Dell Inc. Comprehensive Welfare Benefits Plan Summary Plan Description For U.S. Team Members (National Plans) January 1, 2012
Well at Dell Well at Dell, our health and wellness program, is designed to help you achieve your goals in life and at work to be your best you. The program covers a wide range of services and resources, whether you are in need of professional guidance, tools for saving money or access to experts to maintain, manage or improve your health. We encourage you to learn about Well at Dell offerings and to take advantage of all the benefits available to you. About this Book This Summary Plan Description (SPD) is provided to describe the many benefit programs available at Dell and how certain life events may affect your participation in these programs. The Dell Inc. Comprehensive Welfare Benefits Plan (the Plan) includes the following benefit programs: Medical; Employee Assistance Program; Well at Dell Health Improvement Program; Dental; Vision; Health Care Flexible Spending Account; Dependent (Day Care) Flexible Spending Account; Short-Term Disability; Long-Term Disability; Basic Life and Accidental Death and Dismemberment (AD&D) Insurance; Supplemental Life Insurance; Business Travel Accident Insurance; and Well at Dell Health Center. In addition to the above benefits, this SPD includes information on additional work/life benefits provided by Dell. These benefits are included in the Work/Life Benefits section. Benefits described in that section are not subject to ERISA, the law governing employee benefits, and therefore are not subject to all of the provisions described. This book also includes a Life Events (Qualified Status Change) section that describes what to do when you experience various life events, such as marriage, divorce or birth of a child. While it is the intent of Dell to continue the Plan indefinitely, Dell reserves the right to terminate or modify the Plan and any benefits hereunder even if the benefits are negotiated, including team member and dependent eligibility for the Plan at any time. This SPD is not a contract for employment. Note: Dell offers a variety of benefits, through various providers. The benefits for which you are eligible and the organizations that provide those benefits vary depending on your classification (for example, U.S. Expatriate or OSS team member) and where you live (for example, Hawaii, Rhode Island, etc.). This booklet describes the benefits available to you; separate booklets have been created to describe benefits available from other providers or in other areas. 2 Dell Inc. Comprehensive Welfare Benefits Plan Summary Plan Description
Enrolling, Making Changes and Getting Information If you have questions or need information about any of the programs in the Dell Inc. Comprehensive Welfare Benefits Plan, the following resources are available to you. The Your Benefits Resources TM (YBR) Web Site The Your Benefits Resources (YBR) Web site is available to you via the Dell Intranet and externally through the internet. Through the Dell Intranet site from Inside Dell, go to You and Dell > Benefits > Enroll/Make Changes. Through the internet, visit www.resources.hewitt.com/dell. You will need your benefits user ID and password to access the site externally. The Your Benefits Resources (YBR) Web site provides you with the tools you need to: Enroll in coverage; Make changes to your coverage due to a qualified status change; Locate participating providers; Access an up-to-date copy of this SPD and other important Plan Documents; Find answers to questions; and Sign up to receive personal action reminders. Toll-Free Dell Benefits Center Number The Dell Benefits Center toll-free number 1-888-335-5663 (option 1) is another way for you to get general benefits information and make changes. It is important to note that you must have your benefits user ID and password to access your personal account information. You can change your password from Inside Dell through direct access to the website on You and Dell > Benefits > Enroll/Make Changes. A password and user name are not required if you are logged onto the Dell network and you access through the Intranet. Once logged in, you can view and/or make changes to your benefits user id and password by going to the Your Profile tab and choosing Log On Information, where you may also set security questions to quickly access your account on the phone, even if you do not remember your password. When you call 1-888-335-5663 (option 1), you may: Make changes to your coverage due to an eligible qualified status change; or Talk with a Benefits Representative. 3 Dell Inc. Comprehensive Welfare Benefits Plan Summary Plan Description
Additional Contact Information Benefit Program Contact Contact Information Adoption Assistance Program Dell Intranet http://intranet.dell.com/dept/hr/ Local/US/Benefits/takingtimeforyo urself/programs/pages/adoptionad option%20assistance%20assistance. aspx Advocacy Dell Benefits Center 1-888-335-5663 Bicycle Reimbursement Program WageWorks 1-877-924-3967 www.wageworks.com Business Travel Accident Program ACE USA U.S.: 1-800-262-8028 Outside U.S.: 1-302-476-6194 COBRA Administrator Dell Benefits Center 1-888-335-5663 Commuter Benefits Program WageWorks 1-877-924-3967 www.wageworks.com Dell Benefits Center Dell Benefits Center US: 1-888-335-5663 Outside U.S.: 001-847-883-0936 www.resources.hewitt.com/dell Dell Benefits Communications Website (for online benefits information) www.wellatdellbenefits.com Dental Programs MetLife 1-800-942-0854 www.metlife.com/mybenefits Employee Assistance Program (EAP) ValueOptions 1-877-888-6440 Health Rewards Account WageWorks 1-877-924-3967 www.wageworks.com Leave of Absence Dell Benefits Center 1-888-335-5663, Option 5 Life Insurance Programs: Basic Life and AD&D Insurance Programs Dell Benefits Center 1-888-335-5663 Supplemental Life Insurance Program Dell Benefits Center 1-888-335-5663 Evidence of Insurability/ Statement of Health Submission Status Status of Life Insurance Claim Submission MetLife SOH Unit 1-800-638-6420, prompt 1 MetLife 1-800-638-6420, prompt 2 Porting Coverage MetLife 1-888-252-3607 Converting Coverage MetLife 1-877-ASKMET7 (1-877-275-6387), option 1 4 Dell Inc. Comprehensive Welfare Benefits Plan Summary Plan Description
