Page 1 CHS LiveWELL Health Plan OVERVIEW OF 2015 TEAMMATE BENEFITS PACKAGE CHOICE 30 with HEALTH SAVINGS ACCOUNT Eligibility: 24 or more standard hours per week The Choice 30 health plan offers you control to take responsibility for your healthcare costs. As a consumerdirected (high-deductible) plan, it allows you to explore your options of care select what is best for you while at the same time investing in your personal health savings account (HSA). MedCost Benefit Services administers the Choice 30 medical plan. CHOICE 30 Annual (Calendar Year) Deductible and Out-of-Pocket Maximums Choice 30 Plan Feature CHS Provider Network Provider Out of Network Deductible (Individual) $1,850 $2,600 $4,000 Deductible (Family) $3,700 $5,200 $8,000 Out-of-Pocket Maximum (Individual) $5,600 $6,450 $11,000 Out-of-Pocket Maximum (Family) $11,200 $12,900 $22,000 Additional Plan Features CHS Network Network Provider Preventive Care Services, including office visit Covered 100% in-network PCP Copay (non-preventive care) 75% after deductible 70% after deductible Specialist Copay (non-preventive care) 75% after deductible 70% after deductible On-Site Care Copay $10 copay after deductible Inpatient Facility (after deductible) 70% 60% Inpatient Physician 75% after deductible 70% after deductible Urgent Care Copay Emergency Room Copay Lifetime Benefit Maximum Pre-Existing Condition Limitations 75% after deductible 75% after deductible UNLIMITED NONE Deductibles, copays and coinsurance (including any related to pharmacy expenses) all apply to the annual out-of-pocket maximum. More detailed information about Choice 30, including out-of-network benefits, is available in the CHS LiveWELL Health Plan Summary of Benefits and Coverage (SBC) or the Medical Plan Summary (SPD).
Page 2 Carolinas HealthCare System provides many services and care options to assist healthcare consumers make informed decisions for the care they receive and the cost associated with care. Nurse Advice Line Easy, convenient phone call to a registered nurse 24 hours a day/7 days a week to answer questions and help determine appropriate level of care needed, including providing assistance with appointments for follow-up care at no cost to teammates CHS Back Pain Clinic and Teammate Injury Helpline Provides an assessment for any new or pre-existing back pain (including but not limited to a work-related injury) to determine back care needs to access care more quickly and includes a financial incentive to participate for those teammates on the CHS LiveWELL Health Plan, their covered spouses and dependents 18 years of age and older CHS Virtual Visit CHS Virtual Visit gives teammates, spouses and their dependents (under age 13 and over age 17) located in North Carolina live access to a Carolinas HealthCare System medical provider 24 hours a day, 7 days a week via mobile device, tablet, smart phone or computer. Cost for Choice 30 participants is $49 until deductible is met, then $10. Teammates not participating in the health plan pay $25 CHS On-Site Care CHS LiveWELL Health Plan participants have access to care at many locations. The cost is based on a market value rate depending on the level of service until the annual deductible is met; your Health Savings Account may be used to pay for services. After the deductible is met the cost is a copay of $10. Teammates not participating in the health plan pay $25 Employee Assistance Program (EAP) Provides free, confidential short-term counseling services for teammates and their immediate family Choice 30 CHOICE 30 PREMIUMS Teammate Monthly Cost for Medical Coverage Full-Time Teammate Applies to teammates with standard hours of 30 or