Part-Time or Seasonal Employees Actively-at-Work Requirements Mandated Coverage for Hawaii Employees Making Changes The order does not require new types or forms of benefits unless specified by state law. If the QMCSO is qualified, will enroll the child and the eligible employee, if not already enrolled, in one of s health plan options as a dependent of the employee. The child will not have to provide proof of insurability to enroll. All other provisions, limitations, and exclusions of the plan will apply to the child as they would to any other participant. Appropriate deductions will be taken from the employee s pay as required to cover a child under the plan. To obtain a copy of the QMCSO procedures from the plan administrator, contact Employee Services at 866.411.2772, ext. 20600. Changing Your Benefit Elections Enrollment How to Enroll When Coverage Ends Health Care, EAP, Health Care FSA Dependent (Day) Care FSA Life Insurance and AD&D and Business Travel Accident Enroll by your deadline on Gapweb (https://portal.gap.com)> benefits. Enrollment will close at midnight Central Time on the 30th day after your date of hire, rehire or job classification change to full-time. You can also enroll or change your benefits each year during the annual Open Enrollment, which is generally held in May. If you do not enroll in benefits by your deadline or during Open Enrollment each year, you will be automatically enrolled in default coverage. Newly hired or newly eligible employees: Default coverage includes benefits that are 100% paid by and cover only you, not your dependents: - Vision (basic) - Life Insurance (basic) - Short-Term (basic) - Long-Term (basic). Keep in mind that wage replacement benefits received through the basic Short-Term and Long-Term plans are considered taxable income. Also, once you are enrolled in default benefits, you may elect the Plus plans only during annual Open Enrollment, and your future disability benefits will be limited for conditions including pregnancy that exist before you elect coverage. Current employees: Default coverage includes the benefits that you currently have, with the exception of the Flexible Spending Accounts (FSAs). Default coverage may change in a new plan year if there are any differences in your benefits that are announced during Open Enrollment and you take no action. If you choose to enroll dependents in any of the benefit plans, you will be required to provide a Social Security number for each dependent to secure coverage. 5
Welcome After You Enroll Eligibility You should review your enrollment summary page at the end of the online enrollment process. This will give you an opportunity to make further changes before you log off. Be sure to print out a copy of your benefits enrollment summary page for your records. You may go online any time before your enrollment deadline to make changes. Eligible Employees Eligible Dependents Child Support Orders Enrollment How to Enroll If You Do Not Enroll After You Enroll Late Enrollment for Life Insurance Beneficiaries When Coverage Begins Full-Time Employees Part-Time or Seasonal Employees Actively-at-Work Requirements Mandated Coverage for Hawaii Employees Making Changes Changing Your Benefit Elections When Coverage Ends An enrollment confirmation statement will be mailed after your enrollment deadline. The statement will list all your coverage, including company-paid and optional coverage you elected. When you receive the confirmation statement, make sure it reflects the coverage you selected. If you enroll in a medical or dental plan, you will receive ID cards for each plan. For UnitedHealthcare plans, you will receive a medical ID card from UnitedHealthcare and a separate prescription drug ID card from Express Scripts. If you have questions, call your health plan or on Gapweb. Reminder: A few weeks after you have enrolled, make sure that the appropriate deductions for your benefits are being taken from your paycheck. If deductions do not start promptly, notify Employee Services immediately at 866.411.2772, ext. 20600 to ensure coverage. Health Care, EAP, Health Care FSA If you decline enrollment for yourself or for an eligible dependent (including your spouse) because you have other medical coverage, you may be able to enroll yourself and your dependents in a medical plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing to that coverage). You may also generally drop coverage in a medical plan if you become eligible for coverage under another plan, including Medicaid or the Children s Health Insurance Program (CHIP). However, you must request to enroll or drop coverage within 30 days, ending at midnight Central Time, after you or your dependents become eligible for the other coverage or after the other coverage ends (or after the employer stops contributing toward other coverage). If you gain a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your new dependents in a medical plan. You must enroll within 30 days, ending at midnight Central Time, after the marriage, birth, adoption, or placement for adoption. To request a special enrollment, you must process a life event on Gapweb (https://portal.gap.com)> benefits. Dependent (Day) Care FSA Life Insurance and AD&D and Business Travel Accident 6 HIPAA Special Enrollment Notice Plan Coverage
