ELCA Health Benefits Plan ELCA-Primary Health Benefits

Transcription

1 SUMMARY PLAN DESCRIPTION» Effective Jan. 1, 2014 ELCA Health Benefits Plan ELCA-Primary Health Benefits

2 ELCA Benefit Program Description and ELCA-Primary Health Benefits Summary Plan Description Effective Jan. 1, 2014 About Portico Benefit Services For over 25 years, Portico Benefit Services (formerly called the ELCA Board of Pensions) has offered health, retirement, and other benefits designed to enhance the well-being of those who serve. Because we focus on those who serve through the Evangelical Lutheran Church in America and other faith-based organizations, we can tailor our benefits to include advantages and options suited just for our membership. As part of the ministry community and as experienced professionals, we are qualified to design and manage all aspects of the ELCA s benefit plans. Portico serves more than 7,000 congregations and organizations, and more than 50,000 people across the ELCA during their working years and in retirement including pastors, associates in ministry, diaconal ministers, deaconesses, lay employees, retirees, and their family members. About Our Plans The ELCA Pension and Other Benefits Program provides health, flexible spending, retirement, disability, and survivor benefits presented as one comprehensive program to members. Benefit plans are governed and administered individually through separate plan documents. The ELCA Board of Pensions, doing business as Portico Benefit Services, maintains the following plans: the ELCA Retirement Plan, the ELCA Disability Benefits Plan, the ELCA Survivor Benefits Plan, the ELCA Health Benefits Plan (which includes postretirement medical benefits, an obligation of the ELCA), and the ELCA Flexible Benefits Plan. We also maintain three group retirement plans for ELCA-affiliated social ministry organizations the ELCA Master Institutional Retirement Plan, the ELCA Retirement Plan for The Evangelical Lutheran Good Samaritan Society, and the ELCA 457(b) Deferred Compensation Plan. The assets of each plan are held in various trusts and therefore do not allow one plan to fund a shortfall of another plan. Portico Benefit Services plans are not subject to the Employee Retirement Income Security Act (ERISA). The health and disability plans and the retiree survivor benefit are self-insured and are not protected through any type of insurance program. Our ability to pay self-insured claims is dependent on continued contributions and market performance. The basic, supplemental, and dependent life insurance benefits are fully insured by Minnesota Life Insurance Company. We reserve the right to change any of the terms of the plans at any time through the amendment or termination process described in each plan s summary plan description About This Document This document describes eligibility and enrollment for the ELCA Pension and Other Benefits Program, effective Jan. 1, Use it as a reference when you have questions about the ELCA benefit program. For the most current information, sign in to myportico (myportico.porticobenefits.org).

3 Contents Part 1: ELCA Pension and Other Benefits Program Description About the ELCA Benefit Program... 1 Church-Sponsored Program Supports Ministry... 1 Employers Eligible to Participate... 2 Online Benefit Administration... 3 Program Eligibility... 5 Those Eligible to Enroll in the Program... 5 Eligible Family Members... 5 Enrolling in the Program... 6 Timely Enrollment... 6 Late Enrollment... 7 Annual Open Enrollment... 8 Opportunity for Employees Not Enrolled in a Timely Manner... 9 Waiving Health Coverage Paying for Benefits When You re Sponsored in the ELCA Benefit Program When You Have Coverage Continuation When Contributions Aren t Paid When a Call or Employment Change Affects Your Benefits If You Change Call or Employment If Your Employment Ends If You Go On Leave From Call If Your Interim Assignment Ends If You're a Missionary Sponsored by ELCA Global Mission If You Leave the Roster and Aren t Sponsored If You Become Sponsored by Multiple Employers... 26

4 If You and Your Spouse Both Become Sponsored If Your Employer No Longer Sponsors You If You re Called to Serve in the Military When a Life Change Affects Your Benefits If You Get Married If You Become a Parent If You Get Divorced If You re a Former Spouse If Your Covered Adult Child Reaches Age If Family Members Are Eligible for Different Health Benefits If You Retire If You Turn Age 65 and Continue to Be Sponsored If You Become Disabled If You Die If You Become a Surviving Spouse ELCA-Primary Health Benefits Medical and Mental Health Benefit Platinum+ and Gold+ Medical and Mental Health Benefit Chart Silver+ and Bronze+ Medical, Mental Health & Prescription Drug Benefit Chart Preventive and Screening Services Eligible Providers and Network Paying For Care Eligible Medical Services Eligible Mental Health Services While Traveling Health Support Programs Prescription Drug Benefit Platinum+ and Gold+ Prescription Drug Benefit Chart Silver+ and Bronze+ Medical, Mental Health & Prescription Drug Benefit Chart... 73

5 Eligible and Ineligible Prescription Drugs Formulary Preventive Medications Pharmacy Options During a Hospital Stay Cost Saving and Safety Programs Paying for Prescription Drugs Creditable Coverage Dental Benefit Dental Benefit Chart Eligible Dental Expenses Non-Eligible Dental Expenses In-Network Providers Out-of-Network Providers Preventive Care Basic Dental Care Major Restorative Care Orthodontic Care Paying for Care Employee Assistance Program (EAP) ELCA NurseLine SM Fitness Center Discount Wellness Dollars Mayo Clinic Health Solutions Hearing Discount Program Health Care Advocacy Team Health Savings Account HSA Features Those Eligible for an HSA... 88

6 Eligible Health Care Expenses Debit Card Personal Wellness Account Eligibility Contributions Eligible Expenses Non-Eligible Expenses If Your Situation Changes No Additional Contributions Debit Card Health Flexible Spending Account FSA Features FSA Enrollment Debit Card Miscellaneous Provisions Confidentiality and Privacy Practices Appeals Procedure Glossary Contact Information Cards For Your Wallet ELCA Philosophy of Benefits

7 About the ELCA Benefit Program The ELCA Pension and Other Benefits Program, also called the ELCA benefit program, is designed to help ELCA congregations and organizations provide an efficient, wellness-oriented bundle of benefits to those they sponsor. This document describes how the program is designed to work for a typical sponsored member: The benefits it includes The types of sponsoring employers and individuals eligible to participate The enrollment process Contribution rates and bill paying rules We then describe how eligibility for benefits changes when you experience life changes: A life change like marriage, divorce, or turning age 65 A professional change like changing call or employment, working for multiple employers, or ending a call Church-Sponsored Program Supports Ministry Through the ELCA benefit program, Portico strives to empower our members to live well physically, financially, and emotionally for life. We believe that by living well as whole people of God, we can better enhance the lives of others doing God s work in Christ s name for the sake of the world. For more than 25 years, foundational principles have helped Portico design the ELCA benefit program in alignment with church values. The ELCA Philosophy of Benefits articulates these principles and affirms the importance of benefits to the health and wellness of this whole church as it engages in ministry. See ELCA Philosophy of Benefits, page 114. The ELCA benefit program includes five benefit plans: Combined, they offer resources to help you and those you care about live well, enhance the lives of others, and be a good steward of your faith. ELCA Medical and Dental Benefits Plan (ELCA Health Benefits Plan) Health-related benefits including medical, mental health, dental, prescription drugs, 24/7 nurse line, and wellness support programs and financial incentives. Benefits provided by Aetna International support missionaries sponsored by ELCA Global Mission. ELCA Flexible Benefits Plan Flexible spending accounts (FSA) and health savings accounts (HSA) allow you to set aside pretax dollars for eligible health care and dependent (day) care expenses ELCA Survivor Benefits Plan Benefits to help your family take care of financial obligations in the event of a death ELCA Disability Benefits Plan Provides eligible disabled members monthly income, ELCA Retirement Plan contributions, and health and survivor benefits ELCA Retirement Plan A defined contribution retirement plan to help you save so you can live well in retirement Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 1

8 We describe what these benefits are and how you use them in detail online at myportico. They are also described in summary plan descriptions found on myportico. These five plans are bundled together as a package. Employers sponsor their plan members in the ELCA benefit program and cannot purchase individual ELCA benefit plans separately. A comprehensive benefit program serves our ministry community by: Helping protect rostered leaders and lay employees against significant financial loss from a variety of risks Saving administrative time for sponsoring employers, freeing them to focus on ministry Providing consistency throughout this church, which helps enable rostered leaders to serve wherever they are called without the inconvenience of having to change health plans Designating clergy retirement plan distributions as eligible for the housing allowance exclusion from federal gross income Supporting the physical and financial well-being of those serving as missionaries through ELCA Global Mission Note the following exceptions to the bundled program: Plan members who qualify may waive ELCA health benefits while participating in the rest of the ELCA benefit program. See Waiving Coverage on page 11 for more information. Plan members have certain choices within the ELCA benefit program about which benefits they wish to use. For example, contributing to a flexible spending account or health savings account is optional. While plan members who lose their sponsored status are no longer eligible for the comprehensive ELCA benefit program, they may be eligible to continue coverage under some ELCA benefit plans. In some cases, coverage is available for a limited period of time. ELCA institutions and non-elca organizations sponsoring eligible employees in only the ELCA Retirement Plan on Dec. 31, 2002, may continue to sponsor eligible employees in the ELCA Retirement Plan, provided at least one employee remains enrolled. Employers Eligible to Participate The following are ELCA employers eligible to participate in the ELCA benefit program. Some are required to participate. The ELCA synods, seminaries, and other ministries of the ELCA churchwide organization (except for the ELCA publishing house, Augsburg Fortress) are required to sponsor all their eligible employees in the ELCA benefit program. However, they are not required to sponsor temporary employees or non-elca pastors. ELCA congregations may sponsor any or all of their pastors, rostered laypersons, and other eligible employees. ELCA institutions not subject to the coverage requirements of the Tax Reform Act of 1986 may sponsor any or all of their eligible employees. These institutions generally include elementary and secondary schools, day care centers, camps, and conference centers. ELCA institutions subject to the coverage requirements of the Tax Reform Act of 1986 may sponsor any or all of their eligible ELCA pastors, and all or none of their eligible rostered laypersons and other employees. These institutions generally include ELCA-affiliated social ministry organizations, colleges and universities, nursing homes, and hospitals. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 2

9 Other employers may sponsor pastors and rostered laypersons in the ELCA benefit program if they fall into one of these categories: Other tax-exempt organizations (referred to as 501(c)(3) organizations): - Former ELCA congregations that sponsored at least one eligible employee on or after Jan. 1, 2005, may sponsor any or all eligible employees. - A congregation or qualified church-controlled organization of a non-elca church body that has common religious bonds with the ELCA and has petitioned to and been approved by Portico to be the church body s sole benefits provider may sponsor any or all eligible employees. - Ecumenical partner congregations (full communion partners) may sponsor any or all ELCA pastors or rostered laypersons serving under call to a non-elca ministry. - Other tax-exempt organizations may sponsor any or all ELCA pastors serving under call to a non-elca ministry. They may also sponsor ELCA rostered laypersons serving under call, but then must sponsor all those eligible. These organizations include social ministry organizations, ecumenical agencies, non-ecumenical congregations, and pastoral care organizations. Taxable organizations (non-501(c)(3) organizations) may sponsor any or all ELCA pastors serving under call to a non-elca ministry. These organizations include government agencies and for-profit organizations. An eligible employer can also be an individual who performs service in the exercise of his or her ministry. This individual is considered by Portico to be his or her own employer, and can either be an ELCA ordained minister who is self-employed or one who is employed by a 501(c)(3) organization but is not sponsored by his or her employer. Online Benefit Administration To steward benefit resources, our goal is to move nearly all benefit transactions online, replacing the need for paper forms and improving the speed and accuracy with which we process requests. Portico offers a customized web experience for plan members and sponsoring employers. Both are asked to register and sign in to Portico s website to take required steps like Open Enrollment and viewing bills and statements. By signing in, they can see personalized benefit information, receive timely alerts, and conduct many benefit transactions on Portico s website. One-time registration is required. Plan members Visit myportico (myportico.porticobenefits.org) and register using a seven-digit Member ID, three-digit Security Validation Code (SVC), and address. Sponsoring employers Visit EmployerLink (EmployerLink.PorticoBenefits.org) and register using the organization s 11-digit Access Code and an address. NOTE: Registration on myportico is not currently available for spouses or other family members. Eligible plan members who ve registered on myportico can do the following online: Complete annual Open Enrollment Update personal profile Review defined compensation (see Glossary) Review retirement account balance, statements, and fund performance Change retirement account investment choices Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 3

10 Change pretax retirement contribution Review health benefit elections for yourself and family Review flexible spending account elections Review and change health savings account elections Pay monthly benefit bill, for those on coverage continuation View Advice of Deposit Sponsoring employers who have registered on EmployerLink can do the following online on behalf of their organization: Complete annual Open Enrollment Change profile information View or edit the organization s payroll frequency Pay the monthly benefit bill View pretax deduction amounts Report changes in a plan member s defined compensation Report employee count and tax identification number as required by Medicare Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 4

11 Program Eligibility The ELCA benefit program is a bundled collection of five benefit plans health, flexible benefits, survivor, disability, and retirement. The following eligibility criteria apply to those enrolling in the program as sponsored members. Those Eligible to Enroll in the Program You re eligible to enroll in the ELCA benefit program when you are sponsored as: A pastor or rostered layperson serving under call, employed by an eligible employer, and scheduled to work at least 15 hours per week for six or more months per year or A lay employee employed by an eligible employer, scheduled to work at least 20 hours per week for six or more months per year, and have completed any probationary period specified by your employer (not to exceed 90 days) You re eligible to enroll in the ELCA benefit program when you are a self-sponsoring ELCA pastor and are: Called to a non-elca ministry and your employer chooses not to sponsor you in the ELCA benefit program or Called to a ministry in which you are considered self-employed in accordance with Internal Revenue Code 414(e)(5)(A)(i) NOTE: Self-employed individuals are not eligible to participate in the flexible spending accounts offered through the ELCA Flexible Benefits Plan. Eligible Family Members When you re sponsored in the ELCA benefit program, the following family members are eligible to enroll in the ELCA health plan: Your spouse or eligible same-gender partner (ESGP) (see Glossary) A child under age 26 who falls within one of three categories: 1. Your or your spouse s natural child, legally adopted child, or a child placed in your home for adoption 2. Your never-married grandchild or a child for whom you are a guardian if he or she is: Living in your household and Receiving primary support from you and Claimed by you as a tax dependent for federal income tax purposes 3. The natural or legally adopted child of your ESGP When you re sponsored in the ELCA benefit program, the following family members are eligible for dependent life insurance as long as you purchase supplemental life insurance for yourself: A spouse or ESGP Eligible children up to age 26, including: Your biological children, legally adopted children, children placed in your household as a step toward legal adoption by you, stepchildren, or natural or legally adopted children of an ESGP or grandchildren living in your household Children not living in your household who are unmarried and dependent on you for more than 50% of financial support Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 5

12 Enrolling in the Program Plan members are typically enrolled in the ELCA benefit program by an eligible sponsoring employer. Once a year, members and sponsoring employers make annual benefit selections for the coming plan year during Portico s annual Open Enrollment. In the event that a member is no longer sponsored, Portico maintains the member s ELCA retirement account and offers the opportunity to continue health and life insurance coverage at his or her own expense, if eligible. In some cases, coverage is available for a limited period of time. Timely Enrollment If you and your employer complete your enrollment within 60 days of meeting the ELCA benefit program s eligibility criteria, and the first date of your coverage falls within this 60-day period, you re enrolled in a timely manner. Health Your health coverage takes effect for you (and your family) on the date designated by your employer or the date you were hired if you are employed by a synod, seminary, or ministry of the ELCA churchwide organization. Flexible Spending Accounts If you are a new employee hired after Jan. 1 and enroll in the Platinum+ or Gold+ health benefit option, an ELCA Medicare-Primary health benefit option or waive health benefits, you are eligible to enroll in the health flexible spending account (FSA) the first day you are sponsored in the ELCA benefit program. All sponsored members are eligible to enroll in the dependent care FSA. Your FSA enrollment must be completed within 60 days of your eligibility. Your participation begins the first day of the month following enrollment in an FSA. Health Savings Account If you elect the Silver+ or Bronze+ health benefit option during annual enrollment or as a new member enrolled after Jan. 1 you are eligible to participate in a health savings account (HSA). An account will be opened for you when you enroll. Survivor If you enroll within 60 days of eligibility: You will be enrolled in basic group life insurance without needing to provide evidence of insurability (EOI). You will be able to purchase supplemental and dependent life insurance without needing to provide EOI. If you enroll in supplemental and/or dependent life insurance outside the 60-day eligibility period, you will be required to provide EOI. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 6

13 Disability If you enroll within 60 days of the date you meet the eligibility criteria of the ELCA benefit program, you are entitled to receive disability benefits under the ELCA Disability Benefits Plan unless: You become partially or totally disabled within the first six months of becoming a sponsored member and The disability is caused by a pre-existing condition that was diagnosed or treated in the six-month period prior to the date of membership in the ELCA benefit program Retirement Upon enrollment, all employer contributions to the ELCA Retirement Plan are 100% vested. Late Enrollment If you and your employer don t complete your enrollment within 60 days of meeting the ELCA benefit program s eligibility criteria, you re subject to late enrollment rules. Health If your enrollment application is not submitted within 60 days of meeting the ELCA benefit program s eligibility criteria, you and your family will have to wait 90 days to enroll in health coverage. Exceptions: You enroll during the annual Open Enrollment period in November with health coverage effective the next Jan. 1 or You had a valid waiver within 60 days prior to enrolling The 90-day waiting period begins the day your enrollment is completed. No health plan contribution is due during this waiting period. If you enroll late, health coverage takes effect for you (and your family) the last day of the 90-day waiting period or Jan. 1 of the following year, whichever is earlier. If you re eligible to enroll but don t enroll in a timely manner, you can enroll during annual Open Enrollment in November without a 90-day waiting period for health coverage. Coverage begins Jan. 1 of the following year. Flexible Spending Accounts Your FSA enrollment must be completed within 60 days of your eligibility. Your participation will begin the first day of the month following FSA enrollment. If you don t meet this deadline, you must wait until the next plan year to participate unless you experience a qualifying election change event (see Glossary). Survivor If your enrollment application is not submitted within 60 days of meeting the ELCA benefit program s eligibility criteria, you will be required to provide evidence of insurability (EOI) in order to purchase supplemental and dependent life insurance. The EOI must be approved by Minnesota Life. Your coverage will not be effective until your EOI is approved. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 7

14 Disability If your enrollment application is submitted more than 60 days after meeting the ELCA benefit program s eligibility criteria, you are not entitled to receive any disability benefits under the ELCA Disability Benefits Plan if: You become partially or totally disabled within the first 18 months after enrolling and The disability is caused by a pre-existing condition diagnosed or treated in the six-month period prior to your enrollment date Annual Open Enrollment Portico requires members and employers to confirm or change their benefit options during annual Open Enrollment in November. Eligible spouses, eligible same-gender partners (ESGP), and eligible children may also be enrolled during this period. Benefits elected during Open Enrollment are effective Jan. 1 of the next year and continue throughout the year. You make decisions about some or all of the following benefits depending on your eligibility. Health The health benefit option you choose during Open Enrollment for the coming year applies for the entire plan year, unless you re no longer sponsored or you become eligible for ELCA Medicare- Primary health benefits. If you re eligible, you can waive health benefits for you and family members. You can add or remove family members. Flexible Spending Accounts If eligible, you enroll in the FSA each year during annual Open Enrollment by electing annual pretax contribution amounts for the health FSA and/or the dependent (day) care FSA. Your FSA election(s) remains in effect Jan. 1 Dec. 31 unless you experience a qualifying election change event. If you enroll during 2014 Open Enrollment, your FSA begins Jan. 1, If you don t make an election for the health FSA or the dependent FSA during the annual enrollment period, you are not eligible to participate until the next plan year unless you experience a qualifying election change event (see Glossary). Health Savings Account If eligible, you decide whether to make a pretax contribution to your HSA. You can start or change it throughout the year. Survivor During Open Enrollment, you can purchase after-tax: Supplemental life insurance for yourself Dependent life insurance for your spouse or ESGP and eligible children if you also purchase supplemental life insurance for yourself Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 8

15 IMPORTANT: 2014 Open Enrollment is the only time you can purchase supplemental life insurance for you and dependent life insurance for your spouse or ESGP without having to prove good health, also called evidence of insurability (EOI). If you purchase after 2014 Open Enrollment, you have to submit an EOI application, which must be reviewed and approved by Minnesota Life Insurance Company before supplemental or dependent coverage becomes effective. This restriction does not apply to eligible children during subsequent annual Open Enrollment periods. Retirement During Open Enrollment, you decide whether to have a pretax retirement contribution withheld from your paycheck by your employer and how much to contribute. You can also do this throughout the year. How Open Enrollment Works Your sponsoring employer signs in to EmployerLink (EmployerLink.PorticoBenefits.org) to learn about the health benefit options Platinum+, Gold +, Silver+, or Bronze+. You sign in to myportico to learn about your benefit options. On EmployerLink, your employer selects one health benefit option to offer. If Silver+ or Bronze+ is selected, your employer can also select to contribute money to your health savings account (HSA). You make the following benefit decisions, and enter them online by signing in to myportico: - Required: Whether to enroll in the health benefit option your employer selected, buy up to a higher priced option and pay the difference, or waive health benefits, if you qualify (see below for waiver details) - Optional: Whether to contribute to flexible spending accounts, if you re eligible, to help pay for eligible out-of-pocket health care costs and/or day care expenses - Optional: Whether to contribute to a health savings account, if you re eligible, to help pay for eligible out-of-pocket health care costs - Optional: Whether to purchase supplemental life insurance for yourself and/or dependent life insurance for your spouse, ESGP, or children - Optional: Whether to start or change a pretax retirement contribution In 2014, Portico bills your employer for your health benefit buy-up costs, contributions to flexible spending accounts, health savings account, pretax retirement contributions, and supplemental and dependent life insurance premiums. Your employer then withholds these amounts from your paycheck. Opportunity for Employees Not Enrolled in a Timely Manner Eligible employers who don t enroll eligible employees in the ELCA benefit program in a timely manner can enroll them in November without a 90-day waiting period for health coverage. If your employer enrolls you in November, your benefits will start Jan. 1 of the following plan year. You re eligible to enroll during this time if: Your employer didn t enroll you in a timely manner You waived coverage in the ELCA health plan and your other coverage was terminated for more than 60 days You re enrolled and want to enroll an eligible spouse or ESGP and eligible children Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 9

16 This opportunity is not available to individuals whose eligibility period to elect coverage continuation under the health plan has lapsed (former spouses, surviving spouses, or individuals who previously terminated coverage, except retirees). Waiving Health Coverage As a sponsored member of the ELCA benefit program, you can waive (decline) ELCA health coverage while continuing to participate in the flexible benefits and retirement plans and receive coverage under the disability and survivor plans. If you waive health coverage, your spouse or eligible same-gender partner and children: Must also waive ELCA coverage if you are sponsored or receiving disability benefits Can continue ELCA coverage at their own expense if you are an ELCA pastor or rostered layperson on leave from call Can continue ELCA coverage for a limited time at their own expense if you are retired If you are retired, you can waive coverage for your spouse or dependents without having to waive coverage for yourself. To ensure that you can activate coverage for family members at a later date without a 90-day waiting period, you must first enroll them as waived members in the ELCA Health Benefits Plan. To avoid late enrollment consequences, you need to notify the Portico Service Center of any change in family status while you are waiving coverage marriage, birth, divorce, loss of eligibility for a dependent, and death. To waive, you must meet one of the two criteria described below. If you don t meet these criteria and don t enroll in ELCA health coverage, you are no longer enrolled in the bundled ELCA benefit program. 1. You have other group health coverage provided by one of the following: An employer other than your sponsoring employer, provided that this employer is not an ELCA congregation, seminary, synod, or ministry of the ELCA churchwide organization An employer or former employer of your eligible spouse or ESGP, as a result of your spouse s employment Your former employer, as a result of your previous employment Your (or your spouse s) employer or former employer if you are a retired member Your (or your spouse s) employer or former employer if you are on leave from call Your parent s employer or former employer (if you are a child) A government-sponsored program outside the United States Federal Medicaid and state-sponsored Medicaid-like medical assistance programs A post-secondary educational institution attended by a coverage continuation member, eligible spouse, or eligible child A Medicare health plan option under Medicare Advantage The U.S. Department of Veterans Affairs 2. You purchase coverage through a state, federal, or state/federal partnership health insurance exchange and receive a premium tax credit (also called a subsidy) in accordance with the Patient Protection and Affordable Care Act of Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 10

17 If you choose to waive ELCA health coverage, your waiver of coverage will take effect the first day of the month following the date your waiver request is received by Portico, or on any future first day of the month you designate. If you enroll in other employer-provided group health coverage, contact the Portico Service Center for a certificate of group health coverage (Health Insurance Portability and Accountability Act creditable coverage notice). You may need this certificate to confirm prior coverage. Activating Health Coverage After Waiving If you previously waived ELCA health coverage, you can activate it during annual Open Enrollment or at any time during the plan year as long as you can document that you met waiver criteria and meet the plan s eligibility criteria. You can either accept the health benefit option selected by your employer or buy up to a higher priced option. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 11

18 Paying for Benefits When You re Sponsored in the ELCA Benefit Program Benefits Paid by Your Sponsoring Organization In accordance with the ELCA Philosophy of Benefits, your sponsor is billed for the contribution amount for your participation in the ELCA benefit program, including the full cost of the health benefit option it selected during annual Open Enrollment for you and any covered family members. Most contribution rates are expressed as a percentage of your defined compensation. (See Glossary.) This helps our ministry community support each other in mission by sharing benefit costs between sponsoring organizations of greater and lesser means. Contribution rates are typically approved annually by Portico s board of trustees and announced in the fall for the next plan year. Your sponsoring organization is billed monthly and can estimate its contribution amount online using the 2014 Benefit Costs Calculator on EmployerLink. Health contributions Your employer s health contribution rate is based on a percentage of your defined compensation (subject to a minimum and maximum) and the following: The health benefit option provided by your sponsoring organization Eligible family members you choose to cover: you, your spouse or ESGP, and your children Your sponsor s assigned rate class (all sponsoring organizations within a synod are assigned a rate class that reflects the region s average health care costs; seminaries are grouped into a separate rate class) Your age NOTE: If you qualify and decide to waive ELCA health benefits, your employer does not pay a health contribution. Health Savings Account contributions If your employer selects the Silver+ or Bronze+ health benefit option and chooses to contribute money to your HSA during annual Open Enrollment, Portico bills your employer monthly for this contribution and directs it to your HSA once it s received from your employer. Survivor contributions In 2014, your employer pays 0.8% of your defined compensation to provide you with basic group life insurance and accidental death and dismemberment (AD&D) protection. Disability contributions Your employer pays a percentage of your defined compensation to provide you with disability benefit protection. In 2014, your employer is not being charged for your disability coverage due to the strong financial position of the ELCA Disability Benefits Trust. Employer retirement contributions Your employer pays a percentage of your defined compensation to help you save for retirement. Once Portico receives it, we credit your employer s contribution to your ELCA Retirement Plan account. The percentage of defined compensation may differ depending on your employer and whether you re a rostered leader or lay employee. - If you are employed by an ELCA synod, seminary, or ministry of the ELCA churchwide organization, your employer must contribute a minimum of 10% of your defined compensation. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 12

