Cleveland Clinic. BeneFlex Program. Summary Plan Description

Transcription

1 Cleveland Clinic BeneFlex Program Summary Plan Description Calendar Year 2015

2 Table of Contents THE CLEVELAND CLINIC BENEFLEX PROGRAM About the Program Eligibility Dependents Eligible for Coverage BeneFlex Enrollment Process Newly Hired Employees Current Employees CLEVELAND CLINIC BENEFLEX PROGRAM SUMMARY Life Event Changes Your Benefit Options How BeneFlex Works Health Care Benefit Programs Dental Benefit Programs Vision Benefit Program Group Life Insurance Benefit Program Beneficiary Designation Dependent Life Insurance Short Term Disability (Full-Time Employees) Long Term Disability (Full-Time Employees) Flexible Spending Accounts Taxes Avoided, Not Deferred Effects on Other Benefits Changes of Status, Leaves of Absence FSA Reimbursement/Deadline Reimbursement for Health Care Expenses Reimbursable Expenses Reimbursement for Dependent Care Expenses Reimbursable Expenses Expenses Not Covered Tax Information Termination, Status Change to Temporary Status or Retirement COBRA Coverage Consolidated Omnibus Budget Reconciliation Act (COBRA) Coverage ADDITIONAL INFORMATION A Statement of Your Rights Under ERISA Receive Information About Your Plan and Benefits Continue Group Health Plan Coverage Prudent Actions by Plan Fiduciaries Enforce Your Rights Assistance with Your Questions ERISA Required Information Notes

3 About the Cleveland Clinic BeneFlex Program BeneFlex is Cleveland Clinic s flexible benefits program that allows you to make choices in several areas of individual benefit coverage. You design a program that matches the specific benefit needs of you and your family. This booklet summarizes the Cleveland Clinic BeneFlex Program and provides information about: Who can participate in the program When and how you can change your elections, and What benefit options you have Please carefully read through the following pages in order to get the most benefit from your BeneFlex Program. If you should have any questions about the information provided in this summary, please contact the Total Rewards Department. 1

4 Eligibility You are eligible to participate in the Cleveland Clinic BeneFlex Program if you are a regular full-time or part-time employee of Cleveland Clinic and certain subsidiaries or a Cleveland Clinic hospital. Note: 1. If both employees (spouses) work for Cleveland Clinic or a Cleveland Clinic hospital, they cannot carry any family member twice. 2. If an employee has a child who is employed outside of Cleveland Clinic and is eligible for benefits through his or her employer, he or she is not eligible to enroll in any of the Cleveland Clinic Health, Dental or Vision Benefit Programs. Dependents Eligible for Coverage Several of the BeneFlex options offer coverage for your eligible dependents. Under the BeneFlex Program, your eligible dependents include: 1. Your lawful spouse (neither divorced nor legally separated). 2. Your children who are: your natural children, stepchildren, legally adopted children (or under placement for adoption), or children under an officially court-appointed guardianship who are under age 26 (Health Benefit Programs) or under age 23 (Dental and Vision Benefit Programs). Coverage for your children ends on the last day of the month in which they reach age 26 (Health) and age 23 (Dental and Vision). 3. Your unmarried children age 26 or older (Health Benefit Programs) or age 23 or older (Dental and Vision Benefit Programs) who are disabled as determined by the Social Security Administration. Proof of disability must be provided to Human Resources within 31 days after the determination of disability. Your eligible dependents will be covered under Cleveland Clinic Employee Health Plan Total Care only if you elect coverage for them and provide documentation that they are eligible dependents. Ineligible members include the employee's parents, grandchildren, nieces, nephews, ex-spouses, commonlaw marriage partners (after the year 1991) and foster children who have not been legally adopted or who have not been placed for adoption. Under the Health Benefit Program options, you can choose one of these coverage categories: Employee Only Employee + One Child Employee + Spouse Family I (two or three dependents*) Family II (four or more dependents*) *Spouse and/or children Under the Dental and Vision Benefit Program options, you can choose one of these coverage categories: Employee Only Employee + One Dependent (spouse or child) Employee + Family You can vary choices for dependent coverage under the medical, dental and vision benefit programs. For example, you can elect coverage for you and your family under medical and you and one dependent under dental. 2

