BENEFITS. your Woodmen of the World Group Benefits. A Guide for MEDICARE-ELIGIBLE Retirees and Dependents

Transcription

1 your BENEFITS A Guide for MEDICARE-ELIGIBLE Retirees and Dependents Woodmen of the World Benefits , ext Phone: Fax: Benefits_Mailbox@woodmen.org Form 8059 R-9/14 The Hartford / Mercer (Health Benefits) Group Number AGP 6003 For residents of KS, MD, MT, NY & OR Group Number AGP 6040 For residents of all other states MetLife (Voluntary Dental Benefits) Group Number metlife.com/mybenefits ScriptSave Benefit Group #394A

2 HR Benefits & Wellness Dear Woodmen of the World Retiree, This Benefits Guide is designed to provide you an overview of your benefits package, contact information for the insurance carriers and an introduction to your Benefits team. We want to provide you with the information needed to make informed decisions about your benefits, along with an ongoing point of reference. This book was designed to include the non-medicare-eligible retiree benefits on one side, and the Medicare-eligible retiree benefits on the other. Eligible retirees and/or their dependents who are not eligible for Medicare will have the choice of two health plans through BlueCross BlueShield of Nebraska. Each plan option includes a prescription drug benefit. Eligible retirees and/or their spouses who are eligible for Medicare will be offered a Medicare Supplement Plan through The Hartford. This plan will supplement claims for those enrolled in original Medicare A and B. Woodmen of the World will continue subsidizing a portion of the health coverage for retirees with 10 or more years of service. For families who may have a member who is not Medicare-eligible and a second who is Medicare-eligible, each will be enrolled in the appropriate plan and provided with their own individual identification cards. Sincerely, Woodmen of the World Benefits Team Karla Gochenour Vice President, Human Resources Missy Beber Director, Compensation & Benefits Christi Speck Manager, Benefits Peggy Dunston Consultant, Associate Well-being Sontia Green Sr. Benefits Consultant, Benefits Suzie Waller-Bannister Sr. Benefits Consultant, Benefits Kathy Tech Sr. Benefit Specialist, Benefits Woodmen of the World Benefits , ext Phone: Fax: benefits_mailbox@woodmen.org

3 Table of Contents Medicare-Eligible Retirees and Dependents 2015 Edition Eligibility and Enrollment 4 Medicare and Life Benefits 5 Your Rights as a Health Care Consumer 6 Retiree Health Plan Premiums 7 Health Plan and Drug Card Benefits 8 Health Plan Overview 9 Voluntary Dental Plan Benefits 11 Medicare Part D 12

4 Eligibility and Enrollment Benefit Eligibility Requirements To be eligible to take part in Woodmen of the World s retiree benefit plans, retirees must meet the following criteria: Age 55 or older with a minimum of 20 years of service, or Age 65 or older with a minimum of five years of service. In addition, the following requirement applies to Alpha Field Representatives: $30,000 in Actual Earnings from Oct. 1 through Sept. 30 of the year prior to retirement. To be eligible to continue Retiree Group Health coverage into retirement, you and your dependents, if applicable, must be enrolled in a Woodmen of the World Group Health Plan immediately prior to your retirement date. You will have the option to continue the current coverage through COBRA, or if eligible, continue the Woodmen of the World Retiree Group Health Plan. The election between these two options is only available at the time you retire. New Retirees Retiree benefits are effective on the first of the month following your retirement date, or equal to your retirement date if it is the first of the month. Please review the benefits and complete the enclosed form prior to your retirement date. A specific due date will be included in your retirement paperwork. Annual Enrollment Annual Enrollment takes place from Nov. 1 through Nov. 15, Coverage and the new premiums are effective Jan. 1, Your current plan election will automatically continue for If you would like to change plans or terminate your coverage, please complete the enclosed form by Nov. 15,