19 - If you are a sponsored pastor or rostered layperson, your sponsoring organization must contribute a minimum of 10% of your defined compensation. - If you are lay employee and not sponsored by an ELCA synod, seminary, or ministry of the ELCA churchwide organization, your sponsoring organization must contribute a minimum of 6% of your defined compensation. - Your employer may choose to contribute more than the required amount, subject to contribution limits described in the ELCA Retirement Plan Summary Plan Description. - If you participated in a predecessor plan on Dec. 31, 1987, were at least age 45 on that date, and have continuously participated in an ELCA retirement plan since Jan. 1, 1988, your employer must contribute at least 11%. - If you are an eligible self-sponsoring pastor, you pay the employer contribution of at least 10% of your defined compensation. - If you are a lay employee of an ELCA institution or a non-elca organization, your employer must contribute the same percentage for all non-clergy sponsored members and it can t be less than 6% of defined compensation, as determined by your employer. Housing equity retirement contributions Your employer may choose to pay additional amounts toward your ELCA Retirement Plan account if you are a pastor sponsored by a congregation, synod, seminary, or ministry of the ELCA churchwide organization. Housing equity contributions are retirement plan contributions made by an employer for pastors living in churchowned housing. Housing equity contributions are made in addition to employer retirement contributions. Your employer decides the effective date and the contribution amount (either a percentage of your defined compensation or a flat dollar amount), subject to contribution limits described in the ELCA Retirement Plan Summary Plan Description. Retiree support contributions In 2014, your employer pays 0.7% of your defined compensation to help the ELCA provide health coverage for certain retired members who served a predecessor church body. Benefits Paid by You You can elect to pay for optional benefits. Portico includes your costs on your sponsoring employer s monthly bill. Your employer is responsible for deducting the appropriate amount from your paycheck and remitting it to Portico on your behalf. Your sponsoring employer can sign in to EmployerLink to review details about payroll withholdings. Health buy-up costs If you chose to buy up to a higher-priced health benefit option than the one your sponsoring employer selected during annual Open Enrollment, you are responsible for paying the cost difference. Your employer deducts this amount from your paycheck on a pretax basis. Health FSA contributions If eligible, you may set aside money to help you manage eligible out-of-pocket health care expenses. Your employer deducts this amount from your paycheck on a pretax basis. Portico credits your contribution to your health FSA once it s received from your employer. Your total annual election is available to you on the date your health FSA is effective. Dependent (Day) care FSA contributions If eligible, you may set aside money to pay for day care that enables you and your spouse to work or seek work. Your employer deducts this amount from your paycheck on a pretax basis. Portico credits your contribution to your dependent (day) care FSA once it s received. Your contributions are not available to you until they are credited to your account. HSA contributions If eligible, you may set aside money to help you manage eligible out-ofpocket health care expenses. Your employer deducts this amount from your paycheck on a pretax Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 13

20 basis. Portico deposits your contribution into your HSA once it s received from your employer. Your contributions are not available to you until they are deposited into your account. Life insurance premiums If eligible, you may purchase supplemental life insurance for yourself and dependent life insurance for your spouse or ESGP and children. Your employer deducts this amount from your paycheck on an after-tax basis. Pretax retirement contributions You may set aside money to help you save for retirement. Your employer deducts this amount from your paycheck on a pretax basis. Portico credits your contribution to your ELCA Retirement Plan account once it s received. When You Have Coverage Continuation When you are no longer sponsored in the ELCA benefit program by an eligible employer, you pay the contribution amount for any benefits you continue. In some cases, coverage is available for a limited period of time. This is referred to as coverage continuation. If eligible, you and family members may continue health coverage when you: Retire Become disabled and entitled to benefits from the ELCA Disability Benefits Plan and your employer is not making health contribution payments for the first two months of your disability Begin on leave from call status Terminate employment (other than for reasons of gross misconduct) Experience a reduction in hours of employment that causes you to lose eligibility for coverage under the ELCA health plan Take a leave of absence without pay Are called to military service Rates are typically approved annually by Portico s board of trustees and announced in the fall for the next plan year. Coverage is billed monthly using current coverage continuation rates. You ll find your bill online around the 20 th of each month. You can estimate your contribution amount online by visiting the Coverage Continuation Rates page in the Overview & Life Changes section on myportico. Health contributions If eligible, you may purchase ELCA health benefits for you and/or eligible family members. In 2014, your rate depends on the following variables: - Your health benefit option - Eligible family members you choose to cover: you, your spouse or ESGP, and your children - Your age, if you re covered - Your spouse or ESGP s age, if he or she is covered Health FSA contributions If you have a positive balance (you ve contributed more than you ve been reimbursed) at the time your sponsored employment ends, you can continue your health FSA contributions for the remainder of the plan year by setting up after-tax contributions with Portico. Your after-tax contribution must be the same as your pretax health FSA election for the plan year (unless you have a qualifying election change event). Portico bills you monthly for amounts you elected for the plan year. If you don t pay these after-tax contributions or you decide not to continue after-tax contributions, you will forfeit the balance in your account. Dependent (day) care FSA contributions You can t continue your dependent care FSA contributions when your sponsored employment ends. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 14

21 HSA contributions If eligible, you may contribute money after-tax to an HSA to help you manage eligible out-of-pocket health care expenses. Portico bills you monthly for your contribution and deposits it into your HSA once it s received. Your contributions are not available to you until they are deposited into your account. Life insurance premiums You re eligible to continue basic group life insurance with accidental death and dismemberment (AD&D) protection by contacting Minnesota Life Insurance Company. You will be billed by Minnesota Life. If you purchased supplemental and dependent life insurance while sponsored, you can continue this coverage by contacting Minnesota Life Insurance Company. You will be billed by Minnesota Life. Disability contributions If you are an interim pastor or interim rostered layperson serving under a term call from a synod council and between assignments after completing an interim or term call from your synod council, you can purchase up to 12 months of limited disability benefit coverage at your own expense. In 2014, this rate is $25 per month per $1,000 of coverage. When Contributions Aren t Paid If the contributions for your benefits are not paid in full, Portico begins a process 60 days after the due date to collect the outstanding balance. During this process, your sponsoring employer (or you, if you have coverage continuation) must pay the balance in full or agree to a payment plan with Portico or your benefits will end. Portico notifies you of your benefit termination date. You (and your family) may reactivate coverage at a later date if you are eligible for coverage and if the unpaid amount is paid in full. You will be subject to the 90-day waiting period for health coverage unless you reactivate coverage during annual Open Enrollment or had other employer-provided group coverage within 60 days prior to re-enrolling. You will also be subject to a longer exclusion period for pre-existing conditions under the ELCA Disability Benefits Plan. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 15

22 When a Call or Employment Change Affects Your Benefits If You Change Call or Employment If you leave one call or position and accept another with an eligible ELCA employer, you must complete a change of call report and send it to Portico as soon as possible. If we receive it within 60 days of the date you become eligible for ELCA benefits and your new employer begins sponsoring you within this period, your employer will be responsible for paying all benefit contributions effective the date of your new sponsorship. If we don t receive your change of call report within 60 days of the date you become eligible, you and your dependents will have a 90-day waiting period for health coverage and you ll be subject to an 18-month preexisting condition exclusionary period under the ELCA Disability Benefits Plan. Health Your employer selects one ELCA-Primary health benefit option during annual Open Enrollment. Unless you waive health benefits, you enroll in that option or buy up to a higher priced option, and retain it while sponsored during the plan year. If you start a new call or position midyear, expect the following: You will continue the health benefit option you originally chose for the year, unless you are eligible and opt to waive ELCA health coverage. (See page 11 for details about waiving coverage.) You ll keep your progress toward your 2014 deductible and out-of-pocket limit. If your new employer offers a lower-priced option than you chose for the year, you re responsible for paying the health contribution difference. If your new employer offers a higher priced option than you chose for the year, you will continue to have the option you originally selected. If you bought up to a higher priced option during Open Enrollment and your new employer offers that option or an even higher priced option, you are no longer charged the buy-up cost. If you had chosen the Silver+ or Bronze+ option and your new employer offers one of them, you ll receive the HSA contribution selected by your new employer and can continue to make contributions to your HSA. If you have a gap between employers of more than 31 days, you can choose a different option while on coverage continuation at your own expense. Then, if you re again sponsored during the same plan year, you ll return to the health benefit option you originally chose for the year. You can continue to earn wellness dollars up to the annual maximum allowed. EXAMPLES: Your prior employer selected Gold+ and you enrolled in it during 2014 Open Enrollment. If your new employer provides Silver+, you continue to have the Gold+ option and pay the buy-up costs through payroll deduction. If your new employer provides Platinum+, you continue to have Gold+. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 16

23 Your prior employer selected Silver+ and you enrolled in it during 2014 Open Enrollment. If your new employer also offers Silver+, you continue to have Silver+ but you receive the employer HSA contribution level that the new employer provides. If your new employer offers Gold+, you continue to have Silver+ and no longer receive employer HSA contributions. Your prior employer selected Bronze+ and you bought up to Silver+ during 2014 Open Enrollment. If your new employer offers the Platinum+ or Gold+ options, you continue with Silver+ and are no longer charged the buy-up cost. When your employment ends with an eligible employer, your ELCA health benefits terminate. If you re sponsored by another eligible employer with 31 days, coverage for you (and your family) will be retroactively reinstated after Portico receives your change of call form from your new employer. Portico provides health coverage during this time for up to 31 days at no additional cost to you or your employers. Contact Portico shortly before your call ends for help coordinating this process in order to potentially avoid a situation where a claim is denied. If there are more than 31 days between the dates your current call ends and your next call begins, you re responsible for the cost of continuing health benefits while between calls. Before your employment ends, indicate your choice of health benefit option on an election form and submit it to the Portico Service Center. Flexible Spending Accounts If you are a sponsored member and have 31 days or fewer between eligible employers, you are required to continue your health FSA with the same annual election you chose prior to changing employment (unless you have a qualifying election change event that allows you to change your election). If you are a sponsored member and have more than 31 days between eligible employers, your participation in the plan terminates. Your employer must withhold FSA contributions through your last scheduled paycheck. Health FSA If you have a positive balance at the time your call or employment ends, you can: - Submit any claims incurred prior to the date your call or employment ends, or forfeit the balance in your account. Expenses incurred after the date of termination are not eligible to be reimbursed. - Continue your health FSA contributions until your next call or employment begins by setting up after-tax contributions with Portico. Your after-tax contributions must be the same as your pretax health FSA election for the plan year (unless you have a qualifying election change event). Portico bills you monthly for amounts you elected for the plan year. If you don t pay these after-tax contributions, you will forfeit the balance in your account. When your next call or employment begins, the maximum health FSA contribution you can elect is the annual contribution limit less the amount you previously contributed in the plan year. Dependent (day) care FSA You can t continue your dependent care FSA contributions. You must submit any claims incurred prior to the date your call or employment ends, or forfeit the balance in your account. Expenses incurred after the date of termination are not eligible to be reimbursed. When your next call or employment begins, the maximum dependent care FSA contribution you can elect is the annual contribution limit less the amount you previously contributed in the plan year. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 17

24 Health Savings Account If you had chosen the Silver+ or Bronze+ option and your new employer offers one of them, you ll receive the HSA contribution selected by your new employer and can continue to make contributions to your HSA. Survivor If you have 31 days or fewer between eligible employers, you will continue to be covered under the basic group life insurance benefit during this period. This coverage is provided at no additional cost to you. If you have more than 31 days between eligible employers, you can elect to continue this coverage. If you re an ELCA pastor or rostered layperson, you can continue coverage for 36 months and will be billed $7.50 per month by Portico. If you re a lay employee and are between employers, you can continue this coverage for 18 months at your own expense by contacting Minnesota Life Insurance Company. If you purchased supplemental and dependent life insurance while sponsored and you are between eligible employers for more than 31 days, you can continue this coverage by contacting Minnesota Life Insurance Company. If your leave is fewer than 90 days, you are guaranteed (no EOI needed) to be issued the same amount of supplemental life insurance you had purchased before going on leave. If you ve been on leave for 90 or more days, you are considered a new employee when you return to sponsored employment. Disability If you have 31 days or fewer between eligible employers, you will continue to be covered under the ELCA Disability Benefits Plan during this period. This coverage is provided at no additional cost to you. If you have more than 31 days between eligible employers, you have no disability coverage after 31 days. If Your Employment Ends This section describes termination of employment for lay employees. Rostered leaders, if you re leaving a call, see If You Go On Leave From Call, page 21, or If You Leave the Roster, page 25. If your employment ends, your participation in the program as a sponsored employee ends. Your participation in the ELCA benefit program ends the date through which the contribution has been paid. Your employer discontinues sponsoring you in the program by notifying Portico. If your employer does not notify us and does not pay the required amount, your sponsored status will end 60 days after the contribution due date. Health If you ve left employment (other than for reasons of gross misconduct), you and your family may continue health coverage for up to 18 months at your own expense by submitting the appropriate form to the Portico Service Center within 60 days of the day your employment ends. You may choose any of the four health benefit options. Coverage is billed monthly using current coverage continuation rates based on age and enrolled family members. You ll find your bill online around the 20 th of each month. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 18

25 Flexible Spending Accounts Your participation in the plan terminates. Your employer must withhold FSA contributions through your last scheduled paycheck. Health FSA If you have a positive balance at the time you terminate employment, you can: o Submit any claims incurred prior to your termination date within four months of the date of termination, or forfeit the balance in your account. Expenses incurred after the date of termination are not eligible to be reimbursed. o Continue your health FSA contributions for the remainder of the plan year by setting up after-tax contributions with Portico. Your after-tax contributions must be the same as your pretax health FSA election for the plan year (unless you have a qualifying election change event). Portico bills you monthly for amounts you elected for the plan year. If you don t pay these after-tax contributions, you will forfeit the balance in your account. Dependent (day) care FSA You can t continue your dependent care FSA contributions when you terminate employment. You must submit any claims incurred prior to your termination date within four months of the date of termination, or forfeit the balance in your account. Expenses incurred after the date of termination are not eligible to be reimbursed. Health Savings Account You can continue to pay for eligible expenses from your health savings account until your account balance is zero. If you continue health coverage at your own expense and choose the Silver+ or Bronze+ option, you can continue or start making your own contributions to an HSA. Portico bills you monthly. Survivor You can continue your basic group life and any supplemental and dependent insurance you have purchased for yourself and your dependents for up to 18 months by contacting Minnesota Life. You must elect and pay for coverage continuation within 60 days of terminating employment. If you don t opt to continue coverage, your basic group life insurance terminates as of your termination date along with any supplemental and dependent coverage you purchased. Disability You are no longer eligible for coverage under the ELCA Disability Benefits Plan. Retirement If your account balance is more than $500 when your employment ends, you can leave your account invested in the ELCA Retirement Plan or make withdrawals subject to plan limitations. If you leave your money invested in the retirement plan, you will receive the same level of service and account flexibility as when you were employed (online access, online quarterly statements, ability to choose from among the 20 investment fund options, customer advocacy, and access to Ernst & Young financial advisers with no out-of-pocket costs). According to IRS rules, you must begin receiving distributions from your account by April 1 following the year you reach age 70½, or end of employment, if later. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 19

26 If You Go On Leave From Call If your call ends, your participation in the program ends. ELCA pastors and rostered laypersons on leave from call and wanting to continue benefits must continue both health benefits (or waive) and basic group life insurance. Report this change and your decision to continue benefits by contacting the Portico Service Center. If you continue benefits throughout your leave, you won t have a new pre-existing condition exclusion period under the disability plan when you re next sponsored by an eligible employer following your leave. If you don t contact us to confirm or waive health benefits within 60 days of ending your call, your ELCA health coverage will terminate as of the date through which your last contribution was paid. If your ELCA health coverage terminates: You and your family can t re-enroll in the ELCA health plan until you re sponsored by an eligible employer. You can t continue basic group life insurance under the ELCA Survivor Benefits Plan. You will be subject to a new pre-existing condition exclusion period under the disability plan when you re-enroll in the ELCA benefit program. Health Your employer selects one ELCA-Primary health benefit option during Open Enrollment. Unless you waive health benefits, you enroll in that option or buy up to a higher priced option. The first time you go on leave from call during the plan year and continue your ELCA-Primary health benefits, you choose one of the four benefit options. If you take a new call and become sponsored during the plan year, you ll resume the option you had when last sponsored. If this call ends during the plan year and you want to continue health benefits, you ll resume the option you chose when you first went on leave from call during the plan year. You need to report your health benefit option choice or decision to waive health benefits to the Portico Service Center within 60 days of ending your call. Coverage is billed monthly using current coverage continuation rates based on age and enrolled family members. You ll find your bill online around the 20 th of each month. Flexible Spending Accounts Your participation in the plan terminates. Your employer must withhold FSA contributions through your last scheduled paycheck. Health FSA If you have a positive balance at the time you go on leave from call, you can: o Submit any claims incurred prior to going on leave from call within four months of the date of leave, or forfeit the balance in your account. Expenses incurred after the date of termination are not eligible to be reimbursed. o Continue your health FSA contributions for the remainder of the plan year by setting up after-tax contributions with Portico. Your after-tax contributions must be the same as your pretax health FSA election for the plan year (unless you have a qualifying election change event). Portico bills you monthly for amounts you elected for the plan year. If you don t pay these after-tax contributions, you will forfeit the balance in your account. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 20

27 Dependent (day) care FSA You can t continue your dependent care FSA contributions when you go on leave from call. You must submit any claims incurred prior to going on leave from call within four months of the date of leave or forfeit the balance in your account. Expenses incurred after the date of termination are not eligible to be reimbursed. Health Savings Account You can continue to pay for eligible expenses from your health savings account until your account balance is zero. If you continue health coverage at your own expense and choose the Silver+ or Bronze+ option, you can continue or start making your own contributions to an HSA. Portico bills you monthly Survivor You can continue your basic group life insurance at your own expense through Portico for up to 36 months while on leave from call. Portico will bill you $7.50 per month. After 36 months, you are eligible to continue your basic group term life insurance policy through Minnesota Life, who will bill you directly. If you take a new call in less than 90 days, you are guaranteed (no EOI needed) to be issued the same amount of supplemental life insurance you had purchased before going on leave. If you ve been on leave for 90 or more days, you are considered a new employee when you return to sponsored employment. You can continue your supplemental life insurance at your own expense by contacting Minnesota Life. You can continue dependent life insurance at your own expense by contacting Minnesota Life as long as you also continue your supplemental life insurance. If you don t opt to continue coverage, your basic group life insurance, along with any supplemental and dependent coverage you purchased, terminates as of the date you go on leave from call. Disability If you are not sponsored in the ELCA benefit program by an eligible employer, you are not eligible for coverage under the ELCA Disability Benefits Plan. If you continue health and survivor benefits, you will not be subject to a new pre-existing condition exclusion period under the disability plan when you re-enroll in the ELCA benefit program. Retirement You can continue making investment decisions for your retirement account while on leave. You can roll money into the plan from eligible IRAs or other eligible pretax retirement accounts but you can t make contributions into your retirement account while you re not sponsored by an eligible employer. If Your Interim Assignment Ends As a sponsored interim pastor or rostered layperson, your employer pays monthly contributions for your ELCA benefits, and you are eligible for all benefits offered by the ELCA benefit program. If you want to continue benefits when an interim assignment ends, you must continue both health benefits (or waive) and basic group life insurance at your own expense. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 21

28 Health Your employer selects one ELCA-Primary health benefit option during Open Enrollment. Unless you waive health benefits, you enroll in that option or buy up to a higher priced option. The first time you end an interim assignment during the plan year and choose to continue your ELCA-Primary health benefits, you choose one of the four benefit options. If you take a new interim assignment and become sponsored during the plan year, you ll resume the option you had when last sponsored. If this interim assignment ends during the plan year and you want to continue health benefits, you ll resume the option you chose when your first interim assignment of the plan year ended. You need to report your health benefit option choice or decision to waive health benefits to the Portico Service Center within 60 days of ending your assignment. Coverage is billed monthly using current coverage continuation rates based on age and enrolled family members. You ll find your bill online around the 20 th of each month. Flexible Spending Accounts Your participation in the plan terminates. Your employer must withhold FSA contributions through your last scheduled paycheck. Health FSA If you have a positive balance at the time your interim assignment ends, you can: o Submit any claims incurred prior to the end of your interim assignment within four months of the termination date, or forfeit the balance in your account. Expenses incurred after the date of termination are not eligible to be reimbursed. o Continue your health FSA contributions for the remainder of the plan year by setting up after-tax contributions with Portico. Your after-tax contributions must be the same as your pretax health FSA election for the plan year (unless you have a qualifying election change event). Portico bills you monthly for amounts you elected for the plan year. If you don t pay these after-tax contributions, you will forfeit the balance in your account. Dependent (day) care FSA You can t continue your dependent care FSA contributions when you are not sponsored. You must submit any claims incurred prior to the end of your interim assignment within four months of the termination date or forfeit the balance in your account. Expenses incurred after the date of termination are not eligible to be reimbursed. Health Savings Account Survivor You can continue to pay for eligible expenses from your health savings account until your account balance is zero. You can continue or start making your own contributions to an HSA if you continue health coverage at your own expense and choose the Silver+ or Bronze+ option. Portico bills you monthly. You can continue your basic group life insurance at your own expense through Portico for up to 36 months while between assignments. Portico will bill you $7.50 per month. After 36 months, you are eligible to continue your basic group term life insurance policy through Minnesota Life, who will bill you directly. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 22

29 If you take a new assignment in less than 90 days, you are guaranteed (no EOI needed) to be issued the same amount of supplemental life insurance you had during your last assignment. If you start your next assignment after 90 or more days, you are considered a new employee. You can continue your supplemental life insurance at your own expense by contacting Minnesota Life. You can continue dependent life insurance at your own expense by contacting Minnesota Life as long as you also continue your supplemental life insurance. If you don t opt to continue coverage, your basic group life insurance, along with any supplemental and dependent coverage you purchased, terminates as of the date your interim assignment ends. Disability You can choose to purchase disability coverage for up to 12 months at your own expense if you are a called interim pastor or interim rostered layperson serving under a term call from a synod council and between assignments after completing an interim or term call from a synod council. If you become disabled while continuing disability coverage, this benefit will provide you with monthly income. The benefit will not make retirement, health, or survivor benefit contributions on your behalf. Retirement You can continue making investment decisions for your retirement account while on leave. You can roll money into the plan from eligible IRAs or other eligible pretax retirement accounts but you can t make contributions into your retirement account while you re not sponsored by an eligible employer. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 23

30 If You're a Missionary Sponsored by ELCA Global Mission Your health coverage is provided by Aetna International. It s designed for sponsored ELCA Global Mission missionaries and their eligible family members who reside outside the United States. Health If you terminate employment midyear as a missionary with ELCA Global Mission and become sponsored by another eligible ELCA employer, your health benefit administrator changes and you have ELCA- Primary health benefits. Your eligible medical and mental health expenses incurred in the same calendar year while you were covered by Aetna International are applied as follows: In-network medical and mental health expenses incurred prior to the change are applied to your ELCA-Primary in-network deductible and out-of-pocket limit under your medical and mental health benefit. Out-of-network medical and mental health deductible and out-of-pocket limits are applied to your ELCA-Primary your out-of-network medical and mental health benefit. Flexible Spending Accounts Missionaries with ELCA Global Mission are not eligible to enroll in flexible spending accounts. If You Leave the Roster and Aren t Sponsored If you leave the roster and end sponsored employment, your participation in the program as a sponsored employee ends. Your employer discontinues sponsoring you in the program by notifying Portico. If your employer does not notify us of your termination from employment and does not pay the required amount, your sponsored status ends 60 days after the contribution due date. NOTE: Your bishop must notify Portico of your removal from the roster. Health If you leave your employment (other than for reasons of gross misconduct), you and your family may continue health coverage for up to 18 months at your own expense. You may choose any of the health benefit options available to you. You need to report your benefit option choice or decision to waive health benefits to the Portico Service Center within 60 days of ending your call. Coverage is billed monthly using current coverage continuation rates based on age and enrolled family members. You ll find your bill online around the 20 th of each month. Flexible Spending Accounts Your participation in the plan terminates. Your employer must withhold FSA contributions through your last scheduled paycheck. Health FSA If you have a positive balance at the time your sponsored status ends, you can: o Submit any claims incurred prior to the end of your sponsored status within four months of the date of termination, or forfeit the balance in your account. Expenses incurred after the date of termination are not eligible to be reimbursed. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 24

31 o Continue your health FSA contributions for the remainder of the plan year by setting up after-tax contributions with Portico. Your after-tax contributions must be the same as your pretax health FSA election for the plan year (unless you have a qualifying election change event). Portico bills you monthly for amounts you elected for the plan year. If you don t pay these after-tax contributions, you will forfeit the balance in your account. Dependent (day) care FSA You can t continue your dependent care FSA contributions when your sponsored status ends. You must submit any claims incurred prior to the end of your sponsored status within four months of the date of termination, or forfeit the balance in your account. Expenses incurred after the date of termination are not eligible to be reimbursed. Health Savings Account You can continue to pay for eligible expenses from your health savings account until your account balance is zero. You can continue or start making your own contributions to an HSA, if you continue health coverage at your own expense and choose the Silver+ or Bronze+ option. Portico bills you monthly. Survivor You can continue your basic group life and any supplemental insurance you have purchased for yourself and your dependents for up to 18 months by contacting Minnesota Life. You must elect and pay for coverage continuation within 60 days of terminating employment. If you don t opt to continue coverage, your basic group life insurance, along with any supplemental and dependent coverage you purchased, terminates as of the date your employment ends. Disability You are not eligible for coverage under the ELCA Disability Benefits Plan. Retirement If your account balance is more than $500 when your position ends, you can leave your account invested in the ELCA Retirement Plan or make withdrawals subject to plan limitations. If you leave your money invested in the retirement plan, you will receive the same level of service and account flexibility as when you were employed (online access, online quarterly statements, ability to choose from among the 20 investment fund options, customer advocacy, access to Ernst & Young financial advisers with no out-of-pocket costs). According to IRS rules, you must begin receiving distributions from your account by April 1 following the year you reach age 70½, or the year in which you retire, if later. Retirement contributions made prior to your removal from the roster will still be designated as housing allowance eligible when distributed. NOTE: If you are leaving the roster but continuing to work for your current employer, you can continue to be sponsored in the ELCA benefit program. Contributions made to your retirement account after you re removed from the roster will not be designated as eligible for the housing allowance exclusion from federal gross income. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 25

32 If You Become Sponsored by Multiple Employers If you serve more than one sponsoring employer, your employers will share the cost of your benefits. Any pretax or after-tax member contributions you elect will be withheld by the employer offering the health benefit option you choose. Health Benefit Option While each of your sponsoring employers selects one of the four health benefit options, you can only have one health benefit option. During Open Enrollment, Portico offers you the option selected by the employer who selects the higher priced option. If all your employers select the same option, then you have the option chosen by the employer at which you contributed to an FSA in If you didn t contribute to an FSA in 2013, then you ll have the option selected by the employer paying you the highest defined compensation. If compensation is equal, then you ll have the option selected by the employer with the lowest employer number assigned by Portico. If the employer selected for you through this process offers an HSA contribution, your sponsoring employers will share equally in the cost of that HSA contribution. If you choose a higher priced option, each of your employers withholds from your paycheck the proportional share of the cost of this option. If you want a lower priced option offered by one of your employers, call Portico before you enroll. Once the plan year starts, you can choose an option in the following situations: If you waived health coverage during 2014 Open Enrollment and want to activate ELCA-Primary health benefits during the plan year, you can choose from the health options offered by your sponsoring employers. If you are newly sponsored by more than one employer and the sponsorships start on the same day, you may choose one of the health benefit options selected by your sponsoring employers. If you had multiple employers and now have only one employer, you will remain in the health benefit option elected during annual Open Enrollment. If this option is more expensive than the option selected by your current employer, you may now be required to pay a buy-up cost. Contributions In 2014, each employer s health contribution will be based on your age, rate class, defined compensation from each employer, and the number of employers. Your employers share payment of your health contribution. As shown in the following example, each is billed for a portion of what it would have paid if you were only sponsored by that employer. EXAMPLE (for illustration only): Jill is a 35-year-old single member who works for two employers, both located in rate class 3. The member s defined compensation at Employer 1 is $25,000 annually and the member s total defined compensation at Employer 2 is $55,000 annually. Both employers selected the Gold+ health benefit option, and Jill enrolled in that option. To calculate the contribution for Employer 1, take the $25,000 defined compensation and multiply it by the health rate based on age 35 and rate class 3. This amount is lower than the health Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 26

