Benefit Enrollment Guide

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1 Benefit Enrollment Guide January 1, 2016 to December 31, 2016 Provided by: 3401 Quebec Street Suite 8000 Denver, CO PH # FAX #

2 EMPLOYEE RESOURCES Rocky Vista University LLC and Rocky Vista Health Center LLC is committed to offering our employees opportunities for both personal and professional growth. We are dedicated to building a strong organization and providing for the immediate tangible needs of our employees. To aid in this process, we are proud to present a range of benefit options. We want to ensure that our employees understand the benefits offered to them and their families, and we work hard to provide the necessary resources to allow employees to maximize their coverage and options. We recognize that benefits can be confusing and encourage employees to ask questions about anything that may be unclear. To help you answer these questions, Rocky Vista University LLC and Rocky Vista Health Center LLC has teamed up with AmCheck to provide the best information and resources possible. AmCheck Denver is the Employee Benefits Broker for Rocky Vista University LLC and Rocky Vista Health Center LLC. They have dedicated staff members that are available to answer questions you or your family may have in regards to your insurance coverage. Please reach out to the Employee Benefits Staff at AmCheck with any questions about your benefit coverage: Charlotte Coaton - Licensed Benefits Broker: Contact for coverage questions, claims issues, advisory assistance, and escalated issues with your policy. All personal health information will be kept confidential and is protected under HIPAA Law. Extension 202 Charlotte.Coaton@amcheck.com Ann Westphal - Licensed Insurance Professional: Contact for coverage questions, claims issues, advisory assistance, and escalated issues with your policy. All personal health information will be kept confidential and is protected under HIPAA Law. Extension 212 Ann.Westphal@amcheck.com Toni Waltman - Can help with adding or removing dependents, updating personal information i.e. address changes with the carrier(s), and assisting with ordering new cards and printing temporary cards. Benefits.Denver@amcheck.com 2

3 GENERAL INFORMATION Eligibility Waiting Period Eligible Dependents Waiving Coverage Changing Coverage All full-time employees who work a minimum of 30 hours per week. Employees are eligible for medical, HSA, dental, vision, life, buy up life, buy up AD&D, short term disability, long term disability and FSA/Dependent Care accounts on the first of the month following date of hire. Your spouse, common law spouse, civil union partner, and/or your dependent child(ren) to age 26. A mentally or physically disabled child may continue coverage beyond age 26 if he/she is currently a dependent. If you are waiving medical coverage for yourself and/or your dependents, please complete the waiver portion on the Online Enrollment Center. Once you make your benefit selections, you can ONLY make changes to your selections during the annual open enrollment period or if there is a Qualifying Event. Examples of qualifying events are: Birth or adoption of a child Marriage, civil union, divorce or legal separation Death of a spouse or child Change in your spouse s employment Moving out of the HMO s service area All Qualifying Events will require supporting documentation and you have 30 days to submit your application, add or change after the qualifying event date. Due to the retro termination laws in Colorado, all terminations must be submitted in the month that coverage is to end. Enrolling as a New Hire You must have the appropriate forms completed within thirty (30) days of when you are eligible for coverage or the qualifying event. If you do not enroll within the 30 days you will have to wait until open enrollment. Annual Open Enrollment: Medical, Dental, Vision, FSA and Dependent Care: November 17 th December 8 th (changes effective January 1 st ) 3

4 MEDICAL Rocky Vista University LLC and Rocky Vista Health Center LLC provides comprehensive medical coverage to employees through Cigna Healthcare. You have an option between a copay driven plan and an HSAqualified plan. You can begin to participate in the plan of your choice on the first of the month following your date of hire. Rocky Vista University LLC and Rocky Vista Health Center LLC contributes 80% towards employee and dependents medical premiums. Employee is responsible for any remaining premiums. You may change between the different medical plans at Open Enrollment only. All changes take effect January 1 st of the new plan year. Please note that you cannot change your coverage level without a Qualifying Event during the plan year. Please refer to the General Information section for a list of Qualifying Events. Please refer to page 11 for instructions on finding In Network providers. MEDICAL RATE TABLE Cigna Healthcare Monthly Medical Premiums Plan E $500 Dependent Status Employee Cost Employer Cost Monthly Total Employee Only $ $ $ Employee and Spouse $ $1, $1, Employee and Child(ren) $ $1, $1, Employee and Family $ $1, $2, Cigna Healthcare Monthly Medical Premiums Plan G $2000 HDHP Dependent Status Employee Cost Employer Cost Monthly Total Employee Only $ $ $ Employee and Spouse $ $1, $1, Employee and Child(ren) $ $1, $1, Employee and Family $ $1, $2,