5 BeneFlex Enrollment Process Newly Hired Employees When you begin working at a Cleveland Clinic facility, you are given an opportunity to sign up for BeneFlex. You must elect benefits within 31 days of your hire date in order for your benefits to become effective. As long as you elect benefits within 31 days of your hire date, your benefits are effective on the first day you actively start to work. If you DO NOT elect benefits for yourself and your dependents, you will be enrolled in the Core Life and Accidental Death and Dismemberment Insurance only. You will not be entitled to other benefits until the next open enrollment period unless you experience a qualified Life Event Change, as described on page 4. Open enrollment takes place annually. At this time, benefit eligible employees have the opportunity to elect benefits for the upcoming calendar year. If an employee begins employment at Cleveland Clinic between October and December, near the open enrollment period, he/she will have the opportunity to elect benefits for the current year and will also be given information about making benefit election changes for the new calendar year. Current Employees Current employees have the opportunity to re-enroll for their benefits each year during the BeneFlex Open Enrollment period. Through this process, you can choose to keep the same coverage you have or to make changes for the upcoming calendar year. If you are currently enrolled in benefit options and do not make changes to those options, you will maintain the same benefits you currently have except you will have no Paid Time Off (PTO) trade-in and no Flexible Spending Accounts. 3

6 Cleveland Clinic BeneFlex Program SUMMARY Life Event Changes To help Cleveland Clinic design a cost-effective benefit program each year, maintain costs, and to anticipate future needs, you are required to keep your selected BeneFlex elections unless you or your dependents experience a Life Event Change. Under Internal Revenue Service guidelines, the following occurrences meet the definition of a qualifying life event and permit you to change certain elections: 1. Changes in legal marital status, including marriage, death of a spouse, divorce, legal separation or annulment. 2. Changes in the number of dependents for reasons that include birth, adoption, placement for adoption, the assumption of legal guardianship, or death. 3. Employment status changes, meaning an employee, spouse or dependent starts a new job or loses a current job. 4. Work schedule changes, meaning a reduction or increase in hours of employment for the employee, spouse, or dependent, including a switch between part-time and full-time, a strike or lockout, or the beginning or end of an unpaid leave of absence. 5. Changes in work location, meaning a change in the place of residence or work of an employee, spouse, or dependent. 6. A dependent satisfies or no longer satisfies the eligibility requirements for unmarried dependents because of age, job status or other circumstances. 7. A qualified medical child support court order (QMCSO), or other similar order, that requires coverage for an employee s child. 8. The employee, spouse or dependent qualifies for Medicare or Medicaid. (If this happens, health plan coverage may be cancelled for that individual.) If you experience a qualifying life event and wish to change your coverage, you must contact the Total Rewards Department within 31 days of the event and provide the necessary supporting documentation. Any adjustment to coverage must be consistent with the changes resulting from the qualifying life event. Employees/dependents covered under another health, dental and/or vision plan who lose that coverage as a result of one of the life events listed above are eligible to participate in a Cleveland Clinic Health, Dental or Vision Benefit Programs. Your Benefit Options The benefit programs made available to you through BeneFlex include: Health (including prescription drug coverage) Dental Vision Group Life Insurance and Accidental Death and Dismemberment Insurance Dependent Life Insurance Short Term and Long Term Disability (Full-time employees who have completed one continuous year of regular, full-time employment) 4

