Medical and Dental HMO Summary Plan Description (SPD) Effective January 1, 2014

Transcription

1 Human Energy. Yours. TM Medical and Dental HMO (SPD) Effective January 1, 2014 Effective January 1, 2014 COBRA/Continuation Coverage Page 1

2 This document provides information about the Medical and Dental HMO Plans for you and your eligible dependents. If you choose a medical or dental health maintenance organization (HMO or DHMO) as your Chevron medical or dental coverage, you should review this document for information on plan eligibility and participation. For information about all other aspects of your coverage, you should review the evidence of coverage (EOC) (sometimes called a certificate of coverage) provided by your HMO or DHMO. If you choose HMO coverage, the insurer for the plan is the HMO or DHMO you elect. This information constitutes the summary plan description (SPD) of the Medical and Dental HMO Plans as required by the Employee Retirement Income Security Act of 1974 (ERISA). These descriptions don t cover every provision of the plan. Many complex concepts have been simplified or omitted to present more understandable plan descriptions. If these plan descriptions are incomplete, or if there s any inconsistency between the information provided here and the official plan texts, the provisions of the official plan texts will prevail. reserves the right to change or terminate a plan at any time and for any reason. A change also can be made to premiums and future eligibility for coverage and can apply to those who retired in the past, as well as to those who retire in the future. Once approved, plan changes are incorporated into the plan texts, SPDs and vendor administration at the effective date. Non-U.S.-payroll expatriates working in the United States should refer to the Health Benefits for Expatriates in the U.S. summary plan description available at hr2.chevron.com for information about the medical and dental benefits that apply to you. To find general benefit summaries and information about other plans that Chevron offers, visit the U.S. Benefits website at hr2.chevron.com. Effective January 1, 2014 COBRA/Continuation Coverage Page 1

3 Table of Contents Key Benefit Contacts... 3 Description of the Plan... 4 Overview... 5 Types of Health Maintenance Organizations (HMOs)... 6 Eligibility... 7 Participation How Much You Pay for Coverage HMO/DHMO Claim Disputes and Appeals How to File Claim for Eligibility How HMO Participation Affects Other Benefits Wellness Programs Other Plan Information...28 Administrative Information Your ERISA Rights Other Legislation That Can Affect Your Benefits Third Party Responsibility Continuation Coverage and COBRA Coverage...44 Introduction Who s Eligible for Continuation Coverage Qualifying Events How to Enroll How Much Continuation Coverage Costs When Continuation Coverage Starts When Continuation Coverage Ends Continuation Coverage vs. Retiree and Survivor Coverage Additional Rights and Rules How to Contact ADP for More Information Glossary...60 Company Contributions to Medical Coverage... SUPPLEMENT Effective January 1, 2014 Medical and Dental HMO Page 2

4 Key Benefit Contacts Human Resources (HR) Service Center If you have questions regarding your plan options, eligibility and enrollment, please call the HR Service Center at ( outside the U.S.) (inside the U.S.) (outside the U.S.) U.S. Benefits HR2 Website on the Internet You can access the HR2 website on the Internet, from home or at work. You can access summary plan descriptions, other benefit information and links to other key benefit websites, such as Benefits Connection. hr2.chevron.com U.S. HR Website on the Chevron Intranet You can access the U.S. HR website only from the Chevron intranet. You can access HR information in addition to information about your benefits, such as summary plan descriptions and links to other key benefit websites, such as Benefits Connection and Vanguard. hr.chevron.com/northamerica/us/ ADP Benefit Services COBRA and Continuation Coverage (Inside the U.S.) Select option 2, then * (Outside the U.S.) Select option 2, then * Medical and Dental HMO Plans If you choose medical or dental HMO coverage, the insurer administrator for the plan is the HMO you elect. For questions about your coverage, you should contact the plan directly. You can reach your HMO or DHMO at the website addresses and telephone numbers shown on your member ID card. Or get your plan s information by calling the HR Service Center (see above). Or get your plan s information on the U.S. Benefits HR2 Website on the Internet (see above). Effective January 1, 2014 Medical and Dental HMO Page 3

5 Human Energy. Yours. TM Update to the Effective January 1, 2017 All changes described in this SMM are effective January 1, 2017 unless otherwise indicated. This enclosed newsletter serves as an official summary of material modification (SMM) for the plans referenced herein. Please keep this information with your other plan documents for future reference. This communication provides only certain highlights about changes of benefit provisions. It is not intended to be a complete explanation. If there are any discrepancies between this communication and the legal plan documents, the legal plan documents will prevail to the extent permitted by law. There are no vested rights with respect to Chevron health care plans or any company contributions towards the cost of such health care plans. Rather, reserves all rights, for any reason and at any time, to amend, change or terminate these plans or to change or eliminate the company contribution toward the cost of such plans. Such amendments, changes, terminations or eliminations may be applicable without regard to whether someone previously terminated employment with Chevron or previously was subject to a grandfathering provision. Some benefit plans and policies described in this document may be subject to collective bargaining and, therefore, may not apply to unionrepresented employees. You can access the summary plan descriptions for your benefits on the Internet at hr2.chevron.com or by calling the HR Service Center at ( if you re outside the U.S.), option 2. This SMM applies to the following summary plan description: January 1, 2014 Medical HMO section of the Medical Dental HMO Summary Plan Description (both the individual SPD posted online and the Your Chevron Health Benefits for U.S.-Payroll Employees compilation available in print.) January 1, 2017 Official Summary of Material Modification (SMM)

