NYU HOSPITALS CENTER. Retirement Plan. Your Health & Welfare Plan Benefits

NYU HOSPITALS CENTER Retirement Plan Your Health & Welfare Plan Benefits

1 What s Inside Welcome to the NYU Hospitals Center Retiree Health & Welfare Program Retiree Health & Welfare Benefits At-A-Glance... 2 Eligibility... 3 What Happens to My Active Benefit Coverages At Retirement.....4 Your Medical Plan Choices... 6 UnitedHealthcare Medical Plan Options... 6 National Prescription Administrators (NPA) Prescription Drug Coverage... 9 Aetna Retiree Group Term Life Insurance... 10 Your Cost For Retiree Health & Welfare Coverage... 10 Some TIPS About Retiring And The NYU Hosptials Center Retiree Health & Welfare Program... 11 General Information About Medicare... 11 Coordination Of Benefits Example - With A Non-Medicare Plan... 13 Coordination Of Benefits Example - With Medicare... 13

2 Welcome to the NYU Hospitals Center Retiree Health & Welfare Program This guide explains some of the key features of the NYU Hospitals Center Retiree Health & Welfare benefit Program effective March 1, 2002. Complete details of each of the plans are contained in the official plan documents. If there is ever a conflict between this guide and the official plan documents, the plan documents will prevail. The following chart provides an overview of the NYU Hospitals Center Retiree Health & Welfare Program options: Retiree Health & Welfare Benefits At-A-Glance Benefit Type Under Age 65 (Pre-Medicare) Options Age 65 or Older (Medicare Eligible) Option Medical and Prescription Drug* UnitedHealthcare Basic PPO Option with National Prescription Administrators (NPA) Prescription Drug Plan, Or UnitedHealthcare Plus PPO Option with NPA Prescription Drug Plan UnitedHealthcare Medicare Supplement Indemnity Option with National Prescription Administrators (NPA) Prescription Drug Plan Life Insurance Life Insurance amounts are based upon eligibility. Please refer to the Life Insurance Schedule on page 10. * There is no HMO coverage available from NYU Hospitals Center in retirement.

3 Eligibility The NYU Hospitals Center Retiree Health & Welfare Plan covers eligible retirees and dependents (including same-gender domestic partners at your retirement and their eligible dependent children at the time of your retirement) who meet the criteria outlined below. Eligibility Criteria and Employment Status Full-time staff members are eligible to participate in the NYU Hospitals Center Retiree Health & Welfare Program if, upon retirement, they are at least age 55 with 15 years or more of continuous service after the attainment of age 40, or have completed at least 25 years of continuous service as of 9/1/94. This includes: All regular full-time salaried non-bargaining unit staff with base hours of 17.5 or more per week* Employees who have completed 10 years of continuous service and qualify for Permanent and Total Disability. To be eligible for Disability Retirement an employee must be awarded Social Security Income or Long Term Disability (LTD) Income under the Mount Sinai NYU Health LTD Plan. *Staff must satisfy the minimum required hours of service per week, as described above, in each of the 15 years prior to retirement. For purposes of NYU Hospitals Center Retiree Health & Welfare Program eligibility, years of service are determined solely by reviewing years of service with Mount Sinai NYU Health and NYU School of Medicine. Eligible retirees include all regular full-time salaried non-bargaining unit staff who terminate employment, change to non-compensated status or change to a schedule of less than 17.5 hours per week, but have attained 55 years of age and have already completed at least 15 years of continuous service after age 40. The following employees are not eligible to participate in the NYU Hospitals Center Retiree Health & Welfare Program: House Staff (clinical fellows) Non-Bargaining Unit Staff hired on a temporary basis Student Interns, on-call and per diem based employees Members of Local 810 Members of Local 1199 Dependents The following dependents may be covered under the medical/prescription drug retiree plans Your spouse at your retirement or same-gender domestic partner at your retirement (1) or dependent children at your retirement (or the dependent children of your same gender domestic partner at the time of your retirement) (2). Spouses and dependent children (currently enrolled in the health plan) of eligible employees with 10 or more years of continuous service who die during active service. (1) A completed Statement of Domestic Partnership form along with required proof must be submitted before coverage is provided. Information and forms are available from Human Resources. (2) Eligible dependent children (or your same-gender domestic partner s children) can be covered until December 31 st of the year in which they turn age 19.