7 Health Care Flexible Spending Account Dependent Care Flexible Spending Account This booklet contains a brief summary of these benefits. For detailed information about these plans, refer to the corresponding Summary Plan Description (SPD) for that benefit or contact the Total Rewards Department. How BeneFlex Works BeneFlex is designed to help you customize your benefit program; to waive benefits you may not need; and to pay for your benefits in a tax-favorable way. Some of the benefits under BeneFlex the core coverages are provided to you at no cost. Others are optional and require you to pay part or all of the cost. During the annual open enrollment period, if you would like to offset part or all of your cost, you can trade-in up to ten days (or 80 hours) of your projected Paid Time Off (PTO) allowance. For each day (eight hours) that you trade-in, you will receive an amount equal to your hourly rate of pay times eight hours. For example, if your base rate of pay is ten dollars and you trade-in eight hours of PTO, you will receive $80 to apply to the cost of your benefits. If you do not trade-in PTO or if the total cost of the benefits you elect is more than your PTO trade-in, you will pay for the cost of your elections through pre-tax payroll deductions. The advantage to paying for your benefits with pre-tax dollars is that you do not pay Federal, State or Social Security taxes on your pre-tax earnings. Note: If you elect to trade-in PTO and you terminate, retire, change status to temporary/prn, or experience a Life Event Change during the year, your PTO cannot be returned to you. In addition, you cannot change your PTO trade-in amount during the year. Note: You are not eligible to trade-in PTO if you are a resident, intern or fellow. Calculating Annualized Base Pay for the Subsequent Plan Year October 1 Base Hourly Rate x Regular Scheduled Hours = Annualized Base Pay For example, if your October 1 base rate of pay is ten dollars and you are scheduled to work 2080 hours per year, your annualized base pay is $20,800. Health Care Benefit Programs Cleveland Clinic offers several health care benefit programs from which employees may choose. All of the programs include prescription drug coverage. You pay part of the cost for your health care coverage. The amount of that cost depends on the option and the coverage category you elect and your employment status. Dental Benefit Programs Cleveland Clinic offers several dental benefit programs from which employees may choose. You pay part of the cost for your dental care coverage. The amount of that cost depends on the option and the coverage category you elect. 5

8 Vision Benefit Program Employees may also elect a Vision Benefit Program, which provides coverage for eyeglasses or contact lenses. You pay all of the cost of the Vision Benefit Program. Group Life Insurance Benefit Program If you are a full-time or part-time employee, Cleveland Clinic provides you with a core life insurance and accidental death and dismemberment benefit equal to one times your annual base salary, to a maximum benefit of $500,000. If you desire additional coverage, you may elect supplemental life insurance coverage equal to from one to ten times your annual base salary. Your cost for supplemental coverage is based on your age and the amount of insurance selected. Your combined core and supplemental benefit is subject to a maximum amount of $2,000,000. If you elect supplemental life insurance coverage when it is first available to you as a new hire, evidence of insurability will be required to obtain coverage of more than six times your annual salary or a benefit that is greater than $1,000,000. If you are already enrolled in supplemental life insurance during the annual open enrollment period, you may elect up to two incremental units without evidence of insurability. A new election or an election of more than two incremental units will require evidence of insurability. Based on Internal Revenue Service regulations, the cost of your life insurance that is over $50,000 in coverage may result in additional tax liability (imputed income). This does not apply to the cost you pay for the coverage through payroll deduction. Any tax liability will be reported on your annual Form W-2 Statement of Earnings. Beneficiary Designation A beneficiary is the person(s) who will receive your Group Life and Accidental Death and Dismemberment Insurance benefits in the event of your death. It is important that you name a beneficiary for your benefits. Your beneficiary designation can be made online through the HRConnect Portal. Dependent Life Insurance Under BeneFlex, you may purchase Dependent Life Insurance coverage for all your eligible family members. The coverage provided by this option is equal to: $25,000 on the life of your spouse, and $10,000 on the life of each of your eligible children. All your eligible family members are covered if you enroll for this option. In the event of the death of an enrolled member of your family, payment will be made to you. If you and your spouse both work at Cleveland Clinic and are eligible for this option, either one OR both of you may apply for this coverage. Dependent children will be eligible for benefits from both the father and the mother. If you do not elect this coverage when it is first available to your eligible family members but later wish to elect it, members of your family will have to provide evidence of insurability. Evidence of insurability will not be required if you wish to provide Dependent Life Insurance on your: New spouse, or Newly acquired children if you already have Dependent Life coverage or do not have other eligible dependents at the time of the qualified Life Event Change. The cost of the coverage is the same for all employees, regardless of the number of your eligible family members. In accordance with IRS regulations, your payroll deduction for this coverage must be made on an after-tax basis. 6