6 medical HMO plans Chevron offers several health maintenance organization (HMO) medical plan options that include medical coverage, prescription drug coverage and basic vision coverage. With a Medical HMO Plan, you must visit a provider in the HMO s network, otherwise your services aren t covered (except for certain emergency situations). HMOs are not available in all areas and the plan choices vary based on your zip code. The Benefits Connection enrollment website will indicate if an HMO is available in your area, and the website will display the monthly cost for each plan available to you. Typically, you need a referral to a specialist under the Medical HMO Plans. new monthly premium cost Chevron will currently continue to share the monthly cost of coverage the premium with you. Typically the monthly premium amounts for Medical HMO Plans are only available starting with the open enrollment preview period, but we re making this information available early to support your decisionmaking process this year. Please go to hr2.chevron.com and click on 2017 Benefit Changes to review a listing of the 2017 monthly premiums for the Medical HMO Plans. deductibles now included under most medical HMO plans If you re in a Medical HMO Plan, you re required to use the plan s network. Out-of-network services are not covered (except for certain emergency situations). That will not change. But in 2017, most HMOs will introduce a new annual deductible. The average annual deductible for most Medical HMO Plans is $300. However, some Medical HMO Plans may have a different deductible, and a few will continue to have no deductible at all. You ll need to contact the HMO directly starting in January to understand what s included in your deductible. There will continue to be no deductible for mental health and substance abuse services received under the Chevron Mental Health and Substance Abuse Plan from a network provider. Go to hr2.chevron.com and click on 2017 Benefit Changes to review the Summary of Benefits and Coverages for the 2017 deductible amount for each Medical HMO Plan. other medical HMO plan changes The Benefits Connection website will list the Medical HMO Plans available to you next year (if any). Your provider or other plan features, like monthly premiums, copayments or prescription drug coverage could change. See your Medical HMO Plan s Summary of Benefits and Coverage (SBC) for more information about your Medical HMO Plan s features or contact the HMO directly. Even if your current Medical HMO Plan will be available in 2017, that doesn t guarantee that it is still available to you. Each year, the HMOs review the ZIP codes and counties in which they have providers. An HMO may choose to discontinue coverage to residents of certain areas. Your HMO provider may have changed. Remember that HMOs require you to use doctors, pharmacies and hospitals that are part of their provider network. Contact your HMO directly to find out if your current provider continues to be in the network. If not, you will need to change providers or choose a new medical plan option to ensure that your medical services continue to be covered. Copayment and other changes in your current HMO coverage may apply because of state filings, compliance with the Health Care Reform law provisions, or to align them more closely with Chevron s standard benefit design. You ll be able to view more information about Medical HMO Plan changes, if any, in the 2017 Evidence of Coverage document available for each Medical HMO Plan. Contact the HMO directly to request a copy. Important reminder about your mental health and substance abuse coverage If you are enrolled in a Chevron Medical HMO Plan, you have the choice to use the mental health and substance abuse benefits provided by your Medical HMO Plan, or to use the benefits provided under the MHSA Plan administered by Beacon Health Options. However, you cannot make a claim to both your Medical HMO Plan and the MHSA Plan for the same service. If you are enrolled in a Chevron Medical HMO Plan and you choose to use your MHSA Plan benefit, remember you must use a Beacon network provider to receive benefits. Out-of-network provider services are covered for emergencies only. U.S. Pay and Benefit News 20

7 tobacco surcharge Chevron has established a tobacco surcharge for medical and supplemental life insurance coverage. This means there are different monthly premium rates for Medical HMO Plan coverage for tobacco and non-tobacco users. See Page 47 for tobacco surcharge information. second opinion for certain surgeries Medical HMO Plan participants do not need to seek a second opinion through the Health Decision Support Program prior to receiving knee, hip, back or spine surgery. That s because many Medical HMO Plans already have programs and procedures in place to address the positive benefits of seeking a second opinion. However, Medical HMO Plan participants are still encouraged and eligible to use the services of the Health Decision Support program to seek a second opinion on any diagnosis they may be facing. See Page 30 for more information. Participate in healthy habits in 2017 and save up to $750 annually on your Medical HMO Plan premium in 2018 In 2017, when you participate in qualifying healthy activities, you ll earn points. Earn enough points by the 2017 deadline and you can qualify to save up to $750 annually on your Chevron medical coverage premium in 2018, including the Medical HMO Plan premium. More details about the new health rewards opportunity will be released later this year and in early January 2017, when the new program starts. Learn more Go to hr2.chevron.com and click on 2017 Benefit Changes to access additional resources that make it easier to understand health plan features. September

8 tobacco surcharge effective january 1, 2017 Chevron has established a tobacco surcharge for Chevron medical and supplemental life insurance coverage. This means there are different monthly rates for this coverage for tobacco and nontobacco users. The tobacco surcharge information here applies to all active U.S.-payroll employees (and those on a leave of absence). There are no changes to the tobacco surcharge for However, important reminders about the tobacco surcharge are included here for your reference. Go to hr2.chevron.com for additional details about the tobacco surcharge. September

