2016 BENEFIT PLAN OPEN ENROLLMENT. Open Enrollment Period November 9 December 4

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1 2016 BENEFIT PLAN OPEN ENROLLMENT Open Enrollment Period November 9 December 4

2 Table of Contents 2016 Open Enrollment Overview Benefit Fair: November 6, :00 a.m.-4:00 p.m. Online Open Enrollment Process Resources and Information Benefit Information Session Schedule 2016 Open Enrollment: Overview of Benefit Plans Frequently Asked Questions Appendices (UltiPro Logon Instructions, 2016 Rates, Summary of Benefit Coverage) Online Open Enrollment 2016 Open Enrollment is online through the UltiPro HR Payroll System. From SaraNet, click on Employee Center and then UltiPro HR Payroll. You also can access UltiPro from the Saratoga Hospital website on the For Employee tab at 2

3 2016 OPEN ENROLLMENT CHECKLIST It All Starts with the Benefit Fair on Friday, November 6 th : Hospital Cafeteria 7 a.m. 4 p.m. Representatives from many of the benefit plans will be on site to discuss the plans and answer your questions. CDPHP Delta Dental Davis Vision Morgan Stanley (Service Provider Retirement Plan of Saratoga Hospital) AFLAC (cancer and critical care indemnity plan, accident indemnity plan) New York Life (whole life insurance) Liberty Mutual (Home and Auto) Gary P. Decresce and Associates-Indexed Universal Life Plan through Penn Mutual LifeTime Benefit Solutions (flex spending account administrator)* EnvisionRxOptions* MetLaw (Hyatt Legal)* Unum Insurance Co. (supplemental term life, voluntary short and long term disability)* * No representative in attendance. Informational packets available. All Open Enrollment will be done online through UltiPro. With few exceptions, the open enrollment process will be paperless. Help and Information are Available in Human Resources, on SaraNet and on the Saratoga Hospital Website ( Information on all benefit plans Domestic Partner application paperwork (required if you are adding a domestic partner) COBRA information - If you are enrolling for the first time you will need to sign and acknowledge receipt of this information. Unum Voluntary Long Term Disability, Short Term Disability and Supplemental Term Life Evidence of Insurability Forms Help with access to UltiPro for completing the on-line open enrollment process

4 2016 Open Enrollment Benefit Information Session Schedule A number of benefit information sessions have been scheduled to provide opportunities for you to ask questions or receive assistance in completing the online enrollment. You can also stop into Human Resources Monday - Friday between 7a.m. 5 p.m. to ask questions or for assistance with completing your online enrollment in UltiPro. Human Resources will also stay open until 6 p.m. on the following days: Thursday November 12 th, Tuesday November 17 th and Friday December 4 th. Date Time Location Wednesday, November 11 th 7 a.m. 9 a.m. Hospital Computer Training Room Friday, November 13 th 11 a.m. 1 p.m. HR Conference Room Wednesday, November 18 th 2:30 p.m. 5:30 p.m. Hospital Computer Training Room Tuesday, November 24 th 11:30 a.m. 1:30 p.m. Hospital Computer Training Room Monday, November 30 th 3 p.m. 530 p.m. HR Conference Room Wednesday, December 2 nd 7 a.m. 9 a.m. Hospital Computer Training Room