9 Short Term Disability (Full-Time Employees) If you are a full-time employee with at least one year of continuous regular, full-time service, you are eligible for disability coverage under BeneFlex. Short Term Disability, which is provided as a core benefit, protects your income for up to the lesser of 26 weeks or 1080 hours if you are unable to work due to a non-occupational illness or injury. This means that if you are placed on an authorized Medical Leave of Absence and are unable to work as diagnosed by a physician, the Program will pay you a percentage of your base salary after a seven consecutive calendar day waiting period. The Short Term Disability benefit provides 60% of your base salary for the duration of your approved Short Term Disability period. Long Term Disability (Full-Time Employees) In the event that your medical condition continues beyond 26 weeks (six months), you may be eligible to receive benefits from the LTD Plan. The core benefit, which is paid by Cleveland Clinic, will pay you 60% of your base salary up to a maximum of $15,000 per month. The total 60% income benefit includes other disability benefits which you may receive, such as Social Security, Workers Compensation and similar benefits. In addition, it is important to know that benefits will not be payable for any disability due to a pre-existing condition. Flexible Spending Accounts BeneFlex offers two Flexible Spending Accounts (FSAs), one for medical expenses not covered by medical, dental or vision plans and one for qualified dependent/child care expenses. Contributions to either of these accounts are determined by you and funded with money you wish to contribute through pre-tax salary reduction. These special accounts provide you with valuable tax advantages by allowing you to reimburse yourself for qualified expenses incurred by you or your eligible dependents with tax-free money. Your expenses must be incurred during the Plan Year and submitted for reimbursement within the established time frame after the end of the Plan Year to be eligible for reimbursement. When making decisions about your Flexible Spending Accounts, it is important to remember the following: The money must be used for qualified related expenses. The minimum amount you can deposit into the Medical Flexible Spending Account is $100 per calendar year (unless you are depositing leftover PTO trade-in dollars), and the maximum amount is $2,500 per calendar year. The minimum amount you can deposit into the Dependent Care Flexible Spending Account is $100 per calendar year (unless you are depositing leftover PTO trade-in dollars), with the maximum amount of $5,000 per calendar year if you are single or you are married and filing a joint tax return. If you are married and you and your spouse file separate tax returns, the maximum amount you can deposit is $2,500 per calendar year. Money cannot be transferred from one account to the other. Money that you do not spend during the course of the Plan Year cannot be returned to you or carried over into the next calendar year. Therefore, it is extremely important that you carefully consider the amount that you wish to deposit into either or both of these accounts. 7