Benefit Program Contact Contact Information Medical Programs: BlueCross BlueShield of Texas PPOs and Indemnity BCBS TX 1-888-514-5643 www.bcbstx.com/dell UnitedHealthcare PPOs UnitedHealthcare (UHC) 1-866-480-4989 www.myuhc.com/groups/dell or www.welcometouhc.com/dell (for new team members) Medicare Centers for Medicare and Medicaid Services (CMS) 1-800-MEDICARE (633-4227) CMS: www.cms.gov Medicare: www.medicare.gov Mental Health and Substance Abuse ValueOptions 1-877-888-6440 www.achievesolutions.net/dell Prescription Drug Program Express Scripts, Inc. (ESI) 1-866-272-6695 www.express-scripts.com Flexible Spending Account Programs: Dependent Care (Day Care) FSA WageWorks 1-877-924-3967 www.wageworks.com Health Care Flexible Spending Account WageWorks 1-877-924-3967 www.wageworks.com Short-Term and Long-Term Disability Programs Aetna Disability Benefits 1-800-354-1779 Vision Program Vision Service Plan (VSP) 1-800-877-7195 www.vsp.com Well at Dell Health Center (for Team Members in Austin and Plano) Well at Dell Health Decision Support Resource and Nurse Line Well at Dell Health Center Round Rock: 1-512-728-9355 Plano: 1-972-295-5200 Parmer South: 1-512-728-9355 Well at Dell 1-866-935-5335 5 Dell Inc. Comprehensive Welfare Benefits Plan Summary Plan Description
Table of Contents Plan Participation... 10 Eligibility... 10 Enrollment... 13 Cost of Benefit Coverage... 16 Taxation of Domestic Partner Benefits... 17 Changing Your Election... 17 When Coverage Ends... 20 COBRA Continuation Coverage... 22 Medical Program... 29 Medical Program Option Summaries... 29 Coverage Tiers... 29 PPO Programs... 30 Indemnity Plan... 36 PPO and Indemnity Pre-Certification... 38 PPO Benefit Summary... 39 Indemnity Benefit Summary... 54 PPO and Indemnity Covered Expenses... 58 PPO and Indemnity Exclusions and Limitations... 72 Medical Programs Compliance... 79 Mental Health and Substance Abuse Program... 83 Mental Health and Substance Abuse Benefit Summary... 83 Mental Health and Substance Abuse Covered Services... 84 Mental Health and Substance Abuse Pre-Certification and Notification... 84 Contacting ValueOptions... 85 Mental Health and Substance Abuse Claims and Appeals... 85 Employee Assistance Program... 86 EAP Benefits... 86 Receiving EAP Benefits... 86 Well at Dell Health Improvement Program... 88 Well at Dell Health Improvement Program Eligibility... 88 Incentives: How the Health Improvement Program Works... 88 Healthy Lifestyle Discount Requirements... 88 Your Health Survey Results... 90 Next Steps: After You Complete Your Health Survey... 90 How the Well at Dell Program Determines Which Programs Need to be Completed... 91 Healthy Lifestyle Discount and Refund Details... 93 Medical Inability to Complete Programs... 93 Additional Well at Dell Self-Care Resources... 93 Opting Out of the Health Improvement Program... 93 E-Personal Health Records... 94 Privacy of Your Health Information... 94 Prescription Drug Program... 95 Pharmacy Benefit Overview... 95 Using a Retail Pharmacy... 95 Using the Home Delivery Pharmacy... 96 Generics Preferred... 97 6 Dell Inc. Comprehensive Welfare Benefits Plan Summary Plan Description
Specialty Drugs... 98 Prescription Drug Program Copays and Coinsurance... 99 Helpful Hints for Filling Prescriptions...100 Prescription Drug Program Covered Expenses...100 Prescription Drug Program Prior Authorization...102 Step Therapy...104 Drug Quantity Management Program...105 Drug Utilization Review...112 State Requirements...112 Prescription Drug Exclusions and Limitations...112 Prescription Drug Claim Determinations...114 Prescription Drug Appeal Process...115 Dental Program...117 How the Dental Program Works...117 Dental Program Benefit Summary...118 Dental Program Covered Expenses...119 Dental Pretreatment Estimates...120 Dental Program Exclusions and Limitations...121 Dental Claims and Appeals...122 Vision Program...123 How the Vision Program Works...123 Vision Program Benefit Summary...124 Vision Program Exclusions...125 Vision Claims...126 Health Care Flexible Spending Account Program...127 Deciding How Much to Contribute...127 Health Care Flexible Spending Account Eligible Expenses...127 Expenses Not Eligible for Health Care Flexible Spending Account Reimbursement...128 WageWorks Health Care Card...129 Health Care Flexible Spending Account Claims...130 Health Rewards Account...133 Dependent Care (Day Care) Flexible Spending Account Program...134 Deciding How Much to Contribute...134 Changing Your Dependent Care Flexible Spending Account Contribution...135 Dependent Care FSA vs. Federal Income Tax Credit...136 Taxation of Dependent Care Expenses...136 Eligible Dependents for Flexible Spending Account...136 Qualified Dependent Care Expenses...137 Expenses Not Eligible for Dependent Care Flexible Spending Account Reimbursement...138 Dependent Care Flexible Spending Account Claims...138 Leaves of Absence...140 Family and Medical Leave...141 Military Leave of Absence...142 Company Discretionary Leave Policy...143 Contributions for Coverage While on Leave...144 Short-Term Disability (STD) Program...145 STD Eligibility and Waiting Period...145 Definition of Disabled for STD Benefits...145 Short-Term Disability Benefits...146 7 Dell Inc. Comprehensive Welfare Benefits Plan Summary Plan Description
When STD Payments End...148 When STD Program Participation Ends...149 Filing an STD Claim...149 Long-Term Disability (LTD) Program...150 Transitioning to LTD Benefits...150 Eligible LTD Program Disabilities...150 Long-Term Disability Benefit...151 When LTD Payments End...152 When LTD Program Participation Ends...154 Basic Life and Accidental Death and Dismemberment (AD&D) Insurance Program for Team Members...155 Basic Life Insurance Coverage for Team Members...155 AD&D Coverage for Team Members...156 Life and AD&D Beneficiary Designation...160 Actively at Work Requirement for Life and AD&D Coverage...160 Assignment of Life and AD&D Coverage...161 Porting or Conversion of Life and AD&D Coverage...161 Age Reductions for Life and AD&D Coverage...161 Supplemental Life Insurance Coverage...162 Team Member Supplemental Life Insurance Coverage...162 Spouse/Domestic Partner Supplemental Life Insurance Coverage...163 Actively at Work Requirement for all Life Insurance Coverage...163 Child Supplemental Life Insurance Coverage...164 Exclusions for Supplemental Life Insurance...164 Evidence of Insurability (Statement of Health) for Supplemental Life Insurance Coverage...164 Cost of Supplemental Life Insurance Coverage...164 Supplemental Life Living Benefit/Accelerated Benefit Option...165 Supplemental Life Insurance Beneficiary Designation...165 Assignment of Supplemental Life Insurance Coverage...165 Portability of Supplemental Life Insurance Coverage...166 Conversion of Supplemental Life Insurance Coverage...166 Age Reductions for Supplemental Life Insurance Coverage...166 Business Travel Accident Program...167 BTA Benefits...167 BTA Benefit Features...168 BTA Exclusions...171 Well at Dell Health Center...172 Well at Dell Health Center Cost...172 How to Access the Health Centers...172 Health Center Available Services...173 When Health Center Coverage Ends...173 Work/Life Benefits...174 Adoption Assistance Program...174 Commuter Benefits Program...175 Emergency Dependent Backup Care Benefit...178 Additional Benefits to Help You Manage Your Life...179 Life Events (Qualified Status Change)...182 Adding an Eligible Dependent...183 Child Loses Plan Eligibility...185 COBRA Coverage from Another Plan Ends...185 8 Dell Inc. Comprehensive Welfare Benefits Plan Summary Plan Description
