Annual Benefits Enrollment: Oct. 31 Nov. 11 The annual enrollment period for making changes to your 2012 benefits is Oct. 31 Nov. 11. During annual enrollment, you can make any changes to your benefits on the BSA benefits website at bsabenefits.mercerhrs.com. These changes will become effective Jan. 1, 2012. Please note that changes were made to the website on Aug. 15, including the addition of new, enhanced security features that will better protect your personal information. New login guidelines are provided in the BSA Benefits Website section of this annual enrollment bulletin. If you need assistance with the website, you can call the BSA Benefits Center at 1 800 444 4416 between 9 a.m. and 6 p.m. Central, any business day. If you are calling from outside the United States, please call 972 720 2000. A personalized enrollment worksheet will be mailed to your home address during the week of Oct. 10. This worksheet will show all of the benefits you are currently enrolled for, benefits you have waived, if any, and your 2012 monthly cost for your benefits. SPECIAL NOTE: If you are currently enrolled in the BSA High Deductible Medical plan, please note that this plan will not be offered in 2012, and your personalized enrollment worksheet will reflect that you have been assigned coverage in the Basic Plan for 2012. You will have an opportunity to select the Buy up plan or waive coverage during the enrollment period. During annual enrollment, you can: 1) Enroll or waive coverage in a benefit. 2) Add or drop any eligible family members to/from your benefits. 3) Change your medical plan election between the Basic or Buy up medical plans or waive coverage. 4) Change coverage levels on your optional life, dependent life, or accidental death and dismemberment insurance. (If you enroll, increase your coverage, or add dependents to your optional or dependent life coverage, a Statement of Health form will be required by MetLife.) 5) Use the Cost Compare feature of WebMD on the BSA benefits website. This tool helps you compare your 2012 estimated out of pocket health care expenses between the Basic and Buyup medical plans to assist you in making a choice between them.
If you do not make any changes, the benefit elections shown on your personalized enrollment worksheet will be your coverage under the BSA benefit plans for 2012. A confirmation statement will be mailed to your home address the week of Nov. 14. Please review this statement carefully, and if you have any questions or concerns about your enrollment choices, or if you do not receive a confirmation statement, call the BSA Benefits Center. Friday, Dec. 2 is the last date that corrections will be accepted for 2012 annual enrollment elections. You are responsible for making sure your benefit choices are correct. Benefits and other information is available on the BSA benefits website, including a link to the Boy Scouts of America Benefits Handbook, and links to our benefit providers (such as UnitedHealthcare, MetLife, Fidelity Investments, and Mutual of America). If you want a printed copy of the handbook, contact the BSA Benefits Center. 2012 Medical Plan Changes Online Health Assessment Your ability to select coverage under the Basic or Buy up medical plans for 2012 will not be conditioned on completion of the online Health Assessment in 2011. However, since the online Health Assessment continues to provide you with an opportunity to learn about and monitor your personal health and well being, it will continue to be available for you to complete on a voluntary basis. High Deductible Health Plan The High Deductible Health plan will not be offered for 2012. If you are currently enrolled in the High Deductible Health plan, your personalized enrollment work sheet will show the Basic Plan as your medical coverage for 2012. If you do not want coverage under the Basic plan, you may waive medical coverage, or elect coverage under the Buy up plan during