5 Medicare and Life Benefits Medicare Eligibility If you and/or your spouse become eligible for Medicare during the year, please provide a copy of your Medicare identification card to the Benefits Department. Upon receipt, you or your spouse will be enrolled in the Medicare-eligible plan in conjunction with the Medicare effective date. Attention: Those considering a Medicare Advantage Plan The Woodmen of the World Retiree Health Plan will not provide a benefit after your Medicare Advantage Plan. The Retiree Health Plan will only be allowed to supplement claims for those enrolled in original Medicare A & B. Group Life Insurance Benefits into Retirement The following applies to group life insurance in force at the time of retirement: Non-Contributory Life Insurance (applies to retirements after Feb. 1, 1986) Upon retirement, the death benefit will reduce to $10,000. The difference between the life benefit at retirement and $10,000 can be converted. Contributory Life Insurance You may elect to continue this benefit into retirement. The benefit will reduce 10%, starting at age 66 and will continue to reduce by a like amount until the benefit terminates at age 75. The death benefit will be payable to the beneficiary on record in the Benefits Department. Beneficiary change forms are available on wowalumni.org or by contacting the Benefits Department. 5

6 Your Rights as a Health Care Consumer Woodmen of the World s group plans support your rights as a health care consumer and comply with federal and state legislation regarding health care information and specific types of care. Benefit Summaries The Summary Plan Descriptions (SPDs) for the eligible Health and Welfare Plans are encompassed in one document, the Retiree Welfare Benefit Plan of Woodmen of the World SPD. The SPDs contain important information related to your benefits under the Plans, including a summary of the Plans provisions and details regarding administration of the Plans. The Affordable Care Act requires group health plans to provide a uniform Summary of Benefits and Coverage (SBC) to plan participants and beneficiaries. The SBC is a standard, plain language summary designed to help you better understand your health plan options. The SBC does not replace the SPD, but is a supplement to the SPD. The Benefit Summaries can be found on wowalumni.org under the Benefits tab, then click Summary Plan Description or by contacting the Benefits Department. These documents reflect the most current document and/or plan changes. Women s Health and Cancer Rights Act Woodmen of the World s plans comply with the Women s Health and Cancer Rights Act, whereby if a breast cancer patient elects breast reconstruction in connection with a mastectomy, coverage will be provided in a manner determined in consultation with the attending physician and patient. Children s Health Insurance Program Reauthorization Act of 2009 A state Children s Health Insurance Program (CHIP) generally provides health insurance for children whose families cannot afford private healthcare but do not qualify for Medicaid. The Children s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) expanded CHIP coverage by providing additional special enrollment rights related to group health plan coverage. CHIPRA also permits states to offer eligible low-income children and their families a premium assistance subsidy to help pay for employersponsored group health coverage. If you or your dependents are already enrolled in Medicaid or CHIP, you can contact your State Medicaid or CHIP office at KIDS NOW, or go to insurekidsnow.gov to find out how to apply. Your Privacy Rights Certain information, as outlined in the Health Insurance Portability and Accountability Act (HIPAA), cannot be used or disclosed without your specific authorization, under penalty of law. If you want information released to anyone, such as your spouse, you will need to complete an authorization form. Authorization forms are available from the Benefits Department. COBRA Rights COBRA rights provide limited extended coverage to individuals who lose medical, dental and vision coverage due to retirement. COBRA also provides benefits to surviving spouses, divorced or legally separated spouses or certain dependents who would otherwise lose coverage when ceasing to qualify as eligible. Generally, benefits can be continued up to 18 months and for certain qualifying events, up to 29 or 36 months, upon completing an application and submitting applicable payment within the specified time frame. Participants with a health care flexible spending account may also be eligible to extend participation on an after-tax basis. 6

7 Retiree Health Plan Premiums Premium contributions the amounts you and Woodmen of the World pay to cover the cost of your coverage are determined each year based on: Retiree s years of service with Woodmen of the World Covered individual s Medicare status Woodmen of the World also must take into consideration actual claims experience over the prior years, projected claims and administrative expenses for the upcoming year. Retirees with more years of service pay a smaller premium compared to retirees with fewer years of service. This is also true for the retiree s spouse. Please remember the total monthly retiree premium you pay is determined by adding the retiree, spouse, and child(ren) premium amounts together, which may include non-medicare premiums from the other side of the guide. Health Plan Monthly Premiums Retiree Years of Service Retiree (Medicare-Eligible) 30 years and over $40 20 to 29 years $99 15 to 19 years $ to 14 years $217 5 to 9 years $217 Retiree Years of Service Spouse (Medicare-Eligible) 30 years and over $99 20 to 29 years $ to 19 years $ to 14 years $217 5 to 9 years $217 Retirees and/or spouses who are eligible for Medicare Part B but choose not to carry it are responsible for the full premium amount under Woodmen of the World s Retiree Health Plan, unless proof of credible group coverage can be provided. This amount is $1,252 (HRA) and $1,027 (HSA) per person per month. Please contact the Benefits Department for additional information. 7

