September 5, 2017 ACTION REQUIRED: 2018 Benefits Open Enrollment In June, MITRE announced that we are consolidating health insurance plans under a single, national administrator: Aetna. This packet includes everything you need to elect your new health insurance plan and to make changes to your dental or vision elections for 2018. Please note: To enroll in MITRE benefits, you must be in good standing. If you separate from MITRE prior to January 1, 2018, you will not be eligible to re-enroll. IMPORTANT: Because MITRE is replacing its current health plans with new offerings, you MUST complete the enclosed medical enrollment form to obtain health insurance coverage through MITRE for 2018. If you do not submit the paperwork, you will not be covered even if you are currently enrolled in an Aetna plan. This year, MITRE s Benefits Open Enrollment ends earlier than usual: November 17, 2017. Please review this letter s information, instructions, and enclosed materials carefully. How to Enroll in 2018 Benefits 1 Understand your health plan options. MITRE is offering two plan options in 2018, both under Aetna: The Flex Care PPO and the High-Deductible (HD) Care PPO. Both plans: Provide pharmacy coverage through CVS/Caremark Provide the flexibility of using doctors and hospitals both in and out-of-network Offer coverage under the same provider network: Aetna Choice POS II (Open Access) Cover 100% of preventive services like routine check-ups, routine mammograms, and colonoscopies Cover the same services and treatments; however, how you pay for those services differs by plan (i.e., through different premium amounts, and size and application of deductibles). To learn more about the plans and choose the best fit for you, use the comparison chart (enclosed) and the suite of resources at MITRE.org/2018Healthcare. 2 Check 2018 rates. Monthly premiums for COBRA medical, dental, and vision insurance are enclosed. There are no changes to dental or vision insurance, except changes to dental rates. 3 Submit your completed health plan enrollment form by November 17. Use the enclosed stamped envelope (or email hrsc@mitre.org) to return your completed form to the MITRE HR Service Center. You MUST submit your form by November 17 if you want 2018 medical coverage through MITRE. No action = no coverage. 4 Submit your completed dental and vision form to WageWorks--ONLY if you want to make changes to this coverage. If you do not want to change these elections, no action is required; your 2017 elections will carry over into 2018 unless you notify WageWorks of changes. The MITRE Corporation 202 Burlington Road Bedford, MA 01730
2018 Benefits Open Enrollment Page 2 If you are currently an Aetna or CVS member, your ID numbers will remain the same for 2018. For those not currently on Aetna or CVS, your new ID numbers will be available in early December so you can begin scheduling appointments for 2018, start transition of care applications (if necessary), and transfer prescriptions (if you currently receive pharmacy coverage through Kaiser). NOTE: By law, the Affordable Care Act (ACA) requires health plan information documents be available to health plan members to evaluate their health insurance choices and make informed coverage decisions. The Summary of Benefits and Coverage (SBC) provides a common format for describing the RESOURCES Enrollment & Benefit Questions? HR Service Center: 781-271-4700 or hrsc@mitre.org Questions about 2018 Health Plans? Aetna: 866-239-2670 CVS: 877-323-1717 MITRE.org/2018Healthcare benefits and coverage under a health plan and the Uniform Glossary provides standard definitions of terms commonly used in health insurance coverage. These documents will be available in late October at www.wageworks.com. Interested in the HD Care PPO? Please note: MITRE contributes funds toward Health Savings Accounts (HSAs) only for active employees; this does not include retirees, individuals on long-term disability, or individuals covered through COBRA. Billing Information Please be sure the premium you submit to WageWorks starting in January matches the 2018 rates as shown on the attached. If you are using a bill paying service, make sure you notify the service of the new rate. Premiums are due on the 1 st of each month. Bills with monthly coupons are sent annually. If you have any questions about your bill, please contact WageWorks at 877-502-6272. MITRE Benefit Fairs Coming in November McLean November 2, 11 am to 2 pm MITRE 3, 2 nd floor atrium off M2 skybridge Bedford November 7, 11 am to 2 pm MITRE Center, 2 nd floor atrium Representatives will be on hand to answer questions and provide materials to assist you in making decisions regarding your healthcare. Because healthcare is of utmost importance to you, we stand ready to assist. Please consider the HR Service Center experts a reliable MITRE resource and first contact for any questions or concerns at 781-271-4700 or hrsc@mitre.org. Erin Sarin Manager, Corporate Benefits