5 Saratoga Hospital is committed to providing you with benefits that promote health and well-being as part of a total compensation and benefit package. Our goal is to offer a wide range of benefits to meet the needs of you and your family. Open enrollment is the once-a-year opportunity for you to review your current benefit coverage, make changes, add or drop dependents and re-elect a flex spending account. The only other time that you can make these changes during the year is when you experience a qualifying event (birth of a child, marriage, divorce or change of employment status for you or your spouse). It all Starts with the Benefit Fair: November 6 th 7:00 a.m. - 4:00 p.m. Open enrollment begins with the Benefit Fair on November 6 th in the Hospital Cafeteria. Representatives from CDPHP, AFLAC, Delta Dental, Davis Vision, Morgan Stanley and New York Life will be on hand to review benefit programs and answer any questions you might have. Information will also be available on Metlaw, LifeTime Benefit Solutions Flex Spending, Unum supplemental term life and voluntary short and long term disability coverage and the hospital s prescription drug plan through Envision RxOptions. What to Expect in 2016 We will continue to offer a wide range of benefit programs this year. With just a few exceptions, all open enrollment will be completed online through the UltiPro HR Payroll system. Online Open Enrollment through the UltiPro HR System You can access UltiPro three different ways: 1. From Inside the Hospital Go to SaraNet. Go to the Employee Center. Find UltiPro on the drop down menu and click. This will bring you to the UltiPro home page. 2. From outside the hospital. Go to the Saratoga Hospital web page at Find the For Employees button at the top of the home page. Click. This will bring you to a page that provides a link to UltiPro, and a place where all benefit information will be posted for Open Enrollment. This will work on a computer either inside or outside of the hospital. 3. Enter Web address directly. You can enter the web address for UltiPro into a web browser. This will work on a computer either inside or outside of the hospital. To get ready for open enrollment, make sure you have successfully logged into UltiPro, created your unique password and reviewed your current benefit elections. If you haven t done this already, instructions for logging into UltiPro can be found in Appendix A of this guide. Review Your Current Benefit Elections Saratoga Hospital 2016 Open Enrollment Overview Your current benefit elections are summarized in the Current Benefits section of your UltiPro account. From your personal UltiPro home page, click on the Current Benefits tab at the top. Take a few minutes to review your current coverage and election of benefits. IF YOU DO NOT PLAN ON MAKING ANY CHANGES TO YOUR CURRENT BENEFIT ELECTIONS, YOU DON T HAVE TO TAKE ANY ACTION. You will be automatically enrolled in the same benefits at the same coverage in 2016 with the applicable rates for Exceptions: If you want to continue a Flex Spending Account; Dependent Care or Medical Reimbursement, you must elect a new amount. Your current election will not roll over to In addition, if you are a full time employee and are not covered by the hospital s medical insurance, you must elect to receive the 2016 waiver credit through the on line open enrollment process.

6 2016 Benefit Plans Overview Medical Plan (CDPHP) The medical plan will continue to be administered by CDPHP. The plan design remains the same. The plan will continue to waive office visit copayments for Saratoga Hospital employed physicians (Saratoga Regional Medical Group; also referred to as the Domestic Network in the plan) through the Courtesy Discount. The Domestic Network of Saratoga Hospital employed physicians has continued to grow adding the Saratoga Midwifery practice, Saratoga Inpatient Physicians and additional primary care physicians. Prescription Plan (EnvisionRxOptions) The hospital will continue to provide prescription coverage through EnvisionRxOptions. The copays for generic, brand and non-preferred brand will increase this year to $10.00/$40.00/$55.00 respectively. The deductible for specialty drugs remains at 25% with the out of pocket maximum the same as last year, $ Mail order and 90 day fills done at the retail level will continue to be a cost saving option for those who are able to have their monthly medications filled in this manner that provides a three month supply for the cost of two monthly copays. Dental Plan In 2016, the hospital will no longer offer the preventive dental option to new enrollees. The hospital will continue to offer the comprehensive plan. Those that are currently enrolled in the preventive plan can continue to stay enrolled in that option. The annual yearly maximum benefit remains at $1,500 per individual. The 2016 rates for Medical, Prescription, Dental and Vision can be found in Appendix B of this Guide. Retirement Plan of Saratoga Hospital In 2016, the hospital will make a non-elective (core) contribution of 2.75% to all eligible employees who are enrolled in the plan and have worked a minimum of 975 hours in In addition, a matching percent based on years of service will also be made. The match is described in the chart below: Years of Plan Service Matching Contribution Total Contribution 0-5 Years 40% of the first 2% of Pay [0.8%] 3.55% 6-9 Years 80% of the first 2% of Pay [1.6%] 4.35% Years 120% of the first 2% of Pay [2.4%] 5.15% Over 20 Years 150% of the first 2% of Pay [3.0%] 5.75% To be eligible for the employer match, you must have deferred a minimum of 2.0% during the plan year. The employer contribution is made once per year, usually in February to reflect the contribution earned from the prior calendar year. The maximum amount you can defer in 2016 is $18,000 for those under age 50 and $24,000 for those over 50. Any changes you wish to make to the allocation of your funds or how much you contribute bi-weekly to your retirement account must be done online at or by calling Deferral change requests cannot be made in UltiPro.