Death of Dependent...186 Death of Team Member...187 Divorce or Termination of Domestic Partnership...188 Family Member s Coverage Costs Significantly Change...189 Family Member Gets New Coverage...190 Family Member Makes New Annual Enrollment Election...191 Gain Eligibility in Another Plan...192 If You Become Disabled...193 Loss of Eligibility in Another Plan...194 Loss of Government or Educational Institution Plan Coverage...195 Loss of Plan Eligibility or Termination of Employment...195 Loss of Subsidy from Another Employer...196 Medicare or Medicaid Eligibility...197 Move or Worksite Change...198 New Hire or Newly Eligible...198 Repatriating to the U.S...199 Claims and Appeals Procedures...200 Types of Claims...200 Eligibility Claims and Appeals Procedures...200 Health Care Benefit Claims and Appeals...201 Disability Benefit Claims and Appeals...209 Death Benefit Claims and Appeals...211 Assignment of Benefits...213 Action for Recovery...213 About the Overall Claims and Appeals Process...214 Benefits Administration Committee Contact Information...215 Authorized Representatives...215 Release of Information...215 Coordination of Benefits...216 Subrogation and Right of Reimbursement...218 Notice of Privacy Practices for Protected Health Information...220 Plan Administration Information...226 Plan Basics...226 Benefits Administration Committee...227 Your ERISA Rights...228 Glossary...230 9 Dell Inc. Comprehensive Welfare Benefits Plan Summary Plan Description
Plan Participation Eligibility Eligible Team Members You are eligible to participate in the Dell Inc. Comprehensive Welfare Benefits Plan if you are a regular team member scheduled to work at least 25 hours per week. Not Eligible The following groups are not eligible for coverage: Members of a collective bargaining unit that have no agreement for coverage under the Plan; Leased or contracted individuals (a person who is not paid by Dell, but who instead is paid by another employer under a leasing or staffing arrangement); Non-resident aliens with no earned income from Dell that is considered income from sources within the United States; Temporary employees (as classified by Dell); Interns/co-ops (an undergraduate student, masters candidate or MBA candidate who experiences a period of temporary employment with Dell); and Individuals who are designated as classified or treated by Dell as non-common law employees. Dependent Eligibility You may enroll your eligible dependents for coverage in the programs that provide dependent coverage. Dell may require documentation to prove your dependents relationship or eligibility, either when you enroll or at any time while they are on the Dell Plan. Eligible dependents include your: Spouse (same-sex or opposite-sex), if you: - Are legally married under the state in which you receive benefits; or - Have a common law marriage as defined by applicable state law and you both state you are married on your federal tax return(s). Note: Ex-spouses are not considered spouses and are therefore not eligible for coverage under the Plan, regardless of any Qualified Domestic Relations Order (QDRO) directive, except where coverage is required by law. Domestic partner (same- or opposite-sex), if: - You and your domestic partner both indicate that you have lived together in a relationship where you have been responsible for each other s welfare for at least six consecutive months; - You are the sole domestic partner of each other; - You are both at least 18 years of age; and - You are not legally married to anyone else. Children who meet the criteria as eligible children shown below and who: - Are under age 26; or - Are any age if disabled (verification is required) if under the Medical Program at the time of disability. 10 Dell Inc. Comprehensive Welfare Benefits Plan Summary Plan Description
Note: All eligible children under age 26 are eligible for coverage under their Medical Program regardless of the child s status as a dependent for income tax purposes or the child s residency, student, employment or marital status. However, for life insurance, only unmarried eligible dependents may be. In addition, children are not eligible for the Well at Dell Health Improvement Program. Note: Once an individual is under a group health plan, a retroactive termination (that is, a rescission) is prohibited unless the individual performs an act, practice or omission that constitutes fraud or if the individual makes an intentional misrepresentation of material fact, as prohibited by the terms of the Plan. In this case, the Plan must provide at least 30 days advance written notice to each participant who would be affected before coverage may be rescinded. If it is determined (for example, through a dependent eligibility audit) that an individual has enrolled an ineligible dependent or does not timely certify a dependent in Dell's Plan, that would constitute an intentional misrepresentation of a material fact and could result in a retroactive termination of that ineligible dependent s coverage. A retroactive termination is not a rescission to the extent it is attributable to a failure to timely pay required premiums or contributions for the cost of coverage. Eligible Children An eligible child includes your natural born child, your stepchild, your spouse s or domestic partner s child, your foster child or your adopted child, including a child placed with you for adoption or for whom you are appointed legal guardian. If you are divorced or separated, you may still enroll your child if the child is in the legal custody of one or both parents. In addition to the above, your child may be eligible for health care coverage from the Plan under the terms of a Qualified Medical Child Support Order (QMCSO), even if you do not have legal