4 What Happens to My Active Benefit Coverages At Retirement If you are a participant in any of the following Health & Welfare benefit plans prior to retirement, the chart below describes what happens to these coverages upon retirement: Benefit Type Medical Coverage Coverage ends on the last day of the month in which you retire Prescription Drug Coverage ends on the last day of the month in which you retire Dental Vision Group Term Life Insurance Dependent Life Insurance Accidental Death & Dismemberment Insurance Coverage ends on the last day of the month in which you retire Retirees and eligible dependents can continue coverage under COBRA for up to 18 months Coverage ends on the last day of the month in which you retire Retirees and eligible dependents can continue coverage under COBRA for up to 18 months. Coverage is reduced on the first day of retirement* You may convert the balance of your coverage (active coverage amount minus retiree coverage) in effect just prior to your retirement to an individual life policy*, at your own expense Coverage ends on the last day of active service You may convert your active coverage in effect just prior to your retirement to an individual life policy, at your own expense Coverage ends on the last day of active service Disability - Short Term Long Term Coverage ends on the last day of active service Coverage ends on the last day of active service You may convert to an individual long term disability policy with UNUM/Provident, at your own expense. *Please see life insurance section on page 10 for the amount of retiree life insurance for which you are eligible.

5 Benefit Type Health Care Reimbursement Account Dependent Care Reimbursement Account 403(b) Retirement Plan Transportation Reimbursement Incentive Program (TRIP) Coverage Contributions cease at retirement, but you can submit claims to UnitedHealthcare for expenses incurred prior to retirement, up to your annual goal amount. Contributions cease at retirement, but you can submit claims to UnitedHealthcare for expenses incurred in the calendar year of retirement, up to the amount contributed to your account. Contributions stop at retirement You can leave money in the Plan Various forms of payment options are available. You can continue to make fund exchanges You can rollover your account balance to an IRA or another employersponsored 403(b) or 401(k) plan. There is a mandatory commencement of distribution for terminated employees beginning as of April 1st following the year in which age 70½ is attained. Your participation ends on your last day of active service. You can claim up to your account balance for expenses incurred prior to your date of retirement, subject to plan limits Paid Time Off (PTO) You will be paid for all earned but unused PTO time at the time of retirement. Conversely, unearned PTO time used during the course of active service will be deducted from your final paycheck. If you are not covered by the PTO program, please consult your personnel policies with respect to vacation, personal, and sick time.

6 Your Medical Plan Choices The NYU Hospitals Center Retiree Health Plan offers both eligible retirees and dependents under age 65, two retiree PPO (Preferred Provider Organization) health plan options. Retirees and eligible dependents age 65 or over (or otherwise Medicare eligible) can elect a Medicare Supplement Indemnity Plan. Eligible dependents less than age 65 must select the same PPO option as retirees less than age 65. Your retiree health plan choices are: Health Plan Option 1 Option 2 Eligible Retirees and Dependents* Under Age 65 UnitedHealthcare Basic PPO Option with NPA Prescription Drug Plan UnitedHealthcare Plus PPO Option with NPA Prescription Drug Plan Eligible Retirees and Dependents* Over Age 65 UnitedHealthcare Medicare Supplement Indemnity Option with NPA Prescription Drug Plan * Including same gender Domestic Partners and their children The following sections highlight the key features of each option. Detailed summaries and additional information are included in the back of this booklet. UnitedHealthcare Medical Plan Options Retirees and Eligible Dependents Under Age 65 As a participant in the UnitedHealthcare under age 65 Retiree Medical Plan - you have two plan options from which to choose- a Basic PPO option and a Plus PPO option. Both the Basic and Plus PPO options provide three ways to access medical care when you need it. The level of benefits you receive depends on the provider you select. You may use: Mount Sinai NYU Health providers listed in the top tier network roster, receive the top tier level of coverage and have the least out-of-pocket cost Other providers in the UnitedHealthcare PPO nationwide network (called Options PPO ), receive the middle tier level of coverage and have some out-of-pocket cost Out-of-network providers, receive the least coverage available under the plan and have the greatest outof-pocket cost. Whether you choose the Basic or Plus PPO you receive prescription drug coverage through NPA as described on page 9.