the annual enrollment period. Basic Medical Plan Changes The 2012 in network annual deductible for the Basic Plan has been adjusted upward from $300 to $600 for an individual and from $600 to $1,200 for a family, with corresponding increases to the out of network deductibles to $1,200 for an individual and $2,400 for a family. All other plan features will remain the same. The new deductible amounts, in addition to reducing the 2012 monthly increase in contributions for all Basic Plan participants, are also more consistent with similar basic plans offered in other organizations. Buy up Medical Plan Changes There are no changes to benefits for the 2012 Buy up Plan. Medical Plan Coverage Cost Increase There will be an average 9.8 percent contribution increase for participation in the Basic and Buy up plans for 2012 (between $5 and $85 per month based on the number of dependents covered). Monthly contributions for both medical plans are shown in the rates section of this annual enrollment bulletin. 2012 Dental Assistance Plan There will be no benefit or contribution changes to the dental benefit for 2012. 2
2012 Vision Care Plan Changes Changes to Vision Coverage Coverage for photochromic lenses will not be offered in 2012. Benefits will increase for the following out of network services as follows: Service 2011 Reimbursement 2012 Reimbursement Examination, up to: $45 $50 Single Vision Lenses, up to: $45 $50 Bifocal Lenses, up to: $65 $75 Trifocal Lenses, up to: $85 $100 Frames, up to: $47 $70 Vision Care Plan Cost Increases Contributions will increase for the first time since 2006. The increase will be approximately $0.84 per month for individual coverage and $2.32 per month for family coverage. Monthly contributions are shown in the rates section of this annual enrollment bulletin. BSA Group Life Insurance and Scout Executives Alliance Changes to Group Life and SEA Coverage The Accelerated Benefit Option for a terminally ill participant to receive a partial distribution of benefits has changed for the BSA Group Life benefit and for the Scout Executives Alliance. The maximum period of life expectancy to receive a benefit has increased from 6 months to 24 months. All remaining provisions of the Accelerated Benefit Option will remain the same. Please refer to the Boy Scouts of America Benefits Handbook for more information about this benefit. There will be no contribution changes for these benefits in 2012. Accidental Death and Dismemberment There will be no benefit or contribution changes for these benefits in 2012. Changes to the BSA Benefits Website New online features that make managing your benefits easier became available on the BSA benefits website (bsabenefits.mercerhrs.com) starting Aug. 15, 2011. These new features make it easier for you to get a total picture of your benefits, access important information, utilize health tools and resources, and make life status event changes. BSA Benefits Website Login Guidelines If you have not visited the BSA benefits website since Aug. 15, please refer to the following instructions to log in and change your User ID and password to complete annual enrollment elections. 3
Initial Login: Upon initial login your User ID has been reset to your Social Security number (SSN). Format: ######### Example: 123456789 Initial Password: Date of Birth Format: mmddyy Example: 010111 After you log in for the first time, you will be required to change your User ID and password. The requirements for both are provided below: Login requirements The User ID you choose must meet the following conditions: Between 8 and 32 characters Must contain at least one letter Must contain at least one number Can contain the following special characters only: (at sign, period, dash/hyphen, underscore, asterisk. (@. _ *) Cannot contain more than three repeating letters, or special characters, i.e. AAA, 111, Cannot contain more than three sequential numbers, i.e. 123, 987 Cannot match