2017 BENEFITS RETIREE GUIDE /16

Transcription

1 2017 BENEFITS RETIREE GUIDE /16

2 The retired employee benefit programs described in this Benefit Guide are effective in The information is a summary of Dartmouth s Retiree benefits, and every attempt has been made to ensure its accuracy. The actual provisions of each benefit program will govern if there is any inconsistency between the information in this Benefit Guide and Dartmouth s formal plans, programs, policies or contracts, or any subsequent change in such plans, programs, policies or contracts.

3 Table of Contents Your Benefit Options Open Enrollment... 2 RETIRED EMPLOYEES UNDER AGE 65 Changes for Medical Coverage...4 Health Reimbursement Account Open Access Plus Plan (OAP) Cigna Choice Fund Plan (CCF) High Deductible Health Plan (HDHP) Medical Plan Comparison Chart Prescription Drug Coverage...11 Vision...12 How to Enroll...12 Wellness at Dartmouth...13 RETIRED EMPLOYEES OVER AGE 65 Eligibility and Medicare...15 Information About Medicare...16 Dartmouth College Medicare Supplement Plan (DCMS)...17 How to Enroll...17 Important Reminders...18 Annual Required Notices...19 Contacts Words to Know...21

4 Your Benefit Options Every year Dartmouth College reviews the benefit plans offered to Retirees and their dependents. We continue to work to provide a benefit that not only meets the long-term institutional obligations of the Dartmouth plans, but that also encourages a sustainable option for covered members. This benefits guide provides an overview of the retiree benefits program offered to eligible retirees and their eligible dependents. This information covers both early retirees and Medicare eligible retirees. See the section applicable to you to view how your coverage will be affected. It contains a summary of your benefit choices, important reminders, and information about how to enroll through the FlexOnline benefits enrollment system. Levels of Coverage You may elect one of the following levels of coverage for medical insurance: Retiree; Retiree plus Spouse/Same Sex Partner; Retiree plus child/ren up through age 25; Retiree plus family Covering Dependents Retirees who elect coverage under a Dartmouth medical plan may also elect coverage for a spouse, same-sex domestic partner, and/or dependent children, who were eligible dependents at the time you retired. dartgo.org/retirees Benefits for Retired Employees Under Age 65 Dartmouth offers three different health plan choices covering medical needs ranging from catastrophic to preventive and routine care. You can elect either the Open Access Plus Plan(OAP); Cigna Choice Fund Plan (CCF), or High Deductible Health Plan (HDHP). All plans are administered by Cigna. Contact Cigna toll-free at or online at mycigna.com Benefits for Retired Employees Over Age 65 The Dartmouth College Medicare Supplement (DCMS) plan is available to qualifying Dartmouth College Medicare eligible retirees beginning at age 65, members who are Medicare eligible due to disability, and their eligible/ qualifying dependents. For qualifying members Medicare is the primary medical coverage and the DCMS plan acts as a secondary payer. Turning 65 and/or becoming Medicare Eligible in 2017 When you or your spouse/same sex partner become Medicare eligible, Dartmouth offers Medicare supplemental coverage called The Dartmouth College Medicare Supplement (DCMS) Plan. You (or your spouse/same sex partner) become eligible for Medicare on the first day of your 65th birth month. However, if your birthday is on the first day of the month, your coverage will start the first day of the prior month. At that time Medicare becomes your primary medical insurance and Dartmouth will contact you to give you the option to enroll in the DCMS plan as a secondary payer. The DCMS Plan is available to qualifying Dartmouth College Medicare eligible retirees age 65+, members who are Medicare eligible due to disability and their eligible/ qualifying dependents. You must contact Social Security up to 3 months prior to your effective date, to enroll in Medicare Part A and Part B. Enrollment in the DCMS plan requires that you have Medicare Part A and Part B at the time your coverage begins. Dartmouth College must receive a copy of your Retiree Health Election form, and a copy of your Medicare ID card, showing Part A and Part B effecitve dates, within 45 days prior to your effecive date in order to be enrolled on time. Late enrollments will result in a delay in your prescription drug coverage. Upon electing the DCMS plan you will automatically be enrolled in SilverScript, Dartmouth s Medicare Part D prescription drug plan. 1

5 2017 Open Enrollment Dartmouth College Open Enrollment period is your annual opportunity to evaluate and make necessary changes to your retiree benefits elections. The Dartmouth College Open Enrollment for the 2017 plan year begins October 17 at 12 am and ends October 31 at 11:59 pm. All benefit changes must be in the FlexOnline system by 11:59 pm on Monday, October 31, 2016 and will take effect January 1, Open Enrollment If you are currently enrolled in the Under 65 medical plan, you MUST elect or waive coverage online this year even if you are not making changes to your benefits. If no action is taken, you will be defaulted to the Cigna Choice Fund (CCF) plan. Dartmouth College Medicare Supplement (DCMS) plan Open Enrollment There are no changes to the DCMS plan for All deductible, copayments and coinsurances will remain the same. The 2017 DCMS premium base rate is $ per month. The invoice you receive mid-january will refect the new premium amount. If you do not owe a household premium, you will not receive an invoice. Check out Dartmouth s Benefits website, dartgo.org/retirees for additional information about the Dartmouth College retiree medical benefits. 2