Welcome Late Enrollment for Life Insurance Designating Your Beneficiaries Eligibility Late enrollment rules apply to coverage under the Supplemental Life Insurance or Spouse Life Insurance plans. If you do not enroll in these benefits when you are first eligible, you are considered a late enrollee and evidence of insurability (EOI) or proof of good health will be required to enroll. If approved, coverage takes effect on the approval date by the insurance company, subject to the pre-existing condition limitations (if any). EOI will not be required for enrollment in Spouse Life Insurance (for coverage amounts up to $25,000) in the case of marriage or start of a partnership. See You Get Married or Establish a Partnership on page 207. You should name a beneficiary for your Basic and Supplemental Life Insurance, AD&D, and Business Travel Accident plans. You may choose your spouse or partner, children, parents, a friend, estate, or trust as a beneficiary, and you may name one or multiple beneficiaries. Please complete your beneficiary elections when you enroll online for benefits coverage. Eligible Employees Eligible Dependents Child Support Orders Enrollment How to Enroll If You Do Not Enroll After You Enroll Late Enrollment for Life Insurance Beneficiaries When Coverage Begins Full-Time Employees Part-Time or Seasonal Employees Important: Late enrollment is not allowed for the medical, dental, vision, or Flexible Spending Account plans unless you have a qualified life event. Actively-at-Work Requirements You may change your beneficiary elections at any time on Gapweb (https://portal.gap.com)> benefits. If you haven t named a beneficiary, or if none of the named beneficiaries are living at the time the benefit is payable, payment will be made in this order: 1. To the executors or administrators of your estate 2. To your spouse if there is no executor or administrator 3. To your children in equal shares if you have no spouse Mandated Coverage for Hawaii Employees 4. To your parents in equal shares if you have no children 5. To your brothers or sisters in equal shares if your parents are deceased. Making Changes Changing Your Benefit Elections When Coverage Ends Health Care, EAP, Health Care FSA Dependent (Day) Care FSA Life Insurance and AD&D and Business Travel Accident 7
Welcome When Coverage Begins Eligibility Full-Time Employees Eligible Employees Coverage under the following plans will be effective on your eligibility date: Eligible Dependents Child Support Orders Enrollment How to Enroll If You Do Not Enroll Dental Vision Group Life Insurance Late Enrollment for Life Insurance Short-Term and Long-Term plans Beneficiaries When Coverage Begins Health Care or Dependent (Day) Care Flexible Spending Account (FSA) plans, and Full-Time Employees (EAP). Part-Time or Seasonal Employees Your eligibility date is the first of the month following the date of the events listed below or on the first of the month if the event occurs on that date: Mandated Coverage for Hawaii Employees Making Changes Changing Your Benefit Elections When Coverage Ends Health Care, EAP, Health Care FSA Dependent (Day) Care FSA Life Insurance and AD&D and Business Travel Accident Your hire date Your rehire date The date you are classified as full-time, subject to plan limitations and exclusions, or The date you experience a life event for health coverage (note: in the case of birth, adoption or legal guardianship, changes you make take effect on the date of birth, adoption or legal guardianship). For other benefits, you must be activelyat-work in order for coverage to be effective. See Actively-atWork Requirements Life, AD&D and Coverage on page 9. If your hire date is entered into the payroll system outside of the 30-day enrollment period, you will be given an additional 15 days to enroll, ending at midnight Central Time, from the date on 8 For example: If your hire or full-time status date is May 1 and the status change is not entered into the payroll system until July 15, your effective date would be August 1 (the first of the month following the date your status change was entered). Part-Time or Seasonal Employees Who Experience a Status Change to Full-Time After You Enroll Actively-at-Work Requirements which your hire date was entered. Your coverage effective date for benefits will be the first of the month following the date your hire date was entered. If your status changes to full-time from part-time or seasonal classification, you are eligible to participate in the benefits programs on the first of the month following the date your classification changes to full-time or the first of the month if the change occurs on that date. See the Directory on page 205 for more information. You must complete your online enrollment within 30 days, ending at midnight Central Time, of your job classification change to fulltime. If you do not complete your enrollment within the required timeframe, you cannot enroll in coverage until the next Open Enrollment or if you experience a life event. If your classification to full-time is entered into the system outside of the 30-day enrollment period, you will be given an additional 15 days, ending at midnight Central Time, from the date on which your classification to full-time was entered, to enroll. Your coverage effective date for benefits will be the first of the month following the date your classification to full-time was entered. For example: If your job classification changes from part-time to full-time on May 1 and the status change is not entered into the payroll system until July 15, your effective date would be August 1 (the first of the month following the date your status change was entered).
