Introduction Who Can Answer Your Questions... 4

Transcription

1 2012 BENEFITS GUIDE

2 TABLE OF CONTENTS Introduction... 3 Who Can Answer Your Questions... 4 Flexible Benefits Plan Premium Account... 5 Sample Case of Benefits taken Pre-Tax vs. After-Tax... 7 Enrollment Q & A... 8 Medical Benefits Medicare Creditable Coverage Information HIPAA/Special Enrollment Provisions Medicaid and the Children s Health Insurance Program (CHIP) Benefit Highlights of the Deductible Plan & Benefits Costs Enrollment Q & A Dental Benefits Benefit Highlights Benefit Costs Enrollment Q & A Life & AD&D Insurance Benefits Benefit Highlights Benefit Costs Enrollment Q & A Supplemental Life Insurance Plan Benefit Highlights and Benefit Costs (Employee) Benefit Highlights and Benefit Costs (Spouse/Dependent) Enrollment Q & A Supplemental AD&D Plan Benefit Highlights Benefit Costs Enrollment Q & A Long Term Disability Income Benefits Benefit Highlights Benefit Cost Enrollment Q & A Flexible Spending Accounts Enrollment Q & A Medical and Dental Reimbursement Account Q & A Medical and Dental Reimbursement Account Sample Expenses Reimbursement of Orthodontic Expenses Orthodontic Service Agreement Form Dependent Care Reimbursement Account Q & A Retirement Plan Benefit Highlights Notice Long Term Care Information Enrollment Form... Last Page 1

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4 INTRODUCTION Welcome to The Archdiocese of Saint Paul & Minneapolis Benefits Summary and Enrollment Guide. This guide is designed to be used during your enrollment period. It will introduce all of the benefits, explain who is eligible, show what cost is associated with each benefit and explain how to enroll. An enrollment form found at the back of this guide is provided for your initial benefits elections. This guide is not intended to be your certificate or benefit plan document. It is a summary only, whose sole purpose is to help guide you through your enrollment period. Once you make your elections you will receive the appropriate benefit certificates and plan documents that explain your benefits in detail. The actual plan documents determine actual benefits. Total Compensation Means More Than Just Salary! In today's employment arena, one cannot look at salary alone when reviewing employment positions. We understand this and just how important benefits can be to our employees and their families. The fact is benefits have become a major part of compensation. The "benefit" portion of compensation takes many forms, from health care provisions to administration of retirement savings. Many times non-salary benefits, such as medical, life, and disability insurance, workers compensation, pension contributions, etc. can actually total more than 25% of your total annual compensation. Because we understand the high value you place on these benefits, The Archdiocese of Saint Paul & Minneapolis has designed its benefits package so that it offers you and your family valuable and competitive protection and coverage. You Can Help Control The Cost of Benefits In The Future. Yes, insurance premium rates are influenced by our claims history, a higher claims history usually means a higher premium rate. You can help control future costs by using services wisely. Only you can determine when to see a doctor. Economically, "two visits may not necessarily be better than one." A phone call may be just as good as a visit. When your doctor gives you a recommendation, it is okay to question the appropriateness and/or cost of their recommendation. As health care purchasers, you have the right to question and compare the services you receive from your practitioners, so that you can obtain the most safe, effective, and economical treatment available. Remember, this important step should be no different from purchasing any other service or commodity. IMPORTANT: All eligible employees, regardless of benefit elections, must complete in full the enclosed enrollment form found at the back of this guide and return it in the enclosed business reply envelope. If the form is incomplete, it will be returned to you for completion. If you have any questions, please contact Corporate Health Systems, Inc at (952) ext

5 WHO CAN ANSWER YOUR QUESTIONS? Following is a directory of numbers if you have general questions concerning claims or benefit coverages. Health Insurance: Carrier: Blue Cross Blue Shield of MN Plan Name: Comprehensive Major Medical Website: Group Policy Number:... EP914-W0... (651) (866) Dental Insurance: Carrier: Delta Dental Plan Name: Delta Dental of Minnesota Website: Group Policy Number: (651) (800) Long Term Disability: Carrier: UnumProvident Group Policy Number: (800) Long Term Care: Carrier: CNA... (866) Retirement Plan: Carrier: MetLife Group Policy Number: Visit - Group and Supplemental Life Insurance: Carrier: UnumProvident Group Policy Number: (800) Flexible Spending Accounts: Administrator: Corporate Health Systems, Inc....(952) ext 123 or 124 Group and Supplemental AD&D Insurance: Carrier: Mutual of Omaha Group Policy Number: T5MP Supplemental Policy Number: T66BA (800) Ext Benefits Communications Firm: Corporate Health Systems, Inc....(952) ext 123 FOR QUESTIONS ABOUT GENERAL BENEFIT COVERAGE PLEASE REFER TO YOUR BENEFIT CERTIFICATES OR CONTACT CORPORATE HEALTH SYSTEMS, INC. 4

6 The Archdiocese of Saint Paul & Minneapolis FLEXIBLE BENEFITS PLAN Medical and Dental Insurance Premium Accounts 5

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8 SAMPLE CASE OF BENEFITS TAKEN PRE-TAX VERSUS AFTER TAX FLEXIBLE BENEFITS AFFECTS TAXES AND MAY BOOST...YOUR TAKE-HOME PAY An example: The following example illustrates the effect of paying for eligible benefit expenses after-tax (salary deduction) compared to paying for benefits pre-tax (salary reduction) through our flexible benefits plan. This example is based on a monthly gross pay of $2,000.00, for a married person claiming two exemptions (2012 tax tables). They figure monthly day care expenses are $200, and monthly medical and dental expenses are $10. Their monthly medical insurance premium cost is $50. Benefits Taken WITH FLEXIBLE BENEFITS (Pre-Tax) Benefits Taken WITHOUT FLEXIBLE BENEFITS (After-Tax) Gross Wages $2, $2, Benefits Paid Before Taxed: Health Insurance Premiums $50.00 $0.00 Dependent Care Reimbursement $ $0.00 Medical Reimbursement $10.00 $0.00 Taxable Wages $1, $2, Taxes: Social Security and Medicare Tax $ $ Federal Tax $43.00 $71.00 State Tax $32.00 $47.00 Benefits Paid After Tax: Health Insurance Premiums $0.00 $50.00 Dependent Care Reimbursement $0.00 $ Medical Reimbursement $0.00 $10.00 Disposable Income $1, $1, By paying these expenses PRE-TAX, disposable income is increased by $62.89 per month or $ annually. 7

9 FLEXIBLE BENEFITS PLAN ENROLLMENT Q & A Q. What is a Flexible Benefits Plan? A. A Flexible Benefits Plan is an innovative approach to providing employee benefits. A flexible benefits plan allows you to make medical and dental premium payments prior to income tax withholdings, therefore lowering your taxable income. A flexible benefits plan also allows you to choose the benefits that best fit you and your family's individual needs. Because of the flexibility that these optional features provide, these types of benefit plans have become known as flex plans. These benefit plans must meet the requirements of IRS Code Sections 105, 125 and 129 so that their contributions qualify for payment through payroll reduction prior to taxes. The Flexible Benefits program has been carefully designed so that you may take the most advantage of tax laws. Remember, with all benefit options there are IRS regulations that must be followed. These are outlined in the following pages of this guide. Q. Will my premium taken pretax change if our contract is re-negotiated during the year? A. Yes, the premium amounts will automatically be adjusted at the time of the change. Q. Who is eligible for premiums to be deducted on a pre-tax basis? A. You must be designated a full-time employee, regularly scheduled to work 25 hours or more per week, in anticipation of working five consecutive months. You are eligible to become a participant on the first of the month following date of hire or coinciding with date of hire if it falls on the first of the month. Pre-Tax Premiums IRS code section 125 allows you to fund your qualifying monthly medical and dental premiums on a pre-tax basis rather than an after-tax basis. Q. How are the premiums taken out of my paycheck? A. Your group medical and dental premiums are automatically taken from your paycheck pre-tax, before taxes are calculated. 8

10 FLEXIBLE BENEFITS PLAN ENROLLMENT Q & A Q. What is a status change? A. Under the federal government, a change in status allows you to change your elections under the plan during the year if the change is due to and consistent with any of the following events: 1. marriage, 2. divorce, 3. birth or adoption of a child, 4. death of a spouse or child, 5. commencement or termination of your or your spouse s or child s employment, 6. change from full-time to part-time employment or vice versa by you or your spouse, 7. a significant change in your or your spouse s health coverage due to your spouse s employment, 8. taking an unpaid leave of absence by you or your spouse, 9. a child reaches the limiting age of 26, 10. dependent/spouse qualifies for Medicare or Medicaid. 11. employee/dependent qualifies for (or looses) State Premium Assistance under Medicaid or SCHIP (has a 60 day election period). If you have a change in status, you can obtain a Family Status Change Form from your employer or Corporate Health Systems. The form must be submitted within 31 days of the occurrence of a change in status. Q. Why are medical and dental insurance the only items that are taken as pretax? A. According to the IRS, only medical and dental insurance and the first $50,000 of group life insurance are eligible for a pre-tax status. Supplemental Life insurance is not taken as a pretax item since administratively it would be very difficult to achieve. Q. What documents should I expect to receive if I enroll in the Flexible Benefits Plan? A. Flexible Benefits Summary Plan Description Q. Will taking premiums pre-tax reduce my future Social Security retirement benefits? A. Converting pay to a Flexible Benefits Program may have an effect on the benefits you and your family will receive from Social Security since the formula used in determining your benefit takes into account your social security taxable wages, which are lowered by your pre-tax elections. 9

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12 The Archdiocese of Saint Paul & Minneapolis MEDICAL BENEFITS PLAN A Comprehensive Medical, Hospital and Surgical Plan 11

13 12 This is a benefit summary only, and does not outline all your benefits. When you enroll, you will receive a Summary Plan Description. If there is a discrepancy between information in this summary and the Summary Plan Description, the Summary Plan Description will take precedence in determining your benefits. Contact the insurance carrier for more information and answers to specific questions, or call Corporate Health systems, Inc. for a copy of the Plan Document before making a decision.