7 Group Term Life Insurance The hospital will continue to provide group term life insurance to all full time employees at no cost. This plan is administered by Unum. The coverage remains the same; one times your annual salary up to a maximum of $200,000. The coverage is automatic and requires no action on your part other than to identify a beneficiary. You can designate your beneficiary through the online enrollment. Health Insurance Waiver Credit The waiver credit of $360 is available to those full time employees who have completed one year of service and who have medical insurance coverage through an insurance plan other than the Saratoga Hospital plan. Employees must indicate their eligibility for the waiver credit during open enrollment through the online open enrollment process. Employees who do not elect the waiver credit during the open enrollment time period, or who change status during the year, will not be eligible to receive the waiver credit in If you indicated that you were eligible for the waiver credit during open enrollment last year, the credit will be paid to you in the last pay period of Employees eligible to receive the waiver credit will receive a letter in mid- November requesting evidence of insurance coverage for the 2015 plan year to receive the waiver credit. Acceptable forms of evidence of insurance coverage include a letter from the employer s human resource department or from the insurance company providing the coverage. Change in Waiver Credit for 2016 Plan Year: Effective for the 2016 plan year, waiver credit payments will not be provided to full time employees that are covered as a spouse or dependent under another employee on the Saratoga Hospital Health Insurance Plan. Flex Spending Accounts Flexible Spending Accounts (FSA) allows employees to pay for unreimbursed medical/dental/vision expenses or child care with pretax dollars. You must elect a new flex spending amount during open enrollment. Previous election amounts do not roll over from one year to the next. This can be done online through UltiPro. There are two types of Flex spending accounts: Medical Reimbursement Account: You can defer up to $2,550 in 2016 on a pre-tax basis to be used for the reimbursement of eligible, non-reimbursed medical expenses (for example: copays, deductibles, coinsurance). Dependent Care Account: A Dependent Care Account allows you to defer up to $5,000 per calendar year on a pretax basis to be used for reimbursement of eligible dependent care expenses. You will be reimbursed out of your account for qualifying medical/dental or child care expenses incurred during the plan year. Our plan provides participants with Flex spending debit cards. The cards are good for three years. You will not get a new one when you re-enroll if your current card has not as yet expired. Flex Spending for Dependents: You may make contributions to your flexible spending account on a pre-tax basis to pay for covered health expenses for your children through the end of the calendar year in which your child reaches age 26, even if your child is not your tax dependent. You will be reimbursed through your account for all medical expenses incurred through the end of the year that your child turns age 26. YMCA Contribution The hospital provides $200 towards a full or part time benefit eligible employee s membership to one YMCA in the Saratoga Region, Glens Falls, and Greater Glenville branch of Capital District YMCA or Southern Saratoga. The employee must be one of the members listed on the membership. Please note that this amount is considered a taxable fringe benefit under IRS regulations and will be added to your W2 at the end of the year.