6 RETIRED EMPLOYEES UNDER AGE 65 3

7 Changes for 2017 Medical Plans Dartmouth will continue to offer employees three medical plan options. A summary of changes is below. Details on each of the medical plan options can be found later in this guide. There will be an average increase of 1.4% to medical plan rates in The Open Access Plus (OAP) plan 1 and OAP 2 have been consolidated into one plan. The new OAP will have a $500/member deductible, capped at $1,000 for families, a 10% member coinsurance, with no change in medical or prescription co-pays. The family deductible now requires the equivalent of only two individuals to reach the deductible before the plan begins to pay for a portion of services. Similarly, the out-of-pocket maximum for families only requires the equivalent of two individuals to reach the out-of-pocket maximum before all eligible services for the family are covered at no cost. Dartmouth will add a new plan called the Cigna Choice Fund. Same provider network as the OAP plan. The new Cigna Choice Fund plan will have a $1,500 per member deductible, capped at $3,000 for families. The Cigna Choice Fund plan will also have 10% member coinsurance and new medical and prescription copays. The Cigna Choice Fund plan will include an employer contribution to an HRA of $500 for employee only and $1,000 for plans covering two or more family members. The HRA will be used to pay for medical services subject to deductible and coinsurance, as applicable.. Note: Your unused HRA funds may be carried over to the next benefit year if you remain in the same health plan. No plan changes to the High Deductible Health Plan (HDHP). Medical Coverage The following pages will highlight the important features in the 2017 medical plans. The 2017 options available to you were designed to provide you and your family members with affordable and accessible health care. The information contained within this guide is a summary of Dartmouth s benefits. The Dartmouth Medical Plans are self-insured and administered by Cigna. Pharmacy plan benefits are administered by CVS/caremark. Important features of the medical plans All plans provide coverage for medical care, including visits to your doctor s office, hospital stays, mental health and substance abuse services, chiropractic treatment, physical therapy and other services. All three plans offer: An option to choose a primary care doctor to help guide your care. It s recommended, but not required. A national network of providers, as well as emergency coverage when traveling abroad for personal travel. No referral is needed to see a specialist, although precertification may be required. In-network preventive care* services covered at no additional cost to you. See your plan materials for a list of covered preventive care services. 24-hour emergency care, in- or out-of-network. The amount you pay out-of-pocket is limited by your plan s out-of-pocket maximum. Once you spend the annual maximum amount, the health plan pays your covered health care costs at 100%. No claim paperwork is necessary when you receive care in-network. * Some preventive services may not be covered. For example, immunizations for travel are generally not covered. Other non-covered services/supplies may include any service or device that is not medically necessary or services/supplies that are unproven (experimental or investigational). 4

8 Health Reimbursement Account Overview Feature Which Health Plan must I elect to participate? Who administers the plan? Who may contribute to the account? What are the permitted annual limits on contributions? What is the annual Dartmouth contribution? What is the maximum I can contribute? What is the tax treatment of contributions? Can funds be carried over from one year to the next? Can I take my funds with me if I leave the Dartmouth retiree medical plans? Does interest accrue on funds deposited in the account? Which expenses are eligible? Can I use Dartmouth Health Connect? Other features Health Reimbursement Account (HRA) A Dartmouth-funded account that provides reimbursement for qualified health care expenses. Cigna Choice Fund HDHP with HRA Cigna Solely funded by Dartmouth. No federal income tax law limits. Individual maximum: $500 Family of 2 or more: $1,000 N/A Retirees do not contribute to this plan Dartmouth contributions are excluded from your gross income. Yes, unused amounts can carry into the next year if you remain on the same health plan. No, unused HRA balances are forfeited if you leave or changes jobs. COBRA regulations also apply. No, interest is not accrued. Only services subject to deductible and coinsurance. Note: The HRA will not offset office visit, emergency room and prescription drug copays in the Cigna Choice Fund. Yes, only if you are not enrolled in any part of Medicare. No substantiation required. Medical expenses are paid automatically from your account. Product availability may vary by location and plan type and is subject to change. All group health insurance policies and health benefit plans contain exclusions and limitations. For rates and complete details of coverage, visit dartgo.org/retirees 5