7 UnitedHealthcare Basic and Plus PPO Options Benefits At-A-Glance Benefits Schedule Basic PPO Option ( Options PPO ) Plus PPO Option ( Options PPO ) Office Visit Copayment / Coinsurance Top Tier Middle Tier Out-of-Network Annual Deductible Top Tier Middle Tier Out-of-Network $10 per visit $20 per visit Plan pays 70% of the reasonable & customary charge after the deductible has been met $400/$1,200 family $5 per visit $15 per visit Plan pays 80% of the reasonable & customary charge after the deductible has been met $300/$900 family Hospital Copayment Top Tier * Middle Tier Out-of-Network $ 500 per admission $ 1,000 per admission $ 300 per admission $ 600 per admission Annual Out-of-Pocket Maximum Top Tier Middle Tier Out-of-Network $1,600/$4,800 family (excludes deductibles) $1,200/$3,600 family (excludes deductibles) * Top Tier hospitals include: NYU Hospitals Center, Hospital for Joint Diseases, NYU Downtown Hospital, Mount Sinai Hospital, and Mount Sinai Hospital of Queens. What is a PPO? PPO stands for Preferred Provider Organization. A PPO is a group of doctors, hospitals, and facilities that have agreed to give care to plan participants at discounted rates. With a PPO, you do not need to select a primary care physician and you can go directly to a specialist without a referral. Tools for Finding UnitedHealthcare Options PPO Nationwide Network Providers Near You Mount Sinai NYU Health Top Tier provider directories are available in Human Resources Call UnitedHealthcare at 866-936-6007 for Options PPO nationwide directory information Online at www.uhc.com

8 Medical Services And Supplies Requiring Prior Notification To UnitedHealthcare The UnitedHealthcare pre-medicare plans require advance notification for certain services to ensure that claims are considered for payment. Failure to notify UnitedHealthcare in advance of receiving these medical services and supplies will result in a $400 penalty under the Basic PPO, and a $400 penalty under the Plus PPO. These services are: Medical Facility Admissions Out-Of-Network Services - includes referrals to providers and hospitals that are not contracted with UnitedHealthcare where a request for in-network reimbursement exists (only applicable when a UnitedHealthcare network provider is unavailable). Home Health Care Services Surgical Procedures - including Blepharoplasty, Upper Lid, Breast Reconstruction, Breast Reduction, Sclerotherapy, Vein Stripping, and Ligation. Dental Services Relating To An Accident Durable Medical Equipment with a retail cost of over $1,000 Retirees and Eligible Dependents Age 65 and Older As a participant in the UnitedHealthcare Retiree Plan for participants age 65 and older - you are offered a UnitedHealthcare Medicare Supplement Indemnity option (with NPA drug coverage). The Medicare Supplement Indemnity option pays 80% of reasonable & customary charges after a calendar year $250 deductible has been met, with an annual $1,250 out-of-pocket maximum (including the deductible) protection feature. Hospital semi-private room and board charges as well as ancillary facility charges are paid at 100% after Medicare pays its share. The deductible is waived. The plan has a $1 million dollar lifetime maximum. Please note that since Medicare is your primary coverage at age 65, UnitedHealthcare has no prior notification requirements for any services under the Medicare Supplement Indemnity option.

