2015 Benefits for YMCA of Greater Boston

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1 2015 Benefits for YMCA of Greater Boston January 2015

2 FINAL 2015 RATES BCBS Options HMO BCBS Options HMO Includes your 2.5% discount! Regular Employee Rates Healthy Employee Rates Individual $ $ 1, Individual + 1 $ $ Family $ $ 6, Individual $ $ 1, Individual + 1 $ $ 3, Family $ $ 6, BCBS Dental BCBS Dental Individual $ 7.26 $ Individual + 1 $ $ Family $ $ Individual $ 7.26 $ Individual + 1 $ $ Family $ $ Guardian Vision Plan Guardian Vision Plan Individual $ 3.49 $ Individual + 1 $ 5.30 $ Family 1 $ 9.31 $ Individual $ 3.49 $ Individual + 1 $ 5.30 $ Family $ 9.31 $

3 YMCA of Greater Boston Employee Effective January 1, 2015 the YMCA will continue to offer Medical, Dental and Life with Accidental Death & Dismemberment (AD&D) Benefits. Flexible and Dependent Care Spending Accounts and a Retirement Fund will also be offered to all eligible employees. You must submit your enrollment election forms by December 10, 2014 to Human Resources to guarantee coverage. If you choose not to enroll in any or all of the coverages, you must send a waiver to Human Resources. Please fax or scan all enrollment forms and waivers to (617) or cringquist@ymcaboston.org. Life with Accidental Death & Dismemberment (AD&D) Plan The YMCA offers employees an opportunity to participate in the Life with AD&D plan at no cost. Eligibility: Full Time Employees working a minimum of 37.5 regularly scheduled hours per week. Benefit Waiting Period: None Life: 2X Salary up to a max of $350,000 Basic AD&D: 2X Salary up to a max of $350,000 Long Term Disability The YMCA offers employees an opportunity to participate in the Long Term Disability plan at no cost. Eligibility: Full Time Employees working a minimum of 37.5 regularly scheduled hours per week. Benefit Waiting Period: None Benefit Amount: 60% of Basic Monthly Earnings not exceeding a maximum of $5,000. Definition of Disability: You will be considered disabled if during the 90 day elimination period and the next 24 months of disability you, as a result of injury or sickness, are unable to perform the duties of your job; and thereafter, you are unable to perform, within reason, the duties of any job. Flexible Spending Account (FSA) Flexible Spending Accounts A Flexible Spending Account is a benefit provided by the YMCA that allows you to set aside pre-tax dollars* at the beginning of your plan year to pay for eligible out-of-pocket Health, Dental and Vision expenses. Dependent Care Flexible Spending Account A Dependent Care Flexible Spending Account is a benefit provided by the YMCA that allows you to set aside pretax dollars* at the beginning of your plan year to pay for eligible out-of-pocket Dependent Care expenses. Some examples this benefit maybe used towards are Day Care expenses, Summer Camp and After School Care. * FSA and Dependent Care Contributions are deducted before federal and most state taxes. State taxes do apply in Massachusetts and may apply in other states. Check with your tax advisor. 403b Smart Account The YMCA is offering employees an opportunity to save for retirement. All eligible team members who are age 21 or older may enroll in the 403b Smart Account. The YMCA has a retirement plan for employees who have completed 2 years of employment with a minimum of 1,000 hours per year. Vesting is immediate at enrollment. For more information please contact Carol Ringquist at (617) or Erika Barrie at (617)