33 contribution minimum, so the minimum applies. Divide the minimum amount by 12, which results in a monthly cost of $410. Then divide $410 by 2. Cost at Employer 1 is $205. To calculate the contribution for Employer 2, take the $55,000 defined compensation and multiply it by the health rate based on age 35 and rate class 3, and divide it by 12, which results in a monthly cost of $454. Then divide $454 by 2. Cost at Employer 2 is $227. If you have multiple employers and are a member of a sponsored couple, the health contribution is first divided between your employer(s) and your spouse s employer(s) based on the split described in If You and Your Spouse Are Both Sponsored on page 29. Then, your health contribution is calculated for your employers as described above. Flexible Spending Accounts If you enroll in a health and/or dependent (day) care FSA, your contributions will be withheld pretax by the employer whose health benefit option you have. This employer will be billed for your contributions on its monthly billing statement. Health Savings Account Survivor If you select a health benefit option that includes an employer HSA contribution, your sponsoring employers will share equally in the cost of that HSA contribution. If you make HSA contributions, they will be withheld pretax by the employer whose health benefit option you chose. This employer will be billed for your contributions on its monthly billing statement. Each employer s 2014 contribution for your basic group life insurance is 0.8% of the defined compensation it pays you. If you choose to purchase supplemental and dependent life insurance, your premiums will be withheld after-tax by the employer whose health benefit option you have. This employer will be billed for your contribution on its monthly billing statement. Disability Typically, each employer s contribution for your disability coverage is a percentage of the defined compensation it pays you. In 2014, your employers are not being charged for disability coverage due to the strong financial position of the ELCA Disability Benefits Trust. Retirement If you make pretax retirement contributions, they will be withheld by the employer whose health benefit option you have. This employer will be billed for your contribution on its monthly billing statement. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 27

34 If You and Your Spouse Both Become Sponsored When you and your spouse or ESGP are sponsored by the same or different employers, Portico enables you and your spouse to enroll together as one family. This can reduce your employer s health contribution and may lower your family s out-of-pocket health care costs. Health To enable you to enroll as a family, Portico must designate one of you as the primary health benefit member. This person chooses the health benefit option the family elects and which family members to enroll in health coverage, if any. Depending on eligibility, both of you can make elections regarding optional benefits flexible spending accounts, health savings account, life insurance, and pretax retirement contributions. Benefit Option If the same sponsoring employer sponsors both you and your spouse, either you or your spouse or ESGP is designated as the primary member prior to Open Enrollment. During Open Enrollment, the primary member enrolls in the option your shared employer provides, buys up to another option and pays the difference, or waives health benefits if he or she qualifies. At the same time, he or she chooses which family members to cover, if any. If you and your spouse have different sponsoring employers, either you or your spouse or ESGP is designated as the primary member prior to Open Enrollment. During Open Enrollment, Portico compares the health benefit option selected by each of your employers and determines whether they ve selected the same or different options. If your employers selected the same health benefit option, the person who was primary prior to Open Enrollment continues in that role. If you re both newly enrolled in the ELCA benefit program, the older of the two of you is designated primary. If your employers selected different health benefit options, Portico designates as primary the spouse or ESGP whose employer selected the higher priced health benefit option. During Open Enrollment, this person enrolls in the option his or her employer selected, buys up to another option and pays the difference, or waives health benefits if he or she qualifies. Also during Open Enrollment, this person chooses which family members to cover, if any. If you prefer the other employer s health benefit selection, contact Portico for assistance before you enroll. Portico will switch the primary designation if the primary member is no longer sponsored or turns age 65. If both are eligible for ELCA-Primary health benefits after the primary designation switches: The couple remains on the health benefit option they elected during enrollment Deductibles and out-of-pocket limit accumulations are transferred to the new primary member s account. The family receives new ID cards from the health benefit administrators (Blue Cross and Blue Shield, Express Scripts, and Delta Dental) and will need to use them going forward. NOTE: See page 30 if one of you turns age 65 and becomes eligible for ELCA Medicare-Primary health benefits. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 28

35 Contributions We bill employers for half of the health contribution each organization would pay if its plan member was not part of a sponsored couple. If you re sponsored by the same organization, a health contribution is calculated for each of you, based on your age, your defined compensation, family members enrolled, and the health benefit option your family chooses. The resulting amount for each member is divided by two, and both contributions are included on your employer s monthly bill. If you re sponsored by different organizations, a health contribution is calculated for each of you, based on your age, your defined compensation, family members enrolled, and the health benefit option your family chooses. The resulting amount for each member is divided by two, and each employer is billed for its respective employee s contribution. This means that your employers will likely pay different amounts if you and your spouse earn different amounts or are different ages. Your buy-up costs, if any, are calculated based on the primary employer s health benefit selection and each employee s defined compensation and age. If you buy up, each of your employers withholds from your paychecks the proportional share of the cost of the higher priced option. EXAMPLE (for illustration only): Sally and Walt, age 52 and 50 as of Jan. 1, 2014, are married and sponsored in the ELCA benefit program. Their employers are both located in rate class 3. Sally s annual defined compensation is $65,000 and Walt s is $55,000. Sally is currently designated by Portico as the primary health benefit member. Because both employers selected the Gold+ health benefit option, Sally remains primary, and she opted not to buy up. To calculate the contribution for Sally s employer, take the $65,000 defined compensation and multiply it by the health rate based on her age and rate class 3, and divide by 12 which results in a monthly cost of $1,354. Then divide $1,354 by 2. Cost for Sally s employer is $677. To calculate contribution for Walt s employer, take the $55,000 total defined compensation and multiply it by the health rate based on his age and rate class 3, and divide by 12, which gives us a monthly cost of $1,110. Then divide $1,110 by 2. Total cost for Walt s employer is $555. If you have multiple employers and are a member of a sponsored couple, the health contribution is first divided between your employer(s) and your spouse s employer(s) based on the split described above. Then, your health contribution is calculated for your employers as described in If You Become Sponsored by Multiple Employers on page 27. If one of you is receiving total disability benefits during annual Open Enrollment: The ELCA Disability Benefit Trust offers members the Gold+ option while receiving total disability benefits. The spouse not receiving disability benefits is identified by Portico as the primary health benefit member. If this requires changing the primary designation, the family receives new ID cards from the health benefit administrators (Blue Cross and Blue Shield, Express Scripts, and Delta Dental) and will need to use them going forward. The employer of the spouse not receiving disability benefits pays its portion (50%) of the Gold+ option, even if it selected a different health benefit option during Open Enrollment. The ELCA Disability Benefits Trust pays 50% of the Gold+ option. If, as a couple, you buy up to Platinum+, you ll each pay your portion of the buy-up cost. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 29

36 If the employer of the spouse not receiving disability benefits selected Platinum+, you both will be enrolled in the Platinum+ option and the ELCA Disability Benefits Trust will pay the Platinum+ contribution for the member receiving disability benefits throughout Using Your ELCA-Primary Health Benefits If, as a couple, you enroll in the Platinum+ or Gold+ option: The primary member has a personal wellness account. Wellness dollars earned by either member are credited to this account. By IRS rule, neither of you can contribute to health savings account. If, as a couple, you enroll in the Silver+ or Bronze+ option, refer to the Health Savings Account section below. Changes in Circumstance If One of You Is No Longer Sponsored If the primary health benefit member is no longer sponsored, Portico designates the other person primary. The couple continues to have the health benefit option elected during enrollment for the remainder of the plan year. Accumulations toward your deductibles and out-of-pocket limits incurred under the first primary are transferred to the new primary s account. If the member who is not primary stops being sponsored, the couple keeps the health benefit option elected during enrollment for the remainder of the plan year. In both of the above cases, the family s health benefit contributions will be billed to the remaining sponsoring employer(s). If You Turn Age 65 While Sponsored If either of you works for an employer with 20 or more employees and turns age 65, both of you will continue to have the ELCA-Primary benefit option the primary member chose during enrollment. If both of you work for employers with fewer than 20 employees and one of you is under age 65 and the other turns age 65, the 65-year-old member becomes Medicare-eligible and will be enrolled in the ELCA Medicare-Primary Standard option. That member receives a new health benefit ID card. The member who is under age 65 remains in the ELCA-Primary benefit option chosen during enrollment. When this younger member turns age 65, he or she is enrolled in the ELCA Medicare-Primary Standard option. If One Member of the Couple Becomes Eligible for ELCA Total Disability Benefits During the Plan Year The spouse not receiving disability benefits is identified by Portico as the primary health benefit member. In the event that the primary designation needs to be changed: o Deductibles and out-of-pocket limit accumulations are transferred to the new primary member s account. o The family receives new ID cards from the health benefit administrators (Blue Cross and Blue Shield, Express Scripts, and Delta Dental) and will need to use them going forward. If you and your spouse have the Silver+ or Bronze+ option, you will be enrolled in the Gold+ option. The ELCA Disability Benefits Trust pays a portion (50%) of the Gold+ contribution for the Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 30

37 member receiving disability benefits. The other member s employer pays its portion (50%) of the Gold+ option. If one of your employers offered the Platinum+ option and as a couple, you chose it during Open Enrollment, you will remain on the Platinum+ option for the remainder of the year. The employer for the spouse not receiving disability benefits continues to pay its portion of the Platinum+ contribution, and the ELCA Disability Benefits Trust pays its portion of the Platinum+ contribution for the member receiving disability benefits. If, as a couple, you bought up to the Platinum+ option during Open Enrollment, you will keep that option and continue to pay the buy-up cost. Flexible Spending Accounts If you re sponsored and don t have an HSA, you are each eligible to enroll in and contribute to a health FSA, subject to IRS limits. Your sponsoring employer is billed for your FSA contributions. All sponsored members are eligible to enroll in and contribute to a dependent (day) care FSA subject to IRS limits. Your sponsoring employer is billed for your dependent (day) care contributions. Health Savings Account If, as a couple, you enroll in the Silver+ or Bronze+ option: You both have your own HSA as long as neither of you will be age 65 on or before Jan. 1, The 2014 IRS family contribution limit is $6,550. If you are age 55 or older during the 2014 plan year, you can contribute an additional $1,000. If both of you are age 55 or older in 2014, your family maximum is $8,550. Your employer s HSA contributions are deposited into your own HSA. You make pretax contributions to your own HSA through your own employer. Wellness dollars earned by either of you are deposited into the primary member s HSA. Neither of you are eligible for an HSA if one or both of you will turn age 65 on or before Jan. 1, In this case: Each of you will have a personal wellness account (also called a health reimbursement arrangement), and any employer contributions will be credited to your respective wellness accounts. Wellness dollars earned by either of you are credited to the primary member s personal wellness account. By IRS rule, you can t contribute to a personal wellness account. Survivor You each are covered by basic group life insurance. You can both purchase supplemental life insurance for yourself. Neither of you can purchase dependent spouse or ESGP life insurance for the other. Only the member designated as primary for health benefits can purchase dependent life insurance for your child(ren). Disability If one of you is disabled, the ELCA Disability Benefits Trust and the sponsored member s employer each contribute a portion to your family s health contribution. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 31

38 Retirement Each of your employers makes required contributions to your retirement accounts. You can each make pretax retirement contributions to your own retirement accounts. If Your Employer No Longer Sponsors You If your employer chooses to stop sponsoring you, you are no longer eligible for the ELCA benefit program. This can happen for several reasons: A reduction in hours causes you to no longer be eligible for coverage under the program Your employer decides not to participate in the program Your employer fails to pay the bill in a timely way You take a leave of absence without pay Your participation in the ELCA benefit program ends the date through which the contribution has been paid. Your employer (except for ministries of the ELCA churchwide organization, synods, and seminaries) discontinues sponsoring you in the program by notifying Portico. If your employer does not notify Portico and does not pay the required amount, your sponsored status will end 60 days after the contribution due date. Health If your employer no longer sponsors you (other than for reasons of gross misconduct), you and your family may continue health coverage for up to 18 months at your own expense by submitting the appropriate form to the Portico Service Center within 60 days of your change in status. You may choose any of the four health benefit options. Coverage is billed monthly using current coverage continuation rates based on age and enrolled family members. You ll find your bill online around the 20 th of each month. Flexible Spending Accounts Your participation in the plan terminates. Your employer must withhold FSA contributions through your last scheduled paycheck. Health FSA If you have a positive balance at the time your sponsored status ends, you can: o Submit any claims incurred prior to the end of your sponsored status within four months of the date of termination, or forfeit the balance in your account. Expenses incurred after the date of termination are not eligible to be reimbursed. o Continue your health FSA contributions for the remainder of the plan year by setting up after-tax contributions with Portico. Your after-tax contributions must be the same as your pretax health FSA election for the plan year (unless you have a qualifying election change event). Portico bills you monthly for amounts you elected for the plan year. If you don t pay these after-tax contributions, you will forfeit the balance in your account. Dependent (day) care FSA You can t continue your dependent care FSA contributions when you re no longer sponsored. You must submit any claims incurred prior to your termination date within four months of the date of termination, or forfeit the balance in your account. Expenses incurred after the date of termination are not eligible to be reimbursed. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 32

39 Health Savings Account Survivor You can continue to pay for eligible expenses from your health savings account until your account balance is zero. If you continue health coverage at your own expense and choose the Silver+ or Bronze+ option, you can continue or start making your own contributions to an HSA. Portico bills you monthly. If you are a lay employee, you can continue your basic group life insurance for 18 months at your own expense by contacting Minnesota Life. You can continue your supplemental life insurance at your own expense by contacting Minnesota Life Insurance Company. You can continue dependent life insurance at your own expense by contacting Minnesota Life as long as you also continue your supplemental life insurance. If you don t opt to continue coverage, your basic group life insurance will terminate along with any supplemental and dependent coverage you purchased. Disability You are no longer eligible for coverage under the ELCA Disability Benefits Plan. Retirement If your account balance is more than $500 when your sponsored status ends, you can leave your account invested in the ELCA Retirement Plan or make withdrawals subject to plan limitations. You can continue making investment decisions for your retirement account after your sponsored status ends. You can roll money into the plan from eligible IRAs or other eligible pretax retirement accounts but you can t make contributions into your retirement account while you re not sponsored by an eligible employer. According to IRS rules, you must begin receiving distributions from your account by April 1 following the year you reach age 70½, or the year in which you retire, if later. If You re Called to Serve in the Military Your sponsored status ends. Contact the Portico Service Center as soon as you are activated. Health You may continue ELCA health coverage for the first 24 months of military service to ensure continuous health coverage for your covered family members during a military call-up. You may choose any of the four health benefit options. Health coverage is billed monthly based on current coverage continuation rates. You ll find your bill online around the 20 th of each month. Flexible Spending Accounts Your participation in the ELCA Flexible Benefits Plan terminates. Your employer must withhold FSA contributions through your last scheduled paycheck. Health FSA If you have a positive balance at the time your sponsored status ends, you can: Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 33

40 o Submit any claims incurred prior to the end of your sponsored status within four months of the date of termination, or forfeit the balance in your account. Expenses incurred after the date of termination are not eligible to be reimbursed. o Continue your health FSA contributions for the remainder of the plan year by setting up after-tax contributions with Portico. Your after-tax contributions must be the same as your pretax health FSA election for the plan year (unless you have a qualifying election change event). Portico bills you monthly for amounts you elected for the plan year. If you don t pay these after-tax contributions, you will forfeit the balance in your account. Dependent (day) care FSA You can t continue your dependent care FSA contributions when you re no longer sponsored. You must submit any claims incurred prior to your termination date within four months of the date of termination, or forfeit the balance in your account. Expenses incurred after the date of termination are not eligible to be reimbursed. If you are enrolled in an FSA and your benefits were terminated during a military leave of absence (as defined under the Uniformed Services Employment and Reemployment Rights Act of 1994, or USERRA), you are entitled to reinstate coverage when you return from leave, as provided for under USERRA. Health Savings Account You can continue to pay for eligible expenses from your health savings account until your account balance is zero. You can continue or start making your own contributions to an HSA, if you continue health coverage at your own expense and choose the Silver+ or Bronze+ option. Portico bills you monthly. Survivor You can continue your basic group life and any supplemental insurance you have purchased for yourself and your dependents for up to 18 months by contacting Minnesota Life. You must elect and pay for coverage continuation within 60 days of terminating employment. If you don t opt to continue coverage, your basic group life insurance will terminate as of the date your employment ends along with any supplemental and dependent coverage you purchased. The accidental death & dismemberment (AD&D) rider precludes paying any loss due to acts of war or when in service in the military of any nation. Disability You are not eligible for coverage under the ELCA Disability Benefits Plan. Retirement You may make additional pretax retirement contributions upon resumption of employment. You can continue making investment decisions for your retirement account after your sponsored status ends. You can roll money into the plan from eligible IRAs or other eligible pretax retirement accounts but you can t make contributions into your retirement account while you re not sponsored by an employer. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 34

41 When a Life Change Affects Your Benefits If You Get Married Health If you get married, your new spouse or eligible same-gender partner (ESGP) and stepchildren will be eligible for health benefits. To enroll your spouse or ESGP, call the Portico Service Center or complete the appropriate form and send it along with a copy of your marriage certificate or Affidavit of Partnership (as appropriate) to the Portico Service Center within 60 days of your marriage or partnership. To enroll a stepchild, send a copy of his or her birth certificate or adoption paperwork to the Portico Service Center. Their coverage will take effect the date of your marriage or date the Service Center receives your Affidavit of Partnership. All family members must be enrolled in the same health benefit option. If you enroll new family members after 60 days, they will have a 90-day waiting period for health coverage. Flexible Spending Accounts Because getting married and adding a stepchild are qualifying events, sponsored members can enroll in or make changes to health and dependent care FSAs. To enroll or make FSA changes, you must first notify Portico within 60 days of the date of the marriage or the date the ESGP is added. The effective date of your FSA election change will be the first day of the month after Portico receives your FSA election change request. Health Savings Account If you have Silver+ or Bronze+ single coverage and you enroll your spouse or ESGP in the health plan, you now have family coverage and are eligible for the maximum family HSA contribution amount as defined by the IRS. If your sponsoring employer is contributing to your HSA, shifting to family coverage will increase your employer contribution. Survivor When you get married, you are eligible to buy supplemental and dependent life insurance without providing evidence of insurability (EOI) within 60 days of the date on your marriage certificate or Affidavit of Partnership. You must purchase supplemental life insurance for yourself in order to purchase dependent life insurance for your spouse or children. You may purchase one increment (up to $50,000 depending on your age) of supplemental life coverage for yourself or increase existing coverage by one increment (up to $50,000 depending on your age) without needing to provide EOI and subject to the active work requirement (see Glossary). You may purchase for your spouse or ESGP, without providing EOI, an amount of dependent life insurance no greater than 50% of your supplemental coverage to a maximum of $50,000. You may purchase $5,000 or $10,000 of dependent life insurance for your children or increase the coverage to $10,000 without providing EOI. Coverage is effective for your spouse and children on the date of your marriage as long as they are not hospitalized or confined due to illness or disease. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 35

42 Retirement Your spouse or ESGP becomes your automatic beneficiary for your retirement account. Your spouse must be your sole primary beneficiary unless he or she agrees to the designation of another beneficiary and gives written notarized consent on the beneficiary form provided by Portico. If You Become a Parent Your benefits support you and your family as you become a parent, stepparent, or legal guardian of a child. Health To enroll your eligible child (defined on page 5) in ELCA health benefits and avoid a 90-day waiting period for health coverage, you must notify Portico within 60 days of your child s birth, adoption, or placement for adoption. Your child s coverage will take effect the date of birth, adoption, or placement for adoption if Portico is notified within 60 days. To enroll your stepchild(ren), contact the Portico Service Center. You must also submit a copy of the child s birth certificate or adoption paperwork to Portico. To avoid a 90-day wait for health coverage, you must submit the birth certificate or adoption paperwork within 60 days of the date your stepchild(ren) becomes eligible to be enrolled in health benefits. To enroll your eligible grandchild(ren), complete the appropriate enrollment form. In order to avoid a 90- day wait for health coverage, you must submit the form within 60 days of the date your grandchild(ren) becomes eligible to be enrolled in health benefits. To enroll a child for whom you are the legal guardian, complete the appropriate form and send a copy of the legal document appointing you as the child s guardian to the Portico Service Center. To avoid a 90-day wait for health coverage, you must enroll within 60 days of the date the child(ren) becomes eligible to be enrolled in health benefits. Adding a child to your health benefits may increase the cost to your sponsoring employer, so Portico will notify them that the change will be reflected on the next month s billing statement. Flexible Spending Accounts Adding an eligible dependent is a qualifying event that allows sponsored plan members to enroll in, or make changes to, health and dependent care FSAs. The change to your FSA, however, must be consistent with the birth or adoption event. To enroll or make FSA changes you must notify Portico within 60 days of the date of the birth, adoption, or placement for adoption. The effective date of your FSA election change will be the first day of the month after Portico receives your FSA election change request. However, if you notify us of the birth, adoption, or placement for adoption within 30 days of the event, the effective date of the change for your health FSA will be the date of the birth, adoption, or placement for adoption. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 36

43 Health Savings Account If you had Silver+ or Bronze+ single coverage and you enroll your child in the health plan, you are eligible for the family maximum HSA contribution amount as defined by the IRS. If your employer is contributing to your HSA, this will increase your employer contribution. Survivor Within 60 days after becoming a parent, you re eligible to purchase supplemental and dependent life insurance. However, you must purchase supplemental life insurance for yourself in order to purchase dependent life insurance for your spouse, ESGP, or children. You may purchase one increment (up to $50,000 depending on your age) of supplemental life coverage for yourself or increase existing coverage by one increment (up to $50,000 depending on your age) without needing to provide EOI and subject to the active work requirement (see Glossary). You can purchase the first benefit level or increase existing coverage of dependent life insurance for your spouse or ESGP not to exceed 50% of your supplemental coverage up to a maximum of $50,000 but your spouse or ESGP must provide EOI. Coverage is effective the date Minnesota Life approves the application. You can purchase $5,000 or $10,000 of dependent life insurance for your children or increase the coverage to $10,000 without providing EOI. Coverage is effective for your children on the date of birth or adoption as long as they are not hospitalized or confined due to illness or disease. Retirement Your spouse or ESGP must be your sole primary beneficiary unless he or she agrees to the designation of another beneficiary and gives written notarized consent on the beneficiary form provided by Portico. If you are not married and wish to designate your child(ren) as primary beneficiaries, or if you wish to designate your child(ren) as secondary or contingent beneficiaries, submit a beneficiary designation form to the Portico Service Center. If You Get Divorced Health Your health coverage is unaffected. You can continue your child s health coverage if you re enrolled in the ELCA Health Benefits Plan. If your former spouse or ESGP was enrolled in the ELCA Health Benefits Plan on the effective date of the divorce decree, he or she may continue coverage at his or her own expense for up to 36 months. To continue coverage, he or she must send a completed coverage election form and a copy of the judge-signed divorce decree to Portico within 60 days of the divorce date. The day after the divorce is the effective date of the coverage continuation. If the judge-signed divorce decree arrives at Portico more than 60 days from the effective date of the decree, the former spouse: Loses coverage in the ELCA Health Benefits Plan on the date we receive the decree Loses eligibility to continue coverage, waive, or enroll at a later date Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 37

44 If your former spouse or ESGP is enrolled in the ELCA health plan, he or she can provide ELCA health coverage for your child at his or her own expense. If he or she terminates coverage, the child is no longer eligible to be covered through your former spouse or ESGP. Flexible Spending Accounts When you divorce, you become eligible to start or change FSA elections. The change must be consistent with the divorce event and submitted to Portico within 60 days of your divorce. Health Savings Account If you have Silver+ or Bronze+ family coverage and now have single coverage due to divorce, you may have to decrease HSA contributions The decrease applies to any month in which you have single coverage on the first day of the month. Contact SelectAccount for details. If your sponsoring employer is contributing to your HSA, shifting to single coverage will decrease your sponsoring employer contribution. Survivor If you purchased dependent life insurance for your spouse or ESGP, it terminates effective the date of divorce or date of termination of the eligible same-gender partnership. Your former spouse or ESGP can convert it to an individual policy by paying for coverage through Minnesota Life Insurance Company within 60 days of the date of divorce or dissolution of partnership. If you re covered under the lump-sum survivor benefit for retirees, a divorce or the filing of an affidavit of dissolution of partnership with Portico automatically revokes any designation of a spouse or ESGP as your beneficiary. You can designate your former spouse or ESGP as your beneficiary, but you must complete a new form dated after the date of the divorce decree or affidavit of dissolution of partnership naming your former spouse or ESGP as your beneficiary. If a new form isn t filed, the designation of your former spouse or ESGP as beneficiary will be void and your non-spousal or contingent beneficiaries will become primary. Disability If you re receiving benefits under the ELCA Disability Benefits Plan at the time of a divorce, monthly disability benefits may be assigned to an alternate payee such as a former spouse or ESGP, child, or dependent. Retirement In the event of divorce A divorce automatically revokes any designation of a spouse as your beneficiary. You may designate your former spouse as your beneficiary, but you must complete a new beneficiary designation form dated after the date of the divorce decree naming him or her as your beneficiary. If a new form is not filed, the designation of your former spouse as beneficiary is void and your non-spousal beneficiaries become primary. In the event of dissolution of partnership or divorce from your ESGP The filing of an Affidavit of Dissolution of Partnership with Portico automatically revokes any designation of a same-gender partner as your beneficiary. You may designate your former partner as your beneficiary, but you must complete a new beneficiary designation form dated after the date you filed the Affidavit of Dissolution of Partnership naming him or her as your beneficiary. If a new Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 38

45 form is not filed, the designation of your former partner as beneficiary is void, and secondary beneficiaries become primary. If your divorce includes a QDRO (a legal order subsequent to divorce or legal separation that assigns the rights to receive all or part of a sponsored member s benefits to an alternate payee), it may stipulate that part or all of your retirement account be assigned to an alternate payee, such as a former spouse or former ESGP, child, or dependent. If you have a QDRO, you must provide a judge-signed copy to Portico to allow us to process in accordance with this legal order. The amount assigned will be transferred to a separate account in the alternate payee s name. Any remaining money in your retirement plan account will remain in your name. If you divorce while receiving monthly annuity payments, up to 100% of your monthly payment may be assigned to your alternate payee through a QDRO. Your alternate payee will receive the assigned portion of your annuity until your death. The alternate payee s portion of your participating annuity will increase or decrease if your annuity payment increases or decreases. If You re a Former Spouse Health If you are a former spouse or ESGP enrolled in the health plan or waiving coverage at the time of your divorce, you may continue your choice of health benefit options at your own expense as described below: If you had coverage continuation as a former spouse on May 1, 2010, you can continue until remarriage. At the time of remarriage, you may continue coverage for an additional 36 months. If you began coverage continuation as a former spouse or ESGP on or after May 2, 2010, you may continue coverage for up to 36 months. You must elect to continue coverage within 60 days of the date of divorce or dissolution of partnership. The day after the divorce is the effective date of the coverage continuation. If your judge-signed divorce decree arrives at Portico more than 60 days from the effective date of the decree, you lose eligibility to continue coverage, waive, or enroll at a later date in the ELCA Health Benefits Plan and your coverage ends on the date we receive the decree. If you continue ELCA health coverage, you may also cover an eligible child. If your coverage terminates, the child is no longer eligible to be covered through you. Flexible Spending Accounts You aren t eligible for this benefit. Survivor If your former spouse or ESGP purchased dependent life insurance for you, it terminates effective the date of divorce or date of termination of the eligible same-gender partnership. You can convert it to an individual policy by paying for coverage through Minnesota Life Insurance Company within 60 days of the date of divorce. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 39