9 National Prescription Administrators (NPA) Prescription Drug Coverage With NPA prescription drug coverage, there are several ways to receive benefits. Where you fill a prescription determines the benefits you receive. The highest-level benefits are paid when you choose to utilize the NYU Hospitals Center FPO in-house pharmacy. NPA Prescription Drug Benefits At-A-Glance* Benefits Schedule NYUHC FPO In-House Pharmacy (30-day supply) Benefits $5 for formulary drugs For non-formulary drugs: Generic drugs: $5 Brand name drugs: $10 NPA In-Network retail Pharmacy (30-day supply) NPA Mail Service Pharmacy (CFI) (90-day supply for maintenance drugs, such as hypertension medication) (1) Generic drugs: $5 Brand name drugs: $10 Generic drugs: $10 Brand name drugs: $20 (1) Remember, the 90 day supply of maintenance prescriptions can alternatively be filled at the reduced copayment level at the FPO Pharmacy on the NYU campus, or through the mail order program (CFI); a 90 day supply is not available at other in-network pharmacies under the NPA plan. The definition of a maintenance medication is determined by NPA. *The same NPA plan design applies regardless of which of the three UnitedHealthcare medical plan options that you are enrolled in. Tools for Finding NPA Network Pharmacies Call NPA at 800-467-2006 Online at www.e-npa.com Identification Cards If you select retiree medical coverage, UnitedHealthcare will be mailing you an ID card(s). If you need additional ID cards, you can call UnitedHealthcare directly and order them at 866-936-6007. You will recieve a seperate prescription drug ID card from NPA. UnitedHealthcare ID cards for participants under age 65 will have Options PPO on the card. Options PPO is the name of the UnitedHealthcare product signifying their nationwide PPO network. When you turn age 65, if you enroll in the UnitedHealthcare Medicare Supplement Indemnity Plan, you will receive a new card, simply entitled Indemnity Plan. The same NPA ID card that you recieve upon retirement will apply regardless of your age in retirement.

10 Aetna Retiree Group Term Life Insurance At retirement, your group term life insurance coverage amount is reduced according to the schedules listed below. The policy is further reduced with age until you reach the minimum level of coverage. Any amounts of insurance reduced because of retirement or subsequent age reductions may be converted within 31 days to an individual policy with Aetna, at your own expense, without the requirement of a physical examination or insurance company approval. At retirement, the following is the schedule of Retiree Group Term Life Insurance for Management and Specialist Staff who were insured for total basic and supplemental life insurance in the amount of $40,000 as of 2/29/00 or the actual amount in effect prior to retirement if retirement occurred prior to 2/29/00: Reduction on the Anniversary Life Insurance of your Retirement Amount Less than age 65 at retirement $20,000 Age 65 $18,000 Age 66 $16,000 Age 67 $14,000 Age 68 $12,000 Age 69 $10,000 Age 70 $ 8,000 Age 71 $ 6,000 Age 72 or older $ 4,000 At retirement the following life insurance reduction applies for: 1) Technical Staff, Professional Occupational Staff, Office Clerical Staff and Occupational Ancillary Staff insured for a basic life insurance amount of $15,000 or a total basic and supplemental life insurance amount of $23,000, and 2) Management and Specialist Staff insured for a basic life insurance amount of $15,000 as of 2/29/00 or a lower amount if termination occurred earlier than 2/29/00: At retirement, life insurance reduces by 10% of the amount in effect on 2/29/00 or at termination, whichever came first. Retiree life insurance is further reduced by 10% each year thereafter to a minimum of 20% of the original policy amount. Your Cost for Retiree Health & Welfare Coverage MEDICAL AND PRESCRIPTION DRUG PLANS - The actual cost for health coverage is shared between the retiree (or surviving spouse) and NYU Hospitals Center. Participants less than age 65 are charged approximately 40% of the overall cost. Participants who are at least age 65 (or otherwise Medicare eligible) are charged approximately 20% of the overall costs. Your personalized retirement letter from Human Resources will specify your required monthly cost for each applicable health plan option. RETIREE GROUP TERM LIFE INSURANCE NYU Hospitals Center pays 100% of the Life Insurance premium on behalf of the retiree.