9 Open Access Plus Plan (OAP) Has the highest base plan rates, but lowest deductible, and lowest out of pocket costs for medical and prescription expenses Key benefits of choosing the Open Access Plus (OAP) plan: Has the lowest deductible and out-of-pocket costs for medical and prescription expenses. You and your dependents age 18+ can utilize Dartmouth Health Connect at no additional cost. Other considerations: Has the highest plan rates of all three plans. Medical and prescription copays count toward out-of-pocket maximums but not deductibles. In-network Out-of-network Medical deductible Individual $500 $1,000 Family $1,000 $2,000 Out-of-pocket maximum Individual $2,500 $5,000 Family $5,000 $10,000 Coinsurance Individual 10% 30% Family 10% 30% Office visit $20 Deductible/Coinsurance Specialist visit $30 Deductible/Coinsurance Emergency room $100 $100 Urgent care $50 $50 Prescription drugs Generic/Preferred/Non-Preferred 30-Day retail pharmacy $5/$25/$40 N/A 90-Day mail order $10/$50/$80 N/A 90-Day CVS retail $10/$50/$80 N/A How your OAP plan works What s Covered: Copays for office visits, emergency room visits, prescription drugs, or other services subject to copays do not count towards the deductibles. For services subject to the deductible, please see diagram below: YOU PAY FOR COVERED SERVICES WITH PERSONAL FUNDS UNTIL YOU REACH YOUR PLAN S DEDUCTIBLE, THEN YOU PAY 10% IN-NETWORK COINSURANCE + YOUR HEALTH PLAN PAYS 90% COINSURANCE ONCE YOU REACH THE PLAN S OUT OF POCKET MAXIMUM YOUR HEALTH PLAN PAYS 100% OF YOUR COSTS FOR COVERED SERVICES FOR THE REMAINDER OF THE PLAN YEAR. 6

10 Cigna Choice Fund Plan (CCF) Has mid-level plan rates and out-of-pocket costs Key benefits of choosing the Cigna Choice Fund plan: The employer-funded Health Reimbursement Account (HRA) helps you pay for out-of-pocket medical expenses subject to your annual deductible, while keeping your plan rates low. The money used from your HRA typically counts toward your deductible and coinsurance (as applicable). Unused money will be available to you in the following year if you re-enroll in the CCF plan. No paperwork or IRS reporting required for HRA funding. Deductibles are automatically paid by Cigna and deducted from your account as needed. You and your dependents age 18+ can utilize Dartmouth Health Connect at no additional cost. Other considerations: Medical and prescription copays count toward out-of-pocket maximums but not deductibles. Federal Government regulations prohibit J Visa holders from enrolling in this plan. HRA contribution from employer* Medical deductible In-network Out-of-network $500 individual $1,000 family Individual $1,500 $3,000 Family $3,000 $6,000 Out-of-pocket maximum Individual $4,000 $6,000 Family $8,000 $12,000 Coinsurance Individual 10% 30% Family 10% 30% Office visit $30 Deductible/Coinsurance Specialist visit $45 Deductible/Coinsurance Emergency room $150 $150 Urgent care $50 $50 Prescription drugs Generic/Preferred/Non-Preferred 30-Day retail pharmacy $5/$30/$50 N/A 90-Day mail order $10/$60/$100 N/A 90-Day CVS retail $10/$60/$100 N/A * Employer contribution is available to use on January 1, How your CCF Plan with HRA works How your HRA is funded: Money from your employer. What s covered: Copays for office visits, emergency room visits, prescription drugs, or other services subject to copays do not count towards the deductibles. For services subject to the deductible, please see diagram below: HRA YOUR HRA PAYS FOR DEDUCTIBLE COSTS UNTIL ITS FUNDS ARE USED UP. THEN YOU PAY FOR COVERED SERVICES, USING PERSONAL FUNDS, UNTIL YOU REACH YOUR PLAN S DEDUCTIBLE. THEN, YOU PAY 10% IN-NETWORK COINSUARNCE + YOUR HEALTH PLAN PAYS 90% COINSURANCE ONCE YOU REACH THE PLAN S OUT- OF-POCKET MAXIMUM YOUR HEALTH PLAN PAYS 100% OF YOUR COSTS FOR COVERED SERVICES, FOR THE REMAINDER OF THE YEAR. 7

11 High Deductible Health Plan (HDHP) Lowest plan rates but has the potential for highest out-of-pocket exposure dependent upon utilization Key benefits of choosing an HDHP: The HDHP has the lowest plan rates of all three plans. Other considerations: Has the potential for lowest total cost with low utilization or highest total cost with high utilization. You pay 100% of prescription drug costs until the deductible is met. Know the retail cost of your prescriptions prior to choosing this plan. Federal Government regulations prohibit J Visa holders from enrolling in this plan. HRA contribution from employer Medical deductible In-network Out-of-network $500* individual $1,000* family Individual $2,600 $4,100 Family $5,200 $8,200 Out-of-pocket maximum Individual $4,000 $6,500 Family $8,000 $13,000 Coinsurance Individual 10% 30% Family 10% 30% Office visit Deductible/Coinsurance Deductible/Coinsurance Specialist visit Deductible/Coinsurance Deductible/Coinsurance Emergency room Deductible/Coinsurance In-Network Deductible/ Coinsurance Urgent care Deductible/Coinsurance In-Network Deductible/ Coinsurance Prescription drugs 30-Day retail pharmacy Deductible/Coinsurance N/A 90-Day mail order Deductible/Coinsurance N/A 90-Day CVS retail Deductible/Coinsurance N/A * Employer contributions will be available in your account beginning January 1, HRA YOUR HRA PAYS FOR DEDUCTIBLE COSTS UNTIL ITS FUNDS ARE USED UP. THEN YOU PAY FOR COVERED SERVICES, USING PERSONAL FUNDS, UNTIL YOU REACH YOUR PLAN S DEDUCTIBLE. THEN, YOU PAY 10% IN-NETWORK COINSUARNCE + YOUR HEALTH PLAN PAYS 90% COINSURANCE ONCE YOU REACH THE PLAN S OUT- OF-POCKET MAXIMUM, YOUR HEALTH PLAN PAYS 100% OF YOUR COSTS FOR COVERED SERVICES, FOR THE REMAINDER OF THE YEAR. 8

