ENROLLMENT APPLICATION

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1 ENROLLMENT APPLICATION HOW TO ENROLL IN EHP Please detach this page and review these instructions before completing the "Enrollment Application". If you have any questions, please contact an HR Service Representative before signing this Application. Contact EHP Customer Service at (410) or , or the EHP website at INSTRUCTIONS FOR NEW APPLICANTS: PLEASE PRINT OR TYPE. COMPLETE SECTIONS NUMBERED #1- #20. Enter the information about your family members who are to be covered in #11- #15. In #16, please write the name and number of the physician you wish to select as your Primary Care Physician. Primary Care Physicians can be found on the EHP website at under Find a Doctor. An EHP Primary Care Provider Directory can also be found on the website. COMPLETE #18. Your application cannot be processed without this information. However, do not enter your current insurance information if that insurance will be cancelled when EHP becomes effective. IF YOU ARE COVERED BY MEDICARE, COMPLETE #19. Please refer to your Federal Medicare Card (red, white & blue) for the information requested here. SIGN AND DATE #20 ON THIS FORM AND RETURN IT TO YOUR EMPLOYER. INSTRUCTIONS FOR APPLICANT CHANGES: PLEASE PRINT OR TYPE. COMPLETE #1 BY CHECKING THE TYPE OF CHANGE YOU ARE REQUESTING. COMPLETE #2 THROUGH #19 (ONLY AS THEY APPLY TO THE CHANGE YOU REQUESTED IN #1). SIGN AND DATE #20 ON THIS FORM AND RETURN IT TO YOUR EMPLOYER. WARNING: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION, OR FILES A CLAIM CONTAINING A FALSE, OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD WHICH MAY BE PUNISHABLE AS A FELONY.

DEP 3 DEP 2 DEP 1 SPOUSE SELF Johns Hopkins Health System Corporation/Johns Hopkins Hospital Enrollment Application (PLEASE PRINT PRESS FIRMLY USING BALL POINT PEN) 6704 Curtis Court Glen Burnie, MD