The MITRE Corporation 2018 COBRA Monthly Rates COBRA RATES All Locations Employee Employee +1 Family HD Care PPO $326.98 $1,024.16 $1,232.65 Flex Care PPO $489.35 $1,474.09 $1,736.46 Dental Plan Basic $41.85 $98.64 $124.12 Dental Plan Plus $60.90 $143.31 $180.61 Vision Plan $7.08 $11.90 $19.15 The MITRE Corporation 2018 COBRA MONTHLY RATES
The MITRE Corporation 2018 Plan Design Comparison Chart FLEX CARE PPO HD CARE PPO Deductible (Calendar Year) In-Network Out-of-Network In-Network Out-of-Network Individual $500 $1,000 $2,000 $4,000 Employee + 1 $1,000 $2,000 $4,000 $8,000 Family $1,000 $2,000 $4,000 $8,000 Embedded Deductible* ( / No) Do deductible amounts cross-apply? (In-Network and Out-of-Network) No Out-of-Pocket Maximum (Calendar Year) In-Network Out-of-Network In-Network Out-of-Network Expenses that apply towards accumulation: All covered medical and prescription drug expenses (including deductible) - amounts shown below are separate. All covered medical and prescription drug expenses (including deductible) combined. Separate Prescription Drug accumulation ( / No) No Individual Medical: $1,000 Rx: $1,500 Medical: $2,000 Rx: $3,000 Medical & Rx: $4,000 Medical & Rx: $8,000 Employee + 1 Medical: $2,000 Rx: $3,000 Medical: $4,000 Rx: $6,000 Medical & Rx: $8,000 Medical & Rx: $16,000 Family Medical: $2,000 Rx: $3,000 Medical: $4,000 Rx: $6,000 Medical & Rx: $8,000 Medical & Rx: $16,000 Embedded OOPM ( / No) Do accumulation amounts cross-apply? (In-Network and Out-of-Network) * Embedded Deductible Definition: If you are enrolled on an employee + 1 or family medical plan with an embedded deductible, your plan contains two components, an individual deductible and a family deductible maximum. Each member of your family is subject to the individual deductible, not to exceed the employee + 1 or family deductible. The individual deductible is embedded in the family deductible. The MITRE Corporation 2018 Plan Design Comparison Chart page 1
FLEX CARE PPO HD CARE PPO Prescription Drugs In-Network Out-of-Network In-Network Out-of-Network Preventive Drugs Retail Pharmacy Mail Order / Maintenance Choice (90-day supply) Tier 1 (Generic): $5 copayment Tier 2 (Brand Formulary): $30 copayment $50 copayment applies Tier 1 (Generic): $5 copayment Tier 2 (Brand Formulary): $30 copayment $50 copayment applies Tier 1 (Generic): $10 copayment Tier 2 (Brand Formulary): $60 copayment $100 copayment applies 20% coinsurance 20% coinsurance Not available Tier 1 (Generic): $5 copayment Tier 2 (Brand Formulary): $30 copayment $50 copayment applies In-network deductible applies, then: Tier 1 (Generic): $5 copayment Tier 2 (Brand Formulary): $30 copayment $50 copayment In-network deductible applies, then: Tier 1 (Generic): $10 copayment Tier 2 (Brand Formulary): $60 copayment $100 copayment 20% coinsurance 20% coinsurance Not available Preventive Care In-Network Out-of-Network In-Network Out-of-Network Well-Child Care Visit Adult Routine Preventive Care Immunizations (well-child, adult, travel, and flu) Routine OB/GYN Routine Eye Exam Routine Hearing Exam The MITRE Corporation 2018 Plan Design Comparison Chart page 2
FLEX CARE PPO HD CARE PPO Emergency / Urgent Care Services In-Network Out-of-Network In-Network Out-of-Network Emergency Room Visit Urgent Care Facility $150 copayment, waived if admitted Teladoc $5 copayment N/A Minute Clinic $10 copayment N/A Ambulance ($40 deductible) N/A N/A Provider Visits / Services In-Network Out-of-Network In-Network Out-of-Network Office Visits (includes primary care, specialists, etc.) Chiropractor Frequency / Limit 30 visits per year 30 visits per year Acupuncture Frequency / Limit 30 visits per year 30 visits per year Outpatient Short-Term Rehabilitation Physical and Occupational Therapy (performed at an office) Frequency / Limit 60 visits combined per year 60 visits combined per year Autism Spectrum Disorder Services (including PT / OT / ST, behavioral therapy, ABA analysis) Hearing Aids Frequency / Limit Hearing aid for each ear every 24 months Hearing aid for each ear every 24 months The MITRE Corporation 2018 Plan Design Comparison Chart page 3