9 update your tobacco use status for 2017 Open enrollment is your only opportunity to update your tobacco use status for Open enrollment October 17 through October 28, 2016 is your only opportunity to change your tobacco use status for If you miss this deadline, you cannot change your 2017 tobacco use status until the next open enrollment period. And you cannot change your 2017 tobacco use status during the year, even if you experience a qualifying life event like getting married or having a baby. do I need to do anything during open enrollment? If your 2016 certification status is Tobacco User, But Commit to Coaching, you may need to take action during open enrollment to update your 2017 tobacco use status. If you do not make a new tobacco use certification during open enrollment, your 2017 tobacco use status will be automatically assigned as Tobacco User and the tobacco surcharge will apply to you for all of If you make a new 2017 tobacco use certification during open enrollment, your certification choice will determine whether or not the tobacco surcharge applies to you for all of If your 2016 certification status is either Not a Tobacco User, Tobacco User or Decline to Disclose, your 2016 status will continue automatically in 2017 unless you make a change to your status during open enrollment. You do not need to do anything if this designation still accurately describes your tobacco use status surcharge amounts There is no change to the tobacco surcharge amounts effective January 1, 2017 so they continue to be as follows: $25 more each month for medical coverage, if enrolled. 20 percent more each month for Chevron Supplemental Life Insurance Plan coverage, if enrolled. how to update your tobacco use status You can update your tobacco use status October 17 through October 28, 2016, by calling the HR Service Center or by going online to Benefits Connection, the same website you use to make open enrollment elections. Open enrollment instructions will be sent to you in October or you can go to hr2.chevron.com to learn more. certification choices Your 2017 tobacco certification choices and requirements are as follows: Not a Tobacco User. You will not be subject to the surcharge in Tobacco User. If you re a tobacco user and don t intend to stop using tobacco, the surcharge will apply to you in Tobacco User, But Commit to Coaching. If you commit to complete at least three Tobacco Cessation Specialty Coaching sessions through WebMD between July 1, 2016 and December 31, 2017, the surcharge will not apply to you in Tobacco Cessation Specialty Coaching combines one on one telephone coaching, nicotine replacement therapy and integrated online resources to help participants try to stop using tobacco products. Contact WebMD at (or from outside the U.S.) to enroll. You can use this service again, even if your past attempts to quit have been unsuccessful. Go to hr2.chevron.com/wellness to learn more about this and other Tobacco Free Program resources. Decline to Disclose. If you decline to disclose your tobacco use, you will be defaulted to Tobacco User and the surcharge will apply to you in What s considered tobacco use? Indicate your tobacco use status only; you don t have to certify the tobacco use status of your spouse or domestic partner and other dependents for The definition of tobacco use has not changed for Any use, regardless of frequency or location, is considered use. This includes daily, occasional or social use. It also includes if it s used only at your home. Tobacco use means you ve used any of the following at any point since July 1, 2016: Tobacco (cigarette, pipe, cigar). Smokeless tobacco (such as snuff or chewing tobacco). The Federal Drug Administration now regulates e-cigarettes as tobacco, but they will not be included in the definition of tobacco use for purposes of the 2017 tobacco surcharge. Chevron does, however, intend to change the definition in 2018 to include e-cigarette use as tobacco use. U.S. Pay and Benefit News 48

10 Human Energy. Yours. TM Update to the Effective January 1, 2017 All changes described in this SMM are effective January 1, 2017 unless otherwise indicated. This enclosed newsletter serves as an official summary of material modification (SMM) for the plans referenced herein. Please keep this information with your other plan documents for future reference. This communication provides only certain highlights about changes of benefit provisions. It is not intended to be a complete explanation. If there are any discrepancies between this communication and the legal plan documents, the legal plan documents will prevail to the extent permitted by law. There are no vested rights with respect to Chevron health care plans or any company contributions towards the cost of such health care plans. Rather, reserves all rights, for any reason and at any time, to amend, change or terminate these plans or to change or eliminate the company contribution toward the cost of such plans. Such amendments, changes, terminations or eliminations may be applicable without regard to whether someone previously terminated employment with Chevron or previously was subject to a grandfathering provision. Some benefit plans and policies described in this document may be subject to collective bargaining and, therefore, may not apply to unionrepresented employees. You can access the summary plan descriptions for your benefits on the Internet at hr2.chevron.com or by calling the HR Service Center at ( if you re outside the U.S.), option 2. This SMM applies to the following summary plan description: January 1, 2014 Dental HMO section of the Medical Dental HMO Summary Plan Description (both the individual SPD posted online and the Your Chevron Health Benefits for U.S.-Payroll Employees compilation available in print.) January 1, 2017 Official Summary of Material Modification (SMM)