8 Health Plan and Drug Card Benefits Through a partnership with The Hartford and Mercer, a supplemental retiree health plan is available to eligible Woodmen of the World retirees and their spouses who are also eligible for Medicare. The plan is a Medicare Supplement Plan F, which pays 100% of the Medicare-approved charges on almost all medical services after Medicare pays. This plan will only supplement claims for those enrolled in original Medicare A and B. A schedule of all the benefits will be provided by Mercer. Eligible dependents include: Legally married spouse, according to federal law; Married or unmarried child(ren) up to age 26 including stepchild(ren), legally adopted grandchild(ren), and child(ren) under court-appointed guardianship; and Disabled child(ren). Mercer Claim Filing and Inquiries Mercer will work on your behalf to have your claims filed with the Woodmen of the World Retiree Health Plan automatically by Medicare. This means you and/or your provider will not need to file claims to Mercer. Knowledgeable customer service associates are available Monday through Friday from 7:30 a.m. to 5:00 p.m. (CST) to assist you if you have any questions regarding the processing of your claims. You can also check your claim information via their automated system at any time. To do so, follow the easy steps below: Call ; you will be greeted with an automated menu. After the initial greeting, select a claim status from the list of options. You will be asked to identify yourself by stating your certificate number (12-digit number on your identification card), your date of birth and your ZIP code. You will then be asked which claim you are calling about, which can be identified most easily by the date of service. Between the hours of 7:30 a.m. and 5:00 p.m. (CST) Monday through Friday, you can also speak to a customer service representative by saying representative. ScriptSave Benefit Woodmen of the World members are eligible for a prescription drug savings card. This customer discount, administered by ScriptSave, provides you with discounts at participating pharmacies. To request a card or to inquire about this benefit, call ScriptSave Cardholder Services at You can also enroll online by visiting scriptsave.com and referring to Group #394A. You cannot use the Woodmen of the World prescription drug savings card in conjunction with other prescription drug programs. If you reach your annual maximum benefit, ask your pharmacist which option will provide you with the greatest savings. (The ScriptSave discount is NOT creditable coverage.) 8

9 Health Plan Overview The charts on the following pages provide an overview of the benefits for illustrative purposes. While the charts are intended to show the Benefits effective Jan. 1, 2015, the Medicare amounts for 2015 have not been updated. Once the amounts have been released, a 2015 Schedule of Benefits will be mailed from Mercer. The coverage is the same for all Medicare-eligible retirees, although the description of the benefits may differ slightly due to the state in which you reside Services Medicare Pays Hartford Plan Pays You Pay HOSPITAL CONFINEMENT BENEFIT 1 Semi-private room and board, general nursing and miscellaneous services and supplies: First 60 days All but $1,216 $1,216 $0 61st through 90th day All but $304 per day $304 per day $0 91st through 150th day (60-day Lifetime Reserve Period) Once Lifetime Reserve days are used (or would have ended if used) additional 365 days of confinement per person per life-time All but $608 per day $608 per day $0 $0 100% $0 Beyond the Additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE Semi-private room and board, skilled nursing and rehabilitative services, and other services and supplies. You must meet Medicare s requirements, including having been in a hospital for at least three days and entered a Medicare-approved facility within 30 days after leaving the hospital: First 20 days All approved amounts $0 $0 21st through 100th day All but $152 per day Up to $152 per day $0 101st through 365th day $0 $0 All costs HOSPICE CARE Pain relief, symptom management and support services for terminally ill: As long as Physician certifies the need All costs, but limited to costs for outpatient drug and in-patient respite care Co-insurance charges for in-patient respite care, drugs and biologicals approved by Medicare All other charges BLOOD DEDUCTIBLE Hospital Confinement and Outpatient Medical Expenses when furnished by a hospital or skilled nursing facility during a covered stay: First three pints $0 100% $0 Additional amounts 100% $0 $0 OUTPATIENT MEDICAL EXPENSES In or Out of the Hospital and Outpatient Hospital Treatment, such as Physician s services, In-Patient and Outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment: Medicare Part B Deductible First $147 of Medicare-approved amounts $0 $147 $0 Remainder of Medicare-approved amounts Generally 80% 20% 0% Clinical Laboratory services, blood tests, urinalysis, and more 100% $0 $0 Part B Excess Charges cover the difference between the actual Medicare Part B charge as billed and the Medicare-approved Part B charge. Medicare amounts as of Jan. 1, $0 100% $0 9