Welcome Eligibility Eligible Employees Eligible Dependents Child Support Orders Enrollment How to Enroll If You Do Not Enroll After You Enroll Late Enrollment for Life Insurance Beneficiaries When Coverage Begins Full-Time Employees Part-Time or Seasonal Employees Actively-at-Work Requirements Mandated Coverage for Hawaii Employees Making Changes Changing Your Benefit Elections Please notify Employee Services at 866.411.2772, ext. 20600, if you need assistance enrolling in benefits. Actively-at-Work Requirements Life, AD&D and Coverage You must be actively at work on your eligibility date for your Basic, Supplemental or Dependent Life Insurance, Short-Term and Long-Term, and Accidental Death & Dismemberment (AD&D) coverage to take effect. Actively at work means you are performing all the material duties of your job at your usual place of business or at any other place your job requires you to go. If you are not actively at work on your eligibility date, your coverage will go into effect once you return to work. Mandated Coverage for Hawaii Employees You are eligible to participate in the medical plans on the date you are classified as a full-time employee in Hawaii. You will be automatically enrolled in the UnitedHealthcare Hawaii PPO medical plan for yourself only. You may enroll your dependents or change your coverage to another available medical plan by enrolling on Gapweb within 30 days, ending at midnight Central Time, of your date of hire, rehire or job classification change to full-time. If you have other medical coverage, or are otherwise exempt from the state of Hawaii s health coverage requirements, you may terminate your coverage by completing and returning the Employee Notification to Employer form (Form HC-5) to the Benefits Department. You will receive the Form HC-5 with your benefit enrollment package. The Form HC-5 is also available from the state of Hawaii s Department of Labor and Industrial Relations at http://hawaii.gov/labor/forms. You must complete a new Form HC-5 each January 1 to remain exempt from mandatory coverage. If your other coverage or exemption ends, notify Employee Services immediately at 866.411.2772, ext. 20600. You must enroll in a medical plan effective on the date your other coverage ends. If you are disabled and unable to work, your medical coverage will continue for up to three months after the month in which you became disabled. You must continue to pay your contribution during this period. Premiums will be deducted from your disability checks while you are on a leave of absence. If Gap Inc. is unable to deduct benefits premiums from your disability checks, any past-due contributions will be deducted upon your return from work. When Coverage Ends Health Care, EAP, Health Care FSA Dependent (Day) Care FSA Life Insurance and AD&D and Business Travel Accident 9
Welcome Making Changes Eligibility Changing Your Benefit Elections Eligible Employees, Dental, Vision, and Flexible Spending Account Plans You can make changes to your medical, dental, vision, and Flexible Spending Account plan elections: Eligible Dependents Child Support Orders Enrollment How to Enroll If You Do Not Enroll After You Enroll Late Enrollment for Life Insurance Beneficiaries When Coverage Begins Full-Time Employees Part-Time or Seasonal Employees Actively-at-Work Requirements Mandated Coverage for Hawaii Employees Making Changes Changing Your Benefit Elections When Coverage Ends Health Care, EAP, Health Care FSA Dependent (Day) Care FSA Life Insurance and AD&D and Business Travel Accident During the annual Open Enrollment (with changes effective July 1) If you or your dependent has a life event (as defined below) that is consistent with the change in coverage. You must complete your changes on Gapweb (https://portal.gap.com)> benefits within 30 days, ending at midnight Central Time, from the date of the life event. You may also make changes to your medical coverage within 30 days, ending at midnight Central Time, if you experience a special enrollment event. Supplemental and Dependent Life Insurance, AD&D Insurance and You can make changes to your Supplemental and Dependent Life Insurance and Accidental Death & Dismemberment (AD&D) Insurance elections during Open Enrollment or if you have a life event: If you are enrolled in Supplemental Life Insurance, you may increase your coverage by one level, without having to provide evidence of insurability (EOI), to up to three times your annual base pay. For election amounts greater than three times your annual base pay, you must submit EOI. If you have previously waived Supplemental Life coverage, you may increase your supplemental coverage by one level without EOI. Any other election requires EOI. 10 If you are enrolled in Dependent Life Insurance for a spouse or partner, you may increase your coverage without having to provide EOI, up to the lesser of 50% of your Basic Life Insurance amount or $25,000. EOI is required for amounts of insurance greater than $25,000. If you previously waived Dependent Life Insurance, any election requires EOI (except in the event of marriage or start of a partnership, for coverage amounts up to $25,000). See You Get Married or Establish a Partnership on page 207. You can make changes to your Short-Term and Long-Term coverage only during Open Enrollment: If you enroll in the Plus plans, your future disability benefits will be limited to the basic level for pre-existing conditions including pregnancy for the first 12 months of coverage. The following are considered life events that may allow you to make changes to your pre-tax benefit elections, which include medical, dental or vision coverage, and Flexible Spending Accounts (FSAs). See the Directory on page 205 for a detailed list of life events. Legal marital status. An event that changes your legal marital status, including marriage, divorce, death of a spouse, legal separation, or annulment. Partnership status. An event that changes the status of your partnership, including establishment or termination of a partnership, or death of your partner. Number of children. An event that changes your number of children, including birth, death, adoption, and placement for adoption.