4 Your Medical Benefits Covered Services Plan-year Deductible Plan-year Out-of-Pocket Maximum Your Cost for Enhanced Benefits None Your Cost for Standard Benefits $500 per member $1,000 per family Your Cost for Basic Benefits $2,000 per member $4,000 per family $5,000 per member/$10,000 per family includes deductible, co insurance, and copayments that are more than $100 per visit (if any), excluding prescription drug copayments Preventive Care Services Well-child care exams, including routine tests and immunizations Routine adult physical exams, including routine tests and immunizations Routine GYN exams, including related lab tests (one per calendar year) Routine hearing exams, including routine tests Routine vision exam (one every 24 months) Family planning services office visits Other Outpatient Care Emergency room visits $150 per visit (waived if admitted or for observation stay) $150 per visit (waived if admitted or for observation stay) $150 per visit (waived if admitted or for observation stay) Office visits PCP, network nurse practitioner, or nurse midwife (billed by PCP) Network nurse practitioner or nurse midwife (not billed by PCP) Other network providers $15 per visit $15 per visit $50 per visit $25 per visit $15 per visit $50 per visit $50 per visit $15 per visit $50 per visit Mental health and substance abuse treatment $15 per visit $15 per visit $15 per visit Chiropractor services* $50 per visit $50 per visit $50 per visit Short-term rehabilitation therapy physical and occupational (up to 60 visits per calendar year**) Speech, hearing, and language disorder treatment speech therapy $50 per visit $50 per visit $50 per visit $50 per visit $50 per visit $50 per visit Allergy injections only Home health care and hospice services Oxygen and equipment for its administration Prosthetic devices Durable medical equipment such as wheelchairs, crutches, and hospital beds (up to $750 per calendar year***) Surgery and related anesthesia Office setting: PCP/Other network providers Surgical day care unit Ambulatory surgical facility Diagnostic X-rays, lab tests, and other tests, excluding CT scans, MRIs, PET scans, and nuclear cardiac imaging tests General hospitals Other covered providers CT scans, MRIs, PET scans, and nuclear cardiac imaging tests General hospitals Other covered providers All charges beyond the calendar-year benefit maximum $15 per visit/$50 per visit Nothing Nothing service service All charges beyond the calendar-year benefit maximum $25 per visit/$50 per visit after deductible $200 per admission at selected hospitals Nothing after deductible Nothing service after deductible service All charges beyond the calendar-year benefit maximum $50 per visit/$50 per visit $1,000 per admission after deductible Nothing after deductible Nothing $450 per category per date of service after deductible service * For a network chiropractor in Maine, you pay $25 per visit. ** No visit limit applies when short-term rehabilitation therapy is furnished as part of covered home health care and for the treatment of autism spectrum disorders. *** No dollar limit applies when durable medical equipment is furnished as part of covered home dialysis, home health care, or hospice services. To provide geographic access to members, the lower Standard Benefits Tier copayment applies for BHS Franklin Medical Center, Falmouth Hospital, Martha s Vineyard Hospital and Nantucket Cottage Hospital. The deductible does not apply to these admissions. 3 In Connecticut, when the copayments for CT scans, MRIs, PET scans, and/or nuclear cardiac imaging tests add up to the total of $375 per member in a calendar year, you pay nothing for these tests for the remainder of that calendar year.