10 Services Medicare Pays Hartford Plan Pays You Pay PREVENTIVE MEDICAL CARE & CANCER SCREENINGs(2) Coverage for expenses incurred by a covered person for physical exams, preventive screening tests and services, cancer screenings, and any other tests or preventive measures determined to be appropriate by the attending Physician. Refer to your Medicare and You handbook for more information on Preventive services. Welcome to Medicare Physical Exam -within first 12 months of Part B enrollment 100% $0 $0 Annual Wellness Visit 100% $0 $0 Vaccinations 100% $0 $0 Breast Cancer Screening Mammogram once per year Breast exam once every two years, or once per year if at high risk Colon Cancer Screening Fecal occult blood test once per year Colonoscopy once every 10 years, or every two years if high risk Barium enema once every four years, or once every two years if at high risk Cervical Cancer Screening Pap Smear and Pelvic exam once every two years, or once per year if high risk Prostate Cancer Screening PSA Test once per year Digital Rectal exam once per year Ovarian Cancer Surveillance Tests Once per year if at high risk 100% 100% for Fecal Occult Blood Test and Colonoscopy 80% after deductible Barium Enema $0 $0 $0 $0 100% $0 100% $0 $0 100% for PSA Test $0 $0 80% after deductible for Digital Rectal exam 100% $0 80% after deductible 100% $0 FOREIGN TRAVEL EMERGENCY Medically necessary emergency care services beginning during the first 60 days of each trip outside the United States: First $250 each Calendar Year $0 $0 $250 deductible Remainder of charges Medicare amounts as of Jan. 1, $0 80% of (to a lifetime maximum of $50,000) 20% of expenses incurred (to a lifetime maximum of $50,000, 100% thereafter) 1. A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. 2. If any of the cancer screening tests are not covered by Medicare, the plan will pay the usual and customary charges incurred. For residents of all eligible states, except Kansas, Maryland, Montana, New York, Oregon, Vermont, and Washington. The summary of program benefits described herein is for illustrative purposes only. In case of differences or errors, the Group Policy governs. 10

11 Voluntary Dental Plan Benefits Voluntary Retiree Dental Plan A full-service dental plan is available to the retirees of Woodmen of the World. Following your retirement date, you will have the option to continue your current dental coverage through COBRA or choose from two retiree dental plans: Option 1 Covers preventive and basic dental treatment (i.e.: cleanings, X-rays and fillings) Option 2 Covers some of the major, more expensive procedures (i.e.: crowns and dentures) in addition to preventive and basic services Both retiree dental plan options offer MetLife s negotiated fees for all in-network services, which can save you money on out-ofpocket costs. The negotiated fees even extend to non-covered services, which include services provided after the annual benefit maximum is exceeded. The plan design and rates will be mailed to your home. If you have questions, please contact MetLife at to speak to a Customer Service Representative. The retiree dental plans are only available at the time of your retirement. Retiree Dental Summary of Benefits Plan Features Option 1 Option 2 Coverage Type: Preventive Basic Restorative Major Restorative Deductible: 3 Retiree Retiree +1 Retiree + 2 or more In-Network 100% of PDP Fee 1 70% of PDP Fee 1 0% of PDP Fee 1 $75 $150 $225 Out-of-Network 100% 2 70% 2 0% 2 $75 $150 $225 In-Network 100% of PDP Fee 1 70% of PDP Fee 1 50% of PDP Fee 1 $75 $150 $225 Out-of-Network 100% 2 70% 2 50% 2 $75 $150 $225 Annual Maximum: Per Person $750 $750 $1,500 $1, PDP Fee refers to the fees that participating dentists have agreed to accept as payment in full. 2. Reasonable and customary charges are based on the research of a dentist s usual, actual and community average charge as determined by MetLife. 3. Applies only to Basic and Major Services. 11