Welcome Eligibility Eligible Employees Employment status. An event that changes your, your spouse s, or your child s employment status, resulting in a gain or loss of eligibility for coverage. Examples include: Eligible Dependents - Beginning or terminating employment Child Support Orders - Starting or returning from an unpaid leave of absence Enrollment How to Enroll - Changing from part-time to classified full-time employment or vice versa If You Do Not Enroll - A change in worksite. After You Enroll Late Enrollment for Life Insurance Beneficiaries When Coverage Begins Full-Time Employees Part-Time or Seasonal Employees Actively-at-Work Requirements Mandated Coverage for Hawaii Employees Making Changes Changing Your Benefit Elections When Coverage Ends Health Care, EAP, Health Care FSA Dependent (Day) Care FSA Life Insurance and AD&D and Business Travel Accident Child eligibility status. An event that causes your children to become eligible or ineligible for coverage because of age or similar circumstances. Residence. A change in your or your dependent s place of residence, resulting in a gain or loss of eligibility for coverage. Consistency Requirements According to federal law, the change you make to your benefit elections must be due to and consistent with your life event. Your life event and corresponding change in election must meet both of the following requirements: Effect on eligibility. Except for the Dependent (Day) Care FSA, the life event must have an effect on eligibility for coverage under a -sponsored plan or under a plan sponsored by the employer of your spouse or other dependent. Eligibility for coverage is affected if you become eligible (or ineligible) for coverage or if the life event results in an increase or decrease in the number of your dependents who may benefit from coverage under the plan. Corresponding election change. The election change must correspond with the life event. For example, if your dependent loses eligibility for coverage under the terms of a medical plan, you may cancel medical coverage only for that dependent. 11 For the Dependent (Day) Care FSA, the life event must affect the amount of dependent care expenses eligible for reimbursement. (For example, your child reaches age 13, and day care expenses are no longer eligible for reimbursement.) Changes in Coverage or Cost In some instances, you can make changes to your elections for other reasons, such as mid-year events affecting your cost or coverage, as described below. These rules do not apply to the Health Care FSA. Changes in Coverage If adds or eliminates a plan option in the middle of the plan year, or if -sponsored coverage is significantly reduced or ends, you can elect different available coverage for yourself and/or eligible dependents in accordance with IRS regulations (if the other plan option permits). Coverage events may also include election opportunities allowed under other Gap Inc. plans. Here are some examples: If there is a reduction under a plan option that reduces coverage to participants overall, in general, participants enrolled in that plan option may revoke their election and elect coverage under another option providing similar coverage. If adds another plan option mid-year, participants can drop their existing coverage and enroll in the new plan option. You may also enroll yourself and/or eligible dependents in the new plan option even if not previously enrolled for coverage at all (if that plan option permits). If another employer s plan allows you, your spouse, or your child to make an election change during that plan s annual Open Enrollment period, you may make a corresponding mid-year election change.