custody of the child or if any other enrollment restrictions might otherwise apply for the child. If the Plan receives a valid QMCSO and you do not enroll the child, the custodial parent or a state agency may enroll the child. Federal law requires that a QMCSO meet certain form and content requirements to be valid. If you have any questions or you would like a copy of the written procedures for determining whether a QMCSO is valid, please contact the Dell Benefits Center at 1-888-335-5663 (option 1). A grandchild is considered an eligible child if: He or she is not already by the Plan; His or her parent is a dependent in the Plan or the dependent parent predeceases your grandchild; and He or she qualifies as your dependent or your spouse s or domestic partner s dependent for federal income tax purposes. Domestic Partner Status You may be required to submit an Affidavit of Domestic Partner Status. In addition, certain Dell providers may require certification information, and it is your responsibility to submit information to these providers if requested. Information you provide regarding your domestic partnership will be disclosed only to Dell Benefits, financial services and human resources department personnel to implement and administer Dell s benefit plans and arrangements or as otherwise required by law. Domestic partner benefits may affect your liability to each other, taxing authorities or third parties. You and your domestic partner should consult with your own tax and legal advisors regarding these and other potential consequences. 11 Dell Inc. Comprehensive Welfare Benefits Plan Summary Plan Description
Note that the value of coverage for your domestic partner and your domestic partner s children, if they are not your children by birth or adoption, is considered taxable income to you and your domestic partner unless they can be claimed as dependents on your federal taxes. See the Cost of Benefit Coverage section for more information. Upon termination of the domestic partner relationship, or if a designated domestic partner no longer meets the criteria to qualify as your domestic partner, you must remove him or her and your domestic partner s children, if they are not otherwise eligible for coverage, from your coverage by reporting the life event (qualified status change). Note: If you legally marry your domestic partner while he or she is under the Dell Plan, you must report the marriage within 31 days. Call the Dell Benefits Center at 1-888-335-5663 (option 1) to change your dependent from domestic partner to spouse. If you report this change after the 31-day window, the domestic partner status will not be changed retroactively, and any imputed income cannot be corrected. Dependent Verification You must provide proof of eligibility for all newly added dependents, including those added during your initial eligibility period. Documentation is required to prove the dependents relationship to you and must be submitted within 45 days of adding the dependent to coverage. Dependents will be initially added to coverage and will remain on coverage through the 45-day substantiation period. If approved documentation is not provided before the deadline, your dependent(s) will be dropped prospectively two weeks from when the Plan Administrator is notified. Specific information on the required documentation and substantiation deadline will be mailed to your home address and sent to your Dell e-mail account when a new dependent is added to your coverage. Please allow 1-2 weeks for this information to arrive. If Your Spouse, Domestic Partner or Child Works at Dell If your spouse, domestic partner or child works for Dell, you cannot have duplicate coverage in the Medical, Dental and Vision Programs. This means that neither you nor they may be enrolled as both a team member and a dependent for medical, dental and vision coverage. Likewise, if both parents work at Dell, their dependent children may only be under the Medical, Dental and Vision Programs of one parent. For example, if both you and your spouse work for Dell, you may be as a dependent under your spouse s medical coverage or you could each have you own medical coverage. You cannot have both. In addition, if you and your spouse have children, only one of you may cover your children under the Medical Program, not both of you. Duplicate coverage is allowed under the Supplemental Life Insurance Program and Health Care and Dependent Care (Day Care) Flexible Spending Accounts. However, IRS regulations limit benefits under these plans. See the Health Care Flexible Spending Account Program and Dependent Care (Day Care) Flexible Spending Account Program sections for information about these limits. 12 Dell Inc. Comprehensive Welfare Benefits Plan Summary Plan Description
COBRA Eligibility The Plan will provide coverage to qualified beneficiaries under COBRA, which allows continuation of medical (including prescription drug), dental, vision; Health Care Flexible Spending Account, Health Rewards Account and Well at Dell Health Center coverage under the Plan if certain events occur that would otherwise cause you to lose coverage under the Plan. See the COBRA Continuation Coverage section. Enrollment Some of the programs in the Plan require that you enroll yourself and/or your eligible dependents to participate. Some programs automatically enroll you if you are eligible for coverage. You must enroll within 31 days of initial eligibility to receive the following benefits: Medical; Dental; Vision; Health Care Flexible Spending Account (you must make a new election each year; your election does not carry over from year to year); Dependent Care (Day Care) Flexible Spending Account (you must make a new election each year; your election does not carry over from year to year); Long-Term Disability; and Supplemental Life Insurance. You are automatically eligible for coverage under the following programs, which means you do not need to enroll: Employee Assistance Program (EAP); Well at Dell Health Improvement Program; Well at Dell Health Center; Short-Term Disability; Basic Life and Accidental Death and Dismemberment (AD&D) Insurance; and Business Travel Accident Insurance. Each year during annual enrollment, you will have the opportunity to enroll for or make changes to your coverage elections, with changes generally becoming effective the following January 1. Additional information will be provided during the annual enrollment period. New Hires and Newly Eligible You must enroll within 31 days of your hire date or the date you become eligible for benefits (for example, when you begin working the required number of hours per week). If you do not enroll within 31 days, you will not be able to participate in the programs requiring enrollment. You will not have another opportunity to enroll until the next annual enrollment, with changes generally becoming effective the following January 1, unless you have a qualified status change or special enrollment event during the year. See the Changing Your Election section for more information. 13 Dell Inc. Comprehensive Welfare Benefits Plan Summary Plan Description