14 Important Notice from your Plan Sponsor About Your Prescription Drug Coverage and Medicare Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with your Plan Sponsor and about your options under Medicare s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2. Your Plan Sponsor has determined that the prescription drug coverage offered by the benefit plan is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from November 15 th through December 31 st. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you do decide to join a Medicare drug plan, and drop your current Plan Sponsor s benefit plan coverage, be aware that you and your dependents may be affected and may not be able to get this coverage back. When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with the Plan Sponsor and don t join a Medicare drug plan within 63 continuous days after your current coverage ends, you 13 information in this summary and the Summary Plan Description, the Summary Plan Description will take precedence in determining your benefits. Contact the insurance carrier for more information and answers to specific questions, or call Corporate Health systems, Inc. for a copy of the Plan Document before making a decision.

15 may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following November to join. For More Information About This Notice Or Your Current Prescription Drug Coverage Contact the person listed below for further information; NOTE: You ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through the Plan Sponsor changes. You also may request a copy of this notice at any time. For More Information About Your Options Under Medicare Prescription Drug Coverage More detailed information about Medicare plans that offer prescription drug coverage is in the Medicare & You handbook. You ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: Visit Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the Medicare & You handbook for their telephone number) for personalized help Call MEDICARE ( ). TTY users should call If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at or call them at (TTY ). Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty). Date: July 1, 2012 Name of Entity/Sender: The Archdiocese of St Paul and Minneapolis Contact--Position/Office: Plan Administrator Address: 226 Summit Ave, St Paul MN Phone Number: (651) information in this summary and the Summary Plan Description, the Summary Plan Description will take precedence in determining your benefits. Contact the insurance carrier for more information and answers to specific questions, or call Corporate Health systems, Inc. for a copy of the Plan Document before making a decision.

16 Health Insurance Portability and Accountability Act HIPAA Federal HIPAA law requires us to notify you about two very important Plan provisions prior to your enrollment. The first is your right to enroll under a Special Enrollment Provision if you acquire a new dependent, or you or an eligible dependent declines coverage because of alternative coverage and later lose such coverage due to certain qualifying reasons. Second, the notice advises you of the Plan s Pre-Existing Condition exclusion rules that may temporarily exclude coverage for certain pre-existing conditions that you or your family may have. Your health premiums are deducted on a pre-tax basis and are therefore subject to the rules and regulations of IRS Code Section 125. Once you have made your health plan elections during the Annual Benefits Enrollment or during your initial enrollment period, there are limited circumstances under which you can make changes known as family status or HIPAA Special Enrollment events: o If you have a family status change as defined by IRS Code Section 125 during the plan year, you are allowed o to make coverage level changes to your coverage that are consistent with that event. If you have a family status change that is also a HIPAA Special Enrollment event and your employer offers more than one health plan, you will also be able to move to another health plan offered by the employer. Example: You currently have employee only coverage but, will have a new dependent as a result of marriage: this is a HIPAA Special Enrollment. You can add your new spouse to your health insurance coverage (change from employee only to employee + spouse coverage). A family status change may also be a HIPAA Special enrollment. What makes a family status change ALSO a HIPAA Special Enrollment is when the event involves circumstances previously unknown which necessitate the addition of coverage for yourself or your dependent. Please refer to the Special Enrollment Provisions below for details. Loss of Coverage Special Enrollment Provisions If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance coverage, and that coverage terminates due to certain qualifying reasons (i.e., COBRA exhaustion or state law continuation rights; eligibility loss due to legal separation, divorce, death, employment termination, or reduction in hours; or because employer contributions for other coverage cease) you may in the future be able to enroll yourself or your dependents in the benefit plans, provided that you request enrollment within 30 days after your other coverage ends and that you meet certain other important conditions described in the Summary Plan Description. You must inform us in writing at the time you decline coverage that you are declining coverage because of other health insurance coverage in order to be eligible for this special enrollment period. In general, coverage will become effective the day following the date on which your other coverage would normally end. Effective April 01, 2009, two additional special enrollment provisions have been added: If you or a dependent lose eligibility for Medicaid or coverage under a state children s health insurance program (SCHIP) If you or a dependent become eligible for a state premium assistance subsidy under the plan through Medicaid or SCHIP. Special enrollment for these two new special enrollment provisions must be requested within 60 days after the termination of coverage or the determination of eligibility for a state premium assistance subsidy, as applicable. Marriage, Birth, or Adoption If you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents, provided that you request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption and that you meet certain other important conditions as described in your Summary Plan Description. In general, coverage will become effective the date of marriage, birth, adoption or placement for adoption. 15 information in this summary and the Summary Plan Description, the Summary Plan Description will take precedence in determining your benefits. Contact the insurance carrier for more information and answers to specific questions, or call Corporate Health systems, Inc. for a copy of the Plan Document before making a decision.

17 All coverage request changes must be consistent with the family status change. Pre-Existing Conditions The Medical Plan imposes a Pre-Existing Condition Exclusion. This means that if you have a medical condition before coming on to the plan, you might have to wait a certain period of time before the Plan will provide coverage for that condition. This exclusion applies only to conditions for which medical advice, diagnosis, care, or treatment was recommended or received within the 6 month period prior. Generally, this 6 month period ends the day before your coverage becomes effective. However, if you were in a waiting period for coverage, the 6 month period ends on the day before the waiting period begins. The pre-existing conditions exclusion may last up to 18 months for late enrollees from the first day of coverage, or if in a waiting period, from the first day of the waiting period. However, the exclusion period can be reduced by the number of days you have prior creditable coverage. Most prior health coverage is creditable coverage and can be used to reduce the preexisting condition exclusion if you have not experienced a break in coverage of at least 63 days. To reduce the 18 months exclusion period by your creditable coverage, you should give us a copy of any creditable coverage (HIPAA Certificates) you have. The Pre-Existing Conditions Limitation does not apply to pregnancy or disabled dependents. It also does not apply to newborns or adopted children, who you enroll for medical coverage within 30 days of birth, adoption, or placement for adoption. Effective first plan year renewal after September 23, 2010 Pre-Existing Conditions Limitation does not apply to enrollees under age 19. The prohibition of pre-existing conditions provides protection from denial of enrollment or denial of specific benefits based on the pre-existing condition. HIPAA generally defines a pre-existing condition exclusion as a limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the date of enrollment for the coverage whether or not any medical advice, diagnosis, care or treatment was recommended or received before that date. Certificates of Creditable Coverage The Health Insurance Portability and Accountability Act of 1996 (HIPAA) limits the circumstances under which coverage may be excluded for medical conditions present before you enroll. You have a right to receive a certificate showing you or your dependents prior health coverage. If you enroll in the Health Plan, and have a pre-existing condition, which is excluded under the Plan, you may be entitled to reduce the period of the pre-existing condition exclusion by providing a certificate of coverage. The period during which the Pre- Existing Conditions Limitation applies will be reduced by the number of months during which you were previously enrolled for coverage under most group health plans, an individual health policy or most government health programs (Creditable Coverage), provided there has been no break in coverage which exceeds 63 days. In order to receive credit for prior coverage, you will be required to provide Certification to the Plan of such prior coverage. The Certification must include documentation of the duration of coverage under the prior health plan (including COBRA coverage) or other coverage and any waiting/affiliation periods used under the prior coverage. If you buy health insurance coverage other than through an employer group health plan, a certificate of your prior coverage may help you obtain coverage without a pre-existing condition exclusion. Contact your State Insurance Department for further information if you purchase private insurance coverage. At such time as you or your dependents cease to be covered under this Plan, we will provide you with a Certificate of Coverage, which you may present at the time you become enrolled for coverage under another plan of health coverage. 16 information in this summary and the Summary Plan Description, the Summary Plan Description will take precedence in determining your benefits. Contact the insurance carrier for more information and answers to specific questions, or call Corporate Health systems, Inc. for a copy of the Plan Document before making a decision.

18 Medicaid and the Children s Health Insurance Program (CHIP) Offer Free Or Low-Cost Health Coverage To Children And Families If you are eligible for health coverage from your employer, but are unable to afford the premiums, some States have premium assistance programs that can help pay for coverage. These States use funds from their Medicaid or CHIP programs to help people who are eligible for employersponsored health coverage, but need assistance in paying their health premiums. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, you can contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, you can contact your State Medicaid or CHIP office or dial KIDS NOW or to find out how to apply. If you qualify, you can ask the State if it has a program that might help you pay the premiums for an employer-sponsored plan. Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, your employer s health plan is required to permit you and your dependents to enroll in the plan as long as you and your dependents are eligible, but not already enrolled in the employer s plan. This is called a special enrollment opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you live in one of the following States, you may be eligible for assistance paying your employer health plan premiums. The following list of States is current as of January 31, You should contact your State for further information on eligibility ALABAMA Medicaid Website: Phone: ALASKA Medicaid Website: Phone (Outside of Anchorage): Phone (Anchorage): ARIZONA CHIP Website: Phone (Outside of Maricopa County): Phone (Maricopa County): COLORADO Medicaid Medicaid Website: Medicaid Phone (In state): Medicaid Phone (Out of state): FLORIDA Medicaid Website: Phone: GEORGIA Medicaid Website: Click on Programs, then Medicaid Phone:

19 IDAHO Medicaid and CHIP Medicaid Website: Medicaid Phone: CHIP Website: CHIP Phone: INDIANA Medicaid Website: Phone: IOWA Medicaid Website: Phone: KANSAS Medicaid Website: Phone: KENTUCKY Medicaid Website: Phone: LOUISIANA Medicaid Website: Phone: MAINE Medicaid Website: Phone: MASSACHUSETTS Medicaid and CHIP Website: Phone: MINNESOTA Medicaid Website: Click on Health Care, then Medical Assistance Phone: MISSOURI Medicaid Website: Phone: MONTANA Medicaid Website: clientindex.shtml Phone: NEBRASKA Medicaid Website: Phone: NEVADA Medicaid Medicaid Website: Medicaid Phone: NEW HAMPSHIRE Medicaid Website: Phone: NEW JERSEY Medicaid and CHIP Medicaid Website: dmahs/clients/medicaid/ Medicaid Phone: CHIP Website: CHIP Phone: NEW YORK Medicaid Website: Phone: NORTH CAROLINA Medicaid and CHIP Website: Phone: NORTH DAKOTA Medicaid Website: Phone:

20 OKLAHOMA Medicaid and CHIP Website: Phone: OREGON Medicaid and CHIP Website: Phone: PENNSYLVANIA Medicaid Website: Phone: RHODE ISLAND Medicaid Website: Phone: SOUTH CAROLINA Medicaid Website: Phone: SOUTH DAKOTA - Medicaid Website: Phone: TEXAS Medicaid Website: Phone: UTAH Medicaid and CHIP Website: Phone: VERMONT Medicaid Website: Phone: VIRGINIA Medicaid and CHIP Medicaid Website: HIPP.htm Medicaid Phone: CHIP Website: CHIP Phone: WASHINGTON Medicaid Website: Phone: ext WEST VIRGINIA Medicaid Website: Phone: , HMS Third Party Liability WISCONSIN Medicaid Website: Phone: WYOMING Medicaid Website: Phone: To see if any more States have added a premium assistance program since January 31, 2012, or for more information on special enrollment rights, you can contact either: U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services EBSA (3272) , Ext OMB Control Number (expires 09/30/2013)

21 20 This is a benefit summary only, and does not outline all your benefits. When you enroll, you will receive a Summary Plan Description. If there is a discrepancy between information in this summary and the Summary Plan Description, the Summary Plan Description will take precedence in determining your benefits. Contact the insurance carrier for more information and answers to specific questions, or call Corporate Health systems, Inc. for a copy of the Plan Document before making a decision.

