BeneFlex. Summary Plan Description 2013

Transcription

1 Summary Plan Description 2013 Call the Mount Sinai Benefits Center at MSMC(6762) Visit the Mount Sinai Benefits Enrollment Web-site at

2

3 What s Inside 1 What s Inside Preface...2 Welcome to...3 Benefits At-A-Glance...4 Eligibility...5 How Works...6 Enrollment...6 Annual Open Enrollment...6 Administrative Information...6 Your Medical Plan Choices...9 UnitedHealthcare Choice Plus (PPO) Options...9 Health Maintenance Organization (HMO) Options...11 Declining Medical Coverage...11 Condition Management Program...12 Your Prescription Drug Plan Choices...13 Express Scripts Prescription Drug Benefits At-A-Glance...13 Prescription Programs...14 Express Scripts Step Therapy Program...14 Express Scripts Maintenance Medication Program...14 Employee Pharmacy at Mount Sinai...14 Health Savings Account (HSA)/High Deductible Health Plan (HDHP) Choice...15 Medical Plan Choice High Deductible Health Plan (HDHP)...18 Prescription Drug Plan Choice - High Deductible Health Plan...19 Express Scripts Prescription Drug Benefits At-A-Glance...19 Health Risk Assessment Survey (HRA) - All UnitedHealthcare Participants...20 Smoking Cessation Plan - Quit For Life Program...22 Your Dental Plan Choices...23 MetLife Dental Preferred Provider Organization (PPO) Options...23 CIGNA (DHMO)...24 Declining Dental Coverage...24 Your Vision Plan Choices...25 The Vision Plan...25 Declining Vision Coverage...25 Your Life Insurance Plan Choices...26 Aetna Life Insurance Benefits At-A-Glance...26 Supplemental Life Insurance Options...27 Declining Life Insurance Coverage...27 Dependent Life Insurance...27 Accidental Death & Dismemberment (AD&D) Coverage...27 Your Disability Plan Choices...28 Short-Term Disability Coverage...28 Long-Term Disability Coverage...29 Declining Disability Coverage...29

4 2What s Inside Flexible Spending Accounts Health Care (HCRA) and Dependent Care (DCRA) Reimbursement Accounts...30 Health Care Reimbursement Account (HCRA)...31 Limited Purpose Flexible Spending Account (Limited HCRA)...31 Dependent Care Reimbursement Account (DCRA)...32 Transportation Reimbursement Incentive Program (TRIP)...34 Transit and Parking Accounts (ADP)...34 Available Payment Methods...36 The First Method: On-Line Commuter Benefits (OCB)...36 The Second Method: Paper Method...36 How to Enroll:...38 Open Enrollment...38 Default Coverage If You Do Not Enroll...39 Summary of Plan Information...40 ERISA Information...41 Appendix A:...55 Benefit Plan Summaries...55 Frequently Asked Questions...89 Choice Plus/High Deductible Health Plan...89 Condition Management Program (CMP)...90 On Line Commuter Benefits...91 Health Risk Assessment Survey (HRA)...92 UnitedHealthcare (UHC) Health Risk Assessment (HRA) Instructions...93 Smoking Cessation Plan - Quit For Life Program...94 Appendix B Continuation Coverage Rights Under Cobra...95 Appendix C Mid-Year Election Changes...99 Useful Phone Numbers and Web-Sites...INSIDE BACK COVER PREFACE The Mount Sinai Hospital ( Mount Sinai ) maintains the Welfare Benefit Plan (the Plan ) to provide designated health and welfare benefits to Employees (as defined below). This document, the group insurance contracts, coverage certificates and/or other documentation describing the health and welfare programs available to eligible employees (the Component Plans ) are intended to constitute one single plan document and summary plan description ( SPD ) for purposes of the reporting and disclosure requirements of the Employee Retirement Income Security Act of 1974, as amended ( ERISA ) and the Internal Revenue Code of 1986, as amended (the Code ). The primary purpose of this SPD is to provide you with a non-technical explanation of the most important features of the Plan. All official Component Plan documents are available for your inspection during normal business hours at: The Benefits office, 19E 98th Street, Rm 1E, New York, NY All statements made in this booklet are subject to the provisions and terms of the Component Plans. Except where otherwise noted, in case of conflict or inconsistency between the official Component Plans and this document, the Official Component Plans will govern in all cases. For more information about the Component Plans, refer to the section, Summary of Plan Information. This booklet is provided for informational purposes only and shall not be deemed to be a contract between Mount Sinai and any Employee or to be a consideration or an inducement for the employment of any Employee. Nothing contained in this Plan shall give any Employee the right to be retained in the service of Mount Sinai or interfere with the right of Mount Sinai to discharge or change the status of any Employee at any time regardless of the effect which such discharge or change of status will have upon him or her as an Employee.

5 Welcome to 3 Welcome to The Mount Sinai Medical Center program offers advantages to our Faculty and Staff. For our Faculty and Staff: The program gives individuals the flexibility to choose the benefits and coverage levels that are right for their personal lifestyles and family situations. Now is your opportunity to choose your benefits. If you haven t made benefits elections before, rest assured that the process is not complex. This Summary Plan Description will help you through the decision-making process. If you have any questions during enrollment, contact MSMC(6762) for assistance. The term you as used in this Summary Plan Description refers to an employee of Mount Sinai and its affiliates who otherwise meets all the eligibility and participation requirements under the Plan (an Employee ). Receipt of this Summary Plan Description does not guarantee that the recipient is in fact a participant under the Plan and/or otherwise eligible for benefits under the Plan.

6 4Welcome to Benefits At-A-Glance Benefit Type Medical Prescription Drug Vision Dental 1 Options UnitedHealthcare Choice Plus (PPO) basic or plus options, Choice Plus/High Deductible Health Plan Health Maintenance Organization (HMO) Blue Cross Blue Shield, HIP Decline coverage (if covered under another medical plan) Express Scripts basic or plus options Express Scripts High Deductible Health Plan UnitedHealthcare Vision network-based voluntary plan Decline coverage MetLife Preferred Provider Organization (dental PPO) basic or plus options CIGNA Dental Health Maintenance Organization (DHMO) Decline coverage Life Insurance Employee coverage Dependent coverage (with Aetna) Multiple Aetna options Spouse: increments of $25,000 to a maximum of $100,000 Accidental Death & Dismemberment Disability 2 Health Care Reimbursement Account Dependent Care Reimbursement Account TRIP Equal to the TOTAL life insurance you elect. Decline coverage Short-term Prudential New York State mandated Short Term Disability Enhanced Short Term Disability option Long-term 60% of base salary up to $15,000 a month Child(ren): $5,000 each child or $10,000 each child $2,500 maximum pre-tax annual contribution (minimum = $240) Decline participation $5,000 maximum pre-tax annual contribution (highly compensated Faculty and Staff are limited to a $1,385 annual contribution) Decline participation $1,500 Maximum pre-tax annual contribution (Minimum $120) TRANSIT $2,880 Maximum pre-tax annual contribution (Minimum $120) PARKING Decline participation 1 North Shore staff and offsite physician practices (hourly employees) are not eligible for Dental Coverage. 2 Paid Visiting Faculty/Associates, Post-Doc Fellows, Trainees, Temporary Employees, North Shore staff, members of the Brotherhood Security Personnel Officers, Guards International Union, and the members of the Mount Sinai Hospital Pharmacy Association and offsite physician practices (hourly employees) are not eligible for LTD. House Staff Residents receive, at no cost, a monthly LTD benefit equal to 60% of base monthly pay to a maximum of $3,500.

7 Eligibility Faculty and Staff The following Faculty and Staff hired on or before December 31, 2003 with base hours of at least 17.5 per week are eligible to participate in the program. Faculty and Staff hired on or after January 1, 2004, must be scheduled to work at least 60% of a normal work week to be eligible for. Bargaining Unit Members, please refer to your collective union contract. Regular salaried Faculty Regular salaried non-bargaining unit Staff Members of the International Brotherhood of Electrical Workers - Local 3 Offsite physician practices hourly employees 1,2 Members of the American Physical Therapy Association Paid Visiting Faculty/Associates 1 Members of the Mount Sinai Hospital Pharmacy Association 1 North Shore Staff 1,2 House Staff Residents and Clinical Fellows Members of the Brotherhood of Security Personnel Officers and Guards International Union 1 Trainees, Post-Doc Fellows and non-bargaining Temporary Employees hired to work more than six months. 1 The following employees (and former employees) are not eligible for coverage under (coverage may be available under other plans): Graduate Students Medical Students Members of Local 32B-J 3 Members of Local 1199 Non-Paid Visiting Faculty/Associates 5 Welcome to Members of the New York State Nurses Association (NYSNA) Non-bargaining unit staff hired on a temporary basis Long Term Disability recipients Dependents The following dependents may be covered under the medical, prescription drug, dental and vision plan options of : Your spouse or same-gender domestic partner - The term spouse means a spouse as defined in the Federal Defense of Marriage Act (1 U.S.C. 7) ( DOMA ). Under DOMA, a spouse refers only to a person of the opposite sex who is a husband or a wife. Accordingly, the term marriage as used throughout the SPD means marriage, as recognized under federal law. In the event a particular state has adopted a definition of marriage that includes same-sex marriages or legally recognizes a same-sex partner in a civil union, the Plan will recognize such State law with respect to individuals residing in such State or another State recognizing that State s law, treating such person under the Plan as a same sex domestic partner. If coverage is elected for a domestic partner, a completed Statement of Same Gender Domestic Partnership form, along with required proof, must be submitted to Human Resources before coverage is provided. Information and the required form, are available on the benefits enrollment Web-site, under the Forms Library at Subject to the eligibility requirements of the applicable benefit options, each of your children, married or unmarried, who is age 26 or younger (coverage is available as of the last day of the month in which age 26 is reached). Health coverage includes medical, prescription, dental and vision. Children means the following: your biological children, your domestic partner s children, your stepchildren, your legally adopted children, your foster children, any children placed with you for adoption, any eligible children for whom you are responsible under court order, and children for whom you are appointed legal guardianship. Note: If you apply for or continue coverage for anyone (including a domestic partner) who is not an eligible dependent under the terms of the Plan, you may be guilty of fraud or intentional misrepresentation and your and the ineligible individual s coverage will be rescinded, to the extent permitted by law. You may also be subject to discipline up to and including a termination of employment. In addition, if the Plan expends funds for coverage of ineligible individuals, you may be liable for premiums and all costs related to coverage for such individuals who are not eligible dependents. Note for same gender domestic partner coverage: If coverage for a domestic partner (including same-sex spouse) is elected, certain tax rules apply. To the extent your same-gender domestic partner and your partner s children do not satisfy the definition of a dependent under Section 152 of the Internal Revenue Code, the value of coverage for your partner and your partner s children is taxable to you and considered income. This amount will show on your pay stub as Dom Part. Please note that this is not a deduction. Contact your tax advisor for any tax-related questions. 1 Not eligible for Long-Term Disability 2 Not eligible for Dental Coverage 3 Only eligible for Short-term disability 4 Part-time and Per Diem Nurses are eligible for basic Short Term Disability benefit

8 6Welcome to How the Cost of Benefits are Determined To make benefits equally affordable for Faculty and Staff at all salary levels, your salary is used to determine the cost to you for certain coverages. Please note: Your base salary for calculation of salary driven benefits is determined once per calendar year (i.e. just prior to Open Enrollment or upon eligibility). Your age impacts the cost of your Supplemental life insurance. Basic life insurance is provided at no cost to you. On the other hand, if you need to file a claim for life insurance benefits, your actual salary at the time of filing will apply. How Works Through, you play an active role in determining your own benefits coverage. Instead of getting a standard one-size-fits-all package of benefits, you have the opportunity to buy the benefits options that best meet your needs. Mount Sinai subsidizes the cost of medical/prescription drug coverage, dental coverage, short-term disability insurance, as well as life insurance. Basic short-term, long-term disability and basic life insurance is covered at no cost to you. Enrollment To enroll in Beneflex, please follow the instructions provided on the enrollment web-site at If you are a new hire or otherwise newly benefits eligible (newly eligible) and do not enroll by the last day of the enrollment period (30 days from date of hire or newly eligible date), you will be assigned limited coverage (as highlighted in the chart on page 39) that may not meet your needs or your family s needs. NOTE: If you are a new hire, or otherwise newly eligible, your coverage begins on your first day of work provided it is the first day of the month. Otherwise, your coverage begins on the first day of the following month. Annual Open Enrollment Open Enrollment is offered every year to all eligible employees. During this time, you are given the opportunity to review your current benefits, make changes to your benefits or if you do not want to change your benefits allow your current selections to rollover to the following year. Please note: you must re-enroll in the Dependent Care Reimbursement, Health Care Reimbursement and Limited Purpose Health Care Reimbursement programs each year. These elections do not rollover to the following year, provided that such benefits remain available. Administrative Information Changing Coverage During the Year Because so few circumstances permit you to make mid-year changes, be sure to consider your choices carefully before making your elections. In general, you cannot change your benefits elections during the year (except for TRIP elections) unless you experience a qualifying change in status or certain other events as provided below. In this case you may make changes to all or some of your benefit selections. These status changes, known as qualifying events, include: Marriage Legal separation or divorce Birth or adoption of a child Death of a dependent Changes in your or your dependents health care coverage due to changes in employment status Reaching the maximum age for dependent child eligibility No election changes are allowed with respect to any change of status event of a domestic partner unless such domestic partner also qualifies as the employee s dependent under Section 152 of the Internal Revenue Code.

9 Qualifying Mid-Year Benefit Changes If you experience a qualifying change in family status, you are permitted to make benefits changes within 31 days of the event(s). This 31 day limit for making benefit changes is generally the limit but certain exceptions may apply, and longer periods will be allowed to the extent of the law. Visit or call MSMC(6762) for more details and for instructions on how to initiate the changes. The following chart shows some examples of how you may change your benefits coverage if you experience a qualifying change in your family status. TRIP Plan contributions may be changed at any time. See Appendix C for a more complete list of events that may result in changes to your benefit coverage under the Plan. It is the employee s responsibility to make benefit changes within 31 days of the event, or such longer period as required by law, and to change coverage levels impacting payroll deductions, if there is a change in family status. Your current coverage will remain in effect through the end of the month. The effective date of the new coverage is on the 1st day of the following month with the exception of the birth of a child or adoption of a child. The effective date for newborns and an adoption of a child is on the date of the event. Qualifying* Event Marriage Add samegender domestic partner 1 Birth or adoption of a child Legal separation or divorce Dependent/Employee gains other coverage or Awarded Medicare Coverage Death of spouse or Domestic partner Dependent loses Eligibility on account of reaching maximum age. 1 Medical/Prescription Drug/ Dental/Vision Coverage Partial Listing Of Qualifying Events Increase/decrease coverage level Elect/decline coverage Increase/decrease coverage level Elect/decline coverage Increase/decrease coverage level Elect/decline coverage Increase/decrease coverage level Elect coverage Increase/decrease coverage level Decline coverage Increase/decrease coverage level Elect coverage Dependent Life Elect coverage Not applicable Elect coverage Decline coverage Decline coverage Decline coverage Reimbursement Accounts 2 Health Care Dependent Care Elect/decline participation Not applicable Elect/decline participation Elect/decline participation Elect/decline participation Death of a Spouse only: Elect/decline participation 7 Welcome to Elect/decline participation Not applicable Elect/decline participation Elect/decline participation Elect/decline participation Death of a Spouse only: Elect/decline participation Increase/decrease coverage level No changes No changes No changes 1 See the definition of an eligible dependent on page 5. 2 Under current IRS rules, expenses cannot be claimed for same gender domestic partners and their dependents under HCRA/Limited FSA/DCRA, unless such individual is the employee s dependent under Code Section 152. *For a complete listing please call ADP at 1(866) 700-MSMC(6762)

10 8Welcome to Coordination of Benefits Coordination of benefits is a method of paying benefits when more than one plan covers you or a family member. If you are eligible for benefits under another group medical, dental or vision plan for example, if your spouse works and has employer-provided coverage the two plans may coordinate their benefit payments so that the combined payments of both plans do not exceed the actual expenses incurred. If you and/or your eligible family members are covered by more than one medical plan, here are a few rules to keep in mind about coordination of benefits: The Mount Sinai Medical Center Plan is always the primary coverage for enrolled Mount Sinai Faculty and Staff Your spouse s plan is always primary for your spouse For dependent children, generally the plan of the parent whose birthday month falls earlier in the year is primary ( birthday rule ) If the Mount Sinai Medical Center Plan is the primary payer that is, the plan that pays benefits first it pays expenses as if no other insurance were involved. Before you enroll, be sure to check the coordination of benefits rules of all plans involved. Continuation of Coverage If you become newly ineligible (for instance if you terminate employment, your hours drop below the hours required for benefits eligibility or you are awarded Long Term Disability benefits) your Beneflex health plan coverages will cease on the last day of the month (unless you become newly ineligible on the first day of a month, in which case coverage will end that day), and your disability, life insurance(s), transit/parking and reimbursement account coverages will end on the actual date that you became newly ineligible. Under certain circumstances, such as termination of employment, age limitations for your child(ren) or reduction in your hours affecting your benefits eligibility, you and your eligible covered dependents may be entitled to continue your medical (with or without prescription drug), dental, vision coverage, healthcare reimbursement account and Limited HCRA under the federal law COBRA (Consolidated Omnibus Budget Reconciliation Act of 1986). Benefits may be extended for a certain number of months, depending on the reason for the continuation. For life insurance, dependent life insurance, and long-term disability, which are not mandated by COBRA, you have the opportunity to convert to an individual policy and pay the full cost of the premium. In the case of Long Term Disability (LTD), you must have been enrolled in the LTD plan for at least one year in order to be eligible to apply for a conversion policy. See Appendix B, page 99, for additional COBRA information. For More Information For more information on changing coverage during the year, coordination of benefits and continuation of coverage, please call MSMC(6762).

11 9 Your Medical Plan Choices Medical Coverage Ask yourself How much money am I willing to pay out of my own pocket for medical care? How often will my family and I be using medical services this year? Can I afford to choose an option with a higher out-of-pocket maximum and deductible? Do I have access to other medical coverage for example, through my spouse s employer? Do I want the freedom to choose my own physicians and hospitals? Do I need coverage for myself only, or do I need to cover any eligible family members? What is a PPO? PPO stands for Preferred Provider Organization. A PPO is a group of doctors, hospitals and facilities that have agreed to give care to plan participants at discounted rates. With a PPO, you do not need to select a Primary Care Physician (PCP), and you can go directly to a specialist without a referral. Your Medical Plan Choices offers you a choice of five* medical plans plus and the option to decline medical coverage. While the five plans pay different levels of benefits, they all provide comprehensive health care coverage. Your medical plan choices are: UnitedHealthcare Choice Plus (PPO) basic or plus options, High Deductible Health Plan Blue Cross Blue Shield HMO HIP HMO Decline coverage (if covered under another medical plan). Generally, your share of the cost of medical coverage is paid for with before tax dollars. See the note regarding special tax treatment for domestic partners on page 5. The following sections highlight the key features of each option. Also, medical costs not covered by the options here may be eligible for reimbursement through the Health Care Reimbursement Account (HCRA). For more information regarding HCRA, please refer to page 30. UnitedHealthcare Choice Plus (PPO) Options The Basics As a participant in the UnitedHealthcare Choice Plus (PPO) basic or plus options you have three ways to access medical care when you need it. The level of benefits you receive depends on the provider you select. Under both plans, you may use: Mount Sinai providers listed in the top tier network, receive the top tier level of coverage and have the least out-of-pocket cost. Claim forms are not necessary. Other providers listed in the UnitedHealthcare Choice Plus PPO network, receive the middle tier level of coverage and have some out-of-pocket cost. Claim forms are not necessary. Out-of-network providers, receive the least coverage available under the plan and have the greatest out-of-pocket cost. Claim forms are necessary and can be found at You do not need to select a Primary Care Physician (PCP) for either PPO option. And, you can see a specialist in or out of the network without a referral. Of course, you can still ask your physician for advice and assistance in coordinating treatment with specialists. It s up to you. * The Aetna HMO medical plan is no longer offered as an option for medical coverage. Employees who are Aetna participants must select one of the available medical plan choices during Open Enrollment. If a medical plan is not selected, coverage will be defaulted to the employee s current level of coverage with UnitedHealthcare, Basic Plan.