12 Medical Plan Comparison Chart Open Access Plus Plan (OAP) Cigna Choice Fund Plan (CCF) High Deductible Health Plan (HDHP) Medical plan highlights Medical deductible Individual Family Out-of-pocket maximum Individual Family Coinsurance Indivdiual Family Contribution from employer 1 Individual Family In-network Out-of-network In-network Out-of-network In-network Out-of-network $500 $1,000 $2,500 $5,000 10% 10% Dartmouth Health Connect $1,000 $2,000 $5,000 $10,000 30% 30% $1,500 $3,000 $4,000 $8,000 10% 10% Dartmouth Health Connect is a highly innovative relationship based primary care practice right on the Dartmouth campus that provides the type of health care patients deserve. Patients can expect highly personalized, friendly, expert care delivered by a team of professionals who are passionate about managing health in a better way. Other key benefits that Dartmouth Health Connect patients enjoy include: 24/7 access to their care teams by phone and guaranteed same or next day visits when they are sick. Access to a care team that gets to know you well and focuses on preventive care to help you stay healthy No cost for office visits Enhanced care through partnership with physicians, nurses, health coaches, and an available in-house behavioral health specialist. Convenient location at 7 Allen Street in Hanover Accessible care team who often engage by phone, , text, and video to help patients. Retirees and adult (18+) family members enrolled in a Cigna health plan through Dartmouth College as their primary insurance, and who are not enrolled in Medicare are able to join Dartmouth Health Connect. For more information, please visit or call to learn more about becoming a patient at Dartmouth Health Connect. 9 HRA $500 $1,000 $3,000 $6,000 $6,000 $12,000 Pharmacy OAP CCF HDHP Retail pharmacy network (up to a 30-day supply) Generic $5 $5 Deductible/Coinsurance Preferred brand $25 $30 Deductible/Coinsurance Non-preferred brand $40 $50 Deductible/Coinsurance Caremark mail service or CVS Pharmacy (up to 90-day supply) Generic $10 $10 Deductible/Coinsurance Preferred brand $50 $60 Deductible/Coinsurance Non-preferred brand $80 $100 Deductible/Coinsurance 30% 30% $2,600 $5,200 $4,000 $8,000 Prescription out-of-pocket-maximum: Out-of-pocket maximum includes all prescription drug and medical expenses (copays, deductibles, and coinsurance). 1. Employer contributions to HRA accounts are available to use on January 1, % 10% HRA $500 $1,000 $4,100 $8,200 $6,500 $13,000 30% 30%

13 Open Access Plus Plan (OAP) Cigna Choice Fund Plan (CCF) High Deductible Health Plan (HDHP) Office/Routine care What you ll pay once you meet your deductible In-network Out-of-network In-network Out-of-network In-network Out-of-network Adult preventive care 100% 2 Deductible/Coinsurance 100% 2 Deductible/Coinsurance 100% 2 Deductible/Coinsurance Office visit $20 Deductible/Coinsurance $30 Deductible/Coinsurance Deductible/Coinsurance Deductible/Coinsurance Specialist visits $30 Deductible/Coinsurance $45 Deductible/Coinsurance Deductible/Coinsurance Deductible/Coinsurance Chiropractic $20 Deductible/Coinsurance $30 Deductible/Coinsurance Deductible/Coinsurance Deductible/Coinsurance Physical, occupational and speech therapy $20 Deductible/Coinsurance $30 Deductible/Coinsurance Deductible/Coinsurance Deductible/Coinsurance Well-childcare 100% 2 Deductible/Coinsurance 100% 2 Deductible/Coinsurance 100% 2 Deductible/Coinsurance Lab, X-ray, diagnostic tests Durable medical equipment Deductible/Coinsurance Deductible/Coinsurance Deductible/Coinsurance Deductible/Coinsurance Deductible/Coinsurance Deductible/Coinsurance Deductible/Coinsurance Deductible/Coinsurance Deductible/Coinsurance Deductible/Coinsurance Deductible/Coinsurance Deductible/Coinsurance Hospital care Inpatient hospitalization Deductible/Coinsurance Deductible/Coinsurance Deductible/Coinsurance Deductible/Coinsurance Deductible/Coinsurance Deductible/Coinsurance Outpatient surgery Deductible/Coinsurance Deductible/Coinsurance Deductible/Coinsurance Deductible/Coinsurance Deductible/Coinsurance Deductible/Coinsurance Emergency room $100 $100 $150 $150 Deductible/Coinsurance Urgent care center $50 $50 $50 $50 Deductible/Coinsurance In-Network Deductible/ Coinsurance In-Network Deductible/ Coinsurance Ambulance Deductible/Coinsurance Deductible/Coinsurance Deductible/Coinsurance Deductible/Coinsurance Deductible/Coinsurance Deductible/Coinsurance Mental health and substance abuse Inpatient Deductible/Coinsurance Deductible/Coinsurance Deductible/Coinsurance Deductible/Coinsurance Deductible/Coinsurance Deductible/Coinsurance Outpatient $20 Deductible/Coinsurance 3 $30 Deductible/Coinsurance 3 Deductible/Coinsurance Deductible/Coinsurance 3 2. Certain in-network preventive care services and well-childcare services are covered at no added cost to you. You have no deductible to meet for these services. 3. Mental Health Exception Benefit: When utilizing out-of network mental health providers through any of Dartmouth College s Health plans, you or your covered family members may attend up to 12 visits with an out-of-network provider at a 10% member coinsurance cost. This exception benefit does not renew annually, therefore all visits beyond the initial 12, are subject to out-of-network deductible and coinsurance. Hearing Aid Coverage Hearing aids are covered on all three plans as follows: Age 19 and over $3,000 maximum per calendar year Age 18 and under Unlimited maximum per calendar year Includes testing and fitting of hearing aid devices covered at PCP or Specialist Office visit level 10