22 MEDICAL BENEFITS PLAN BENEFIT HIGHLIGHTS Blue Cross Blue Shield - DEDUCTIBLE PLAN In-Network Out-of-Network ANNUAL DEDUCTIBLE $500 per person $500 per person $1,500 per family $1,500 per family OUT-OF-POCKET MAXIMUM Once your out-of-pocket maximum is reached, the plan pays 100% until the end of the plan year. This maximum applies to medical care. There is a separate plan year maximum on prescription drug costs. Once this maximum is reached, the plan pays 100% until the end of the plan year. $1,500 per person $4,500 per family $750 per person $1,000 per family $1,500 per person $4,500 per family $750 per person $1,000 per family LIFETIME MAXIMUM Unlimited Unlimited PHYSICIAN SERVICES Preventive care (routine physicals, well-child care 100% 80% after deductible through age 5, prenatal care, eye and ear exams, cancer screenings, immunizations and vaccinations) OFFICE VISITS FOR SICKNESS AND INJURY 80% after deductible 80% after deductible Lab and X-rays 80% after deductible 80% after deductible OTHER PROVIDER SERVICES Chiropractic care ($500 per person plan year limit for 80% after deductible 80% after deductible out-of-network) Physical, occupational and speech therapy ($500 per 80% after deductible 80% after deductible person plan year limit for out-of-network) HOME HEALTH CARE 80% after deductible 80% after deductible OUTPATIENT HOSPITAL SERVICES Outpatient surgery 80% after deductible 80% after deductible Lab and X-rays 80% after deductible 80% after deductible PREADMISSION TESTS, RADIATION THERAPY, 80% after deductible 80% after deductible CHEMOTHERAPY AND KIDNEY DIALYSIS INPATIENT HOSPITAL SERVICES 80% after deductible 80% after deductible EMERGENCY ROOM 80% after $70 copay 80% after $70 copay AMBULANCE SERVICES 80% after deductible 80% after deductible DURABLE MEDICAL EQUIPMENT 80% after deductible 80% after deductible MENTAL HEALTH AND CHEMICAL DEPENDENCY CARE INPATIENT CARE 80% after deductible 80% after deductible Outpatient care 80% after deductible 80% after deductible Office visit 80% after deductible 80% after deductible PRESCRIPTION DRUGS Retail pharmacies (31-day supply) For preferred only: 100% after $10 copay or 20% coinsurance, whichever is greater, to a maximum of $25 Mail-order drugs (90-day supply) Available by mail through Prim or at retail outlets in the Extended Supply Network. For preferred only: 100% after $20 copay or 20% coinsurance, whichever is greater, to a maximum of $50 MEDICALBENEFITS PLAN BENEFIT COSTS Summary of Benefit Costs: Please see the Employer Benefit Cost Listing included in this enrollment package. 21 This is a benefit summary only, and does not outline all your benefits. When you enroll, you will receive a Summary Plan Description. If there is a discrepancy between information in this summary and the Summary Plan Description, the Summary Plan Description will take precedence in determining your benefits. Contact the insurance carrier for more information and answers to specific questions, or call Corporate Health systems, Inc. for a copy of the Plan Document before making a decision.

23 MEDICAL BENEFITS PLAN ENROLLMENT Q & A Q. Who is eligible for the Medical Benefits Plan and when? Q. How do I enroll in the Medical Benefits Plan? A. Employee Eligibility: You must be designated a full-time employee, regularly scheduled to work 25 hours or more per week, in anticipation of working five consecutive months. You are eligible to become a participant on the first of the month following date of hire or coinciding with date of hire if it falls on the first of the month. Dependent Eligibility: If you are an eligible employee and elect medical coverage for yourself, you may also cover your eligible dependents. Eligible dependents include your spouse and children up until age 26, regardless of their marital or student status. If you are not actively at work on the date your coverage would be effective, you may become a participant as soon as you return to work, assuming you have applied for coverage. Q. Who is the health insurance carrier? A. Blue Cross and Blue Shield of Minnesota is the insurance carrier. They will process your medical claims. If you have any questions regarding your claims, how benefits will be paid, or finding a provider, you may contact them by phone at (651) or (866) You may also try their website at Q. What if I choose not to enroll now? A. If you decline medical coverage for yourself and/or your dependents because of spousal group coverage or medicare coverage during your eligibility period, and wish to apply for coverage at a later date, you must wait until the annual enrollment period, unless you have a family status change. A. Every eligible employee has a one-time eligibility period (first 31 days after becoming eligible). During the eligibility period, employees and their dependents may sign up the Deductible Plan. At the end of this guide, there is an enrollment form to fill out and return to Corporate Health Systems, Inc. Whether or not you are enrolling for coverage, the completed enrollment form must be signed and returned. If the form is not filled out in its entirety, it will be returned to you for completion. Q. What is a Family Status Change? A. Under federal law, a change in status allows you to change your elections under the plan during the year, if the change is due to and consistent with any of the following events: 1. marriage, 2. divorce, 3. birth or adoption of a child, 4. death of a spouse or child, 5. commencement or termination of your or your spouse s or child s employment, 6. change from full-time to part-time employment or vice versa by you or your spouse, 7. a significant change in your or your spouse s health coverage due to your spouse s employment, 8. taking of an unpaid leave of absence by you or your spouse. 9. a child reaches the limiting age of 26, 10. dependent/spouse qualifies for Medicare or Medicaid. 11. employee/dependent qualifies for (or looses) State Premium Assistance under Medicaid or SCHIP (has a 60 day election period). If you have a change in status, you can obtain a Family Status Change Form from your employer or Corporate Health Systems. The form must be submitted within 31 days of the occurrence of a change in status. 22 This is a benefit summary only, and does not outline all your benefits. When you enroll, you will receive a Summary Plan Description. If there is a discrepancy between information in this summary and the Summary Plan Description, the Summary Plan Description will take precedence in determining your benefits. Contact the insurance carrier for more information and answers to specific questions, or call Corporate Health systems, Inc. for a copy of the Plan Document before making a decision.

24 MEDICAL BENEFITS PLAN ENROLLMENT Q & A Q. What documents/items should I expect to receive, if I enroll in the Medical Benefits Plan? A. Blue Cross will mail directly to your home your Group Identification Card(s) and Corporate Health Systems, Inc. will mail directly to your home the Certificate of Coverage. Q. What is the purpose of my Group Identification Card? A. The ID card is a wallet card that is used to show your provider who your carrier is for submitting medical claims. It includes a telephone number for verification of benefits and pre-certification phone numbers. This card is also used for obtaining prescription drugs. A card will be provided for each covered family member. Q. What is the purpose of my Certificate of Coverage? A. The Certificate of Coverage is a detailed summary of your employer s group health plan. It should be used as a reference tool. If you still have questions after reviewing your Certificate of Coverage, please call Blue Cross Customer Service. Q. What doctors can I see? A. The Blue Cross Aware Plan allows you to choose your physician from a list of participating providers. To check to see if you doctor is in the Blue Cross Aware Network ask your physician, go to or contact customer service at (651) or If you choose a physician outside of the Blue Cross Aware Network, your benefits will be paid as Out-of-Network Services. Q. What is pre-certification and when do I need to pre-certify? A. Pre-certification is the process used to notify Blue Cross Blue Shield when your provider requests any in-patient procedure. The main reason for precertification is to help you obtain the correct treatment at the correct cost. As long as you are using a participating provider, they will coordinate your pre-certification with Blue Cross Blue Shield. It is your responsibility to obtain precertification when using a non-participating provider. The Blue Cross Blue Shield telephone number is on the back of your medical identification card. Q. When do I need prior authorization? Your Blue Cross Blue Shield Certificate of Coverage defines which physician and outpatient hospital procedures require prior authorization. Prior authorization is the member s responsibility only when using a non-participating provider. Q. Is there a pre-existing condition clause? A. No. The pre-existing condition clause does not apply under Blue Cross Blue Shield. Enrollment will not be accepted other than the initial enrollment period, an annual enrollment period, or a qualifying event as indicated on page 22 of this guide or in the Master Group Contract. Late entrants may be declined in some cases. Coverage applied for during the annual enrollment period will be effective on July 1. 23