12 10Your Medical Plan Choices Tools for Finding UnitedHealthcare Choice Plus PPO Providers Near You Top Tier directory/guide can be found on our web-site at Intranet1.mountsinai.org/ humanresources or at Call UnitedHealthcare at Online at Certain women s preventative health services must be offered at no cost at point of service. This includes approved contraceptives, some forms of counseling and screenings, and certain devices. Please contact UnitedHealthcare at for details. In-Network benefits The choice you make about where to receive medical care determines the level of benefits you receive higher benefits are paid when you choose an in-network provider. When you use an in-network PPO physician (whether from Mount Sinai or another UnitedHealthcare network provider), you will save money and have the assurance that your physician has been screened and approved by the PPO. Also, when you go in-network: Coverage is provided for preventive care, including routine physicals and gynecological exams. There are no claim forms. Out-of-Network Benefits You may go to any provider you wish outside of the PPO network and receive coverage under the plan. However, the PPO has not negotiated discounts with out-of-network providers, so your out-of-pocket cost will be higher. In addition, consider these points about care received out-of-network. You generally must pay the full cost for care at the time you receive services and then submit a claim form to UnitedHealthcare for reimbursement. You must meet a higher deductible before the plan pays any benefits. Once the deductible is met, the plan pays a certain percentage of covered charges, and you pay the remaining balance. The deductible you pay and the percentage of covered charges the PPO pays depend on the plan option you choose. UnitedHealthcare utilizes the 140% of Medicare allowable charge schedule for outof-network reimbursements. Certain services are not available out-of-network. A detailed Plan Summary is included in Appendix A.* Top Tier Directory The Top Tier Directory should only be used as a guide. The physicians listed in the directory are subject to change. Please call the physician's office before making an appointment to verify if the physician is a Top Tier physician. Medical Services and Supplies Requiring Prior Notification to UnitedHealthcare Listed below are some of the medical services and supplies for which UnitedHealthcare requires prior notification. Failure to notify UnitedHealthcare in advance of receiving these medical services and supplies may result in a $400 penalty. For a complete listing, please contact UnitedHealthcare at MEDICAL FACILITY ADMISSIONS HOME HEALTH CARE SERVICES SURGICAL PROCEDURES including Blepharoplasty, Upper Lid, Breast Reconstruction, Breast Reduction, Sclerotherapy, Vein Stripping, and Ligation. DENTAL SERVICES RELATING TO AN ACCIDENT DURABLE MEDICAL EQUIPMENT with a retail cost of over $1,000 * The UnitedHealthcare and Express Scripts Summary of Benefits and Coverage (SBC) will be available on after November 1st under the Plan Summary tab.

13 Health Maintenance Organization (HMO) Options One or more Health Maintenance Organizations (HMOs) through Blue Cross Blue Shield and HIP may be available to you. The Basics HMOs stress preventive services and health promotion. If you are enrolled in an HMO, a Primary Care Physician (PCP) must be selected to coordinate care for yourself and your dependents. You may choose one PCP for yourself and your enrolled dependents or each dependent may choose a different PCP. In addition, you may change PCPs by calling the HMO member services line shown on your ID card. Each time you need care, you must go through your PCP to receive benefits under the plan. Your PCP is responsible for: Diagnosing medical conditions Ordering laboratory tests and x-rays Delivering routine care Arranging for HMO network specialist care when necessary. Arranging for HMO network hospitalization when necessary. HMO physicians, hospitals and other health care suppliers must provide all of your care. Services received outside the HMO network are not covered, except in an emergency. In addition, emergency notification procedures must be followed to receive the full amount of benefits. (Call the HMO for details.) HMO Benefits Overview Benefits vary by HMO. But in general, HMOs feature: No deductible or claim forms 100% coverage for most services after a copayment No coverage for health care obtained outside the HMO, except in an emergency. A detailed Plan Summary for HIP and Empire Blue Cross Blue Shield (HMO) are included in Appendix A.* If you are electing HMO coverage for the first time, (or a different HMO than you are currently enrolled in), or if you are adding a dependent not previously covered, you are required to select a primary care physician. A pediatrician may be a primary care physician. Please visit the HMO s website for a directory of physicians. Under the HIP HMO and the Empire Blue Cross Blue Shield HMO, you do not need prior authorization from the Plan or from any other person, including your primary care provider, in order to obtain access to obstetrical or gynecological care from a health care professional; however, you may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, visit the corresponding website. Declining Medical Coverage If you have medical coverage through another plan such as through your spouse s employer you may decline medical coverage through Mount Sinai. Mount Sinai believes it is important for all Faculty and Staff to have medical coverage. If you decline medical coverage on-line, proof of other medical coverage is required. To do so, submit the waiver form found at or on If you do not provide evidence of other coverage, you automatically will be enrolled in the basic PPO for single coverage. If this happens, you will be charged the applicable employee medical cost-share rate. * The Summary of Benefits and Coverage (SBC) for HIP and Empire Blue Cross Blue Shield will be available on after November 1st under the Plan Summary tab. 11 Your Medical Plan Choices Tools for Finding HMO Providers Near You Online at Online at HIP-TALK Certain women s preventative health services must be offered at no cost at point of service. This includes approved contraceptives, some forms of counseling and screenings, and certain devices. Please contact the Empire Blue Cross Blue Shield HMO at or HIP HMO at HIP-TALK.

14 12Condition Management Program Condition Management Program Mount Sinai understands that facing and managing a long-term chronic illness can be difficult and challenging for our employees and their family members. This is why Mount Sinai in conjunction with UnitedHealthcare is offering, at no cost, a condition management program. This program provides the necessary information and guidance to better understand and manage a chronic condition. This valuable program focuses on the following five (5) chronic conditions: Asthma COPD Diabetes Coronary Artery Disease Heart Failure UnitedHealthcare will identify the employees who can benefit from this program. A condition management registered nurse will contact the employees over the phone to explain and invite the employee to enroll in the program. Please note that participation in the program is voluntary. The program will help employees: Learn about proven guidelines for quality care and treatment Work closely with their physicians (this program does not take the place of your physicians care. It only complements and reinforces your doctor s instructions) Follow recommended guidelines that are crucial to lowering risk of complications Understand how regular exercise, eating well and making healthful lifestyle choices can have a positive effect on their condition. Please be aware that Mount Sinai does not receive any information from UnitedHealthcare that could identify the employee as eligible or a participant of this program. The privacy of the information provided by the employee is protected by the Mount Sinai Medical Health and Welfare Plan Notice of privacy practices. Please see page 90 for frequently asked questions.

15 Prescription Coverage Ask Yourself How much did I spend for prescription drugs last year? Is anyone in my family on maintenance medication? How important is the freedom to go to a non-participating pharmacy? What unreimbursed prescription drug expenses except for non-prescribed over-the-counter medications could be covered through the Health Care Reimbursement Account? See page 30. Please Note The lifetime benefit for covered prescription drugs related to the treatment of infertility is limited to $1,800. Diabetic supplies are only covered under the Express Scripts Plan. Your Prescription Drug Plan Choices 13 Your Prescription Drug Plan Choices If you enroll in a medical plan any of the PPO or HMO options you automatically receive basic prescription drug coverage through Express Scripts. If you need additional prescription drug coverage, you can purchase the plus option instead. With the basic and plus options, there are several ways to receive prescription drugs. The prescription drug option you select and where you fill a prescription determines the benefits you receive. Also, prescription drug costs (except for over the counter drugs not prescribed by a physician), that are not covered by Express Scripts may be eligible for reimbursement through the Health Care Reimbursement Account (HCRA). For more information regarding HCRA please refer to page 30. Remember, if you join an HMO your prescription drug benefits (basic or plus) will be provided through Express Scripts, not through the HMO. Your share of the cost of the plus option is paid for with before tax dollars. If you decline medical coverage, prescription drug coverage is not available. Certain women s preventative health services must be offered at no cost at point of service. This includes approved contraceptives, some forms of counseling and screenings, and certain devices. Please contact Express Scripts at for details. Express Scripts Prescription Drug Benefits At-A-Glance 1* Benefits Schedule Plus Option Basic Option Employee Pharmacy (Mount Sinai Pharmacy) (30-day supply) In-Network Pharmacy (30-day supply) Generic drugs: $5 Preferred (Brand Formulary) drugs: $15 * Preferred (Brand Formulary) drugs: $20 Formulary list drugs only. Generic drugs: $10 Preferred (Brand Formulary) drugs: $35 Non Preferred (Brand non-formulary) drugs: $55 Out-of-Network Pharmacy You pay 30% You pay 30% Home Delivery Service Pharmacy (90-day supply for maintenance drugs, such as hypertension medication) Generic drugs: $25 Preferred (Brand Formulary) drugs: $80 Non Preferred (Brand non-formulary) drugs: $130 Generic drugs: $5 Preferred (Brand Formulary) drugs: $15 * Preferred (Brand Formulary)drugs: $20 Formulary list drugs only. Generic drugs: $10 Preferred (Brand Formulary) drugs: $40 Non Preferred (Brand non-formulary) drugs: $60 Generic drugs: $25 Preferred (Brand Formulary) drugs: $95 Non Preferred (Brand non-formulary) drugs: $150 1 To learn which in-network retail pharmacies participate, call or visit To verify if a prescription drug requires pre-authorization, call Express Scripts. This plan does not apply to participants of the Choice Plus/HDHP. * Drugs that the Hospital can offer at a lower cost because of a favorable contract with the pharmaceutical supplier and because the drugs have been determined to be as effective as medications that are more expensive (e.g. Nexium instead of Prilosec for reducing acid reflux). ** The UnitedHealthcare and Express Scripts Summary of Benefits and Coverage (SBC) will be available on after November 1st under the Plan Summary tab.

16 14Your Prescription Drug Plan Choices Prescription Programs Express Scripts Step Therapy Program The Step Therapy program puts prescription drugs generally into two categories: Typically generic drugs and Brand name drugs This means that if you have certain medical conditions, your treatment will begin with a generic medication. Inform your physician at your next visit about the Step Therapy Program so that you may be treated accordingly. If the generic medication proves ineffective or has proven ineffective in the past your physician may send a request to Express Scripts to use a brand name drug. To inquire if the medications you are taking will be impacted by this program or to obtain additional information regarding this program, please call Please note that the Basic, Plus and HDHP prescription plans and as any prescriptions filled at the employee pharmacy at Mount Sinai are subject to this program. Express Scripts Maintenance Medication Program This program allows you to receive three fills, each for a 30-day supply, at a participating retail pharmacy for certain maintenance drugs. After the third fill, you will have two options: You may continue to fill your prescription at a retail pharmacy, at a higher cost. This means that an additional $5 will be added to the corresponding retail co-pay for a generic drug, or an additional $35 for a formulary drug, or an additional $55 for a non-formulary drug. You may use the Home Delivery Service Pharmacy. You may fill a 90-day supply at a lower one time co-pay. Express Scripts may contact you after your third fill* to assist you with participating in this program. You may also visit To inquire if the medications you are taking are impacted by this program, please call Please note that the Basic, Plus and HDHP* prescription plans and any prescriptions filled at the employee pharmacy are subject to this program. Employee Pharmacy at Mount Sinai As a participant of the Express Scripts Plan you have several ways in which you can use the Plan. One of the lower cost options is to use the Employee Pharmacy to fill your prescriptions. While not all prescription drugs are available at the Employee Pharmacy, the following prescription drugs are now available: Nexium Crestor Lovenox Cellcept These four prescription drugs are available at a 30-day supply and are not subject to the Maintenance Medication Program. If your prescription drug is not one of the 4 listed above, this does not mean that the Employee Pharmacy does not carry your prescription. Please call the Employee Pharmacy at regarding other prescription drugs that may be available. The Employee Pharmacy is conveniently located near the Annenberg elevators on the MC level. The Employee Pharmacy is open from 8:30 am to 5 pm. *High Deductible Health Plan Prescription Plan - The surcharge will be added to your co-insurance once the deductible has been satisfied.

17 15 Your Benefits Advantages To Enrolling in this Plan Affordability Your medical and prescription employee contribution (the amount deducted from your paycheck) will be lower if you switch to the High Deductible Health Plan (HDHP) option. In addition, your HDHP can still protect you against covered catastrophic medical bills. Savings You can use the funds accumulated in your HSA account to pay for medical care and prescription drugs except for non-prescribed over-thecounter medications. You can also leave unused money in your HSA and let it grow through investment earnings. The unused funds in the account will roll over from year to year. There are no use it or lose it rules for this account. Portability Since you own your HSA account you can continue to use the funds in your account to pay for qualified medical and prescription expenses except for non-prescribed over-thecounter medications even after you leave employment. Taxes The earnings on qualified contributions and withdrawals for qualified expenses are tax-free. Health Savings Account (HSA)/High Deductible Health Plan (HDHP) Choice Mount Sinai offers a combined HSA-eligible, High Deductible Health Plan for medical coverage through UnitedHealthcare and prescription drug coverage through Express Scripts. This option allows you to save money in an HSA, which is an interest-bearing trust account. The money in this account can accumulate year to year or be used to pay for current healthcare services. The Plan choices are with: UnitedHealthcare Choice Plus/High Deductible Health Plan Express Scripts Prescription Drug Plan What is a High Deductible Health Plan (HDHP) A High Deductible Health Plan (HDHP) is a health plan that requires you to meet a high deductible before eligible medical services and prescription drug services are covered by the Plan. The employee cost-share for this plan is lower than they are for the other health plans offered by Mount Sinai. Note that preventive services are covered before the deductible has been met. What is a Health Savings Account (HSA) A Health Savings Account (HSA) is an account that you can contribute to on a tax-advantaged basis. Your contributions are generally tax-free, investment earnings grow tax-free, and withdrawals to pay for medical care or prescription drugs, except for non-prescribed over-the-counter medications, are not taxed. Please consult your tax advisor for specific tax information. The maximum contribution you can make to your HSA is up to $3,250 if you select single HDHP coverage with the HDHP or $6,450 if you select employee +1 or family coverage. Unused money in your account may be saved to pay for future expenses and is allowed to grow in your account through untaxed investment earnings. Unlike the Healthcare Reimbursement Account, your unused HSA contributions and earnings may remain in your account from year to year. Additional contributions to an HSA If you are age 55 or older you can make additional catch up contributions.

18 16Your Benefits Frequently Asked Questions (FAQs) Please refer to the FAQ section in Appendix A, page 89. Important Information for HSA Accounts Effective January 1, 2011, expenses for nonprescription drugs that constitute medical care under Section 213 of the Code (other than insulin) obtained without a prescription (i.e., over the counter drugs) are not eligible for reimbursement. This change does not currently apply to medical items, equipment, supplies or diagnostic devices, such as bandages, crutches or blood sugar test kits, obtained over the counter. How Can You Open an HSA You are responsible for opening an HSA account, paying any account fees and for making the contributions to your account. Please note that Mount Sinai is not providing payroll deductions for this account. You may open an HSA account with: UnitedHealthcare (OptumHealth Bank) A financial institution of your choice If you select to use the services offered by UHC, an application for OptumHealth Bank will be mailed to your home address when you are enrolled with the High Deductible Health Plan (HDHP). You may also visit to access the appropriate forms or call (800) Please note that you must first be enrolled in the UHC High Deductible Health Plan to enroll in the HSA offered by UHC. Regardless of where you choose to open your HSA account, the most you can contribute annually is $3,250 for single coverage, $6,450 for employee +1 or family coverage. Example: With a plan that has a single deductible of $1,250 and an employee + 1 or family deductible of $2,500 (In-Network) your maximum contribution is $3,250 for single coverage and $6,450 for employee + 1 or family coverage. If you are age 55 or older you may make additional catch-up contributions. Please visit for these limits. There will be fees for opening an account through UHC or any other financial institution. You are responsible for paying these fees. Information for the fees charged by UHC can be obtained on You must enroll in the High Deductible Health Plan (HDHP) offered through UnitedHealthcare (UHC) and the Prescription Drug coverage offered through Express Scripts to enroll and contribute to the UHC Health Savings Account (HSA). HSA and Healthcare Reimbursement Account (HCRA) Eligibility You are not required to open an HSA if you participate in an HDHP. If you do not open an HSA, you will not be able to utilize the tax advantages of this account. You may open and contribute to an HSA at any time that you are eligible to do so. If you open an HSA, you can no longer participate in the regular Healthcare Reimbursement Account (HCRA). However, you may participate in the Limited Purpose Flexible Spending Account (Limited HCRA) which will reimburse dental, vision, and preventative care expenses (preventative care for dental, vision, and some medical care) incurred that are not reimbursable through any other benefits. If you do not open an HSA account, you will be allowed to participate in the regular Healthcare Reimbursement Account (HCRA) to pay for eligible medical, prescription drug, dental and vision expenses.

19 17 Your Benefits Non-Qualified Medical and Prescription Expenses If you withdraw funds from your account for purposes other than to pay for qualified expenses, these withdrawals are taxable as income and subject to an additional 20% tax penalty. The 20% additional penalty will not apply to non-qualifying distributions made after you turn age 65, become disabled, or after your death. The IRS may ask for documentation regarding the services you have withdrawn money for, so you should save your receipts. Please Note In general, you may contribute to an HSA if you are not covered under any other type of non-hdhp medical or prescription drug coverage, including your spouse s medical Plan or healthcare reimbursement account. However, if you are covered under your spouse s HDHP, special limits apply to your HSA contributions. Please note that you may also contribute to an HSA if your spouse and dependents are covered under both your HDHP and your spouse s medical plan. Please contact with your tax advisor regarding these limitations. How Do You Access Your Money in an UHC HSA OptumHealth Bank will provide you with a Master Card Debit Card. You may use this card as follows: To withdraw money from your HSA account to reimburse/pay yourself for your qualified out-of pocket expenses. The doctor s office and pharmacy may debit your account from the office or pharmacy to pay for the cost of qualified services. You should also be able to access funds through the use of checks, for an additional fee. Please note that you are responsible for your account and verifying that sufficient funds are available in the HSA and that the funds are used for qualified expenses. For a list of qualified expenses please consult with your tax advisor and visit What Happens To Your Unused Funds If you do not use the entire account to meet your out-of-pocket expenses, you can save the contributions you make to the HSA account and grow your account through investment earnings or you may use the funds in your account to meet your future deductible, co-pays and co-insurance expenses. The unused funds in the account will rollover from year to year. There are no use it or lose it rules for this account. What Happens If You Stop Working Your account is portable. You can keep your account with the same institution or you can transfer your funds to another qualified HSA provider. Account Statements for UHC HSA Accounts You may see all account activity online by visiting or you may request that UHC mail a statement to your home by calling (800) Beneficiary Designation for UHC HSA Accounts In order to designate a beneficiary for your HSA account upon your death, you will need to complete a Beneficiary Designation form available on High Deductible Health Plan (HDHP) You must be enrolled in the HDHP offered through UHC to open and contribute to a UHC Health Savings Account. Please see a description of this plan on the next page.