FLEX CARE PPO HD CARE PPO Diagnostic Procedures In-Network Out-of-Network In-Network Out-of-Network X-Rays & Labs (performed as part of a physician office visit and billed by a physician) X-Rays & Labs (performed at outpatient or freestanding facility, including independent lab) Complex Imaging: MRIs / CT Scans / PT Scans / etc. (pre-authorization required) Surgery / Hospitalization In-Network Out-of-Network In-Network Out-of-Network Outpatient Surgery (performed in an office setting) Outpatient Surgery (performed in an ambulatory or outpatient facility) Inpatient Hospitalization 0.1383 in Mental Health / Substance Abuse In-Network Out-of-Network In-Network Out-of-Network Outpatient Mental Health Therapy Visits and Ancillary Services Behavioral Health Telemedicine (Arcadian Telephsychiatry, Inpathy, MDLive) Other Services In-Network Out-of-Network In-Network Out-of-Network Hospice Care Inpatient / Outpatient Skilled Nursing Facility / Convalescent Facility Frequency / Limit 120 days per year 120 days per year Durable Medical Equipment Fitness and Nutrition Reimbursement up to $200 per contract (contract = individual, employee + 1 or family) up to $200 per contract (contract = individual, employee + 1 or family) The information contained in this document is intended to provide a general description of MITRE s health plans. In the event of any inconsistency between the information provided and actual policies or documents, or to the degree the actual policies or documents contain more complete or detailed information, the plan policies or documents will govern and take precedence. The MITRE Corporation 2018 Plan Design Comparison Chart page 4
The MITRE Corporation Open Enrollment 2018 Election Form COBRA Health Enrollment YOU ARE REQUIRED TO COMPLETE THIS FORM TO CONTINUE COVERAGE IN 2018. THIS FORM MUST BE RETURNED TO MITRE NO LATER THAN NOVEMBER 17, 2017 ALL CHANGES WILL BE EFFECTIVE JANUARY 1, 2018. PLEASE PRINT CLEARLY PARTICIPANT INFORMATION Last First Middle Street Address City State Zip Phone Email Address SSN DOB LIST ALL DEPENDENTS TO BE COVERED. DEPENDENT INFORMATION Name (Last, First, Middle) DOB SSN Relationship Gender BENEFIT ELECTIONS. Please indicate the health plan name and coverage level below. MEDICAL COVERAGE Plan Name (insert Flex PPO OR HD PPO) Individual Employee + 1 Family AETNA Statement of Understanding and Election: I hereby apply for benefits under the terms and conditions of the benefits program, and I agree to pay the premium as required. I also understand that payments are due on the 1st of each month and that failure to remit payments within the grace period specified under the Plan will result in termination of coverage. PARTICIPANT SIGNATURE Return this Open Enrollment Election Form by November 17 to: DATE: The MITRE Corporation 202 Burlington Road Attn: HR Service Center M/S M126 Bedford, MA 01730 Or email: hrsc@mitre.org
The MITRE Corporation Open Enrollment 2018 Election Form COBRA Dental/Vision Change Form THIS FORM MUST BE RETURNED TO WAGEWORKS NO LATER THAN NOVEMBER 17, 2017 ALL CHANGES WILL BE EFFECTIVE JANUARY 1, 2018. PLEASE PRINT CLEARLY PARTICIPANT INFORMATION Last First Middle Street Address City State Zip Phone Email Address SSN DOB LIST ALL DEPENDENTS TO BE COVERED. Mark (X) the appropriate box for Medical (M) Dental (D) Vision (V) DEPENDENT INFORMATION Name (Last, First, Middle) DOB SSN Relationship Gender M D V BENEFIT ELECTIONS DENTAL COVERAGE Plan Name (insert Basic OR Plus) Individual Employee + 1 Family VISION COVERAGE Plan Name - VSP Individual Employee + 1 Family VSP Statement of Understanding and Election: I hereby apply for benefits under the terms and conditions of the benefits program, and I agree to pay the premium as required. I also understand that payments are due on the 1st of each month and that failure to remit payments within the grace period specified under the Plan will result in termination of coverage. PARTICIPANT SIGNATURE DATE: (Election Forms received without a signature will be rejected and potentially cause delay in your COBRA coverage.) Return all pages of this Open Enrollment Election Form by November 17 to: WageWorks, Inc. FAX: (877) 220-3249 P.O. Box 14055 Lexington, KY 40512-4055 FRMWW WW-3581-COBRA-OE-ELECT-PAS-V0814 Page 1