If you are newly eligible for coverage under the Plan but do not enroll within 31 days, you are automatically assigned the following coverages (these defaults do not apply to annual enrollments). As a new hire, your dependents are never automatically assigned any coverages. Default Election Categories Employed Spouse Contribution Medical Program Healthy Lifestyle Discount Dental Program Vision Program Health Care Flexible Spending Account Dependent Care (Day Care) Flexible Spending Account Short-Term Disability Long-Term Disability Basic Employee Life Insurance Accidental Death and Dismemberment Insurance Supplemental Life Insurance Business Travel Accident Insurance Coverage Assigned at Initial Eligibility (Does Not Apply to Annual Enrollment) Contribution does apply if spouse/domestic partner is enrolled No coverage Healthy Lifestyle Discounts are applied on a prorated basis for the remainder of the first calendar year as long as you remain eligible No coverage No coverage No coverage No coverage Coverage No coverage 1 times your benefits eligible earnings 1 times your benefits eligible earnings No coverage 3 times your benefits eligible earnings Once you enroll in coverage or have been assigned coverage, you will not be able to change your benefit elections until the next annual enrollment, unless you or your dependent qualify for special enrollment, are required to enroll a child under a Qualified Medical Child Support Order or experience a qualified status change. See the Changing Your Election section for more information. Social Security Numbers Needed: When you enroll, you will be required to provide Social Security Numbers for yourself and all eligible family members you are enrolling. (For a newborn, you must enroll the dependent within 31 days; if the Social Security Number is not yet available, it may be provided later.) Medicare Secondary Payer rules require group health plan insurers, third-party administrators and plan administrators or fiduciaries to report specific information regarding all members to the Centers for Medicare and Medicaid Services (CMS). The statute and regulations are designed to benefit employer groups by making it easier to pay claims correctly the first time, thus increasing the accuracy of coordination of benefits with Medicare. 14 Dell Inc. Comprehensive Welfare Benefits Plan Summary Plan Description
Rehires If you return to Dell within 30 days and within the same calendar year that you left, you will automatically receive the same coverage you had when your employment ended; this includes your annual FSA election(s); however, contributions will be recalculated based on the remaining pay periods. If you return in a different calendar year or more than 30 days from your termination of employment, you must follow the same enrollment guidelines as a new hire. How to Enroll To enroll in coverage go to Your Benefits Resources (YBR) Web site via the Dell Intranet: You and Dell > Benefits > Enroll/Make Changes. Read the instructions carefully and make your elections. When you have finished choosing your benefits, you must submit your elections and receive confirmation. If you do not submit your elections, none of the benefit elections you have made will be saved by the system. If you have difficulties enrolling on-line, or prefer to enroll by phone, please call the Dell Benefits Center at 1-888-335-5663 (option 1). Once your elections have been submitted, a paper Confirmation of Enrollment will be mailed to your home address. When you receive your paper confirmation, please review it carefully for confirmation and next steps. Contact the Dell Benefits Center immediately if you have questions about your coverage or do not receive a Confirmation of Enrollment. Coverage Begins Your coverage begins on: The date you become eligible if you are a newly eligible team member (new hire eligibility is your hire date); January 1 following annual enrollment for current team members making annual enrollment coverage choices; or The date of a status change if your coverage changes due to a qualified status change. For programs requiring enrollment, you must complete enrollment; your coverage will not begin automatically. While coverage begins as described above, if you elect an amount of life insurance that requires evidence of insurability (Statement of Health), your effective date of coverage will be the date that your evidence of insurability is approved. Pre-Existing Condition Exclusions Do Not Apply: The Dell Inc. Comprehensive Welfare Benefits Plan does not impose any pre-existing condition exclusions for medical, dental and/or vision coverage. A pre-existing condition is an illness or condition you had before you become under a plan. With a pre-existing condition exclusion, limits are imposed on coverage for that condition. 15 Dell Inc. Comprehensive Welfare Benefits Plan Summary Plan Description
Cost of Benefit Coverage The cost of benefit coverage under the Plan is shared by you and Dell as follows: You and Dell share the cost of the Medical, Dental and Vision Programs for you and your family. - Your cost for the Medical Program is based on your team member career level, how you respond to enrollment questions and whether your spouse or domestic partner is employed and eligible for medical benefits through his or her employer and the coverage choices you make (for example, team member only, team member plus spouse, etc.). You can compare your costs for your available medical options on the Your Benefits Resources (YBR) Web site or by calling the Dell Benefits Center at 1-888-335-5663 (option 1). - You pay your share of the cost for the Medical, Dental and Vision Programs on a pre-tax basis. This means that your contribution is taken from your pay before federal and most state taxes are withheld which lowers your taxable income and helps you pay less in taxes. You pay an office visit copayment for the Well at Dell Health Center for