12 Medicare Part D Retirees who are Medicare-eligible In 2006, Medicare prescription drug coverage became available to everyone with Medicare through Medicare prescription drug plans and Medicare Advantage Plans that offer prescription drug coverage. All Medicare prescription drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. Because Woodmen of the World does not provide prescription drug coverage as part of the health plan for retirees who are eligible for Medicare, you will want to consider enrolling in a Medicare prescription drug plan. Individuals can enroll in a Medicare prescription drug plan when they first become eligible for Medicare, and each year from Oct. 15 through Dec. 7. Beneficiaries leaving employer coverage may be eligible for a Special Enrollment Period to sign up for a Medicare prescription drug plan. If you do not enroll in a Medicare prescription drug plan when you are first eligible, or during a Special Enrollment Period, you may have to pay a higher premium (a penalty) if you join later. You will pay that higher premium as long as you have Medicare prescription drug coverage. More detailed information about Medicare plans that offer prescription drug coverage is in the Medicare & You handbook from Medicare. You ll receive a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare-approved prescription drug plans. For more information about Medicare prescription drug plans: Visit medicare.gov; Call your State Health Insurance Assistance Program (see your copy of the Medicare & You handbook for their telephone number) for personalized help; or Call MEDICARE ( ) (TTY ). For people with limited income and resources, extra help paying for Medicare prescription drug coverage is available. Information about this assistance is available from the Social Security Administration (SSA) online at socialsecurity.gov, or you can call (TTY ). 12

13 Flip this Guide Non-Medicare-Eligible Guide for Retirees and Dependents over for the Medicare-Eligible Flip this Guide This document contains proprietary information of Woodmen of the World Life Insurance Society and/ or Omaha Woodmen Life Insurance Society, and may not be reprinted, copied or reproduced in any manner, in whole or in part, without the express prior written consent of Woodmen of the World Life Insurance Society. This document is published solely for the educational and training purposes of our associates. It is not intended for distribution or use by the public. over for the Guide for Retirees and Dependents The information in this booklet is a partial description of benefits, limitations, exclusions, and other provisions of the group benefits provided by Woodmen of the World Life Insurance Society and/or Omaha Woodmen Life Insurance Society. If there is a difference between the information in this summary and the plan document for each plan, the plan documents govern. For more detailed information, refer to the Summary Plan Description of each plan. Woodmen of the World may amend these plans at any time. The description of the plan is not a guarantee of benefits and should not be construed as such.

14 your BENEFITS A Guide for NON-MEDICARE-ELIGIBLE Retirees and Dependents Woodmen of the World Benefits , ext Phone: Fax: Benefits_Mailbox@woodmen.org PayFlex healthhub.com BlueCross BlueShield of Nebraska Group Number nebraskablue.com MetLife (Voluntary Dental Benefits) Group Number metlife.com/mybenefits Prescription Drug Mail Order Program Prime Therapeutics nebraskablue.com Specialty Drug Benefit Prime Specialty Pharmacy