20 18Your Benefits Medical Plan Choice High Deductible Health Plan (HDHP) The Basics The HDHP option requires you to meet a high deductible before eligible medical services are covered by the Plan. The HDHP may protect you against catastrophic medical bills and is offered at a price that is lower than the other health plans provided by Mount Sinai. Your medical plan choice for this Plan is UnitedHealthcare Choice Plus/High Deductible Health Plan You may access medical services by using: Mount Sinai providers listed in the top tier roster, and you will not be subject to a co-insurance after the deductible is satisfied. Middle Tier providers listed in the UHC network, and you will be subject to a co-insurance and out-of-pocket costs after the deductible is satisfied. Out-of-Network providers and be subject to a higher deductible, co-insurance and out-of-pocket costs. UnitedHealthcare utilizes the 140% Medicare allowable charge schedule as the basis for out-of-network reimbursements. Please see detailed Plan Summary in Appendix A.* Tools For Finding UnitedHealthcare Providers The Top Tier directory/guide can be found on intranet1.mountsinai.org/ human resources or at Call UnitedHealthcare at Online at Certain women s preventative health services must be offered at no cost at point of service. This includes approved contraceptives, some forms of counseling and screenings, and certain devices. Please contact UnitedHealthcare at for details. How Do You Meet Your HDHP Deductible The deductible is met by first paying out-of-pocket costs associated with eligible medical and prescription drugs services up to the amount of the annual HDHP deductible. Example: if you have employee +1 coverage that has a $2,500 deductible (In-Network), and you have met $1,500 in expenses you or your spouse will still need to incur $1,000 in additional medical or prescription drug expenses before the HDHP will start to reimburse your expenses. UHC Identification Card You will receive a card for yourself and your family once you are enrolled in the HDHP. Declining Coverage If you have medical coverage through another plan - such as through your spouse s employer - you may decline this coverage. To decline medical coverage, you must submit proof of other coverage. You must complete and submit a medical waiver form. The form is available at Prescription Plan If you elect to be a participant of the HDHP, your prescription coverage is available with Express Scripts. Please see the description of the Prescription Drug Plan on the next page. Top Tier Directory The Top Tier Directory should only be used as a guide. The physicians listed in the directory are subject to change. Please call the physician's office before making an appointment to verify if the physician is a Top Tier physician. * The UnitedHealthcare and Express Scripts Summary of Benefits and Coverage (SBC) will be available on after November 1st under the Plan Summary tab.

21 Prescription Drug Plan Choice - High Deductible Health Plan The Basics If you enroll in the HDHP, you automatically receive prescription drug coverage. Your prescription plan choice for this Plan is Express Scripts. You will use your eligible prescription and medical expenses to meet your High Deductible Health Plan. Once the HDHP deductible is met, the participant will pay the 20% co-insurance up to the applicable pharmacy maximum and minimum amounts per the chart below, until the HDHP Out-of-Pocket maximum is reached. Once it is reached prescription expenses are paid at 100% for the remainder of the calendar year. Express Scripts and UnitedHealthcare will coordinate your out-of-pocket expenses to determine when the HDHP deductible is reached. Co-Insurance The type of prescription being filled (generic, preferred or non-preferred) and the cost of that particular prescription drug, will determine the amount of your co-insurance. Your co-insurance cannot exceed the minimum or maximum amount outlined in the chart below. Example: If the preferred prescription drug costs $350, and you have already satisfied the HDHP annual deductible and are filling your preferred prescription drug at a participating innetwork pharmacy, the cost to you will be 20% (co-insurance) of $350, which is $70. However, you will only be responsible to pay $60, the maximum amount required for a preferred drug. Annual Out-Of-Pocket Maximum Frequently Asked Questions (FAQs) Please refer to the FAQ section in Appendix A, page 89. Once a participant reaches the Maximum Out-of Pocket maximums, the prescription expenses will be paid at 100% for the remainder of the year. Included in the out-of-pocket maximum is the deductible. If you decline medical coverage, prescription drug coverage is not available. Please see page 14 for information regarding the prescription programs. Please call , if you have any questions. Diabetic supplies are covered only under Express Scripts. Express Scripts Prescription Drug Benefits At-A-Glance 1** Benefits Schedule Prescription Option Employee Pharmacy (Mount Sinai Pharmacy) (30-day supply) In-Network Pharmacy (30-day supply) Out-of-Network Pharmacy You pay 30% Home Delivery Service Pharmacy (90-day supply for maintenance drugs, such as hypertension medication) 19 Your Benefits Certain women s preventative health services must be offered at no cost at point of service. This includes approved contraceptives, some forms of counseling and screenings, and certain devices. Please contact Express Scripts at for details. (after HDHP deductible is satisfied) Minimum Maximum Coinsurance: 20%, subject to the following: Generic drugs: $5 $10 Preferred (Brand Formulary) drugs:* $10 $20 Preferred (Brand Formulary) drugs: $15 $30 Coinsurance: 20%, subject to the following: Generic drugs: $10 $20 Preferred (Brand Formulary) drugs: $30 $60 Non Preferred (Brand non-formulary) drugs: $45 $135 Coinsurance: 20%, subject to the following: Generic drugs: $25 $55 Preferred (Brand Formulary) drugs: $75 $150 Non Preferred (Brand non-formulary) drugs: $110 $335 1 To learn which in-network retail pharmacies participate, obtain a Home Delivery service form and instructions or to verify if a prescription drug requires pre-authorization, call , or visit * Drugs that the Hospital can offer at a lower cost because of a favorable contract with the pharmaceutical supplier and because the drugs have been determined to be as effective as medications that are more expensive (e.g. Nexium instead of Prilosec for reducing acid reflux). ** The UnitedHealthcare and Express Scripts Summary of Benefits and Coverage (SBC) will be available on after November 1st under the Plan Summary tab.

22 20Your Benefits Frequently Asked Questions (FAQs) Please refer to the FAQ section in Appendix A, page 92. Health Risk Assessment Survey (HRA) All UnitedHealthcare Participants* During every Open Enrollment, employees will be given the opportunity to complete a Health Risk Assessment Survey at However, the savings described below will only be provided to employees who are UnitedHealthcare participants and who complete the survey during a specified time period. This survey is provided by the University of Michigan. The responses to the questions are coded and without identifying information. They are collected and compiled by the University of Michigan and an individualized report is provided only to you. The results of the survey are provided to UnitedHealthcare so that they may provide you with information regarding ways on how to improve and maintain your health. Your individual responses or results are kept in strict confidence and are not provided to Mount Sinai. Mount Sinai offers this voluntary HRA survey to all UnitedHealthcare participants as a valuable tool to obtain information regarding lifestyle options individually tailored to the results of your survey and provides the employee an opportunity to avoid an additional increase in the following year s medical cost-share rate. If you take the survey and enter your numbers: height, weight, total cholesterol, HDL levels and blood pressure, you will avoid an increase to your medical cost-share rate for the following year. New Hires and Newly Eligibles New hires and newly eligibles will not be required to take the HRA survey. The increase is not applicable to all new hires and newly eligibles. In order to continue to avoid an increase to your cost-share, however, new hires will be required to take the HRA survey during each yearly Open Enrollment. *The HRA survey is not applicable to Medical Students, House Staff with employee only coverage or NYSNA members with UnitedHealthcare coverage.

23 21 Your Benefits Changing from an HMO to UnitedHealthcare If during Open Enrollment you change your medical carrier from an HMO to UnitedHealthcare, you will not be required to take the Health Risk Assessment Survey to receive the credit. It will automatically be applied to your 2013 cost-share. During any subsequent Open Enrollment, however, you will need to complete the Survey, with your numbers. HRA: The Amount Saved The amount saved will be reflected as a credit in your paycheck. If you complete the HRA, you will see a credit reflected in your paycheck (HRA_CRED). The credit is paid as a special pay and is subject to taxes. HRA Survey The survey takes approximately 15 minutes to complete. Prior to taking the survey, know your numbers. Please be sure to have recent medical information at hand such as your cholesterol levels (total and HDL), blood pressure, height and weight. Please be sure that once you have completed the survey, with your numbers, that you click on the submit button. You will immediately see a Personalized Health Assessment Report and be able to print out a Health Assessment Completion Certificate for your records. Once you start the survey you will need to complete it in one single session. The survey will not allow you to save your information and return at a later date. At every Open Enrollment you will be able to take the survey again to save on your cost-share for the start of the following year. Information will be provided to all eligible employees regarding the survey and the specified period in which the survey should be completed. Note: Your spouse and dependents who are covered under your benefits are not required to complete the survey. However spouses and dependents who are covered are welcome to take the survey.

24 22Your Benefits Smoking Cessation Plan Quit For Life Program As part of Mount Sinai s commitment to provide Mount Sinai employees with available wellness resources and to assist employees reach the goals identified by the aggregate results of the Health Plan Assessment Survey (HRA), we are offering the Quit-For-Life program, smoking cessation plan. The program is sponsored by the American Cancer Society and Alere Wellbeing. These two organizations have 35 years of combined experience in tobacco cessation coaching and have helped more than one million tobacco users. The program is offered at no cost to faculty, staff and their spouses who are enrolled in one of the Mount Sinai medical health plans (i.e., UnitedHealthcare Basic, Plus or HDHP Plans, HIP or Blue Cross Blue Shield). To join the program please call 1 (866) Quit-4-Life 1 [(866) ]. When you join, a package will be sent to your home address detailing the program. What Does the Quit For Life Program include? When you join Quit For Life you will partner with an expert Quit Coach who will help you create an easy-to-follow Quitting Plan that will show you how to get ready, take action an then live the rest of your life as a non-smoker. The program may include: Access to Web Coach, a private on-line community where you can complete activities, watch videos, track your progress and join in discussions with others in the program. When you join you will have lifetime access to the web site. An easy-to-use printed workbook that you can reference in any situation to help you stick with your quitting plan. Free 8 week supply of nicotine replacement therapy (patch/gum) mailed directly to your home address, if appropriate. Recommendations on type, dose, and duration of nicotine replacement or medication if appropriate (including patch, gum, Bupropion or Chantix). Twelve months of unlimited toll-free access to Quit coaches who offer support as needed. Total of five (5) calls from a Phone based Quit Coaches. If you do not quit on the first try, you may re-enroll in the program. The Quit For Life Program is tailored to the needs of each participant and is designed to end the addiction to tobacco in all forms: cigarettes, cigars, pipes an even smokeless tobacco. Under federal law, all employees of Alere Wellbeing and the American Cancer Society are required to protect the confidentiality of participants personal health information. If you have specific questions about how Alere Wellbeing protects participants privacy, please contact Free and Clear at 1 (866) Quit-4-Life, 1 (866) Please refer to page 94 for Frequently asked questions.

25 Your Dental Plan Choices 23 Your Dental Plan Choices Dental Coverage Ask Yourself How much money am I willing to pay out of my own pocket for dental care? How often do my eligible dependents and I visit the dentist each year? Do I want the freedom to choose my own dentist? Will my eligible dependents and I need extensive dental care this year, or just regular check-ups and cleanings? Tools for Finding MetLife PPO Providers Near You Call MetLife at Online at offers you a choice of three dental plans* and the option to decline dental coverage. While the three plans provide different levels of dental benefits, each gives you and your family access to affordable and quality dental care. Your dental plan choices are: MetLife Preferred Provider Organization (dental PPO) basic or plus options CIGNA Dental Health Maintenance Organization (DHMO) Decline Coverage. The following section highlights the key features of each option. Detailed summaries and additional information are available in Appendix A. Also, dental costs not covered by the options here may be eligible for reimbursement through the Health Care Reimbursement Account (HCRA). For information regarding HCRA, please refer to page 30. If you are enrolled in the High Deductible Health Plan, please refer to page 31. Your share of the cost of dental coverage is paid for with before tax dollars. MetLife Dental Preferred Provider Organization (PPO) Options If you elect to participate in the dental PPO basic or plus options you will have a choice each time you receive dental care. You may: Go to a dentist in the MetLife PPO network Go to a dentist outside the network. The dental plan covers the same services whether you use a dentist who is in or out of the network. However, your out-of-pocket costs generally are lower when you use an in-network dentist. This is because in-network providers have agreed to give care to plan participants at discounted rates. How Does the Plan Work? If you go to a dentist in the PPO network: You will be charged a percentage of a negotiated fee for the services you receive. In most cases, your dentist will submit a claim form for you. If you go to an out-of-network dentist: You pay the full cost of the visit and then submit a claim form for reimbursement If you and two or more dependents are enrolled in the plan, you can meet the family deductible by any combination of payments toward your family members individual deductibles Payments for covered services are based on a percentage of reasonable and customary charges; you pay any difference between the reasonable and customary charge and the amount your dentist charges. * North Shore staff and Offsite Physician Practices (hourly employees) are not eligible for Dental coverage.

26 24Your Dental Plan Choices Predetermination Review A predetermination review protects you from unexpected dental bills by telling you exactly what the plan will cover and what your out-of-pocket cost will be. If you are a participant in the dental PPO the basic or plus option and your provider proposes dental work that will cost more than $300, you can ask MetLife for a predetermination review. You (or your doctor) should call the MetLife Dental Customer Service Center at and speak to a customer service representative who can help you determine what you need to do. MetLife ID Cards MetLife does not issue I.D. cards. Instead, your dental provider will verify your coverage directly with MetLife. Tools for Finding CIGNA DHMO Providers Near You Call CIGNA at Online at or CIGNA DHMO The CIGNA Dental Health Maintenance Organization (DHMO) is similar to an HMO for medical care. For services to be covered, you must use the dentists who participate in the CIGNA DHMO network. There are no annual deductibles, no annual benefit maximums and no claim forms. You pay only a copayment for most covered services. When you enroll in a DHMO, you must select a DHMO Primary Care Dentist to manage your dental care. You may choose one dentist for yourself and your enrolled dependents or each dependent may choose a different dentist. In addition, you can change dentists by calling the DHMO member services line shown on your ID card. How Does the Plan Work? With the CIGNA DHMO, the in-network dentist you select provides most of your dental care. If you need to see a specialist, your dentist will refer you and make all of the arrangements. When you use CIGNA DHMO dentists, most preventive services are covered in full by the plan. For all other services, you pay only a copayment. A list of current required copayments and services is available in Appendix A. If you need emergency care away from home, you will receive temporary coverage, up to a set dollar limit. Call CIGNA as soon as possible to verify coverage levels and confirm follow-up procedures. You will need to schedule any follow-up appointments with your primary dentist to receive the full amount of benefits available under the plan. Declining Dental Coverage You may decline coverage through Mount Sinai. Proof of other coverage is not required to decline dental coverage.

27 Your Vision Plan Choices 25 Your Vision Plan Choices Vision Coverage Ask Yourself Do I need an eye exam in the near future? What about my family? How much do I usually pay in vision care expenses each year? Do I have vision coverage elsewhere, such as through my spouse s employer? How does the cost of the plan compare to the amount of coverage I expect to receive? Tools for Finding UHC Vision Care Providers Near You Call Online at Regular eye examinations and the use of corrective vision lenses when needed are important for your well-being. The Mount Sinai Medical Center program offers a vision plan to help you meet the costs of vision care for yourself and your family. Your vision plan choices are: UnitedHealthcare Vision (UHC Vision). Decline coverage. The following section highlights the key features of the vision plan. More detailed plan information will be provided to you when you enroll for vision coverage. Detailed summaries and additional information are included in Appendix A. Also, eye care costs not covered by UHC Vision may be eligible for reimbursement through the Health Care Reimbursement Account (HCRA). For information regarding HCRA, please refer to page 30. If you are enrolled in the High Deductible Health Plan, please refer to page 31. The Vision Plan The Basics The vision plan helps you pay for the cost of an annual eye examination, eyeglass frames and lenses, or contact lenses. Network providers can perform eye examinations and write prescriptions for both eyeglasses and contact lenses. Benefits also may be provided under your medical plan if you have a medical condition affecting your eyes. To receive vision care, you may: Go to a provider in the UHC Vision Plan network (no claim forms necessary) Go to a provider outside the network. Please submit your claims for out of network expenses (receipts, proof of payment) to: UnitedHealthcare Vision Inc., Claims Department P.O. Box Salt lake City, UT or Fax: (248) You receive the highest possible benefits when you obtain vision care through the UHC Vision network. Vision ID Cards Please note that you may obtain an I.D. Card at If you do not have a card, the provider can also contact UHC Vision to verify your coverage. Declining Vision Coverage You may decline vision coverage.the vision plan is a voluntary benefit. You pay for the full cost of the coverage.

28 26Your Life Insurance Plan Choices You may not elect coverage for your spouse or children if they are an active member of the armed forces of any country or international authority. Maximum Basic Life $1,000,000 Evidence of Insurability Requirement (EOI) Not required for Basic Life Insurance Supplemental Life Insurance Open Enrollment 2 Newly Eligible Participants 2013 New Hires or Options Maximum Supplemental Life allowed without Evidence of Insurability (EOI) Requirement Your Life Insurance Plan Choices Aetna Life Insurance Benefits At-A-Glance Basic Life insurance 1 Employer Paid Basic Life Insurance (no cost to employee) Life insurance provides a lump sum benefit in the event of your death. The Mount Sinai Medical Center program gives you basic coverage at no cost to you, and the opportunity to purchase valuable supplemental financial protection for yourself and your dependents. 0.5 to 7.5 x your base salary in 0.5 increments. Maximum Supplemental Life Allowed $1,500,000 Total Life Insurance coverage $2,500,000 (Includes Basic and Supplemental Life Insurance) Reduction of Life Insurance due to Age None Dependent Life Insurance Coverage Spouse: increments of $25,000 up to $100,000 Child(ren): $5,000 each child or $10,000 each child Evidence of Insurability Requirement (EOI) 1.5 x your base salary up to a maximum of 1,000,000; or Flat $50,000 (not subject to imputed income) The maximum amount allowed is 1x base salary. An EOI is required for an amount greater than 1x base salary. On any amount purchased for your spouse over $25,000 Accidental Death & Dismemberment (AD&D) Coverage Coverage equals your total Life Insurance you elected. Decline coverage House Staff Residents Flat $100,000 in basic life insurance coverage and flat $100,000 in AD&D The maximum amount allowed is 2x base salary up to a maximum amount of $500,000. An EOI is required for an amount greater than 2x or $500, This is a group term life insurance plan, which does not build cash value. -- Employer paid basic coverage in excess of $50,000 is subject to imputed income tax. To avoid paying this imputed income tax, you may select the employer paid $50,000 coverage in place of the higher employer paid basic coverage. 2 Supplemental Life Insurance is additional life insurance that you may purchase and is paid by you with after-tax dollars. -- Preferred Life Insurance Program: Some employees are alternatively covered under a grandfathered preferred life program through Mass Mutual or Executive Life Insurance. Mass Mutual only: EOI is required for any level change for this program, including any salary increases. Please note that there are no changes to the Preferred Life Program. Imputed Income Imputed Income is the value the Internal Revenue Service (IRS) places on employer-paid group term life insurance coverage in excess of $50,000. It is considered taxable income. This value is determined using a set scale of rates published in the Internal Revenue Code. The IRS value of your Imputed Income is added to your gross income for federal tax purposes. At the end of the year, Mount Sinai must report the taxable portion on your W2 form. During the year, this amount is shown separately on your pay stub as LIFEIMPT. This is NOT a deduction. Any supplemental life insurance you may have elected is not included in the calculation of Imputed Income. Supplemental life is fully paid for by the employee there is no employer-paid coverage and therefore no imputed income.

29 Your Life Insurance Plan Choices 27 Supplemental Life Insurance Options The price of supplemental life insurance coverage for yourself is based on the cost of the option you select, your base salary as of a date determined by Human Resources and your age as of December 31 st prior to the plan year. For new hires or newly eligible employees, the price of supplemental life insurance and your coverage level is based on the cost of the option you select, your base salary and your age at the time of eligibility. The price of supplemental life insurance is adjusted once each year to reflect your new salary. Declining Life Insurance Coverage While you may decline dependent life insurance coverage, you cannot decline life insurance coverage for yourself. Mount Sinai believes it is important for every member of the Faculty and Staff to have some life insurance and requires that you at least carry basic coverage. Dependent Life Insurance You also may purchase dependent life insurance coverage for your spouse, domestic partner, and eligible dependent children through Aetna. You can elect coverage for: Your spouse or domestic partner in increments of $25,000, up to a maximum of $100,000 in life insurance and/or Your eligible child(ren) in the amount of $5,000 per child or $10,000 per child. If you elect Dependent Life Insurance, it is important to note that spouse/domestic partner and child coverage is elected jointly. When you select this option, all your eligible dependents will be enrolled under this coverage. You pay for this coverage with post-tax dollars. Coverage for your spouse cannot exceed 100% of your total life insurance. A certificate of coverage will be available upon request. Evidence of Insurability Evidence of Insurability will be required if you purchase dependent life insurance coverage for your spouse/domestic partner in any amount over $25,000. Accidental Death & Dismemberment (AD&D) Coverage You also may elect Accidental Death and Dismemberment (AD&D) coverage equal to the amount of total life insurance you have elected. AD&D coverage provides a benefit if you die or become dismembered as a result of an accident. If the accident results in your death, these benefits are paid in addition to your life insurance coverage. You pay for this coverage with after tax-dollars.ad&d coverage is available to employees only. Naming a Beneficiary If you want to choose a beneficiary for the first time, or if you want to change your current beneficiary designation, the Hartford Beneficiary Designation website at will be available until 12/31/2012. You will need a username and password to use the site. If you do not have this information, please contact Hartford at Effective 01/01/2013, Aetna will become the system of record for beneficiary information. Faculty and staff will receive a notice from Aetna in January instructing them to review or update their beneficiary information. You may name anyone as your beneficiary. If you name more than one person, you must indicate what percentage of the total payment each should receive. If you don t specify a percentage, your beneficiaries will receive equal amounts. The beneficiary you select for your life insurance coverage also will be the beneficiary for your AD&D coverage. You are automatically the beneficiary for dependent life insurance. In general, if you do not complete a beneficiary form or if a no named beneficiary survives you, we may at our option, pay: 1) The executors or administrators of your estate; or 2) All to your surviving spouse; or 3) If your spouse does not survive you, in equal shares to your surviving children; or 4) If no child survives you, in equal shares to your surviving parents.