8 New York State Short Term Disability The hospital provides state mandated short term disability that covers 50% of your weekly salary up to a maximum of $170 per week in the event that you are out of work due to a non-work related illness or injury for more than 7 calendar days. No action is needed on your part to be enrolled in this benefit. Voluntary Benefit Programs Additional voluntary benefit programs are also available. These programs are offered through Saratoga Hospital at group rate discounts. The voluntary benefit programs include: Vision: The vision plan is administered through Davis Vision and provides benefit eligible employees with an annual eye exam as well as an annual benefit amount to be used toward the purchase of frames and lenses, including contact lenses by in-network providers. Voluntary Short Term Disability: This program is administered by Unum and allows benefit eligible employees to purchase additional coverage to supplement the New York State short term disability in the event that you are out of work due to a non-work related illness or injury for more than seven calendar days. Short term disability provides coverage for up to 26 weeks at 50% of your weekly wages up to a maximum of $2,000 per week. Rates are based on age and weekly salary amount. New enrollees must complete an Evidence of Insurability form and submit to Unum for review and approval. Forms can be obtained through Human Resources, SaraNet/Employee Center/2016 Open Enrollment or through the employee portal on the hospital website at The completed form can be mailed or faxed to Unum. You must also elect this plan through the online open enrollment in UltiPro. Your deductions will not start until you are approved by Unum. Voluntary Long Term Disability: Full time benefit eligible hourly employees can purchase long term disability coverage through Unum Insurance. Long term disability provides coverage if you have been out of work for 6 months. The benefit is 50% of your monthly pay up to a maximum of $10,000 per month. Rates are based on age and monthly salary amount. New enrollees must complete an Evidence of Insurability form and submit to Unum for review and approval. Forms can be obtained through Human Resources, SaraNet/Employee Center/2016 Open Enrollment or through the employee portal on the hospital website at The completed form can be mailed or faxed to Unum. You must also elect this plan through the online open enrollment in UltiPro. Your deductions will not start until you are approved by Unum. Voluntary Supplemental Term Life Insurance: This product is administered by Unum. You can purchase life insurance for yourself up to $300,000, your spouse up to $100,000 and dependents up to $4,000. New enrollees or current enrollees who are increasing coverage above the guaranteed issue amount of $100,000 for themselves or $30,000 for their spouse must complete an Evidence of Insurability form and submit to Unum for review and approval. Forms can be obtained through Human Resources, SaraNet/Employee Center/2016 Open Enrollment or through the employee portal on the hospital website at The completed form can be mailed or faxed to Unum. You must also elect this plan through the online open enrollment in UltiPro. Your deductions will not start until you are approved by Unum.

9 NY Life Voluntary Whole Life Insurance: Voluntary whole life insurance is offered through New York Life to full time employees with six months or more of service. New York Life Guaranteed Issue Whole Life insurance is available for you, your spouse, children, and grandchildren. You can get coverage for yourself up to $100,000 and up to $25,000 on your spouse, children or grandchildren. The New York Life representative will visit every department between Monday, November 2 nd - Friday, November 13 th. You can Benefits@saratogacare.org if you would like to set up an appointment or you can call the representative directly at You must also elect this plan through the online open enrollment in UltiPro. Your deductions will not start until you are approved by NY Life. AFLAC Cancer Care and Critical Illness: This voluntary cancer and critical care protection plan is provided through AFLAC Insurance and offers financial assistance to cover costs such as transportation, travel, lodging, household costs and other living expenses when an the insured individual is diagnosed with cancer or other critical illness. Visit or call the AFLAC plan representative at for more information or contactbenefits@saratogacare.org if you would like to schedule an appointment. You must also elect this plan through the online open enrollment in UltiPro. Your deductions will not start until you are approved by AFLAC. AFLAC Accident Only Indemnity Plan: This plan provides coverage to an employee, spouse and/or dependent under age 26. The plan covers costs related to an accident. It pays for accident emergency treatment, x-rays due to accident, accident follow up treatment, hospitalization, intensive care inpatient due to accident, physical therapy and appliance needs (wheelchair, crutches, leg brace, walker) due to accident. It also covers transportation costs, prosthesis, family lodging and accidental death and dismemberment. There are no deductibles, no copayments, no lifetime limit, no network restrictions and no coordination of benefits. Visit or call the AFLAC plan representative at for more information or contact Benefits@saratogacare.org if you would like to schedule an appointment. You must also elect this plan through the online open enrollment in UltiPro. Your deductions will begin when approved by AFLAC. Legal Plan: This benefit is available through MetLaw and Hyatt Legal Plans and offers eligible employees an opportunity to access affordable legal assistance for a wide range of needs including wills, real estate matters, family and traffic court, etc. Once enrolled the employee must remain in the plan for the entire plan year. Liberty Mutual: This plan offers homeowners and auto insurance at group discounts. Rates are determined by the level of coverage elected. Indexed Universal Life Insurance: This plan provides portable life insurance coverage through Penn Mutual for employees and their spouses. The interest earned on the cash value of the policy is based on the Standard and Poor s 500 index using both an upside and downside cap. The plan provides the option for a monthly retirement income stream through the use of the loans option drawn against the policy death benefits.