Welcome Eligibility Eligible Employees Eligible Dependents Child Support Orders Enrollment How to Enroll If You Do Not Enroll After You Enroll Late Enrollment for Life Insurance Beneficiaries When Coverage Begins Full-Time Employees Part-Time or Seasonal Employees Actively-at-Work Requirements Mandated Coverage for Hawaii Employees Making Changes Changing Your Benefit Elections When Coverage Ends Health Care, EAP, Health Care FSA Dependent (Day) Care FSA Life Insurance and AD&D and Business Travel Accident If another employer s plan (for example, your spouse s employer) allows you, your spouse, or your child to change his or her health plan elections in accordance with IRS regulations, you may make a corresponding mid-year election change to your coverage. If you or your dependents become eligible for medical coverage under Medicaid or the Children s Health Insurance Program (CHIP), you may make a corresponding mid-year election change to your coverage. If your or your dependent s Medicaid or Children s Health Insurance Program (CHIP) coverage terminates as a result of loss of eligibility, you may make a corresponding mid-year election change to your coverage. You must contact within 30 days, ending at midnight Central Time, of termination. Changes in Cost If your cost for coverage increases or decreases significantly during the plan year, you may make a corresponding election change. For example, you may elect another plan option with similar coverage (if that plan option permits), or drop coverage if no other coverage is available. In addition, if there is a significant decrease in the cost of a plan option during the year, you may enroll in that plan option, even if you declined to enroll in that plan option earlier. Any change in the cost of your plan option that is not significant will result in an automatic increase or decrease, as applicable, in your share of the total cost. For example, if you change your dependent care provider mid-year, you may change your Dependent (Day) Care FSA contributions to correspond with the new provider s charges. If your dependent care provider (other than a provider who is your relative) raises or lowers its rates mid-year, you may increase or decrease your contributions. Additionally, if your dependent care provider 12 reduces or increases the number of hours that it provides care, you may make a corresponding change to your Dependent (Day) Care FSA election. Special Note Regarding Partner Coverage The events qualifying you to make a mid-year election change described in this section also apply to events related to your same-sex spouse/partner or his or her tax dependents. However, IRS rules generally do not permit you to make a mid-year change on a pre-tax basis for such events unless they involve tax dependents. Special enrollment rules that apply to spouses will also apply to partners. The plan administrator may from time to time establish and communicate a maximum number of changes that can be made to Dependent (Day) Care FSA elections in a particular plan year. HIPAA Special Enrollment for Plan Coverage You and your eligible dependents may also enroll in a medical plan outside of annual Open Enrollment if you lose coverage or acquire newly eligible dependents, as long as you enroll yourself and/or your dependents within 30 days, ending at midnight Central Time, of one of the events described below. These are similar to life events described above. Loss of other coverage. This rule applies if you meet the following conditions: - You (or your dependents) were covered under other medical coverage (for example, under another employer s medical plan) when coverage was offered to you
Welcome - You (or your dependents) lose other coverage because: Eligibility You or your dependents exhaust rights to COBRA coverage, Eligible Employees The employer s contributions to the other coverage stop, or Eligible Dependents Child Support Orders Enrollment How to Enroll If You Do Not Enroll After You Enroll Late Enrollment for Life Insurance Beneficiaries When Coverage Begins Full-Time Employees Part-Time or Seasonal Employees Actively-at-Work Requirements Mandated Coverage for Hawaii Employees Making Changes Changing Your Benefit Elections When Coverage Ends Health Care, EAP, Health Care FSA Dependent (Day) Care FSA Life Insurance and AD&D You or your dependent is no longer eligible under that plan. Loss of eligibility does not include a loss due to a failure to timely pay premiums or termination of coverage for cause. - You or your covered dependents lose medical coverage under Medicaid, CHIP, or a state premium assistance program. Acquiring new dependents. When you acquire a newly eligible dependent (through marriage, birth, partnership, adoption, or placement for adoption), you may enroll yourself, your spouse or partner and your eligible children in a medical plan. You must enroll within 30 days, ending at midnight Central Time, of the date you acquire the new dependent. Coverage will start on the date of birth, adoption or placement for adoption, as long as the child is enrolled within 30 days. Medicare or Medicaid Entitlement You may change an election for health coverage mid-year if you, your spouse, or your child becomes entitled to or loses eligibility for coverage under Medicare or Medicaid. However, you are limited to reducing your medical coverage only for the person who becomes entitled to Medicare or Medicaid, and to adding medical coverage only for the person who loses eligibility for Medicare or Medicaid. and Business Travel Accident 13