2 DEP 3 DEP 2 DEP 1 SPOUSE SELF Johns Hopkins Health System Corporation/Johns Hopkins Hospital Enrollment Application (PLEASE PRINT PRESS FIRMLY USING BALL POINT PEN) 6704 Curtis Court Glen Burnie, MD (410) (800) NEW ENROLLMENT/CHANGES IN ENROLLMENT 1. TYPE OF REQUEST (CHECK BOXES, AS APPROPRIATE) NEW APPLICANT ADD SPOUSE/DEPENDENT DELETE SPOUSE/DEPENDENT CHANGE NAME/ADDRESS MEDICAL DENTAL EMPLOYEE EMPLOYEE & SPOUSE EMPLOYEE & SAME SEX DOMESTIC PARTNER EMPLOYEE & CHILD(REN) EMPLOYEE & FAMILY EMPLOYEE & FAMILY WITH SAME SEX DOMESTIC PARTNER HIGH OPTION COMPREHENSIVE EMPLOYEE EMPLOYEE & SPOUSE EMPLOYEE & SAME SEX DOMESTIC PARTNER EMPLOYEE & CHILD(REN) EMPLOYEE & FAMILY EMPLOYEE & FAMILY WITH SAME SEX DOMESTIC PARTNER APPLICANT INFORMATION 2. NAME LAST FIRST INITIAL 3. SOCIAL SECURITY NO 4. DATE OF EMPLOYMENT 5. MAILING ADDRESS CITY STATE ZIP CODE COUNTY 6. HOME PHONE NO. WORK PHONE NO. 7. MARITAL STATUS SINGLE MARRIED 9. ARE YOU RETIRED? YES NO 10 ARE YOU CURRENTLY ACTIVELY AT WORK? YES NO IF NO, GIVE REASON: 8. EMPLOYER SPOUSE/DEPENDENT INFORMATION (COMPLETE THIS SECTION FOR YOURSELF AND COVERED DEPENDENTS) 11. NAME (LAST, FIRST, MIDDLE INITIAL) 12. SEX (M/F) 13. BIRTHDATE MO DAY YR 14. RELATIONSHIP 15. DISABLED (Y/N) 16. LIST NAME & ID NUMBER OF THE PRIMARY CARE PHYSICIAN () FROM THE DIRECTORY FOR EACH MEMBER I.D. NO. CURRENT PATIENT Y/N CHILD STEPCHILD (SPECIFY) CHILD STEPCHILD (SPECIFY) CHILD STEPCHILD (SPECIFY) 17. IS YOUR SPOUSE/DEPENDENT EMPLOYED? YES NO IF YES, NAME OF EMPLOYER 18. DO YOU OR ANY OF YOUR DEPENDENTS HAVE : A. GROUP HEALTH COVERAGE? YES NO IF YES, IS COVERAGE SINGLE OR FAMILY B. GROUP DENTAL COVERAGE? YES NO IF YES, IS COVERAGE SINGLE OR FAMILY IF YES, NAME OF HEALTH INSURANCE CARRIER: POLICY NUMBER: NAME OF DENTAL INSURANCE CARRIER: POLICY NUMBER: NAME OF INSURED: FAMILY MEMBER COVERED AND RELATIONSHIP: DATE OF BIRTH: OF COVERAGE: TERMINATION DATE OF COVERAGE: 19. IF YOU OR ANY DEPENDENT LISTED ABOVE WILL BE COVERED BY MEDICARE WHILE ENROLLED IN THIS HEALTH PLAN, PLEASE COMPLETE THE FOLLOWING: ENROLLEE NAME: MEDICARE NO. PART A PART B ENROLLEE NAME: MEDICARE NO. PART A PART B 20. I apply for EHP enrollment for the persons listed, and agree that I and my family members shall be covered according to the terms of the Plan. I hereby authorize deductions from my earnings of any required contribution as applicable. I hereby authorize any licensed physician, medical practitioner, hospital, clinic or other medical or medical-related facility, insurance company, the Medical Information Bureau, or other organization, institution, or person that has any records or knowledge of me or my family s health to give EHP such information. A photographic copy of this authorization shall be as valid as the original. To the best of my knowledge and belief, all statements to the questions in the application are complete and true, and I agree that they will be the basis of the issuance of any coverage. I will notify EHP promptly in writing concerning any changes in the above information. Any material misrepresentation, whether intentional or not, may result in denial of a claim or retroactive cancellation of coverage. APPLICANT SIGNATURE: DATE: REASON FOR SUBMITTING APPLCIATION NEW HIRE LATE ENROLLEE OPEN ENROLLMENT/ELECTION PERIOD EMPLOYMENT STATUS CHANGE FAMILY STATUS CHANGE ` : FOR EMPLOYER/GROUP USE ONLY GROUP NO: MEDICAL DENTAL SUBGROUP: WORK LOCATION VISION (IF APPLICABLE EHP USE ONLY INITIAL DATE

3 Effective January 1, Services & Supplies Calendar Year Deductible Co-Insurance Out of Pocket Maximum (Includes Deductible but not Co-pays) (5) Lifetime Maximum Individual Family $100 (Inpatient services only) $200 (Inpatient services only) $750 $0 $1500 $0 Individual $2000 $3500 N/A Family $4000 $7000 N/A Unlimited Acupuncture Allergy Tests & Procedures Ambulance Transportation Chemotherapy/ Radiation Therapy Chiropractic Care Durable Medical Equipment Emergency Services Home Health Services Services & Supplies (In Alphabetical Order) Medically Necessary for anesthesia, pain control, and therapeutic purposes ($1500 annual maximum) $40 co-pay 70% of R&C after deductible $40 co-pay Allergy Tests 100% 70% of R&C after deductible 100% Desensitization materials and serum 100% 70% of R&C after deductible 100% Medically Necessary transport 100% 100% of R&C 100% Physician Visit 100% 70% of R&C after deductible 100% Physician Materials 100% 70% of R&C after deductible 100% Restricted to initial exam, X-rays, & spinal manipulations ($1500 annual max) $15 co-pay 70% of R&C after deductible $15 co-pay Equipment and Medical Supplies 100% 70% of R&C after deductible 100% Custom Molded Orthotics (pre-certification required) 100% 70% of R&C after deductible 100% Prosthetic Appliances (pre-certification required) 100% 70% of R&C after deductible N/A Medically Necessary hearing aids for dependent children under age 19 (3) Emergency Care (facility and professional fees) (i.e., the onset of a sudden and serious condition requiring immediate care) Medically Necessary services must be pre-authorized (40 days per year maximum) 100% 70% of R&C after deductible N/A $150 co-pay then 100%, waived if admitted $150 co-pay then 100%, waived if admitted Deductible waived $150 co-pay then 100%, waived if admitted 100% 70% of R&C after deductible 100% Hospice Care Inpatient and Home Hospice 100% (4) 70% of R&C after deductible (4) 100% *Hopkins Affiliated Facilities include: Johns Hopkins Hospital, Johns Hopkins Bayview Medical Center, Howard County General Hospital, Suburban Hospital, Sibley Memorial Hospital, and All Children s Hospital. Page 1 of 4