30 28Your Disability Plan Choices Additional Coverage (Enhanced STD option) Please note that if you have enough accrued sick bank days and PTO days to use while you are out on LOA, purchasing additional STD coverage may not be the right choice for you. The disability insurance company will only send you a disability payment when you are no longer using your accrued time. Disability Coverage Ask Yourself If I become disabled, what other sources of income would be available? What are my regular monthly expenses? Who will pay the bills if I become disabled and can t work? If I become disabled, would I need to hire someone to care for me? If so, how would I pay for that care? Do I have any other disability coverage (besides Mount Sinai coverage) that I should take into consideration? Your Disability Plan Choices Disability benefits help protect your family s standard of living if you are unable to work because of a disabling illness or injury. Short-Term Disability Coverage Your non-occupational short-term disability (STD) coverage through Prudential provides protection beginning after you ve been disabled for seven calendar days. Benefits begin on the eighth day and last for up to 26 weeks. Telephone Claim Submission If you are disabled for more than seven consecutive calender days, you are required to call Prudential to submit your disability claim. Make sure to have your disability benefits card, that is part of the Telephone Claim Submission Brochure, available when you call. You may obtain the brochure from the Human Resources website or visit your Local Benefits Office. Please also refer to Appendix A, page 87 for a copy of the brochure that has step by step instructions on how to submit your disability claim. Mount Sinai provides basic STD coverage at no cost to you. This amount cannot be waived. The benefit offered is equal to 66 2/3% of base salary, up to a benefit of $170 per week. Additional STD coverage to increase your benefit to 66 2/3% of base salary up to $1,000 per week can be purchased. You pay for additional STD coverage with pre-tax-dollars. While out on short-term disability any STD benefits you actually receive will be taxed as regular income. For employees eligible for sick time, or disability income protection under the PTO (Paid Time Off) Program, any unused sick leave or savings sick time days should be used while out on short-term disability. If you do not have enough accrued days while you are on STD, Prudential may begin to send you disability payments for the remaining time you are out on STD. Evidence of Insurability During Open Enrollment, if you elect to opt up to the Enhanced STD Plan, you will be required to complete an Evidence of Insurability application (EOI). Please complete the application that is available on the enrollment website. Please print and submit the application to Prudential at the address or fax number, on the form, by the end of November. An application is also available under the Forms Library on enrollment site, Prudential will review your application and provide you with their determination. Approval from Prudential is required to receive the higher benefit. If approval is not provided, you will be enrolled in the basic STD plan. Worker s Compensation Occupational accidents or illnesses are covered under Worker s Compensation that is provided by Mount Sinai. Please contact your supervisor regarding any on-the-job accidents or illnesses. Prudential LTD Benefits At-A-Glance Employer Paid LTD Percentage of Base Salary Benefit Replaces Maximum Monthly Benefit Coverage 1 60% $15,000 House Staff Residents receive, at no cost, a monthly LTD benefit equal to 60% of base monthly pay to a maximum of $3,500. 1Paid Visiting Faculty/Associates, Post-Doc Fellows, Trainees, Temporary Employees, North Shore staff, members of the Brotherhood Security Personnel Officers, Guards International Union, Offsite Physician Practices (hourly employees) and the members of the Mount Sinai Hospital Pharmacy Association are not eligible for LTD.

31 Your Disability Plan Choices29 What Happens to Your Benefits while out on LTD If an employee is approved for long-term disability (LTD) and begins to receive LTD payments, their status will change to termination. The effective date of the termination is generally on the day the LTD is approved. At this point, if eligible, the employee will be eligible for the LTD program. The LTD program provides the employee the opportunity to continue their benefits as follows: Single coverage for Medical, Basic Prescription, and Dental under the BasicCare program. There is an ongoing monthly cost-share for coverage. Dependents that were covered at the onset of the disability may be covered under COBRA for medical, prescription, dental and vision. If under 60 years old at the onset of the disability, life insurance can continue at no cost, provided the application is approved by Aetna. If 60 or over, life insurance may be converted to an individual policy. Vision coverage may continue through COBRA. Once LTD is approved, Human Resources will notify the participant regarding covered benefits and cost while out on LTD. Long-Term Disability Coverage Your long-term disability (LTD) coverage, also through Prudential, protects you and your family from loss of income if you are certified as disabled (due to occupational or non-occupational causes), by the insurance company, beyond an initial 26-week period. Your LTD benefits options are listed in the following chart. This benefit is provided at no cost to you. Pre or Post-Tax LTD Benefit Payment: If LTD coverage is selected on a pre-tax basis: this means that the cost to Mount Sinai for this coverage is not reported as taxable income on the employee s W-2. If the employee becomes disabled and is entitled to receive disability payments from the insurance company, those payments are taxed as ordinary income. If LTD coverage is selected on a post-tax basis: this means that the cost to Mount Sinai for this coverage is reported as taxable income on the employee s W-2. The employee can also see the amount on their pay stub under LTD Value. If the employee becomes disabled and is entitled to receive disability payments from the insurance company, those payments are tax free. Certificate of coverage for Short and Long Term Disability Plans are available upon request. How Long Your Benefit Continues Generally, if you remain totally disabled, you will continue to receive benefits according to the following schedule. From time to time, the insurance company may require proof of your continued disability. Age When Totally Disabled Under age 61 Age 61 Age 62 Age 63 Age 64 Age 65 Age 66 Age 67 Age 68 Age 69 and over *Your normal retirement age is the age as determined by Social Security. Declining Disability Coverage You cannot waive STD coverage. New York State law requires employers to provide a minimum level of short-term disability coverage. Long Term Disability coverage cannot be waived. Length of Benefits To your normal retirement age*, but not less than 60 months To your normal retirement age, but not less than 48 months To your normal retirement age, but not less than 42 months To your normal retirement age, but not less than 36 months To your normal retirement age, but not less than 30 months 24 months 21 months 18 months 15 months 12 months

32 30Health Care and Dependent Care Reimbursement Accounts Flexible Spending Accounts Health Care (HCRA) and Dependent Care (DCRA) Reimbursement Accounts What is a Reimbursement Account? A Reimbursement Account provides you with a way to pay for certain health care and dependent care expenses on a pre-tax basis. The tax exemption for the account applies to federal income and social security taxes. However, state tax laws vary and you should consult your tax advisor to determine if any part of your pre-tax contribution may be taxable for state purposes. How the Accounts Work Each year you must decide if you want to participate in HCRA and/or DCRA, and how much you want to contribute to each. Once you decide on your annual contribution(s), money is deducted from your paycheck on a pre-tax basis. The money set aside is used to reimburse for eligible expenses and you are not taxed on the reimbursement. Eligible Expenses Eligible expenses must be incurred between January 1 and December 31 of the current year: If you join the plan in the middle of the year (i.e. new hires or as a result of a qualifying event), expenses must be incurred during the period you are actually contributing to the plan. You have until March 31st of the following year to submit claims incurred between January 1 and December 31 of the current year for reimbursement. Submitting Claims Claim forms can be found at or on Special IRS Rules The IRS places important restrictions on these accounts in return for their tax advantages, so you must plan carefully. Use It or Lose It! If you do not incur expenses for all the money in an account by the end of the plan year, the unused money will be forfeited. In some instances, you may elect or decline coverage during the year provided that you have a qualifying event. Examples of qualifying events include marriage, divorce or legal separation, a change in your spouse's employment or health coverage, birth or adoption, death of a spouse or child. Changes must be recorded within 31 days of the qualifying event, or such longer period as required by law, or you will have to wait until the next annual enrollment. Funds set aside for dependent care cannot be used to reimburse health care expenses and vice versa. Because IRS requirements offset the tax-advantage of this benefit, same-gender domestic partners of Mount Sinai employees (and their children) cannot participate in either reimbursement account unless they qualify as dependents under Code Section 152. Each year you must sign up for this benefit, if you wish to participate. For a complete list of eligible expenses, visit the Internal Revenue Service website at

33 Note: Premiums for health insurance, including COBRA (Consolidated Omnibus Reconciliation Act) premiums for a dependent, and expenses related to cosmetic surgery are not eligible for reimbursement. Important Information: HCRA and Limited HCRA Accounts Effective January 1, 2011, expenses for nonprescription drugs that constitute medical care under Section 213 of the Code (i.e., over the counter drugs) are not eligible for reimbursement (other than insulin) obtained without a prescription. This change does not currently apply to medical items, equipment, supplies or diagnostic devices, such as bandages, crutches or blood sugar test kits, obtained over the counter. If You Leave Mount Sinai: You may submit claims for health care expenses incurred prior to your termination date. You will forfeit any funds remaining in your account after all eligible claims have been paid, unless you elect to continue your contributions on an after tax basis under COBRA. In this case, you will also pay administrative costs. Health Care and Dependent Care Reimbursement Accounts 31 Health Care Reimbursement Account (HCRA) You may contribute a minimum of $240, up to $2,500 annually in pre-tax dollars to HCRA. Eligible unreimbursed expenses can be for yourself, your spouse, or other eligible family members*, even if they are not covered under Mount Sinai's medical (including prescription drug), dental or vision plans as long as you claim them as dependents on your tax return. Limited Purpose Flexible Spending Account (Limited HCRA) Notwithstanding any other provision of this SPD, if you elect to contribute to an HSA account, you may not enroll in a Health Care Reimbursement Account described above, but you may enroll in the Limited Purpose Flexible Spending Account (a "Limited HCRA"). A Limited HCRA is subject to all of the terms and conditions described in this SPD, except that the only eligible expenses that may be reimbursed by a Limited HCRA are dental, vision, and preventive care expenses as described in IRS Notice incurred that are not reimbursable through any other benefits. Eligible Expenses Medical, dental and drug expenses excluding non-prescribed over-the-counter medications not covered under your health insurance. This can include the deductibles, co-payments, co-insurance (the percentage of charges not paid by an insurance carrier), and medical and dental expenses over reasonable and customary limits or plan maximums or private hospital rooms. Vision expenses not covered under your insurance plan, including prescription glasses and contact lenses. Expenses for hearing aids and examinations beyond what the medical plan may cover. Other types of health care expenses that you could claim as federal income tax deductions. The IRS limits the amount you can claim on your tax return, but these limits do not apply to a reimbursement account. For a complete listing of eligible expenses, please log on to the flex direct website at Getting Reimbursed Reimbursement Services ADP offers you the convenience of either having your claim payments directly deposited into your bank account or by receiving a paper check. Enrollment forms and the Direct deposit authorization form are available on the benefits enrollment Web-site in the Forms Library at or at You can file an eligible claim at any time prior to March 31 of the following year, up to your annual HCRA specified election amount, for claims incurred during the current year. Proof of Expenses An Explanation of Benefits statement from the health plan insurance company indicating the amounts the plan paid and the remaining balance. Itemized bills from your doctor, dentist or other health care provider showing the date the expenses were incurred and the amount of each expense not covered by your health care plans. * Family members are defined by IRS regulations.

34 32Health Care and Dependent Care Reimbursement Accounts Special Rule for Qualified Reservists If you were ordered or called to active duty for a period in excess of 179 days or for an indefinite period, you may be eligible to take a distribution of all or a portion of the balance in your HCRA (a Qualified Reservist Distribution ). In order to do so, you must submit a paper claim form to ADP for the Qualified Reservist Distribution, indicating the amount you would like to withdraw, during the period beginning on the date of the order or call and ending on the last date that reimbursements could otherwise be made under the HCRA for the Plan Year that includes the date of such order or call. If the requirements are satisfied for a Qualified Reservist Distribution, ADP will make the Qualified Reservist Distribution to you within a reasonable time (not to exceed 60 days) following your request. Dependent Care Reimbursement Account (DCRA) You may contribute up to $5,000 annually in pre-tax dollars to DCRA per household. There is no annual minimum as required with HCRA. Children under age 13 whom you may claim as a deduction on your federal income tax return are considered eligible dependents. Other dependents-for example, a disabled spouse or parent - will be considered eligible if they require full-time care because of physical or mental disability and they are claimed as dependents on your federal income tax return. A person other than your spouse must rely on you for more than one-half of his or her support to qualify as a dependent. You are eligible to participate if you are: A single head of household Paying for dependent care in order to work Married - both you and your spouse must be "gainfully" employed or a full-time student to qualify Additional factors which may impact your decision: If you are married and filing separate tax returns, your maximum limit is $2,500. If you are married and your spouse has elected an amount under his/her plan at work then your maximum limit is reduced by that amount. The maximum amount you may elect is limited to your earned income for the calendar year, if it s less than $5,000, after all reductions in compensation (including the reduction related to dependent care assistance). The total amount you elect for your dependent care account cannot be greater than the lesser of your or your working spouse s annual income. Due to IRS requirements, highly compensated employees with an annual compensation of more than $115,000 a year will be limited to a $1,385 annual contribution per household, with the possibility of further adjustment. Those affected may be able to contribute more through a spouse's plan, and should check with a tax advisor to be sure. Eligible Expenses Reimbursable dependent care expenses include: Non-educational care, such as before and after school programs, preschool tuition (below kindergarten, as long as it does not include charges for any educational tuition), summer day camp (but not overnight camp), and daycare centers. Child care provided outside or in your home by someone other than another dependent who is at least 18 years of age. Housekeeping expenses, but only the amount directly related to caring for a dependent. Care provided outside the home for a dependent other than a child as long as the dependent spends at least eight hours a day in your home. Senior Centers.

35 Health Care and Dependent Care Reimbursement Accounts 33 For a complete list of eligible expenses, visit the Internal Revenue Service website at Note: The IRS requires you to furnish the tax ID number, name and address of any dependent care provider when filing a claim. Although the IRS allows a tax credit on dependent care expenses, the credit does not apply to expenses paid through a reimbursement account. Generally, if you earn more than $24,000 per year, the reimbursement account should save you more than the tax credit, but you may need to seek professional tax advice before deciding which approach is better for you. Getting Reimbursed Reimbursement Services ADP offers you the convenience of either having your claim payments directly deposited into your bank account or by receiving a paper check. Enrollment forms and the EFT Direct deposit authorization form are available on our Web-site under the Forms Library at or at You can file a claim at any time, although the amount you can be reimbursed for at any one time is limited to the amount already deposited in your account. Reimbursement for expenses will be processed once the service is completed. In order for ADP to know when the service is completed you must indicate an end date on your claim form. If an end date is not indicated, your claim will not be processed. If the claim amount exceeds your reimbursement account balance, the remainder will be paid once you have accumulated sufficient funds. Please note that services for day camp must be completed before payment can be received. Other necessary proof of expenses can include: Original bills from the provider, nurse, day care center, etc. The Federal Tax Identification number or Social Security number of the provider Other proof of payment Important Deadline! You have until March 31st of the following year to submit claims for reimbursement of expenses incurred in the previous year.

36 34Transportation Reimbursement Incentive Program (TRIP) Transportation Reimbursement Incentive Program (TRIP) Transit and Parking Accounts (ADP) The Transportation Reimbursement Incentive Program The Basics As part of Beneflex, the Transportation Reimbursement Incentive Program or TRIP is an easy-to-use- employee benefit program that helps to reduce the burden of qualified transportation and parking expenses. Eligible Faculty and Staff can realize savings by paying less in income taxes. This is done by allowing Faculty and Staff to contribute on a pre-tax basis to special Transit and Parking accounts. How the TRIP Accounts Work TRIP allows you to make pre-tax contributions through payroll deductions into TRIP accounts. The pre-tax contributions are exempt from federal income and Social Security taxes. In addition, TRIP contributions are exempt from New York and Connecticut State and Local taxes. However, New Jersey and Pennsylvania do not permit exemptions for TRIP contributions. The contribution amounts that you may contribute to the program are as follows: Minimum and Maximum TRIP Amounts Minimum contribution per month Maximum contribution per month Maximum contribution per year For public transit or vanpooling expenses $10 $125 $1,500 For parking expenses $10 $240 $2,880

37 TRIP 35 The Transportation Reimbursement Incentive Program allows for very specific transit and parking expenses. You can participate in one or both of the TRIP accounts. Qualified Transportation and Parking benefits eligible for reimbursement under TRIP are defined in the Internal Revenue Code as follows: Transit or Commutation Vanpooling. Vanpooling means transportation to and from work and an employee s residence, but only if in a commuter highway vehicle with a seating capacity of six or more adults (not including the driver), and at least 80 percent of the mileage use of which can reasonably be expected to be for purposes of transportation of employees between work and residences, and on trips during which the number of employees carried is at least one-half of the adult seating capacity of such vehicle (not including the driver). This can include transportation furnished by your employer. It does not include expenses for car, taxi or limousine service limited to only a small number of passengers usually one or two employees. Transit pass. Transit pass means any pass, token, farecard, voucher, or similar item that entitles the employee to transportation to and from work (or transportation at a reduced price), provided that such transportation is on mass transit facilities, or provided by an entity in the business of transporting persons if such transportation is provided in the type of commuter highway vehicle eligible for use in vanpooling. Some examples of Transit expenses eligible for reimbursement: New York City subway and buses New York, New Jersey, Connecticut and Pennsylvania Commuter Bus Services Commuter Rail Services including but not limited to Amtrak, Long Island Rail Road, Metro-North, NJ Transit, PATH, and Staten Island Railway Ferry Services Parking Qualified parking. Qualified parking, means parking provided to an employee on or near the business premises of Mount Sinai Medical Center. It can also mean parking provided on or near a location from which the employee commutes to work by mass transit, vanpooling, in a commuter highway vehicle, or by carpool. It does not include parking on or near an employee s residence. Some examples of expenses not eligible for reimbursement: Car or vanpooling expenses, including taxis, when there are less than six passengers, not including the driver (however, qualified parking would be eligible) Tunnel, bridge or highway tolls Non-work related transportation or parking expenses (i.e. parking at home, parking at the ball game or transit passes used to visit your family Expenses you may incur in traveling from your office to business or client meetings, etc.