5 Your Medical Benefits (continued) Covered Services Inpatient Care (including maternity care) General hospital care (as many days as medically necessary) Mental health and substance abuse facility care (as many days as medically necessary) Chronic disease hospital care (as many days as medically necessary) Rehabilitation hospital care (up to 60 days per calendar year) Skilled nursing facility care (up to 100 days per calendar year) Your Cost for Enhanced Benefits Your Cost for Standard Benefits after deductible $200 per admission at selected hospitals* Your Cost for Basic Benefits $1,000 per admission after deductible Prescription Drug Benefits At designated retail pharmacies (up to a 30-day formulary supply for each prescription or refill) (or $250 per family) planyear $15 for Tier 1 $30 for Tier 2 $50 for Tier 3 (or $250 per family) plan-year $15 for Tier 1 $30 for Tier 2 $50 for Tier 3 (or $250 per family) planyear $15 for Tier 1 $30 for Tier 2 $50 for Tier 3 Through the designated mail service pharmacy (up to a 90-day formulary supply for each prescription or refill) (or $250 per family) planyear $30 for Tier 1 $60 for Tier 2 $150 for Tier 3 (or $250 per family) plan-year $30 for Tier 1 $60 for Tier 2 $150 for Tier 3 (or $250 per family) planyear deductible, you pay $30 for Tier 1 $60 for Tier 2 $150 for Tier 3 * To provide geographic access to members, the lower Standard Benefits Tier copayment applies for BHS Franklin Medical Center, Falmouth Hospital, Martha s Vineyard Hospital and Nantucket Cottage Hospital. The deductible does not apply to these admissions. Healthy Blue Programs At Blue Cross Blue Shield of Massachusetts we offer you a group of programs, discounts and savings, resources, and tools to help you get the most you can from your health care plan. Call us at to receive information that outlines these special programs. A Fitness Benefit toward membership at a health club (see your subscriber certificate for details) Reimbursement for a Blue Cross Blue Shield of Massachusetts designated weight loss program Living Healthy Vision discounts on eyewear (frames, lenses, supplies, and laser vision correction surgery) Safe Beginnings discounts on home safety items Blue Care Line to answer your health care questions 24 hours a day call BLUE (2583) Living Healthy Naturally discounts on different types of complementary and alternative medicine services such as acupuncture, massage therapy, nutritional counseling, personal training, Pilates, tai chi, and yoga Visit for an around-the-clock healthy approach to fitness, family, and fun Questions? Call For questions about Blue Cross Blue Shield of Massachusetts, visit the website at Interested in receiving information from Blue Cross Blue Shield of Massachusetts via ? Go to to sign up. No additional charge $150 per year, per individual/family $150 per year, per individual/family Discount varies Discount varies No additional charge Up to a 30% discount No additional charge Limitations and Exclusions. These pages summarize the benefits of your health care plan. Your subscriber certificate and riders define the full terms and conditions in greater detail. Should any questions arise concerning benefits, the subscriber certificate and riders will govern. Some of the services not covered are: cosmetic surgery; custodial care; hearing aids; most dental care; and any services covered by workers compensation. For a complete list of limitations and exclusions, refer to your subscriber certificate and riders. Registered Marks of the Blue Cross and Blue Shield Association. SM Service Marks of the Blue Cross and Blue Shield Association. SM Service Marks of Blue Cross and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield HMO Blue, Inc Blue Cross and Blue Shield of Massachusetts, Inc B (11/10) 6C LC 4

6 Dental Blue Program 2 with Orthodontics 5

7 Medical Enrollment Form Dental Enrollment Form Basic Life and AD&D and Supplemental Life Enrollment Form / Beneficiary Form Flexible and/or Dependent Care Spending Account Enrollment Form: at open enrollment Waiver for any or all coverage Medical/Rx Blue Cross Blue Shield Of Massachusetts Member Services Confirm eligibility and benefits, order ID cards, obtain information on submitted claims, find a provider Dental Blue Cross Blue Shield Of Massachusetts Member Service Confirm eligibility and benefits, order ID cards, obtain information on submitted claims, find a provider Life with AD&D Liberty Mutual Carol Ringquist Inquires regarding life insurance coverage and claim questions Vision Guardian Vision Member Service Confirm eligibility and benefits, order ID cards, obtain information on submitted claims, find a provider YMCA Retirement Fund 403b Smart Account 800-RET-YMCA ( ) Inquiries regarding your retirement plan FSA / Dependent Care Benefit Resources Inquiries regarding your flexible spending accounts Willis CARE Center Benefits Consultant Willis North America james.margitich@willis.com Jim Margitich Option 2 You should call your insurance plan first if you have an issue or question. If you feel that your call was not handled properly, that you have been given incorrect information or if your issue was not resolved appropriately contact Jim Margitich. Human Resources YMCA of Greater Boston cringquist@ymcaboston.org ebarrie@ymcaboston.org Carol Ringquist or - Erika Barrie Confirm eligibility and pricing. This is only a brief summary of your benefits as of January 1, Please refer to the Summary Plan Description for detailed information on the Plan Benefits. You can request this from Human Resources. In case of discrepancy between this information and the actual documents, the actual documents will prevail. Participation in any benefit plan is not to be construed as a contract of employment. 4

8 Willis Human Capital Practice 2015