14 Prescription Drug Coverage Retirees who take advantage of the medical benefits at Dartmouth College are automatically enrolled in a pharmacy plan, offered through CVS/caremark. Key features of the CVS/caremark pharmacy plan include: Broad retail network of more than 67,000 participating pharmacies nationwide, including: Independent pharmacies Chain pharmacies CVS pharmacy locations Your CVS/caremark prescription ID card must be presented when filling a prescription Flexible prescription service for your maintenance medications. You may fill a 90-day supply of maintenance medications through CVS/caremark s mail order pharmacy or at any CVS pharmacy location. 90-day prescriptions are available at a reduced cost. Certain preventive prescriptions offered at no cost for members enrolled in the HDHP. Tiered drug pricing, ranging from: Pharmacy OAP Cigna Choice Fund HDHP Retail Pharmacy Network (up to a 30-day supply) Generic $5 $5 Deductible/Coinsurance Preferred brand $25 $30 Deductible/Coinsurance Non-preferred brand $40 $50 Deductible/Coinsurance Caremark Mail Service or CVS Pharmacy (up to 90-day supply) Generic $10 $10 Deductible/Coinsurance Preferred brand $50 $60 Deductible/Coinsurance Non-preferred brand $80 $100 Deductible/Coinsurance Advance Control Formulary to help guide you and your doctor in choosing a clinically appropriate and cost-effective brand-name medicine if a generic is not available. Should your medication be excluded starting January 1st, you will receive a notification from Caremark in December identifying your alternatives. We recommend that you discuss these alternatives with your prescriber to identify the safest and most cost-effective treatment for you. Prior authorization requirement for certain specialty medications, as determined by the Specialty Guideline Management Program. If a drug you are taking requires pre-authorization, your pharmacist will let you know, and your doctor will need to contact Caremark Connect for approval. Drug Savings Review Program Clinicians at CVS/caremark review prescription history to ensure that you are taking the safest and most costeffective medications available. If CVS/caremark identifies an opportunity to simplify your prescription regimen or find a more cost-effective medication, they will work with your physician to review your medical needs and update your prescriptions if appropriate. Please note, no changes will be made to your prescriptions unless your physician has approved a new therapy. For additional details about the CVS/caremark pharmacy plan: Visit dartgo.org/pharmacy 11

15 Vision Coverage As part of the preventive care services under your Dartmouth College medical plan, coverage includes the following: In-network OAP and CCF Plans Out-of-network Frequency period* In-network HDHP Out-of-network Frequency period* Exam copay $0 N/A 12 months $0 N/A 12 months Exam coinsurance (once per frequency period) Covered 100% Covered 70% 12 months Covered 100% Covered 100% up to reasonable and customary amount Materials allowance** Up to $50 Up to $50 12 months N/A N/A N/A * Your Frequency Period begins on January 1 (calendar year basis). ** Declining balance can be applied towards any covered Materials (Frames, Lenses, and Contact Lenses) and drawn against throughout the stated frequency period. In addition, you can also take advantage of vision discounts through: Cigna Healthy Rewards *** visit dartgo.org/healthy_rewards for more information. For more information, visit dartgo.com/benefits months *** Healthy Rewards is a discount program. Some Healthy Rewards programs are not available in all states and programs may be discontinued at any time. If your Cigna plan includes coverage for any of these services, this program is in addition to, not instead of, your plan benefits. Healthy Rewards programs are separate from your plan benefits. A discount program is NOT insurance, and you must pay the entire discounted charge. How to Enroll To enroll in benefits or to make changes to your current benefits elections during open enrollment, here's how to access your FlexOnline benefits page:. 1. Go to dartgo.org/flexonline 2. Choose the link for RETIREES 3. Enter the User ID and PIN (follow the "New to this site" instructions). 4. From the welcome page, click the open enrollment tile to make your 2017 elections. 5. Once you have made your choices, click "ACCEPT" and "SUBMIT" to complete your enrollment. 6. For a printed copy of your confirmation statement, select "PRINT THIS PAGE", then click "OK". 7. You may continue to log-in and make changes to your 2017 elections until 11:59pm on Monday, October 31, Changes cannot be made after October 31,