46 Retirement If your divorce includes a QDRO that awarded you assets in the ELCA Retirement Plan, an account is created for you and you become an ELCA Retirement Plan member. If Your Covered Adult Child Reaches Age 26 Health Your child may continue coverage under the health plan at his or her own expense for an additional 36 months when he or she reaches age 26 if he or she was covered under the plan on the day prior to turning age 26. If your adult child is totally disabled as determined by the Social Security Administration and has been continuously enrolled in or waived ELCA health benefits immediately prior to reaching age 26, he or she remains eligible for benefits as long as he or she is disabled. To continue coverage, the appropriate form will need to be submitted to the Portico Service Center within 60 days of your child s 26 th birthday. He or she will become an individual ELCA-Primary health plan member and will carry over to his or her new individual coverage any deductible and out-of-pocket expenses he or she accumulated during the plan year. Health contributions will be billed monthly based on his or her health benefit option and current coverage continuation rates. If this child is your only dependent, the cost of your benefits will go down. If you have other covered children, the cost will remain the same. Flexible Spending Accounts When your adult child reaches age 26, you are no longer able to reimburse expenses incurred by your adult child from your health FSA. Consequently, you are eligible to stop or decrease your FSA election. Health Savings Account If your child continues ELCA-Primary coverage and elects Silver+ or Bronze+, he or she can open an HSA and contribute up to the maximum allowed by the IRS. If you have Silver+ or Bronze+ coverage and your child was your only covered dependent, your maximum HSA contribution as defined by the IRS decreases when you change to single coverage. If your sponsoring employer is contributing to your HSA, changing to single coverage will also decrease your sponsoring employer contribution. Survivor Dependent coverage for children terminates when your child reaches age 26. Your child can contact Minnesota Life Insurance Company to convert dependent coverage to an individual policy by applying for and paying the first premium for an individual policy within 60 days following his or her 26 th birthday. If Family Members Are Eligible for Different Health Benefits Some family members can be eligible for Medicare while others are eligible for ELCA-Primary health benefits. Portico accommodates this in the following ways. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 40

47 You re eligible for ELCA-Primary health benefits but a family member is eligible for Medicare If you work for a large employer (20+ employees), then you and your family member enroll in your employer s ELCA-Primary health benefit option or buy up to a higher priced option. If you work for a small employer (less than 20 employees), then you enroll in one of the ELCA- Primary health benefit options and your family member enrolls in the ELCA Medicare-Primary Standard option. If you re on coverage continuation, then you enroll in the ELCA-Primary health benefit option that you choose, and your family member chooses to enroll in his or her choice of ELCA Medicare- Primary options. However, if you re on leave from call, your family member is only eligible for the ELCA Medicare-Primary Standard option. You re eligible for Medicare but a family member is eligible for ELCA- Primary health benefits If you work for a large sponsoring employer (20+ employees), then you and your family member enroll in your sponsoring employer s option or buy up to a higher priced option. If you work for a small employer (less than 20 employees), then you enroll in the ELCA Medicare- Primary Standard option and your family member enrolls in the ELCA-Primary health benefit option selected by your employer or buys up to a higher priced option. If you re on coverage continuation, then you enroll in your choice of ELCA Medicare-Primary health benefit options. However, if you re on leave from call, you re only eligible for the ELCA Medicare-Primary Standard option. You enroll your family member in your choice of ELCA- Primary health benefit options. If you re enrolled in ELCA Medicare-Primary health benefits and you have no spouse or ESGP enrolled, any eligible children are enrolled in ELCA-Primary health benefits. You choose one of the four benefit options on their behalf and the ELCA health plan automatically credits wellness dollars to one personal wellness account in the youngest child s name. Your children can t have an HSA, even if they have the Silver+ or Bronze+ option. If you switch midyear to ELCA Medicare-Primary health benefits Your progress toward deductible and out-of-pocket limit as an ELCA-Primary member does not transfer to your new benefits. Your spouse or ESGP and any children with ELCA-Primary health benefits have a new account with Blue Cross and Blue Shield, and receive a new Blue Cross and Blue Shield ID number and card. You can t earn additional wellness dollars from the health plan. You can continue to be reimbursed from your personal wellness account for eligible expenses incurred after changing to ELCA Medicare-Primary coverage but you need to submit a claim form with expense documentation to SelectAccount. If your spouse or eligible same-gender partner has the Platinum+ or Gold+ option and earns wellness dollars, those wellness dollars are credited to your spouse s or ESGP s personal wellness account. If your spouse or eligible same-gender partner has the Silver+ or Bronze+ option and will be age 65 on or before Jan. 1, 2015, and earns wellness dollars, those wellness dollars are credited to your spouse s or ESGP s personal wellness account. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 41

48 If your spouse or ESGP has the Silver+ or Bronze+ option and is under age 65 on or before Jan. 1, 2015, and earns wellness dollars, those wellness dollars are deposited into your spouse s or ESGP s HSA. If You Retire You re eligible to retire at age 60 or after completing 30 years of service. Health If you are sponsored in the ELCA benefit program up to the day you retire and meet the above criteria, you may: Continue ELCA health coverage for you and eligible family members during your retirement at your own expense or Waive coverage in retirement (allows you to activate ELCA health coverage at any time within 60 days of terminating your other health coverage) or Terminate ELCA coverage (with the option to re-enroll during Open Enrollment or at any time with a 90-day wait) You may also enroll or waive ELCA health coverage if you are retired upon reaching age 60 or completing 30 years of service with an eligible employer, and you: Had an account in the ELCA Retirement Plan, ELCA Master Institutional Retirement Plan, or ELCA Retirement Plan for The Evangelical Lutheran Good Samaritan Society immediately prior to retirement and Had employer-provided group health coverage immediately prior to your retirement and continuously thereafter, with no more than a 60-day gap in coverage prior to enrollment in the ELCA health plan You may also enroll in or waive ELCA health coverage if you participated in The American Lutheran Church Major Medical-Dental and Disability Plan or the Ministerial Health Benefits Plan of the Lutheran Church in America on Dec. 31, 1987, and are now retired, and: Your former employer is eligible to participate in the ELCA Master Institutional Retirement Plan and You were employed by your former employer from Dec. 31, 1987, to your date of retirement and You had employer-provided group health coverage up to the date of your retirement and continuously thereafter, with no more than a 60-day gap in coverage prior to enrollment in the ELCA health plan If you retire before age 65, you may choose one of the ELCA-Primary health benefit options and pay for it at your own expense. If you retire at or after age 65, you enroll in Medicare Part A (hospital insurance) and Part B (medical insurance). If you wish to continue ELCA health coverage, Medicare becomes your primary hospital and medical coverage and you choose an ELCA Medicare-Primary health benefit option to supplement Medicare s coverage. In either case, if you want to continue coverage and ensure no health coverage interruption, you need to let the Portico Service Center know within 60 days of your retirement date. You are billed monthly based on Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 42

49 benefit elections. You must be registered on myportico to access your billing statement. You ll find your bill online around the 20 th of each month. Payment is due upon receipt. Flexible Spending Accounts Your participation in the plan terminates. Your employer must withhold FSA contributions through your last scheduled paycheck. Health FSA If you have a positive balance at the time you retire, you can: o Submit any claims incurred prior to your retirement within four months of the date of termination, or forfeit the balance in your account. Expenses incurred after the date of termination are not eligible to be reimbursed. o Continue your health FSA contributions for the remainder of the plan year by setting up after-tax contributions with Portico. Your after-tax contributions must be the same as your pretax health FSA election for the plan year (unless you have a qualifying election change event). Portico bills you monthly for amounts you elected for the plan year. If you don t pay these after-tax contributions, you will forfeit the balance in your account. Dependent (day) care FSA You can t continue your dependent care FSA contributions when you retire. You must submit any claims incurred prior to your termination date within four months of the date of termination, or forfeit the balance in your account. Expenses incurred after the date of termination are not eligible to be reimbursed. Health Savings Account You can continue to pay for eligible expenses from your health savings account until your account balance is zero. You can continue or start making your own contributions to an HSA, if you re eligible to continue ELCA-Primary health coverage at your own expense, choose the Silver+ or Bronze+ option, and are eligible for an HSA. Portico bills you monthly. Survivor When you retire, your basic group life insurance coverage through Minnesota Life Insurance Company ends. If you re sponsored or receiving ELCA disability benefits at the time you retire, Portico continues to provide you with a lump-sum death benefit at no cost to you if you meet all the following requirements when you retire: You have at least 10 total years of service with an eligible employer or predecessor church You reach age 60 or have completed 30 years of church service This lump-sum benefit amount reduces with age from age 60 to 70. The benefit will not be greater than $50,000 nor less than $6,000. If you have group life insurance through Minnesota Life Insurance Company when you retire, you can continue your basic life and any supplemental and dependent insurance for up to 18 months or convert them to individual whole life policies by contacting Minnesota Life. You must elect and pay for coverage at your own expense. Retirement Upon retirement, you can: Continue to make investment decisions for your retirement account Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 43

50 Consolidate retirement savings from other plans into your ELCA Retirement Plan account Withdraw money from your ELCA Retirement Plan account according to plan provisions Transfer all or part of your ELCA Retirement Plan assets into the ELCA Participating Annuity Trust Access Ernst & Young financial advisers, with no out-of-pocket costs, to help you better understand retirement income options If You Turn Age 65 and Continue to Be Sponsored Health If you remain employed past age 65, the size of your employer determines your benefit options. Portico will contact you and your sponsoring employer approximately three months prior to your 65 th birthday to request information related to your Medicare eligibility. Based on the information we receive from you and your employer, we ll determine whether Medicare is primary or secondary for you. If you are sponsored by an employer with fewer than 20 employees, your health benefits change from ELCA-Primary health benefits to the ELCA Medicare-Primary Standard option. This means that Medicare provides primary hospital and medical services coverage. ELCA Medicare-Primary health benefits supplement Medicare s coverage by helping to reimburse your eligible Medicare Part A and Part B deductibles and copayments. You apply for Medicare Part A (hospital insurance) and Part B (medical insurance). The ELCA plan reimburses you for the cost of the Medicare Part B premium if you meet one of these criteria: You or your spouse or eligible same-gender partner are eligible for Medicare (age 65 or over) and you are sponsored by an organization with fewer than 20 employees You are disabled and receiving benefits from the ELCA Disability Benefits Plan If you meet these criteria, you need to provide Portico proof of enrollment in Medicare Part B within 60 days of becoming eligible. If Portico receives this after 60 days of eligibility, you will be reimbursed the first of the following month. If you work for an employer with 20 or more employees, ELCA-Primary benefits continue to be your primary coverage, and Medicare is your secondary coverage. You apply for Medicare Part A (hospital insurance). You ll enroll in Part B when you retire to cover your medical services. If you become eligible for ELCA Medicare-Primary coverage midyear, your progress toward meeting your ELCA-Primary health deductible and out-of-pocket limit does not transfer to your ELCA Medicare-Primary deductible and out-of-pocket limit. Contact Portico when you change employers. Your coverage may change due to your Medicare eligibility. Flexible Spending Accounts Becoming eligible for Medicare is a qualifying election change event. If you re sponsored, you can stop or decrease your FSA election. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 44

51 Health Savings Account If you turn age 65 while enrolled in the Silver+ or Bronze+ option, you re no longer eligible to make contributions to your HSA. You can, however, continue to pay for eligible health care expenses from your HSA until your account balance is zero. Survivor Your group life insurance options through Minnesota Life Insurance Company continue as described below: The basic group life insurance benefit is two times your annual defined compensation, with a minimum benefit of $6,000, and a maximum of $50,000. If you re sponsored while age 70 74, basic group and supplemental insurance benefits pay 50% of the original benefit. If you re sponsored at age 75 or older, basic group and supplemental insurance benefits pay 25% of the original benefit. In addition, you remain eligible to purchase supplemental and dependent life insurance, which reduce according to the schedule described above. Disability You may receive disability benefits beyond the Social Security full-retirement age, up to a maximum benefit period, if you are sponsored in the ELCA benefit program and become disabled at age 63 or over. If you become disabled under age 63, disability benefits end upon reaching full-retirement age as defined by Social Security. Retirement You can continue to make pretax contributions, manage investment elections, and take distributions as allowed by the ELCA Retirement Plan. If You Become Disabled The ELCA Disability Benefits Plan provides a monthly income if you become partially or totally disabled as defined by the plan. While you are disabled, the plan also makes contributions to your retirement account and pays to continue your health and survivor coverage. (Interim pastors, see disability rules specific to you on page 16.) Health If You Receive Total Disability Benefits For the first two months of total disability, your employer pays your defined compensation and the contribution for your benefits. Beginning with the third month, the contributions for these benefits are paid by the ELCA Disability Benefits Trust. If you receive benefits under the ELCA Disability Benefits Plan due to total disability and are eligible for ELCA-Primary health benefits, Portico enrolls you in the Gold+ option, even if you were previously enrolled in a different benefit option. If you had Silver+ or Bronze+, deductibles and out-of-pocket limit accumulations carry forward and you ll receive new Blue Cross and Blue Shield ID cards. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 45

52 If Gold+ is provided by your employer, you will remain in Gold+ and contributions are paid by the ELCA Disability Benefits Trust for the remainder of the year. If you had Platinum+: o Was provided by your employer, contributions are paid by the ELCA Disability Benefits Trust for the remainder of the year. o Was chosen by you as a buy-up option, you ll continue to pay contributions for the remainder of the year. If you are eligible for ELCA Medicare-Primary benefits, Portico enrolls you in the Standard option. Family members are enrolled in either an ELCA-Primary benefit option or ELCA Medicare-Primary Standard option, depending on their eligibility. If You Receive Partial Disability Benefits For the first two months of partial disability, your employer pays your defined compensation and the contribution for your benefits. Beginning with the third month, the contributions for these benefits are shared by the ELCA Disability Benefits Trust and your sponsoring employer. When you enroll, you select the health benefit option offered by your sponsoring employer or choose to buy up to a higher benefit option and are responsible for any buy-up costs. If you become partially disabled midyear and you remain eligible for ELCA-Primary health benefits, you keep the benefit option you chose during enrollment. The health coverage contribution for your benefit option is split by your sponsoring employer and the ELCA Disability Benefits Trust. Flexible Spending Accounts When you re receiving total disability benefits, you are eligible for the health FSA but not the dependent (day) care FSA. If you begin receiving total disability benefits and you have a dependent care FSA, you must submit any claims incurred prior to your date of disability within four months of that date, or forfeit the balance in your account. Expenses incurred after the date of termination are not eligible to be reimbursed. Health Savings Account If you begin to receive total disability benefits and were enrolled in the ELCA-Primary Silver+ or Bronze+ health benefit option, you are automatically enrolled in the Gold+ option and are no longer able to contribute to an HSA. You can, however, continue to pay for eligible expenses from your HSA until your account balance is zero. Survivor Your basic group life insurance continues while you re receiving disability benefits. If you re receiving total disability benefits, the ELCA Disability Benefits Trust pays the full contribution. If you re receiving partial disability benefits, the contribution is shared between the ELCA Disability Benefits Trust and your sponsoring employer. A Waiver of Premium Rider is included in supplemental and dependent life insurance offered by Minnesota Life Insurance Company. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 46

53 If you purchased supplemental life insurance prior to receiving total disability benefits, your supplemental life insurance continues at no cost to you. Any dependent insurance also continues at no cost to you as long as your dependents remain eligible. If you receive total or partial disability payments, you can t purchase supplemental and dependent life insurance. Disability If you are sponsored in the ELCA benefit program within 60 days of eligibility, exclusions for pre-existing conditions apply for six months after you enroll. If you enroll in the program more than 60 days after eligibility, exclusions for pre-existing conditions apply for 18 months after you enroll. If you re sponsored in the ELCA benefit program and begin receiving disability benefits at age 63 or older, you may receive these benefits beyond the Social Security full-retirement age (determined by your year of birth) up to a maximum benefit period as defined by the ELCA Disability Benefits Plan. If you become disabled before reaching age 63, disability benefits end upon reaching full-retirement age as defined by Social Security. For the first two months of total disability, the employer pays the contributions for your benefits. Beginning the third month, contributions are paid by the ELCA Disability Benefits Trust. Your monthly total disability income benefit is based on two-thirds of your monthly benefit compensation (basic benefit), minus any Social Security or other government offsets. Your monthly income benefit may increase each Jan. 1, based on the annual increase factor. The partial disability benefit is based on your basic benefit (two-thirds of your monthly benefit compensation before you became disabled), minus any Social Security and other government offsets. This amount is multiplied by the percentage of defined compensation you are no longer receiving due to a reduction in your normal workload. You are not eligible for disability benefits if the disability results from: Willful and illegal participation in fights, riots, civil insurrections, or while committing a felony Incarceration in a penal or correctional institution upon conviction of a felony A self-inflicted injury Cosmetic surgery, unless the surgery is covered under the ELCA Health Benefits Plan Retirement Monthly contributions will be made to your ELCA Retirement Plan account while you are receiving ELCA disability benefits (unless you are a called interim pastor continuing disability coverage at your own expense). These contributions are invested in the ELCA investment funds you designate for your retirement account. If you are totally disabled, the contribution amount is the minimum employer contribution rate times your basic benefit. The basic benefit may be increased annually. If you are partially disabled, the contribution amount is the minimum employer contribution rate (based on your basic benefit) multiplied by the percentage of your defined compensation that you are no longer receiving due to a reduction in your normal workload. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 47

54 If you re disabled according to Social Security, additional withdrawal options are available. If You Die Health Eligible family members covered under the ELCA health plan, or who waive ELCA health benefits, are eligible to continue or begin receiving health benefits at their expense in the event of your death. To continue coverage, they must contact the Portico Service Center within 60 days of your death. If you were sponsored at the time of your death, the cost of health coverage is billed to your employer through the date of your death. If your eligible family members enroll in ELCA health benefits, their coverage becomes effective the next day. If you die and your children are enrolled in ELCA-Primary health benefits but your spouse or ESGP is not, your children can continue coverage with one of the four benefit options for as long as they are eligible. The ELCA health plan automatically credits wellness dollars to one personal wellness account in the youngest child s name. Your children can t have an HSA, even if they have the Silver+ or Bronze+ option. Flexible Spending Accounts If you re enrolled in a health and/or dependent (day) care FSA, your survivors may submit claims incurred by you or eligible family members up to and including the date of your death. Claims must be submitted within four months of your death, or the balance in your account is forfeit. If money is available in your account, a reimbursement is paid to your surviving spouse or ESGP, the personal representative of your estate, or another person whom the plan administrator determines to be legally entitled to such payment. Health Savings Account HSA funds are transferred to your designated beneficiary who is responsible for any administrative fees after your death. If your spouse is your designated beneficiary, your HSA becomes your spouse s HSA after your death. If the beneficiary is not your spouse, the account stops being an HSA and its fair market value becomes taxable to the beneficiary in the year you die. Survivor Accelerated Death Benefit To ease your financial burden when you are terminally ill, you can request that all or a portion of your life insurance or lump sum benefit be paid to you as an accelerated death benefit before your death. You must have a terminal condition and 12 months or less to live. If you are eligible, the accelerated death benefit is paid in a lump sum to you and not to your designated beneficiary. The accelerated payment reduces any benefit paid after your death. Death Benefit If you die while sponsored or on leave from call and continuing survivor coverage, your beneficiary receives a basic group life insurance benefit that pays a minimum of $6,000 and a maximum of $50,000. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 48

55 Amounts are reduced starting at age 70. If applicable, your beneficiary receives an additional accidental death and dismemberment (AD&D) benefit. If you purchased supplemental life insurance, your beneficiary receives a benefit in the amount of your supplemental life insurance, which is paid in addition to your basic group life benefit. If applicable, your beneficiary will receive an additional AD&D benefit. If you die while retired, Portico pays your beneficiary a lump-sum death benefit if you met all the following requirements when you retired: You had at least 10 total years of service with an eligible employer or predecessor church You reached age 60 or completed 30 years of church service This lump-sum benefit amount reduces with age, between age 60 and 70, and pays between $6,000 and $50,000. Dependent Life If you die, your family members are no longer eligible to continue the dependent life insurance coverage you purchased. They can contact Minnesota Life to convert this coverage to individual policies at their own expense without needing to provide evidence of insurability. Retirement If you have a balance in your ELCA Retirement Plan account, the account is transferred to the named beneficiary when Portico receives your certificate of death and any other requested documentation. If you were receiving payments from the ELCA Participating Annuity at the time of your death, surviving co-annuitants may be eligible to receive payments depending on the annuity option you selected. If You Become a Surviving Spouse Health A surviving spouse may continue coverage at his or her own expense for his or her lifetime, if enrolled in the health plan or waiving coverage at the time of the member s death. You must elect coverage continuation within 60 days of the date of your spouse s death or you will not be eligible to continue coverage under the ELCA Health Benefits Plan. If you are under age 65 If you wish to continue ELCA health coverage, you choose one of the ELCA- Primary health benefit options and pay for it at your own expense. If you are age 65 or older If you haven t yet done so, you need to enroll in Medicare Part A (hospital insurance) and Part B (medical insurance). If you wish to continue ELCA health coverage, Medicare is your primary health coverage provider and you choose an ELCA Medicare-Primary health benefit option. Generally, surviving spouses don t have the opportunity to waive ELCA health coverage. If you became a surviving spouse prior to Jan. 1, 2004, however, you may waive provided it was elected prior to that date and you can continue only to age 65 at which point you have to activate coverage or terminate. If at some point after Jan.1, 2004, you re-enrolled in ELCA health coverage, you aren t permitted to waive again. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 49

56 If on coverage continuation in the ELCA Health Benefits Plan, you may provide ELCA health coverage to an eligible child. If your ELCA coverage terminates, the child is no longer eligible to be covered under your coverage. Survivor If your spouse purchased dependent life insurance for you and/or your children, you can contact Minnesota Life to convert this coverage to individual policies at your own expense without needing to provide evidence of insurability. If you do nothing, your life insurance coverage will end. Retirement As a surviving spouse, you have the same options (regarding your account) as any member who is separated from service. As early as the month following your spouse s death, the money in his or her account will be transferred to a separate account set up for you. You can: Designate beneficiaries Remain in the plan and make investment decisions Make withdrawals Roll over additional eligible money to the ELCA Retirement Plan from another eligible plan or to another eligible plan from the ELCA Retirement Plan Convert some or all of the account balance to a participating annuity to provide a stream of lifetime income Annuity payments If your spouse received participating annuity payments at the time of his or her death, payments will be made to you based on the annuity option your spouse chose at the time he or she annuitized. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 50

57 ELCA-Primary Health Benefits ELCA-Primary health benefits are designed to help rostered leaders and lay employees enhance their wellbeing during their years of service in ministry which, in turn, strengthens their ability to enhance the lives of others. In 2014, Portico offers a choice of four health benefit options, described below. Each provides a nearly identical list of ELCA-Primary benefits: Medical and Mental Health benefit Prescription Drug benefit Dental benefit Employee assistance program ELCA NurseLine SM Fitness center discount Wellness dollars Mayo Clinic EmbodyHealth Hearing discount Health care advocacy team The four options compare to the metallic plans found on the state health insurance exchanges created by the Patient Protection and Affordable Care Act of 2010 (health care reform). Each offers essential benefits required of exchange plans, plus (+) large provider networks, dental benefits, a fitness center discount, health support programs, and wellness incentives features less likely to be included in typical exchange plans. The options differ by annual deductible, out-of-pocket limit, and monthly contribution rate. Benefit Option Features Platinum+ Highest contribution rate Lowest deductible and out-of-pocket limit Per-person and family deductibles and out-of-pocket limits Copayment for prescription drugs; copayments apply to combined medical, mental health, and prescription drug out-of-pocket limit Wellness dollars credited to personal wellness account Gold+ Same deductible and out-of-pocket limit as 2013 Per-person and family deductibles and out-of-pocket limits Copayment for prescription drugs; copayments apply to combined medical, mental health, and prescription drug out-of-pocket limit Wellness dollars credited to personal wellness account Silver+ High Deductible Health Plan as defined by IRS Single or family deductible and out-of-pocket limit; with family coverage, must meet family deductible before plan begins to pay Plan member pays 100% of prescription drug costs until combined medical, mental health, and prescription drug deductible is met Pairs with health savings account (HSA) to help manage eligible expenses Sponsoring employer and member can contribute to HSA; wellness dollars also deposited into HSA Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 51

58 Bronze+ Lowest contribution rate High Deductible Health Plan as defined by IRS Highest deductible and out-of-pocket limit Single or family deductible and out-of-pocket limit; with family coverage, must meet family deductible before plan begins to pay Plan member pays 100% of prescription drug costs until combined medical, mental health, and prescription drug deductible is met Pairs with health savings account (HSA) to help manage eligible expenses Sponsoring employer and member can contribute to HSA; wellness dollars also deposited into HSA Medical and Mental Health Benefit Administered by Blue Cross and Blue Shield, the Medical and Mental Health benefit offers a broad provider network and 100% coverage for eligible in-network preventive services plus medically necessary services including hospital, specialized facility, surgical, office visit, urgent care, emergency room, lab work, X-rays, imaging, and individual and group counseling. This benefit pays for these services subject to deductibles and out-of-pocket limits Platinum+ and Gold+ Medical and Mental Health Benefits Important: Your Medical and Mental Health benefit is administered by Blue Cross and Blue Shield. Benefits are subject to provider billing practices and Blue Cross claims payment rules. Prescription drug copayments apply to the out-of-pocket limit. Plan only pays for eligible expenses subject to deductible and out-of-pocket limits. In-network benefits apply to all emergency room and urgent care services. Out-of-network services are subject to the Blue Cross allowed amount. Inpatient and certain outpatient services require prior authorization. Facility expenses for knee/hip replacements, spine/bariatric surgeries, and transplants will receive: 80% of facilities charges covered after deductible if performed at a Blue Cross Blue Distinction Center; 60% of their facilities charges covered after deductible for an in-network facility that is not a Blue Distinction Center; no plan benefit if the procedure is performed at an out-of-network facility. Benefits are subject to change without notice. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 52