10 Courtesy Discount The courtesy discount is offered to all benefit eligible part time and full time employees, their spouse, dependents, domestic partner * and hospital retirees. The courtesy discount is available at the following Saratoga Hospital employed physician practices including: Family Health Centers (Galway, Schuylerville, Saratoga Family Health at Wesley), Milton Health Center, Saratoga Family Physicians, Endocrinology, Pain Management, Pulmonology, Nephrology, Podiatry, Medical Oncology, General and Bariatric Surgery, Urology, Saratoga Midwifery, Saratoga Inpatient Physicians, and Neurology The courtesy discount also applies to outpatient, ambulatory and inpatient services provided at Saratoga Hospital and its outpatient facilities. For employees who have insurance through Saratoga Hospital, all copays, deductibles and coinsurance are discounted at 100% with the exception of the exclusions noted below. For employees who are covered under another insurance plan, the courtesy discount covers a maximum of $150 per outpatient visit and $1,000 per inpatient visit. For ED visits, the courtesy discount only applies to those plans that have copayments or deductibles over $100. For example, if your plan has an ED copayment of $50.00, you will be responsible for the full copayment. If your plan has an ED copayment or deductible of $200.00, you will be responsible for $ and the courtesy discount will be applied to the remaining $ Exclusions to Courtesy Discount: The following exclusions apply: Saratoga Hospital Emergency Department ($ copay for employees with insurance with Saratoga Hospital. Maximum discount of $ for employees with other insurance) Malta Medical Emergent Care ($75.00 copay with a $25.00 credit applied through Patient accounts) * A statement of Domestic Partnership must be on file with the Human Resource Department for the domestic partner to receive the courtesy discount. See complete policy information under Domestic Partner policy # **For a current list of Saratoga Hospital providers included in the Domestic Network and included under the Courtesy Discount, please refer to the Domestic Provider list under the Health Insurance tab of the Employee Center/Benefits and Pay on SaraNet. Important Contact Information Benefit Program Vendor Website Telephone Health Insurance CDPHP Prescription Plan EnvisonRXOptions Retirement Plan of Saratoga Hospital Transamerica Dental Insurance Delta Dental Vision Insurance Davis Vision