more per week (60 or more per pay period) Non-Smoker/ Non-Tobacco User Smoker/Tobacco User 1 Part-Time Teammate Applies to teammates with standard hours of 24-29 per week (48-59 per pay period) Non-Smoker/ Non-Tobacco User Teammate Only $41.49 $47.71 $58.61 $67.38 Family Plans: Teammate + Spouse $351.33 $404.02 $428.10 $492.32 Teammate + Working Spouse 2 $422.83 $475.52 $499.60 $563.82 Teammate + Child(ren) $288.09 $331.31 $351.03 $403.68 Teammate, Spouse and Child(ren) $486.60 $559.59 $592.91 $681.85 Teammate, Working Spouse 2 and Child(ren) $558.10 $631.09 $664.41 $753.35 1Carolinas HealthCare System is committed to your health and well-being. There is a smoker/tobacco user medical plan premium surcharge to encourage you to make healthy decisions regarding tobacco use and to support our tobacco-free environments. 2If your covered spouse is eligible for medical coverage through his/her employer (not applicable if your spouse also works for Carolinas HealthCare System) and you choose to cover him/her in the LiveWELL Health Plan, you must choose one of these coverage levels. +Teammates can earn a special LiveWELL Health Plan premium incentive up to $750 by completing certain wellness activities throughout the year. During 2015, teammates can earn up to $750 and upon completion of the program, amounts will be deposited to the HSA if Choice 30 is elected (some deposits will not occur until 2016). If it is determined that you are not paying the appropriate medical plan rate, you will be required to retroactively pay the smoker/tobacco user premium surcharge or the working spouse rate. Further disciplinary action may be taken. Smoker/Tobacco User 1
Prescription Medications (Pharmacy Network through Catamaran; Prescription Mail Service administered by CarolinaCARE) Page 3 Prescription medication drug coverage is included when you enroll in medical coverage. Deductibles, copays and coinsurance (including any related to prescription medication expenses) all apply to the annual out-of-pocket maximum. Choice 30 Prescription Medication Coverage Prescription Drugs Retail CMC Rx Pharmacies Other Area Pharmacies Affordable Care Act (ACA) Preventive $0 copay $0 copay Drugs 1 Preventive Generic 1 $4 copay $15 copay Other Generic 1 deductible then $10 copay deductible then $15 copay Preferred Brand 1 deductible then 25% coinsurance; not less than $35 or more than $45 deductible then 30% coinsurance; not less than $35 or more than $100 Non-preferred Brand 1 deductible then 40% coinsurance; not less than $50 or more than $150 deductible then 50% coinsurance; not less than $60 or more than $250 Specialty Drugs 2 deductible then 20% coinsurance; not more N/A (self-injectable, administered at home) than $125 CarolinaCARE CarolinaCARE Prescription Drugs Mail Service (30-day supply) (90-day supply) ACA Preventive Drugs $0 copay $0 copay Preventive Generic $4 copay $12 copay Other Generic deductible then $10 copay deductible then $25 copay Preferred Brand deductible then $35 copay deductible then $85 copay Non-preferred Brand deductible then 40% coinsurance; not less than $50 or more than $150 deductible then 40% coinsurance; not less than $125 or more than $375 Specialty Drugs deductible then 20% coinsurance; not more (self-injectable, administered at home) than $125 N/A 1Maximum of three fills allowed at retail for maintenance medications. Plan requires transition to Mail Service or member will pay full cost, which will not apply to deductible or annual out-of-pocket expense 2Maximum of three fills for specialty drugs allowed at a CMC Rx pharmacy then Mail Service is required. Some exceptions may apply to limited distribution drugs.