38 36TRIP Available Payment Methods There are two methods that are available to you if you are a participant of the TRIP program. Before you use these methods, you will need to first determine the pre-tax amount you want deducted from your paycheck. These payroll deductions are held in TRIP transit and parking accounts by ADP. To specify the amount you want deducted from your paycheck, visit The First Method: On-Line Commuter Benefits (OCB) The On-Line Commuter Benefits allows ADP to purchase your commuter card or pay your parking vendor with the deductions in your TRIP account. To use this method the following time line must be followed: You must place your order through OCB at by the 5th of every month to receive your transit pass by the first of the following month. When an order is placed, you will also be asked for credit card information. This is requested in case that there are not enough funds in your TRIP account to cover the cost of the order. If you do not provide your credit card information, the order may not be processed due to insufficient funds and you will be required to send in a claim form to ADP for reimbursement. If you forget to use the OCB for any month, you must send in a reimbursement claim form for the month(s) you did not use the OCB method. (Please see second method.) You have the option to make a per month purchase, or you can elect a recurring order so you do not have to order your transit pass/parking set-up each month. Your transit pass will be mailed to your home address or your parking vendors will be paid between the 17 th and the 23 rd of every month. You should not attempt to submit a claim form (paper method) and use the online ordering method at the same time. Please select the option that best meets your needs. Please contact ADP at by the third business day of the month to report a pass that has not been received. An OCB Guide is available for you to review on or intranet\mountsinai.org/humanresources. It provides step by step instructions for you to follow. If you have any questions regarding OCB, please contact The Second Method: Paper Method Direct Deposit or Paper Check On-Line Commuter Method Please see page 91 for Frequently Asked Questions The OCB Method is not replacing the current paper method of reimbursement. You can continue to receive reimbursement for incurred transportation and parking expenses by first paying for the service and then filing a claim for reimbursement with ADP. Claim forms can be found on our benefits enrollment Web-site at Claim Submission can also be processed on-line at Reimbursement Services ADP offers you the convenience of having your claim payments directly deposited into your bank account. In order to initiate the direct deposit option, please call ADP at 1(866) and request that ADP send you an EFT Authorization form to complete. You can also visit or print forms from our Forms Library on the benefits enrollment Web-site at The form must be returned to ADP for processing. ADP will process your request in 10 full business days. Please note that the first TRIP reimbursement(s) will be paper check and future reimbursements will be direct deposit. If you cancel or change the bank account to which your reimbursement is being direct deposited, please notify ADP as soon as possible. If you choose your monies to be reimbursed through paper check, your reimbursement will be sent to your home address. Please be aware that the cash reimbursement check will be made out in your name. Checks may not be made out to a provider, such as a parking facility, transit authority, etc.

39 TRIP 37 Important Reminder For the Parking Benefit Both TRIP and the Mount Sinai Pre-Tax Parking Program are governed by Internal Revenue Code Section 132, which allows employees to have the cost of qualified parking expenses deducted from their pay on a pre-tax basis, up to the Plan limit. If you are currently participating in the Mount Sinai Pre-Tax Parking Program, then you are already eligible to receive the maximum parking benefit allowed by law and, therefore, cannot, in addition, participate in the TRIP Parking account. If you have any questions specific to your Mount Sinai Pre-Tax Parking deduction, please contact Security at /5662. Important Deadline! You have until March 31st of the following year to submit claims for reimbursement of expenses incurred in the previous year. Eligible Claims Eligible expenses for reimbursement are for services that you incur during a month while you are an active participant. Claim amounts in excess of the monthly limitations will not carry over to the next month for reimbursement. However, unclaimed monthly contributions will rollover from month to month until the end of the calendar year. Rollover Contributions You should submit a claim form to ADP by March 31 of the following year for contributions made in the previous year. If you do not claim your contributions by this date the unclaimed contributions will rollover to the following year. The unclaimed contributions will rollover in April of each year. Please note that you may need to adjust your current contributions (Do not stop your contributions.) so not to exceed the monthly maximum. The same maximums will continue to apply. If you do not adjust your contribution amount, the excess contributions will continue to rollover from year to year. If you terminate employment you can only claim contributions up to the maximum monthly amount for the months that you were actively employed in the year you terminate. Enrolling in the Plan You may enroll in the TRIP program at any time effective as quickly as administratively possible. Only Mount Sinai Medical Center employees are eligible to enroll in the program. Your spouse or your other dependents are not eligible to enroll. You may enroll by using the ADP enrollment Web-site at Once you are enrolled you will not need to enroll each year, unless you wish to terminate or modify your elections. This means that your elections will automatically roll over to the following year. You may, at any time during the year, use the ADP enrollment Web-site to increase or decrease contributions, or revoke future contributions. For more detailed information about TRIP, visit the benefits enrollment Web-site at Effective Date of Changes The effective date of all changes is on the first day of the following month.

40 38How to Enroll How to Enroll Open Enrollment During this period your selections will rollover to the following year if you do not make any changes to your benefits. If you want to make changes please visit the enrollment site at during Open Enrollment. Please note: you must re-enroll in the Dependent Care Reimbursement, Health Care Reimbursement and Limited Purpose Health Care Reimbursement programs each year. These elections do not rollover to the following year. Confirmation Period There is an additional time period after Open Enrollment in which you will be able to review your benefits again and make any other changes. Read the Materials Read the information in this Summary Plan Description (SPD) and the rest of the materials provided in the open enrollment information that was mailed to your home address. Meet the Deadline If you are a new hire, or otherwise newly eligible, and you do not enroll by the last day of the enrollment period (30 days) you will be assigned limited coverage (as highlighted in the chart on page 39). Enroll via our Web-site at Using the enrollment Web-site, log in by entering your Social Security number and PIN number, which are the 2 digits of your birth month and the last 2 digits of your birth year (ex: May 1970=0570). You will be asked to change your PIN number to a unique one. Specify your covered dependents/make your elections, submit your elections. If you like, you may print a confirmation of your enrollment selections at the end of your session. When you enroll for benefits, you must elect a coverage level for the Medical, Dental and Vision Plans. You may choose from the following coverage levels: Yourself only Yourself and one eligible family member Yourself and two or more eligible family members. You may choose the same or different coverage levels for each plan. However, the coverage level for prescription drug coverage must be the same as your election for medical coverage. Questions or Assistance with Enrolling on the Website Call MSMC(6762)

41 How to Enroll 39 Default Coverage If You Do Not Enroll If you do not enroll and submit any required forms by the enrollment deadline, you will be assigned the following default coverage. Benefit Plan Medical Prescription Drug Dental Vision Life Insurance Short-Term Disability Long-Term Disability HCRA/DCRA And TRIP Default Coverage UnitedHealthcare Choice Plus basic PPO (single coverage) Express Scripts basic coverage (single coverage) No coverage No coverage Basic Life Insurance Aetna No Dependent Life Insurance or AD&D coverage 66 2/3% of base salary up to $170/week through Prudential 60% of base salary up to $15,000 a month through Prudential No participation

42 40Summary of Plan Information Summary Of Plan Information Plan Name: Plan Sponsor: Plan Insurers: Employer Identification Number: Participating Employers: Plan Number: 501 Type of Plan: Plan Benefits: Type of Administration: Plan Administrator: Agent for Service of Plan Year: Plan Funding: The Mount Sinai Medical Center Cafeteria Benefit Plan The Mount Sinai Hospital One Gustave Levy Place Box 1019 New York, NY UnitedHealthcare Basic or Plus PPO, or Choice Plus/High Deductible Health Plan, HIP HMO, Empire Blue Cross Blue Shield HMO (for medical benefits), Express Scripts (for prescription drug benefits), ADP (for flexible spending benefits), MetLife or Cigna DHMO (for dental benefits), Prudential (for disability benefits), UnitedHealthcare Vision (for vision benefits) and Aetna Life Insurance (for life insurance benefits). The Mount Sinai Hospital (includes Mount Sinai Hospital of Queens) The Mount Sinai Medical Center The Mount Sinai School of Medicine, inclusive of Faculty and Staff at - City Hospital at Elmhurst Affiliation - Queens Hospital Center Affiliation Welfare Plan Medical and prescription drug benefits, dental benefits, vision benefits, health care and dependent care flexible spending benefits, life insurance benefits, long-term disability and short-term disability benefits. The Plan is administered by the Plan Administrator. However, the Plan insurers will be responsible for administration to the extent duties and responsibilities are delegated to them by the Plan Administrator. The Mount Sinai Hospital One Gustave Levy Place Box 1019 New York, NY The Plan Administrator. Calendar year The following Plan benefits are paid through group insurance policies with the Plan insurers: HIP HMO, Empire Blue Cross Blue Shield HMO, Cigna HMO, Prudential Insurance and Aetna Life Insurance. The following Plan benefits are self-insured and paid from the assets of the Mount Sinai Medical Center: UnitedHealthcare Basic or Plus PPO, Choice Plus/High Deductible Health Plan, MetLife and Express Scripts To obtain any information about the Plan, or to apply for benefits under the Plan, you should contact the Plan Administrator (at the above address). Because the Plan is a welfare benefit plan, as defined by ERISA, the benefits under the Plan are not guaranteed by the Pension Benefit Guarantee Corporation.

43 Your Rights Under the Employee Retirement Income Security Act of Your Rights Under the Employee Retirement Income Security Act of 1974 As a participant in the Plan, you are entitled to certain rights and protections under the Employee Retirement and Income Security Act of 1974, as amended ( ERISA ). ERISA provides that all Plan participants shall be entitled to: Receive Information About Your Plan and Benefits Examine, without charge, at the Plan Administrator s office and at other specified locations, such as worksites and union halls, all documents governing the Plan, including insurance contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the Plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration. Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the Plan, including insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated summary plan descriptions. The Plan Administrator may make a reasonable charge for the copies. Receive a summary of the Plan s annual financial report. The Plan Administrator is required by law to furnish each participant with a copy of this summary annual report. Continue Group Health Plan Coverage Continue health care coverage for yourself, spouse or dependents if there is a loss of coverage under the Plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review this summary plan description and the documents governing the Plan on the rules governing your COBRA continuation coverage rights. Reduction or elimination of exclusionary periods of coverage for preexisting conditions under your group health plan, if you have creditable coverage from another plan. You should be provided a certificate of creditable coverage, free of charge, from your group health plan or health insurance issuer when you lose coverage under the Plan, when you become entitled to elect COBRA continuation coverage, and when your COBRA continuation coverage ceases, if you request it before losing coverage, or if you request it up to 24 months after losing coverage. Without evidence of creditable coverage, you may be subject to a preexisting condition exclusion for 12 months (18 months for late enrollees) after your enrollment date in your coverage. Prudent Actions by Plan Fiduciaries In addition to creating rights for Plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your Plan, called fiduciaries of the Plan, have a duty to do so prudently and in the interest of you and other Plan participants and beneficiaries. No one, including your employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a benefit or exercising your rights under ERISA. Enforce Your Rights If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules. Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of Plan documents or the latest annual report from the Plan and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a State or Federal court. In addition, if you disagree with the Plan s decision or lack thereof concerning the qualified status of a domestic relations order or a medical child support order, you may file suit in Federal court. If it should happen that Plan fiduciaries misuse the Plan s money, or if you are discriminated against for asserting your rights, you may seek assistance

44 42Your Rights Under the Employee Retirement Income Security Act of 1974 from the U.S. Department of Labor, or you may file suit in a Federal court. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous. Assistance with Your Questions If you have any questions about your Plan, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington, D.C You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration. Qualified Medical Child Support Order ( QMCSO ) Federal law requires health plans to honor Qualified Medical Child Support Orders ( QMCSOs ). In general, QMCSOs are state court (or administrative agency) orders requiring a parent to provide medical support to a child, for example, in cases of legal separation or divorce where the child would otherwise not be eligible for coverage under the health plan. A QMCSO may require the health plan to make coverage available to your child even though, for income tax or plan purposes, the child is not your dependent (e.g., your child does not reside with you). In order to qualify as a QMCSO, the medical child support order must be a judgment, decree or order (including approval of a settlement agreement) issued by a court of competent jurisdiction or by an administrative agency, which does the following: Specifies your name and last known address, and the child s name and last known address; Provides a reasonable description of the type of coverage to be provided by the group health plan, or the manner in which the type of coverage is to be determined; States the period to which it applies; and Specifies each plan to which it applies. In addition, a National Medical Support Notice issued pursuant to ERISA Section 609(a)(5)(C) which has been appropriately completed and which satisfies the requirements listed above, will be deemed to be a QMCSO. The QMCSO may not require the health plan to provide coverage for any type or form of benefit, or any option, not otherwise provided under the terms of the health plan. Upon approval of a QMCSO, the health plan is required to pay benefits directly to the child, or to the child s custodial parent or legal guardian, pursuant to the terms of the order to the extent it is consistent with the terms of the health plan. You and the affected child will be notified if an order is received and will be provided with a copy of the health plan s QMCSO procedure. A child insured under the health plan pursuant to a QMCSO will be treated as a dependent under the health plan. Additionally, you or your beneficiaries may obtain, without charge, additional information or a copy of the procedures from the Plan Administrator. Subrogation Subrogation seeks to conserve Plan assets by imposing the expense for accidental injuries suffered by you or your eligible dependents, on those responsible for causing such injuries. If you or your dependents are injured as a result of the negligence or other wrongful acts of a third party and you or your dependents apply to the Plan for benefits and receive such benefits, the Plan shall then have a first priority lien for the full amount of the benefits that are paid to you and/or your dependents should you seek to recover any monies from the third party that caused the injuries. The employer strongly recommends that if you are injured as a result of the negligence or wrongful act of a third party, you should contact an attorney for advice and counsel. However, the Plan cannot and does not pay for the fees your attorney might charge.

45 Your Rights Under the Employee Retirement Income Security Act of Should you seek to recover any monies from the third party that caused your injuries, you must give notice to the Plan Administrator within ten (10) days after either you or your attorney first attempt to recover such monies, and if litigation is commenced, you are required to give notice to the Plan Administrator of any pretrial conferences within five (5) days of the same. Representatives of the Plan reserve the right to attend such pretrial conference. By accepting benefits from the Plan, you agree that you will timely comply with any and all requests from the Plan for documentation concerning any legal proceedings, settlement negotiations and/or medical information that may give rise to or affect the Plan s right to subrogation and/or restitution. The Plan s lien is a lien on the proceeds of any compromise, settlement, judgment and/or verdict received from the third party, his insurance carrier and/or any other party settling on his behalf. By applying for and receiving benefits from the Plan in such third party situations, you agree to restore to the Plan the full amount of the benefits that are paid to you and/or your dependents from the proceeds of any such compromise, settlement, judgment and/or verdict, to the extent permitted by law. By applying for benefits, you agree that the proceeds of any compromise, settlement, judgment and/or verdict received from the third party, his insurance carrier and/or any other party settling on his behalf, if paid directly to you, will be held by you in constructive trust for the Plan. The receipt of such funds makes you a fiduciary of the Plan with respect to such funds and, therefore, subject to the fiduciary provisions and obligations of ERISA. By applying for benefits, you agree that the proceeds of any compromise, settlement, judgment and/or verdict received from the third party, his insurance carrier and/or any other party settling on his behalf, and paid to a person or entity other than you, including but not limited to, a trust, an attorney or an agent thereof, shall be held by such other person, entity or trust in constructive trust for the Plan. The recipient of such funds is a fiduciary of the Plan with respect to such funds and is subject to the fiduciary provisions and obligations of ERISA. The Plan reserves the right to seek recovery from such person, entity or trust and to name such person, entity or trust as a defendant in any litigation arising out of the Plan s subrogation or restitution rights. By applying for benefits, you agree that any lien the Plan may seek will not be reduced by any attorney fees, court costs or disbursements that you and/or your attorney might incur in your action to recover from the third party, and these expenses may not be used to offset your obligation to reimburse the Plan for the full amount of the lien. Further, you agree that any recovery will not be reduced by and is not subject to the application of the common fund doctrine for the recovery of attorney s fees. The Plan does not require you to seek any recovery whatsoever against the third party, and if you do not receive any recovery from the party, you are not obligated in any way to reimburse the Plan for any of the benefits that you applied for and accepted. In the event you fail to notify the Plan as provided for above, and/or fail to restore to the Plan such funds as provided for above, the Plan reserves the right, in addition to all other remedies available to it at law or equity, to withhold any other monies that might be due to you from the Plan for past or future claims, until such time as the Plan s lien is discharged and/or satisfied. Any and all amounts received from a third party by judgment, settlement, or otherwise, must be applied first to satisfy your restitution obligation to the Plan for the amount of expenses paid by the Plan on behalf of you or your beneficiary. The Plan s lien is a lien of first priority for the entire recovery of funds paid on your behalf. Where the recovery from the third party is partial or incomplete, the Plan s right to restitution takes priority over your or your beneficiary s right of recovery, regardless of whether or not you or your beneficiary has been made whole for his or her injuries or losses. The Plan does not recognize and is not bound by any application of the make whole doctrine. Claims Procedure The claim procedures are intended to comply with United States Department of Labor Regulation and the Patient Protection and Affordable Care Act of 2010 (the Affordable Care Act ), and should be construed in accordance with such regulation. In no event shall it be interpreted as expanding your rights beyond what is required by United States

46 44Your Rights Under the Employee Retirement Income Security Act of 1974 Department of Labor Regulation and the Affordable Care Act. In the event that you or other payees have a dispute over a claim for benefits under any of the programs under the Plan, you or other payees may file a claim under the following procedures. To the extent these claim procedures are inconsistent with the claims procedures of the Component Plan, such as Component Plan s claims procedures will apply to the claims of participants thereunder, as long as such Component Plan s claims procedures comply with the requirements for non-grandfathered group health plans under the Affordable Care Act. (a) Initial Claims. If you or other payees are denied any benefit under this Plan, you may file a claim with the Plan Administrator, or the Plan insurer, if applicable. The Plan Administrator, or Plan insurer, if applicable, will review the claim itself or appoint an individual or an entity to review the claim. (i) Non-Health and Non-Disability Benefit Claims. In the case of a claim for a benefit other than a health or disability benefit, you will be notified within 90-days after the claim is filed whether the claim is allowed or denied, unless you receive written notice from the Plan Administrator (or Plan insurer, if applicable) prior to the end of the 90-day period stating that special circumstances require an extension of the time for decision, such extension not to extend beyond the day which is 180 days after the day the claim is filed. (ii) Health Benefit Claims. (A) Urgent Care Claims. If your claim is for urgent care health benefits, the Plan Administrator (or Plan insurer, if applicable) will notify you of the Plan s benefit determination (whether adverse or not) as soon as possible, taking into account the medical exigencies, but not later than 72 hours after receipt of the claim by the Plan, unless you fail to provide sufficient information to determine whether, or to what extent, benefits are covered or payable under the Plan. In the case of such a failure, the Plan Administrator will notify you as soon as possible, but not later than 24 hours after receipt of the claim by the Plan, of the specific information necessary to complete the claim. The notification may be oral unless written notification is requested by you. You will be afforded a reasonable amount of time, taking into account the circumstances, but not less than 48 hours, to provide the specified information. The Plan Administrator will notify you of the Plan s determination as soon as possible, but in no case later than 48 hours after the earlier of (1) the Plan s receipt of the specified additional information or (2) the end of the period afforded to you to provide the specified additional information. If you fail to follow the Plan s procedures for filing an urgent care claim, the Plan Administrator will notify you of the failure and the proper procedures to follow, not later than 24 hours after the procedural failure. This notification may be oral, unless you request written notification. You will only receive notification of a procedural failure if the claim is received by the Plan Administrator and it includes (i) your name, (ii) your specific medical condition or symptom, and (iii) a specific treatment, service or product for which approval is requested. A health benefits claim is considered an urgent care claim if the application of the time periods for making non-urgent care determinations could seriously jeopardize your life or health or your ability to regain maximum function or, in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that could not be adequately managed without the care or treatment which is the subject of the claim. Notwithstanding the foregoing, if you are enrolled in the HIP HMO or the Empire Blue Cross Blue Shield HMO, you will receive notice of the benefit determination in writing or electronically as soon as possible, but no later than 24 hours unless you fail to provide sufficient information to determine whether, or to what extent, benefits are covered under the Plan. In addition to the notice standards described above, all claim denial notices to individuals enrolled in the HIP HMO or the Empire Blue Cross Blue Shield HMO must include the following: (a) information identifying the claim involved, including the date of service, the health care provider, the claim amount, the diagnosis code, the treatment code, and the corresponding meaning of these codes; (b) the reason or reasons for the adverse benefit determination that includes the denial code and its corresponding meaning and a description of the Plan s standard, if any, that was used to deny the claim (for notices of final adverse benefit determinations, the description will include a discussion of the decision); (c) a description of available internal appeals and external review processes, including how to initiate an appeal; and (d) contact information for any applicable office of health insurance consumer assistance or ombudsman established under Health Care Reform to assist individuals with the internal claims and appeals and external review processes.