a User ID already in use for the site/url. The password must meet the following conditions: Between 8 and 20 characters Must contain at least one letter Must contain at least one number Can contain the following special characters only: (at sign, period, dash/hyphen, underscore, asterisk. (@. _ *) Cannot contain more than three repeating letters, or special characters, i.e. AAA, 111, Cannot contain more than three sequential numbers, i.e. 123, 987 Cannot be the same as your User ID 403(b) Plans National Council Employees Saving through the BSA 403(b) Thrift Plan with Fidelity Investments is one of the best ways to defer taxes today while investing for tomorrow. Once you have reached age 21 and completed one year of service with BSA, you are eligible to make salary reduction pre tax contributions to the BSA 403(b) Thrift Plan (a portion of which is matched by your employer). To sign up or change your contribution, visit the BSA benefits website at www.bsabenefits.mercerhrs.com, or call the BSA Benefits Center at 1 800 444 4416. Also, you are eligible to make salary reduction pre tax contributions to the BSA 403(b) Tax Deferred Annuity Program. Local Council Employees Check with your payroll representative to see if your council participates in a 403(b) plan. If it does and you want to obtain more information, sign up, or change your contributions, see your payroll representative. Saving in a 403(b) is one of the best ways to defer taxes today while investing for tomorrow. 4
MEDICAL PLAN COMPARISON CHART CHOICE PLUS PLANS BASIC PLAN BUY UP PLAN In Network Out of Network In Network Out of Network Deductible Individual $600 $1,200 $0 $300 Family $1,200 $2,400 $0 $600 Out of Pocket Maximum Deductible and co pays do not apply. Deductible and co pays do not apply Individual $2,000 $2,000 $2,000 $2,000 Family $4,000 $4,000 $4,000 $4,000 Co insurance 20% after deductible 40% after deductible 10% 30% after deductible Office Visits $30 PCP/$40 specialist 40% after deductible $20 PCP/$30 specialist 30% after deductible Preventive Care 0% Not covered 0% Not covered Emergency Room $100 co pay if not admitted $100 co pay if not admitted $100 co pay if not admitted $100 co pay if not admitted Urgent Care Center $50 co pay 40% after deductible $35 co pay 30% after deductible Inpatient and Outpatient Lab and X rays, MRIs, CT Scans 20% after deductible 40% after deductible 10% 30% after deductible Outpatient Facility 20% after deductible 40% after deductible 10% after deductible 30% after deductible Inpatient Hospital 1st 5 days; $150 co pay per day + 20% of balance. Days 6 + 20% 1st 5 days; $150 co pay per day + 40% of balance. Days 6 + 40% 1st 5 days; $150 co pay per day + 10% of balance. Days 6 + 10% 1st 5 days; $150 co pay per day + 30% of balance. Days 6 + 30% Prescription Drugs Annual Deductible $50 $50 Tier 1 $7 $5 Tier 2 Co insurance 25% 25% Min. Co pay $30 $20 Max. Co pay $60 No coverage $40 Tier 3 Co insurance 25% 25% Min. Co pay $50 $35 Max. Co pay $100 $70 No coverage This overview of benefits is not intended to be complete or legally binding. A description of the benefits currently offered is set forth in the summary plan descriptions contained in the Boy Scouts of America Benefits Handbook. This can be found on the website or you can request a printed copy from the BSA Benefits Center. In addition, note that all benefit plans may be amended, modified, or terminated in whole or in part at any time by the National Executive Board of the Boy Scouts of America 5