59 You Pay 2014 Platinum+ and Gold+ Medical and Mental Health Benefit Chart Administered by Blue Cross and Blue Shield Platinum+ In-Network Gold+ In-Network Platinum+ Out-of-Network Gold+ Out-of-Network Deductible 1 $500 per person $750 member and child(ren) 2 $1,000 member and spouse or ESGP 2 $1,000 member, spouse or ESGP, and child 2 $1,000 per person $1,500 member and child 2 $2,000 member and spouse or ESGP 2 $2,000 member, spouse or ESGP, and child 2 $500 per person $750 member and child 2 $1,000 member and spouse or ESGP 2 $1,000 member, spouse or ESGP, and child 2 $1,000 per person $1,500 member and child 2 $2,000 member and spouse or ESGP 2 $2,000 member, spouse or ESGP, and child 2 Costs After Deductible (Coinsurance) 20% to out-of-pocket limit 20% to out-of-pocket limit 40% to out-of-pocket limit 40% to out-of-pocket limit Out-of-Pocket Limit 1 Plan pays 100% after limit is reached. Limit includes deductible, costs after deductible, and prescription drug copayments. $3,000 per person $3,600 per person $3,000 per person $3,600 per person $6,000 family 3 $7,200 family 3 $6,000 family 3 $7,200 family 3 Plan Pays Platinum+ In-Network Gold+ In-Network Platinum+ Out-of-Network Gold+ Out-of-Network Medical and Mental Health Services Hospital, specialized facility, surgical, office visit, urgent care and emergency room, lab work, X-rays, imaging, individual and group counseling, medication management, etc. Preventive/Screening Services 4 See list on page % after deductible 100% after out-of-pocket limit 60% after deductible 100% after out-of-pocket limit 100%; no deductible 60%; no deductible 1 There are separate deductibles and out-of-pocket limits for in-network and out-of-network services. 2 The family deductible is met when the eligible expenses of two or more family members reach this amount during the year. If you have family coverage, the individual deductible is the maximum deductible amount per family members. 3 Family = member + child(ren), member + spouse or ESGP, or member + spouse or ESGP + child(ren). 4 Services are considered preventive/screening services when billed by a provider as preventive. All other services are considered medical services except that the first of the following services billed as preventive or non-preventive will be paid at the preventive/screening services benefit level: cholesterol/lipid profile, PSA test, Pap test, colonoscopy, mammogram, hemoglobin A1C test, vision exam, and urine microalbumin screening. General anesthesia administered as part of a preventive procedure like a colonoscopy is not considered a preventive expense, even if the provider bills it as preventive. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 53

60 2014 Silver+ and Bronze+ Medical, Mental Health & Prescription Drug Benefits Important: The deductible and out-of-pocket limit for these options is met using eligible medical and mental health expenses and prescription drug costs. Single coverage means only one person has ELCA-Primary health benefits. Family coverage means that you and one or more family members have ELCA-Primary health benefits. The family deductible and out-of-pocket limit can be met by one or more family members; family coverage has no individual deductible and out-of-pocket limit. Out-of-network services are subject to the Blue Cross allowed amount. In-network benefits apply to all emergency room and urgent care services. Inpatient and certain outpatient service require prior authorization. Benefits are subject to provider billing practices and Blue Cross claims payment rules. Only eligible expenses under the terms of the plan are eligible for benefits. Facility expenses for knee/hip replacements, spine/bariatric surgeries, and transplants will receive: 80% of facilities charges covered after deductible if performed at a Blue Cross Blue Distinction Center; 60% of their facilities charges covered after deductible for an in-network facility that is not a Blue Distinction Center; no plan benefit if the procedure is performed at an out-of-network facility. Benefits are subject to change without notice. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 54

61 You Pay 2014 Silver+ and Bronze+ Medical, Mental Health & Prescription Drug Benefit Chart Administered by Blue Cross Blue Shield and Express Scripts Deductible 1 Includes eligible medical, mental health, and prescription drug expenses. Costs After Deductible (Coinsurance) Out-of-Pocket Limit 1 Plan pays 100% after limit is reached. Limit includes deductible and costs after deductible. Silver+ In-Network Bronze+ In-Network Silver+ Out-of-Network Bronze+ Out-of-Network $2,000 single $4,500 single $2,000 single $4,500 single $4,000 family 2,3 $9,000 family 2,3 $4,000 family 2,3 $9,000 family 2,3 20% to out-of-pocket limit 20% to out-of-pocket limit 40% to out-of-pocket limit 40% to out-of-pocket limit $3,600 single $6,000 single $3,600 single $6,000 single $7,200 family 2,4 $12,000 family 2,4 $7,200 family 2,4 $12,000 family 2,4 Plan Pays Medical and Mental Health Services Hospital, specialized facility, surgical, office visit, urgent care and emergency room, lab work, X-rays, imaging, individual and group counseling, medication management, etc. Preventive/Screening Services 5 See list on page 57. Prescription Drugs Preventive Prescription Drugs Certain contraceptives Fluoride for children Iron supplements for children ages 6 12 months Folic acid for women ages Silver+ In-Network Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Bronze+ In-Network 80% after deductible 100% after out-of-pocket limit Silver+ Out-of-Network Bronze+ Out-of-Network 60% after deductible 100% after out-of-pocket limit 100%; no deductible 60%; no deductible 80% after deductible 100% after out-of-pocket limit 60% after deductible 100% after out-of-pocket limit 100%; no deductible 60%; no deductible 1 There are separate deductibles and out-of-pocket limits for in-network and out-of-network services. 2 Family = member + child(ren), member + spouse or ESGP, or member + spouse or ESGP + child(ren). 3 Family meets deductible together, using expenses from one or more family members. There is no individual deductible for families. 4 Family meets out-of-pocket limit together, using expenses from one or more family members. There is no individual out-of-pocket limit for families. 5 Services are considered preventive/screening services when billed by a provider as preventive. All other services are considered medical services except that the first of the following services billed as preventive or non-preventive will be paid at the preventive/screening services benefit level: cholesterol/lipid profile; PSA test; Pap test; colonoscopy; mammogram; hemoglobin A1C test; vision exam; and urine microalbumin screening. General anesthesia administered as part of a preventive procedure like a colonoscopy is not considered a preventive expense, even if the provider bills it as preventive. Page 55

62 Preventive and Screening Services Preventive and screening services are intended to promote wellness through prevention and early detection. In-network The plan pays 100% of eligible expenses Out-of-network The plan pays 60% of allowed eligible expenses The following are eligible preventive services when billed by a provider as routine or preventive. No other services are considered preventive services. Routine physical examination, including depression and hypertension screenings; if age-appropriate, skin, testicular prostate-digital rectal, rectal-digital, and breast examinations Routine laboratory tests and screenings: urine microalbumin, cholesterol/lipid profile, thyroid, and diabetes Routine vision examination: glaucoma, acuity, and refraction screenings Routine hearing examination: pure tone, air-only screening, and threshold audiometry Well-child care: medical history, height/weight, body mass index, developmental, lead, and tuberculosis screenings Immunizations (pediatric and adult) Routine radiological osteoporosis screenings Well-woman visit: preconception counseling and routine prenatal care FDA-approved contraceptive methods: sterilization by intratubal occlusion device, intrauterine device (IUD), and contraceptive counseling (except drugs covered under your Prescription Drug benefit) Screenings for pregnant women: gestational diabetes, iron-deficiency anemia, bacteriuria, hepatitis B, and Rh incompatibility Breast-feeding counseling and certain supplies, including rental or purchase of manual breast pump from an in-network provider Newborn screenings: hearing, thyroid disease, phenylketonuria, sickle cell anemia, and enzyme deficiency diseases HPV testing for women age 30 and older Sexually transmitted infection screening and counseling, including HIV Mammogram breast cancer screening Counseling related to prevention of breast cancer, counseling about BRCA gene testing, and BRCA gene testing Cervical cancer screening: Pap test and HPV screening Colorectal cancer screening: occult blood test, proctosigmoidoscopy, barium enema, sigmoidoscopy, and colonoscopy (Note: General anesthesia administered as part of a preventive procedure like a colonoscopy is not considered a preventive expense, even if the provider bills it as preventive.) Ovarian cancer screening: CA-125 test, trans-vaginal ultrasound Prostate cancer screening: prostate specific antigen (PSA) Abdominal aortic aneurysm screening Domestic violence screening and counseling Other tests, screenings, and services considered eligible preventive services by Blue Cross and Blue Shield NOTE: The first time you receive one of the following services in a plan year, it is processed as preventive care, regardless of how the claim is submitted by your provider: cholesterol/lipid profile, PSA test, Pap test, Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 56

63 colonoscopy, mammogram, hemoglobin A1C test, vision exam, and urine microalbumin screening. General anesthesia administered as part of a preventive procedure like a colonoscopy is not considered a preventive expense, even if the provider bills it as preventive. Eligible Providers and Network Provider Network In-network and out-of-network deductibles and out-of-pocket limits are separate. If you receive care within the provider network (from an in-network provider), you receive in-network benefits. If you receive care from outside the provider network (from an out-of-network provider), you receive out-of-network benefits. You may seek care from the provider of your choice. If you choose an in-network Blue Cross and Blue Shield preferred provider organization (PPO) provider, your out-of-pocket costs are likely to be lower than if you visit a provider who does not participate in the PPO network. Before seeking care, find out if your provider (including providers of diagnostic services such as X-rays, CT scans, imaging, laboratory exams, and tests) participates in Blue Cross s network. Call Blue Cross or visit the Blue Cross website (see Contact Information). In-Network Provider When you receive medical and mental health care from an in-network provider, eligible services are paid at the in-network benefit level. In-network providers contract with Blue Cross to accept contracted rates as payment in full for treatment or services (less deductible and costs after deductible). This means that in-network providers can t bill you for any amount that exceeds the contracted amount. Out-of-network providers are not bound by a contract and may bill you for any amount that exceeds the allowed amount. Your provider calls Blue Cross to obtain prior authorization if needed and submits claims for you. You are responsible for any deductible, or costs after deductible. NOTE: The plan covers 80% of facility charges after deductible for knee or hip replacement surgery, bariatric or spine surgery, and transplants done at a Blue Cross Blue Distinction Center. The plan covers 60% of facility charges after deductible for surgery done at an in-network facility not designated a Blue Cross Blue Distinction Center. Out-of-Network Provider When you choose an out-of-network provider, eligible services are paid at the out-of-network level. Out-ofnetwork services are subject to the Blue Cross allowed amount (see Glossary), which can be significantly less than the amount billed by an out-of-network provider. Out-of-network provider costs that exceed the Blue Cross allowed amount are not eligible plan expenses. This means that you are responsible for any out-of-network deductible, costs after deductible, and any amount that exceeds the Blue Cross allowed amount. The excess amount you owe can be significant and does not apply to any deductible or out-of-pocket limit. NOTE: The plan does not cover facility expenses for knee or hip replacement surgery, bariatric or spine surgery, and transplants performed at an out-of-network facility. If you use an out-of-network provider: You or your out-of-network provider is responsible for contacting Blue Cross for any services requiring prior authorization. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 57

64 You may need to file claims with Blue Cross if your out-of-network provider will not file claims on your behalf. You are reimbursed directly by Blue Cross for most out-of-network claims, and it is your responsibility to pay the out-of-network provider. In-network benefits apply to emergency room and urgent care center services whether the provider is innetwork or out-of-network. Comparison of In-Network and Out-of Network Costs The following chart shows what a plan member pays for the same non-emergency service when it s delivered by an in-network and out-of-network provider. (Assume the plan member s deductible is met.) In-Network Provider Out-of-Network Provider Provider Bills $1,500 $3,000 Blue Cross Allowed Amount $1,000 $600* Plan Pays $800 (80% of allowed amount) $360 (60% of allowed amount) Member Pays $200 (20% of the allowed amount) $240 (40% of the allowed amount) PLUS $2,400 (difference between billed amount and allowed amount)** $2,640 * Blue Cross allowed amount is based on Medicare s allowed amount, which is usually less than the allowed amount for an in-network provider for the same service, and can be significantly less than the out-of-network provider s billed charges. ** Expenses that exceed the allowed amount don t apply to the plan s out-of-network deductible or out-of-pocket limits. Eligible Medical Providers An eligible medical provider must perform services within the scope of his or her license and be licensed by the state in which the services are performed. The following are eligible medical providers: Medical doctor Dentist Nurse practitioner Chiropractor Optometrist Podiatrist Osteopath Acupuncturist Naturopath The plan also covers care from the following providers if they are licensed by their state, performing services within the scope of their license, and acting under the orders and/or supervision of a provider listed above: Physical therapist Dietitian Physician assistant Registered nurse Audiologist Licensed practical nurse Respiratory care practitioner Massage therapist Occupational therapist Speech therapist Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 58

65 Eligible Mental Health Providers An eligible mental health provider must perform services within the scope of his or her license and be licensed by the state in which the services are performed. The following are eligible mental health providers: Licensed psychiatrist who is either a medical doctor or a doctor of osteopathy Licensed doctoral-level psychologist with a Ph.D., Ed.D., or Psy.D. degree Masters-prepared therapist who possesses a master s degree from an accredited institution in a licensable mental health discipline Pastoral counselor who is a licensed doctoral-level psychologist who holds a Ph.D., Ed.D., or Psy.D. degree, or a masters-prepared therapist who possesses a master s degree from an accredited institution in a licensable mental health discipline Any other provider considered eligible by Blue Cross Eligible Medical and Mental Health Hospitals and Facilities An eligible hospital or alternative specialized treatment facility is a hospital or facility that qualifies for reimbursement from and meets Blue Cross s standards and requirements. Call Blue Cross before receiving inpatient care and certain outpatient services to make sure that the facility and provider are in-network. Innetwork facilities will handle prior approval requirements on your behalf. You or your out-of-network provider must contact Blue Cross before receiving inpatient care and certain outpatient services that require prior approval. Paying For Care The claim filing deadline is 12 months from the date you incurred the expense. For example, if you incur expenses on Feb. 12, 2014, the filing deadline for that claim would be Feb. 12, Debit Card In 2014, claims don t cross over to SelectAccount for automatic reimbursement from your personal wellness account. All members receive a debit card by mail from SelectAccount as a convenient way to access money in their personal wellness account, health FSA, or HSA to pay for health care expenses. If you have a balance on your SelectAccount debit card, you can use it to pay for medical and mental health expenses. This smart debit card only accesses funds that are currently available. You can use your debit card to pay for retail purchases like prescription drugs and vision services. For medical, mental health, and dental services, you can allow your claim to process, then enter your debit card number on the payment stub just as you would a credit card number and mail it to your provider. You call also call the provider and give the debit card number over the phone. Eligible expenses can also be reimbursed by submitting a paper or online claim to SelectAccount as long as you didn t use your debit card to pay for them. You may order additional cards at selectaccount.com. Eligible Medical Services Expenses for treatment or diagnosis of medical or mental health illness, injury, disease, or related symptoms are eligible expenses only if they are: Medically necessary (see Glossary) except for specific preventive/screening services listed starting on page 57 Qualified for reimbursement as determined by Blue Cross Allowed amounts according to Blue Cross guidelines Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 59

66 Performed by an eligible medical or mental health provider and/or in an eligible hospital or alternative specialized treatment facility Blue Cross may review your treatment to ensure that it is medically necessary and not inappropriate, misused, or over used. In this situation, Blue Cross may contact your doctor or you for information on the planned course of treatment. Based on its review, Blue Cross may coordinate, limit, or deny services and supplies. Get Prior Approval for Certain Services To receive benefits, some medical and mental health services require approval from Blue Cross to verify that they are medically necessary (see Glossary) and that treatment is provided at the proper level of care. You or your provider should call Blue Cross at least 10 days prior to a non-emergency hospital stay or before receiving medical or mental health services requiring approval. Sign in at myportico for the list of these services. If you or your provider does not contact Blue Cross, your claim will be reviewed retrospectively. If Blue Cross determines that the treatment is not medically necessary, the treatment and all related expenses will not be eligible for reimbursement under the plan. Office Visit The plan covers medically necessary office visits (see Glossary) with an eligible provider that may include medical history, examination, decision-making, counseling, coordination of care, consultation about your presenting problem, and treatment. Urgent Care When you visit your urgent care center or urgent care clinic, you receive in-network benefits for all eligible treatment if billed by the provider as an urgent care visit. Emergency Care In a life-threatening emergency, call 911 or go immediately to the nearest hospital or source of medical or mental health care. You receive in-network benefits for outpatient emergency department care whether the facility is innetwork or out-of-network. After the emergency has been treated and you are released, you receive in-network benefits if the follow-up care is provided by an in-network PPO provider. You or someone acting on your behalf must notify Blue Cross within 48 hours following an emergency inpatient admission so the treatment plan can be reviewed with your doctor and a determination made regarding the medical necessity of the admission and any continued inpatient care. Failure to notify Blue Cross of an emergency inpatient admission may result in a delay in processing your claim. Your claim will be reviewed retrospectively. If the treatment is determined not medically necessary, the treatment and all related expenses will not be eligible for reimbursement under the plan. Ambulance Service This benefit covers expenses for ambulance services only in these situations: An emergency Local transfers to your home when required by the attending doctor Transfers to the nearest hospital with adequate facilities, if the patient s condition requires treatment at a facility not available at the hospital at which he or she is hospitalized Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 60

67 Medical transportation to the patient s home or a medical rehabilitation facility when prescribed by the attending physician following knee or hip replacement surgery, spinal surgery, or transplant performed at a Blue Cross Blue Distinction Center. The cost of air ambulance service to the nearest hospital with adequate facilities is an eligible medical expense only: When the patient s condition requires treatment and adequate facilities are not available at the hospital at which he or she is hospitalized When the patient is transported to the nearest hospital on an emergency basis from a remote geographic area Hospital and Facility-Based Medical Care The health plan covers eligible hospital or alternative specialized treatment facility expenses, including: Semi-private room, meals, special diets, and general nursing care, including hospice care Private room when isolation or intensive care is medically necessary and prescribed by your doctor, or when you are in a hospital or facility that has only private room accommodations Operating rooms, emergency rooms, special-care units, hospital-based clinics, casts and surgical dressings, drugs, oxygen, X-rays, blood and plasma, anesthesia, and any other medically necessary hospital or facility services and supplies Skilled nursing, convalescent, or extended care in an alternative specialized treatment facility not to exceed 120 days per calendar year Hospital and Facility-Based Mental Health Care This benefit covers allowed amounts for medically necessary (see Glossary) mental health and substance abuse treatment including: Room, meals, 24-hour general nursing care, psychotherapy, a structured milieu for the administration of necessary medical services, daily medical care, and supplies incurred while admitted as a patient in an accredited hospital or specialized care facility Treatment provided in a halfway house or residential treatment facility Partial hospitalization program and intensive outpatient program that provide coordinated, intense, comprehensive, multi-disciplinary outpatient treatment when there is no need for 24-hour intensive psychiatric or nursing care Electroshock therapy Emergency department, laboratory, and ambulance services Chiropractic Care You receive in-network benefits when you visit a chiropractor who participates in the Blue Cross network. You receive out-of-network benefits when you receive care from a non-participating provider. Blue Cross reviews claims to ensure that your chiropractic care is medically necessary. NOTE: Treatments that are not medically necessary, such as nutritional supplements and adjustments primarily for the maintenance of health, are not covered. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 61

68 Maternity Care Routine prenatal care is a covered preventive service. The plan covers maternity expenses, including a hospital stay, as a medical service. Consistent with federal law, the plan does not require authorization for a maternity hospitalization of up to: 48 hours following a normal vaginal delivery 96 hours following a Caesarean section After consultation with the mother, the mother s or newborn s attending provider may discharge the mother or her newborn earlier than 48 hours (or 96 hours as applicable). Any hospitalization that extends beyond 48 hours (or 96 hours) must be authorized by Blue Cross. The plan also covers medical expenses for services provided in a qualified hospital or eligible facility by a midwife, if he or she is state-licensed or state-certified or acting under the supervision of a doctor. Home Health Care If prior authorization is given, the plan covers home health care, including private duty or visiting nurse care, or home health aide services as an alternative to confinement in a hospital or facility. Hospice Care This benefit covers the following medical expenses for care received from a home hospice care agency during the final six months of a terminal illness: Up to eight hours per day for part-time or intermittent care by a professional nurse or a licensed home health aide Medical social services, including assessment of the patient s social, emotional, and medical needs, and identification of available community resources Psychological and dietary counseling Consultation or case-management services by a doctor Physical and occupational therapy Medical supplies, drugs, and medicines prescribed by a doctor Recuperative Nursing Home You or your doctor must contact Blue Cross for prior authorization before you enter a nursing home or other alternative specialized treatment care facility for recuperative purposes. To be eligible, the nursing home or facility must meet Blue Cross standards and requirements. If prior authorization is given, the plan covers up to 120 days per calendar year for skilled nursing, convalescent, or extended care that is provided in a treatment facility for recuperative purposes only. Durable Medical Equipment This benefit covers the purchase or rental of durable medical equipment if it meets all the criteria listed below. Prescribed by your doctor to treat an illness or injury Essentially medical in nature Usable only in the presence of illness or injury Usable only by the patient for whom it was prescribed Able to withstand repeated use Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 62

69 To be eligible for in-network benefits, durable medical equipment (rented or purchased) must be obtained from an in-network PPO provider. Prior authorization is required for some durable medical equipment. Sign in at myportico for the list of services requiring prior authorization. Breast Reconstruction In conformity with federal law, the plan provides breast reconstruction benefits to members and dependents receiving care in connection with a mastectomy. These benefits are provided in a manner determined in consultation with the attending doctor and the patient. The plan provides coverage (subject to the plan s deductible and out-of-pocket limit) for: Reconstruction of the breast on which the mastectomy was performed Surgery and reconstruction of the other breast to produce a symmetrical appearance Prostheses and treatment for physical complications, including lymphedema, in all stages of a mastectomy Specific Surgeries and Organ Transplants Knee or hip replacement surgery, spine surgery, or bariatric surgery Call Blue Cross for approval before receiving these surgeries. Coverage is provided for facility expenses only if such surgery is performed at a Blue Distinction Center or an in-network facility. The plan covers 80% of facility charges after deductible for surgery done at a Blue Cross Blue Distinction Center. The plan covers 60% of facility charges after deductible for surgery done at an in-network facility not designated a Blue Cross Blue Distinction Center. The plan covers no facility expenses if surgery is performed at an out-of-network facility. If approved in advance by Blue Cross, you are also reimbursed up to $10,000 for travel and lodging expenses related to the organ transplant, bariatric, spinal, knee replacement, and hip replacement surgery for you and a companion. Due to IRS regulations, meals cannot be reimbursed. Contact Blue Cross for details and approval. NOTE: For dependents under age 18, the in-network benefit (80% after deductible) applies to knee and hip replacement, spinal, and bariatric surgeries performed at Blue Distinction Centers or at an in-network facility. The out-of-network benefit applies at an out-of-network facility. Organ transplant Coverage is provided for facility expenses only if such procedures are approved in advance by Blue Cross and performed at a Blue Distinction Center or an in-network facility except in case of emergency or if you are too ill to travel. The plan covers: 80% of facility charges after deductible for surgery done at a Blue Cross Blue Distinction Center 60% of facility charges after in-network deductible for surgery done at an in-network facility not designated a Blue Cross Blue Distinction Center No facility expenses are covered if surgery is performed at an out-of-network facility The following transplants and any others approved by Blue Cross are covered under the plan: Bone marrow Cornea Heart Heart-lung Kidney Liver Lung (single or double) Pancreas Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 63

70 Other Eligible Medical Services and Supplies In addition to services and supplies already described in this document, this benefit covers the allowed amount for the following medically necessary services and supplies: Casts and surgical dressings X-rays, CT scans, magnetic resonance imaging, or other similar diagnostic imaging procedures Laboratory examinations and tests, including preadmission testing on an outpatient basis for an illness or injury requiring hospitalization Physical therapy performed by a licensed or registered physical therapist or occupational therapy performed by a licensed or registered occupational therapist, under the orders or supervision of an eligible medical provider Private duty nursing by a registered nurse or a licensed practical nurse who is not a member of the patient s immediate family, in a hospital that does not have an intensive care unit or when care in such a unit is not available or medically feasible, if prior authorization is given Emergency care and up to 12 months of follow-up care for treatment of accidental injury to the teeth or their supporting structures, including care provided by a dentist Up to $10,000 lifetime maximum for infertility treatment per member: includes doctor visits and services, tests, imaging procedures, doctor-administered medications, all methods of artificially assisted fertilization such as artificial insemination, in vitro fertilization, gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), embryo transfer procedures, and infertility counseling for, or related to, artificially assisted fertilizations (does not include sperm banking, donor ova or sperm, services and prescription drugs for, or related to, gender selection service) when pre-certified by Blue Cross Up to 12 visits per calendar year for acupuncture performed by an eligible medical provider for: - Treatment of chronic pain that has lasted six months or more or when other forms of therapy have failed or - Prevention and treatment of nausea associated with surgery, chemotherapy, or pregnancy Up to 12 massage therapy visits per calendar year. Massage therapy visits include: - Any service provided by a licensed massage therapist and - Massage therapy received from another eligible medical provider Smoking-cessation treatment provided by an eligible medical provider Over-the-counter nicotine replacement products if you are enrolled in and are participating in the Blue Cross telephonic Stop Smoking program Weight loss treatment and services provided by an eligible medical provider (medical doctor, dietitian) or in a hospital-based program Treatment for cleft lip and palate including oral surgery and orthodontia Treatment for temporomandibular joint disorder and craniomandibular disorder including orthodontia Treatment for oral cancer, and tooth extractions and dental implants required as a result of the surgical removal of a cyst, tumor, neoplasm or growth in the cheek or jaw where the surgery was covered as an eligible medical expense under this plan Hospital and anesthesiologist services rendered in connection with eligible dental services Speech therapy by a licensed or registered speech therapist for adults and children who originally had speech ability is covered in the event of vocal cord surgery, stroke, accidental injury, or speech-related illness (children s speech therapy for medically necessary speech development is also covered) Services or prescribed devices to prevent conception, other than those covered as preventive service under this Medical and Mental Health benefit or those drugs or devices purchased at a pharmacy and covered under the plan s Prescription Drug benefit Initial diagnostic X-rays prior to initiation of chiropractic treatment Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 64

71 Certain routine care for approved cancer clinical trials approved by Blue Cross in advance of treatment Other allowed amount medical expenses determined to be medically necessary by Blue Cross Non-Eligible Medical Services and Supplies This benefit does not cover these medical expenses: Medical care, supplies, or treatment received in facilities owned or operated by the government or received elsewhere for which you are not (in the absence of insurance) legally obligated to pay Services or supplies that are experimental or investigational, as determined by Blue Cross The portion of costs for out-of-network services in excess of Blue Cross allowed amount for the service Treatments not provided or prescribed by eligible medical providers or that are outside the scope of the provider s license or not medically necessary as defined by this plan Services by unlicensed doctors, practitioners, or providers of service, or by providers of service not specified as eligible medical providers under this plan Treatment or diagnosis of any disease, illness, injury, or physical or mental condition that is covered under this plan s Prescription Drug or Dental benefit All acupuncture treatment that does not meet the requirements of those listed in Eligible Medical Services and Supplies beginning on page 65 Additional costs for private rooms, unless isolation or intensive care is prescribed by the attending doctor Costs incurred for services in a hospital that don t meet the requirements established for a hospital or facility as determined by Blue Cross Prescription drugs covered under this plan s Prescription Drug benefit (except when administered to a hospitalized patient and included as a hospital expense) Personal comfort services (radio, television, beauty and barber services, guest services, and similar incidental services) Nursing home or convalescent facility care (except up to 120 days per calendar year if solely for recuperative purposes and determined to be medically necessary by Blue Cross) Cosmetic surgery (except when needed for prompt treatment and correction due to an accidental injury) Oral surgery or any other services by a dentist or dental care practitioner covered under this plan s dental benefit, except those listed as eligible medical services by this plan Routine exams not considered preventive services under this plan Services for correction of refraction error Hearing aids, eyeglasses, or contact lenses (except for one pair of eyeglasses or contact lenses required after cataract surgery, or medically necessary prosthetic contact lenses) Private duty nursing and home health aide services for respite and all other care (except those with prior authorization) Medibus, cabulance, bus fare, taxi fare, or personal car expense, except as described on pages Weight loss treatments and programs, unless rendered by an eligible medical provider Treatments and programs for smoking cessation, unless rendered by an eligible medical provider Exercise programs and equipment All massage therapy that does not meet the requirements as listed in Eligible Medical Services and Supplies on page 65 Sperm banking, donor ova or sperm, services and prescription drugs for, or related to, gender selection services Facility expenses if knee replacement, hip replacement, spine, bariatric, or organ transplant surgery is performed at an out-of-network facility (unless under age 18) Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 65