5 MEDICAL SUMMARY Covered Services: Cigna Plan E $500 Cigna Plan G $2000 HDHP DEDUCTIBLE Individual: $500 $2,000 Family: $1,500 $4,000 OUT-OF-POCKET MAX Individual: $3,500 $2,000 Family: $9,000 $4,000 HOW COINSURANCE WORKS Coinsurance is the percentage you pay after your deductible has been met. PHYSICIAN SERVICES Office Visits: $20 PCP / $40 Specialist 0% after deductible Preventive Care: 100% Covered (deductible waived) 100% Covered ( Deductible Waived) Diagnostic Lab/X-Ray: $0 Copay 0% after deductible Imaging (CT/PET scans, MRIs): $150 Copay per type of scan per day and 20% after deductible 0% after deductible Chiropractic Care: $40 Copay (20 visits) 0% after deductible (20 visits) PRESCRIPTION DRUGS Rx: $15 / $40 / $80 / 20% In Network Only 0% after deductible HOSPITAL FACILITY SERVICES Inpatient Hospital Services: 20% after deductible 0% after deductible Outpatient Surgery: 20% after deductible 0% after deductible EMERGENCY SERVICES Emergency Room: $150 Copay (waived if admitted) 0% after deductible Emergency Transport/Ambulance: 20% after deductible 0% after deductible Urgent Care: $75 Copay (waived if admitted) 0% after deductible MENTAL HEALTH Outpatient Services: $40 Copay 0% after deductible Inpatient Services: 20% after deductible 0% after deductible NOTES HSA Qualified Plan No Yes Out of Network Coverage: Yes (not for Rx) Yes Copays and Rx apply to OOP Max/Stop once OOP Max is hit? Yes Yes 5

6 HSA SAVINGS ACCOUNT Rocky Vista University LLC and Rocky Vista Health Center LLC offers the following HSA qualified health plans: Cigna Plan G $2000 HDHP Who Can Open an HSA? Any adult can contribute to an HSA if they: HSA Qualified Expenses: Are enrolled in an HSA qualified high deductible health plan (HDHP) Have no other first dollar coverage Are not enrolled in Medicare Medical Deductibles Cannot be claimed as a dependent on someone else s tax return If you participate in the High Deductible Health Plan (HDHP) / HSA medical option, you can set aside money in a Health Savings Account, pre-tax, to pay for qualified medical, dental, and vision expenses. An HSA qualifies you to pay for health care expenses with pre-tax dollars. You may refer to IRS Publication 502 for details on qualified medical expenses which is included in your electronic Benefit Enrollment Packet. You can make contributions to your HSA through payroll deductions. To set this up please refer to HSA Direct Deposit Form in your Enrollment Packet. This amount can be changed at any time. Individual: 2016 HSA Contribution Limits Family: $3,350 $6,750 Catch-Up: Anyone age 55 or older can contribute an additional $1,000 *Please note that you are responsible for keeping all records of your HSA expenses. You may choose your bank of choice with which to set up your HSA account. The bank account you set up must be an HSA account, which is separate from your checking or savings account.. Prescription Drug Costs Dental Costs Orthodontia Contact Lenses LASIK Eye Surgery COBRA Premiums * If you participate in both the FSA and HSA, the FSA will become limited purpose. For an in-depth explanation please see page 9. 6

7 DENTAL Rocky Vista University LLC and Rocky Vista Health Center LLC offers employees and their families dental coverage through Cigna Healthcare. This dental plan gives you a broad choice of providers and includes coverage with both In Network and Out of Network providers. There is a Cigna Low plan and a Cigna High plan. The deductible for both plans is $50 per individual and up to $150 for a family and the calendar year maximum is $1000 or $5,000 depending on the plan chosen. Rocky Vista University LLC and Rocky Vista Health Center LLC contributes 80% towards employee and dependents dental premiums. Employee is responsible for any remaining premiums. Please refer to page 11 for instructions on finding In Network providers. Cigna Healthcare Dental Plan Benefits In Network Services Low Plan High Plan Covers Out of Network Yes Yes Preventative 100% 100% Basic 80% 100% Major 50% 50% Deductible $50 Per Individual, Up to $150 per Family Orthodontia Not Covered 50% to age 19 ($1500 Lifetime Max) Annual Max $1,000 per person $5,000 per person *** Refer to your Summary Plan Description guide for plan limitations & exclusions Cigna Healthcare Monthly Premium Low Plan Dependent Status Employee Cost Employer Cost Monthly Total Employee Only $5.33 $21.31 $26.64 Employee and Spouse $10.26 $41.02 $51.28 Employee and Child(ren) $10.64 $42.58 $53.22 Employee and Family $16.56 $66.22 $82.78 Cigna Healthcare Monthly Premium High Plan Dependent Status Employee Cost Employer Cost Monthly Total Employee Only $11.13 $44.51 $55.64 Employee and Spouse $21.80 $87.22 $ Employee and Child(ren) $23.75 $95.00 $ Employee and Family $36.77 $ $