11 Open Enrollment Questions What if I don t want to make any changes? Do I still have to complete the open enrollment process? The only benefits that require you to take action are the Flex Spending Account: either the Medical Reimbursement or Dependent Care and the Medical Insurance Waiver Credit. For the Flex Spending accounts, you must elect a new amount each year. If you are a full time employee and do not take, or are not a dependent on, the medical insurance through the hospital, you are eligible for the $360 waiver credit and must elect the credit each year and show proof of coverage from the prior year. For all other benefits, you don t need to take any action. All your current benefit elections will continue in 2016 at the 2016 rates. Is there any paperwork that needs to be completed? If you are enrolling in supplemental term life, voluntary short term or long term disability for the first time or increasing your life benefit amount above guaranteed issue limits, you will have to complete an Evidence of Insurability Form and send it to Unum for review and approval. These forms are available in Human Resources, on SaraNet/Employee Center/2016 Open Enrollment or on the Saratoga Hospital website ( in the For Employees under the Benefits button. Are the rates increasing for the plans? There are rate increases for some of the plans this year. The rates are detailed in the table in Appendix B. How does the deductible work in the medical plan? The plan has a $500 deductible per individual with a maximum deductible of $1,500 for a family. The deductible applies for care and services provided outside the Domestic Network of Saratoga Hospital and it s employed providers. Once you meet the $500 deductible, you are then responsible for any applicable coinsurance. Office visit copays to a provider do not count towards the deductible. How do I meet my annual deductible? Whenever you receive diagnostic services at a hospital, health care facility, physician s office setting or have diagnostic testing done somewhere other than Saratoga Hospital or off site locations, the deductible will apply. This includes inpatient care, ambulatory surgery, laboratory work and diagnostic testing. For employees with an individual plan, once you have reached $500, you will have met your deductible for the plan year. For those with a two-person plan, the deductible is $500 per person. For those with family coverage, the deductible is $500 per person with a maximum deductible of $1,500 for the family. What is coinsurance and how does it work? Coinsurance is the amount that an employee pays after the annual deductible is met. It is a percentage that is applied to the contracted rate that CDPHP has agreed to pay a provider. The coinsurance is 20%. Here is an example of how both the deductible and coinsurance work: Example: An employee with individual coverage ($500 deductible) has an ambulatory surgery procedure at St. Peter s Hospital in Albany. CDPHP approved the procedure at $2,000. The employee would first pay $500. This would meet their annual deductible. They would also have a in the amount of $300 (the coinsurance of 20% is applied to the total procedure rate ($2000) less the deductible of $500 or $1,500). For any additional services provided at a hospital other than Saratoga, the employee no longer has a deductible, but would continue to be responsible for any coinsurance. Deductibles and coinsurance can really add up. Is there any cap on my out of pocket expenses? Yes. There is an out of pocket maximum of $3,000 per individual with a total cap of $9,000 for family coverage. The annual out of pocket maximum includes copayments, deductibles and coinsurance for both medical and prescription out of pocket expenses.

12 What do I pay if I receive care at Saratoga Hospital? Care provided at Saratoga Hospital facilities and/or by Saratoga Hospital employed physicians is considered the Domestic Network under our medical plan. For employees who have health insurance through Saratoga Hospital, there are no copays, deductibles or coinsurance applied for services provided at Saratoga Hospital inpatient and outpatient services, Wilton Urgent Care/Medical Arts or any Saratoga Hospital physician practices. When services are provided by providers that are not part of the Domestic Network, copayments, coinsurance and the deductible may apply. Some examples include; x-ray interpretations by radiologists, lab tests reviewed by an outside laboratory and pathologist, Holter monitors or other durable medical equipment. Is there a copayment for a visit to the Saratoga Hospital Emergency Department? Yes. There is a $ copayment for a visit to the Saratoga Hospital Emergency Department. Are there other exceptions to the courtesy discount? Yes. For emergent care services at Malta Med there is a $75.00 copay. For diagnostic services (lab and x-ray) provided on the first floor, these services are subject to the deductible and coinsurance. Care provided at the Community Health Center on Hamilton Street will also require applicable copayments. Employees who have insurance coverage through a spouse are also eligible for a courtesy discount. The discount is up to $ for each outpatient visit and $1,000 for an inpatient stay on the remaining balance after payment by their insurance company. Will I have a copayment or incur additional out of pocket expense if I receive care at Saratoga Hospital by a provider that is not part of the Domestic Network? In most cases yes. For specialists that are not part of the domestic network (Radiologists, Pathologists, Anesthesiologists, Gastroenterologists, Emergency Department Physicians et al) you will be responsible for any copayments that apply. Copayments for specialists are $ My physician ordered lab work and other diagnostic tests in his office and I received a bill for these tests. Can I have that kind of testing done at the hospital? Testing that is done in a Non-Domestic provider office will be subject deductibles and coinsurance. You should discuss with your physician whether you can have diagnostic testing done at the hospital. Laboratory and medical imaging at the hospital would fall under the domestic network and would be eligible for the courtesy discount but, while most care decisions are your choice and decision, your physician may have may have very specific reasons for having the testing done in their office.