4 Effective January 1, Hospital Care Immunizations & Inoculations Services & Supplies Inpatient Care, including inpatient maternity care/delivery (semi-private, unless private room is Medically Necessary) $500 co-pay per admission then 70% of R&C after deductible (4) then 100% Other Inpatient Services 90% after deductible (4) 70% of R&C after deductible (4) 100% Inpatient Physician Services (excluding surgical services) Skilled Nursing/Rehabilitation Facility (120 days per year combined for Medically Necessary services) Outpatient Services (including outpatient testing prior to outpatient surgery) Outpatient Surgery Facility Charges (including freestanding surgical centers) 90% after deductible (4) 70% of R&C after deductible (4) 100% 100% (4) 70% of R&C after deductible (4) 100% 100% 70% of R&C after deductible 100% 100% (4) 70% of R&C after deductible (4) 100% For communicable diseases 100% 70% of R&C after deductible 100% Laboratory Laboratory Tests 100% 70% of R&C after deductible 100% Mental Health & Substance Abuse Services Nutritional Counseling Office Visits for Treatment of Illness or Injury Preventive Services Physical/ Occupational Therapy Outpatient Mental Health Care $15 co-pay 70% of R&C after deductible $15 co-pay Inpatient Mental Health Care $500 co-pay per admission, then 70% of R&C after deductible (4) then 100% Outpatient Substance Abuse Care $15 co-pay 70% of R&C after deductible $15 co-pay Inpatient Substance Abuse Care $500 co-pay per admission, then 70% of R&C after deductible (4) then 100% Partial Hospital Facility Services $15 co-pay, no deductible 70% of R&C after deductible $15 co-pay, no deductible Limited to 2 visits per calendar year (with additional visits if Pre authorized) $15 co-pay 70% of R&C after deductible $15 co-pay Primary Care Office Visit $15 co-pay 70% of R&C after deductible $15 co-pay Specialty Care Office Visit $40 co-pay 70% of R&C after deductible $40 co-pay Diagnostic Services and Treatment 100% 70% of R&C after deductible 100% Preventive Exam (, GYN & Well Child care) 100% 70% of R&C after deductible 100% Diagnostic Services for Physical Exam 100% 70% of R&C after deductible 100% Mammogram & Screening Colonoscopy 100% 70% of R&C after deductible 100% Medically Necessary (60 visits per year combined maximum) $10 co-pay 70% of R&C after deductible $10 co-pay PT/OT authorization required (for visits 13-60) (2) *Hopkins Affiliated Facilities include: Johns Hopkins Hospital, Johns Hopkins Bayview Medical Center, Howard County General Hospital, Suburban Hospital, Sibley Memorial Hospital, and All Children s Hospital. Page 2 of 4