11 dental HMO plans Chevron offers health maintenance organization (HMO) dental plan options. With an HMO, you must visit a provider in the HMO s network, otherwise your services aren t covered (except for certain emergency situations). HMOs are not available in all areas and the plan choices vary based on your zip code. The Benefits Connection enrollment website will indicate if a Dental HMO Plan is available in your area. Chevron has selected a new claims administrator for our dental HMO plans. Effective January 1, 2017: Chevron Dental HMO Plan - United Concordia (UCCI). UCCI is replaced by DeltaCare USA (DeltaCare). Chevron Dental HMO Plan Cigna Dental. Cigna is replaced by DeltaCare USA (DeltaCare). UCCI and Cigna will continue to be the claims administrator for their respective Dental HMO Plan for the remainder of 2016 (see Orthodontic treatment in progress section for exceptions). This section will describe what you need to know about your Dental HMO Plan because of the move to Delta, including what you ll need to know during the transition and how to access your benefits starting in January. do I need to enroll? If you are not currently enrolled in a Chevron dental plan and want coverage in 2017, you need to make an enrollment election during the upcoming open enrollment period, October 17 through October 28, If you are currently enrolled in either of the Chevron Dental HMO plans, your coverage will automatically continue on January 1, 2017, as long as it s still available in your zip code. You do not have to make an enrollment election during open enrollment, unless you want to make a change to your coverage. If you are currently enrolled in the Chevron Dental PPO Plan and you want to change your coverage to the Dental HMO Plan if available in your area you ll need to make an election during open enrollment. eligibility rules Who is covered, and who you can cover the eligibility rules for active employees are the same for the Dental HMO Plan. In addition, you can continue to add and drop eligible dependents during open enrollment or within 31-days of a qualifying life event while you re an active employee. monthly employee premium The monthly employee premium for the Dental HMO Plan effective January 1, 2017 is as follows: new provider network With an HMO you must visit a provider in the HMO s network, otherwise your services aren t covered (except for certain emergency situations). If your provider is not in the network, you will need to change providers or choose a new dental plan option to ensure that your dental services continue to be covered. With a new claims administrator comes a new provider network. Primary care dentist You must visit your selected DeltaCare USA primary care dentist to receive benefits under your Dental HMO Plan. Most services not performed by your primary care dentist must be authorized by DeltaCare. You must select a DeltaCare USA network dentist in order to access benefits under the Dental HMO Plan. If you are enrolled in the Dental HMO Plan, you will be auto assigned to a primary care dentist, when applicable, by DeltaCare. Prior to January 1, you will receive a confirmation in the mail containing your primary care dentist name, your Enrollee ID, and ID card and a description of your benefits from DeltaCare. This package will also provide instructions about how you can change the primary care dentist auto assigned to you. Be sure you take action right away if you want to change to another DeltaCare USA network primary care dentist. Chevron Dental HMO Plan 2017 Monthly Employee Premium $5.50 You only $11.10 You + One adult $9.40 You + Child(ren) $15.00 You + Family U.S. Pay and Benefit News 44

12 get your dental preventive care in 2017, save money on your 2018 dental HMO plan premium We know dental exams like many other preventive care exams are not exactly fun. But there s a reason they are covered by your plan: they are important to good health. The Dental HMO Plan already covers at least two preventive dental cleanings per year, one per six month period; that will continue in Covered preventive dental services are 100 percent paid by your plan, with no annual maximum, deductible or copayment when you use a network provider. If you are enrolled in the Chevron Dental HMO Plan, you re encouraged to take steps to protect your health and receive at least one preventive dental cleaning* between January 1 and December 31, If you do not participate in this preventive care measure in 2017, you will pay $120 more for your annual dental plan premium in It s still your choice to receive a cleaning or not, but if you choose to participate, you ll save money in 2018 and you ll be doing something good for your health. * For participants with dentures, receive at least one oral exam in lieu of a cleaning. Do I need to find a new dentist? With an HMO you must visit a provider in the HMO s network, otherwise your services aren t covered (except for certain emergency situations). If your provider is not in the network, you will need to change providers or choose a new dental plan option to ensure that your dental services continue to be covered. In addition, the Dental HMO Plan requires you to receive services from a DeltaCare USA primary care dentist. A primary care dentist will be automatically assigned to you, but if you want to change dentists, be sure to do so before you schedule an appointment. (See Page 75.) new dental ID cards and enrollee ID You don t need an ID card to receive services, but a DeltaCare USA card for the Dental HMO Plan will be mailed to you prior to January 1. Just tell your dental office that you re covered by DeltaCare USA and provide your: Name Date of birth Employer Name Enrollee ID number (or social security number) If you have enrolled dependents, tell them to provide your details, not their own. What s my Enrollee ID? Your social security number can also be used to identify you, but we all want to avoid sharing that number whenever possible. Your Enrollee ID is a safer choice. DeltaCare will mail a letter to you prior to January 1 that contains your Enrollee ID and ID card, among other useful information. orthodontic treatment in progress The Dental HMO Plan is a health maintenance organization (HMO) dental plan option, so you must visit a provider in the HMO s network, otherwise your services aren t covered. If you or an enrolled dependent has started orthodontic treatment under the UCCI or Cigna Dental plan, you may be able to continue that coverage when you switch to the DeltaCare Dental HMO Plan in Through a provision called orthodontic treatment in progress, your DeltaCare plan allows you to continue treatment you started under your previous dental plan. You can visit the same orthodontist and have the same coverage and copayments as your previous plan. You pay the same amount that you would have paid under your previous coverage, as long as you remain eligible for coverage under your DeltaCare plan. If you started orthodontic treatment in 2016 (or earlier) under your previous UCCI or Cigna dental plan, and if banding has taken place, you are eligible for continuous orthodontic coverage under your DeltaCare USA Dental HMO Plan and may continue to visit the same orthodontist. If banding has not occurred, you are not eligible for continuous orthodontic coverage. In that case, orthodontic treatment must be provided by a DeltaCare network orthodontist in accordance with the copayments, limitations and exclusions defined in your DeltaCare USA Dental HMO Plan. September