47 Your Rights Under the Employee Retirement Income Security Act of (B) Concurrent Care Claims. If the Plan has previously approved an ongoing course of health care treatment to be provided over a period of time or number of treatments, any reduction or termination by the Plan of the previously approved course of treatment (other than by Plan amendment or termination) before the approved time period or number of treatments shall constitute an adverse initial benefit determination. These determinations shall be known as concurrent care decisions. In such a case, the Plan Administrator (or Plan insurer, if applicable) will notify you of the adverse concurrent care decision at a time sufficiently in advance of the reduction or termination to allow you to appeal and obtain a determination on review of that adverse benefit determination before reduction or termination of the benefit. Any request by you to extend a course of urgent care treatment beyond the approved period of time or number of treatments shall be decided as soon as possible, taking into account the medical exigencies, and the Plan Administrator will notify you of the benefit determination, whether adverse or not, within 24 hours after receipt of the claim by the Plan, provided that any such claim is made to the Plan at least 24 hours prior to the expiration of the prescribed period of time or number of treatments. A health benefits claim is considered a concurrent care claim if it is a claim relating to an ongoing course of treatment approved by the Plan which is provided to you over a period of time or for a specified number of treatments. (C) Other Health Benefit Claims. In the case of a health benefit claim not described above: (1) In the case of a pre-service health benefit claim, the Plan Administrator (or Plan insurer, if applicable) will notify you of the Plan s benefit determination (whether adverse or not) within a reasonable period of time appropriate to the medical circumstances, but not later than 15 days after receipt of the claim by the Plan. If, due to matters beyond the control of the Plan, the Plan Administrator needs additional time to process a claim, you will be notified, within 15 days after the Plan Administrator receives the claim, of those circumstances and of when the Plan Administrator expects to make its decision. Under no circumstances may the Plan Administrator extend the time for making its decision beyond 30 days after receiving the claim. If such an extension is necessary due to your failure to submit the information necessary to decide the claim, the notice of extension must specifically describe the required information, and you will be afforded at least 45 days from receipt of the notice within which to provide the specified information. A health benefit claim is considered a pre-service claim if the claim requires approval, in part or in whole, in advance of obtaining the health care in question. If you fail to follow the Plan s procedures for filing a pre-service health benefit claim, the Plan Administrator will notify you of the failure and the proper procedures to follow, not later than 5 days after the procedural failure. This notification may be oral, unless you request written notification. You will only receive notification of a procedural failure if the claim is received by the Plan Administrator and it includes (i) your name, (ii) your specific medical condition or symptom, and (iii) a specific treatment, service or product for which approval is requested. (2) In the case of a post-service health benefit claim, the Plan Administrator will notify you of the Plan s adverse benefit determination within a reasonable period of time, but not later than 30 days after receipt of the claim. If, due to matters beyond the control of the Plan, the Plan Administrator needs additional time to process a claim, you will be notified, within 30 days after the Plan Administrator receives the claim, of those circumstances and of when the Plan Administrator expects to make its decision. Under no circumstances may the Plan Administrator extend the time for making its decision beyond 45 days after receiving the claim. If such a decision is necessary due your failure to submit the information necessary to decide the claim, the notice of extension shall specifically describe the required information, and you will be afforded at least 45 days from receipt of the notice within which to provide the specified information. A health benefit claim is considered a post-service claim if it is a request for payment for services for which you do not need advance approval before receiving medical care. (iii) Disability Benefit Claims. In the case of a disability benefits claim, the Plan Administrator (or Plan insurer, if applicable) will notify you of the Plan s adverse benefit determination within a reasonable period of time, but not later than 45 days after receipt of the claim. If, due to matters beyond the control of the Plan, the Plan Administrator needs additional time to process a claim, you will be notified, within 45 days after the Plan Administrator receives the claim, of those circumstances and of when the Plan Administrator expects to make its decision but not beyond 75 days. If, prior to

48 46Your Rights Under the Employee Retirement Income Security Act of 1974 the end of the extension period, due to matters beyond the control of the Plan, a decision cannot be rendered within that extension period, the period for making the determination may be extended for up to 105 days, provided that the Plan Administrator notifies you of the circumstances requiring the extension and the date as of which the Plan expects to render a decision. The extension notice shall specifically explain the standards on which entitlement to a disability benefit is based, the unresolved issues that prevent a decision on the claim and the additional information needed from you to resolve those issues, and you will be afforded at least 45 days within which to provide the specified information. (iv) Calculation of Time Periods. For purposes of the time periods specified in this section, the period of time during which a benefit determination is required to be made begins at the time a claim is filed in accordance with the Plan procedures without regard to whether all the information necessary to make a decision accompanies the claim. If a period of time is extended due to your failure to submit all information necessary, the period for making the determination shall be tolled from the date the notification is sent to you until the earlier of (i) date you respond or (ii) expiration of the 45- day period within which you must provide the requested additional information. (v) Manner and Content of Denial of Initial Claims. If the Plan Administrator (or Plan insurer, if applicable) denies a claim, you must be provided, in writing or by electronic communication: (A) The specific reasons for the denial or other adverse benefit determination; (B) A specific reference to the pertinent Plan provision or insurance contract provision upon which the denial is based; (C) A description of any additional information or material that you must provide in order to perfect the claim; (D) An explanation of why such additional material or information is necessary; (E) Notice that you have a right to request a review of the claim denial and information on the steps to be taken and the applicable time limits if you wish to request a review of the claim denial; and (F) A statement of your right to bring a civil action under 502(a) of ERISA following a denial on review of the initial denial. In addition, in the case of a denial of health benefits or disability benefits, the following must be provided: (G) A copy of any internal rule, guideline, protocol, or other similar criterion relied upon in making the adverse determination or a statement that the same will be provided upon request by you and without charge; and (H) If the adverse determination is based on the Plan s medical necessity, experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment applying the exclusion or limit to your medical circumstances or a statement that the same will be provided upon request by you and without charge. In the case of an adverse benefit determination concerning a health claim involving urgent care, the notification will also include a description of the expedited review process that applies to such claims. In addition, for urgent claims the information described in this section may be provided to you orally within the permitted time frame, provided that a written or electronic notification in accordance with this section is furnished not later than 3 days after the oral notification. In addition to the notice standards described above, effective January 1, 2012, all claim denial notices under a Component Plan that is a group health plan must include the following: (a) information identifying the claim involved, including the date of service, the health care provider, the claim amount, the diagnosis code, the treatment code, and the corresponding meaning of those codes; (b) the reason or reasons for the adverse benefit determination that includes the denial code and its corresponding meaning and a description of the Plan s standard, if any, that was used to deny the claim (for notices of final internal adverse benefit determinations, the description will include a discussion of the decision); (c) a description of available internal appeals and external review processes, including how to initiate an appeal; and (d) contact information for any applicable office of health insurance consumer assistance or ombudsman established under the Affordable Care Act to assist individuals with the internal claims and appeals and external review processes (as described below). (b) Review Procedures. (i) Non-Health and Non-Disability Benefit Claims. Except in the case of health or disability benefits, a request for review of a denied claim must be made in writing to the Plan Administrator (or Plan insurer, if applicable) within 60 days after

49 Your Rights Under the Employee Retirement Income Security Act of receiving notice of the denial. The decision upon review will be made within 60 days after the Plan Administrator s (or Plan insurer s, if applicable) receipt of a request for review, unless special circumstances require an extension of time for processing, in which case a decision will be rendered not later than 120 days after receipt of a request for review. A notice of such an extension must be provided to you within the initial 60-day period and must explain the special circumstances and provide an expected date of decision. The reviewer shall afford you an opportunity to review and receive, without charge, all relevant documents, information and records and to submit issues and comments in writing to the Plan Administrator (or Plan insurer, if applicable). The reviewer shall take into account all comments, documents, records and other information submitted by you relating to the claim regardless of whether the information was submitted or considered in the initial benefit determination. A document, record or other information is considered relevant to a claim for this purpose if it (i) was relied upon in making the benefit determination, (ii) was submitted, considered, or generated in the course of making the benefit determination, without regard to whether such document, record or other information was relied upon in making the benefit determination, or (iii) demonstrates compliance with the administrative process and safeguards required by law when making the benefit determination. (ii) Health and Disability Benefit Claims. In addition to having the right to review documents and submit comments as described in (b)(i) above, you will have for health or disability benefits at least 180 days following receipt of a notification of an adverse benefit determination within which to request a review of the initial determination. In such cases, the review will meet the following requirements: (A) The Plan will provide a review that does not afford deference to the initial adverse benefit determination and that is conducted by an appropriate named fiduciary of the Plan who did not make the initial determination that is the subject of the appeal, nor is a subordinate of the individual who made the determination. (B) The appropriate named fiduciary of the Plan will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment before making a decision on review of any adverse initial determination based in whole or in part on a medical judgment, including determinations with regard to whether a particular treatment, drug or other item is experimental, investigational or not medically necessary or appropriate. The professional engaged for purposes of a consultation in the preceding sentence shall be an individual who was neither an individual who was consulted in connection with the initial determination that is the subject of the appeal, nor the subordinate of any such individual. (C) The Plan will identify to you the medical or vocational experts whose advice was obtained on behalf of the Plan in connection with the review, without regard to whether the advice was relied upon in making the benefit review determination. (D) In the case of a requested review of a denied initial claim involving urgent health care, the review process shall meet the expedited deadlines described below. Your request for such an expedited review may be submitted orally or in writing by you and all necessary information, including the Plan s determination on review, shall be transmitted between the Plan and you by telephone, facsimile or other available similarly expeditious method. (E) If you are enrolled in the HIP HMO or the Empire Blue Cross Blue Shield HMO, and such HMO is not subject to a State external review process, and your internal appeal of a claim for benefits (not related to employee classifications) under such HMO is denied, you will have the right to request an external (i.e., independent) review in accordance with Health Care Reform. (iii) Deadline for Review Decisions. (A) Urgent Health Benefit Claims. In case of urgent care health claims, the Plan Administrator (or Plan insurer, if applicable) will notify you of the Plan s determination on review as soon as possible, taking into account the medical exigencies, but not later than 72 hours after receipt of your request for review of the initial adverse determination by the Plan.

50 48Your Rights Under the Employee Retirement Income Security Act of 1974 (B) Other Health Benefit Claims. (1) In the case of a pre-service health claim, the Plan Administrator (or Plan insurer, if applicable) will notify you of the Plan s determination on review within a reasonable period of time appropriate to the medical circumstances, but in no event later than 30 days after receipt by the Plan of your request for review of the initial adverse determination. (2) In the case of a post-service health claim, the Plan Administrator (or Plan insurer, if applicable) will notify you of the Plan s benefit determination on review within a reasonable period of time, but in no event later than 60 days after receipt by the Plan of your request for review of the initial adverse determination. (C) Disability Benefit Claims. In the case of disability claims, the decision on review will be made within 45 days after the Plan Administrator s (or Plan insurer s, if applicable) receipt of a request for review, unless special circumstances require an extension of time for processing, in which case a decision will be rendered not later than 90 days after receipt of a request for review. A notice of such an extension must be provided to you within the initial 45-day period and must explain the special circumstances and provide an expected date of decision. (D) Calculation of Time Periods. For purposes of the time periods specified in this section, the period of time during which a benefit determination is required to be made begins at the time a claim is filed in accordance with the Plan procedures without regard to whether all the information necessary to make a decision accompanies the claim. If a period of time is extended due to your failure to submit all information necessary, the period for making the determination shall be tolled from the date the notification requesting the additional information is sent to you until the earlier of (i) date you respond or (ii) expiration of the 45-day period within which you must provide the requested additional information. (iv) Manner and Content of Notice of Decision on Review. Upon completion of its review of an adverse initial claim determination, the Plan Administrator (or Plan insurer, if applicable) will give you, in writing or by electronic notification, a notice containing: (A) its decision; (B) the specific reason or reasons for the decision, with references to the pertinent Plan provisions or insurance contract provisions on which its decision is based; (C) a statement that is entitled to receive, upon request and without charge, reasonable access to, and copies of, all documents, records and other information relevant to your claim for benefits; (D) a statement describing your right to bring civil action for judicial review under 502(a) of ERISA; In addition, in the case of a denial of health benefits or disability benefits, the following must be provided: (E) if an internal rule, guideline, protocol or other similar criterion was relied upon in making the adverse determination on review, a statement that a copy of the internal rule, guideline, protocol or other similar criterion will be provided without charge upon your request; (F) if the adverse determination on review is based on a medical necessity, experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment on which the determination was based, applying the terms of the Plan to your medical circumstances, or a statement that such an explanation will be provided without charge upon your request; and (G) the following statement You and your Plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor Office and, if your benefit is an insured benefit, your State insurance regulatory agency. (v) Before you file a civil action under Section 502(a) of ERISA in federal court, you must have filed a claim and appeal with the Plan Administrator or Plan insurer, if applicable, as described herein, and your claim for benefits and subsequent appeal must have been denied in whole or in part. (vi) Any claim for benefits under the Dependent Care Reimbursement Account will be submitted to and decided by the Plan Administrator (or Plan insurer, if applicable) in accordance with reasonable procedures. The Plan Administrator (or

51 Your Rights Under the Employee Retirement Income Security Act of Plan insurer, if applicable) will be responsible for providing a review of any appeal by you of a full or partial denial of a claim for benefits under the Dependent Care Reimbursement program. (vii) Solely to the extent required by the Affordable Care Act, if the Component Plan is a group health plan that is not subject to a State external review process, and your internal appeal of a claim for benefits (not related to employee classifications) under such Component Plan is denied, you shall have the right to request an external (i.e., independent) review in accordance with the Affordable Care Act, if you do so within four months after receiving notice of an adverse benefit determination or final internal adverse benefit determination. Within five business days after receiving your request, a preliminary review will be completed to determine whether: (i) you are/were covered under the Plan; (ii) the denial was based on your ineligibility under the terms of the Plan;(iii) you have exhausted the Plan's internal process, if required; and (iv) you have provided all information necessary to process the external review. Within one business day after completing the preliminary review, you will be notified in writing if the appeal is not eligible for an external review or if it is incomplete. If the appeal is complete but not eligible, the notice will include the reason(s) for ineligibility. If the appeal is not complete, the notice will describe any information needed to complete the appeal. You will have the remainder of the four month filing period or 48 hours after receiving the notice, whichever is greater, to cure any defect. If eligible for an external review, the appeal will be assigned to an independent review organization (IRO). If the IRO reverses the Plan's denial, the IRO will provide you written notice of its determination. In addition, you will have the right to an expedited external review in the following situations: Following an adverse benefit determination involving a medical condition for which the timeframe for completion of an expedited internal appeal would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function and you have filed a request for an expedited internal appeal. Following a final internal adverse benefit determination involving (i) a medical condition for which the timeframe for completion of a standard external review would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function or (ii) an admission, availability of care, continued stay, or health care item or service for which you received emergency services but have not been discharged from a facility. The IRO will provide notice of its final external review decision as expeditiously as your medical condition or circumstances require, but not more than 72 hours after the IRO receives the request. The Plan Administrator has the exclusive right to interpret the provisions of the Plan. Decisions of the Plan Administrator are final, conclusive and binding. The Plan Administrator has final claims adjudication authority under the Plan. Coverage During Military Duty in The United States Armed Forces If you enter the Armed Forces of the United States, you will be offered the opportunity to continue health coverage under the Plan for yourself and your eligible spouse or domestic partner and dependent children, according to the provisions of the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA), as amended by the Veterans Benefit Improvement Act of 2004, for a period of up to 24 months during your military service. The cumulative length of the leave and all previous periods of military leave from the employer may not exceed five years (unless extended by national emergency or similar circumstances). If the period of military service is less than 31 days, your coverage (and that of your spouse or domestic partner and dependent children) will continue during the period of military service without charge. If the period of military service is 31 days or more, you will be required to pay the applicable COBRA premium to continue coverage for your spouse and dependent children. If you do not choose to continue coverage during your service, you will be entitled to have your coverage reinstated on the date you return to employment with the employer. There will be no exclusion or waiting period, except for certain service-connected disabilities. These rights granted by USERRA are dependent on uniformed service that ends honorably. A notice is required to be provided to employees regarding their rights, benefits and obligations under USERRA. This notice can be found on the Human Resources web-site.

52 50Your Rights Under the Employee Retirement Income Security Act of 1974 FMLA Leave Under the Family and Medical Leave Act (FMLA), you may be eligible to take up to 12 weeks of time off for the care of a qualified family member due to a serious health condition. If you are approved for FMLA leave, your health care coverage will continue as if you were an active employee. At the conclusion of your FMLA leave, you may be eligible for benefits under COBRA if: You or your enrolled dependents are covered on the day before the first day of FMLA leave or become covered during the FMLA leave under a group health plan. You do not return to employment at the end of the FMLA leave; and Your or your enrolled dependent(s) would, in the absence of COBRA, lose coverage under the group health plan before the end of what would be the maximum coverage period. In other words, you would no longer be covered under the same terms and conditions as those in effect for similarly situated active employee and their enrolled dependent(s). However, please note that you would not be eligible for COBRA if Mount Sinai were to eliminate group health plan coverage for its active employees during your FMLA leave. Your COBRA continuation period will begin at the end of your FMLA leave. For example, if you take FMLA leave and later decide not to return to work, your COBRA continuation of coverage would begin on your last day of FMLA leave. If you notify the employer that you do not plan to return to work, your COBRA continuation period will begin on the day after your termination. Newborn s and Mother s Health Protection Act Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother s or newborn s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). Women's Health and Cancer Any Component Plan that constitutes a "group health plan" under the law that provides medical and surgical benefits for mastectomy (the Omnibus Consolidated and Emergency Supplemental Appropriations Act) must also make available coverage for (a) reconstruction of the breast on which the mastectomy has been performed, (b) surgery and reconstruction of the other breast to produce a symmetrical appearance, and (c) prostheses and physical complications at all stages of mastectomy, including lymphedemas, in a manner determined in consultation with the attending physician and the patient. The coverage may be subject to annual deductibles and coinsurance provisions consistent with other benefits under the applicable Component Plan. And the Plan is not permitted to deny to a patient eligibility, or continued eligibility, to enroll or to renew coverage under the Plan, solely for the purpose of avoiding the requirements of this law. Nor may a group health plan penalize or otherwise reduce or limit the reimbursement of an attending physician (or other provider) or provide incentives (monetary or otherwise) to induce the physician to provide care in a manner inconsistent with this law. But nothing in this law prevents a group health plan from negotiating with a physician the level and type of reimbursement for care provided in accordance with this law. Fail-Safe Provisions for Compliance with HIPAA Though we believe that the ordinary terms of the Plan, which are set out in this document, fully comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), we want to be sure there is no misunderstanding.