13 Appendix A Accessing UltiPro You can access UltiPro three ways: 1. To access UltiPro from a hospital computer. Go to SaraNet/Employee Center and click on the UltiPro link at the bottom of the drop down menu. Click on the Click Here to Enter UltiPro. 2. To access UltiPro from a computer outside of the hospital. Go to the Saratoga Hospital website at and click on the For Employees button at the top of the page. This will bring you to a landing page that has a button for UltiPro. Click on this button and it will bring you to the UltiPro log in page. 3. To access UltiPro from a computer outside of the hospital. You can enter the UltiPro web address directly into a web browser. The address is The Online Open Enrollment will be active on Monday November 9, Once you have reviewed your current benefit coverage in your UltiPro account, you can start the open enrollment process by clicking on the Open Enrollment tab at the top of the page. All employees who are benefit eligible will have the access to the 2016 Open Enrollment session beginning Monday, November 9 th. You can go back into the Open Enrollment session and review your elections and make changes throughout the open enrollment period. If you are making any changes, they must be completed by the close of the last day of open enrollment, December 4th. If you do not take any action, you will be automatically enrolled in the same benefits at the applicable rates for Keep in mind flex spend accounts and waiver credit requests are not automatically continued into the next plan year.

14 Appendix B Saratoga Hospital Bi-Weekly Benefit Rates Effective January 1, 2016 December 31, 2016 SARATOGA HOSPITAL HEALTH INSURANCE PLAN RATES FULL TIME HOSPITAL FULL TIME EMPLOYEE PART TIME HOSPITAL PART TIME EMPLOYEE EPO * INDIVIDUAL $ $33.55 $ $ PERSON $ $ $ $ FAMILY $ $ $ $ * Exclusive Provider Organization Administered through Capital District Physician Healthcare Network (CDPHN) Employees who opt to participate in the health plan are also required to participate in the prescription plan. PRESCRIPTION INSURANCE RATES FULL TIME HOSPITAL FULL TIME EMPLOYEE PART TIME HOSPITAL PART TIME EMPLOYEE EnvisionRxOptions INDIVIDUAL $44.79 $7.99 $39.28 $ PERSON $77.50 $27.24 $57.59 $47.15 FAMILY $ $38.93 $69.46 $69.50 DENTAL INSURANCE RATES* FULL TIME HOSPITAL FULL TIME EMPLOYEE PART TIME HOSPITAL PART TIME EMPLOYEE Comprehensive INDIVIDUAL $14.11 $4.76 $10.40 $ PERSON $20.98 $11.42 $14.64 $17.76 FAMILY $29.96 $16.29 $20.90 $25.35 * The hospital no longer offers a preventive dental plan option to new enrollees. Those currently enrolled can stay in the preventive plan, decline or change to the comprehensive plan. VISION INSURANCE RATES FULL AND PART TIME EMPLOYEE INDIVIDUAL PERSON 5.42 FAMILY 8.43 Definitions: Full Time is defined as regularly scheduled to work 75 hours or more per pay period (72 hours for 12 hour shift employees). Part Time is defined as regularly scheduled to work 37.5 hours or more per pay period (36 hours for 12 hour shift employees). Employees are automatically enrolled in a pre-tax benefit. Those wishing to have benefit deductions withheld on a post-tax basis would need to complete a Post Tax Deduction Request form, available on SaraNet or in Human Resources, and submit the completed form with their enrollment paperwork. Once pre-tax deductions are taken no changes can be made to post tax.