13 You must sign up between January 1 and January 31, 2017 to receive this continuous orthodontic coverage. Go to hr2.chevron.com or the DeltaCare website to download the Continuous Orthodontic Coverage Form and a claim form. Please have your treating orthodontist complete and submit both forms by January 31, DeltaCare will coordinate benefits as necessary with your orthodontist. For all other treatments, payment of claims for service depends on the service date: If the service date was prior to January 1, 2017, your UCCI or Cigna coverage will continue to pay for claims pertaining to the service, according to the UCCI or Cigna copayment and fee schedules. For service dates starting on or after January 1, 2017, Delta Dental Insurance Company will become the claims administrator and the DeltaCare USA network, copayment and fee schedules will apply. deltacare website and mobile app DeltaCare provides three ways for you to stay on top of your dental benefit: visit the website from your computer, access the mobile-optimized website via your smartphone, or download and use the free app. No matter which source you choose you ll be able to: Find a dentist (note that you don t have to login to search for a network dentist). View your electronic ID card (and grab your Enrollee ID). See your benefits and eligibility. How to register You can go to the DeltaCare website starting today to search for a provider dentist and view general information about your Dental HMO Plan without registering or logging in. However, you need to wait until January 1, 2017, after your enrollment is complete and your Delta Dental coverage starts, to register and access the full site services. Go to Click on Register Today in the Online Services section. You ll need to provide some basic information to verify your enrollment account. You ll need to provide the Enrollee ID mailed to you from DeltaCare USA. You ll get to setup your own username and password as part of the registration process. Find a provider Go to hr2.chevron.com to find dentists in the DeltaCare USA network to help you make your dental plan enrollment choices in October. U.S. Pay and Benefit News 46

14 Critical Illness Insurance Insurer and Administrator Phone Numbers Website Insured by: Aflac Administrator: Mercer Voluntary Benefits Mercer Voluntary Benefits Contact Mercer for information about plan coverage, how the plans work, or for payroll deduction inquiries. Beginning October 17, a.m. to 5 p.m. Pacific time (8 a.m. to 7 p.m. Central time) Monday Friday HR Service Center To enroll or change coverage, contact the Chevron HR Service Center: (Inside the U.S.) (Outside the U.S.) hr2.chevron.com Click 2017 Benefit Changes to learn more. Click Benefits Connection ongoing to review personal information or make changes. Dental HMO Plan Claims Administrator Network Name Delta Dental Insurance Company DeltaCare USA Group Number Direct Phone Numbers Website Mobile App (Inside the U.S.) 5 a.m. 6 p.m. Pacific (7 a.m. 8 p.m. Central) Full site available on January 1, Provider search available today. Delta Dental app September

15 Human Energy. Yours. TM Update to the Effective January 1, 2016 All changes described in this SMM are effective January 1, 2016 unless otherwise indicated. This enclosed newsletter serves as an official summary of material modification (SMM) for the plans referenced herein. Please keep this information with your other plan documents for future reference. This communication provides only certain highlights about changes of benefit provisions. It is not intended to be a complete explanation. If there are any discrepancies between this communication and the legal plan documents, the legal plan documents will prevail to the extent permitted by law. There are no vested rights with respect to Chevron health care plans or any company contributions towards the cost of such health care plans. Rather, reserves all rights, for any reason and at any time, to amend, change or terminate these plans or to change or eliminate the company contribution toward the cost of such plans. Such amendments, changes, terminations or eliminations may be applicable without regard to whether someone previously terminated employment with Chevron or previously was subject to a grandfathering provision. Some benefit plans and policies described in this document may be subject to collective bargaining and, therefore, may not apply to unionrepresented employees. You can access the summary plan descriptions for your benefits on the Internet at hr2.chevron.com or by calling the HR Service Center at ( if you re outside the U.S.), option 2. This SMM applies to the following summary plan description: January 1, 2014 Medical and Dental HMO (both the individual SPD posted online and the Your Chevron Health Benefits for U.S.- Payroll Employees compilation available in print.) January 1, 2015 Official Summary of Material Modification (SMM)