16 Wellness at Dartmouth $200 Wellness Benefit Get reimbursed up to $200 per family enrolled on a Dartmouth College health plan for certain wellness expenses, including fitness facilities, exercise classes, activity tracking devices, race fees and wellness workshops. Cigna Healthy Rewards Show your Cigna ID card to a participating provider when you pay for services and let the savings begin. Get discounts on the health products and programs you use every day for: Weight management and nutrition Fitness Mind/body Vision and hearing care Alternative medicine Healthy lifestyle To start saving today, visit mycigna.com/rewards or call * Healthy Rewards is a discount program. Some Healthy Rewards programs are not available in all states and this program is in addition to, not instead of, your plan benefits. Healthy Rewards programs are separate from your plan benefits. A discount program is NOT insurance, and you must pay the entire discounted charge. All goods, services and discounts offered through Healthy Rewards are provided by third parties who are solely responsible for their products, services and discounts. 13

17 RETIRED EMPLOYEES WHO ARE MEDICARE ELIGIBLE 14

18 Eligibility and Medicare Your Dartmouth Retiree Medical Plan and becoming Medicare Eligible: You (or your spouse/same sex partner) become eligible for Medicare on the first day of your 65th birth month. However, if your birthday is on the first day of the month, your coverage will start the first day of the prior month. You must contact Social Security three months prior to your Medicare eligibility date to enroll in Medicare Part A and Part B. At that time your retiree medical plan through Dartmouth College offers Medicare supplement coverage called the Dartmouth College Medicare Supplement (or DCMS) plan. In order to be eligible for the DCMS Plan you must meet the minimum qualifications and be enrolled in Medicare Part A and Part B, according to the rules outlined by Social Security. Please note: The Dartmouth College Benefits Office must receive a copy of your Medicare ID card, showing the effective dates of your Medicare Part A and Part B coverage, within forty-five days prior to your effective date in order to avoid a delay in your DCMS Part D prescription drug coverage. You should not enroll in a separate Medicare Part D if you want to be covered on the DCMS plan. Dartmouth will enroll you in prescription drug coverage through SilverScript (Caremark s Medicare Part D plan) upon enrolling in the DCMS plan. Once enrolled in the DCMS plan, you and your eligible dependents will receive new ID cards from Cigna and SilverScript. These ID cards will display different identification numbers for each covered dependent. Please be sure to present your new ID cards to your providers when you seek services on or after your effective date. Medicare Adjustments EXTRA HELP: If you are a low-income beneficiary you may be eligible for the federal EXTRA HELP program. If you are eligible, you will receive notice from the Social Security Administration. Eligibility is determined by Social Security according to income and federal low income tables. If you think you may be eligible but have not received notice from Social Security, contact your local Social Security office for additional information. See page 20 for contact information Income Related Monthly Adjustment Amount (IRMAA): If you are a higher-income beneficiary, according to Medicare Income limits, you will pay an Income Related Monthly Adjustment Amount (IRMAA) for your Medicare Part B and Part D plans. The adjusted amount is determined by income information you have reported to the IRS through your federal tax returns. As a Dartmouth College retiree you may be eligible to receive reimbursement for IRMAA payments related to Medicare Part D. You can obtain a Part D IRMAA reimbursement form by calling the Benefits Office at , or online at: dartmouth.edu/~hrs/forms Social Security will contact you directly if you are considered to be higher-income according to IRS records. Under 65 Dependent Coverage If you cover family members on your plan who are under age 65, they may remain on the same plans offered to active Dartmouth College employees. This information is applicable to retirees both pre and post

19 Information About Medicare Medical Plan for Disabled Employees on Medicare If you have been out of work and on Long Term Disability (LTD) for more than two years, you will be eligible for Social Security benefits and required to enroll in Medicare parts A and B as your primary medical insurance coverage. Dartmouth College offers a robust Medicare gap plan through Cigna Health, to help supplement your Medicare plans. The Dartmouth College Medicare Supplement plan (DCMS) is available for disabled employees. Your family members under age 65 will continue to be eligible to participate in the OAP, CCF and HDHP plans, while your over age 65 dependents who are also enrolled in Medicare parts A and B, may participate in the DCMS plan defined below. How do I apply for Medicare? Three months prior to turning 65 you should call or visit a Social Security office for help with determining whether or not you should sign up for Medicare. You can also apply for Medicare and other Social Security benefits online at: What is the difference between Medicare Part A and Medicare Part B? There are two parts to Medicare: Part A (Hospital Coverage) and Part B (Medical Coverage). Medicare Part A is paid for by a portion of the Social Security tax of people still working. It helps pay for inpatient hospital care, skilled nursing care, and other hospital services. Medicare Part B is paid for by monthly premiums of those who are enrolled and by transfers from the general fund of the U.S. Treasury. Part B pays for doctor s fees, outpatient hospital visits, and other medical services and supplies. What is Medicare Part D? Medicare Part D is a cost-share drug benefit designed to help seniors pay for prescription medications. You will be automatically enrolled in a Medicare Part D plan through SilverScript Prescription Drug Provider (PDP), when you enroll in the DCMS plan. Dartmouth College must have a copy of your Medicare ID card on file, reflecting your Medicare Part A and Part B coverage, in order for SilverScript to pay your claims. 16