MEDICAL PLAN COMPARISON CHART OPTIONS PPO PLANS BASIC PLAN BUY UP PLAN In Network Out of Network In Network Out of Network Deductible Individual $600 $1,200 $0 $300 Family $1,200 $2,400 $0 $600 Out of Pocket Maximum Deductible and co pays do not apply. Deductible and co pays do not apply Individual $2,000 $2,000 $2,000 $2,000 Family $4,000 $4,000 $4,000 $4,000 Co insurance 20% after deductible 20% after deductible 10% 10% after deductible Office Visits $30 PCP/$40 specialist 20% after deductible $20 PCP/$30 specialist 10% after deductible Preventive Care 0% 0% (Subject to reasonable and customary reimbursement rates) 0% 0% (Subject to reasonable and customary reimbursement rates) Emergency Room $100 co pay if not admitted $100 co pay if not admitted $100 co pay if not admitted $100 co pay if not admitted Urgent Care Center $50 co pay 20% after deductible $35 co pay 10% after deductible Inpatient and Outpatient Lab and X rays, MRIs, CT Scans 20% after deductible 20% after deductible 10% 10% after deductible Outpatient Facility 20% after deductible 20% after deductible 10% after deductible 10% after deductible Inpatient Hospital 1st 5 days; $150 co pay per day + 20% of balance. Days 6 + 20% 1st 5 days; $150 co pay per day + 20% of balance. Days 6 + 20% 1st 5 days; $150 co pay per day + 10% of balance. Days 6 + 10% 1st 5 days; $150 co pay per day + 10% of balance. Days 6 + 10% Prescription Drugs Annual Deductible $50 $50 Tier 1 $7 $5 Tier 2 Co insurance 25% 25% Min. Co pay $30 $20 Max. Co pay $60 No coverage $40 Tier 3 Co insurance 25% 25% Min. Co pay $50 $35 Max. Co pay $100 $70 No coverage This overview of benefits is not intended to be complete or legally binding. A description of the benefits currently offered is set forth in the summary plan descriptions contained in the Boy Scouts of America Benefits Handbook. This can be found on the website or you can request a printed copy from the BSA Benefits Center. In addition, note that all benefit plans may be amended, modified, or terminated in whole or in part at any time by the National Executive Board of the Boy Scouts of America 6
Medical Plans Active Employee BASIC BUY UP Employee Employer Employee Employer Self 58.00 504.00 115.00 503.00 Self & spouse 474.00 648.00 588.00 648.00 Self & 1 child 169.00 617.00 248.00 617.00 Self & 2+children 377.00 633.00 479.00 633.00 Self, spouse, & 1 child 620.00 727.00 756.00 727.00 Self, spouse, & 2+children 816.00 755.00 975.00 755.00 Retiree or Survivor Not on Medicare (Under age 65) With at Least 20 Years of Benefit Eligible Service BASIC BUY UP Retiree BSA Retiree BSA Self or spouse or child 496.00 744.00 553.00 829.00 Self & non Medicare spouse 1,016.00 1,523.00 1,133.00 1,699.00 Self or spouse or child + 1 child 586.00 880.00 651.00 976.00 Self & 2+children 696.00 1,043.00 769.00 1,154.00 Self, non Medicare spouse, & 1 child 1,107.00 1,660.00 1,231.00 1,846.00 Self, non Medicare spouse, & 2+children 1,215.00 1,822.00 1,349.00 2,023.00 Self & Medicare spouse 584.00 877.00 652.00 978.00 Self, Medicare spouse, & 1 child 676.00 1,013.00 750.00 1,126.00 Self, Medicare spouse, & 2+ children 784.00 1,177.00 868.00 1,301.00 Retiree or Survivor on Medicare (under age 65) With at Least 20 Years of Benefit Eligible Service BASIC BUY UP Retiree BSA Retiree BSA Self or spouse or child 223.00 335.00 223.00 335.00 Self & non Medicare spouse 448.00 671.00 470.00 706.00 Self or spouse or child + 1 child 313.00 470.00 322.00 483.00 Self & 2+children 403.00 604.00 421.00 631.00 Self, non Medicare spouse, & 1 child 538.00 806.00 569.00 854.00 Self, non Medicare spouse, & 2+children 627.00 941.00 668.00 1,002.00 Self & Medicare spouse 446.00 670.00 446.00 670.00 Self, Medicare spouse, & 1 child 536.00 805.00 545.00 818.00 Self, Medicare spouse, & 2+ children 626.00 939.00 644.00 966.00 7