16 Tobacco Surcharge Changes New Tobacco User Trying to Quit requirements for Open enrollment October 19 through October 30, 2015 is your only opportunity to update your tobacco use status for Chevron has established a tobacco surcharge for medical and supplemental life insurance coverage. All active U.S.-payroll employees (and those on a leave of absence) were previously required to certify their tobacco use status. Open enrollment October 19 through October 30, 2015 is your only opportunity to change your tobacco use status for If you miss this deadline, you cannot change your 2016 tobacco use status until the next open enrollment period. And you cannot change your 2016 tobacco use status during the year, even if you experience a qualifying life event like getting married or having a baby. If your 2015 certification status is Tobacco User, But Will Try to Quit, you may need to take action during open enrollment to update your 2016 tobacco use status. If you do not make a new tobacco use certification during open enrollment, your 2016 tobacco use status will be automatically assigned as Tobacco User and the tobacco surcharge will apply to you for all of If you make a new 2016 tobacco use certification during open enrollment, your certification choice will determine whether or not the tobacco surcharge applies to you for all of If your 2015 certification status is either Not a Tobacco User, Tobacco User or Decline to Disclose, your 2015 status will continue automatically in 2016 unless you make a change to your status during open enrollment. You do not need to do anything if this designation still accurately describes your tobacco use status. There is no change to the tobacco surcharge amounts. The tobacco surcharge effective January 1, 2016 is as follows: $25 more each month in 2016 for medical coverage. 20 percent more each month in 2016 for Chevron Supplemental Life Insurance Plan coverage, if enrolled. How to Update Your Tobacco Use Status You can update your tobacco use status by calling the HR Service Center (see Page 8) or by going online to Benefits Connection, the same website you use to make open enrollment elections. Follow the instructions on Page 8 to make open enrollment elections and update your tobacco use status for Open Enrollment October 2015

17 Tobacco Surcharge Changes Certification Choices for 2016 Your 2016 tobacco certification choices and requirements are as follows: Not a Tobacco User. You will not be subject to the surcharge during Tobacco User. If you re a tobacco user and don t intend to stop using tobacco, the surcharge will apply to you in Tobacco User, But Commit to Coaching. This is a new certification choice for See below for details. Decline to Disclose. If you decline to disclose your tobacco use, you will be defaulted to Tobacco User and the surcharge will apply to you in New for Choice for 2016: Tobacco User, But Commit to Coaching If you commit to complete at least three Tobacco Cessation Specialty Coaching sessions through WebMD between July 1, 2015 and December 31, 2016, the surcharge will not apply to you during Tobacco Cessation Specialty Coaching combines one-on-one telephone coaching, nicotine replacement therapy and integrated online resources to help participants try to stop using tobacco products. Contact WebMD at (or from outside the U.S.) to enroll. You can also go to hr2.chevron.com/wellness to learn more about this and other Tobacco Free Program resources. What s Considered Tobacco Use Indicate your tobacco use status only; you don t have to certify the tobacco use status of your spouse or domestic partner and other dependents for The definition of tobacco use has not changed for Any use, regardless of frequency or location, is considered use. This includes daily, occasional or social use. It also includes if it s used only at your home. Tobacco use means you ve used any of the following at any point since July 1, 2015: Tobacco (cigarette, pipe, cigar). Smokeless tobacco (such as snuff or chewing tobacco). E-cigarettes do not contain tobacco, so at this time e-cigarettes are not included in the tobacco use definition. However, the Federal Drug Administration is currently reviewing e-cigarettes. We continue to monitor this review and may choose to include e-cigarettes in the tobacco use definition in the future. U.S. Pay and Benefits News 17

18 Medical HMO Medical HMO Plans Chevron offers several health maintenance organization (HMO) medical plan options that include medical coverage, prescription drug coverage and basic vision coverage. With an HMO you must visit a provider in the HMO s network, otherwise your benefits aren t covered (except for certain emergency situations). HMOs are not available in all areas and the plan choices vary based on your zip code. The Benefits Connection enrollment website will indicate if an HMO is available in your area and the website will display the monthly cost for each plan available to you. Typically, you need a referral to a specialist under the Medical HMO Plans. The Medical HMO Plans offer comprehensive coverage for the major medical services you d expect, including office visits, emergency services, hospital care, lab services, outpatient care, pregnancy and newborn care and rehabilitative services. Medical Services, Prescription Drugs, Basic Vision: Provided by the HMO Preventive Care All Medical HMO Plans include 100 percent coverage with no deductible for certain preventive care services as specified by the Affordable Care Act when you see a network provider. Additional preventive screenings and services may also be covered, depending on factors like your age and gender. Deductibles There are generally no deductibles in the Medical HMO Plans, but coinsurance or copayments generally apply for all covered services and supplies. Health Care Spending Account (HCSA) You are eligible to participate in the Health Care Spending Account (HCSA), a flexible spending account. The funds you contribute to this account do not roll over from year to year. Learn more about the HCSA on hr2.chevron.com. Choose Open Enrollment. Health Savings Account (HSA) You cannot participate in a health savings account when enrolled in a Medical HMO Plan. However, you can use funds from an existing HSA to pay for qualified medical expenses while participating in a Medical HMO Plan. Mental Health and Substance Abuse (MHSA) Plan If you are enrolled in a Chevron Medical HMO Plan, you have the choice to use the mental health and substance abuse benefits provided by your HMO Plan, or to use the benefits provided under the MHSA Plan administered by ValueOptions, a Beacon Health Company. However, you cannot make a claim to both your HMO Plan and ValueOptions for the same service. If you are enrolled in a Chevron Medical HMO Plan and you choose to use your ValueOptions MHSA benefit, remember you must use a ValueOptions network provider to receive benefits. Out-ofnetwork provider services are covered for emergencies only. U.S. Pay and Benefits News 29