10 Taxes Avoided, Not Deferred When you use the money in your FSA to pay for allowable expenses, you never have to pay tax on the money (according to current tax law). You do not defer taxes that have to be paid sometime in the future; you avoid paying taxes on this money altogether. Your withholding taxes, including Social Security tax, will be calculated and withheld each payday on your reduced pay. So you do not have to wait until you file your income tax return to enjoy the tax advantages. Some expenses eligible for FSA reimbursement also may be eligible for income tax deductions. However, you are allowed to save taxes only once. It is illegal to use FSA dollars to save taxes on an expense and also take another tax deduction for that expense on your income tax return. You should consult with your tax advisor if you have questions about which approach best meets your needs. Effects on Other Benefits Although FSA contributions lower your pay for tax purposes, they do not lower your pay for determining other pay-related benefits, such as: Life Insurance, Disability income benefits, Retirement income benefits, and Savings and Investment Plan contributions. The amounts of these benefits will not be affected by your FSA contributions. Changes of Status, Leaves of Absence If you terminate employment or your employment status changes, making you ineligible for the FSA program, your FSA contributions would stop at the time of that change. You may continue to submit for reimbursement from your FSA for the plan year in which the status change occurs. However, requests for reimbursement must be for expenses incurred while you were actively employed in a benefit-eligible status. If you are on a medical or personal leave of absence without pay, your FSA contributions will stop, then resume when you return to work. You can continue to submit for reimbursement from your FSA for expenses incurred during the year. FSA Reimbursement/Deadline As you incur eligible expenses, you can present your PayFlex Card for payment. You should keep copies of all receipts and itemized statements for each purchase throughout the year. If you do not use your PayFlex Card, you have the option of submitting a claim to PayFlex online using Express Claims or completing a paper claim form and mailing or faxing it along with itemized documentation to PayFlex. For reimbursement from current year s accounts, requests and documentation must be received by no later than March 31 of the following year. If you are reimbursed for services which are not covered, or more than should be allowed, your benefits will become taxable income. You will be responsible for the tax on these amounts. 8

11 Reimbursement for Health Care Expenses Reimbursable Expenses You may use the money in your Medical FSA to reimburse yourself for health care expenses. The entire amount of your annual election is available for reimbursement as soon as the Plan Year begins. Most health-related and dental expenses not otherwise covered by Cleveland Clinic or other benefit programs* can be reimbursed if incurred by you or your IRS dependents. To be eligible, the expense must be incurred in the year in which you select this option. Included are expenses incurred for: Deductible and co-payment amounts for medical or dental services, Eye exams, glasses, contacts and contact lens solutions, Hearing aids, batteries and exams, Reconstructive surgery, Dental expenses, orthodontia, dentures and bridges, Prescription drugs, and Therapeutic devices (such as hospital beds and whirlpools). Reimbursable expenses do not include expenses paid for by any other benefit program or premiums for other insurance coverage. Also not included are air-conditioning, electrolysis, cosmetic dental procedures, cosmetic surgery that is not medically necessary, weight loss programs (unless there is a written prescription from a doctor and the program is prescribed for the treatment of a specific disease), dietary supplements such as vitamins and herbs, and over-the-counter medications such as antacids, allergy medicine, pain relievers and cold medicines (unless there is a written prescription from your doctor). *It is considered fraud to receive FSA reimbursement for expenses that have been paid for by insurance coverage. Reimbursement for Dependent Care Expenses Reimbursable Expenses If you are eligible, you may use the money in your Dependent Care FSA to pay for your dependents care. The payroll deductions must be made to your FSA in order to receive reimbursement. So that you can receive these optional benefits tax-free, the Program has been designed to meet government regulations. To be eligible for the benefits, you must be at work during the time your dependents are receiving care, and be: Single with an eligible dependent, Married with an eligible dependent and a spouse who is a wage earner, or a full-time student for at least five months during the year, or disabled and unable to provide for his or her own care. If you meet the eligibility requirements, you may use your FSA to pay for the care of your dependents who: Are under age 13 and included as exemptions on your Federal Income Tax return, or Are physically or mentally disabled, including your spouse or dependent parents, and unable to care for themselves. In addition, the disabled dependent must spend at least eight hours a day in your home. 9