72 Induced abortions after 20 weeks of pregnancy (except when the life of the mother is threatened or the fetus has lethal abnormalities indicating death is imminent) Services or treatment related to sex reassignment surgery Other medical expenses determined ineligible by Blue Cross Eligible Mental Health Services Expenses for treatment or diagnosis of medical or mental health illness, injury, disease, or related symptoms are eligible expenses only if they are: Medically necessary (see Glossary) except for specific preventive/screening services listed starting on page 57 Qualified for reimbursement as determined by Blue Cross Allowed amounts according to Blue Cross guidelines Performed by an eligible medical or mental health provider and/or in an eligible hospital or alternative specialized treatment facility Blue Cross may review your treatment to ensure that it is medically necessary and not inappropriate, misused, or over used. In this situation, Blue Cross may contact your doctor or you for information on the planned course of treatment. Based on its review, Blue Cross may coordinate, limit, or deny services and supplies. Eligible Mental Health and Substance Abuse Care Expenses The plan covers allowed amounts for medically necessary mental health or substance abuse treatment when provided by an eligible mental health provider, including: Outpatient mental health therapy sessions Medication management Outpatient assessment to confirm the presence of a mental health disorder (DSM-IV or ICD-9) Detoxification and treatment of substance abuse or addiction Marital counseling Blue Cross may review treatment to determine if it is medically necessary, appropriate, and eligible for reimbursement. Non-Eligible Mental Health Expenses Except as covered under employee assistance program (EAP) benefit or as determined as medically necessary by Blue Cross, this benefit does not cover costs for treatment that is: Court-ordered, including adjudication of marital and child support and child custody, unless assessed and certified to be medically necessary Experimental, investigational, primarily for research, or not in keeping with national standards of practice, including but not limited to: - Treatment of sexual addiction, codependency, and conditions that don t have a DSM-IV diagnosis - Regressive therapy - Megavitamin therapy Educational or vocational testing and services, including treatments for personal growth and development Incurred for the treatment of social or economic problems or physical health without a corresponding DSM-IV or ICD-9 diagnosis Residential mental health care services as a diversion from incarceration in the juvenile or adult justice system Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 66

73 Required by law to be provided to a child by the school system Required to maintain employment or insurance, professional continuing education, or credentialing criteria Treatment incurred as part of a treatment plan for: - Smoking cessation - Weight reduction Alternative types of substance abuse treatment, including but not limited to: - Nutritionally-based therapies - Non-abstinence-based treatment - Aversion therapy - Individual therapy in the absence of a structured outpatient program, unless deemed necessary by Blue Cross Custodial in nature; includes (but is not limited to) treatment not expected to reduce the disability to the extent necessary to enable the patient to function outside a protected, monitored, or controlled environment Not medically necessary because the treatment is not reasonably expected to improve an individual s condition or level of functioning. This includes (but is not limited to) treatment for the following conditions, diagnoses, or treatment methods: - Stammering or stuttering - Mental retardation (except initial diagnosis) - Chronic organic brain syndrome - Delirium, dementia, amnesia, and other cognitive disorders - Mental disorders due to a general medical condition - Learning disabilities - Obesity - Transsexualism - Tobacco dependence - Chronic pain, except for pre-certified psychotherapy, biofeedback, or hypnotherapy incurred in connection with a DSM-IV disorder - Sleep/wake schedule disorders - Biofeedback - Therapeutic foster care - Group homes - Supervised apartments - Three-quarter houses - Wilderness programs - Residential/therapeutic schools - Camps Treatment or diagnosis of any disease, illness, injury, or physical condition that is covered under this plan s Prescription Drug or Dental benefit Early intensive behavioral intervention for pervasive development disorders and autism spectrum disorders Other mental health expenses determined ineligible by Blue Cross Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 67

74 While Traveling Within the United States Medically necessary medical and mental health care is covered if you become ill or injured while traveling within the United States. In a medical or mental health emergency, seek care immediately. You receive in-network benefits for any emergency care, 24 hours a day, seven days a week. After the emergency has been treated and you are released, you receive in-network benefits only if your ongoing care is provided by a participating Blue Cross network provider. In a non-emergency, benefits are determined by the provider s network participation unless you are treated at an urgent care center or urgent care clinic. Treatment or services billed by the provider as an urgent care visit are considered in-network medical or mental health expenses. Outside the United States Medically necessary medical and mental health care (excluding preventive care) is covered if you become ill or injured while traveling outside the United States. In a medical or mental health emergency, seek care immediately. You always receive in-network benefits for an emergency room or urgent care visit and appropriate follow-up care as determined by Blue Cross. Non-emergency eligible expenses charged by an in-network PPO provider outside the United States receive innetwork benefits. Care you receive from an out-of-network provider is considered an out-of-network expense. Send your claims to Blue Cross for evaluation and processing. ELCA Global Mission Missionaries sponsored by ELCA Global Mission receive health benefits through Aetna International, not the health benefits described in this book. If you terminate employment mid-year as a missionary with ELCA Global Mission and become sponsored by another eligible ELCA employer, your health benefit administrator will change and you ll have the ELCA-Primary health benefits described in this document. Your eligible medical and mental health expenses incurred in the same calendar year while you were covered by Aetna International will be applied as follows: In-network medical and mental health expenses incurred prior to the change are applied to your ELCA- Primary in-network deductible and out-of-pocket limit under your medical and mental health benefit. Out-of-network medical and mental health deductible and out-of-pocket limits are applied to your ELCA- Primary out-of-network medical and mental health benefits. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 68

75 Health Support Programs Blue Cross offers the following voluntary support programs via a telephonic nurse or coach to support efforts to improve your health or better manage a health condition. Health Support reaches out by letter and/or phone to those whose overall health status (based on medical and pharmacy claims) suggests a meaningful opportunity for health improvement. If you re contacted and willing to participate or you re struggling with an ongoing medical issue and think you d benefit from support, you ll be assigned a dedicated registered nurse who will assess your health needs, offer advice on how to integrate with other health plan services, and help you take positive action. You can also contact Blue Cross customer service and ask to speak with a dedicated nurse if you want to participate. Healthy Start pregnancy program offers guidance and support from a dedicated nurse to women during pregnancy. Call Blue Cross about this program. Stop Smoking program offers coaching guidance and support before, during, and after quitting smoking. Call Blue Cross about this program. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 69

76 Prescription Drug Benefit Administered by Express Scripts, the Prescription Drug benefit covers certain FDA-approved prescription drugs purchased for the treatment or prevention of illness and conditions. The ELCA health plan does not coordinate benefits for prescription drug expenses with other insurance plans. Platinum+ and Gold+ Options You pay a prescription drug copayment when you purchase a prescription drug. The amount depends on whether the prescription drug is on the Express Scripts formulary as a generic or preferred brand-name drug or is a non-formulary drug. The quantity allowed and copayment amount also vary based on where you purchase the drug at a retail, home delivery, or specialty pharmacy. Prescription drug copayments apply to your combined prescription, medical, and mental health out-ofpocket limit. After your combined out-of-pocket limit is met, the plan pays 100% of your eligible prescription drug, medical, and mental health expenses. NOTE: Prescription drug copayments don t apply toward your medical and mental health deductible, only toward your out-of-pocket limit. Silver+ and Bronze+ Options You pay the Express Scripts contracted rate when you purchase a prescription drug. The cost and quantity allowed vary based on where you purchase the drug at a retail, home delivery, or specialty pharmacy. Your medical, mental health, and prescription drug deductible and out-of-pocket limit are met using eligible medical and mental health expenses and prescription drug costs. After your combined medical, mental health, and prescription drug out-of-pocket limit is met, the plan pays 100% of your eligible prescription drug, medical, and mental health expenses. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 70

77 2014 Platinum+ and Gold+ Prescription Drug Benefits Important: Your Prescription Drug benefit is administered by Express Scripts. Specialty drugs are limited to a 31-day supply and must be purchased from Accredo, the Express Scripts specialty pharmacy. If you use a non-participating pharmacy or don t present your Express Scripts card at the time of purchase, in addition to the copayment, you are responsible for the difference between the Express Scripts contracted rate and the purchase price of your prescription. Benefits are subject to change without notice. You Pay 2014 Platinum+ and Gold+ Prescription Drug Benefit Chart Administered by Express Scripts Express Scripts Network Retail Pharmacy Up to 31-day supply Express Scripts Home Delivery Up to 90-day supply Accredo Specialty Pharmacy Up to 31-day supply Non-Participating Pharmacy Up to 31-day supply Plan Pays Express Scripts Network Retail Pharmacy Express Scripts Home Delivery Accredo Specialty Pharmacy Generic Drug Preferred Brand-Name Drug Non-Formulary Drug $8 copayment 1 $43 copayment $69 copayment $18 copayment 1 $94 copayment $152 copayment $8 copayment $43 copayment $69 copayment $8 copayment plus cost difference 2 Generic Drug $43 copayment plus cost difference 2 Preferred Brand-Name Drug 100% after copayment 100% after copayment 100% after copayment $69 copayment plus cost difference 2 Non-Formulary Drug Out-of-Network Pharmacy 100% of contracted amount after copayment 1 No copayment for: Generic and certain brand name oral contraceptives Fluoride for children Iron supplements for children ages 6 12 months Folic acid for women ages In addition to the copayment, you are responsible for the difference between the Express Scripts contracted rate and the purchase price of your prescription. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 71

78 2014 Silver+ and Bronze+ Medical, Mental Health & Prescription Drug Benefits Important: Your Prescription Drug benefit is administered by Express Scripts. The deductible and out-of-pocket limit for these options is met using eligible medical and mental health expenses and prescription drug costs. Single coverage means only one person has ELCA-Primary health benefits. Family coverage means that you and one or more family members have ELCA-Primary health benefits. The family deductible and out-of-pocket limit is met by one or more family members; family coverage has no individual deductible and out-of-pocket limit. Out-of-network services are subject to the Express Scripts allowed amount. You are responsible for the difference between the Express Scripts contracted rate and the purchase price of your prescription. Only eligible expenses under the terms of the plan are eligible for benefits. Specialty drugs are limited to a 31-day supply and must be purchased from Accredo, the Express Scripts specialty pharmacy. Prescription drugs purchased at an in-network retail pharmacy are limited to a 31-day supply; if purchased through Express Scripts home delivery, they re limited to a 90-day supply. Benefits are subject to change without notice. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 72

79 You Pay 2014 Silver+ and Bronze+ Medical, Mental Health & Prescription Drug Benefit Chart Administered by Blue Cross Blue Shield and Express Scripts Deductible 1 Includes eligible medical, mental health, and prescription drug expenses. Costs After Deductible (Coinsurance) Out-of-Pocket Limit 1 Plan pays 100% after limit is reached. Limit includes deductible and costs after deductible. Silver+ In-Network Bronze+ In-Network Silver+ Out-of-Network Bronze+ Out-of-Network $2,000 single $4,500 single $2,000 single $4,500 single $4,000 family 2,3 $9,000 family 2,3 $4,000 family 2,3 $9,000 family 2,3 20% to out-of-pocket limit 20% to out-of-pocket limit 40% to out-of-pocket limit 40% to out-of-pocket limit $3,600 single $6,000 single $3,600 single $6,000 single $7,200 family 2,4 $12,000 family 2,4 $7,200 family 2,4 $12,000 family 2,4 Plan Pays Medical and Mental Health Services Hospital, specialized facility, surgical, office visit, urgent care and emergency room, lab work, X-rays, imaging, individual and group counseling, medication management, etc. Preventive/Screening Services 5 See list on page 57. Prescription Drugs Preventive Prescription Drugs Generic and certain brand name oral contraceptives Fluoride for children Iron supplements for children ages 6 12 months Folic acid for women ages Silver+ In-Network Bronze+ In-Network 80% after deductible 100% after out-of-pocket limit Silver+ Out-of-Network Bronze+ Out-of-Network 60% after deductible 100% after out-of-pocket limit 100%; no deductible 60%; no deductible 80% after deductible 100% after out-of-pocket limit 60% after deductible 100% after out-of-pocket limit 100%; no deductible 60%; no deductible 1 There are separate deductibles and out-of-pocket limits for in-network and out-of-network services. 2 Family = member + child(ren), member + spouse or ESGP, or member + spouse or ESGP + child(ren). 3 Family meets deductible together, using expenses from one or more family members. There is no individual deductible for families. 4 Family meets out-of-pocket limit together, using expenses from one or more family members. There is no individual out-of-pocket limit for families. 5 Services are considered preventive/screening services when billed by a provider as preventive. All other services are considered medical services except that the first of the following services billed as preventive or non-preventive will be paid at the preventive/screening services benefit level: cholesterol/lipid profile; PSA test; Pap test; colonoscopy; mammogram; hemoglobin A1C test; vision exam; and urine microalbumin screening. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 73

80 Eligible and Ineligible Prescription Drugs Eligible Prescription Drugs Medically necessary: FDA-approved drugs available by prescription only Injectable and oral drugs determined to be specialty drugs by Express Scripts when purchased through Accredo Specialty Pharmacy (formerly CuraScript) Disposable diabetes supplies Certain drugs requiring preventive drug coverage by the Patient Protection and Affordable Care Act Drugs must be medically necessary for the condition, diagnosis, or symptoms, based on: FDA-specific indications Outcome data from clinical trials National care and treatment standards Express Scripts determination of appropriate use through such programs as prior authorization, drug quantity management, and step therapy Ineligible Prescription Drugs Over-the-counter medications, except insulin Drugs for cosmetic treatment of hair loss or other cosmetic purposes Vitamins for preventive purposes Drugs taken in preparation for, or in conjunction with, artificial insemination Drugs taken to terminate a pregnancy Drugs considered not medically necessary, based on FDA-specific indications, clinical trial outcomes, and national care and treatment standards Drugs deemed investigational or experimental because FDA approval for marketing has not been granted Drugs and supplies covered as medical expenses under Medicare hospital insurance (Part B) Herbal, mineral, and nutritional supplements Drugs that are covered under any other plan, including those covered under a Medicare prescription drug plan Specialty drugs not purchased from Accredo Specialty Pharmacy Formulary A formulary is a list of preferred medications reviewed and approved by a group of doctors and pharmacists based on clinical effectiveness and cost. Formulary drugs include generic and preferred brand-name medications that provide an affordable alternative to non-formulary drugs. If a generic version of a drug becomes available midyear, the brand-name drug will be non-formulary from that time forward. Generic drugs typically have the lowest cost. The FDA requires generics to have the same quality, strength, purity, and stability as their brand-name equivalents. Preferred drugs are brand-name drugs that have the mid-level cost. Preferred drugs are reviewed and approved for formulary inclusion by an independent committee of doctors and pharmacists. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 74

81 Non-formulary drugs are brand-name drugs that are the most expensive. These drugs are not included on the formulary because they are new to the marketplace or therapeutically equivalent drugs are available for less money. Excluded drugs are drugs not covered by the plan. Safe and clinically effective alternative drugs are covered by the plan. The current formulary list is available on myportico. It is subject to change throughout the year without notice as a result of changes in the pharmaceutical manufacturing industry. Preventive Medications Under the Affordable Care Act of 2010, you pay nothing when you purchase certain prescription drugs from an in-network retail pharmacy or through Express Scripts home delivery, including: Generic and certain brand name oral contraceptives Fluoride for children Iron supplements for babies ages 6 12 months Folic acid for women ages Immunizations Contact Express Scripts with questions. Pharmacy Options When you use the Express Scripts home delivery pharmacy, Accredo specialty pharmacy, or an in-network retail pharmacy, the Express Scripts contracted rate is applied to the cost of the drug and you ll likely pay less than the full retail price. To find an in-network retail pharmacy, use the Pharmacy Locator at express-scripts.com or call Express Scripts (see Contact Information). If you forget to show your identification card at a participating pharmacy, you may be charged the full retail price for your prescription drug rather than the Express Scripts contracted rate. Contact Portico s health care advocacy team for assistance (see Contact Information). Prescription drugs purchased from an out-of-network pharmacy could cost significantly more than drugs purchased from an in-network pharmacy. Local In-network Pharmacy You purchase a prescription of up to 31 days at a retail pharmacy by showing your Express Scripts identification card. You can use your SelectAccount debit card to pay for prescription drugs. Express Scripts Home Delivery Service You can buy long-term prescriptions by ordering a 90-day supply through Express Scripts home delivery service. Generally, you pay less than you would if you filled a prescription three times at your local retail pharmacy. You can use your SelectAccount debit card to pay for prescription drugs. Most maintenance medications ordered through Express Scripts home delivery are shipped by first-class mail to your home or another address you designate. For your convenience, you receive an or a phone call when your order is shipped. Perishable drugs (insulin, etc.) are shipped in temperaturecontrolled containers or cold packs via an overnight delivery service. To request order forms for home delivery, contact Express Scripts or Portico s health care advocacy team. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 75

82 Specialty Drug Pharmacy Specialty drugs are limited to a 31-day supply due to the high cost (average monthly cost is $1,500), special storage needs, limited shelf life, and frequent dosage changes. To receive coverage under the ELCA Prescription Drug benefit, you must purchase specialty drugs through Express Scripts specialty pharmacy, Accredo Specialty Pharmacy. Specialty drugs are not available through Express Scripts home delivery service or your local retail pharmacy. When you contact an Accredo patient care coordinator (see Contact Information), he or she explains the services offered, coordinates order delivery, and provides refill reminders. Accredo will send up to a 31-day supply of your specialty drug to your home or doctor s office. Syringes and needles for administering specialty drugs are provided to you at no additional cost. There is no shipping cost for specialty drugs. You can use your SelectAccount debit card to pay for prescription drugs. You can see the list of specialty drugs by visiting myportico. This list is subject to change without notice. Out-of-Network Pharmacy You pay the full retail price at the time of purchase and submit your claim to Express Scripts for reimbursement. Prescription drugs purchased from an out-of-network pharmacy receive out-of-network benefits and could cost you significantly more than an in-network pharmacy. To ensure that your claim is processed, you need to send the original receipt with a member reimbursement form to the Express Scripts claims address listed on the form within 12 months of the date of purchase. Contact the Portico health care advocacy team (see Contact Information) to request a reimbursement form. Pharmacy Outside the United States You pay the full retail price at the time of purchase and submit your claim to Express Scripts for reimbursement. To ensure that your claim is processed, send the original receipt with a member reimbursement form to the Express Scripts claims address listed on the form within 12 months of the date of purchase. Contact the Portico health care advocacy team (see Contact Information) to request a reimbursement form. During a Hospital Stay Prescription drugs administered during an inpatient hospital stay are considered medical expenses. To save money on drugs you will use at home, verify that the hospital pharmacy is in the Express Scripts network when you re discharged and show your Express Scripts identification card. If the hospital pharmacy is not in the Express Scripts network, you can save money by filling your prescription at your local participating pharmacy. Cost Saving and Safety Programs Step Therapy The step therapy program provides an effective approach to reducing the cost of drugs. Specific high-cost steptwo drugs are covered by the plan only after you try clinically appropriate, proven, and more cost-effective step-one drugs. If step-one drugs don t provide the desired therapeutic benefit, the plan may cover a step-two drug. The step therapy list is subject to change without notice. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 76

83 For more information about step therapy and a complete list of drugs and medical conditions included in this program, sign in to myportico. If you have one of these medical conditions, ask your doctor to prescribe a stepone drug. If you have a question about a specific drug, contact Express Scripts customer service. Drug Quantity Management A per-prescription quantity limit for certain medications promotes patient safety and avoids waste. Quantity limits are based on FDA-approved prescription drug dosing guidelines that prove beneficial for the most medical conditions for the most patients. Even if your prescription is written for more than the allowed quantity, Express Scripts will fill only the maximum allowed quantity per prescription unless you obtain a medical-necessity exception. To obtain a medical-necessity exception to the quantity limit, your doctor must contact Express Scripts (see Contact Information) and request authorization for an exception. Authorization is required before an exception can be made. If you have questions about quantity limits for a specific drug, contact Express Scripts. Quantity limits are subject to change without notice. Prior Authorization Certain prescription drugs require approval before being dispensed because they are costly or may be used inappropriately. To request prior authorization, your doctor must contact Express Scripts (see Contact Information). Standard medical-necessity criteria are used to review all coverage requests. You can view the list of drugs requiring prior authorization by signing in to myportico. This list is subject to change without notice. Paying for Prescription Drugs The claim filing deadline is 12 months from the date you incurred the expense. For example, if you incur expenses on Feb. 12, 2014, the filing deadline for that claim would be Feb. 12, Debit Card In 2014, claims don t cross over to SelectAccount for automatic reimbursement from your personal wellness account. All members receive a debit card by mail from SelectAccount as a convenient way to access money in their personal wellness account, health FSA, or HSA to pay for health care expenses. If you have a balance on your SelectAccount debit card, you can use it to pay for prescription drug expenses. This smart debit card only accesses funds that are currently available. You can use your debit card to pay for retail purchases like prescription drugs and vision services. For medical, mental health, and dental services, you can allow your claim to process, then enter your debit card number on the payment stub just as you would a credit card number and mail it to your provider. You call also call the provider and give the debit card number over the phone. Eligible expenses can also be reimbursed by submitting a paper or online claim to SelectAccount as long as you didn t use your debit card to pay for them. You may order additional cards at selectaccount.com. Creditable Coverage The prescription drug benefit administered by Express Scripts and included in the ELCA-Primary Platinum+, Gold+, and Silver+ options is creditable coverage. Creditable coverage means that the ELCA Prescription Drug benefit is, on average, expected to pay as much or more than the Medicare standard prescription drug benefit. It Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 77

84 also means that you can enroll in Medicare s prescription drug coverage (within 63 days of ending ELCA coverage) with no penalty. The ELCA Prescription Drug benefit administered by Express Scripts and included in the ELCA-Primary Bronze+ option is non-creditable coverage. Non-creditable coverage means the ELCA prescription drug benefit included in the Bronze+ option is, on average, expected to pay less than Medicare s standard prescription drug coverage. If you have non-creditable coverage for any period after the initial Medicare enrollment period when you are first eligible for Medicare, you will be subject to a late-enrollment penalty (higher premiums) if you decide to enroll in Medicare Part D prescription drug coverage in the future. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 78

85 Dental Benefit The dental benefit administered by Delta Dental covers preventive, basic, major restorative, and orthodontic care. It covers allowed amounts for your eligible dental expenses subject to the deductible, costs after the deductible, and the annual benefit maximum. The ELCA-Primary dental benefit is administered by Delta Dental. Basic dental and major restorative expenses are subject to the deductible. Expenses for eligible preventive services are covered at 100% with no deductible. Deductibles, the lifetime orthodontic benefit limit, and annual benefit maximum are subject to change annually. Important: Out-of-network services are subject to the amount Delta Dental allows. Benefit is subject to change without notice. You Pay Deductible Preventive care (See list on page 82.) 2014 Dental Benefit Chart Administered by Delta Dental Basic care Fillings, tooth extractions, root canal therapy, oral surgery (See list on pages ) Major restorative care Crowns, bridges, dentures, implants (See list on page 83.) Orthodontia $150 per person $300 per family $0 In-Network 20% after deductible 50% after deductible 50%; no deductible Plan Pays Annual benefit maximum (Maximum dental benefit paid by the plan for preventive, basic, and major restorative care received in 2014) Preventive care (See list on page 82.) Basic care Fillings, tooth extractions, root canal therapy, oral surgery (See list on pages ) Major restorative care Crowns, bridges, dentures, implants (See list on page 83.) Lifetime orthodontia benefit maximum (Lifetime maximum for orthodontia services begun in 2014) In-Network $2,850 per person 100% 80% after deductible 50% after deductible $2,850 per person Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at or Page 79

86 Eligible Dental Expenses This benefit covers eligible dental expenses for procedures, services, or supplies received from a qualified dentist or licensed dental care practitioner acting within the scope of his or her license or under the supervision of a qualified dentist or doctor. The expenses must be for procedures, services, and supplies that are: Typically used for treatment of the dental condition Rendered on the basis of generally accepted standards of dental practice Medically necessary (except for specified preventive dental care) Most dental procedures are performed and completed on the same day. However, some dental services require multistage procedures and multiple appointment dates. Claims payment is made after the completion of all services. Non-Eligible Dental Expenses This benefit does not cover: Charges that exceed allowed amounts Procedures, services, or supplies primarily for cosmetic reasons and beautification, including charges for personalization and characterization of dentures Procedures, services, or supplies that are not necessary according to accepted standards of dental practice. If a dentist or member elects an alternative or more expensive dental procedure, service, or supply, the plan will cover only the portion of the charge for the adequate treatment of the dental condition. Procedures, services, or supplies that don t meet accepted standards of dental practice, including those that are experimental Replacement of a lost, missing, or stolen orthodontic or prosthetic device or any dental appliance Precision attachments Emergency dental care and up to 12 months of follow-up care for an accidental injury to teeth or their supporting structures that is eligible for reimbursement under the medical portion of this plan Diagnosis or treatment of any disease, illness, injury, or physical condition that is covered under medical or prescription drug benefits Costs for dental veneers and related services and supplies Costs for procedures, services, or supplies, including retreatment, that exceed the frequency limits established by Delta Dental Costs for procedures, services, or supplies that are medical in nature, including but not limited to oral surgery services performed in a hospital including treatment for oral cancer, and tooth extractions and dental implants required as a result of the surgical removal of a cyst, tumor, neoplasm or growth in the cheek or jaw where the surgery was covered as an eligible medical expense Inpatient and outpatient hospital expenses Costs for prescription drug expenses In-Network Providers Reimbursement percentages are the same for any dentist, but you may have significantly lower out-of-pocket expenses if you use a dentist who participates in the Delta Dental PPO or Delta Dental Premier network. Network providers have agreed to accept Delta Dental s allowed amount as complete reimbursement for services. If your dentist is in the Delta Dental network, request that your claim be submitted to the Delta Dental address on the Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 80

87 back of your identification card. Reimbursement for eligible dental expenses is paid directly to your in-network provider. Call Delta Dental or visit Delta Dental online to find in-network providers (see Contact Information). Out-of-Network Providers For out-of-network providers, Delta Dental uses allowed amounts from the Health Insurance Association of America specific to each dental procedure and grouped by geographic area. If your out-of-network dentist s fee for a service is higher than the fee charged by 80% of dentists in the same geographic area, the portion of the fee that exceeds the allowed amount is not covered by the ELCA dental benefit. You are responsible for paying any portion of the fee that exceeds this allowed amount. If your dentist is not in the Delta Dental network: Submit your claim to the address on your Delta Dental identification card Delta Dental reimburses you rather than your out-of-network dentist You pay your dentist Preventive Care This benefit pays 100% of eligible expenses for the following preventive dental care: Routine dental cleaning two per calendar year Periodontal maintenance cleaning two per calendar year Oral exam two per calendar year Full-mouth X-ray or panorex one every 60 months Supplementary bitewing X-rays one every 24 months for adults and one every 12 months for dependents through age 18 Topical application of fluoride one per calendar year for dependents through age 18 Sealants or preventive resin restorations for permanent molars one per lifetime for dependents through age 18 Space maintainers for extracted posterior primary teeth for dependents through age 18 Oral hygiene instructions as prescribed by the dentist one per lifetime per individual Basic Dental Care This benefit pays 80% of eligible diagnostic, therapeutic, and restorative expenses (after deductible) for the following basic dental care: Oral exams, including specialist exams and those done in the course of emergency treatment for the relief of pain Tests and laboratory exams, including bacteriologic cultures and pulp vitality tests Non-routine dental X-rays, including full-mouth or other dental X-rays required to diagnose and treat a specific condition Oral surgery: - Routine oral surgery for tooth removal (including alveolectomy, if indicated, and pre- and postoperative care) - All other oral surgeries, such as alveoloplasty, vestibuloplasty, removal of cysts, tumors, growths, neoplasms, and treatment of simple fractures that can be managed in the office of a qualified dentist or licensed dental care practitioner Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 81