19 Medical HMO Plans Monthly Premium This is the fixed amount of money you pay each month to be covered by your health plan. Chevron also currently contributes money each month to help pay for your premium. Varies. The monthly premium is based on the plans available in your area (if any). Go to the Benefits Connection website to see your HMO options and the monthly cost. (See Page 8.) Annual Deductible This is the amount you pay out of pocket before your health plan begins to help pay for covered health care services. No Deductibles. You generally don t need to satisfy a deductible before your plan shares costs with you you ll just have to pay a copayment and/or coinsurance for covered services and prescription drugs. Remember, to receive coverage, you must use an HMO network provider, except in certain emergency situations. Note: Certain union HMO plans have a deductible requirement. See your plan s Summary of Benefits and Coverage (SBC) on hr2.chevron.com for details. Out-of-Pocket Maximum This amount is the most you will have to pay out of pocket for covered health care services for the year. When you reach this amount, your health plan begins to pay 100 percent of the allowed amount for covered health care services. This amount is important because it protects you in the event you have a year with major health expenses. Varies. The out-of-pocket maximum is based on the plans available in your area (if any). Go to the Summary of Benefits and Coverage (SBC) posted on hr2.chevron.com to review the limits for each of your available HMO plans. Tobacco Surcharge Chevron has established a tobacco surcharge for medical and supplemental life insurance coverage. This means there are different monthly rates for this coverage for tobacco and non-tobacco users. The rates above do not include a tobacco surcharge. See Page 16 for tobacco surcharge information. For More Information Be sure to go to hr2.chevron.com for access to a variety of other resources. 30 Open Enrollment October 2015

20 Medical HMO Medical HMO - Altius UT Will Not Be Offered in 2016 This plan will no longer be available to active employees effective January 1, If you are currently enrolled in this plan, you will be automatically enrolled in the Medical PPO Plan Option 1 effective January 1, No action is required, but if you want to enroll in another Chevron medical option available to you, you must make an election during open enrollment, October 19 through October 30, Other Medical HMO Plan Changes If you participate in a Medical HMO offered by Chevron, note that your provider or other plan features, like monthly premiums, copayments or prescription drug coverage could still change. We ve provided the highlights of major changes in the table below, but there could be additional details or other changes received after the printing of this newsletter. Always refer to the 2016 Evidence of Coverage document available for each plan to learn about your HMO plan changes. Contact the HMO directly to request a copy. You can find HMO contact information on hr2.chevron.com or by calling the HR Service Center Medical HMO Plan Change Highlights Medical HMO - Health Plan HI Durable Medical Equipment coverage will increase from 50% to 80% covered. Hawaii mandate for autism coverage now included. Medical HMO - Group Health WA Outpatient Rehabilitation visit limit will be reduced from 60 visits per year to 45 visits per year. Inpatient Rehabilitation visit limit will be reduced from 60 days per year to 30 days per year. Medical HMO - Kaiser HI Specialty Drug tier added ($75 retail, $150 mail-order). Skilled Nursing Facility care day limit will be increased from 100 days to 120 days. Medical HMO - Altius UT This plan will no longer be available to active employees effective January 1, U.S. Pay and Benefits News 31

21 Medical HMO Plan Reminders An HMO option may be available to you in your area. The Benefits Connection website will list the HMOs available to you next year (if any). Your provider or other plan features, like monthly premiums, copayments or prescription drug coverage could change. See your plan s Summary of Benefits and Coverage (SBC) for more information about your plan s features or contact the HMO directly (See Page 10). Even if your current HMO will be available in 2016, that doesn t guarantee that it is still available to you. Each year, the HMOs review the ZIP codes and counties in which they have providers. An HMO may choose to discontinue coverage to residents of certain areas. Your HMO provider may have changed. Remember that HMOs require you to use doctors, dentists and hospitals that are part of their provider network. Contact your medical or dental HMO directly to find out if your current providers continue to be in the network. If they are not, you will need to change providers or choose a new plan to ensure that your medical and dental services continue to be covered. Copayment and other changes in your current HMO coverage may apply because of state filings, compliance with the Health Care Reform law provisions, or to make them more closely align with Chevron s standard benefit design. You ll be able to view more information about HMO plan changes, if any, in the 2016 Evidence of Coverage document available for each HMO plan. Contact the HMO directly to request a copy. 32 Open Enrollment October 2015

22 Human Energy. Yours. TM Update to the Effective January 1, 2015 All changes described in this SMM are effective January 1, 2015 unless otherwise indicated. This enclosed newsletter serves as an official summary of material modification (SMM) for the plans referenced herein. Please keep this information with your other plan documents for future reference. This communication provides only certain highlights about changes of benefit provisions. It is not intended to be a complete explanation. If there are any discrepancies between this communication and the legal plan documents, the legal plan documents will prevail to the extent permitted by law. There are no vested rights with respect to Chevron health care plans or any company contributions towards the cost of such health care plans. Rather, reserves all rights, for any reason and at any time, to amend, change or terminate these plans or to change or eliminate the company contribution toward the cost of such plans. Such amendments, changes, terminations or eliminations may be applicable without regard to whether someone previously terminated employment with Chevron or previously was subject to a grandfathering provision. Some benefit plans and policies described in this document may be subject to collective bargaining and, therefore, may not apply to unionrepresented employees. You can access the summary plan descriptions for your benefits on the Internet at hr2.chevron.com or by calling the HR Service Center at ( if you re outside the U.S.), option 2. This SMM applies to the following summary plan description: January 1, 2014 Medical and Dental HMO Plans (both the individual SPD posted online and the Your Chevron Health Benefits for U.S.-Payroll Employees compilation available in print.) January 1, 2015 Official Summary of Material Modification (SMM)