53 Your Rights Under the Employee Retirement Income Security Act of Access. No Component Plan of this Plan that constitutes a group health plan under HIPAA will exclude an employee, or impose a longer waiting period to get into the Plan, or require any individual to pay a premium or contribution that is greater than the premium or contribution for a similarly situated individual on the basis of health status, medical condition (whether physical or mental), claims experience, receipt of health care, medical history, genetic information, evidence of insurability (including conditions arising out of acts of domestic violence ), or disability, disregarding premium discounts or rebates or modification of copayments or deductibles in return for adherence to Component Plans with respect to health promotion and disease prevention all within the meaning of HIPAA. Portability. No Component Plan that constitutes a group health plan under HIPAA imposes a pre-existing condition limitation. But each person who is covered under any Component Plan that constitutes a group health plan under HIPAA is entitled to a certificate of creditable coverage in the circumstances prescribed by HIPAA, including regulations under HIPAA. This means each employee, each spouse, and each dependent child is treated as a separate individual entitled to a certificate (provided they are covered under the Component Plan, of course). If you would like to request a certificate of creditable coverage, please contact the Plan Administrator. HIPAA The Health Insurance Portability and Accountability Act (HIPAA) was enacted on August 21, 1996 and directed the U.S. Department of Health and Human Services to issue various rules known as the HIPAA regulations. These rules addressed a few topics including: Health care portability features that placed limits on the preexisting condition exclusions from health care coverage. This means that when you, your spouse or dependents lose coverage under the health plan, the covered individuals will be given a certificate, which provides evidence of prior health coverage. You may need to furnish this certificate to another employer if you become eligible under a group health plan that excludes coverage for certain medical conditions that you have before you enroll. Under the law, a pre-existing condition exclusion may not be imposed for more than 12 months (18 months for a late enrollee). This 12-month (or 18-month) period is reduced by any prior health coverage. HIPAA requires that prior health coverage count towards satisfying the pre-existing limit. In short, this makes your prior health coverage portable because it is credited toward any pre-existing condition exclusion. Prior health coverage will count toward the pre-existing condition limitation as long as you have not had a break in coverage between the old plan and the new plan of 63 or more days. HIPAA provides that you and your covered dependents are entitled to a certificate from your prior employer or claims administrator to show evidence of prior health coverage. Upon request to the Plan Administrator, you have the right to receive a certificate of prior health coverage. If you lose coverage under the Plan, check with the Plan Administrator of any new plan under which you become covered to see if your new plan excludes pre-existing conditions and if you need to provide a certificate of previous coverage. Nondiscrimination rules for health plans (affecting premiums, contributions, wellness programs, at-work coverage requirements, etc.). Confidentiality and privacy and certain individual rights in connection with the handling of your health information by health plans (health plans include medical, prescription drugs, vision, dental, and hearing plans). HIPAA requires that your group health plans provide you a copy of a privacy notice. That notice will describe in greater detail all the permitted uses and disclosures of your health information by the health plan, and will explain your privacy rights under HIPAA. By April 14, 2003, the employer will be certifying to the group health plans that it sponsors that the group health plans terms have been changed to include the privacy requirements set forth below, and the group health plans will not disclose your protected health information to the employer until it receives that certification. The following are the restrictions that apply effective April 14, 2003 to your health information that is protected under the HIPAA privacy regulations (referred to as protected health information ) and that is used and disclosed by or to the employer, in its capacity as the sponsor of group health plans:

54 52Your Rights Under the Employee Retirement Income Security Act of 1974 Mount Sinai will only use or disclose your protected health information for reasons relating to your medical treatment, payment for your medical treatment, or for other group health plan administrative purposes, unless it receives your permission. The employer will not use or disclose your protected health information for any reason other than as permitted in this summary plan description except if required by law. If Mount Sinai discloses to any of its agents or subcontractors any of your protected health information that it receives from the group health plans that it sponsors, the employer will require the agent or subcontractor to handle your protected health information and keep it private to the same extent as if your information was handled directly by the employer. Mount Sinai will not use or disclose your protected health information for employment-related actions or decisions or in connection with any other benefit or benefit plan sponsored by the employer, unless the employer receives your express written authorization. The employer will promptly report to your group health plans if it becomes aware of any use or disclosure of your protected health information that is inconsistent with the uses or disclosures permitted by this Plan document. Mount Sinai will allow you or your group health plans to inspect and copy your protected health information that is in the employer s custody and control to the extent permitted or required under the HIPAA regulations. (You should review your health plans privacy notice to learn more about your rights to receive copies of certain types of your health information maintained by your group health plans.) Mount Sinai will allow you to amend, or allow your group health plans to amend, portions of your protected health information to the extent permitted or required under the HIPAA regulations. (You should review your health plans privacy notice to learn more about your rights to request an amendment to the health information that is maintained by your group health plans.) Mount Sinai will keep a written record of certain types of disclosures that it makes, if any, of your protected health information for reasons other than your medical treatment, payment for that medical treatment, or health plan operations. This written disclosure record will include those types of disclosures made for at least the previous six years, except only disclosures made after April 14, 2003 must be listed. The employer will make this disclosure record available to your group health plans so that your group health plans can provide you, upon request, with a copy of that list of disclosures. (You should review your health plans privacy notice to learn more about your rights to request a log of certain types of disclosures of your health information that are made by your group health plans.) Mount Sinai will make its internal practices, books, and records relating to its use and disclosure of your protected health information received from the group health plans available to the Department of Health and Human Services for purposes of determining the group health plans compliance with the HIPAA regulations. Mount Sinai will, if feasible, destroy or return to your group health plans all of your protected health information in the employer s custody or control that the employer has received from your group health plans and retain no copies, when the employer no longer needs your protected health information to administer the group health plans. If it is not feasible for the employer to return or destroy your protected health information, the employer will limit the further use or disclosure of any of your protected health information that it cannot feasibly return or destroy to those purposes that make return or destruction of the information not feasible. Only the following classes of employees or other workforce under the control of the Mount Sinai may be given access to your protected health information on behalf of Mount Sinai in the Mount Sinai s capacity as group health plan sponsor, and these employees may use your protected health information solely for the purposes set forth in this summary plan description: Mount Sinai Benefits Department Human Resources Information Systems Department. If any of these employees or workforce members use or disclose your protected health information in violation of the rules that are set out in this summary plan description, those employees or workforce members will be subject to disciplinary action and sanctions, including the possibility of termination of employment. If Mount Sinai becomes aware of any such violations, the employer will promptly report the violation to your group health plans and will cooperate with your group health plans to correct the violation, to impose appropriate sanctions, and to mitigate any harmful effects to you.

55 Your Rights Under the Employee Retirement Income Security Act of Amendment, Suspension or Termination of the Plan Mount Sinai reserves the power at any time and from time to time, and retroactively if deemed necessary or appropriate, to modify or amend, in whole or in part, any or all of the provisions of the Plan or the insurance contracts maintained to provide benefits under the Plan for any reason, and with respect to any or all employees, dependents, and former employees. Mount Sinai reserves the power to discontinue, suspend or terminate the Plan at any time and for any reason. In the event of the dissolution, merger, consolidation or reorganization of Mount Sinai, the Plan shall terminate unless it is continued by a successor to Mount Sinai. Plan Administration The administration of the Plan shall be under the supervision of the Plan Administrator. It shall be a principal duty of the Plan Administrator to see that the Plan is carried out, in accordance with its terms, for the exclusive benefit of persons entitled to participate in the Plan without discrimination among them. The Plan Administrator will have the exclusive right, power and authority, in its sole and absolute discretion, to administer the Plan in all of its details, apply and interpret the Plan, this SPD, and any other Plan documents (including, but not limited to, insurance policies) and to decide all matters arising in connection with the operation or administration of the Plan, except for matters covered by other provisions of this document, subject to the applicable requirements of law. For this purpose, the Plan Administrator s powers will include, but will not be limited to, the following authority, in addition to all other powers provided by this Plan: (a) To make and enforce such rules and regulations as it deems necessary or proper for the efficient administration of the Plan, including the establishment of any claims procedures that may be required by applicable provisions of law; (b) To interpret the Plan, its interpretation thereof in good faith to be final and conclusive on all persons claiming benefits under the Plan; (c) To decide all questions, including legal or factual questions, concerning the Plan and the eligibility of any person to participate in the Plan; (d) To resolve and/or clarify any ambiguities, inconsistencies and omissions arising under the Plan, including the SPD or other Plan documents; (e) To process and approve or deny benefit claims; (f) To determine the standard of proof required in any case; (g) To appoint such agents, counsel, accountants, consultants and other persons as may be required to assist in administering the Plan; and (h) To allocate and delegate its responsibilities under the Plan and to designate other persons to carry out any of its responsibilities under the Plan. All determinations and interpretations made by the Plan Administrator and/or its authorized designee(s) shall be binding and final upon all parties claiming benefits under the Plan. The Plan Administrator may delegate to the Plan insurers any other such duties or powers as it deems necessary to carry out the administration of the Plan to the plan insurers. Notwithstanding any other provision of the Plan to the contrary, Mount Sinai delegates to each applicable administrator and insurance company the responsibility for administering the respective Component Plan and for exercising other fiduciary functions described in the governing documents related to the applicable Component Plan. Mount Sinai shall retain all fiduciary responsibility with respect to the administration of the Component Plans that Mount Sinai has not delegated to such providers. Termination of Coverage for Domestic Partners Coverage extended to a domestic partner (and his or her dependent child(ren)) will end on the earliest to occur of: the date the employee s coverage under the Plan ends for any reason; the end of the month in which the employee s death occurs; the last day of the month in which the employee and domestic partner no longer satisfy the eligibility requirements for domestic partner coverage, as outlined in the Section titled Eligibility above, provided that the employee must submit written notice of such change to Benefits Administration Office 19 e. 98th Street, Rm. 1E within thirty (30) days of the failure to satisfy the applicable requirements; and

56 54Your Rights Under the Employee Retirement Income Security Act of 1974 the last day of the month in which the employee voluntarily disenrolls the domestic partner (or child) from coverage under the Plan, by submitting written notice to Benefits Administration 19 E. 98th Street. If, at any time, an employee terminates the coverage of a domestic partner or his or her child for any reason, such domestic partner (and/or child) may not re-enroll for coverage under the Plan until: (i) the next annual open enrollment period, or (ii) the occurrence of a life event that would apply to an employee s spouse or child under the terms of the Plan, and the domestic partner (and child) will be subject to all other generally applicable enrollment rules under the Plan. Amendment/Termination of the Plan. If the Plan is amended, modified or terminated, your ability to participate in the Plan, receive benefits, or the type or amount of benefits you receive may be modified or terminated. Among other things, Mount Sinai has the right to do any of the following: Change the eligibility rules; Reduce the amounts of benefits; Increase deductibles or coinsurance; Eliminate particular types of benefits; Substitute certain benefits for others; Impose or decrease maximums on the amount of benefits payable; and Require contributions or increase contributions from participants and beneficiaries as a condition of eligibility. All benefits provided under the Plan and eligibility rules for participants and dependents: Are not guaranteed; May be changed or discontinued by Mount Sinai at any time, in its sole and absolute discretion; Are subject to the rules and regulations adopted by Mount Sinai; Are subject to the terms of the Mount Sinai Medical Center Cafeteria Benefit Plan; and Are subject to the Plan s contracts with the applicable insurance companies, third party administrator or other providers. Under no circumstances will any person obtain a vested or non-forfeitable right to receive, directly or indirectly, any benefits provided by, or assets of, the Plan. Without limiting any other Plan provision for the discontinuance of coverage, your coverage under the Plan will be terminated when the Plan terminates or when you are no longer eligible to receive benefits under the Plan, whichever occurs first. Unclaimed Payments As a condition of entitlement to a benefit under this Plan, Employees and eligible dependents covered under the Plan must keep the Plan informed of their current mailing address and other relevant contact information. If the Plan is unable to locate any individual otherwise entitled to a benefit payment hereunder after exercising reasonable efforts to do so (as determined in the sole discretion of the Plan Administrator), the individual is not entitled to a benefit hereunder and forfeits any rights to any benefits. In addition, as a further condition to any benefit entitlement under this Plan, any person claiming the benefit must present for payment the check evidencing such benefit within one year of the date of issue. If any check for a benefit payable under the Plan is not presented for payment within one year of the date of issue, the Plan shall have no liability for the benefit payment, the amount of the check shall be deemed a forfeiture, and no funds shall escheat to any state. Effect on Employment Neither this summary plan description nor the Plan shall confer upon you any right to be continued in the employment of Mount Sinai or a participating employer, or in anyway diminish Mount Sinai or a participating employer s right to terminate your employment.

57 Appendix A 55 Important Notice Regarding Annual Dollar Limits: In accordance with applicable law, none of the annual dollar limits set forth in this Appendix A (other than the Maximum Plan Benefit) shall apply to essential health benefits, as such term is defined under Section 1302(b) of the Patient Protection and Affordable Care Act of For this purpose, a determination as to whether a benefit constitutes an essential health benefit will be based on a good faith interpretation of the guidance available as of the date on which the determination is made. Benefit Summary The Mount Sinai Medical Center Basic Plan Choice Plus/PPO

58 56Appendix A Participating Providers OUTPATIENT CARE Subject to Deductible & Coinsurance same diagnosis EMERGENCY CARE MATERNITY CARE

59 Appendix A 57 BASIC PLAN TIER) Participating SKILLED NURSING FACILITY CHIROPRACTIC CARE $60 copay per visit - for adults Subject to Deductible & Coinsurance INFERTILITY TREATMENT REHABILITATION THERAPY OTHER ITEMS

60 58Appendix A BENEFIT X-RAY & LAB performed in: Office Setting MOUNT SINAI/ UNITEDHEALTHCA RE NETWORK (TOP TIER) Participating Preventive X-Ray & Lab: No Charge. All other X-Ray & Lab: $15 co-pay per visit applies to office visit charge. X- ray and lab services are reimbursed at 100% BASIC PLAN UNITEDHEALTHCARE NETWORK (MIDDLE TIER) Preventive X-Ray & Lab: No Charge. All non- preventive X-Ray & Lab: $50 copay per visit applies to office visit charge - for adults $25 copay per visit applies to office visit charge - for dependent children up to the age of 26. X-ray and lab services are reimbursed at 100%. Lab and X-ray sent to an outside lab: subject to Deductible and Coinsurance. OUT-OF-NETWORK Subject to Deductible and Coinsurance. Facility Out Patient Services There are no Mt. Sinai Out Patient Facilities participating in the Top Tier therefore utilize one of the middle tier providers and reimbursement will follow the middle tier reimbursement. Preventive X-Ray & Lab: No Charge. All non-preventive X-Ray and Lab: subject to deductible and coinsurance. Subject to Deductible and Coinsurance * These services require advance notification to UnitedHealthcare. You must call UnitedHealthcare at at least 14 days in advance of treatment to notify medical management. For Emergency Admissions, you must call UnitedHealthcare at within 48 hours if admitted. Failure to notify UnitedHealthcare in advance will result in a $400 penalty. **Certain women s preventative helath services are offered at no cost at point of service. This includes approved contraceptives, some forms of counseling and screenings, and certain devices. Please call for details. *** A $2,500 penalty will be implemented for inpatient admissions performed in out-of-network facilities with the exception of pediatric and mental health claims. This penalty will be waived if an admission follows an emergency room visit. Hearing aids are limited to a maximum reimbursement of $350 per 24 month period. DEPENDENT ELIGIBILITY: Eligible dependents include the employee s spouse or same gender domestic partner and dependent children. Dependent children are covered until the end of the month in which they reach 26 years of age regardless of marital status and or student status. The copay for Specialty services, Mental Health and Substance Abuse Outpatient services reflects the Middle Tier Physician office copay. This pertains only to dependent children up to the age of 26. Please note: This same summary of benefits is provided for informational purposes only. The applicable Summary of Benefits will be issued to eligible, enrolled members if requested as part of the UHC Summary Plan Description. Coverage is subject to the terms and conditions of the Summary Plan Description. The UHC Summary Plan Description is available upon request. This is a general summary of your benefits. A more complete description of your benefits and the terms under which they are provided, including limitations and exclusions are contained in the plan documents. If there are any discrepancies between the information contained in this comparison of plan benefits and the provisions of the plan documents, the plan documents are the controlling documents. Like most group medical plans and insurance policies, this plan contains certain exceptions, waiting periods, reductions, limitations and terms. Ask your group representative for complete details. Group Medical Insurance and out of network benefits, except in NY, provided by or through: UnitedHealthcare Insurance Company, Hartford, CT, Administrative services to Self Insured plans outside of NY provided by: UnitedHealthCare Services, Inc., Minneapolis, Minnesota, or UnitedHealthCare Insurance Company, Hartford, CT Group Medical Insurance in NY provided by or through: UnitedHealthCare Insurance Company of New York UnitedHealthcare Service Corp. Administrative services to Self Insured plans in NY provided by: UnitedHealthcare Service Corp. Group Medical Insurance in Ohio is also provided by: UnitedHealthCare Insurance Company of Ohio, Columbus, Ohio, Group Medical Insurance in Illinois is also provided by: UnitedHealthCare Insurance Company of Illinois, Chicago, Illinois, (LL) 1/1/2013

61 Appendix A 59

62 60Appendix A BENEFIT FINANCIAL Deductible Employee Employee + One Employee + Two or more Non-Notification Penalty Coinsurance Maximum out-of-pocket Employee Employee + One Employee + Two or more Maximum Lifetime Benefit per Member PREVENTIVE CARE Physical examination Routine pediatric care Immunizations (Adult immunizations limited to non travel related) OUTPATIENT CARE Physician office visits MOUNT SINAI/ UNITEDHEALTHCARE NETWORK (TOP TIER) Participating Providers None None None $400 None Not applicable Not applicable Not applicable Unlimited No Charge No Charge No Charge $10 copay per visit PLUS PLAN UNITEDHEALTHCARE NETWORK (MIDDLE TIER) $300 $525 $750 $400 10% $1,000 (Excludes Deductible & Hospital copay) $2,000 (Excludes Deductible & Hospital copay) $3,000 (Excludes Deductible & Hospital copay) Unlimited No Charge No Charge No Charge $40 copay per visit, except that the copay for a specialist visit is $50- for adults $20 copay per visit - for dependent children up to the age of 26. OUT-OF-NETWORK $1,200 $2,120 $3,000 $400 40% $4,000 (Excludes Deductible & Hospital copay) $8,000 (Excludes Deductible & Hospital copay) $12,000 (Excludes Deductible & Hospital copay) Unlimited Subject to Deductible & Coinsurance Subject to Deductible & Coinsurance Subject to Deductible & Coinsurance Subject to Deductible & Coinsurance Subject to Deductible & Coinsurance Surgery ALLERGY CARE - Initial visit and all subsequent referral visits Injection only, waive copay HOSPITAL CARE Physician s and Surgeon s services* No Charge Subject to Deductible & Coinsurance Subject to Deductible & Coinsurance $10 copay per visit $50 copay per visit - for adults Subject to Deductible & Coinsurance $20 copay per visit - for dependent children Subject to Deductible & Coinsurance up to the age of 26 No Charge Subject to Deductible & Coinsurance Subject to Deductible & Coinsurance Semi-private room and board* Notification required All inpatient drugs and medication EMERGENCY CARE (UnitedHealthcare must be contacted within 48 hours if admitted) Ambulance services when Medically Necessary At hospital emergency room No Charge No Charge No Charge $150 copay, waived if admitted Emergency Hospitalizations - If you or your dependent s Non-Top Tier hospital stay occurred on an emergency admission basis (no choice as to the facility due to the emergency situation), UHC will review/reconsider the claim(s) for adjusted payment at the Top Tier benefit level upon request and receipt of relevant claim information. Please contact The Mount Sinai Benefits Center at for further information. Subject to Deductible & Coinsurance $300 copay per hospital admission, the copay per hospital admission is not applicable if readmitted to the same hospital within 90 days of initial admission for same diagnosis Subject to Deductible & Coinsurance No Charge $150 copay, waived if admitted: then $300 per hospital admission copay applies, subject to Deductible & Coinsurance Subject to Deductible & Coinsurance $600 copay per hospital admission, the copay per hospital admission is not applicable if readmitted to the same hospital within 90 days of initial admission for same diagnosis Subject to Deductible & Coinsurance No Charge $150 copay, waived if admitted: then $600 per hospital admission copay applies, subject to Deductible & Coinsurance MATERNITY CARE Prenatal and post-natal care* Hospital services for mother* Newborn inpatient nursery care No Charge No Charge No Charge Subject to Deductible & Coinsurance $300 copay per hospital admission, then subject to Deductible & Coinsurance see Hospital Care above Subject to Deductible & Coinsurance Subject to Deductible & Coinsurance $600 copay per hospital admission, then Subject to Deductible & Coinsurance see Hospital Care above Subject to Deductible & Coinsurance

63 Appendix A 61 PLUS PLAN BENEFIT Participating Providers (MIDDLE TIER) SUBSTANCE ABUSE $50 copay per visit - for adults Notification required INFERTILITY TREATMENT regimen. $50 copay per visit - for adults $100 cap per visit, Subject to Deductible OTHER ITEMS and Coinsurance Physician