20 Dartmouth College Medicare Supplement Plan (DCMS) Coverage type Medical Coverage Out-of-pocket costs Medical Administered by Cigna Deductible $250 Coinsurance 20% (up to $200) Annual out-of-pocket medical maximum $450 Prescription drug coverage How to Enroll 17 SilverScript (PDP) Generic Preferred brand Non-preferred brand 1-30 day supply $5 $25 $ day supply $10 $50 $ day supply $15 $75 $120 Home delivery 90-day supply $10 $50 $80 Annual prescription out-of-pocket maximum $450 Total annual out-of-pocket maximum $900 Medicare Part A (Federal Hospital Coverage) (premium-free) Medicare Part B (Federal Medical Coverage) (You pay a premium to Social Security*) Coverage offered through the Federal Government Who Pays What? Medicare Part D (SilverScript) Prescription Drug Plan * Dartmouth pays the base premium The DCMS plan coverage Dartmouth College Medicare Supplement (DCMS) Plan (Administered by Cigna) * If you are considered to be a Higher Income Beneficiary, according to Social Security income tables, you will pay more for Medicare Part B and an additional premium for your Medicare Part D (drug) plan even if you are on the DCMS plan. The College will reimburse you for additional premiums you pay to Social Security for Part D (drug) premiums if you are on the DCMS plan. Dartmouth s Medicare Supplement plan is a self-insured group retiree medical plan. It is NOT a standardized Medicare Supplement (Medigap) plan and is NOT offered under a contract with the federal government. Cigna Health and Life Insurance Company is not connected with or endorsed by the U.S. Government or the federal Medicare program. To enroll in benefits or to make changes to your current benefits elections during open enrollment, here's how to access your FlexOnline benefits page: 1. Go to dartgo.org/flexonline how to access your FlexOnline benefits page:. 2. Choose the link for RETIREES 3. Enter the User ID and PIN (follow the "New to this site" instructions). 4. From the welcome page, click the open enrollment tile to make your 2017 elections. 5. Once you have made your choices, click "ACCEPT" and "SUBMIT" to complete your enrollment. 6. For a printed copy of your confirmation statement, select "PRINT THIS PAGE", then click "OK". 7. You may continue to log-in and make changes to your 2017 elections until 11:59pm on Monday, October 31, Changes cannot be made after October 31, 2016

21 Important Reminders If you will turn 65 during 2017, enroll as usual for the beginning of the year. Contact Social Security 3 months prior to the month you turn 65 to enroll in Medicare Part A and Part B. Contact the Benefits Office with a copy of your new Medicare ID showing coverage in Parts A & B to enroll in the DCMS plan. Change of address or other information You must notify the Benefits Office if you change your address or if any of the information about your spouse/ same sex partner, or other eligible dependents changes. If your mailing address is a P.O. Box, Medicare requires a physical address on file as well. Please make sure Medicare and the Dartmouth Benefits Office has your current mailing and physical address. Billing information If you owe a premium for your Dartmouth College retiree medical plan for either yourself or your covered dependent(s), you will receive a monthly invoice from the Dartmouth College Accounts Receivable Office for the portion you are responsible for. This invoice will arrive on or around the 15th of each month, for the current month s coverage, and is due by the end of that month. Failure to remit your payment within the allotted period will result in a cancellation of your coverage, without the ability to re-enroll. If you do not owe a premium, you will not receive an invoice. Death benefit Retirees of Dartmouth College who retired on or prior to December 31, 2010 have a $5,000 Death Benefit (family members are not eligible for coverage). Please complete a new Beneficiary Form if you want to update your beneficiaries. This form can be obtained by calling the Benefits Office at , or online at: dartgo.org/hrforms. Mail the completed form to Office of Human Resources, 7 Lebanon St. Suite 203, Hanover, NH Spouse/same sex partner, dependent(s) Coverage under this Plan is available only for a person who is your spouse/same sex partner, or legal dependent at the time of your retirement. If you die after retirement, your eligible spouse/same sex partner (if he or she survives you) may continue their Dartmouth retiree benefits coverage elections, and can make changes according to the procedures below. Dropping or reducing coverage If you have coverage under this Plan, you may at any time (i) drop coverage, (ii) change family coverage to two-person or single coverage, or (iii) change two-person coverage to single coverage. Adding or increasing coverage You may (i) add coverage, (ii) change single coverage to two-person or family coverage, or (iii) change twoperson coverage to family coverage. Such a change may be made only (i) during the normal annual Open Enrollment period, or (ii) within 45 days prior to the date the person you want to cover (either you or an eligible dependent) lost other coverage. Dartmouth may require evidence of the loss of other coverage. If you are married after you have retired, your new spouse/same sex partner will not be eligible for coverage through the Dartmouth retiree medical plans. Procedures Changes can be made during open enrollment of any year, or within the year if you have a qualifying event. You can do so either online at dartgo.org/flexonline, or by contacting the Dartmouth College Benefits Office at human.resources.benefits@dartmouth.edu. Any changes made during a normal Open Enrollment period will be effective on the first day of the next plan year. When adding or increasing coverage outside of a normal Open Enrollment period, the new coverage will be retroactive to the date of loss of other coverage (and you will be required to pay any applicable retroactive premiums). When dropping or reducing coverage outside a normal Open Enrollment period, the change will be effective on the first day of the month following the month in which the Benefits Office received the form. 18