25 MEDICAL BENEFITS PLAN ENROLLMENT Q & A Q. How do I file a claim? A. When you visit a participating provider, they will submit your medical claim for you. When you visit a non-participating provider, you will need to submit your claim yourself. Claim forms are available by calling Blue Cross Blue Shield at (651) or (866) When you submit the claim please send along the bill/statement you received from the provider. Some non-participating providers may submit the claim to Blue Cross for you if you ask. Q. What are usual and customary (U & C) charges? A. U & C charges are what the medical community uses to gauge the appropriate cost for a procedure. There are various formats for determining local U & C charges, with all formats attempting to accomplish the same task: fair pricing of procedures. Some carriers use the standard U & C schedule available through the Health Insurance Association of America (HIAA) or one of the other standard programs. In addition, carriers may combine the standard guides with their own U & C studies. Q. How will prescription drugs be paid? A. You will use your medical identification card. Show this card to your pharmacist when requesting doctor-prescribed medication. You will be responsible for only your copay. The pharmacist will submit the rest of your claim to Blue Cross Blue Shield for reimbursement. Q. What is the FirstHelp nurse advice line? A. It offers immediate assistance and free medical information. The FirstHelp Line is open 24 hours a day, 365 days per year. The telephone number is (800) Q. What is an Explanation Of Benefits (EOB) Form? A. The EOB is a form mailed to you from Blue Cross Blue Shield that explains each submitted bill and how it was considered for payment. The actual amount paid on your behalf will be indicated. If you have any questions, there will be a phone number listed for verification or reconsideration. Q. What should I do if a provider requests payment over Usual and Customary charges? A. When a provider bills you for amounts your carrier tells you are over the usual and customary charges for the particular service in question, the administrator is telling you that your provider is charging you too much. As in any over-billing situation, you may want to question your provider and request to know why payment, over what the industry deems standard, should be made. After questioning, you will probably find that your provider will accept what the carrier recommends as the usual and customary fee. Q. What should I do if I have questions regarding my Explanation of Benefits or benefits in general? A. Contact Blue Cross Blue Shield customer service and discuss your concerns with them. If you are unable to come to an understanding with them, contact Corporate Health Systems, Inc. 24

26 The Archdiocese of Saint Paul & Minneapolis DENTAL BENEFITS PLAN A Comprehensive Plan of Prevention, Restoration and Repair 25

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28 DENTAL BENEFITS PLAN BENEFIT HIGHLIGHTS BENEFIT SUMMARY Coverage Year July 1 through June 30 Annual Maximum Benefit Per covered person (Combined in- and out of-network) Deductible Per person / per family (per coverage year) No deductible for diagnostic and preventative services Diagnostic & Preventative Services Oral Exams (Including emergency and specialist exams) 2x / coverage year Bitewing x-rays at one series / coverage year Full mouth x-rays at 1x / 3 coverage years Dental or periodontal prophylaxis (cleaning) 2x / coverage year Fluoride treatment at 1x / coverage year for covered persons under age 19 Sealants at 1x / 4 consecutive coverage years, limited to permanent first and second molars for dependent children under age 16 Basic Services Emergency Treatment for relief of pain Amalgam restorations (silver fillings) Composite resin restorations (white fillings) on anterior (front) teeth General anesthesia / intravenous conscious sedation / IV sedation when performed with complex surgical service Delta Dental PPO Delta Dental Premier Non- Participating $1,000 $1,000 $1,000 $25 / $75 $25 / $75 $25 / $75 100% 100% 100% of maximum allowable fee ** 100% 80% 80% of maximum allowable fee ** Endodontics / Periodontics / Oral Surgery 100% 80% 80% of maximum allowable fee ** Major Restorative Services Crowns, inlays or onlays Resin (white filling) restoration for posterior (back) teeth 50% 50% 50% of maximum allowable fee ** Prosthetic Repairs and Adjustments 50% 50% 50% of maximum allowable fee ** Prosthetics: Removable and Fixed 50% 50% 50% of maximum allowable fee ** **Dentists who have signed a participating network agreement with Delta Dental have agreed to accept the maximum allowable fee as payment in full. Non-participating dentists have not signed an agreement and are not obligated to limit the amount they charge; the member is responsible for paying any difference to the non-participating dentists. DENTAL BENEFITS PLAN BENEFIT COSTS Summary of Benefit Costs: Please see the Employer Benefit Cost Listing included in this enrollment package. 27

29 DENTAL BENEFITS PLAN ENROLLMENT Q & A Q. Why have Dental Insurance? A. Dental coverage is designed to provide protection for you and your family in the event that you require dental services during the year. The dental plan provides levels of coverage for certain dental expenses ranging from routine services to major services. Q. Who is eligible for the Dental Insurance Plan? A. Employee Eligibility: You must be designated a full-time employee, regularly scheduled to work 25 hours or more per week, in anticipation of working five consecutive months. You are eligible to become a participant on the first of the month following date of hire or coinciding with date of hire if it falls on the first of the month. Dependent Eligibility: If you are an eligible employee and elect dental coverage for yourself, you may also cover your eligible dependents. Eligible dependents include your spouse and children up until age 26, regardless of their marital or student status. If you are not actively at work on the date your coverage would be effective, you may become a participant as soon as you return to work, assuming you have applied for coverage. Q. Who is the Dental Insurance Carrier? A. Delta Dental is the dental insurance carrier. Delta Dental will process your dental claims. If you have any questions regarding dental claims or would like to find a participating dentist, you should contact Delta Dental at (651) or their website; Q. Will I have a pre-existing condition clause? A. No, as long as you enroll within your eligibility period. Q. Is there a special list of providers to choose from? A. For your selection of participating dental providers, Delta Dental provider information is available online at or by contacting Delta Dental Customer Service at (651) or (800) Q. How do I enroll in the Dental Plan? A. Every eligible employee has a one-time eligibility period (first 31 days after becoming eligible). During the eligibility period, employees and their dependents may sign up for coverage. At the end of this guide, there is an enrollment form to fill out and return to Corporate Health Systems, Inc. Whether or not you are enrolling for coverage, the completed enrollment form must be signed and returned. If the form is not filled out in its entirety, it will be returned to you to be completed. Q. What is a Family Status Change? A. Under federal law, a change in status allows you to change your elections under the plan during the year, if the change is due to and consistent with any of the following events: 1. marriage, 2. divorce, 3. birth or adoption of a child, 4. death of a spouse or child, 5. commencement or termination of your or your spouse s or child s employment, 6. change from full-time to part-time employment or vice versa by you or your spouse, 7. a significant change in your or your spouse s health coverage due to your spouse s employment, 8. taking of an unpaid leave of absence by you or your spouse, 9. a child reaches the limiting age of dependent/spouse qualifies for Medicare or Medicaid, 11. employee/dependent qualifies for (or looses) State Premium Assistance under Medicaid or SCHIP (has a 60 day election period). If you have a change in status, you can obtain a Family Status Change Form from your employer or Corporate Health Systems. The form must be submitted within 31 days of the occurrence of a change in status. 28

30 DENTAL BENEFITS PLAN ENROLLMENT Q & A Q. What if I choose not to enroll now? A. If you decline dental coverage for yourself and/or your dependents during your eligibility period, and wish to apply for coverage at a later date, you must wait until the annual enrollment period, unless you have a family status change. Q. What documents/items should I expect to receive if I enroll in the Dental Plan? A. Delta Dental will mail directly to your home your Group Identification Card(s) and Corporate Health Systems, Inc. will mail to your home your Certificate of Coverage. Delta Dental provider information is available online at or by contacting Delta Dental Customer Service at (651) or (800) Q. Will I need a claim form when submitting claims? A. When you visit a participating provider, the provider will automatically submit the claim on your behalf. When you visit a non-participating provider you need to submit the claim yourself. You must submit the claim along with a Delta Dental claim form to Delta Dental no later than 365 days after receiving benefits. Your Delta Dental membership number must be on the claim. Many times your provider will submit the bill for you, if you ask them. Delta Dental claim forms can be obtained by contacting Customer Service. Q. Do I need to pre-authorize treatment prior to receiving care? A. Yes, it is recommended that you obtain prior approval from Delta Dental for major services (crowns, bridges, dentures etc). Prior approval is not a guarantee of payment. Benefits are subject to eligibility and all other terms, conditions, exclusions and limitations of the plan at the time services are provided. 29

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32 The Archdiocese of Saint Paul & Minneapolis GROUP LIFE INSURANCE PLANS Group Life Insurance (Employer Paid) & Group Accidental Death & Dismemberment Insurance (Employer Paid) 31

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34 GROUP LIFE INSURANCE PLANS BENEFIT HIGHLIGHTS Employee Group Life Benefit: Employee Benefit Amount (before age 65) 1 x Salary up to a maximum of $50,000 At age 65 At age 70 Become Terminally Ill (Accelerated Death Benefit) 65% of benefit amount 50% of benefit amount 50% of benefit amount Employee Group Accidental Death & Dismemberment Benefit: Employee Benefit Amount (before age 65) 1 x Salary up to a maximum of $50,000 At age 65 At age 70 65% of benefit amount 50% of benefit amount Loss of Life 100% Loss of one hand or one foot by dismemberment or the loss of sight of one eye 50% More than one of the above losses 100% This summary is only an outline of general information. It is not a contract. Please refer to your Summary Plan Description for full details. Contact Corporate Health Systems, Inc. for more information. GROUP LIFE INSURANCE PLANS BENEFIT COSTS Summary of Benefit Costs: Monthly Cost: Employee cost: $ 0.00 Employer cost for Group Life Insurance: $ / $1,000 Employer cost for Group AD&D: $ / $1,000 33

35 GROUP LIFE INSURANCE PLANS ENROLLMENT Q & A Q. Why have Life Insurance? A. Life Insurance is designed to provide protection for your dependents or to enable your beneficiary to settle your affairs when you die. The employer currently pays for the entire cost of the group life insurance. Q. Is the life policy a "term" policy or a cash build-up "whole life" policy? A. All life insurance products offered by the employer are on a term basis. This means that there is no cash build-up of any kind. Q. Who is eligible for the Group Life and Group AD&D Insurance Plan? A. Employee Eligibility: You must be designated a full-time employee, regularly scheduled to work 25 hours or more per week, in anticipation of working five consecutive months. You are eligible to become a participant on the first of the month following date of hire or coinciding with date of hire if it falls on the first of the month. Q. Who is the Group Life and Group AD&D Insurance carrier? A. UNUM is the Group Life Insurance carrier and Mutual of Omaha is the Group AD&D Insurance carrier. Q. Is the Life Insurance Coverage portable/convertible? A. Yes, non-disabled employees can port coverage to an individual policy within 31 days of its termination. Disabled employees can convert coverage to an individual policy within 31 days of its termination. Q. How do I enroll in the Group Life and Group AD&D Insurance program? A. All eligible employees will automatically have group life and group AD&D coverage, provided you complete and return the enrollment form to Corporate Health Systems, Inc. Q. What are some features of the Group Life Insurance Plan? A. Accidental Death and Dismemberment: The employer provided plan includes an accidental death and dismemberment (AD&D) provision. If you lose a life, limb or sight in one eye through an accident, you would receive a full or partial benefit of the accidental death and dismemberment amount. Accelerated Benefits: Since a terminal illness may have a devastating financial impact on an individual and the family, with the Accelerated Benefits Option, 50% of the life insurance may be paid upon proof of terminal illness. Conversion (Disabled Employees): In the event that you terminate your employment, you may generally continue your Group Life coverage for up to 18 months under Minnesota State Law, after which time you may convert to an individual policy. Portability (Non-Disabled Employees): In the event that you terminate your employment, you may generally continue your Group Life coverage for up to 18 months under Minnesota State Law, after which time you may port to an individual policy. Survivor Support: In the event of your death or terminal illness, all eligible employees or their survivors will have the opportunity to receive a face-to-face financial counseling session with an Ayco counselor. Survivor Support is designed to coordinate but not replace the efforts of our human resource associates, your family attorney, accountant or financial advisor. Q. What documents should I expect to receive when I become enrolled in the Group Life Insurance Plan? A. Group Life Insurance Certificate and a Group AD&D Insurance Certificate. 34