8 VISION Rocky Vista University LLC and Rocky Vista Health Center LLC offers employees vision coverage through EyeMed Vision Care. With this coverage, you are eligible for an eye exam every 12 months, lenses or contacts every 12 months and frames every 24 months. Rocky Vista University LLC and Rocky Vista Health Center LLC contributes 80% towards employee and dependents vision premiums. Employee is responsible for any remaining premiums. Please refer to page 11 for instructions on finding In Network providers. EyeMed Vision Plan Summary Services In Network Out of Network Eye Exam $10 copay Up to $30 *Lenses $10 copay Up to $25 / $40 / $55 Frames *Contact Lenses: -Medically Necessary -Conventional -Disposable Frequencies** Lenses Frames Contacts $100 Allowance & 20% off balance over $100 $0 copay $115 Allowance & 15% off balance over $115 $115 Allowance Once per 12 months Once per 24 months Once per 12 months *Must choose either lenses OR contacts per 12 months ** Frequencies are defined by the last date of service, not by calendar or plan year *** Refer to your Summary Plan Description guide for plan limitations & exclusions Up to $50 Covered Up to $200 Covered Up to $92 Covered up to $92 EyeMed Vision Monthly Premium Dependent Status Employee Cost Employer Cost Monthly Total Employee Only $1.44 $5.75 $7.19 Employee and Spouse $2.73 $10.93 $13.66 Employee and Child(ren) $2.87 $11.50 $14.37 Employee and Family $4.23 $16.90 $

9 EMPLOYEE PREMIUM CONTRIBUTIONS (POP PLAN) Rocky Vista University LLC and Rocky Vista Health Center LLC offers employees a Premium Only Plan (POP) through eflexgroup. This allows employees the opportunity to save money by paying your share of the monthly health benefit premiums (medical, dental and vision) on a pretax basis. Please note that if you are enrolled for benefits on a pretax basis, the IRS states that you may not add, drop or change your elections during the plan year unless you experience a qualifying change in status. These qualifying changes include but are not limited to: marriage, divorce, birth, death, change in employment status or gain or loss of other coverage. At retirement, your Social Security benefits may be slightly lower because you did not pay taxes on the amount of your premiums. You are automatically enrolled in the POP plan. You may waive this benefit at the time of your initial enrollment or at the POP annual open enrollment. FLEXIBLE SPENDING ACCOUNTS Rocky Vista University LLC and Rocky Vista Health Center LLC offers employees the opportunity to participate in a Medical Flexible Spending Account and Dependent Care Account. You contribute to these accounts through pre-tax payroll deductions. The maximum annual contribution is $2,500 for the Medical Flexible Spending Account and $5,000 for the Dependent Care Account. There is no minimum annual contribution. Below are examples of how your FSA dollars can be used. If you do not elect to enroll in one of the medical plans, Rocky Vista University LLC and Rocky Vista Health Center LLC will match your FSA contribution dollar for dollar up to $2,000. Flexible Spending Account An FSA allows you to pay for out-of-pocket medical, dental and vision expenses with pre-tax dollars. Dental and Orthodontia expenses Medical expenses copays and ded. 9 Prescription Drug expenses Vision expenses Dependent Care Account The Dependent Care FSA allows you to use pre-tax dollars towards qualified dependent care such as caring for children under the age of 13 or caring for your dependent elders. The annual maximum amount you may contribute to the Dependent Care FSA is $5,000 if married filing jointly, or $2,500 if married and filing separately. Examples of qualified Dependent Care FSA are included below. The cost of outside child or adult dependent care at a center The cost for an individual to provide care, either in or out of your home Nursery schools, preschools and day care centers (excludes Kindergarten) Limited Purpose FSA If you contribute towards both an HSA account and an FSA account your FSA will become limited purpose. This means that you can only use your FSA for dental and vision expenses. You may contribute the full amount towards dependent care regardless if you participate in an HSA account.