Welcome Eligibility Eligible Employees Eligible Dependents Child Support Orders Enrollment How to Enroll If You Do Not Enroll After You Enroll Late Enrollment for Life Insurance Beneficiaries When Coverage Begins Full-Time Employees Part-Time or Seasonal Employees Actively-at-Work Requirements Mandated Coverage for Hawaii Employees Medicaid and the Children s Health Insurance Program (CHIP) Free or Low-cost Health Coverage for Children and Families If you are eligible for health coverage from your employer, but are unable to afford the premiums, some states have premium assistance programs that can help pay for coverage. These states use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage, but need assistance in paying their health premiums. If you or your dependents are already enrolled in Medicaid or CHIP, access the website listed in the next column or contact your state Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, you can contact your state Medicaid or CHIP office by calling 877.KIDS.NOW, or visit www.insurekidsnow.gov to apply. If you qualify, ask if there is a program to help you pay the premiums for an employer-sponsored plan. Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, your employer s health plan is required to permit you and your dependents to enroll in the plan as long as you and your dependents are eligible, but not already enrolled in the employer s plan. This is called a special enrollment opportunity, and you must request coverage within 30 days, ending at midnight Central Time, of being determined eligible for premium assistance. Special enrollment rules that apply to spouses will also apply to partners. For more information refer to: www.dol.gov/ ebsa/pdf/chipmodelnotice.pdf. Making Changes Changing Your Benefit Elections When Coverage Ends Health Care, EAP, Health Care FSA Dependent (Day) Care FSA Life Insurance and AD&D and Business Travel Accident Judgment, Decree or Order You may change health plans if a judgment, decree or order requires health coverage for your child, including a foster child. The order must have resulted from a divorce, legal separation, annulment, or change in legal custody, and must meet the requirements of a Qualified Child Support Order (QMCSO). You may change your health plan election to provide coverage for the eligible child if the order requires coverage to be provided under the plan. You may also cancel coverage for the child if the order requires your spouse, former spouse, or other individual to provide coverage for the child, but only if coverage for the child is actually provided. Proof of coverage may be required. 14 Making Your Election Changes Remember: To take advantage of the life event rules, you must make your election change within 30 days of the event, ending at midnight Central Time. Enroll or elect additional coverage on Gapweb (https://portal.gap.com)> benefits. reserves the right to request documents that support your request to change coverage due to a life event.
Welcome When Coverage Ends Eligibility, Dental, Vision, (EAP), and the Health Care FSA Eligible Employees Eligible Dependents Child Support Orders Enrollment How to Enroll If You Do Not Enroll After You Enroll Late Enrollment for Life Insurance Beneficiaries When Coverage Begins Full-Time Employees Part-Time or Seasonal Employees Actively-at-Work Requirements Mandated Coverage for Hawaii Employees Making Changes Changing Your Benefit Elections When Coverage Ends Health Care, EAP, Health Care FSA Dependent (Day) Care FSA Life Insurance and AD&D and Business Travel Accident Coverage under the medical, dental and vision plans, the (EAP), and the Health Care FSA ends at midnight on the earliest of: The last day of the month in which your employment with Gap Inc. ends. - For example, if your termination date is July 15, your last day of coverage is July 31. First day of non-coverage will be August 1. The last day of the month in which you become ineligible. - For example, if you change from full-time to part-time effective July 15, your last day of coverage is July 31. First day of non-coverage will be August 1. The last day of the month in which your dependent(s) become ineligible. - For example, if you drop coverage for a spouse due to a divorce effective July 15, coverage for your former spouse will end July 31. - However, if you drop coverage for a dependent who has died, coverage will end on the date of the death. If you or a member of your household started counseling with an EAP counselor when your coverage ends, you may continue to receive clinically appropriate counseling for up to the maximum visits allowed by the plan, regardless of whether you elect COBRA. The UnitedHealthcare medical plans, dental plans, vision plans, EAP, and Health Care FSA do not have options to continue coverage under individual policies after your active or COBRA coverage ends. If you are enrolled in an HMO, contact the HMO for information regarding individual policy options. Dependent (Day) Care FSA Your participation in the Dependent (Day) Care FSA ends at midnight on the earliest of: The last day of the month in which your active employment with ends, including termination and leave of absence. The last day of the month you become ineligible. The date the plan(s) terminate. The date the plan terminates. The last day of the month you fail to make a required contribution under the terms of the plan(s). The last day of the month you fail to make a required contribution under the terms of the plan. You may have the opportunity to continue your medical, dental, vision, EAP, and Health Care FSA coverage for a limited time under the Consolidated Omnibus Budget Reconciliation Act (COBRA). Please see Continuation of Coverage Under COBRA on page 241 for COBRA information. You may submit claims for the expenses you have incurred at any time during the plan year, including expenses incurred after your termination date, up to the amount remaining in your account when you leave. All claims must be submitted before September 30 following the end of the plan year. 15 If your employment termination date or status change from fulltime to part-time is entered into the payroll system more than 44 days after your termination or status change date, coverage will end at the end of the month in which your change was entered. COBRA notifications will be sent to you effective the day after coverage ends.