15 Appendix C Saratoga Hospital Health Insurance Plan Summary of Benefit Coverage Saratoga Hospital Health Insurance Plan (EPO) Domestic Network* Non-Domestic Network** Annual Deductible Individual Coverage Not Applicable $500 2-person Coverage Not Applicable $1,000 Family Coverage Not Applicable $1,500 Out-of-Pocket Maximum Individual Coverage Not Applicable $3,000 2-person Coverage Not Applicable $6,000 Family Coverage Not Applicable $9,000 Annual out-of-pocket maximum includes both medical and pharmacy deductibles, copayments, and coinsurance. Lifetime Maximum Coverage None None Physician Services Office visits - PCP/OBGYN Covered in Full $30 Copayment Office visits - Specialist Covered in Full $40 Copayment Well baby and child care Covered in Full Covered in Full Well Adult exam Covered in Full Covered in Full Routine GYN exam Covered in Full Covered in Full Hospital Services Inpatient Hospital (semi-private room) Covered in Full Deductible then Physician Covered in Full $30/$40 Copayment Outpatient Surgery Facility Covered in Full Deductible then Outpatient Surgery Office Covered in Full Deductible then Diagnostic Testing Laboratory services Covered in Full Deductible then Radiology and Imaging (X-rays, MRI's) Covered in Full Deductible then Maternity Physician services (pre/post-natal care) Covered in Full Deductible then Inpatient Hospital Services Covered in Full Deductible then Newborn nursery Covered in Full Deductible then Benefit Summary Continued

16 Saratoga Hospital Health Insurance Plan (EPO) Domestic Network* Non-Domestic Network** Emergency Care Hospital Facility $100 Copayment $150 Copayment Ambulance Not Available in Domestic Network $100 Copayment All Emergency Care is Considered In-Network Urgent Care Covered in Full $75 Copayment Physical Therapy, Occupational Therapy and Speech Therapy Durable Medical Equipment and Prosthetic Devices Chemical Abuse & Dependency Inpatient Detoxification Inpatient Rehabilitation Outpatient Rehabilitation Covered in Full $40 Copayment Not Available in Domestic Deductible then Network Prior authorization required for items in excess of $500 Not Available in Domestic Network Not Available in Domestic Network Not Available in Domestic Network Deductible then Deductible then $40 Copayment Mental Health Inpatient Covered in Full Deductible then Outpatient Not Available in Domestic $30 Copayment Network Prescription Drug Coverage Administered by Envision RX: Services rendered by Out of Network Facilities/Providers are not covered. * Domestic Network- All Saratoga Hospital owned facilities and employed physicians/professionals. ** Non Domestic Network- All other CDPHP (including National Network) facilities & physicians/professionals that participate in CDPHP's EPO network. This summary is provided to highlight some specific provisions of the plan. Some restrictions may apply. This plan does not cover services that are not medically necessary, for example: cosmetic procedures, LASIK surgery. Please refer to your Summary Plan Description for more detailed information including limitations and exclusions. All benefits of the plan are subject to coordination of benefits. This plan is sponsored by The Saratoga Hospital and administered by Capital District Physicians' Healthcare Network, Inc. (CDPHN). While this material is believed to be accurate as of the print date, it is subject to change without notice. In case of a conflict between the plan documents and this information, the plan documents will govern. Questions? CDPHN can answer questions and provide information about the benefits available under this plan. Just visit the Web site at or call (518) or from 8 a.m. to 5 p.m. Eastern Standard Time. The TTY number is For language assistance please call member services.

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