non-preventive services. Dell pays any remaining cost of benefits. Preventive care is at 100%.You pay the full amount that you elect to contribute to a Health Care and/or Dependent Care (Day Care) Flexible Spending Accounts on a pre-tax basis. Pre-tax means that your contribution is taken from your pay before federal and most state taxes are withheld, which lowers your taxable income and helps you pay less in taxes. You and Dell share the cost of the Long-Term Disability Program. You pay your share of the cost for Long- Term Disability coverage on an after-tax basis. Therefore, if you become disabled and receive Plan benefits, the Plan benefits you receive will not be taxed. Dell pays the full cost of the Well at Dell Health Improvement Program, Employee Assistance Program, Short-Term Disability, Basic Life and AD&D Insurance and Business Travel Accident Insurance. You pay the full cost of any Supplemental Life Insurance. You pay your share of the cost for this coverage on an after-tax basis. The Medical Program and the Employed Spouse Contribution In addition to your contribution for any medical coverage for your spouse or domestic partner, if your spouse or domestic partner is employed and eligible for medical benefits through his or her employer and you choose to cover your spouse or domestic partner under the Dell Plan, you will be required to pay an additional fee (surcharge) for this medical coverage. The amount of the additional fee depends on your team member career level and will be provided with your enrollment materials. If both you and your spouse or domestic partner work for Dell, you will not pay the additional fee. You must provide information about your spouse s or your domestic partner s eligibility for medical coverage under another employer plan when you first enroll and during each annual enrollment period. Any surcharge required will be implemented as soon as administratively possible. If you do not fully report information regarding your employed spouse s or domestic partner s eligibility for coverage under another employer plan, this may lead to disciplinary action, up to and including termination of employment. If your spouse s or domestic partner s medical eligibility through his or her employer changes at any time, you must report it through the Dell Benefits Center at 1-888-335-5663 (option 1), within 31 days of the qualified status change. Any change will be implemented as soon as administratively possible. Employed spouse contributions will not be refunded retroactively. 16 Dell Inc. Comprehensive Welfare Benefits Plan Summary Plan Description
Well at Dell Health Improvement Program To help you and your family achieve and maintain a healthy lifestyle, Dell has established the Well at Dell Health Improvement Program. The Well at Dell Health Improvement Program is designed to help you learn about your health status and to identify opportunities to maintain, improve and/or manage your health. The Program also rewards you by allowing you to earn Healthy Lifestyle Discounts, which are Dell medical premium credits, by completing the WebMD Health Survey and achieving all of the 2012 health goals or completing a health improvement program demonstrating improvement (as validated by your program coach). Participation in the Well at Dell Health Improvement Program is encouraged, but is completely voluntary. For more information on this Program, see the Well at Dell Health Improvement Program section. Taxation of Domestic Partner Benefits You must pay your share of the cost of coverage on an after-tax basis for any individual not recognized as a dependent by the Internal Revenue Service (IRS). In addition, the value of any contribution provided by Dell for these individuals will be considered imputed income for federal income tax purposes and must be reported on your W-2 Form. The amount of imputed income is based on the value of the coverage provided. In general, your domestic partner and the children of your domestic partner are not recognized by the Internal Revenue Service as dependents. Certain exceptions apply. Based on existing IRS guidance, it is difficult to prove that your domestic partner or the child of your domestic partner qualifies as your dependent for tax purposes. You should consult with your tax and legal advisors regarding whether your domestic partner or a child of your domestic partner would qualify as your dependent for tax purposes. Changing Your Election Generally once enrolled, your coverage stays in effect for the rest of the plan year (January 1 through December 31). However, you can make changes to your coverage during the plan year if you: Have a qualified status change and report the change within 31 calendar days of the qualified status change event; Experience a special enrollment event and report the change within 31 calendar days of the special enrollment event; or Are subject to a Qualified Medical Child Support Order (QMCSO). Changes may be made to your Medical, Dental, Vision, Health Care Flexible Spending Account, Dependent Care (Day Care) Flexible Spending Account, Long-Term Disability or Supplemental Life Insurance Programs. However, any change in benefits must be consistent with your status change, special enrollment event or QMCSO. Any change will be implemented as soon as administratively possible. 17 Dell Inc. Comprehensive Welfare Benefits Plan Summary Plan Description
If, as the result of a qualified status change, you want to change your Supplemental Life Insurance for: Yourself, you may enroll for coverage up to two times your benefits eligible earnings, not to exceed $500,000 (total coverage), without evidence of insurability (Statement of Health). This coverage amount will go into effect on the date of the qualified status change. If you enroll for more than two times your benefits eligible earnings or exceed $500,000, you will have to provide evidence of insurability. Your coverage will then go into effect on the date your evidence of insurability is approved. If a claim is filed due to death by suicide, no claim will be paid if the death occurs within 24 months of the effective date of the new coverage amount. Your spouse or domestic partner, you may elect up to the lesser of ½ your benefits eligible earnings or $30,000 without submitting a Statement of Health or other evidence of insurability if your spouse/domestic partner was not previously declined for life insurance at Dell. If your spouse/domestic partner was previously declined for insurance, you must submit a Statement