22 Annual Required Notices Here is important information you should read before you enroll. Women s Health and Cancer Rights Act (WHCRA) The Women s Health and Cancer Rights Act of 1998 requires all group health plans that provide medical and surgical benefits for mastectomy to provide coverage for reconstruction of the breast on which the mastectomy was performed; surgery reconstruction of the other breast to produce a symmetrical appearance; and prostheses and treatment of physical complications of all stages of mastectomy, including lymphedema. These services must be provided in a manner determined in consultation with the attending physician and the patient. This coverage may be subject to annual deductibles and coinsurance provisions applicable to other such medical and surgical benefits provided under the plan. Please refer to your Summary Plan Description for deductibles and coinsurance information applicable to the plan in which you choose to enroll. For more information visit: dartgo.org/whcra Medicare Part D Notice of Creditable Coverage (NOCC) The Medicare Modernization Act (MMA) requires entities (whose policies include prescription drug coverage) to notify Medicare eligible policyholders whether their prescription drug coverage is creditable coverage, which means that the coverage is expected to pay on average as much as the standard Medicare prescription drug coverage. For more information visit: dartgo.org/creditable_coverage Children s Health Insurance Program Reauthorization Act (CHIPRA) If you or your children are eligible for Medicaid or CHIP and you re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren t eligible for Medicaid or CHIP, you won t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial KIDS NOW or to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employersponsored plan. If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren t already enrolled. This is called a special enrollment opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. For more information visit: dartgo.org/chip Patient Protection Disclosure Dartmouth College generally allows the designation of a primary care provider. You have the right to designate any primary care provider who participates in your plan s network and who is available to accept you or your family members. For information on how to select a primary care provider, and for a list of the participating primary care providers, visit mycigna.com or contact Cigna customer service at For children, you may designate a pediatrician as the primary care provider. You do not need prior authorization from Cigna or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, 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 mycigna.com or contact Cigna customer service at

23 Contacts DARTMOUTH BENEFITS OFFICE Phone: Website: CIGNA Medical Phone: Website: mycigna.com CVS/CAREMARK Pharmacy under age 65 Phone: Website: DARTMOUTH HEALTH CONNECT Phone: Website: MEDICARE Phone: 800.MEDICARE ( ) Websites: SILVERSCRIPT Pharmacy for Medicare Eligible Phone: Website: SOCIAL SECURITY ADMINISTRATION Phone: Websites: Mailing Addresses: 177 Main Street Littleton, NH ASA Bloomer Bldg. 88 Merchants Row Rutland, VT Suite Commercial Street Concord, NH

24 Words to Know We think that understanding certain words will help you better understand the choices you need to make. So here are some definitions of words and phrases that you will see used in this guide. Deductible: A fixed annual dollar amount that you pay out of pocket during the calendar year, toward health care services before the health plan begins to pay. Copay: A fixed dollar amount you pay at the time health care services or prescription drugs are received, regardless of the total charge for service. The health plan pays the rest. Coinsurance: A fixed percentage of covered health care services or prescription drug costs that you pay, after the deductible amount (if any) was paid. The health plan pays the rest. Out-of-pocket maximum: The most you pay before the health plan begins to pay 100% of covered charges. In-network: Health care professionals and facilities that have contracts with Cigna or Medicare to deliver services at a negotiated rate (discount). You pay a lower amount for those services. Out-of-network: A health care professional or facility that does not participate in your Cigna or Medicare plan s network and does not provide services at a discounted rate. Using an out-of-network health care professional or facility will cost you more. Generics: Generic medications have the same active ingredients, dosage, and strength as their brandname counterparts. You will usually pay less for generic medications. Preferred brands: Preferred brand medications will usually cost more than generics but may cost less than non-preferred brands on your plan. Non-preferred brands: Non-preferred brand medications generally have generic alternatives and/or one or more preferred brand options within the same drug class. You will usually pay more for non-preferred brand medications. Health Reimbursement Account (HRA): An employer funded account that pays up to a pre-determined amount toward certain out-of-pocket medical costs. Your unused HRA funds may be carried over to the next benefit year if you remain in the same Dartmouth retiree health plan. This is a new plan for

25 Office of Human Resources 7 Lebanon St., Suite 203 Hanover, NH USA Any reference to the information or websites of any non-cigna-affiliated entity is provided on behalf of Dartmouth for informational purposes only. Cigna is not responsible for their content or accuracy. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company and Life Insurance Company of North America. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc /16 As to Cigna content/properties 2016 Cigna.