Welcome Life Insurance and AD&D Coverage Eligibility Coverage for all persons covered by Basic Life Insurance, Supplemental Life Insurance, Dependent Life Insurance, and Accidental Death & Dismemberment (AD&D) Insurance ends at midnight on the earliest of: Eligible Employees Eligible Dependents Child Support Orders Enrollment How to Enroll If You Do Not Enroll After You Enroll Late Enrollment for Life Insurance Beneficiaries When Coverage Begins Full-Time Employees Part-Time or Seasonal Employees Actively-at-Work Requirements Mandated Coverage for Hawaii Employees Making Changes Changing Your Benefit Elections When Coverage Ends Health Care, EAP, Health Care FSA Dependent (Day) Care FSA Life Insurance and AD&D and Business Travel Accident The last day of the month in which your employment with ends. - For example, if you change from full-time to part-time effective July 15, your last day of coverage is July 31. First day of non-coverage will be August 1. The last day of the month in which you become ineligible. - For example, if you change from full-time to part-time effective July 15, your last day of coverage is July 31. First day of non-coverage will be August 1. The last day of the month in which your dependent(s) becomes ineligible. - For example, if you drop coverage for a spouse due to a divorce effective July 15, coverage for your former spouse will end July 31. and Business Travel Accident Coverage Coverage for all persons covered by Short-Term, LongTerm, and Business Travel Accident plans ends at midnight on the earliest of: The day your employment with ends. The day you become ineligible. The date the plan(s) terminates. The date you fail to make a required contribution under the terms of the plan(s). - However, if you drop coverage for a dependent who has died, coverage will end on the date of the death. The date the plan(s) terminates. The last day of the month you fail to make a required contribution under the terms of the plan(s). When coverage ends, you may be able to convert your Basic Life Insurance, Supplemental Life Insurance, or AD&D Insurance without evidence of insurability (EOI) to an individual policy if you apply for conversion and pay your first premium within 31 days of the termination of your coverage(s). 16 Your Life Insurance coverage is also portable. You can elect to keep your current level of coverage (up to the maximum stated in Life Insurance and Accidental Death & Dismemberment (AD&D) Insurance starting on page 168) through age 70 if you terminate employment for any reason other than disability, if you become ineligible for coverage, or if your employment status changes to part-time or seasonal. Call Minnesota Life at 866.293.6047 to request an application. You must apply within 31 days of the end of your coverage to be eligible for this option.
UnitedHealthcare Plans HRA and HRA Plus Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan MCS Plan (Puerto Rico) Important Plan Notices Plans offers you medical coverage with flexibility and choice. Depending on your location, you have a choice of medical plan options: UnitedHealthcare Plans: Health Reimbursement Account (HRA) plans HRA or HRA Plus (all locations except Hawaii & Puerto Rico) Important definitions and phrases can be found in Terms You Should Know on page 106. It s a good idea to take a minute to look up a term or phrase you do not know so you better understand how the plan works. Hawaii Preferred Provider Organization (PPO) plan (Hawaii only) Out-of-Area plan (available if your address is not within a reasonable distance from network providers as determined by UnitedHealthcare) Kaiser Health Plans: Kaiser California Health Maintenance Organization (HMO) plan (California only) Kaiser Hawaii Health Maintenance Organization (HMO) plan (Hawaii only) MVP Health Maintenance Organization (HMO) plan (Fishkill, NY only) MCS medical plan (Puerto Rico only) All of the plans cover a wide range of medical services and supplies. You choose the coverage that s right for your personal situation. 17