11 Some TIPS About Retiring & The NYU Hospitals Center Retiree Health & Welfare Program You should notify your department head in writing at least three months prior to your anticipated retirement date in order to ensure that you obtain the benefits to which you are entitled on a timely basis. Within three months of your last day of active employment, you should contact Human Resources to schedule an appointment to discuss your retirement benefits. If your address will be changing at retirement, you should be sure to notify Human Resources. Future address changes may be reported at any time to Human Resources. If you and/or your spouse have received your Medicare card(s), you should bring these cards to your retirement appointment to ensure that your coverage is appropriately coordinated with Medicare and that you receive all the benefits for which you are eligible. Upon the attainment of age 65, you and/or your eligible dependent spouse if applicable, will automatically be transferred into the UnitedHealthcare Medicare Supplement Indemnity Plan. If you and/or your eligible dependent(s) waive retiree coverage at the time of your retirement or at a future date, this decision will be irrevocable. You will not be allowed to obtain benefits under the NYU Hospitals Center Retiree Health Program at any other time in the future. You and your eligible dependent(s) will be given an opportunity each year, during annual enrollment, to make changes to your benefit option election (unless you had previously waived coverage). Annual enrollment usually occurs in the fall and any changes to your coverage will be effective the following January 1st. Changes in your monthly required cost for the upcoming year will also be communicated during open enrollment and will take effect on January 1 st. A surviving spouse of a deceased retiree can retain health plan coverage under the same rules as described in this booklet, including the applicable cost sharing rules. UnitedHealthcare and NPA provide coverage when claims are incurred when you are traveling outside of the United States. If this occurs, contact UnitedHealthcare or NPA directly. General Information About Medicare Although this booklet will explain below some of the provisions of Medicare you should note that Medicare benefits, both costs and coverage s, change regularly. Therefore, questions specific to Medicare coverage, should be addressed to your nearest Social Security office. The toll-free number for Social Security information, booklets and office locations is 1-800-772-1213. For a retiree, the day you or your spouse attains age 65 is an important date. At that time, Medicare becomes your primary medical coverage. This means that once you or your spouse attains age 65 all your medical claims should be submitted to Medicare first. Only after Medicare has reviewed and processed the claim, should that claim be submitted to UnitedHealthcare for any additional benefits.

12 When to Enroll for Medicare and Who is Eligible Approximately six months before either you or your spouse attain age 65, you should visit your nearest Social Security Office to enroll for Medicare. You should do this even if you will not be retiring and even if you are not enrolling for Social Security pension benefits at this time. There are two parts to Medicare insurance - Part A and Part B. Part A is hospitalization coverage and Part B is outpatient medical coverage (and is optional coverage). If you qualify for a Social Security pension (either based on your own earnings or as the spouse of a qualified worker) and attain age 65, you are eligible for Medicare Part A coverage as of the first of the month in which you attain age 65. There is no cost to you. Part B coverage is available to anyone who attains age 65 regardless of their eligibility for Social Security benefits as long as the required monthly premium is paid. The premium for Part B will be higher for those who do not qualify for a Social Security pension. When you retire before or at age 65 and apply for a Social Security Pension, you are automatically enrolled in Part A and Part B at age 65, unless you specifically request to decline Part B insurance. If you continue employment at NYU Hospitals Center beyond age 65, you may elect to decline Part B coverage at age 65 and then enroll in it at your subsequent retirement. There is no penalty for declining Part B as long as you have been covered under NYU Hospitals Center medical plans as an active employee. If you are planning on waiving either Part A or Part B in retirement, be advised that payments made by the NYU Hospitals Center Retiree Health Plan are reduced by what Medicare would have paid whether you actually enrolled in Medicare or not. There are also higher premiums if you waive the insurance at retirement and then wish to enroll later - you will pay 10% more for each full 12 months that you could have been, but were not, enrolled in Part B. Disability and Medicare Disabled employees and dependents will generally qualify for Medicare after receiving 24 months of Social Security disability payments. In a Disability Retirement instance, the NYU Hospitals Center insurance plan will be the primary insurance coverage under UnitedHealthcare and Medicare will be secondary until the retiree and/or the retiree s dependent qualifies for Medicare. Establishing Primary vs. Secondary Coverage (NYU Hospitals Center Coordination With Non-Medicare Plans) 1) If you or your eligible dependent have coverage under a group health plan in addition to the NYU Hospitals Center Retiree Health Plan, the plan which covers the insured as an active employee or as the dependent of an active employee will pay first. 2) If you or your eligible dependent spouse cover each other as dependents under each others separate retiree plans, then the plan covering the individual as a retiree will be primary to the retiree plan covering the individual as a dependent.