12 The expenses covered by the Program on the days you are working include the charges for: Licensed nursery schools and day care centers for pre-school children which care for at least six children, Babysitting whether in or out of your home, Before- and after-school care provided by a school or day care center, Summer day camp programs, Housekeepers in your home if part of their work provides for the well-being and protection of your dependents, A relative who cares for your dependents, so long as he or she is age 19 or older and is not one of your dependents, Home care specialists who provide care to eligible disabled dependents, and Disabled dependent care at centers which comply with state and local laws and regulations. Expenses Not Covered The Program does not cover expenses for: Dependents being cared for by your spouse or by your other children under age 19, Dependents who could be cared for by your employed spouse whose work hours do not coincide with yours, Services which are paid for by another organization or are provided without cost, Transportation to or from the dependent care location, Care provided in full-time residential institutions, such as nursing homes, and homes for the mentally disabled, Educational/tuition expenses (kindergarten, first grade and above), Overnight camp (not even the portion attributed to the daytime cost), Clothing, Entertainment, and Food. Education will be covered if the nursery school or day care center provides schooling as part of its preschool care services. Education expenses are not covered for first grade or higher. Tax Information Even though you may use the Dependent Care FSA to reimburse yourself for dependent care expenses, you will need to report the Social Security Number or Employer Identification Number (EIN) of the caregiver to the Internal Revenue Service when you file your Federal Income Tax return. It will also be necessary to report the Social Security Number or Employer Identification Number of the caregiver each time you submit receipts for reimbursement. The amount reduced from your pay for dependent care during the year will appear on your W-2 form. Termination, Status Change to Temporary Status or Retirement In the event of your termination of employment or retirement: Medical, dental and/or vision benefits in which you are currently enrolled will continue through the end of the month (unless you elect to continue any of these under COBRA see following page). You have conversion privileges and portability provisions for Core Life Insurance, Additional Life Insurance and/or Dependent Life Insurance. (Contact the Total Rewards Department for more information). Your Disability benefits will end on your termination or retirement date. 10

13 COBRA Coverage Consolidated Omnibus Budget Reconciliation Act (COBRA) Coverage The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) may require that you and/or your dependents be provided with the opportunity to continue your group healthcare coverage on a contributory basis under the following circumstances. The extension of coverage applies to almost all employee health plans providing medical, dental, prescription drug, vision or hearing benefits. You will be able to continue coverage through COBRA by paying all of the costs of the plans you choose, including any portion formerly paid for by the Cleveland Clinic facility that employed you. Qualifying Events: Who, When, and for How Long If your Cleveland Clinic coverage terminates, you and your covered dependents may continue medical, dental, vision and/or FSA programs coverage for up to 18 months: 1. If your employment terminates for any reason, including retirement, other than gross misconduct; or 2. If you lose your Cleveland Clinic coverage due to a reduction in your hours of employment; or 3. If you or a dependent become disabled within the first 60 days of COBRA continuation, coverage may be continued for an additional 11 months (29 months total). Your covered dependents may continue such coverage under the Cleveland Clinic Benefit Programs for up to 36 months: 1. If you die while covered by the benefit program; or 2. If you and your spouse are divorced, your marriage is annulled or you are legally separated from your spouse; or 3. If you become eligible for Medicare; or 4. If your dependent child is no longer eligible for coverage under the Cleveland Clinic Benefit Programs. If you are entitled to Medicare benefits at the time coverage terminates due to your termination of employment or reduction in hours, the continuation period for covered dependents will be the longer of: months from the date coverage terminates due to your termination of employment or reduction of hours; or months from the date you became entitled to Medicare. When Continued Coverage Ends The continued coverage will end for any qualified person when: 1. The cost of continued coverage is not paid on or before the date it is due; or 2. That person becomes eligible for Medicare, if later than the date of the COBRA election; or 3. That person becomes covered under another group health plan unless that other plan contains an exclusion or limitation with respect to any pre-existing health condition; or 4. The Cleveland Clinic Programs terminate for all Employees; or 5. You or your dependent are no longer deemed disabled during the additional 11-month extended period; or 6. The last day of the applicable 18, 29 or 36 month time limit. 11