Page 4 Health Savings Account (HSA) An HSA is like a personal savings account for your healthcare expenses and it is all tax-free. You own the account and decide how much to contribute up to the annual IRS limits. To help your savings grow even faster, Carolinas HealthCare System makes an annual contribution and matches your contribution (based on your level of coverage and specific dollar maximums determined each year). To be eligible to participate in an HSA, you must be enrolled in a high-deductible consumer-directed health plan, such as Choice 30, not covered by other health insurance, Medicare or TRICARE and you cannot be claimed on someone else s tax return. Contributions Made by Carolinas HealthCare System to HSA Annual Contribution Matching Contributions Teammate Only $100* Up to $250, based on teammate contribution All Other Family $350 Up to $750, based on teammate contribution Coverage Levels LiveWELL Incentive During 2015, teammates can earn up to $750 and amounts will be deposited to HSA upon completion of program (some deposits will not occur until 2016) *Teammates with 30 or more standard hours with annual base earnings less than $30,000 receive an additional $100 annual contribution to their HSA SPENDING ACCOUNTS (administered by Stanley, Hunt, Dupree, & Rhine (SHDR), a division of BB&T) Type of Account Health Savings Account (HSA) 2015 Annual Allowable Contribution $3,350 (Teammate only medical coverage) $6,650 (all other family coverage tiers) Can be used to reimburse: Annual deductibles, copays, coinsurance and other costs not covered by healthcare plan Eligibility Enrolled in Choice 30 Annual contributions allowable are a combination of those made by Carolinas HealthCare System and Teammate (any balance at year end rolls over) Limited Purpose FSA (LFSA) $2,500 Type of Account Health Care Flexible Spending Account (HCFSA) 2015 Annual Allowable Contribution $2,500 Dependent Daycare Flexible Spending Account (DCFSA) $5,000 Eligible vision and dental expenses Can be used to reimburse: Annual deductibles, copays, coinsurance and other costs not covered by healthcare plan - any account balance after December 31, 2015 will be forfeited Daycare, day camp, elder care or other expenses related to the care of dependent children or parents who are unable to physically or mentally care for themselves Enrolled in Choice 30 or another high-deductible health plan Eligibility 16 or more standard hours and not covered by a high-deductible health plan 16 or more standard hours
Page 5 DENTAL (administered by Delta Dental) Eligibility: 24 or more standard hours per week Dental Plan Features Benefits Calendar Year Maximum $1,200 1,2 per person Calendar Year Deductible Individual $50 per person Aggregate Family Max $150 per family Preventive & Diagnostic Care 100%, no deductible, does not apply to coverage maximum Basic Restorative Care 80% after deductible Major Restorative Care and Orthodontia 50% after deductible (Orthodontia lifetime maximum - $1,500 per person) 1Once calendar year maximum is met additional dental services are paid out-of-pocket for the remainder of the plan year (except preventive). 2Receive preventive care in 2015 and earn an additional $100 toward your annual benefit maximum in 2016. This reward will continue each year that you receive preventive dental care, until your maximum annual benefit reaches $2,000. This applies to each covered member. Teammate Bi-Weekly Cost for Dental Coverage Coverage Level Full-Time Teammate Part-Time Teammate (30 or more standard hours per week) (24-29 standard hours per week) Teammate Only $19.54 $24.83 Family Plans: Teammate + Spouse $51.59 $65.52 Teammate + Child(ren) $64.07 $81.38 Teammate, Spouse, and Child(ren) $90.85 $115.38 VISION (administered by Community Eye Care) Eligibility: 16 or more standard hours per week Vision Plan Features: Annual eye exam Up to $200 allowance for eyewear (frames, lenses, and contact lenses) 20% discount on glasses (frames and/or lenses) and 10% discount on contact lenses for any amount over the $200 allowance $0 copay for contact lens fittings (new patients or changes in lens type; does not apply to annual contact lens evaluation) Teammate Bi-Weekly Cost for Vision Coverage Coverage Level Full-Time Teammate Part-Time Teammate (30 or more standard hours per week) (24-29 standard hours per week) Teammate Only $12.46 $12.46 Teammate + One Dependent $23.77 $23.77 Teammate + Family $35.60 $35.60
Page 6 RETIREMENT SAVINGS PROGRAM 401(k) Retirement Savings Plan Eligibility: 16 or more standard hours per week Teammates over age 18 who have completed 3 months of employment are eligible for this tax deferred savings plan. Teammates who meet these requirements will be automatically enrolled to contribute 3% of their salary. Participants may contribute up to the IRS maximum per calendar year ($18,000 for 2015). If age 50 and up, may contribute up to $24,000 for 2015 through additional catch-up contributions. Contributions are subject to IRS annual compensation limits. Contributions made by teammates may be pre-tax or Roth after-tax. The contribution percentage may be changed at any time. Participants have a variety of investment fund options available. Contribution Type Matching Matching