5 Effective January 1, Radiology Procedures Reproductive Health Speech Therapy Surgical Procedures Urgent Care Center Services & Supplies Advance Imaging including MRI, CT and PET scans $50 co-pay 70% of R&C after deductible $50 co-pay All other imaging studies, including X-ray and ultrasound (excludes ultrasounds for pregnancy) $10 co-pay 70% of R&C after deductible $10 co-pay Physician office visits (prenatal care only) 100% 70% of R&C after deductible 100% Birthing centers (licensed facility) 100% 70% of R&C after deductible N/A Inpatient Maternity Care & Delivery $500 co-pay per admission then 70% of R&C after deductible (4) then 100% Sterilization (voluntary) 100% 70% of R&C after deductible 100% Interruption of pregnancy 100% 70% of R&C after deductible 100% In vitro fertilization and artificial insemination (pre-certification required for all services and prescriptions. Available Under Hopkins Provider Only Available Under Hopkins Provider Only All criteria must be met) (1) 100% after separate $1000 infertility deductible Speech therapy non-developmental Medically Necessary $10 co-pay 70% of R&C after deductible $10 co-pay (30 visits per year maximum) (2) Professional services for inpatient & outpatient surgery Professional services for Medically Necessary reconstructive and/or surgically implanted prosthetic devices Gastric Bypass Surgery (pre-certification required) 90% for inpatient, after deductible, 100% for outpatient 90% for inpatient, after deductible, 100% for outpatient Available Under Hopkins Provider Only 70% of R&C after deductible 100% 70% of R&C after deductible 100% Available Under Hopkins Provider Only 100% after separate $1000 deductible Physician Visit $40 co-pay 70% of R&C after deductible $40 co-pay Diagnostic Services and Treatment 100% 70% of R&C after deductible 100% *Hopkins Affiliated Facilities include: Johns Hopkins Hospital, Johns Hopkins Bayview Medical Center, Howard County General Hospital, Suburban Hospital, Sibley Memorial Hospital, and All Children s Hospital. Page 3 of 4

6 Effective January 1, Prescription Drugs - In Network Retail Pharmacy (30 day supply) - In Network Retail Pharmacy (90 day supply) - Mail Order (90 day supply) Prescription Coverage Generic $10 $30 $20 Preferred $30 $90 $60 Non Preferred $50 $150 $100 Specialty Medications Restrict to 30 day retail supply only (1) $30,000 lifetime maximum combined including prescription drugs, lab work and X-rays, in vitro fertilization attempts limited to a maximum of three per lifetime within the $30,000 lifetime maximum, all services provided at Hopkins facilities only. (2) Covered benefits only include therapy aimed at restoring the level of speech the individual had attained before the onset of a condition (i.e., before an illness or injury). Speech therapy for developmental disorders, such as stuttering, articulation disorders, tongue thrust, lisping, etc., is not covered. (3) Services must be authorized by Care Management and prescribed, fitted and dispensed by licensed audiologist, replacement aids once every 36 months. (4) Failure to obtain pre-certification may result in a penalty or possible denial of benefits. (5) Co-pays are still required after you ve reached your out of pocket maximum. R&C (Reasonable and Customary Charge) This is the usual fee charged by similar providers for the same services or supplies in the same geographic area. Johns Hopkins Employer Health Programs determines what is a Reasonable and Customary Charge. EHP Network providers () will not charge more than the Reasonable and Customary Charge, but non-network providers can charge more. For more information look under the heading Payment Terms You Should Know in your Summary Plan Description (SPD). You are responsible for any charges above R&C. All benefits are subject to medical necessity. This is not a complete description of benefits. For more information, please refer to the Summary Plan Description (SPD). *Hopkins Affiliated Facilities include: Johns Hopkins Hospital, Johns Hopkins Bayview Medical Center, Howard County General Hospital, Suburban Hospital, Sibley Memorial Hospital, and All Children s Hospital. *Hopkins Affiliated Facilities include: Johns Hopkins Hospital, Johns Hopkins Bayview Medical Center, Howard County General Hospital, Suburban Hospital, Sibley Memorial Hospital, and All Children s Hospital. Page 4 of 4

7 Weekly Medical and Dental Rates Employer Health Programs Medical Plan Options Yourself only Yourself and Child(ren) Yourself & Spouse / Domestic Partner Employee & Family EHP PLAN (RATES ARE PER WEEK) $ $ $ $ United Concordia Dental Plan Options Yourself only Yourself and Child(ren) Yourself & Spouse / Domestic Partner Employee & Family Comprehensive High Option $4.61 $6.24 $9.22 $12.48 $12.68 $17.16 $13.83 $18.72

Medical EPO Plan Schedule of Benefits (Effective January 01, 2019) JHH/JHHSC Non-Union and Union Employees and Eligible Dependents

Medical EPO Plan Schedule of Benefits (Effective January 01, 2019) JHH/JHHSC Non-Union and Union Employees and Eligible Dependents Plan Year Deductible Out-of-Pocket Maximum Lifetime Maximum Hopkins Preferred Network Provider EHP Network Provider Individual $500 $500 Family $1000 $1000 Individual $3000 (combined with EHP Network)