14 How to Obtain Coverage When your coverage terminates, the Total Rewards Department will notify the COBRA Administrator (PayFlex). PayFlex then notifies you of your election rights. You will need to make your election within 60 days of the event in order to be eligible for continuation of coverage. For questions regarding COBRA, Payflex can be reached at or you can contact the Total Rewards Department. There is generally a 1-2 week lag time between PayFlex processes the first paid premium and the time the Third-Party Administrator (TPA) is updated. You will be able to receive covered care during this lag time. However, be prepared to provide proof of insurance or be prepared to resubmit the claim if denied the first time. f you elect to continue any benefits under COBRA, the first payment must be made within 45 days of your election to continue coverage. The first payment covers the period beginning with the date the qualifying event occurred through the date the continuation coverage was elected. Thereafter, monthly payments are due on the first of the month and must be paid within the 31 day grace period following the due date. COBRA regulations may change from time to time. The extension of coverage will be provided in accordance with current law. Because COBRA rules are complicated, if you have any questions about eligibility, contact the Total Rewards Department. Veteran Reemployment Cleveland Clinic will also comply with the provisions of the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA). 12

15 Cleveland Clinic BeneFlex Program ADDITIONAL INFORMATION A Statement of Your Rights Under ERISA As a participant in the Cleveland Clinic Welfare Benefits Plan, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all plan participants shall be entitled to: Receive Information about Your Plan and Benefits Examine, without charge, at the Plan Administrator's office and at other specified locations, such as worksites, all documents governing the Plan and/or this Benefit Program including insurance contracts and a copy of the latest annual report (Form 5500 Series) filed by the plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Pension and Welfare Benefit Administration. Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the plan, including insurance contracts, and copies of the latest annual report (Form 5500 Series) and updated Summary Plan Description. The Plan Administrator may make a reasonable charge for the copies. Receive a summary of the plan s annual financial report. The Plan Administrator is required by law to furnish each participant with a copy of this summary annual report. Continue Group Health Plan Coverage Continue health care coverage for yourself, spouse or dependents if there is a loss of coverage under the plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review this summary plan description and the documents governing the plan on the rules governing your COBRA continuation coverage rights. Reduction or elimination of exclusionary periods of coverage for pre-existing conditions under your group welfare benefit plan if you have credible coverage for another plan. You should be provided a certificate of creditable coverage, free of charge, from your group benefit program or health insurance issuer when you lose coverage under the plan, when you become entitled to elect COBRA continuation coverage, when your COBRA continuation coverage ceases, if you request it before losing coverage, or if you request it up to 24 months after losing coverage. Without evidence of creditable coverage, you may be subject to a preexisting condition exclusion for 12 months (18 months for late enrollees) after your enrollment date in your coverage. Prudent Actions by Plan Fiduciaries In addition to creating rights for plan participants ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your plan, called fiduciaries of the plan, have a duty to do so prudently and in the interest of you and other plan participants and beneficiaries. No one, including your employer, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a benefit or exercising your rights under ERISA. 13

16 Enforce Your Rights If your claim for benefits is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules. Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of plan documents or the latest annual report from the plan and do not receive them within thirty (30) days, you may file suit in a Federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the Plan Administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or Federal court. In addition, if you disagree with the plan s decision or lack thereof concerning the qualified status of a domestic relations order or a medical child support order, you may file suit in Federal court. If it should happen that plan fiduciaries misuse the plan s money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a Federal court. The court will decide who should pay court costs and legal fees. If you are successful the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous. Assistance with Your Questions If you have any questions about your plan, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration. 14