23 How to Certify Your Tobacco Use Status All employees (including employees on a leave of absence who are not receiving coverage through COBRA) are required to certify their tobacco use status during open enrollment, October 20 through October 31, During this year s open enrollment period, October 20 through October 31, 2014, all U.S.-payroll employees who participate in Chevron medical or supplemental life insurance coverage will be required to certify their tobacco use status. If you fail to follow the steps to certify your tobacco use status during open enrollment, you ll be charged the higher monthly rates for medical and supplemental life insurance coverage for all of 2015, whether or not you use tobacco. You will not lose your coverage in these plans if you fail to certify, but you will pay the higher rate. If you miss the deadline, you cannot change your tobacco use status until next year s open enrollment for 2016 benefits. Note: COBRA participants are not required to certify their tobacco use status at this time. Tobacco use can affect your health. And your health is important to your quality of life, your family, your career, and the health of our business. That s why Chevron announced an important change to medical and supplemental life insurance coverage earlier this year. Starting January 1, 2015, Chevron will establish a tobacco surcharge for medical and supplemental life insurance coverage. This means there will be different monthly rates for this coverage for tobacco and non-tobacco users. It matters to Chevron that you re in good health at work and at home. That s why we offer a variety of wellness programs and resources to encourage and support better health. We hope our employees tobacco and nontobacco users alike take advantage of these opportunities, whether it s to try to stop using tobacco, participate in exercise programs, or take steps to protect your heart. How to Certify You can certify your tobacco use status by calling the HR Service Center (see Page 6) or by going online to Benefits Connection, the same website you use to make open enrollment elections. If you access Benefits Connection, from the Chevron network, you can use the automatic sign-in feature and you don t need a PIN. But if you need to certify your tobacco use status from outside the Chevron network or by phone, you ll need your PIN. A PIN reminder was mailed to you in September, but if you still don t know your PIN or can t find it, you can request a new one online or by calling the HR Service Center. It can take up to two weeks to receive your PIN in the mail, so take action right away if you need it. Go to hr2.chevron.com and click Open Enrollment, then the Certify Tobacco Status button. Login to Benefits Connection. Choose the Enroll Today button, then the Make Your Elections Now button. From the Make Coverage Elections screen, look for Tobacco Certification and choose Change. After you certify your tobacco use status, your Make Coverage Elections screen will be updated according to your certification choice. 8 Open Enrollment October 2014

24 Your Certification Choices When you certify your tobacco use status, you ll be asked to choose from the status options listed below. Here s what those choices are and what they mean. Tobacco User Tobacco use is a personal choice. It s not our goal to intrude on your personal life and take away that choice. That s why if you currently use tobacco, you can continue using it. If you re a tobacco user and don t intend to stop using tobacco, you ll pay $25 more each month in 2015 for medical coverage than employees who are not tobacco users. If you participate in Chevron s Supplemental Life Insurance Plan, you ll also pay 20 percent more each month in 2015 for that coverage. The higher rates will take effect on January 1, Your benefit plan and the level of coverage you receive will be the same as non-tobacco users, the only difference will be that you pay a higher monthly cost for your coverage. Tobacco User, But Will Try to Quit If you commit to try to stop using tobacco during 2015, we have support resources to help you, and you ll pay the lower monthly rate too. Go to hr2.chevron.com for resources. Not a Tobacco User If you don t use tobacco you will not be subject to the higher medical and supplemental life insurance rates in 2015 as long as you certify your tobacco use status during open enrollment, October 20 through October 31. If you fail to meet this deadline, you ll be charged the higher monthly rates for medical and supplemental life insurance coverage for all of Decline to Disclose You can choose to decline to disclose your tobacco use status, but you ll be charged the higher monthly rates for medical and supplemental life insurance coverage for all of 2015, whether or not you use tobacco. What s considered tobacco use? You ll be asked to indicate your tobacco use status only. You don t have to certify the tobacco use status of your spouse or domestic partner and other dependents for Any use, regardless of frequency or location, is considered use. This includes daily, occasional or social use. It also includes if it s used only at your home. Use of the following since July 1, 2014, will be considered tobacco use: Tobacco (such as cigarette, pipe, cigar). Smokeless tobacco (such as snuff or chewing tobacco). E-cigarettes do not contain tobacco, so at this time e-cigarettes are not included in the tobacco use definition. However, the Federal Drug Administration is currently reviewing e-cigarettes. We continue to monitor this review and may choose to include e-cigarettes in the tobacco use definition in the future. U.S. Pay and Benefits News 9