13 Coordination Of Benefits Example With a Non-Medicare Plan The following is an example of how coordination of benefits works when the NYU Hospitals Center Retiree medical plan is secondary. The total of all plan payments may not exceed 100% of the eligible expense under the NYU Hospitals Center Retiree Health Plan. THE CLAIM Other PRIMARY PLAN UNITEDHEALTHCARE PLAN $1,000 Surgery Bill Eligible Expense: $1,000 Eligible Expense: $1,000 After a $200 deductible After a $400 deductible is met then the Plan pays is met then the Plan pays 80% of the eligible expense 70% of the eligible expense The Primary Plan Calculation The UnitedHealthcare Basic Plan Calculation Total Eligible Expense $1,000 $1,000 Less Deductible - 200-400 Balance 800 600 The Plan Pays $ 640 (which is 80%) $ 420 (which is 70%) The primary plan benefit is $640 and the UnitedHealthcare out-of-network Basic PPO benefit is $420. The total of allowed payments from both plans is $1,060. Because you cannot receive more than 100% of the eligible expense, in this example UnitedHealthcare would pay the difference of $360. Therefore, as illustrated below, the payments from the primary plan ($640) and UnitedHealthcare ($360) equals 100% ($1,000) of the eligible expense. Total Allowable Expense: $1,000 Primary Plan Benefit: 640 Outstanding Balance: 360 UnitedHealthcare pays: $ 360 Coordination of Benefits Example - With Medicare In your retirement at age 65 or older, Medicare insurance will be your primary insurance coverage. If you elect to participate in the UnitedHealthcare Medicare Supplement Indemnity plan option, all claims must be submitted to Medicare first and then to UnitedHealthcare. (If you or your spouse, however, are covered as a dependent under an active employee plan, then that coverage will be primary to Medicare.) The secondary plan (UnitedHealthcare) will pay its normal benefits, minus what Medicare pays. The following is an example of how coordination of benefits with Medicare works when UnitedHealthcare is the secondary payer. In this example the combined benefits of Medicare and UnitedHealthcare pay $3,800 toward a $5,000 bill. THE CLAIM PRIMARY PLAN (MEDICARE) UNITEDHEALTHCARE $5,000 Outpatient Bill Eligible Expense: $4,000* Eligible Expense: $5,000 After a $100 deductible After a $250 deductible is met then the Plan pays is met then the Plan pays 80% of the eligible expense 80% of the eligible expense Medicare Calculation UnitedHealthcare Medicare Supplement Indemnity Calculation Total Eligible Expense $4,000 $5,000 Less Deductible - 100-250 Balance 3,900 4,750 The Plan Pays 80%: $3,120 $3,800** Remaining Balance: $1,880 *Medicare determines the eligible expense which frequently is less than the actual charge. **UnitedHealthcare will pay $680 (Its normal benefits $3,800, minus what Medicare paid $3,120).

14 Assignment of Medicare Benefits If a physician or provider is considered a participating provider by Medicare, this means that he or she will accept assignment of Medicare benefits. Accepting a Medicare assignment means that the doctor agrees to wait for Medicare s ruling on what charge is approved for a particular procedure. The doctor can then only charge the approved amount. This means that the physician cannot bill you, Medicare or any other insurance company for more than the approved amount if assignment is taken. In the above claim example, if the physician would have accepted assignment, the physician charge would have been $4,000 instead of $5,000. If assignment is not accepted by the physician, you will be responsible for both 20% of the approved outpatient amount that Medicare did not pay and the difference between what the doctor charged and the Medicare approved amount, as well as any deductibles you have not paid.

15 Getting Started What You Will Find at the Back of This Booklet UnitedHealthcare detailed plan summaries for the Under Age 65 (Pre-Medicare) Basic PPO Plan and Plus PPO Plan. UnitedHealthcare detailed plan summary for the Over Age 65 (Medicare Eligible) Medicare Supplement Indemnity Plan A sample UnitedHealthcare claim form An NPA mail order prescription drug claim envelope - to assist you in utilizing the mail order plan. Please note that participants can save money by utilizing the mail order feature. A dental/vision plan COBRA application. A life insurance beneficiary designation form. A Group Term Life Insurance & Dependent Life Insurance conversion form - if you are interested in converting to a personal policy with Aetna (at your own expense) any lost amounts of active employee Life Insurance coverage. No evidence of insurability is required. A Long Term Disability conversion form A postage paid return envelope that you may use to return your retiree health plan election and life insurance beneficiary designation form.

16 Notes

12/01 About This Guide This guide explains some of the key features of your NYU Hospitals Center retiree and eligible dependent(s) Health and Welfare benefits plans. Complete details of each of the plans are contained in the official plan documents. If there is ever a conflict between this guide and the official plan documents, the plan documents prevail. NYU Hospitals Center reserves the right to change or end the plans at any time, including plan design features and cost-sharing requirements.