36 The Archdiocese of Saint Paul & Minneapolis SUPPLEMENTAL LIFE INSURANCE PLAN Additional Life Insurance Plan (Employee Paid) 35

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38 SUPPLEMENTAL LIFE INSURANCE PLAN BENEFIT HIGHLIGHTS Employee Supplemental Life Insurance Coverage: You may purchase life insurance on yourself in multiples of your salary... 1x, 2x, 3x, or 4x salary The guarantee issue level is (no proof of good health required)... $500,000 If during the initial eligibility period you decline any coverage for either yourself or your dependents, and apply for coverage at a later date, the Evidence of Insurability Provision applies. You will be required to complete the Evidence of Insurability form (health history) on all amounts and coverage may be denied. The maximum amount you can purchase (no proof of good health required)... $500,000 BENEFIT COSTS Employee Coverage Rates: Age Rates per $1,000 < - 30 $ and over 2.06 Reduction: 65% of the amount on your 65 th birthday 50% of the amount on your 70 th birthday Please note: After a reduction occurs you are not able to increase your election. How do I calculate my monthly costs? To calculate your monthly cost, complete the following using the example as a guide: EXAMPLE: Employee wishes to purchase $50,000 of coverage and is 35 years old. $ 50,000 X $.08 / $1,000 = $ 4.00 (Life amount selected) (Rate from table) Insert on enrollment form Employee Supplemental Life: Your monthly Cost $ X $ / $1,000 = $ (Life amount selected) (Rate from table) Insert on enrollment form The enrollment form in the back of this guide must still be completed. 37

39 Supplemental Life Insurance Plan Con t BENEFIT HIGHLIGHTS AND COSTS Spouse/Dependent Life Insurance: There are two options under the supplemental life plan for your spouse and/or dependents. OPTION #1 Dependent Coverage Amounts: The employee does not need to be insured under optional life plan. Spouse = $2,000 Child (Birth-6 months) = $100 Child (6 mos up until age 26) = $1,000 OPTION #2 Spouse Coverage Amounts: Dependent Coverage Rates: $0.48/month ~ per family unit (Regardless the number of family members). Spouse Coverage Rates: Age Rates per $1,000 The employee must be insured < - 30 $ 0.10 under the optional life plan in order to elect coverage for their spouse and/or dependents Employees may choose for their spouse coverage in increments of $5,000 to a maximum of $100,000. Not to exceed 100% of the employee s coverage amount Evidence of Insurability is required for amounts greater than $25,000. Reduction: 65% of the amount on your 65 th birthday 50% of the amount on your 70 th birthday Child(ren) Coverage Amounts: Employees may choose for their child(ren) coverage in increments of $2,000 to a maximum of $10,000 Please Note: After a reduction occurs you are not able to increase your election. Child(ren) Coverage Rates: $0.28 per $2,000 unit 38

40 SUPPLEMENTAL LIFE INSURANCE PLAN ENROLLMENT Q & A Q. Who is eligible for the Supplemental Life? A. Employee Eligibility: You must be designated a full-time employee, regularly scheduled to work 25 hours or more per week, in anticipation of working five consecutive months. You are eligible to become a participant on the first of the month following date of hire or coinciding with date of hire if it falls on the first of the month. Dependent Eligibility: If you are an active employee, you may cover your eligible dependents. Eligible dependents include your spouse and unmarried tax dependent children up until age 26. Q. Who is the Supplemental Life Insurance Carrier? A. UNUM Q. What are some features of the Supplemental Life Insurance Plan? A. Accelerated Benefits: Since a terminal illness may have a devastating financial impact on an individual and the family, with the Accelerated Benefits Option, 50% of the life insurance may be paid upon proof of terminal illness. Conversion (Disabled Employees): In the event that you terminate your employment, you may generally continue your Supplemental Life coverage for up to 18 months or your coverage under another plan if earlier under Minnesota State Law, after which time you may convert to an individual policy. Portability (Non-Disabled Employees): In the event that you terminate your employment, you may generally continue your Supplemental Life coverage for up to 18 months or your coverage under another plan if earlier under Minnesota State Law, after which time you may port to an individual policy. Q. How do I file a claim? A. Contact Corporate Health Systems, Inc. for a claim form. The form must be completed in its entirety and returned to Corporate Health Systems, Inc. who will then submit it to UnumProvident for processing. Q. What documents should I expect to receive if I enroll in the Supplemental Life Plan? A. Life Insurance Certificate of Coverage Q. How do I enroll in the Supplemental Life Insurance program? A. Every eligible employee has a one-time eligibility period (first 31 days after becoming eligible), in which to sign up for coverage. Employees will be guaranteed up to $500,000. For dependent supplemental life insurance, if you elect Option 1 you do not have to have supplemental life insurance on yourself. If you elect Option 2 you do need to have supplemental life insurance on yourself and amounts greater than $25,000 on your spouse, the Evidence of Insurability Provision applies. Once you make your elections, you may not make any changes until annual enrollment. If you have a family status change, where the dependent is newly eligible for the plan, you may add them within 31 days of the family status change. At the end of this guide, there is an enrollment form to fill out and return to Corporate Health Systems, Inc. Whether or not you are enrolling for coverage, the completed enrollment form must be signed and returned. If the form is not filled out in its entirety, it will be returned to you to be completed. Q. What if I choose not to enroll now? A. If you decline supplemental life insurance coverage for either yourself or your dependents during your initial eligibility period, and wish to apply for coverage at a later date, you must wait until annual enrollment. Or, if you have a family status change, where the dependent is newly eligible for the plan, you may add them within 31 days of the family status change. If you are applying for coverage outside of your initial enrollment period you MUST complete an Evidence of Insurability form in order to be approved. Coverage may be denied from the carrier. Q. Is the life policy a "term" policy or a cash build-up "whole life" policy? A. All life insurance products offered by the employer are on a term basis. This means that there is no cash build-up of any kind. 39

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42 The Archdiocese of Saint Paul & Minneapolis SUPPLEMENTAL ACCIDENTAL DEATH & DISMEMBERMENT (AD&D) PLAN Additional Accidental Death & Dismemberment Insurance Plan (Employee paid) 41

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44 SUPPLEMENTAL AD&D PLAN BENEFIT HIGHLIGHTS Employee Only The minimum purchase amount must be... $ 20,000 The maximum amount you can purchase... $ 250,000* * Amounts in excess of $150,000 cannot exceed 10 times your annual salary. Employee & Family Under the employee and family plan you will be insured for the principal sum elected and your spouse and dependent children will be automatically insured as follows: For your spouse: You have the choice of either 100% or 50% of your benefit amount. For your eligible children: You can elect 10% of your benefit amount for each child. Benefit Payments: For loss of: Life... Both Hands or Both Feet... Sight of Both Eyes... Speech and Hearing... One Hand and One Foot... Sight of One Eye... Either Hand or Foot % of principal sum 100% of principal sum 100% of principal sum 100% of principal sum 100% of principal sum 50% of principal sum 50% of principal sum (This is only a partial list of benefit payments.) 43

45 SUPPLEMENTAL AD&D PLAN BENEFIT COSTS Benefit Selection and Monthly Cost Table for Supplemental AD&D: *Employee must elect Employee Coverage in order to elect coverage for spouse and/or child(ren). Employee Only Benefit ADDING Spousal Coverage at 100% of Employee Benefit ADDING Spousal Coverage at 50% of Employee Benefit ADDING All Children At 10% of Employee Benefit Benefit Amount Cost Benefit Amount Cost Benefit Amount Cost Benefit Amount Cost $20,000 $0.44 $20,000 $0.44 $10,000 $0.22 $2,000 $0.10 $50,000 $1.10 $50,000 $1.10 $25,000 $0.55 $5,000 $0.24 $75,000 $1.65 $75,000 $1.65 $37,500 $0.83 $7,500 $0.36 $100,000 $2.20 $100,000 $2.20 $50,000 $1.10 $10,000 $0.48 $125,000 $2.75 $125,000 $2.75 $62,500 $1.38 $12,500 $0.60 $150,000 $3.30 $150,000 $3.30 $75,000 $1.65 $15,000 $0.72 $200,000 $4.40 $200,000 $4.40 $100,000 $2.20 $20,000 $0.96 $250,000 $5.50 $250,000 $5.50 $125,000 $2.75 $25,000 $1.20 *If you and/or your spouse are age 70 or older at the time you sustain injuries in a covered accident, your Paralysis benefits ceases to be payable and the Plan benefit reduces to 70% of Selected Plan Benefit Amount; at age 75, to 45%; at age 80, to 30%; and at age 85, to 15%. Please Note: After a reduction occurs you are not able to increase your election. 44

46 SUPPLEMENTAL AD&D PLAN ENROLLMENT Q & A Q. Who is eligible for the Supplemental AD&D? A. Employee Eligibility: You must be designated a full-time employee, regularly scheduled to work 25 hours or more per week, in anticipation of working five consecutive months. You are eligible to become a participant on the first of the month following date of hire or coinciding with date of hire if it falls on the first of the month. Dependent Eligibility: If you are an active employee and elect AD&D coverage for yourself, you may also cover your eligible dependents. Eligible dependents include your spouse and unmarried dependent children up until age 26. Q. Who is the Supplemental AD&D Insurance Carrier? Q. How do I enroll in the Supplemental AD&D program? A. Every eligible employee has a one-time eligibility period (first 31 days after becoming eligible). During this period, employees may make their election of benefits. If you waive coverage during this time you may elect coverage at annual enrollment or within 31 days of a qualified family status change. At the end of this guide, there is an enrollment form to fill out and return to Corporate Health Systems, Inc. Whether or not you are enrolling for coverage, the completed enrollment form must be signed and returned. If the form is not filled out in its entirety, it will be returned to you to be completed. Q. How do I file a claim? A. Contact Corporate Health Systems, Inc. for a claim form. The form must be completed in its entirety and returned to Corporate Health Systems, Inc., who will then submit it to Mutual of Omaha for processing. A. Mutual of Omaha Q. What documents should I expect to receive if I enroll in the Supplemental AD&D Plan? A. Accidental Death & Dismemberment Insurance Certificate. 45