88 Treatment of periodontal and other diseases of the gums and tissues of the mouth, including gingivectomy, osseous surgery, and splinting. This includes periodontal scaling and root-planing, repeat non-surgical treatment every 24 months, and repeat surgical treatment every 36 months. Endodontic treatment, including root canal therapy and pulpotomies on primary and permanent teeth (does not cover retreatment of pulpotomies) The following services and supplies, if provided in the office of qualified dentists or licensed dental care practitioners: - Anesthetics (conscious sedation), when medically necessary and administered in connection with cutting procedures in the oral cavity - Injection of antibiotic drugs by an attending dentist - Application of desensitizing medications Restoration of lost tooth structure as a result of tooth decay or fracture, when restored with amalgams (silver alloys), resin (white-colored filling) restorations, or pre-formed crowns for primary teeth Removable appliances for the treatment of bruxism and other harmful habits Major Restorative Care This benefit pays 50% of eligible expenses (after deductible) for the following services and supplies related to major restorative dental care: Repair or recementing of crowns, inlays, onlays, and fixed or removable dentures (including one relining or rebasing of dentures every 36 consecutive months, if the relining or rebasing occurs more than six months after the installation of an initial or replacement denture) Crowns, onlays, or porcelain inlays when the amount of lost tooth structure cannot be restored with filling restorations as described under Basic Dental Care Bridges, standard partial dentures, and full dentures for the replacement of extracted permanent teeth. Eligible expenses are limited to the commonly performed method of tooth replacement. Repairs and adjustments to prosthetic appliances if they serve as the permanent prosthetic appliance Replacement of an existing prosthetic appliance, if five years have elapsed from when last benefited and only if the existing appliance is not and cannot be made satisfactory. Services that are necessary to make an appliance satisfactory will be eligible. Endosteal implants Orthodontic Care This benefit covers orthodontic treatment for the prevention and correction of malocclusion of teeth and associated dental and facial disharmonies. It pays 50% of eligible orthodontic expenses, up to a lifetime benefit limit, including initial orthodontic examinations, X-rays, and models. The lifetime benefit limit for each individual is fixed in the first year orthodontic expenses are incurred. Paying For Care Delta Dental recommends that you ask your provider for a pre-treatment estimate for all dental care expected to exceed $300. This step clarifies coverage before you receive treatment. Your claim must be filed within 12 months of the date the expense was incurred. For example, if you incurred expenses on Feb. 12, 2014, the filing deadline for that claim would be Feb. 12, Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 82

89 Paying for Care In 2014, claims don t cross over to SelectAccount for automatic reimbursement from your personal wellness account. All members receive a debit card by mail from SelectAccount as a convenient way to access money in their personal wellness account, Health FSA, or HSA to pay for health care expenses. If you have a balance on your SelectAccount debit card, you can use it to pay for dental expenses. This smart debit card only accesses funds that are currently available. You can use your debit card to pay for retail purchases like prescription drugs and vision services. For medical, mental health, and dental services, you can allow your claim to process, then enter your debit card number on the payment stub just as you would a credit card number and mail it to your provider. You call also call the provider and give the debit card number over the phone. Eligible expenses can also be reimbursed by submitting a paper or online claim to SelectAccount as long as you didn t use your debit card to pay for them. You may order additional cards at selectaccount.com. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 83

90 Employee Assistance Program (EAP) The employee assistance program (EAP) benefit administered by ValueOptions, a partner of Blue Cross and Blue Shield, provides EAP counseling, support, and referral services to you and your covered family members. You can call to talk to an EAP professional about stress, relationships, family issues, work issues, or any other personal concern 24 hours a day, seven days a week (see Contact Information). An initial phone consultation for legal and financial issues is offered at no cost to you. It is a confidential resource to: Help you with personal and work concerns Obtain referrals to professionals Find support and information resources in your community Eligible EAP Services Eligible EAP services include telephone consultation and assessment and in-person EAP counseling (when clinically appropriate) related to any concern or issue, including: Spouse relational problem Parent-child relational problem Child abuse or neglect Sibling relational problem Relational problem related to a mental disorder or general medical condition Occupational problem Academic problem Acculturation problem Religious or spiritual problem/phase of life problem Relational problem not otherwise specified Bereavement Adult anti-social behavior Childhood or adolescent anti-social behavior Overweight or obesity Tobacco dependence In-Person Counseling Access your EAP for help addressing personal concerns, work issues, stress, relationship problems, and family issues. If the EAP considers it clinically appropriate, the EAP will refer you to an in-person counselor for one to six in-person counseling sessions at no cost to you. An EAP counselor authorizes in-person counseling only when clinically appropriate. This means you won t have in-person counseling authorized if your issue is not expected to be resolved within one to six in-person EAP visits. In this situation, the EAP counselor advises you to seek counseling using the Medical and Mental Health benefit. If, after receiving one to six in-person EAP visits, your counselor determines that you require additional medically necessary care, you can then access your Medical and Mental Health benefit. To have mental health services paid at the in-network level, seek care from an in-network Blue Cross mental health provider. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 84

91 Help With Life Events The EAP can help you with: Work/life events including child care, adoption, child development, adult/elder care, and balancing work and family. EAP can provide referrals to resources in your community and printed educational materials. Legal concerns including divorce, lawsuits, wills and estates, and real estate. EAP provides one 30-minute telephonic or in-person consultation with an attorney at no cost to you. You may also receive discounted services if you retain the services of a participating attorney after your initial consultation. Financial concerns including managing credit, budgeting, and consolidating debt. If you agree to any services that require fees, you are responsible for the fees. ELCA NurseLine SM Health information from a registered nurse is available to you 24 hours a day, seven days a week through OptumHealth SM. Call if you need help: Deciding when self-care, a doctor visit, or the emergency room is appropriate Knowing how to handle a common health problem Understanding a medical condition, recent diagnosis, test results, or treatment options Planning for your doctor visit With questions about medications Fitness Center Discount Portico contracts with Blue Cross to offer a fitness center discount that helps members (and one other adult family member with ELCA-Primary health coverage) pay for membership at a participating fitness center. When you work out at least eight days in a month, you receive up to a $20 credit ($40 max per household) to your bank account or fitness center dues. NOTE: While many plans require you to work out 12 days per month, the ELCA health plan requires that you work out only eight days per month to receive the discount. Wellness Dollars Wellness dollars are financial incentives you earn for completing wellness activities. You earn wellness dollars by taking your annual Mayo Clinic Health Assessment, completing follow-up activities, and reporting them on the Mayo Clinic EmbodyHealth web portal. In 2014, ELCA-Primary plan members and eligible spouses or ESGPs can earn up to $500 each ($1,000 maximum per household). $150 for completing the health assessment on or before Sept. 30, 2014 $350 for completing follow-up activities on or before Nov. 30, 2014 Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 85

92 NOTE: New members who enroll in ELCA-Primary health coverage after Sept. 30, 2014, will not be eligible to earn wellness dollars in Wellness dollars can only be used to reimburse eligible expenses. Depending on which health benefit option you have, wellness dollars you and your spouse or ESGP earn are either credited to your personal wellness account or deposited into your health savings account. If you have an injury, illness, or mental disorder that prevents you from taking the health assessment and engaging in follow-up activities, contact the Portico health care advocacy team (see Contact Information) to request a form for waiving personal wellness account requirements. Your doctor must describe how your condition prevents you from participating in these activities. If a waiver is granted, you ll have $500 credited to a personal wellness account or deposited into a health savings account. Mayo Clinic Health Solutions Portico contracts with Mayo Clinic Health Solutions to provide health and wellness information based on the experience, knowledge, and credibility of more than 2,000 Mayo Clinic doctors and scientists. Web Portal The EmbodyHealth web portal, elcaforwellness.org, is a protected website offering health and wellness information. It is also where you take your annual health assessment and report follow-up activities. This interactive web portal presents you with customized information, suggestions, and tools on a range of subjects based on your health assessment results and topics of interest to you. The more information you provide, the more customized and interactive the portal becomes for you. Health Assessment This online tool helps you take stock of your health and lifestyle habits in less than 30 minutes. You enter personal health information (height, weight, cholesterol, blood sugar, etc.), and the tool identifies your health strengths and risks. It also recommends strategies to maintain or improve health, and delivers a personal action plan. Taking the assessment earns you $150 in your personal wellness account or HSA. You can also earn an additional $350 by doing certain follow-up activities. Health Coaching Some plan members and spouses can receive Mayo Clinic health coaching. If your health assessment indicates certain risks, you will see an online form asking if you are willing to be contacted by a trained health coach. If you agree to be contacted, a health coach will call you. Health coaches provide support and encouragement to help you make lifestyle changes, reduce health risks, and improve your health. Working one-on-one with the coach, you create an action plan and set health-improvement goals. This confidential service is paid for by your ELCA health plan. There is no cost to participants, and participation is voluntary. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 86

93 Monthly Newsletter Plan members also receive the Mayo Clinic monthly newsletter, EmbodyHealth. This newsletter provides easy-toread, practical information on a variety of important health topics written and reviewed by Mayo Clinic. It also features front- and back-page commentary on wellness and benefits from Portico. Hearing Discount Program Delta Dental of Minnesota partners with HearPO to offer members a hearing discount program that can help you and eligible family members save money. It offers: Discounts on more than 1,000 models of digital hearing aids from leading manufacturers A 40% discount on hearing diagnostic testing, including advanced audiology tests A three-year warranty on most hearing aids, covering repairs, loss, and damage A 60-day free trial with no restocking fee Free batteries for two years with a new hearing aid purchase (maximum of 160 cells per hearing aid) One year of free aftercare services More than 2,700 locations nationwide Contact HearPO (see Contact Information) for assistance. Health Care Advocacy Team Portico provides plan members with a team of professionals who understand how the various parts of the health care system fit together. Portico health care advocates know the ins and outs of our health plan benefits including aspects like insurance billing and coding, Medicare payment rules and procedures, insurance industry policies, and procedures. They work with you and our benefit administrators to answer your questions and assist in resolving your problem. Contact the Portico health care advocacy team (see Contact Information) for assistance. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 87

94 Health Savings Account If you are enrolled in the Silver+ or Bronze+ option (considered High Deductible Health Plans (HDHP) by the IRS) and meet eligibility requirements, you have a health savings account (HSA), a tax-favored savings account that pairs with an HDHP. Money in the account can be used to pay for eligible health care expenses incurred by you and your eligible family members with pretax dollars. Money in the account earns interest, is portable, and remains yours regardless of employment. You can use your SelectAccount debit card to pay for eligible health care expenses from this account. NOTE: According to IRS rules, when you have an HSA, your personal wellness account (legally called a health reimbursement arrangement) balance can only be used to reimburse vision (glasses, contact lenses, etc.), dental, and post-deductible expenses in 2014 or beyond. The health savings account is described in detail in the 2014 Flexible Benefits Plan Summary Plan Description. HSA Features The IRS allows 2014 HSA contributions of up to $3,300 for single coverage, or $6,550 for family coverage, plus an additional $1,000 if you re age 55 or older in Per IRS regulations, single coverage is an HDHP covering only an eligible individual. Family coverage is an HDHP covering an eligible individual and at least one other individual. Money can be contributed to your HSA by you, your employer, and the ELCA health plan when you earn wellness dollars. In 2014, employers can choose to contribute the following to your HSA: $0, $600, or $1,200 annually if you have single coverage $0, $1,200, or $2,400 if you have family coverage You and your spouse or ESGP can each earn wellness dollars. They are deposited into your HSA up to $500 each in Your balance rolls over year to year, which helps you accumulate dollars for future eligible health care costs. You own your HSA; the balance is yours to keep after employment ends. Contributions and any interest earned are not included in your taxable income. You cannot have a health FSA and an HSA. Those Eligible for an HSA Members who have the Silver+ or Bronze+ health benefit option are eligible to have a HSA. Exceptions: Members also covered by another non-hdhp plan, such as a spouse s health plan or health FSA Members who can be claimed as a dependent on another person s tax return Members age 65 on or before April. 1, 2014 Any employer contributions that would have been made to an HSA are applied to a personal wellness account (legally, a health reimbursement arrangement) Eligible Health Care Expenses Medical, mental health, and prescription drug out-of-pocket expenses Vision and dental expenses Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 88

95 Eligible over-the-counter items Certain insurance premiums for: Health coverage continuation Health insurance while receiving unemployment Medicare (except for Medicare supplemental coverage) Long-term care insurance NOTE: If you re working for a sponsoring employer, you can t use HSA money to buy up to a higher-priced health benefit option. Debit Card In 2014, claims don t cross over to SelectAccount for automatic reimbursement from your personal wellness account. All members receive a debit card by mail from SelectAccount as a convenient way to access money in their personal wellness account, Health FSA, or HSA to pay for health care expenses. If you have a balance on your SelectAccount debit card, you can use it to pay for eligible health care expenses. This smart debit card only accesses funds that are currently available. You can use your debit card to pay for retail purchases like prescription drugs and vision services. For medical, mental health, and dental services, you can allow your claim to process, then enter your debit card number on the payment stub just as you would a credit card number and mail it to your provider. You call also call the provider and give the debit card number over the phone. Eligible expenses can also be reimbursed by submitting a paper or online claim to SelectAccount as long as you didn t use your debit card to pay for them. You may order additional cards at selectaccount.com. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 89

96 Personal Wellness Account When you enroll in the Platinum+ or Gold+ option, any wellness dollars you earn are credited to your personal wellness account (legally defined as a health reimbursement arrangement, or HRA, under Internal Revenue Service Notice ). Your personal wellness account is administered by SelectAccount SM (an affiliate of Blue Cross and Blue Shield). Wellness dollars you earn during the plan year are credited to this account, and may be used to reimburse eligible medical expenses as defined by the IRS. Any balance remaining in your personal wellness account at the end of the plan year carries over to the next year. You can be reimbursed from your personal wellness account for eligible health care expenses incurred by you or family members who are: Your tax dependents or Your adult children until they reach age 26 (even if not your tax dependent) Eligibility You are eligible to have money credited to a personal wellness account if you enroll in the: Platinum+ or Gold+ option Silver+ or Bronze+ option, if you will be 65 or older on or before April. 1, 2014, and are: Sponsored, retired, disabled, or on coverage continuation or A spouse or eligible family member designated as the ELCA-Primary health coverage member when the member no longer has ELCA-Primary health coverage Contributions Money can be credited to a personal wellness account: By the ELCA health plan if you earn wellness dollars and have the Platinum+ or Gold+ option By your employer if you have the Silver+ or Bronze+ option and will be 65 on or before April. 1, 2014 Eligible Expenses Eligible personal wellness account expenses are 2014 out-of-pocket health care expenses: Incurred by you or your eligible dependent(s) Not reimbursed from another source (the health plan, a flexible spending account, health savings account, or another insurance plan) Considered eligible health expenses under a health reimbursement arrangement by the IRS You cannot withdraw cash from your account or use the balance for non-eligible expenses. Non-Eligible Expenses The following expenses are not eligible for reimbursement from dollars credited to your person wellness account: An expense incurred prior to Jan. 1, 2014 An expense incurred before you are enrolled in the Platinum+ or Gold+ option Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 90

97 An expense previously paid for or eligible to be paid for through the health plan, a health flexible spending account, other insurance, a health savings account, or any other accident or health plan Health insurance premiums Health-related expenses not eligible under IRS guidelines An expense for an individual who is not your eligible spouse or dependent If Your Situation Changes Ending Participation You no longer have a personal wellness account upon the earlier of the: Termination of the personal wellness account portion of the plan or Date you are no longer covered under ELCA-Primary health benefits and have reduced your personal wellness account balance to zero After terminating employment, you can continue to use your SelectAccount debit card to pay for eligible medical expenses incurred until your account balance is reduced to zero. If you elect to continue ELCA-Primary health benefits after you terminate employment, you can continue to earn and use your wellness dollars. If You Enroll in ELCA Medicare-Primary Benefits When you enroll in ELCA Medicare-Primary coverage, you can t earn additional wellness dollars. You can, however, continue to use funds from your personal wellness account for eligible expenses incurred after enrolling in ELCA Medicare-Primary benefits. If your spouse or ESGP continues ELCA-Primary health coverage after you become eligible for ELCA Medicare- Primary coverage, he or she is eligible to earn wellness dollars toward his or her own personal wellness account up to the maximum amount for the year. If you have an ESGP, he or she is eligible to earn wellness dollars toward his or her own personal wellness account only if he or she is your tax dependent as defined in Code 105(b). If You re Rehired After Termination If you terminate employment (including retirement or resignation) without having earned the maximum wellness dollar amount and are rehired within the same plan year, you can continue to earn additional wellness dollars up to the maximum allowed for the current plan year when you enroll in ELCA-Primary health coverage. If You Die If you die, your surviving eligible family members may continue to use funds from your personal wellness account for eligible expenses they incur after your death, until your personal wellness account balance is reduced to zero. No Additional Contributions Your personal wellness account can t be funded with salary-reduction contributions, employer contributions (flexible credits), or other contributions under a cafeteria plan. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 91

98 Debit Card In 2014, claims don t cross over to SelectAccount for automatic reimbursement from your personal wellness account. All members receive a debit card by mail from SelectAccount as a convenient way to access money in their personal wellness account, health FSA, or HSA to pay for health care expenses. If you have a balance on your SelectAccount debit card, you can use it to pay for eligible health care expenses. This smart debit card only accesses funds that are currently available. You can use your debit card to pay for retail purchases like prescription drugs and vision services. For medical, mental health, and dental services, you can allow your claim to process, then enter your debit card number on the payment stub just as you would a credit card number and mail it to your provider. You call also call the provider and give the debit card number over the phone. Eligible expenses can also be reimbursed by submitting a paper or online claim to SelectAccount as long as you didn t use your debit card to pay for them. You may order additional cards at selectaccount.com. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 92

99 Health Flexible Spending Account Eligible sponsored members can choose to set aside pretax money into a health flexible spending account (FSA). Health FSA contributions are used to pay for eligible health care expenses incurred by you and eligible family members with pretax dollars. Money not used is forfeited. The health FSA and the dependent (day) care FSA are described in detail in the 2014 Flexible Benefits Plan Summary Plan Description. Sponsored members can enroll in a health FSA if they: Have the Platinum+ or Gold+ health benefit option or Waive ELCA health benefits or Have ELCA Medicare-Primary benefits or Have the Silver+ or Bronze+ health benefit option and turn age 65 or older on or before April. 1, 2014 Those not eligible to enroll: Self-sponsored members Members who work outside the U.S. Members who have the Silver+ or Bronze+ health benefit option and are enrolled in a health savings account (HSA) FSA Features The plan year is Jan. 1 Dec. 31. You can set aside up to $2,500, pretax, to pay for eligible health care expenses. You can access the full election amount of your health FSA beginning Jan. 1 (or as of your FSA effective date if you enroll or change your election during the plan year). An expense is incurred when care is provided, not the date it s billed. Money not used is forfeited. You must incur health care expenses by Mar. 15, 2015, and file for reimbursement by April 30, 2015, (or within four months of termination of employment, if earlier) to avoid forfeiting the money in your account. You can start, stop, or change your FSA election within 60 days of a qualifying election change event. FSA Enrollment Sponsored plan members are eligible to enroll annually in a health FSA. To participate, you must re-enroll each year. Existing plan members must enroll during the annual Open Enrollment period. New members must enroll within 60 days of eligibility. If you don t enroll within 60 days, you must wait until the next annual Open Enrollment period to participate, unless you have a qualifying election change event such as a marriage or birth of a child. Your participation begins the first payroll period of the month after you enroll, or Jan. 1 if you enroll during the annual Open Enrollment period. Following enrollment, you receive a debit card and an information packet by mail from SelectAccount. The debit card allows you to access funds in your health FSA, if you have a balance. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 93

100 Your employer withholds your health FSA contribution from each paycheck before taxes. Portico bills your employer for your FSA contribution, and your employer sends it to Portico. Debit Card In 2014, claims don t cross over to SelectAccount for automatic reimbursement from your personal wellness account. All members receive a debit card by mail from SelectAccount as a convenient way to access money in their personal wellness account, health FSA, or HSA to pay for eligible health care expenses. If you have a balance on your SelectAccount debit card, you can use it to pay for medical and mental health expenses. This smart debit card only accesses funds that are currently available. You can use your debit card to pay for retail purchases like prescription drugs and vision services. For medical, mental health, and dental services, you can allow your claim to process, then enter your debit card number on the payment stub just as you would a credit card number and mail it to your provider. You call also call the provider and give the debit card number over the phone. Eligible expenses can also be reimbursed by submitting a paper or online claim to SelectAccount as long as you didn t use your debit card to pay for them. You may order additional cards at selectaccount.com. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 94

101 Miscellaneous Provisions Confidentiality and Privacy Practices The Health Insurance Portability and Accountability Act (HIPAA) of 1996 requires health plans to protect the confidentiality and privacy of individually identifiable health information. Portico is the plan administrator of the ELCA Health Benefits Plan and is committed to maintaining the privacy of your personal health information under the plan in accordance with HIPAA privacy standards, which took effect April 14, The plan and its benefit administrators will use and disclose health information only as allowed by federal law. The plan has provided you with a Notice of Privacy Practices, describing how health information about you may be used or disclosed by the plan. If you would like to receive another copy of this notice, please contact the Portico health care advocacy team. Protected Health Information (PHI) PHI is the identifiable health information about you that is created, received, or maintained by the plan. The privacy of your health information that is used or disclosed by the plan is protected by HIPAA. The plan is required by law to: Maintain the privacy of your PHI Provide you with a notice of the plan s legal duties and privacy practices with respect to your PHI HIPAA Rights With respect to your protected health information (PHI), under the Health Insurance Portability and Accountability Act (HIPAA), you have the right to: Inspect and copy certain portions of your PHI maintained by the plan Request an amendment of your PHI Request restriction on the uses and disclosure of your PHI Request communication be made to you through an alternate means or location Obtain an accounting of disclosures the plan has made for reasons other than treatment, payment, or health care operations to you, or for required or authorized disclosures Request that your provider not share PHI with the plan if you paid for the entire service Request copies of your health records in electronic format, if available The plan may use, share, or disclose PHI to pay your health care benefits, operate the plan, or for treatment by a health care provider. In addition, the plan may use or disclose your information in other special circumstances described in the privacy notice. For any other purpose, the plan requires your authorization for the use or disclosure of your PHI. An authorization form is available by calling the Portico health care advocacy team (see Contact Information). Coordination of Benefits The ELCA health plan is designed and funded to help protect you and your family from catastrophic financial loss due to medically necessary treatment of illness or injury. You share in the costs of your medical expenses (deductibles and costs after deductibles) even with duplicate coverage. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 95

102 When you have more than one group health insurance policy for you and your family members, the ELCA health plan determines which plan pays first (primary), second (secondary), or third (tertiary). The health plan does not coordinate prescription drug coverage with other insurance plans. Generally, coverage under two group plans may be of value only if the benefits of the secondary plan are better than the benefits under the primary plan. Determining primary coverage When a plan member is covered under two or more group health plans, the primary responsibility for payment of benefits will be determined by the benefit administrator based on national coordination of benefits insurance guidelines. Generally: The plan that covers the member has primary responsibility for that individual s claims. For example, the ELCA plan will be primary for the sponsored ELCA member s claims and the employer plan of his or her spouse will be primary for the spouse s claims. When a child (whose parents are not divorced) is covered under the plan of both parents, the primary plan is the plan of the parent with the earlier birthday in a calendar year. For example, the plan of the parent born in March will be primary for the child; the plan of the parent born in October will be secondary. When a child is covered under the plan of both parents and his or her parents are divorced or their partnership is terminated: - The plan of the parent made responsible by legal decree is the primary plan for the child - If there is no legal decree that establishes responsibility for the child s medical expenses, the plan that covers the child as a dependent of the parent with custody shall have primary responsibility. However, if the parents have joint custody of the child, the plan that has covered the child for the longest time will have primary responsibility. If the above provisions do not establish responsibility, the primary plan is the plan that has covered the individual the longest. If you have Medicare coverage and the ELCA-Primary Silver+ or Bronze+ option, Medicare s payer order rules will apply. Secondary payer As the secondary payer, benefits under the ELCA health plan are calculated by first determining the normal benefits available, as if no other primary coverage existed. Then the amount already paid by the primary plan is subtracted from the normal benefits. If the primary plan paid the same or more than the normal benefits, the ELCA plan will pay zero. If the primary plan paid less than the normal benefits, the ELCA plan will pay the difference between the normal benefits and the amount paid by the primary plan. In either of these situations, the member will receive between the two plans, at least the amount he or she would have received if he or she had only ELCA plan benefits. Third-Party Liability (Subrogation) Subrogation is a legal process that allows Portico to substitute itself in your place regarding a claim or legal right to compensation from a third party (person or entity) who was responsible for your injury or illness. Upon payment of benefits under the ELCA health plan, Portico will be subrogated to your rights of recovery against any third party, including recoveries from: People who commit wrongful acts, injuries, or damages for which a civil action can be brought (tortfeasor) Underinsured/uninsured motorist coverage Employers and/or workers compensation insurers Other substitute coverage or any other right of recovery, whether based on tort or contract Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 96

103 This applies to you and any person claiming benefits through you or on your behalf (trustee, personal representative, executor, next of kin, heirs, etc.). Reimbursed first Portico will be reimbursed from any recovery before payment of any other existing claims, including any claim by you for general damages. The entire amount of any damages recovered (not only the part specifically allocated to medical and dental expenses) is considered reimbursement for eligible expenses. If you fail to remit to Portico any amount to which it is entitled, Portico may withhold the amount from future payments under this plan. Mandated insurance If you fail to obtain any type of state or federal mandated insurance coverage (Medicare, Medicaid, workers compensation, or no-fault insurance), Portico will be allowed to fully assert our subrogation rights. Lump-sum settlements If you voluntarily accept a lump-sum (or other) settlement without the consent of Portico and the settlement results in a waiver or abolishment of our subrogation rights against the third party, we will be relieved of any obligation to pay past, present, or future claims or expenses relating to the illness or injury. Appeals Procedure The health plan s administrators are responsible for making decisions about claims or requests for benefits according to the terms of the ELCA Health Benefits Plan. The initial determination of benefits is made by the benefit administrator. If you are dissatisfied with the administrator s initial decision, you may appeal as follows: To appeal a Medical and Mental Health benefit adverse determination Contact Blue Cross to request an external independent review with an organization contracted by Blue Cross to provide a binding, final determination. To appeal a Prescription Drug benefit adverse determination Contact Express Scripts to request an external independent review with an organization contracted by Express Scripts to provide a binding, final determination. To appeal a Dental benefit adverse determination You may appeal in writing to the president of Portico within 180 days of your receipt of any adverse determination. Include the facts of your case, any new or additional information not considered in the initial decision, and the outcome you desire. President The president will review your dental claim with the advice and counsel of the internal appeals committee, which will consist of at least three staff members who were not involved with the initial decision. The president will respond in writing within 30 days of receipt of your appeal and signed authorization for disclosure of protected health information (unless the president notifies you of the need for an additional 30 days). The president may approve an appeal only if it is determined that an error was made in the initial determination or the appeal involves matters relating to plan interpretation. In the case of changing technology or circumstances, the president may recommend an expansion of coverage requiring a plan amendment, which may or may not be retroactive. All plan amendments must be approved by the president, the board of trustees of Portico, and/or the ELCA Church Council in accordance with the provisions described on page 101. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 97