17 ERISA Required Information This information is provided in compliance with the Employee Retirement Income Security Act of 1974 (ERISA), as amended. While you should not need these details on a regular basis, the information may be useful if you have specific questions about the Plan. This following provides information specific to the Cleveland Clinic Welfare Benefit Plan (the Plan ), and the BeneFlex Program (the Benefit Program ) which is a component of the Plan and is a welfare plan that provides benefits to certain employees. Official Plan Name Cleveland Clinic Welfare Benefits Plan Official Benefit Program Name... Cleveland Clinic BeneFlex Program Plan Number Type of Administration The Benefit Program is a combination of a fully insured and self-insured benefit plan offering medical benefits, dental, vision, disability, life and FSA benefits. Cleveland Clinic has contracted with a third-party administrator, to administer the Benefit Program. Contributions to the Benefit Programs Benefit Program benefits are paid from the general assets of Cleveland Clinic. Funding Medium Benefits provided by this Benefit Program are provided through Cleveland Clinic and through employee contributions. The Plan Sponsor shall from time to time determine the amount of contributions payable by Participants. Plan Sponsor, Plan Administrator and Plan Fiduciary Cleveland Clinic 3050 Science Park Drive / AC341 Beachwood, OH The administration of the Plan, including the Benefit Program, will be under the supervision of the Plan Administrator. To the fullest extent permitted by law, the Plan Administrator will have the discretion to determine all matters relating to eligibility, coverage and benefits under the Plan. The Plan Administrator will also have the discretion to determine all matters relating to the interpretation and operation of the Plan including any portion thereof. Any determination by the Plan Administrator, or any authorized delegate, shall be final and binding. Agent for Service of Legal Process Cleveland Clinic Law Department / AC Science Park Drive Beachwood, OH Service of legal process may also be made on the Plan Administrator. Plan Year January 1 December Records and reports for the Plan, including Benefit Programs contained therein, are kept on a calendar year (January 1 December 31). The Plan Year is also the Fiscal Year. Employer Identification Number of Plan Sponsor

18 Benefit Program Effective Date... The Plan is effective as of January 1, 2013 and the provisions of the Benefit Program are effective January 1, Plan Documentation If there are any discrepancies between this Summary Plan Description (SPD) and the provisions of the Plan document, including the contract, the Plan document will prevail. No oral interpretations can change this Plan. The Plan Sponsor also reserves the right to interpret the Plan s coverage and meaning in the exercise of its sole discretion. The decisions of the Plan Administrator, Claims Administrator and Appeals Administrator, as applicable, shall be final and conclusive with respect to all questions relating to the Plan. Future of the Plan The Plan Sponsor reserves the right to amend, modify or terminate the Plan, including this Benefit Program, in whole or in part, at any time, without notice, in such manner as it shall determine regardless of a participant s health or treatment status, which may result in the termination or modification of an employee s coverage. If the Plan is amended, modified, or terminated, the rights of employees are limited to services and percentages of Allowed Amounts incurred prior to the Plan s amendment, modification or termination. However, this will not affect any claim for covered expenses incurred prior to the modification or termination of the Plan. No Employment Contract This SPD does not create any contractual rights to employment nor does it guarantee the right to receive benefits under the Plan or Benefit Program. Benefits are payable under the Plan or Benefit Program only to individuals who have satisfied all of the conditions under the Plan document for receiving benefits. Delegation of Responsibility The Plan Administrator may delegate to other persons responsibilities for performing certain duties of the Plan Administrator under the terms of the Plan. The Plan Administrator, Claims Administrator, and/or Appeals Administrator, as applicable, may seek such expert advice as reasonably necessary with respect to the Plan or Benefit Program. The Plan Administrator, Claims Administrator, and/or Appeals Administrator, as applicable, shall be entitled to rely upon the information and advice furnished by such delegates and experts, unless actually knowing such information and advice to be inaccurate or unlawful. The Plan Administrator may adopt uniform rules for the administration of the Plan from time to time, as it deems necessary or appropriate. 16

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21 Cleveland Clinic Every life deserves world class care Euclid Avenue, Cleveland, OH Cleveland Clinic is a top-ranked nonprofit academic medical center founded in With more than 1,300 staffed beds, as well as research and education institutes, the organization is dedicated to providing expert inpatient and hospital care through innovation, quality, teamwork and service. The Cleveland Clinic Foundation