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48 The Archdiocese of Saint Paul & Minneapolis LONG TERM DISABILITY PLAN Employer chooses either: 100% Employer paid or 100% Employee paid (Please see Benefit Cost Listing) 47

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50 LONG TERM DISABILITY PLAN BENEFITS HIGHLIGHTS Definition of Disability: Qualifying Period: You are disabled when UNUM determines that you are limited from performing the material and substantial duties of your regular occupation due to your sickness or injury; and you have a 20% or more loss in your indexed monthly earnings due to the same sickness or injury. After 24 months of payments, Unum will review your claim to determine that due to the same sickness or injury, you are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience. Benefits are payable after 90 or 180 days of continuous disability, depending upon the plan your employer has selected Benefits Payable: 60% of monthly salary to a maximum of $7,500 per month. Benefits may be offset by other sources (i.e., Social Security, Worker s Compensation, etc.). Residual Benefit: If you are partially disabled, you may still receive a reduced benefit. Duration of Benefits: Benefits payable on the following schedule or until no longer disabled, whichever is less. MAXIMUM DURATION OF BENEFITS TABLE Age When Totally Disabled Age 62 or less Age 62 Age 63 Age 64 Age 65 Age 66 Age 67 Age 68 Age 69 and over Benefits Payable To Social Security Normal Retirement Age 60 months 48 months 42 months 36 months 30 months 24 months 18 months 12 months LONG TERM DISABILITY PLAN BENEFITS COSTS Summary of Benefit Costs: Please see the Employer Benefit Cost listing included in this enrollment package. 49

51 LONG TERM DISABILITY PLAN ENROLLMENT Q & A Q. Why have Long Term Disability Plan? Q. How do I enroll in the Long Term Disability Plan? A. Statistically, the chances of your becoming disabled are small, but it can happen. When it does, the financial consequences can be very serious. Hospital and medical expenses will probably be covered by your Medical Insurance. What about your paycheck? If you become too disabled to work, Long Term Disability income will be your main source of income. Q. Who is eligible for the Long Term Disability Plan? A. Employee Eligibility: You must be designated a full-time employee, regularly scheduled to work 25 hours or more per week, in anticipation of working five consecutive months. You are eligible to become a participant on the first of the month following date of hire or coinciding with date of hire if it falls on the first of the month. Dependent Eligibility: Dependents are not eligible for disability coverage. Q. Who is the Long Term Disability Carrier? A. UNUM Q. Is there a pre-existing condition clause? A. A pre-existing condition limitation will apply if you become disabled as a result of a condition for which you received treatment during the 3-month period prior to your effective date under this plan. The plan will not pay disability benefits for that condition during the first 12 months of coverage under this plan. A. For the employer paid disability plan, all eligible employees will automatically have LTD coverage, provided you complete and return the enrollment form to Corporate Health Systems, Inc. For the employee paid disability plan, every eligible employee has a one-time eligibility period (first 31 days after becoming eligible), in which to sign up for coverage. You must complete and return the enrollment form to Corporate Health Systems, Inc. to be enrolled. Once you make your elections, you may not make any changes until annual enrollment. Q. What if I choose not to enroll now? A. If you decline long term disability coverage during your initial enrollment period, you may apply for coverage during annual enrollment, in which case you MUST complete an Evidence of Insurability form in order to be approved. Coverage may be denied from the carrier. Q. What documents should I expect to receive when I enroll in the Long Term Disability Plan? A. Long Term Disability certificate of coverage. Q. How do I file a claim? A. Contact Corporate Health Systems, Inc. for a claim form. The form must be completed in its entirety and returned to Corporate Health Systems, Inc. who will then submit it to Unum for processing. You will begin to receive payments when Unum approves your claim, providing the elimination period has been met and you are disabled. A payment will be sent monthly for any period for which Unum is liable. 50

52 The Archdiocese of Saint Paul & Minneapolis FLEXIBLE SPENDING ACCOUNTS Medical Reimbursement Account Dependent Care Reimbursement Account 51

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54 FLEXIBLE SPENDING ACCOUNTS ENROLLMENT Q & A Q. What is a Flexible Benefits Plan? A. A Flexible Benefits Plan is an innovative approach to providing employee benefits. A flexible benefits plan allows you to make medical and dental premium payments prior to income tax withholdings, therefore lowering your taxable income. A flexible benefits plan also allows you to choose the benefits that best fit you and your family's individual needs. Because of the flexibility that these optional features provide, these types of benefits plans have become known as flex plans. These benefits plans must meet the requirements of IRS Code Sections 105, 125 and 129 so that their contributions qualify for payment through payroll reduction prior to taxes. The Flexible Benefits program has been carefully designed so that you may take the most advantage of tax laws. Remember that with all benefit options there are IRS regulations that must be followed. These are outlined in the following pages of this guide. Be aware of use-it or lose-it rules and that contribution amounts cannot be transferred from one account to another. Medical Reimbursement Account IRS code section 105 allows you to fund your medical and dental expenses not paid by your medical and dental insurance plan on a pre-tax basis rather than an after-tax basis. Dependent Care Reimbursement Account IRS code section 129 allows you to fund your qualifying dependent care expenses on a pre-tax basis rather than an after-tax basis. Q. What if I choose not to enroll now? A. If you decline participation in the flexible benefits plan during your eligibility period you will have to wait until the next annual enrollment period or have a change in status. Q. Who is the Flex Administrator? A. Corporate Health Systems, Inc. Q. Who is eligible to participate in the Flexible Spending Accounts? A. You must be designated a full-time employee, regularly scheduled to work 25 hours or more per week, in anticipation of working five consecutive months. You are eligible to become a participant on the first of the month following date of hire or coinciding with date of hire if it falls on the first of the month. Q. How do I enroll in the Flexible Benefits Plan? A. Every eligible employee has a one-time eligibility period (first 31 days after becoming eligible). During this period, employees may make their annual elections. Once you make your elections, you may not make any changes unless you have a family status change. At the end of this guide, there is an enrollment form to fill out and return to Corporate Health Systems, Inc. Whether or not you are enrolling for coverage, the completed enrollment form must be signed and returned. If the form is not filled out in its entirety, it will be returned to you to be completed. Q. What is the time period of the plan year? A. The plan year runs from July 1 June 30. Your plan year will start when you satisfy the eligibility requirements, and end on June 30. The plan also has a grace period which will allow you to continue to incur expenses until September 15 and be reimbursed against any balance you have in the plan year that ends on June 30, once that balance is exhausted expenses that incurred between July 1 and September 15 will be applied against your new year election. 53

55 FLEXIBLE SPENDING ACCOUNTS ENROLLMENT Q & A Q. What is a status change? A. Under the federal government, a change in status allows you to change your elections under the plan during the year if the change is due to and consistent with any of the following events: Q. Will taking these expenses pre-tax affect or lower my retirement contributions? A. No. 1. marriage, 2. divorce, 3. birth or adoption of a child, 4. death of a spouse or child, 5. commencement or termination of your or your spouse s or child s employment, 6. change from full-time to part-time employment or vice versa by you or your spouse, 7. a significant change in your or your spouse s health coverage due to your spouse s employment, 8. taking an unpaid leave of absence by you or your spouse, 9. a child reaches the limiting age of 26, 10. dependent/spouse qualifies for Medicare or Medicaid, 11. employee/dependent qualifies for (or looses) State Premium Assistance under Medicaid or SCHIP (has a 60 day election period). Q. What documents should I expect to receive if I enroll in the Flexible Benefits Plan? A. Flexible Benefits Summary Plan Description Q. How do I get a Request for Reimbursement Form or a Family Status Change Form? A. Please call Corporate Health Systems, Inc. at (952) ext 123 or ext 124. If you have a change in status, you can obtain a Family Status Change Form from your employer or Corporate Health Systems. The form must be submitted within 31 days of the occurrence of a change in status. Q. Will taking premiums pre-tax reduce my future Social Security retirement benefits? A. Converting pay to a Flexible Benefits Program may have an effect on the benefits you and your family will receive from Social Security since the formula used in determining your benefit takes into account your social security taxable wages, which are lowered by your pre-tax elections. 54

56 FLEXIBLE SPENDING ACCOUNTS MEDICAL REIMBURSEMENT Q & A Q. How should I calculate my estimated annual medical, dental, and optical expenses? A. Should you enroll in the Reimbursement Account you must determine your monthly contribution very carefully. Dollars allocated to this account may be reimbursed for these qualifying expenses only. This money is not transferable to another expense account nor may it be returned to you in the event that you have overestimated your medical, dental, and optical expenses. It is recommended that you estimate conservatively these expenses during your first year in this program. Q. How are my benefits reimbursed? A. You will be reimbursed upon submission of a Request for Reimbursement Form, available from Corporate Health Systems, Inc s website click on forms. Payments for reimbursement of claims will be paid on a weekly basis. Corporate Health Systems, Inc. will reimburse you by subtracting from your Annual Election Amount the amount of your approved expenses and paying you that amount. Direct Deposit of claim reimbursements is available to you. You may print a Direct Deposit form from our website click on forms. Complete the form and attach a voided check or a letter from your bank listing your account number and the bank s routing number and forward to Corporate Health Systems, Inc. Q. When is a Doctor s Statement of Medical Necessity Form required? A. On occasion, a claim may require further information via a Doctor s Statement of Medical Necessity Form. Your CHS administrator will notify you if this is required. Some examples of expenses which require a Doctor s Statement Form are: - Services that are not covered by insurance but are medically necessary for you. - Over-the-counter supplements and vitamins. - Items that are considered dual purpose. The Doctor s Statement of Medical Necessity Form must indicate the specific medical condition, the specific treatment needed and how this treatment will alleviate the medical condition. 55 Q. When must an expense be incurred in order to claim reimbursement? A. The plan year is July 1 st through June 30 th, you may submit expenses for service dates that are incurred while you are considered a benefit eligible employee (ie; hired August 15 th, benefit eligible September 1 st but you term employment April 15 th. You may submit incurred service dates from September 1 st through April 30 th ). If you are an active benefit eligible employee the whole year, your service date range is July 1 st through June 30 th ; however, if needed, the plan allows an additional 75 day grace period at the end of the plan year to allow your incurred service date range to go through September 15 th. Q. If I participate in the pre-tax Medical Reimbursement Account, will expenses still be eligible for credit on my personal tax return? A. Any expenses, which are paid for under the Flexible Benefits Plan, cannot be claimed as an expense on your income tax return. You have already saved taxes by paying for benefits with pre-tax dollars. Q. What is the maximum annual amount I can select on a pre-tax basis? A. The maximum annual election amount is $2,500 per plan year.