of Health form regardless of the level of coverage for which you are applying. If you apply for spouse/domestic partner coverage when your spouse/domestic partner was previously declined coverage at Dell and do not complete a Statement of Health, an application for coverage may be denied and premium payments will be reimbursed. Coverage will go into effect on the date of the qualified status change if evidence of insurability is not required. If evidence of insurability is required, coverage will go into effect on the date MetLife approves your spouse/domestic partner s evidence of insurability. If you are not sure if you have been approved for Supplemental Life Insurance coverage for your spouse or domestic partner, or if you have other questions regarding the status of a submitted Statement of Health, contact MetLife s Statement of Health Unit at 1-800-638-6420, prompt 1. For enrollment or other questions related to Supplemental Life Insurance, contact the Dell Benefits Center at 1-888-335-5663 (option 1). Qualified Status Changes Note: For more information on specific qualified status changes and how they may impact your benefits, refer to the Life Events (Qualified Status Change) section. Qualified status changes include: Change in the number of dependents, for example birth, adoption or placement for adoption of a dependent child; Marriage, establishment of domestic partnership, divorce, legal separation, annulment of a marriage and termination of a domestic partnership; Death of an eligible spouse, domestic partner or dependent child; Loss of your dependent s eligibility (for example, a dependent child who no longer meets the Plan s age limitations); Changes in your, your spouse s, domestic partner s or child s employment status that affect the individual s coverage under the Plan; Changes in place of residence that could affect the availability of coverage in the service area; Changes in your or your eligible dependent s coverage (including coverage changes under Medicare, Children s Health Insurance Program (CHIP) or another employer plan). This would include changes due to an annual enrollment change, significant change in cost or coverage or significant change in level of benefits; You or your eligible dependent become entitled to coverage under Medicare or Medicaid, other than coverage consisting solely of benefits under section 1928 of the Social Security Act; A significant increase in the cost of health care coverage; and Any event that the Benefits Administration Committee determines will permit a change under section 125 of the Internal Revenue Code. 18 Dell Inc. Comprehensive Welfare Benefits Plan Summary Plan Description
Any benefit change made due to a qualified status change must be reported and elections made within 31 calendar days of the status change. Any change will be implemented as soon as administratively possible. If you do not report the status change and make your elections within 31 calendar days, you will not be allowed to make changes to your coverage until the following annual enrollment period, or you experience a separate qualified status change. Special Enrollment If you decline enrollment for yourself or your dependents (including your spouse or domestic partner) for medical, dental or vision coverage, because you or they have other coverage or later need coverage because his or her employer stops contributing toward the employer provided coverage, you may be able to enroll yourself and your dependents in this Plan if you or your dependents lose eligibility for that other employer provided coverage. These are considered special enrollment events. You must enroll within 31 calendar days after your or your dependents other coverage ends (or after the employer stops contributing toward the other coverage). If the special enrollment event is the loss of Children s Health Insurance Program (CHIP) or Medicaid coverage or if you become eligible for contribution subsidies from Medicaid or CHIP, you must enroll in the Plan within 60 calendar days of the event with coverage being effective as of the date of the event. Changes Due to a Qualified Medical Child Support Order (QMCSO) When the Plan receives a Qualified Medical Child Support Order (QMCSO), the Dell Benefits Center will provide written notice to you and each of your dependents named in the QMCSO that it has been received and what the applicable procedures are for administering the order. The Dell Benefits Center will determine, in its sole discretion, if an order meets the requirements for a QMCSO and will notify you and your dependents of its decision. Children who qualify for coverage under the terms of a QMCSO will be treated as any other dependent under the Plan. If you have questions about submitting a QMCSO please call the Dell Benefits Center at 1-888-335-5663 (option 1). You can fax your QMCSO order to 1-847-883-9313 or mail it to: Qualified Order Center P.O. Box 1433 Lincolnshire, IL 60069-1433 In addition, if the Plan receives a National Medical Support Notice (NMSN) from a state agency, the steps noted above for processing a QMCSO will be followed, and the Dell Benefits Center, in its sole discretion, will determine if the NMSN meets the requirements. How to Make Changes To make changes to your benefit elections go to the Your Benefits Resources (YBR) Web site via the Dell Intranet: You and Dell > Benefits > Enroll/Make Changes. Read the instructions carefully and make your elections. Once you finish making your changes, you must submit your elections and you will receive immediate online confirmation (via the Completed Successfully screen; print a copy of this screen for your records). If you do not submit your elections, benefit elections you have made will not be saved by the system and will not take effect. For assistance, contact the Dell Benefits Center at 1-888-335-5663 (option 1). You are encouraged to print any records of your benefit changes because certain electronic records of your attempt to make benefit elections cannot be retrieved. 19 Dell Inc. Comprehensive Welfare Benefits Plan Summary Plan Description