15 HR Benefits & Wellness Dear Woodmen of the World Retiree, This Benefits Guide is designed to provide you an overview of your benefits package, contact information for the insurance carriers and an introduction to your Benefits team. We want to provide you with the information needed to make informed decisions about your benefits, along with an ongoing point of reference. This book was designed to include the non-medicare-eligible retiree benefits on one side, and the Medicare-eligible retiree benefits on the other. Eligible retirees and/or their dependents who are not eligible for Medicare will have the choice of two health plans through BlueCross BlueShield of Nebraska. Each plan option includes a prescription drug benefit. Eligible retirees and/or their spouses who are eligible for Medicare will be offered a Medicare Supplement Plan through The Hartford. This plan will supplement claims for those enrolled in original Medicare A and B. Woodmen of the World will continue subsidizing a portion of the health coverage for retirees with 10 or more years of service. For families who may have a member who is not Medicare-eligible and a second who is Medicare-eligible, each will be enrolled in the appropriate plan and provided with their own individual identification cards. Sincerely, Woodmen of the World Benefits Team Karla Gochenour Vice President, Human Resources Missy Beber Director, Compensation & Benefits Christi Speck Manager, Benefits Peggy Dunston Consultant, Associate Well-being Sontia Green Sr. Benefits Consultant, Benefits Suzie Waller-Bannister Sr. Benefits Consultant, Benefits Kathy Tech Sr. Benefit Specialist, Benefits Woodmen of the World Benefits , ext Phone: Fax: benefits_mailbox@woodmen.org

16 Table of Contents Non-Medicare-Eligible Retirees and Dependents 2015 Edition Eligibility and Enrollment 4 Your Rights as a Health Care Consumer 5 Health Plan Benefits 6 Retiree Health Plan Premiums 8 Voluntary Dental Plan Benefits 9 3

17 Eligibility and Enrollment Benefit Eligibility Requirements To be eligible to take part in Woodmen of the World s retiree benefit plans, retirees must meet the following criteria: 1. Age 55 or older with a minimum of 20 years of service, or 2. Age 65 or older with a minimum of five years of service. In addition, the following requirement applies to Alpha Field Representatives: $30,000 in Actual Earnings from Oct. 1 through Sept. 30 of the year prior to retirement. To be eligible to continue Retiree Group Health coverage into retirement, you and your dependents, if applicable, must be enrolled in a Woodmen of the World Group Health Plan immediately prior to your retirement date. You will have the option to continue the current coverage through COBRA or, if eligible, continue the Woodmen of the World Retiree Group Health Plan. The election between these two options is only available at the time you retire. New Retirees Retiree benefits are effective on the first of the month following your retirement date, or equal to your retirement date if it is the first of the month. Please review the benefits and complete the enclosed form prior to your retirement date. A specific due date will be included in your retirement paperwork. Annual Enrollment Annual Enrollment takes place from Nov. 1 through Nov. 15, Coverage and the new premiums are effective Jan. 1, Your current plan election will automatically continue for If you would like to change plans or terminate your coverage, please complete the enclosed form by Nov. 15, Group Life Insurance Benefits into Retirement The following applies to group life insurance in force at the time of retirement: Non-Contributory Life Insurance (applies to retirements after Feb. 1, 1986) Upon retirement, the death benefit will reduce to $10,000. The difference between the life benefit at retirement and $10,000 can be converted. Contributory Life Insurance You may elect to continue this benefit into retirement. The benefit will reduce 10%, starting at age 66 and will continue to reduce by a like amount until the benefit terminates at age 75. The death benefit will be payable to the beneficiary on record in the Benefits Department. Beneficiary change forms are available on wowalumni.org or by contacting the Benefits Department. 4