57 MEDICAL REIMBURSEMENT ACCOUNT SAMPLE EXPENSES The employee funded Medical Reimbursement Account covers a variety of health care services that may not be included in certain medical and dental insurance plans. These expenses can be paid with PRE- TAX dollars. All medical care expenses and dental expenses that qualify as medical deductions under IRS rules will qualify for tax-free reimbursement under this plan. You will find on this page and the next page a very short list of examples concerning what may and may not be reimbursed through your account. In general, you may use the account for all non-covered health and dental expenses -- just so long as the expenses would otherwise qualify as a deduction for medical expenses on your income tax return. THIS LIST WILL CHANGE FROM TIME TO TIME. FOR A COMPLETE LISTING OF CURRENT MEDICAL EXPENSES, VISIT THE FOLLOWING WEBSITE: ALLOWABLE EXPENSES (But not limited to): Dental and Orthodontic Care: Artificial teeth or dentures Braces, orthodontic devices Therapy and Treatments: X-ray treatments Speech therapy Chemical dependency treatment Drug therapy treatment Acupuncture Physical therapy treatment Vaccinations Hair transplant (if medically necessary) Electrolysis (if medically necessary) Fees and Services: Physicians fees Hospital services fees Services of chiropractors Christian Science practitioner Services connected with donating an organ Physical Exams Hearing Expenses: Hearing aids and batteries Deductibles and Co-Payments (not premiums) Health insurance out-ofpocket expenses Dental insurance out-ofpocket expenses Eye Care: Eyeglasses Contact lenses Saline Solution Laser Eye Surgery Medical Equipment: Wheelchair or autoette (cost of operating/maintaining) Excess cost of orthopedic shoes over cost of ordinary shoes Crutches (purchased or rented) Prescribed special mattress & plywood boards alleviate arthritis Prescribed oxygen & equipment to relieve breathing ailments Support hose (if medically necessary) Artificial limbs Assistance for people with disabilities: Cost of a Guide for the blind Special devices (tape recorder and typewriter) for the blind Costs of equipping automobile Cost of Braille books and of regular editions Service Dog Psychiatric Care: Services of psychotherapists, psychiatrists and psychologists Over the Counter Drugs: Antacids Allergy medications Pain relievers Cold medicines Please Note: Effective 01/01/2011 you will need a prescription for the above items in order to be reimbursed. Please see pages 58 & 59. Continued next page... 56

58 MEDICAL REIMBURSEMENT ACCOUNT EXPENSES NOT ALLOWED Illegal medication Mechanical exercise device not prescribed Vacuum cleaner purchased by an individual with dust allergy Expenses of divorce when doctor of psychiatrist recommends divorce Vitamins, dietary supplements, holistic herbs Contributions to state disability funds Maternity clothes Insurance against loss of income, life, limb or eyesight Distilled water purchased to avoid drinking fluoridated city water supply Mobile telephone used for personal calls as well as calls to physician Treatments unrelated to a specific problem (for example, massage for general wellbeing) Marriage counseling Nursemaids or practical nurses in charge of healthy infants Cosmetic procedures and prescriptions Health Club Memberships Insurance Premiums THIS LIST WILL CHANGE FROM TIME TO TIME. FOR A COMPLETE LISTING OF CURRENT MEDICAL EXPENSES VISIT THE FOLLOWING WEBSITE: 57

59 The Patient Protection and Affordable Care Act bill enacted on March 23, 2010 imposes a significant change to the ability to seek reimbursement for certain over the counter items through your Health Flexible Spending Account. What the bill says in regards to this change: SEC DISTRIBUTIONS FOR MEDICINE QUALIFIED ONLY IF FOR PRESCRIBED DRUG OR INSULIN. (c) HEALTH FLEXIBLE SPENDING ARRANGEMENTS AND HEALTH REIMBURSEMENT ARRANGEMENTS. Section 106 of the Internal Revenue Code of 1986 is amended by adding at the end the following new subsection: (f) REIMBURSEMENTS FOR MEDICINE RESTRICTED TO PRESCRIBED DRUGS AND INSULIN. For purposes of this section and section 105, reimbursement for expenses incurred for a medicine or a drug shall be treated as a reimbursement for medical expenses only if such medicine or drug is a prescribed drug (determined without regard to whether such drug is available without a prescription) or is insulin.. (d) EFFECTIVE DATES. 2) REIMBURSEMENTS. The amendment made by subsection (c) shall apply to expenses incurred with respect to taxable years beginning after December 31, What this means to you: Your Health Flexible Spending Account will not be able to reimburse over the counter drug or medicine expenses that incur on or after January 1, 2011 without a prescription. Under the new law, only expenses for drugs or medicines that are prescribed will be eligible for reimbursement. Without further clarification from the IRS we believe this means that drugs or medicines sold without a prescription will be eligible for reimbursement only if the individual obtains a physician s prescription for the drug or medicine (even though it could be purchased without one). This means that the reimbursement of drugs or medicines (see a list of affected items on the back page) will not be allowed under your plan(s) starting on January 1, 2011, unless you submit a prescription from a physician (on a prescription pad) when requesting reimbursement. Also understand that this change does not impact the reimbursement of over the counter items such as contact lenses cleaners / solutions, bandages or other medical care expense items, these are still eligible expenses and will be reimbursed with proper documentation. In the event IRS issues additional guidance regarding this new requirement that would expand or narrow our current understanding of the law we will provide an update as it becomes available. Please take this change into consideration when making your health flexible spending account election for the current plan year. 58

60 Effective January 1, 2011 items in the following list require a physician s prescription: * Acid Controllers * Cough, Cold & Flu * Allergy & Sinus * Digestive Aids * Antibiotic Products * Hemorrhoidal Preps * Anti-Gas * Laxatives * Anti-Fungal * Motion Sickness * Anti-Itch & Insect Bite * Pain Relief * Anti-Parasitic Treatments * Respiratory Treatments * Baby Rash Ointments/Creams * Sleep Aids & Sedatives * Cold Sore Remedies * Stomach Remedies The following are examples of some of the OTC items that will remain available without a physician s prescription: * Band Aids * Elastic Bandages & Wraps * Braces & Supports * First Aid Supplies * Catheters * Insulin & Diabetic Supplies * Contact Lens Supplies & Solutions * Ostomy Products * Denture Adhesives * Reading Glasses * Diagnostic Tests & Monitors * Wheelchairs, Walkers, Canes Please Note: The above show the most common drug/supply categories however, these are not all inclusive lists. 59

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62 Reimbursement of Orthodontic Expenses With growing confusion concerning reimbursement for orthodontic expenses, it is necessary to specifically address these issues in an effort to clarify the subject. The IRS guidelines for reimbursement affirm that an expense cannot be reimbursed until the service has been provided. What this means for reimbursement of orthodontic expenses is the full amount for orthodontic services cannot be reimbursed when the work commences, even if the total orthodontia expenses have been paid in full. The reason for this is, the person receiving orthodontic work will continue to have services provided, usually for the next 12 to 36 months. Monthly reimbursements with Service Agreement or Contract: We can reimburse orthodontic expenses on a monthly basis in an amount established by a service agreement or contract between the orthodontist and the patient. Such an agreement should include: 1) Place of service (Name of Orthodontic facility) 2) Total cost of services less insurance payments or provider discounts 3) Initial fee (typically a banding fee) 4) Monthly payment amount 5) Number of month s treatment and payments are expected to last 6) Date treatment began 7) Name of person receiving treatment Some providers may require a down payment on your account. A down payment is not eligible for reimbursement as it does not represent any incurred services. You must have the provider break down the initial fee (the cost to have the braces placed) and that amount would be eligible at the time of the banding. The remaining amount would be rolled into the monthly payment amounts. If your provider requires a down payment, please have them complete the service agreement on the next page. If no Service Agreement or Contract is available: If such an agreement or contract is not available, please have your provider complete the Orthodontic Service Agreement Form on the following page to determine the amount you are eligible for reimbursement each month. This form should be completed and signed by your orthodontic provider and submitted with your initial claim. Submitting an orthodontic expense for reimbursement: When submitting your first orthodontic claim, the orthodontic service agreement or contract must be included with a completed Request for Reimbursement Claim Form. Please make sure the claim form indicates the person receiving service, provider name, date of service, the monthly payment amount, and nature of expense being orthodontia. Once the initial orthodontic agreement or contract is submitted, you may request future reimbursements by completing a Request for Reimbursement Claim Form, and one of the following options: OR 1) Attach a receipt or copy of the coupon (if you were provided a payment book) that clearly indicates the person receiving service, provider name, date of service, the monthly payment amount, and the nature of the expense being orthodontia. 2) In the Nature of Expense column, write, contract on file. No other information or receipt is required. 61

63 ORTHODONTIC SERVICE AGREEMENT FORM (Should be used when orthodontic service agreement or contract is not available from your orthodontist) Name of the person receiving the service Date braces were placed: / / Total amount for orthodontic services Insurance payments Provider discount Initial fee due upon placement of braces (typically a banding fee) $ - $ - $ - $ Remaining balance = $ Remaining Balance Divided by treatment months, Equals monthly reimbursements Beginning $ (Qualified monthly reimbursable amount) Provider Signature Name of Orthodontist/Clinic CHS USE ONLY: Date Received: / / Processed by: Notes Entered: / / Date Contract ends: / / 62