Contributions made by Carolinas HealthCare System Amount of Contribution Carolinas HealthCare System will match: $.75 match on every dollar contributed on first 4% of salary $.50 match on every dollar contributed on the next 2% of salary Explanation Provided by Carolinas HealthCare System as a match and based on the your level of participation the in the plan (vested immediately) Eligibility for Basic and Discretionary Contributions Teammates must complete 12 months of service to meet eligibility for basic and discretionary contribution. The teammate becomes a participant in these features of the plan on the last day of the year in which eligibility is satisfied. Teammates must complete 1,000 hours of service and any eligible contributions would be paid the following year. Basic 2% of salary Contributed annually by Carolinas HealthCare System to all eligible teammates whether or not contributing to the plan (vested after 3 years of service) Discretionary 1% for fewer than 10 years of service 1.5% for 10-19 years of service 2% for 20+ years of service Based on System performance expect this to be contributed annually if performance met (vested immediately) ADVANTAGE Retirement Account Plan Eligibility: 4 or more standard hours per week This is a 457(b) tax deferred plan. There is no matching contribution. Eligible full-time, part-time and PRN teammates may contribute up to the IRS maximum per calendar year ($18,000 for 2015). If age 50 and up, may contribute up to $24,000 for 2015 through additional catch-up contributions. These contributions are in addition to the contribution limit for the 401(k) plan. Participants have a variety of investment fund options available. ADDITIONAL BENEFIT OPTIONS Dependent Back-up Care When the unexpected happens, or when your regular care giver is unavailable, the Carolinas HealthCare System Dependent Back-Up Care program helps teammates balance the important demands of work and life. This unique program is offered in partnership with Bright Horizons, a nationally recognized provider of choice for dependent care Voluntary Benefits Includes home and auto insurance; life insurance plans (whole life, supplemental term, and spouse/dependent life); Accidental Death & Dismemberment coverage; legal services plan; identity theft protection; accident insurance; critical illness; long-term care; and short term disability for part-time teammates Teammate extras program Merchant discounts within the community such as living/housing, childcare, automotive, restaurants, banks and retail Charlotte Metro Credit Union Offers checking and savings accounts through payroll deduction; consumer loans at competitive interest rates; discount tickets to movie theaters and other special events; free notary service; and financial planning Free parking at the teammate work location
Page 7 Documentation Must Be Provided to Verify Dependents You Plan to Enroll in Benefits In order to manage healthcare costs and ensure only eligible dependents are enrolled in our plans, all teammates are required to provide proof of eligibility for their enrolled dependents. Once enrolled, a separate request will be mailed to your home address from The Dependent Verification Center. If dependents have not been verified for eligibility within 60 days of enrollment they will be removed from Carolinas HealthCare System benefit plans. COBRA continuation benefits will not be offered to ineligible plan participants. Types of documents required are listed below. All documents will be handled confidentially and maintained securely. Spouse to whom you are married Two forms of documentation are required to verify spouse dependent eligibility proof of marriage and proof spouse resides with you State issued marriage certificate and current year or prior year Federal tax return (see sample in enrollment materials), or State issued marriage certificate and document showing proof of joint ownership (examples: mortgage statement, rental lease agreement, bank statement or credit card statement) Dependent Child documentation is required for each child you enroll Child(ren) under the age of 26 (includes non-citizens) who is your: Biological child, adopted child, step child, foster child or legal ward. Documentation is required to verify child dependent eligibility: Documentation required to show proof that child is your dependent, or that you are required to provide health care coverage may include: Birth certificate showing child and parent name(s) Adoption certificate Court document showing paternity Qualified medical child support order or other legal document requiring teammate or covered spouse to provide health care for child Documentation of legal guardianship or foster care letter of placement Additional documentation is required for a totally disabled child age 26 or older who is unmarried, relies on teammate for total support, and is incapable of sustaining employment by reason of mental or physical disability. Proof of Disability (form available from Benefits Administration 704-631-0263) This is a summary of the benefits for 2015. In the event of a discrepancy, the plan document will control. Carolinas HealthCare System reserves the right to expand, reduce or change programs and benefits at any time.