18 Your Rights as a Health Care Consumer Woodmen of the World s group plans support your rights as a health care consumer, and comply with federal and state legislation regarding health care information and specific types of care. Benefit Summaries The Summary Plan Descriptions (SPDs) for the eligible Health and Welfare Plans are encompassed in one document, the Retiree Welfare Benefit Plan of Woodmen of the World SPD. The SPDs contain important information related to your benefits under the Plans, including a summary of the Plans provisions and details regarding administration of the Plans. The Affordable Care Act requires group health plans to provide a uniform Summary of Benefits and Coverage (SBC) to plan participants and beneficiaries. The SBC is a standard, plain language summary designed to help you better understand your health plan options. The SBC does not replace the SPD, but is a supplement to the SPD. The Benefit Summaries can be found on wowalumni.org/benefits/summary Plan Description or by contacting the Benefits Department. These documents reflect the most current document and/or plan changes Women s Health and Cancer Rights Act Woodmen of the World s plans comply with the Women s Health and Cancer Rights Act, whereby if a breast cancer patient elects breast reconstruction in connection with a mastectomy, coverage will be provided in a manner determined in consultation with the attending physician and patient. Children s Health Insurance Program Reauthorization Act of 2009 A state Children s Health Insurance Program (CHIP) generally provides health insurance for children whose families cannot afford private healthcare but do not qualify for Medicaid. The Children s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) expanded CHIP coverage by providing additional special enrollment rights related to group health plan coverage. CHIPRA also permits states to offer eligible low-income children and their families a premium assistance subsidy to help pay for employer-sponsored group health coverage. If you or your dependents are already enrolled in Medicaid or CHIP, you can contact your State Medicaid or CHIP office at KIDS NOW, or go to insurekidsnow.gov to find out how to apply. Your Privacy Rights Certain information, as outlined in the Health Insurance Portability and Accountability Act (HIPAA), cannot be used or disclosed without your specific authorization, under penalty of law. If you want information released to anyone, such as your spouse, you will need to complete an authorization form. Authorization forms are available from the Benefits Department. COBRA Rights COBRA rights provide limited extended coverage to individuals who lose medical, dental and vision coverage due to retirement. COBRA also provides benefits to surviving spouses, divorced or legally separated spouses or certain dependents who would otherwise lose coverage when ceasing to qualify as eligible. Generally, benefits can be continued up to 18 months and for certain qualifying events, up to 29 or 36 months, upon completing an application and submitting applicable payment within the specified time frame. Participants with a health care flexible spending account may also be eligible to extend participation on an after-tax basis. 5

19 Health Plan Benefits Choose the Coverage Option Right for You Woodmen of the World s health care coverage gives you the flexibility to choose the best plan option for you and your eligible dependents. Each plan has an in-network or out-of-network level of participation. If you retire prior to Dec. 31, and were enrolled in the Select HRA Plan while active, you will remain enrolled in the Select HRA Plan until the end of the calendar year you retire or when you become Medicare eligible. Eligible dependents include: Legally married spouse, according to federal law; Married or unmarried child(ren) up to age 26 including stepchild(ren), legally adopted grandchild(ren), and child(ren) under court-appointed guardianship; and Disabled child(ren). ID Cards The BlueCross BlueShield ID card will list your name only. Your dependents names, if applicable, will not be included on the card. Additional or replacement cards can be requested online or by contacting BlueCross BlueShield. To request online, go to nebraskablue.com, select login to myblue, select My Benefits, then click on Mail New ID Card. Specialty Drug Benefit Patients using a medication on the Specialty Drug List must purchase the medication through Prime Specialty Pharmacy to receive plan benefits. A maximum of a 30-day supply may be purchased at one time. All specialty drugs are subject to Specialty Drug benefits, regardless of their formulary status. To access a list of the specialty drugs, go to the BlueCross BlueShield website at nebraskablue.com. Coordination of Benefits If you or a family member is covered under a Woodmen of the World Health Plan, as well as under other coverage (a spouse s plan, for example), it may be necessary for the multiple plans to coordinate benefits. In most situations, the Woodmen of the World plan will pay first, as primary, on medical claims for the Woodmen of the World associate. Coordination of Benefits does not apply to prescription drug claims. 6