If you are making your benefit changes due to the loss of CHIP or Medicaid coverage or becoming eligible for contribution subsidies from Medicaid or CHIP, you must request enrollment within 60 calendar days of the event. Otherwise, all changes must be made with 31 calendar days of your qualified status change or event. Any change will be implemented as soon as administratively possible. When Coverage Ends For Team Members Coverage under all programs ends on the earliest of the: Date the Plan terminates; Date a Plan Program terminates (coverage under that Program ends); End of the period for which any required contribution is due but not paid; Date you die; Date you are no longer a member of an eligible class of team members; Date you terminate employment with Dell; Date you elect to stop Plan coverage or any Plan Program as permitted by the Plan s change rules; or Last day of the plan year for the Health Care and Dependent Care (Day Care) Flexible Spending Account if you do not re-enroll for the next year. For Eligible Dependents Coverage for your eligible dependents ends under all Programs on the earliest of the: Date your coverage terminates; Date he or she dies; Date he or she no longer meets the Plan s definition of an eligible dependent or as otherwise required under state law; or Date you elect to stop coverage for your eligible dependent under the Plan or any Program in the Plan as permitted by the Plan s change rules. Coverage for dependents who are no longer eligible for the Plan because they turn 26 will end at 11:59 p.m. the date before their 26th birthday. Rescission of Coverage: Once an individual is under a group health plan, a retroactive termination (that is, a rescission of coverage) is prohibited unless the individual performs an act, practice or omission that constitutes fraud or if the individual makes an intentional misrepresentation of material fact, as prohibited by the terms of the Plan. In this case, the Plan will provide at least 30 days advance written notice to the affected participant before coverage may be rescinded. If it is determined that an individual has enrolled an ineligible dependent in Dell's Plan, that would constitute an intentional misrepresentation of a material fact and could result in a retroactive termination of that ineligible dependent s coverage. on 20 Dell Inc. Comprehensive Welfare Benefits Plan Summary Plan Description
Continuation, Porting or Conversion of Life Insurance Coverage You may port or convert your Basic Employee Life Insurance and any Supplemental Life Insurance within 31 days of your termination of coverage. In the event of a loss under one of these Life Insurance Programs during that 31-day porting or conversion period, your coverage under the program before your termination of coverage date will apply regardless of whether you have completed the porting or conversion process. There is no continuation of coverage, porting or conversion for: Adoption Assistance Program; Bicycle Reimbursement Program; Business Travel Accident Insurance; Child Care Discounts; College Coach; Commuter Benefits Program; Dell Merit Scholarship Program; Dependent Day Care Flexible Spending Account; edeals; Educational Assistance; Emergency Dependent Backup Care; Group Auto and Home Insurance Program; Gym Discounts and On-Site Fitness Centers; Healthy Pregnancy Program; Hewitt Personal Finance Center; Lactation Program; Long-Term Disability; Mother s Rooms; Referrals; Short-Term Disability; Well at Dell Health Improvement Program; or Will Preparation. Certificate of Creditable Coverage Dell s Medical Programs do not subject you or your dependents to a pre-existing condition exclusion. However, if you change jobs your new employer s medical plan may require proof of prior coverage. The Health Insurance Portability and Accountability Act of 1996 (commonly known as HIPAA) makes it easier for people changing jobs to be eligible for health plan coverage without being subject to a new employer s pre-existing condition exclusion. When you leave Dell and lose health plan coverage, the Dell Benefits Center will provide you with a Certificate of Creditable Coverage that shows the length and type of coverage you had under Dell s Medical Program. 21 Dell Inc. Comprehensive Welfare Benefits Plan Summary Plan Description
The Dell Benefits Center will provide you with a certificate of your creditable coverage when you lose medical coverage for any reason. You will automatically receive a certificate when: You become a qualified beneficiary entitled to elect COBRA coverage; You lose medical coverage, even though you are not entitled to elect COBRA coverage; and/or Your COBRA continuation coverage ends. You may also request, in writing, a certificate from the Dell Benefits Center at any time or within 24 months after your coverage ends by calling 1-888-335-5663 (option 1). The Dell Benefits Center will mail the certificate to your last known address within a reasonable time after coverage ends. COBRA Continuation Coverage Under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as amended, you and your dependents who are otherwise eligible may be eligible to temporarily extend group health care coverage under the Plan. Dell s Medical, Employee Assistance Program, Prescription Drug, Dental, Vision, Health Care Flexible Spending Account, Health Rewards Account and the Well at Dell Health Center are considered group health plans that are subject to COBRA. Both you and your dependents should take the time to read this section carefully. Your rights and obligations under the law are summarized below. Domestic partners are not eligible for COBRA; however, Dell offers continuation coverage to domestic partners and their children, similar to COBRA coverage. Contact the Dell Benefits Center at 1-888-335-5663 (option 1) for more information on this coverage. The information in this section serves as your and your dependents initial COBRA notice. You should read this section carefully to understand the COBRA continuation coverage rules and the COBRA election process. If you do not understand these rules or the election process, contact the Dell Benefits Center at 1-888-335-5663 (option 1). If the Dell Benefits Center receives a notice from you of a qualifying event, as described below, and the Dell Benefits Center determines that you are not entitled to COBRA, the Dell Benefits Center will provide you with a notice explaining why COBRA continuation coverage is not available. In general, to elect COBRA continuation coverage, you and your dependents must have been under the Plan on the day before the event that caused coverage to terminate. However, any children born to or placed for adoption with you while you are under COBRA will automatically be under the Plan you elect, provided you report the birth or adoption to the Dell Benefits Center at 1-888-335-5663 within 31 days of the event. 22 Dell Inc. Comprehensive Welfare Benefits Plan Summary Plan Description