UnitedHealthcare Plans HRA and HRA Plus Plans How the Plans Work UnitedHealthcare Plans HRA and HRA Plus Plans Plans at a Glance How the HRA Plans Work Using the Plans The HRA plans give you direct access to your health care dollars and the flexibility to make choices that meet your needs. The plans offer a variety of tools, resources and support, so you can make informed decisions on what works best for you and your family. The HRA plans provide covered preventive care services at no cost to you and a safety net for major health care expenses. The HRA plans are health plans with two parts: Other Important Information A comprehensive medical plan, plus Kaiser California HMO Plan A health reimbursement account (HRA) funded by Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Kaiser Hawaii HMO Plan MVP HMO Plan Below is an overview of each of these components. For additional plan details, see Using the HRA and HRA Plus Plans on page 26. Preventive Care Preventive care is the foundation of the HRA plans and is covered at 100%. All eligible preventive services (physicals, routine tests, well-baby care, and women s preventive health care including contraceptives) are free to you. Regular preventive care can help identify and prevent health issues before they become problems or chronic conditions. 18 The health reimbursement account is only available if you enroll in an HRA plan. You cannot elect a health reimbursement account separately. It s a component of the HRA medical plans and is funded only by You can, however, enroll in and contribute to a Health Care Flexible Spending Account (FSA), regardless of which medical plan you enroll in. The Health Care FSA allows you to save money on a pre-tax basis to pay for eligible out-of-pocket health care expenses. Comprehensive Coverage The HRA plans provide comprehensive medical coverage, including: Preventive care at no cost to you. Access to UnitedHealthcare s extensive network of doctors and hospitals. MCS Plan (Puerto Rico) Important Plan Notices Important! Flexibility of in- and out-of-network coverage, with higher benefits (and lower out-of-pocket expenses) when you use innetwork providers. You also don t need to file a claim when you use in-network providers. Prescription drug coverage through Express Scripts. A plan year (July 1 to June 30) deductible that may be offset by your HRA dollars, which are deposited by into your health reimbursement account. You pay the remainder of the deductible.
UnitedHealthcare Plans HRA and HRA Plus Plans How the Plans Work Plans at a Glance Using the Plans Out-of-Area Plan Hawaii PPO Plan Additional Information for UnitedHealthcare Plans What s Covered Other Important Information Kaiser California HMO Plan Kaiser Hawaii HMO Plan MVP HMO Plan After the plan year deductible is met, you pay co-insurance (a share of the cost for services) and pays the rest. receive in the next year. You can use your HRA dollars to pay all or a portion of your deductible and co-insurance. An out-of-pocket maximum that limits what you pay each plan year (July 1 to June 30) and protects you from the expense of a catastrophic illness or injury. If your employment terminates or you retire, your HRA dollars will be forfeited and any remaining HRA dollars will revert back to, unless you elect COBRA coverage. If you elect COBRA coverage, any remaining HRA dollars can be used to pay your medical expenses while COBRA coverage is in effect. Health Reimbursement Account (HRA) At the beginning of each plan year, makes a contribution to your health reimbursement account, called HRA dollars. The amount the company contributes depends on: The plan you select HRA or HRA Plus, and The coverage category you choose. You cannot make contributions to your health reimbursement account it is funded solely from s general assets. HRA dollars are also forfeited if you cancel your coverage in a HRA plan. Note: Any reimbursement you receive through your health reimbursement account or Health Care FSA cannot be used as a medical expense deduction on your federal income tax return. At the end of the plan year, your unused HRA dollars will roll over to the next plan year and will be added to the HRA dollars you MCS Plan (Puerto Rico) Important Plan Notices 19
UnitedHealthcare Plans The HRA Plans: Step-by-Step HRA and HRA Plus Plans Here s how the HRA and HRA Plus Plans work and how you receive benefits for covered medical services: How the Plans Work One Plans at a Glance Using the Plans Out-of-Area Plan Your eligible medical expenses are paid by your health reimbursement account first. contributes HRA dollars to your health reimbursement account each plan year: Hawaii PPO Plan HRA dollars contributed by Additional Information for UnitedHealthcare Plans HRA Plan HRA Plus Plan What s Covered Employee $200 $700 Employee + spouse/partner or Employee+ child(ren) $300 $1,050 Other Important Information Employee + family $400 $1,400 Kaiser California HMO Plan Your HRA dollars can be used for eligible medical expenses, such as your deductible and co-insurance amounts. Kaiser Hawaii HMO Plan HRA dollars cannot be used to pay for prescription drug expenses. MVP HMO Plan Preventive care is free, so HRA dollars are never used for these services. MCS Plan (Puerto Rico) You can use a Health Care FSA to help pay your share. See page 153 for more information. Important Plan Notices 20