64 62Appendix A BENEFIT X-RAY & LAB performed in: Office Setting MOUNT SINAI/ UNITEDHEALTHCARE NETWORK (TOP TIER) Participating Providers PLUS PLAN UNITEDHEALTHCARE NETWORK (MIDDLE TIER) OUT-OF-NETWORK Preventive X-Ray & Preventive X-Ray & Lab: No Charge. Subject to Deductible and Coinsurance. Lab: No Charge. All non- preventative X-Ray & Lab: All other X-Ray & Lab: $40 copay per visit applies to office visit charge for adults $10 co-pay per visit applies to $20 copay per visit applies to office visit office visit charge. X-ray and charge - for dependent children up to lab services are reimbursed at the age of 26. X-ray and lab services are reimbursed at 100% 100%. Lab and X-ray sent to an outside lab: subject to Deductible and Coinsurance. Facility Out Patient Services There are no Mt. Sinai Out Patient Facilities participating in the Top Tier therefore utilize one of the middle tier providers and reimbursement will follow the middle tier reimbursement. Preventive X-Ray & Lab: X-ray & lab services are reimbursed at 100% For non-preventative X-Ray and Lab: X-ray & lab services are reimbursed after Deductible and Coinsurance. Subject to Deductible and Coinsurance. * These services require advance notification to UnitedHealthcare. You must call UnitedHealthcare at at least 14 days in advance of treatment to medical management. For Emergency Admissions, you must call UnitedHealthcare at within 48 hours if admitted. Failure to notify UnitedHealthcare in advance will result in a $400 penalty. ** These services require advance notification to UnitedHealthcare. You must call UnitedHealthcare at at least 14 days in advance of treatment to notify medical management. Hearing aids are limited to a maximum reimbursement of $350 per 24 month period. DEPENDENT ELIGIBILITY: Eligible dependents include the employee s spouse or same gender domestic partner and dependent children. Dependent children are covered until the end of the month in which they reach 26 years of age regardless of marital status and or student status. The Specialty, Mental Health and Substance Abuse Outpatient services are covered under the Physician Office Visits copay (Middle Tier) - for dependent children up to the age of 26. Please note: This same summary of benefits is provided for informational purposes only. The applicable Summary of Benefits will be issued to eligible, enrolled members if requested as part of the UHC Summary Plan Description. Coverage is subject to the terms and conditions of the Summary Plan Description. The UHC Summary Plan Description is available upon request. This is a general summary of your benefits. A more complete description of your benefits and the terms under which they are provided, including limitations and exclusions are contained in the plan documents. If there are any discrepancies between the information contained in this comparison of plan benefits and the provisions of the plan documents, the plan documents are the controlling documents. Like most group medical plans and insurance policies, this plan contains certain exceptions, waiting periods, reductions, limitations and terms. Ask your group representative for complete details. Group Medical Insurance and out of network benefits, except in NY, provided by or through: UnitedHealthcare Insurance Company, Hartford, CT, Administrative services to Self Insured plans outside of NY provided by: United HealthCare Services, Inc., Minneapolis, Minnesota, or United HealthCare Insurance Company, Hartford, CT Group Medical Insurance in NY provided by or through: United HealthCare Insurance Company of New York UnitedHealthcare Service Corp. Administrative services to Self Insured plans in NY provided by: UnitedHealthcare Service Corp. Group Medical Insurance in Ohio is also provided by: United HealthCare Insurance Company of Ohio, Columbus, Ohio, Group Medical insurance in Illinois is also provided by: United HealthCare Insurance Company of Illinois, Chicago, Illinois, 60606

65 Appendix A 63

66 64Appendix A

67 Appendix A 65

68 66Appendix A Your Summary of Benefits HMO Mount Sinai Medical Center Benefit In-Network 2 Lifetime Maximum Children Covered Preventive Services 8 Covered Adult Preventive Care $0 Annual Physical Exam $0 Well-Child Care (to age 19; including covered immunizations) $0 Preventive Well-Woman Care (no PCP referral required) $0 Home/Office/Outpatient Care 1 Home/Office Visits (PCP or Specialist) webvisit 3 Emergency Room/Facility (Initial visit per occurrence) Ambulatory/Outpatient Surgery 4 $0 Presurgery Testing $0 Anesthesia $0 Office Surgery Chemotherapy, Radiation Therapy $0 Routine Maternity Care $0 Laboratory Tests $0 X-rays/MRI 4 /MRA 4, CAT 4, PET 4, Nuclear Cardiology 4 Allergy Testing & Treatment Chiropractic Care 6 Home Healthcare (Up to 200 visits per calendar year) $0 Home Infusion Therapy $0 Hospice Care (Up to 210 days per lifetime) $0 Physical Therapy 1,4 (Up to 30 visits per calendar year combined in home, office or outpatient facility) Unlimited Children up to age 26 (last day of month) Member Pays In-Network $25/$40 copay $5 copay per online consultation $75 copay (Waived if admitted within 24 hours) $25/$40 copay $25 copay $25/$40 copay (Waived for treatment) $25/$40 copay $25/$40 copay in home or office Speech/Language 4, Occupational 4, Vision Therapies 1,4 $25/$40 copay in home or office (Up to 30 visits per calendar year combined in home, office or outpatient facility) Cardiac Rehabilitation $0 Second Surgical Opinion $0 Kidney Dialysis $0 Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

69 Appendix A 67 Your Summary of Benefits HMO Benefit In-Network 2 Inpatient Care 4 Inpatient Hospital (As many days as is medically necessary; semiprivate room and board) Surgery, Surgical Assistant, Anesthesia $0 Physical Therapy, Physical Medicine or Rehabilitation (Up to 30 inpatient days per calendar year) Skilled Nursing Facility (Up to 120 days per calendar year) $0 Mental Health Outpatient Visits in Office Outpatient Visits in Facility $0 Inpatient Care 5 (As many days as is medically necessary; semiprivate room and board) Alcohol/Substance Abuse 5 Outpatient Visits in Office Outpatient Visits in Facility $0 Inpatient Detoxification (As many days as is medically necessary; semiprivate room and board) Inpatient Rehabilitation Other Medical Supplies 7 Durable Medical Equipment 4,7 Prosthetics & Orthotics 4 Ambulance (air ambulance) $0 $250/$625 per admission/maximum per calendar year per contract $250/$625 per admission/maximum per calendar year per contract $25 copay $250/$625 per admission/maximum per calendar year per contract $25 copay $250/$625 per admission/maximum per calendar year per contract $250/$625 per admission/maximum per calendar year per contract $25 copay 20% coinsurance 20% coinsurance Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

70 68Appendix A HMO A network provider must deliver all care with a PCP referral. HMO Rev Aug 2011 Prepared on 08/31/11 Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

71 69

72 70Appendix A

73 Appendix A 71

74 72Appendix A

75 Appendix A 73

76 74Appendix A

77 Appendix A 75

78 76Appendix A

79 Appendix A 77

80 78Appendix A

81 Appendix A 79

82 80Appendix A

83 Appendix A 81 Benefit Summary Choice Plus High Deductible Health Plan (HDHP) With this Choice Plus high-deductible health plan coverage, you have the option to open a Health Savings Account (HSA). An HSA is a financial account that you can use to accumulate tax-free funds to pay for qualified health care expenses, as defined by the Internal Revenue Service. The account acts like a regular checking account with a debit card and accrues interest. All money in the account is owned by you and is fully vested as soon as it is deposited. Funds can accumulate over time and the account is portable among employers. If you use the funds for qualified health care expenses, you will pay no taxes. If you use the money for other expenses, you will pay a tax and a penalty fee. Under the Choice Plus high-deductible health plan, your annual deductible and out of pocket maximum include both medical expenses and pharmacy expenses. All expenses are your responsibility until the deductible is reached. Choice Plus high-deductible health plan gives you the freedom to see any Physician or other health care professional from our Network, including specialists, without a referral. With this plan, you will receive the highest level of benefits when you seek care from a network physician, facility or other health care professional. In addition, you do not have to worry about any claim forms or bills. You also may choose to seek care outside the Network, without a referral. However, you should know that care received from an Out-of-Network physician, facility or other health care professional means a higher deductible and coinsurance. In addition, if you choose to seek care outside the Network, your plan only considers a portion for payment and it is your responsibility to pay the remainder. This amount you are required to pay, which could be significant, does not apply to the Out-of-Pocket Maximum. We recommend that you ask the non-network physician or health care professional about their billed charges before you receive care. Some of the Important Benefits of Your Plan: You have access to a Network of physicians, facilities and other health care professionals, including specialists, without designating a Primary Physician or obtaining a referral. Benefits are available for office visits and hospital care, as well as inpatient and outpatient surgery. Care Coordination SM services are available to help identify and prevent delays in care for those who might need specialized help. Emergencies are covered anywhere in the world. Pap smears, Prenatal Care, Routine check-ups, Childhood immunizations and Mammograms are covered at no cost.

84 82Appendix A Mount Sinai/UnitedHealthcare This Benefit Summary is intended Participating Providers Combined Medical and Drug Combined Medical and Drug Combined Medical and Network physician. 1. Ambulance Services Ground Transportation: No Ground Transportation: 20% Same as Middle Tier Network 2. Durable Medical Equipment* after Deductible Coinsurance after Deductible No Charge after Deductible 20% Coinsurance after 50% Coinsurance after $50,000 Lifetime Maximum 3. Emergency Health Services No Charge after Deductible 20% Coinsurance after Same as Middle Tier Network Emergency Hospitalizations If you or your dependent s Non-Top Tier hospital

85 83 Appendix A Mount Sinai/UnitedHealthcare 4. Home Health Care Participating Providers Not Applicable 20% Coinsurance after 50% Coinsurance after *Notification required 5. Hospice Care No Charge after Deductible 20% Coinsurance after 50% Coinsurance after 6. Hospital Inpatient Stay No Charge after Deductible 20% Coinsurance after 50% Coinsurance after 7. Allergy Care No Charge after Deductible 20% Coinsurance after 50% Coinsurance after Injections 8. Maternity Services No Charge after Deductible 20% Coinsurance after 50% Coinsurance after 9. Outpatient Surgery, Treatments Deductible Deductible

86 84Appendix A Mount Sinai/UnitedHealthcare 10. Physician s Office Services No Charge after Deductible 20% Coinsurance after 50% Coinsurance after Deductible Deductible 11. Preventive Care*** No Charge. Not subject to No Charge. Not subject to No Charge. Not subject to travel related) 12. Professional Fees for Surgical No Charge after Deductible 20% Coinsurance after 50% Coinsurance after and Medical Services Deductible Deductible 13. Prosthetic Devices No Charge after Deductible 20% Coinsurance after 50% Coinsurance after Deductible Deductible 14. Rehabilitation Services No Charge after Deductible 20% Coinsurance after 50% Coinsurance after rehabilitation per calendar year. 15. Skilled Nursing No Charge after Deductible 20% Coinsurance after *50% Coinsurance after per calendar year. 16. Transplantation Services No Charge after Deductible 20% Coinsurance after 50% Coinsurance after 17. Urgent Care Center Services No Charge after Deductible 20% Coinsurance after Deductible per transplant. 50% Coinsurance after Deductible Mental Health Services No Charge after Deductible 20% Coinsurance after 50% Coinsurance after Health/Substance Abuse Designee. Mental Health Services No Charge after Deductible 20% Coinsurance after 50% Coinsurance after

87 85 Appendix A Mount Sinai/UnitedHealthcare Substance Abuse Services No Charge after Deductible 20% Coinsurance after 50% Coinsurance after Substance Abuse Services No Charge after Deductible 20% Coinsurance after 50% Coinsurance after Chiropractic Care Not Applicable 20% Coinsurance after 50% Coinsurance after Infertility Treatment No Charge after Deductible 20% Coinsurance after Not Covered Prescription Drugs **** 20% after Deductible 20% after Deductible 30% after Deductible

88 86Appendix A Exclusions Except as may be specifically provided in Section 1 of the UHC Summary Plan Description (UHC SPD) or through a Rider to the Plan, the following are not covered: A. Alternative Treatments Acupressure; hypnotism; rolfing; massage therapy; aromatherapy; acupuncture; and other forms of alternative treatment. B. Comfort or Convenience Personal comfort or convenience items or services such as television; telephone; barber or beauty service; guest service; supplies, equipment and similar incidental services and supplies for personal comfort including air conditioners, air purifiers and filters, batteries and battery chargers, dehumidifiers and humidifiers; devices or computers to assist in communication and speech. C. Dental Except as specifically described as covered in Section 1 of the UHC SPD for services to repair a sound natural tooth that has documented accident-related damage, dental services are excluded. There is no coverage for services provided for the prevention, diagnosis, and treatment of the teeth, jawbones or gums (including extraction, restoration, and replacement of teeth, medical or surgical treatments of dental conditions, and services to improve dental clinical outcomes). Dental implants and dental braces are excluded. Dental x-rays, supplies and appliances and all associated expenses arising out of such dental services (including hospitalizations and anesthesia) are excluded, except as might otherwise be required for transplant preparation, initiation of immunosuppressives, or the direct treatment of acute traumatic Injury, cancer, or cleft palate. Treatment for congenitally missing, malpositioned, or super numerary teeth is excluded, even if part of a Congenital Anomaly. D. Drugs Prescription drug products for outpatient use that are filled by a prescription order or refill. Self-injectable medications. Non-injectable medications given in a Physician s office except as required in an Emergency. Over-the-counter drugs and treatments. E. Experimental, Investigational or Unproven Services Experimental, Investigational or Unproven Services are excluded. The fact that an Experimental, Investigational or Unproven Service, treatment, device or pharmacological regimen is the only available treatment for a particular condition will not result in Benefits if the procedure is considered to be Experimental, Investigational or Unproven in the treatment of that particular condition. F. Foot Care Routine foot care (including the cutting or removal of corns and calluses); nail trimming, cutting, or debriding; hygienic and preventive maintenance foot care; treatment of flat feet or subluxation of the foot; shoe orthotics. G. Medical Supplies and Appliances Devices used specifically as safety items or to affect performance primarily in sports-related activities. Prescribed or non-prescribed medical supplies and disposable supplies including but not limited to elastic stockings, ace bandages, gauze and dressings, ostomy supplies, syringes and diabetic test strips. Orthotic appliances that straighten or re-shape a body part (including cranial banding and some types of braces). Tubings and masks are not covered except when used with Durable Medical Equipment as described in Section 1 of the UHC SPD. H. Mental Health/Substance Abuse Services performed in connection with conditions not classified in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association. Services that extend beyond the period necessary for short-term evaluation, diagnosis, treatment, or crisis intervention. Mental Health treatment of insomnia and other sleep disorders, neurological disorders, and other disorders with a known physical basis. Treatment of conduct and impulse control disorders, personality disorders, paraphilias and other Mental Illnesses that will not substantially improve beyond the current level of functioning, or that are not subject to favorable modification or management according to prevailing national standards of clinical practice, as reasonably determined by the Mental Health/Substance Abuse Designee. Services utilizing methadone treatment as maintenance, L.A.A.M. (1-Alpha-Acetyl- Methadol), Cyclazocine, or their equivalents. Treatment provided in connection with or to comply with involuntary commitments, police detentions and other similar arrangements, unless authorized by the Mental Health/Substance Abuse Designee. Residential treatment services. Services or supplies that in the reasonable judgment of the Mental Health/Substance Abuse Designee are not, for example, consistent with certain national standards or professional research further described in Section 2 of the UHC SPD. I. Nutrition Megavitamin and nutrition based therapy; nutritional counseling for either individuals or groups. Enteral feedings and other nutritional and electrolyte supplements, including infant formula and donor breast milk. J. Physical Appearance Cosmetic Procedures including, but not limited to, pharmacological regimens; nutritional procedures or treatments; salabrasion, chemosurgery and other such skin abrasion procedures associated with the removal of scars, tattoos, and/or which are performed as a treatment for acne. Replacement of an existing breast implant is excluded if the earlier breast implant was a Cosmetic Procedure. (Replacement of ASO an existing breast implant is considered reconstructive if the initial breast implant followed mastectomy.) Physical conditioning programs such as athletic training, bodybuilding, exercise, fitness, flexibility, and diversion or general motivation. Weight loss programs for medical and non-medical reasons. Wigs, regardless of the reason for the hair loss. K. Providers Services performed by a provider with your same legal residence or who is a family member by birth or marriage, including spouse, brother, sister, parent or child. This includes any service the provider may perform on himself or herself. Services provided at a free-standing or Hospital-based diagnostic facility without an order written by a Physician or other provider as further described in Section 2 of the UHC SPD (this exclusion does not apply to mammography testing). L. Reproduction Surrogate parenting. The reversal of voluntary sterilization. M. Services Provided under Another Plan Health services for which other coverage is required by federal, state or local law to be purchased or provided through other arrangements, including but not limited to coverage required by workers compensation, no-fault automobile insurance, or similar legislation. If coverage under workers compensation or similar legislation is optional because you could elect it, or could have it elected for you, Benefits will not be paid for any Injury, Mental Illness or Sickness that would have been covered under workers compensation or similar legislation had that coverage been elected. Health services for treatment of military service-related disabilities, when you are legally entitled to other coverage and facilities are reasonably available to you. Health services while on active military duty. N. Transplants Health services for organ or tissue transplants are excluded, except those specified as covered in Section 1 of the UHC SPD. Any solid organ transplant that is performed as a treatment for cancer. Health services connected with the removal of an organ or tissue from you for purposes of a transplant to another person. Health services for transplants involving mechanical or animal organs. Any multiple organ transplants not listed as a Covered Health Service in Section 1 of the UHC SPD. O. Travel Travel or transportation expenses, even though prescribed by a Physician. Some travel expenses related to covered transplantation services may be reimbursed at our discretion. P. Vision and Hearing Purchase cost of eye glasses, contact lenses, or hearing aids. Fitting charge for hearing aids, eye glasses or contact lenses. Eye exercise therapy. Surgery that is intended to allow you to see better without glasses or other vision correction including radial keratotomy, laser, and other refractive eye surgery. Q. Other Exclusions Health services and supplies that do not meet the definition of a Covered Health Service - see definition in Section 10 of the UHC SPD. Physical, psychiatric or psychological examinations, testing, vaccinations, immunizations or treatments otherwise covered under the Plan, when such services are: (1) required solely for purposes of career, education, sports or camp, travel, employment, insurance, marriage or adoption; (2) relating to judicial or administrative proceedings or orders; (3) conducted for purposes of medical research; or (4) to obtain or maintain a license of any type. Health services received as a result of war or any act of war, whether declared or undeclared or caused during service in the armed forces of any country. Health services received after the date your coverage under the Plan ends, including health services for medical conditions arising prior to the date your coverage under the Plan ends. Health services for which you have no legal responsibility to pay, or for which a charge would not ordinarily be made in the absence of coverage under the Plan. Charges in excess of Eligible Expenses or in excess of any specified limitation. Services for the evaluation and treatment of temporomandibular joint syndrome (TMJ), whether the services are considered to be medical or dental in nature. Upper and lower jaw bone surgery except as required for direct treatment of acute traumatic Injury or cancer. Orthognathic surgery, jaw alignment, and treatment for the temporomandibular joint, except as a treatment of obstructive sleep apnea. Non-surgical treatment of obesity (including morbid obesity). Growth hormone therapy; sex transformation operations; treatment of benign gynecomastia (abnormal breast enlargement in males); medical and surgical treatment of excessive sweating (hyperhidrosis); medical and surgical treatment for snoring, except when provided as part of treatment for documented obstructive sleep apnea. Oral appliances for snoring. Custodial care; domiciliary care; private duty nursing; respite care; rest cures. Psychosurgery. Speech therapy except as required for treatment of a speech impediment or speech dysfunction that results from Injury, stroke or Congenital Anomaly. Diabetic supplies are not covered. This summary of Benefits is intended only to highlight your Benefits and should not be relied upon to fully determine coverage. This plan may not cover all your health care expenses. Please refer to the Summary Plan Description for a complete listing of services, limitations, exclusions and a description of all the terms and conditions of coverage. If this description conflicts in any way with the Summary Plan Description, the Summary Plan Description prevails. Summary Plan Descriptions are available to members if requested. Terms that are capitalized in the Benefit Summary are defined in the Summary Plan Description 1/1/2013

89 Appendix A 87

90 88Appendix A