20 BlueCross BlueShield Select HSA Select HRA Benefit Summary In-Network Out-of-Network In-Network Out-of-Network Deductible/Coinsurance Aggregate Aggregate Retiree $1,500 $3,000 $2,000 $4,000 Retiree Plus* $3,000 $6,000 $4,000 $8,000 Coinsurance 25% 40% 30% 50% Out-of-Pocket Maximum (includes Deductible, Coinsurance and Copays) Retiree $3,000 $6,000 $4,000 $8,000 Retiree Plus* $6,000 $12,000 $8,000 $16,000 Office Visit Primary Care Deductible/Coinsurance Deductible/Coinsurance $25 Copay Deductible/Coinsurance Specialist Deductible/Coinsurance Deductible/Coinsurance Deductible/Coinsurance Deductible/Coinsurance Other Office Visit Services Deductible/Coinsurance Deductible/Coinsurance Included in Copay Deductible/Coinsurance Preventive Care 100% Deductible/Coinsurance 100% Deductible/Coinsurance Urgent and Emergency Care Physician Deductible/Coinsurance Deductible/Coinsurance $50 Copay Deductible/Coinsurance Other Urgent Care Services Deductible/Coinsurance Deductible/Coinsurance Included in Copay Deductible/Coinsurance Emergency Care Deductible/Coinsurance Same as In-Network Prescription Drug Retail 30-day supply $150 Copay plus Deductible/Coinsurance Same as In-Network Generic Deductible/Coinsurance In-Network + 25% $10 Copay In-Network + 25% Formulary Deductible/Coinsurance In-Network + 25% 30%, $25 min to $75 max In-Network + 25% Non-Formulary Deductible/Coinsurance In-Network + 25% 30%, $45 min to $150 max In-Network + 25% Specialty Deductible/Coinsurance Not covered 30%, $50 min to $100 max Not covered Prescription Drug Mail-Order 90-day supply Generic Deductible/Coinsurance Not covered $20 Copay Not covered Formulary Deductible/Coinsurance Not covered 20%, $50 min to $150 max Not covered Non-Formulary Deductible/Coinsurance Not covered 20%, $90 min to $300 max Not covered *Retiree Plus means Retiree + Child(ren), Retiree + Spouse or Retiree + Family. 7

21 Retiree Health Plan Premiums Premium contributions the amounts you and Woodmen of the World pay to cover the cost of your coverage are determined each year based on: Retiree s years of service with Woodmen of the World Covered individual s Medicare status Woodmen of the World also must take into consideration actual claims experience over the prior years, projected claims and administrative expenses for the upcoming year. Retirees with more years of service pay a smaller premium compared to retirees with fewer years of service. This is also true for the retiree s spouse. Please remember the total monthly retiree premium you pay is determined by adding the retiree, spouse and child(ren) premium amounts together, which may include Medicare premiums from the other side of the guide. Select HRA or Select HSA Plan* Monthly Premiums Retiree Years of Service Retiree (Non-Medicare-Eligible) 30 years and over $ to 29 years $463 Retiree Years of Service Spouse (Non-Medicare-Eligible) 30 years and over $ to 29 years $694 5 to 19 years $925 Retiree Years of Service Child(ren) 5 years and over $173 *All Non-Medicare-Eligible family members must be enrolled in the same plan. 8

22 Voluntary Dental Plan Benefits Voluntary Retiree Dental Plan A full-service dental plan is available to the retirees of Woodmen of the World. Following your retirement date, you will have the option to continue your current dental coverage through COBRA or choose from two retiree dental plans: Option 1 Covers preventive and basic dental treatment (i.e. cleanings, X-rays and fillings) Option 2 Covers some of the major, more expensive procedures (i.e. crowns and dentures) in addition to preventive and basic services Both retiree dental plan options offer MetLife s negotiated fees for all in-network services, which can save you money on out-ofpocket costs. The negotiated fees even extend to non-covered services, which include services provided after the annual benefit maximum is exceeded. The plan design and rates will be mailed to your home. If you have questions, please contact MetLife at to speak to a Customer Service Representative. The retiree dental plans are only available at the time of your retirement. MetLife Benefits Summary Option 1 Option 2 Coverage Type: Preventive Basic Restorative Major Restorative In-Network 100% of PDP Fee 1 70% of PDP Fee 1 0% of PDP Fee 1 Out-of-Network 100% 2 70% 2 0% 2 In-Network 100% of PDP Fee 1 70% of PDP Fee 1 50% of PDP Fee 1 Out-of-Network 100% 2 70% 2 50% 2 Deductible: 3 Retiree Retiree +1 Retiree + 2 or more $75 $150 $225 $75 $150 $225 $75 $150 $225 $75 $150 $225 Annual Maximum: Per Person $750 $750 $1,500 $1, PDP Fee refers to the fees that participating dentists have agreed to accept as payment in full. 2. Reasonable and customary charges are based on the research of a dentist s usual, actual and community average charge as determined by MetLife. 3. Applies only to Basic and Major Services. 9

23 Notes

24 Notes