64 FLEXIBLE SPENDING ACCOUNTS DEPENDENT CARE REIMBURSEMENT ACCOUNT Q & A Q. How should I calculate my estimated dependent care expenses? Q. When must an expense be incurred in order to claim reimbursement? A. Should you enroll in the Reimbursement Account you must determine your monthly contribution very carefully. Dollars allocated to this account may be reimbursed for these expenses only. This money is not transferable to another expense account nor may it be returned to you in the event that you have overestimated your dependent care expenses. It is recommended that you estimate conservatively these expenses during your first year in this program. Please Note: The dependent care rule states that in order to claim dependent care expenses you and your spouse (if applicable) must be gainfully employed (actively working), looking for work, going to school (full-time), or you are incapable of self-care. When estimating your dependent care expenses you must take this into consideration. Also, if you are a teacher taking the summer months off, those months are not reimbursable. Q. How are my benefits reimbursed? A. You will be reimbursed upon submission of a Request for Reimbursement Form, available from Corporate Health Systems, Inc s website click on forms. Payments for reimbursement of claims will be paid on a weekly basis. Corporate Health Systems, Inc. will reimburse you by subtracting from your Annual Election Amount the amount of your approved expenses and paying you that amount. Direct Deposit of claim reimbursements is available to you. You may print a Direct Deposit form from our website click on forms. Complete the form and attach a voided check or a letter from your bank listing your account number and the bank s routing number and forward to Corporate Health Systems, Inc. A. An expense must be incurred during the plan year. Claims cannot be made for expenses incurred before enrollment in the plan. Q. If I participate in the pre-tax dependent care account, will expenses still be eligible for credit on my personal tax return? A. Any expenses, which are paid for under the Flexible Benefits Plan, cannot be claimed as an expense on your income tax return. You have already saved taxes by paying for benefits with pre-tax dollars. Q. What is the maximum annual amount I can select on a pre-tax basis? A. Under the current plan, you may designate up to $5,000 per calendar year if you are married and file a joint return, or are single or a head of household, for tax purposes. If you are married, reside together, and file a separate tax return, the maximum you may designate is $2,500 per calendar year. 63

65 FLEXIBLE SPENDING ACCOUNTS DEPENDENT CARE REIMBURSEMENT ACCOUNT Q & A Q. What are some of the expenses the IRS allows? A. If you need to pay for child care or for the care of a dependent or spouse with mental or physical disabilities, if such care is needed to enable you to work, you may use the Dependent Care Account to reimburse you for the cost up to certain limits. Child care or dependent care services will qualify for reimbursement under the plan if they meet these requirements: 1. If you are married, the services must be provided to enable both you and your spouse to be employed, unless one spouse is a fulltime student at an educational institution and the other is employed full-time. 2. If you are a teacher and are home during the summer months, or are on a Leave of Absence and at home, but still sending children to daycare, those expenses are NOT eligible for reimbursement. 3. If you are a teacher and are not working during the summer months, but are taking Continuing Education Courses, daycare expenses for you to attend class ARE eligible for reimbursement. 4. The amount to be reimbursed must not be greater than your or your spouse's income, whichever is lower. 5. A child must be under 13 years old, or, if older, mentally or physically incapable of caring for himself or herself. 6. The services may be provided inside or outside your home, but not by someone who is your dependent for income tax purposes, such as an older child, your spouse, or a grandparent who lives with you. 7. If child care is provided at a daycare center, the center must comply with all the rules and regulations issued by the state. 64

66 The Archdiocese of Saint Paul & Minneapolis RETIREMENT PLAN 65

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68 RETIREMENT PLAN BENEFIT HIGHLIGHTS Tax Deferred Annuity (TDA) Plan Advantages of the TDA Plan: All employees 18 years of age and older may participate. All employee contributions are 100% vested. All employer contributions: are subject to a 1 year credited service waiting period require the employee to be 25 years of age or older are subject to a 5 year vesting provision. All contributions and earnings are tax deferred until withdrawal. You may take a loan against your account (based on certain limitations). You benefit when you start saving, letting interest/investment earnings compound. You may shelter up to a maximum of $17,000 per year. Based on certain limitations and guidelines of the Maximum Exclusion Allowance Provision. To find your MetLife representative information visit: Pension Plan Pension Eligibility: The Pension Plan for lay employees was frozen as of January 31, Please contact Human Resources/Benefits Office for more information on this plan. Medical and Dental Plan Retiree Eligibility: If you cease active employment, you and your eligible dependents may be eligible to continue your coverage under the Archdiocese Medical Benefits Plan (until the first of the month during which you attain age 65) if: You are at least 60 years of age; and You are entitled to benefits under the Pension Plan; and You were continuously covered under this plan as an active employee on the day prior to the date you terminated employment. The retiree can continue up to age 65 or 18 months, whichever is greater. Upon the 65 th birthday of the retiree, a younger spouse may be able to continue coverage to age 65 or 18 months, whichever if greater. A Medicare supplement coverage will be offered at age 65, or when you become eligible for Medicare benefits. 67

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70 NOTICE This guide does not replace, supplement or change any of the individual benefit summary plan descriptions or certificates and should not be used in determining actual benefits available. The sole purpose of this booklet is to help guide you in your benefits elections. The Archdiocese of Saint Paul & Minneapolis reserves the right, in its sole discretion, to amend, suspend, or terminate all or any part of any of its benefit programs, at any time. Benefit plans are governed by detailed plan benefit documents that determine the rights of participants. If there is any discrepancy between the plan documents and this guide or the certificates and summaries, the plan documents will control. You can review or purchase copies of the plan documents by contacting Corporate Health Systems, Inc. 69 information in this summary and the Summary Plan Description, the Summary Plan Description will take precedence in determining your benefits. Contact the insurance carrier for more information and answers to specific questions, or call Corporate Health systems, Inc. for a copy of the Plan Document before making a decision.

71 70 information in this summary and the Summary Plan Description, the Summary Plan Description will take precedence in determining your benefits. Contact the insurance carrier for more information and answers to specific questions, or call Corporate Health systems, Inc. for a copy of the Plan Document before making a decision.

72 Long Term Care Protection: What is it? Long term care is not one service, but a variety of services available to individuals who are unable to care for themselves due to an illness, accident or disability. The services are provided in a setting other than the acute care portion of a hospital. Common reasons why long term care services may be required include: car accident, sporting accident, stroke, aging process, Alzheimer's or Multiple Sclerosis. Long term care services can be provided on a temporary or a permanent basis. Long term care services can range from simple help with meal preparation to assistance with bathing and dressing or to complete 24-hour monitored care. Long Term Care Protection: Why Now? No health questions for employees. All newly eligible employees actively at work who enroll in the long term care plan during the new hire open enrollment period are guaranteed to be accepted into the program without having to answer medical questions. Employees that apply after this new hire open enrollment period will be required to submit evidence of good health and be approved for coverage. A simplified spouse application. All spouses of newly eligible employees who are actively at work can enroll in the long term care plan during the new hire open enrollment period by completing a simplified application. Spouse coverage is NOT guaranteed Premiums. The younger you are when your coverage begins, the lower your premiums will be for the duration of your participation in the plan. That's because once you're in the plan, your rates do not increase just because you grow older. For premiums to change there would have to be a change in premiums for everyone in your age category who has the kind of coverage that you do. As long as you pay your premiums, we cannot cancel your coverage and you can never be singled out for a rate increase because you get older, become ill or because of claims that you may file. Here are some sample monthly rates for selected ages and plan options: Sample: 3 Year Plan or 5 Year Plan Lifetime Maximum Benefit Daily Facility Care $109,500 (3 yr Plan)** $100/Day $182,500 (5 yr Plan) ** $100/Day Age /month $21.01/month Age 50 $32.09/month $33.77/month Age 60 $60.54/month $70.26/month 71 information in this summary and the Summary Plan Description, the Summary Plan Description will take precedence in determining your benefits. Contact the insurance carrier for more information and answers to specific questions, or call Corporate Health systems, Inc. for a copy of the Plan Document before making a decision.

73 Don't group medical plans cover long term care? No. Group plans are not designed to cover long term care services for chronic conditions. They usually cover acute/short-term medical expenses that are designed to improve the individual's condition. These services must also be "medically necessary". Because of the requirement that services be "medically necessary", group plans exclude the most commonly required long term care service: custodial long-term care. Won't my family take care of me? Although most long term care services are still provided by family and friends, this is becoming an increasingly more difficult task due to the changing American family: both spouses are working full-time children are living in different states people are living longer, requiring individuals to care for their children and their parents simultaneously. Can't I use my savings or a bank loan? Unfortunately, most Americans are unaware that the estimated national average cost of a one-year stay in a nursing home is $55,000 1, and can be twice that much in some regions. Do you have that type of money set aside for long term care services, or are you sure that a bank will loan you the money once services are required? Why should I consider long term care insurance? Besides the limitations noted, these are the most common reasons cited 2 for purchasing long-term care insurance: 1. maintain independence 2. preserving assets 3. not relying on changing government programs 4. not wanting to become a burden to family. Want to Know More? The Archdiocese of St Paul and Minneapolis offers the Group Long Term Care insurance program though CNA. If you have questions about the long term care plan, you may call CNA toll-free at Please reference the Educational Pool when asking for enrollment materials. Representatives are available Monday through Friday, 8:00 am to 5:00 pm EST. You can also visit their website at (The Educational Pool password is CHSLTCPOOL). This piece is for illustrative purpose only and is not a contract. It is intended to provide a general overview of the plan described. Please remember only the insurance policy can give actual terms, coverage, amounts, conditions and exclusions. **3 year or 5 year Standard Plan. Depending on the plan you select, the minimum length of time your lifetime maximum benefit will last if you use the full Daily Facility Care Benefit every day. Your lifetime maximum benefit can last longer than 3 or 5 years if your actual expenses are less than the maximum benefit for Facility Care. Underwritten by Continental Casualty Company, one of the CNA Insurance Companies. 1 CNA nursing home survey, HIAA, Buyer Survey, information in this summary and the Summary Plan Description, the Summary Plan Description will take precedence in determining your benefits. Contact the insurance carrier for more information and answers to specific questions, or call Corporate Health systems, Inc. for a copy of the Plan Document before making a decision.

74 15153 Technology Dr Suite B Eden Prairie MN /2012