104 Appeals committee A dental benefit appeal may be filed with the appeals committee of Portico s board of trustees within 60 days of your receipt of the president s written response if you are dissatisfied with the decision of the president. The appeals committee will consist of five to seven members of the board of trustees, at least one of whom must be a participant in the ELCA Pension and Other Benefits Program. Additionally, the committee may include independent consultants with expertise in the area of the appeal, to serve with voice but not vote. The appeals committee will schedule a meeting within 30 days of receiving your appeal and signed authorization. The final decision of the appeals committee will be forwarded to you within 60 days of receipt of the appeal. All decisions of the appeals committee are final. Court system In the event you have exhausted the previously described appeals procedures and are dissatisfied with the final decision of the appeals committee of Portico, you may initiate legal action in the Minnesota Fourth Judicial District Court, Hennepin County. Any removal of such action must be to the United States Court for the District of Minnesota. Limitation of Liability Portico is not liable for the failure of any employer to enroll its rostered leader or lay employee as a sponsored member in the plan or for the failure of any employer to make contributions to the plan on the member s behalf. Also, Portico is not liable to any member or other person or entity for any of its acts carried out in good faith and based upon information available at the time. Obligations of a Sponsored Member As a sponsored member of the ELCA health plan, you agree to comply with all of Portico s requirements regarding enrollment and administration of the plan. This includes, but is not limited to, providing your: Date of birth Disability status Marital status Social Security number Family support obligations Medicare status If you fraudulently or inappropriately use, misuse, or overuse these plan services and/or supplies, Portico has the right to terminate your participation in the ELCA Pension and Other Benefits Program. In addition, you will not be eligible for coverage continuation under the ELCA health plan. Obligation of a Sponsoring Employer By sponsoring an eligible employee in the ELCA health plan, the sponsoring employer agrees to: Be bound by the terms of the ELCA health plan Provide the necessary information to Portico for the administration of the ELCA health plan Promptly notify Portico of any IRS audit or change in status that could cause the employer to cease to be eligible to participate in the plan Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 98

105 An employer may discontinue participating in the ELCA Pension and Other Benefits Program by notifying Portico and complying with any procedures established by Portico for discontinuing participation. Portico may discontinue the participation of an employer if Portico, in its sole discretion, determines the employer is no longer an eligible employer, as defined by the program, or if the employer has failed to comply with the provisions of the program. Correction of Errors It is recognized that in the operation and administration of the ELCA Health Benefits Plan, certain mathematical and accounting errors may be made or mistakes may arise for various reasons, including factual errors in information supplied to the benefit administrators, Portico, or the board of trustees. Portico has the power to make equitable adjustments to correct such errors as Portico, in its sole discretion, considers appropriate. Adjustments will be final and binding on all persons. Plan Information While every effort has been made to ensure that the information contained in this communication is correct, if there is any omission or misstatement, the applicable legal plan document will control. The eligibility for any benefit will be governed by the terms of the applicable plan, program, or policy. Portico (and its designee or the insurer or claims administrator, as applicable) shall have the power, including, without limitation, discretionary power to make all determinations that the plan requires for its administration, and to construe and interpret the plan for purposes of determining eligibility and benefits. The assets of each plan are held in various trusts and therefore do not allow one plan to fund a net shortfall of another plan. The ELCA health plan is self-insured and is not provided through an insurance company. Portico s ability to pay claims is dependent on continued contributions, claims experience and market performance. Portico reserves the right to amend, modify, or terminate any plan or benefit policies or programs, in whole or in part, at any time. Plan documents are available by contacting Portico. Our policies, programs, and plans are not subject to the Employee Retirement Income Security Act (ERISA). Self-Insured Plan The ELCA health plan is a self-insured plan. Although Portico has contracted with other companies to administer certain benefits of the plan, these companies do not insure any part of the plan. All benefits to which a person becomes entitled hereunder shall be provided only out of the ELCA Medical and Dental Benefits Trust and only to the extent that such trust is adequate therefore. Exception: Health benefits for ELCA Global Mission missionaries are insured and administered by Aetna International. QMCSO Notice Please call Portico for more information if you have a Qualified Medical Child Support Order (QMCSO) that needs to be processed. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 99

106 Amendment to the Plan The ELCA Churchwide Assembly, the ELCA Church Council, or Portico may propose amendments to the plan. All proposed amendments must be submitted to Portico for recommendation before final action is taken by the Church Council. The president of Portico will approve amendments involving no change in policy and little or no change in cost or benefits. Amendments approved by the president will be reported to the board of trustees of Portico. The ELCA Church Council will approve amendments involving a significant change in policy or a significant change in cost or benefits. The Church Council may, in its sole discretion, submit any proposed amendment to the Churchwide Assembly for final action. The board of trustees of Portico will approve all other amendments. Amendments approved by the board of trustees will be reported to the ELCA Church Council. No amendment will reduce entitlement under the ELCA health plan for expenses incurred prior to the effective date of the amendment. No Guarantee of Tax Consequences Portico makes no commitment or guarantee that any amounts paid to or for the benefit of a member under this plan will be excludable from the member s gross income for federal, state, or local income tax purposes. It is the member s responsibility to determine whether each payment is excludable from his or her gross income for income tax purposes. It is also the member s responsibility to notify Portico if he or she has any reason to believe a payment is not excludable for income tax purposes. Non-Assignability of Rights The member s rights to receive any reimbursement under this plan are not transferable by the member through assignment or any other method and are not subject to claims by the member s creditors by any process whatsoever. Any attempt to do so will not be recognized by Portico, except as required by law. Termination of the Plan The plan is designed, and contribution rates are established, to maintain long-term plan viability. However, the ELCA Church Council may terminate the ELCA health plan by following the previously described amendment procedure. If the plan is terminated, the existing funds will be used to pay benefits for expenses incurred prior to the effective date of the termination. Any surplus funds will be distributed back to the ELCA. If the funds are distributed, no future benefit payments will be made from the plan. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 100

107 Fiduciary Standards Prudent investor rule Managers and trustees administering or investing assets are bound by the prudent investor rule. This common-law concept has evolved through the years and is set forth in the American Law Institute s Restatement of the Law of Trusts, Third, section 227, which states in part that: The trustee is under a duty to the beneficiaries to invest and manage the funds of the trust as a prudent investor would, in light of the purposes, terms, distribution requirements, and other circumstances of the trust. (a) This standard requires the exercise of reasonable care, skill, and caution, and is to be applied to investments not in isolation but in the context of the trust portfolio and as a part of an overall investment strategy, which should incorporate risk and return objectives reasonably suitable to the trust. (b) In making and implementing investment decisions, the trustee has a duty to diversify the investments of the trust unless, under the circumstances, it is prudent not to do so. Many states, including Minnesota, have incorporated the prudent investor rule in their statutes. Portico, a nonprofit corporation incorporated in Minnesota, is governed by Minnesota Statute 501B.151 which sets the statutory requirements governing trust investments. Fiduciaries Fiduciaries (those responsible for the plan s assets) invest the plan contributions expressly with members interest in mind and in agreement with the following requirements: For the exclusive purpose of providing benefits to members, less reasonable expenses of administering the plan With the care, skill, prudence, and diligence under the current conditions that a prudent person with like character, similar aims, and knowledge of fiduciary matters would use By diversifying the investments of the plan to minimize the risk of large losses, unless, under the circumstances, it is clearly prudent not to do so In accordance with the provisions of the ELCA health plan Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 101

108 Glossary Active Work Requirement To be eligible to become insured or receive an increase in the amount of your life insurance, you must be actively at work, fully performing your customary duties. If you are not actively at work on the date coverage or an increase would otherwise be effective, the coverage or increase will not begin until you return to active work. However, if your absence is on a non-work day (scheduled time off for vacation, personal holiday, weekend and holiday, and non-medical approved leave of absence), coverage will not be delayed if you were actively at work on the work day immediately preceding the non-work day. Except as otherwise provided for under the life insurance policy, you are eligible to continue to be insured only while you remain actively at work. Non-work day does not include time off for medical leave of absence, temporary layoff, employer suspension of operations in total or in part, strike, and any time off due to sickness or injury including sick days, short-term disability or long-term disability. Aetna International Administrator for health benefits available to plan members and their eligible family members who reside outside the United States and are sponsored by ELCA Global Mission. Allowed Amount The amount determined by a benefit administrator to be the maximum allowable charge for the service provided by an out-of-network provider. This is the lesser of billed charge or a percentage of the innetwork contracted rate for the same or similar services. Eligible expenses are limited to this amount. Amounts that exceed the allowed amount are the member s responsibility and don t apply to the deductible or out-of-pocket limit. Blue Distinction Center Blue Distinction is a designation awarded by Blue Cross and Blue Shield to medical facilities that have demonstrated expertise in delivering quality health care. The designation is based on rigorous, evidencebased, objective selection criteria established in collaboration with expert doctor and medical organization recommendations. Its goal is to help consumers find quality specialty care on a consistent basis, while enabling and encouraging health care professionals to improve the overall quality and delivery of care nationwide. Brand-Name Drug A drug that has a trade name and is protected by a patent. It is known by this name rather than its chemical name. Brand-name drugs are usually sold for higher prices than their generic equivalents. Affidavit of Partnership The form the ELCA requires plan members with eligible same-gender partners to complete in order to enroll this person in the ELCA health plan. It attests that they are financially interdependent (share financial obligations), not married to or legally separated from anyone else, and live in a publicly accountable, lifelong, monogamous, same-gender relationship. Buy Up When plan members purchase a higher priced ELCA-Primary health benefit option than the one their sponsoring employer selected and pay the cost difference through payroll deduction. Coverage Continuation When plan members pay the cost to keep ELCA health coverage. In some cases, coverage is available for a limited period of time. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 102

109 Coverage Continuation Members Individuals who previously received ELCA benefits from a sponsoring employer but now purchase ELCA benefits at their own expense plan members who are retired, on leave from call, and separated from service, as well as their surviving spouses or ESGPs, former spouses, and other family members. Eligibility and length of coverage continuation rules apply. Copayment A fixed amount specified by the plan that plan members pay for certain eligible health care services, such as prescription drugs, usually when the services are received. Deductible A fixed amount specified by the plan that plan members pay for certain eligible health care services during the year before the health plan starts to pay. Defined Compensation Base salary plus any housing allowance, Social Security allowance, and furnishings and utilities allowance. For those living in employer-provided housing (such as a parsonage), defined compensation is also increased by 30% of salary and Social Security allowance. These amounts are calculated prior to any payroll deductions. Dental Benefit Administrator Delta Dental, the entity contracted with Portico to administer dental benefits. Responsibilities include: Credentials and contracts with dental providers to provide treatment and services to members who have dental coverage and to accept negotiated rates as payment in full Administers claims for eligible dental expenses Administers medical-necessity requirements and allowed amount limits for dental services Dependent (Day) Care Flexible Spending Account (FSA) A tax-advantaged account that allows sponsored plan members to set aside pretax dollars for eligible dependent care (such as day care) expenses that enable the member and spouse to work or seek work. Money not used by the end of the year is forfeited. ELCA Church Council The board of directors of this church that serves as the interim legislative authority between meetings of the Churchwide Assembly. Includes the Presiding Bishop, Vice President, Secretary, Treasurer, Chair of the Conference of Bishops, and 33 to 45 people elected by the Churchwide Assembly. ELCA Medicare-Primary Health Benefits Health benefits available to plan members and their eligible family members who are age 65 and over (unless sponsored by an organization with 20 or more employees); also includes those under age 65 and receiving Medicare due to a disability. Includes three health benefit options in 2014: Premium, Standard, and Economy. ELCA Philosophy of Benefits The ELCA s perspective on benefits intended to help organizations, rostered leaders, and other church employees make benefit decisions in alignment with ELCA values. The ELCA Philosophy of Benefits document was revised and approved by the ELCA Church Council in 2013, and is included starting on page 114. ELCA-Primary Health Benefits Health benefits available to plan members and their eligible family members who are under age 65 except those receiving primary Medicare coverage due to disability; also includes those age 65 and over who are sponsored by an organization with 20 or more employees. Includes four health benefit Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 103

110 options in 2014: Platinum+, Gold+, Silver+, and Bronze+. Eligible Dependent A person who is covered as a member of the ELCA Health Benefits Plan and meets the definition of an eligible spouse, eligible same-gender partner, or eligible child. Eligible Expense A service or supply that is considered for reimbursement under the plan, because it: Is incurred while you (or your family) are covered under the plan Is billed to you (or your dependent) Is ordered by an eligible plan provider Is medically necessary Is not specifically limited or excluded under the rules of this plan Meets the allowed amount guidelines used by one of the plan s benefit administrators Eligible Family Member A member s spouse, eligible same-gender partner, or eligible child who is enrolled in the ELCA Health Benefits Plan. Eligible Same-Gender Partner An eligible same-gender partner (ESGP) is an individual who, together with a member of the ELCA benefit program, completes and signs an Affidavit of Partnership attesting that they are financially interdependent (share financial obligations), not married to or legally separated from anyone else, and live in a publicly accountable, lifelong, monogamous, same-gender relationship. Employer Contributions Amounts that employers pay to sponsor their plan members in the ELCA benefits program, including health, health savings account (HSA), retirement, housing equity, disability, survivor, and retiree support contributions. Exchange A marketplace where individuals can buy health insurance. Created by the Patient Protection and Affordable Care Act of Each state will have one either operated by that state, the federal government, or a state-federal partnership. Experimental Drug, Device, Procedure, or Treatment Charges related to a drug, device, procedure, or treatment that is deemed experimental or investigational by the benefit administrator are considered ineligible expenses under the ELCA Health Benefits Plan. The benefit administrator determines a drug, device, procedure, or treatment is experimental or investigational if: Controlled clinical trials have not substantiated its safety and effectiveness Approval has not been granted by the FDA for marketing, if required A recognized national medical or dental society or regulatory agency has determined, in writing, that it is experimental, investigational, or for research purposes only The protocol(s) used by the treating facility states that it is experimental, investigational, or for research purposes If a member has a life-threatening illness or condition (which is likely to cause death within one year of the request for treatment), Blue Cross may determine that an experimental or investigative treatment meets the definition of a covered benefit for that illness or condition. Family Deductible Platinum+ and Gold+ options The individual deductible and individual out-of-pocket limit apply to each covered family member, unless the family deductible or out-of-pocket limit has been met. The family deductible is met when the eligible expenses of two or more family members reach the family maximum amount during the year. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 104

111 Silver+ and Bronze+ options The family deductible and out-of-pocket limits are met when the eligible expenses of one or more family members reach the maximum amount during the year. Formulary A list of both generic and preferred drugs maintained by a prescription drug benefit administrator. Formulary prescription drugs generally cost plan members less than nonformulary drugs. Generic Drug A drug known by its chemical name rather than by a brand name and not protected by patents. The FDA requires generics to have the same quality, strength, purity and stability as brand-name drugs. Generic drugs are usually sold for significantly lower prices than their name-brand equivalents. Health Flexible Spending Account (FSA) A tax-advantaged account that allows eligible plan members to set aside pretax dollars for eligible health care expenses. Money not used by the end of the year (and any grace period) is forfeited. Health Savings Account (HSA) A tax-advantaged account that allows plan members and sponsoring employers to set aside pretax dollars for eligible health care expenses. Money in an HSA earns interest, is not forfeited at year-end, and is the member s to keep even if he or she leaves the ELCA health plan. High Deductible Health Plan (HDHP) A health insurance plan that meets specific IRS rules for deductible and out-of-pocket expenses. Only plan members who are covered by an HDHP can contribute to a health savings account. The 2014 ELCA-Primary Silver+ and Bronze+ health benefit options qualify as HDHPs. Maintenance Medication Medication taken on an ongoing basis for a chronic condition. Marketplace Another word for exchange; see entry for Exchange. Medical and Mental Health Benefit Administrator Blue Cross and Blue Shield, the entity contracted with Portico to administer the Medical and Mental Health benefit. Responsibilities include: Credentials and contracts with in-network providers to provide treatment and services to members with ELCA-Primary health benefits and to accept contracted rates as payment in full Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or May provide financial incentives to innetwork providers to promote delivery of effective, cost-efficient care Administers claims for eligible in-network and eligible out-of-network medical and mental health expenses, subject to allowed amount limitations for expenses from outof-network providers Administers the precertification and medical necessity requirements for ELCA-Primary health benefits Administers programs to help members improve health and manage chronic conditions Medically Necessary Treatment A service or supply furnished by an eligible provider that is determined by the benefit administrator to be appropriate for the diagnosis, care, or treatment of the disease or injury. The fact that a provider prescribes, orders, recommends, or approves health services does not in itself make the services medically necessary. To be appropriate, the health care service or supply must be one that a provider, exercising prudent clinical judgment, would provide Page 105

112 to a patient for the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms. The service must be: In accordance with generally accepted standards of medical practice, standards that are based on creditable scientific evidence published in peer reviewed medical literature generally recognized by the relevant medical community, specialty society recommendations, and the views of providers practicing in relevant clinical areas and any other relevant factors Clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the patient s illness, injury, or disease Not primarily for the convenience of the patient, physician, or other health care provider Not more costly than an alternative service or sequence of services At least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient s illness, injury, or disease The following services or supplies are not considered to be medically necessary: Those that don t require the technical skills of a licensed provider of a service covered under this plan who is acting within the scope of his or her license Those furnished mainly for your personal comfort or convenience or that of your caregiver, family member, or health care provider or facility Those that are furnished solely because you are an inpatient, when the disease or injury could safely and adequately be diagnosed or treated while you are not hospitalized Those that could safely and adequately be provided in a less costly setting or manner Those that are inappropriately used, misused, or overused by a member Member A member is a sponsored or retired individual, or someone on coverage continuation, who is entitled to benefits from this plan. Also includes spouses, former or surviving spouses (or ESGPs), and children who are entitled to benefits from this plan. Member Buy-Up Cost Amount that plan members pay through payroll deduction to purchase a higher-priced ELCA- Primary health benefit option than the option their sponsoring employer selected during Open Enrollment. Member Contributions Amounts that plan members pay to fund their taxadvantaged account(s), including pretax retirement, health savings account (HSA), health flexible spending account (FSA), or dependent (day) care flexible spending account (FSA) contributions. Metallic Plans Refers to the platinum, gold, silver, and bronze categories of plans on the new health insurance exchanges ELCA-Primary health benefit options are called Platinum+, Gold+, Silver+, and Bronze+ because they are designed to compare to the metallic plans by providing all the basics required of exchange plans, plus (+) broad provider networks, dental benefits, a fitness center discount, health support programs, and wellness incentives. Multiple Employments When a plan member works for two or more employers that each sponsor them in the ELCA benefit program. Network The facilities, providers, and suppliers contracted by a health benefit administrator to provide health care services at contracted rates. The in-network deductible and out-of-pocket limit are separate from the out-of-network deductible and out-of-pocket limit. Plan members may seek care from the Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 106

113 provider of their choice. Costs may be lower at innetwork providers. Network Provider A provider that has contracted with a plan benefit administrator to accept contracted rates as payment in full for treatment or services (less copayments, deductible, and post-deductible costs) and to perform agreed-upon tasks (obtain prior authorization, submit claims, etc.) on your behalf. Non-Formulary Drugs Brand-name drugs that are not included on the formulary because they are new to the marketplace or there are therapeutically equivalent drugs that cost less. Open Enrollment When sponsoring employers and plan members make certain benefit decisions for the coming year. Also when eligible employees who did not enroll in a timely manner can enroll in the ELCA benefit program for the coming year without a 90-day waiting period for health benefits. Out-of-Network Provider An eligible plan provider or entity that has not contracted with the administrator but provides treatment or services that are eligible for reimbursement under this plan as eligible out-ofnetwork medical expenses, subject to a benefit administrator s allowed amount guidelines. The allowed amount can be significantly less than the amount billed by the out-of-network provider. Out-of-Pocket Limit The maximum annual amount that plan members pay for certain eligible health care services before the health plan starts to pay 100%. Patient Protection and Affordable Care Act Legislation that became law in March 2010; also known as health care reform. Personal Wellness Account A health reimbursement arrangement into which plan members can earn wellness dollars to pay for eligible health care expenses. Personal Wellness Account Administrator SelectAccount (affiliate of Blue Cross), the entity contracted with Portico to manage and administer the personal wellness account. As the administrator, SelectAccount processes and pays claims submitted to your personal wellness account. Prescription Drug Benefit Administrator Express Scripts, Inc., the entity contracted with Portico to manage and administer the ELCA Prescription Drug benefit. Responsibilities include: Contracts with participating network pharmacies to provide prescription drugs to members who have prescription drug coverage and to accept negotiated rates as payment in full Operates the prescription drug home delivery service Establishes and administers medicalnecessity criteria Administers claims for eligible prescription drug expenses Determines the list of eligible specialty drugs and operates the specialty drug pharmacy Administers Medicare prescription drug plans Prior Authorization A mandatory process (initiated by your doctor, you, or someone acting on your behalf) to request prior Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 107

114 approval from a benefit administrator for all inpatient and certain types of outpatient medical, facility-based mental health services, and some drugs. Qualifying Election Change Event An eligible life event allowing you to start, increase, or stop a health FSA election for the remainder of the plan year. The qualifying election change must result in you or your eligible dependent gaining or losing eligibility for ELCA health coverage or your spouse s health coverage. You may start, stop, or change a dependent care FSA election for the remainder of the plan year if you experience a qualifying election change event that changes your dependent (day) care costs or coverage. Any new election must be consistent with the event. Rate Class One component in determining a sponsoring employer s health contribution rate. Rate classes are geographic designations that represent regional differences in health care costs. Sponsoring employers are assigned a rate class according to the synod in which they are located. Separation from Service A member is considered separated from service when he or she is no longer serving in a participating congregation or organization due to resignation, discharge, retirement, death, or failure to return to active service at the end of an authorized leave of absence. NOTE: A pastor or rostered layperson on leave from call is not considered separated from service. Sponsored Members Individuals who are called or employed by an eligible organization and receive ELCA benefits provided by that organization. Includes pastors, rostered laypersons, and lay employees. Eligibility rules apply. Tax-Advantaged Account A financial account that allows the owner to receive special treatment by federal and most state tax laws for the purpose of tax savings. Contribution and withdrawal rules vary by the type of account. The ELCA benefit program offers the following taxadvantaged accounts: personal wellness account (health reimbursement arrangement), health flexible spending account (FSA), health savings account (HSA), and dependent (day) care flexible spending account (FSA). Waive When plan members who are eligible for ELCA health benefits meet qualifying criteria and choose not to participate in the health plan. To qualify to waive, members must have valid other group coverage or purchase coverage through a health insurance exchange for which they receive a premium tax credit (subsidy). Members who waive are eligible to restart ELCA health benefits without a waiting period. Wellness Dollars Financial incentives earned for completing wellness activities. Wellness dollars are credited to either personal wellness accounts or deposited in health savings accounts (HSA). Sponsored Couple When a plan member and spouse or ESGP are each employed by a sponsoring employer that provides ELCA benefits. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 108

115 Contact Information Portico Benefit Services myportico.porticobenefits.org Portico Service Center Contact or with questions about your eligibility or contribution rates or if you have a change of family status, address, or coverage or / F mail@porticobenefits.org Health Care Advocacy Team Contact the Portico health care advocacy team if you need help understanding your health care benefits or / F healthcare@porticobenefits.org Mailing address Portico Benefit Services 800 Marquette Ave., Ste Minneapolis, MN Blue Cross and Blue Shield Medical and Mental Health Benefit bluecrossmn.com/elca Register or sign in to check medical and mental health claims history, view your health savings account, personal wellness account and/or FSA, download spending account claim and direct deposit forms, and find network providers. Customer Service Call about medical and mental health claims, dedicated nurse support, fitness discount program, Healthy Start pregnancy program, Stop Smoking program, personal wellness account, health savings account, flexible spending accounts, SelectAccount debit card and identification cards. Call to request prior authorization. Phone Hours 7 a.m. 8 p.m. (Central), Monday Friday Privacy Contact Contact or for information about the plan s privacy practice, to exercise your rights, or to complain about how the plan is handling your protected health information. Portico Benefit Services Attn: Privacy Contact 800 Marquette Ave., Ste Minneapolis, MN or , ext privacycontact@porticobenefits.org Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 109

116 Delta Dental Dental Benefit deltadentalmn.org Use Find a Dentist to locate a participating provider: choose Delta Dental PPO or Delta Dental Premier providers. Customer Service Call about the benefit, claims, pretreatment estimates, getting additional identification cards, or to find a participating dentist. Phone Hours 7 a.m. 7 p.m. (Central), Monday Friday Claims address Delta Dental P.O. Box Minneapolis, MN Express Scripts, Inc. Prescription Drug Benefit express-scripts.com Create an online account and log in to find participating pharmacies in your area (select Pharmacy Locator), order home delivery service prescription refills, transfer a prescription to home delivery service, and find information about drugs and health conditions. Customer Service Call for benefits information, to find participating pharmacies, order home delivery service refills, and with questions about home delivery service. Phone / TTY Hours Accessible 24 hours a day, seven days a week Prior authorization (for doctors only) Your doctor can call Express Scripts to request authorization for certain drugs before the prescription can be filled (if the quantity exceeds the limit or if a drug is prescribed before the comparable, less expensive step-one drug has been tried). Accredo Specialty Pharmacy Customer service Contact Accredo (formerly CuraScript), an Express Scripts subsidiary for assistance with specialty drugs. Specialty drugs include injectable and oral drugs with specific storage and handling requirements. Phone Hours 7 a.m. 8 p.m. (Central), Monday Friday 8 a.m. noon (Central), Saturday Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 110

117 HearPO Hearing Discount Program (Through a partnership with Delta Dental of Minnesota) hearpo.com/deltadentalmn Customer Service Call HearPO to get discounts on hearing aids and other hearing services a.m. 7 p.m. (Central), Monday Friday Mayo Clinic Health Solutions Health Assessment, EmbodyHealth Web Portal, and Newsletter elcaforwellness.org Register on the EmbodyHealth web portal using an address and a password you choose. Enter the identification number from your Blue Cross identification card when requested. OptumHealth SM ELCA NurseLine SM Call with health questions or concerns 24 hours a day, seven days a week. Phone / TTY ; ask to be connected to Outside the United States: and press 2 to speak to a nurse Hours Accessible 24 hours a day, seven days a week ValueOptions Employee Assistance Program Call to talk to an EAP professional about stress, relationships, family issues, work issues, or any other personal concern. Eligible EAP services include telephone consultation, assessment, and in-person counseling. Phone Hours Accessible 24 hours a day, seven days a week Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 111

118 Cards For Your Wallet The ELCA Medical and Mental Health benefit is administered by Blue Cross and Blue Shield. Show this card to your medical or mental health care providers. Contact Blue Cross at if you need additional identification cards. The benefit charts for the Platinum+ and Gold+ options are found on page 54. Benefit charts for the Silver+ and Bronze+ options can be found on page 56. The ELCA Prescription Drug benefit is administered by Express Scripts, Inc. Show this card when you purchase prescriptions at your local pharmacy. Use the information on this card when you purchase prescription drugs through Express Scripts home delivery service. Contact Express Scripts at if you need additional Identification cards. The benefit charts for the Platinum+ and Gold+ options are found on page 72. Benefit charts for the Silver+ and Bronze+ options can be found on page 74. The ELCA Dental benefit is administered by Delta Dental. Show this card to your dental care provider. Contact Delta Dental at if you need additional identification cards. See information beginning on page 80 for details of this benefit. The SelectAccount debit card is a convenient way to pay for eligible health care expenses from a personal wellness account, health flexible spending account (FSA), or health savings account (HSA). See page 60 for details. Sign in to myportico (myportico.porticobenefits.org) for the most current information. See all summary plan descriptions in Overview & Life Changes, Program Overview, Tools on myportico. Contact the Portico Service Center at mail@porticobenefits.org or Page 112