10 LIFE & BUY UP LIFE Rocky Vista University LLC and Rocky Vista Health Center LLC provides all employees who are eligible for health insurance, 1 times salary up to $300,000 of Life & AD&D coverage through Cigna Healthcare. This coverage is 100% Employer paid and automatically setup at initial enrollment. You may change your beneficiary at any time. Life insurance decreases with age starting at the age of 65. Rocky Vista University LLC and Rocky Vista Health Center LLC contributes 100% towards your life premiums. Rocky Vista University LLC and Rocky Vista Health Center LLC also offers employees the ability to buy up life coverage and AD&D coverage through Cigna Healthcare on a voluntary basis. You can buy coverage for yourself, your spouse and children. Life insurance decreases with age starting at the age of 65. Employee is 100% responsible for Buy up Life and AD&D Premiums. **Employees can only enroll in Life coverage during their New Hire Open Enrollment. There is no Annual Open Enrollment for this coverage. If you would like to enroll in Life coverage after your New Hire Open Enrollment you must complete the Evidence of Insurability form and you will be underwritten. Please see the Buy Up Life Summary on your Online Enrollment system for offerings and rates. *** Refer to your Summary Plan Description guide for plan limitations & exclusions SHORT TERM AND LONG TERM DISABILITY Rocky Vista University LLC and Rocky Vista Health Center LLC offers employees Short Term (STD) and Long Term Disability (LTD) coverage through Cigna Healthcare. This is a gross up plan which means you will pay taxes on the premium amount. This way, if you have a claim, the disability benefits will be tax free. Both STD and LTD covers you if you have an accident or sickness that prevents you from being able to work. The STD covers 60% of your weekly salary up to $1,500, and LTD covers 60% of your monthly salary up to $8,000. Rocky Vista University LLC and Rocky Vista Health Center LLC contributes 100% of your disability premiums. Cigna Healthcare Company Short Term Disability Long Term Disability (LTD) Benefit Amount 60% of weekly salary Benefit Amount 60% of monthly salary Maximum Weekly Benefit $1,500 Maximum Monthly Benefit $8,000 Elimination Period 15 days Elimination Period 90 days Maximum Benefit Period 11 Weeks Maximum Benefit Period SSNRA Own Occupation Duration Not applicable Own Occupation Duration 2 years *** Refer to your Summary Plan Description guide for plan limitations & exclusions 10

11 AFLAC Rocky Vista University LLC and Rocky Vista Health Center LLC offers access to AFLAC s voluntary specialty products. Some of the programs offered by AFLAC are Cancer, Accident, and Hospital Plans. Contact your AFLAC representative for products and rates. CONTACT INFORMATION Company Benefit Group Number Customer Service Cigna Healthcare Health/Dental/Life/Vol Life/STD/LTD EyeMed Vision Eflexgroup HSA/FSA/POP n/a AFLAC Specialty XQ AmCheck Client #D226 & D FINDING IN-NETWORK PROVIDERS Cigna Healthcare 1. Best is to log into your mycigna account for participating physicians. Or 2. Go to 3. Select Find a doctor, dentist or hospital,pharmacy or facility or go to the popular searches section. 4. Enter in the appropriate search criteria EyeMed (Vision) 1. Go to 2. Under Locate a Provider select the Access network and enter your zip code 11

12 FREQUENTLY ASKED QUESTIONS & ANSWERS What do I need to do in order to complete initial enrollment (Step by Step)? All employees MUST waive or enroll in coverage by logging on to Enrollease.com. A. Your employer will provide a login guide for your initial login (either printed or as an ). B. Please check with your Manager for deadlines to make your selections. What changes can be made during Open Enrollment? Make changes in medical, dental, vision and FSA plans. Enroll or terminate individual and/or dependent coverage in the medical, dental, vision and/or buyup life plans. For those making changes during the plan year, where do I find these forms? Contact Human Resources or AmCheck for all forms. When are the forms due and where do I return them? All forms are due prior to your effective dates and must be returned to Human Resources. You may be responsible for any catching-up of missed deductions. When do rates change? Rates change every year at the plan renewals. They can also change if you add or remove dependents. Who do I contact with Questions? Contact Human Resources or AmCheck with any additional questions you may have. Please note that the information in this Benefits summary is presented for illustrative purposes and is based on information provided by the employer. The text contained in this Summary was taken from various summary plan descriptions and benefit information. While every effort was taken to accurately report your benefits, discrepancies or errors are always possible. In case of discrepancy between the Benefits Summary and the actual plan documents, the actual plan documents will prevail. All information is confidential, pursuant to the Health Insurance Portability and Accountability Act of If you have any questions about this summary, contact Human Resources. 12

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