Retiree or Survivor Not on Medicare (Under age 65) With at Least 10 But Less than 20 Years of Benefit Eligible Service BASIC BUY UP Retiree BSA Retiree BSA Self or spouse or child 868.00 372.00 967.00 415.00 Self & non Medicare spouse 1,777.00 762.00 1,982.00 850.00 Self or spouse or child + 1 child 1,026.00 440.00 1,139.00 488.00 Self & 2+children 1,217.00 522.00 1,346.00 577.00 Self, non Medicare spouse, & 1 child 1,937.00 830.00 2,154.00 923.00 Self, non Medicare spouse, & 2+children 2,126.00 911.00 2,360.00 1,012.00 Self & Medicare spouse 1,023.00 438.00 1,141.00 489.00 Self, Medicare spouse, & 1 child 1,182.00 507.00 1,313.00 563.00 Self, Medicare spouse, & 2+ children 1,373.00 588.00 1,518.00 651.00 Retiree or Survivor Medicare (Under age 65) With at Least 10 But Less than 20 Years of Benefit Eligible Service BASIC BUY UP Retiree BSA Retiree BSA Self or spouse or child 391.00 167.00 391.00 167.00 Self & non Medicare spouse 783.00 336.00 823.00 353.00 Self or spouse or child + 1 child 548.00 235.00 564.00 241.00 Self or spouse & 2+children 705.00 302.00 736.00 316.00 Self, non Medicare spouse, & 1 child 941.00 403.00 996.00 427.00 Self, non Medicare spouse, & 2+children 1,098.00 470.00 1,169.00 501.00 Self & Medicare spouse 781.00 335.00 781.00 335.00 Self, Medicare spouse, & 1 child 939.00 402.00 954.00 409.00 Self, Medicare spouse, & 2+ children 1,096.00 469.00 1,127.00 483.00 Vision Care Plan ALL GROUPS Employee Self 12.38 Self & spouse 19.84 Self & 1 child 20.26 Self & 2+children 20.26 Self, spouse, & 1 child 34.18 Self, spouse, & 2+children 34.18 8
Dental Assistance Plan Active Employee Employee Employer Self 31.00 Self & spouse 32.00 31.00 Self & 1 child 30.00 31.00 Self & 2+children 56.00 31.00 Self, spouse, & 1 child 56.00 31.00 Self, spouse, & 2+children 86.00 31.00 National or Local Council Retiree or Survivor Employee Self 31.00 Self & spouse 63.00 Self & 1 child 61.00 Self & 2+children 87.00 Self, spouse, & 1 child 87.00 Self, spouse, & 2+children 117.00 Group Life Insurance Basic Life (1 x salary provided by BSA) $0.580/$1,000 of coverage Optional Life (1x 6x salary) Premium per thousand dollars is age based, as follows: AGE ACTIVE, LTD, OR RETIREE RATE Under 30 $0.05 30 34 $0.07 35 39 $0.08 40 44 $0.09 45 49 $0.14 50 54 $0.23 55 59 $0.43 60 64 $0.66 65 69 $1.26 70 74 $1.93 75+ $2.98 Dependent Life $5,000 for $2.30 or $10,000 for $4.60 9
Scout Executives Alliance Membership Rates All employees who join the Scout Executives' Alliance when first eligible will have the first 12 months of membership contribution waived. After the first 12 months of membership, the contribution is based on the member s annual salary or annual pension per the following: Active Members The 2011 rate is $0.23 per $1,000 of annual salary (maximum premium per month of $32.00). Retired Members The 2011 rate is $0.23 per $1,000 of annual pension (maximum premium per month of $17,50). Accidental Death and Dismemberment Insurance Employer Paid coverage National and Local Council Staff Employees $0.20 for $10,000 of coverage National and Local Council commissioned professionals, certified executives, and professional technical employees $1.00 for $50,000 of coverage Employee Paid Coverage $0.024 per $1,000 for employee only $0.037 per $1,000 for family ADDITIONAL COVERAGE AMOUNT PREMIUM FOR EMPLOYEE ONLY PREMIUM FOR FAMILY $25,000 $0.60 $0.93 $50,000 $1.20 $1.85 $75,000 $1.80 $2.78 $100,000 $2.40 $3.70 $125,000 $3.00 $4.63 $150,000 $3.60 $5.55 $175,000 $4.20 $6.48 $200,000 $4.80 $7.40 $225,000 $5.40 $8.33 $250,000 $6.00 $9.25 $275,000 $6.60 $10.18 $300,000 $7.20 $11.10 $325,000 $7.80 $12.03 $350,000 $8.40 $12.95 $375,000 $9.00 $13.88 $400,000 $9.60 $14.80 $425,000 $10.20 $15.73 $450,000 $10.80 $16.65 $475,000 $11.40 $17.58 $500,000 $12.00 $18.50 Retiree coverage maximum is $250,000. 10
Required Federal Notices Federal law requires that plan participants be provided with the following notices. Notice about the Early Retiree Reinsurance Program You are a plan participant, or are being offered the opportunity to enroll as a plan participant, in an employment based health plan that is certified for participation in the Early Retiree Reinsurance Program. The Early Retiree Reinsurance Program is a Federal program that was established under the Affordable Care Act. Under the Early Retiree Reinsurance Program, the Federal government reimburses a plan sponsor of an employment based health plan for some of the costs of health care benefits paid on behalf of, or by, early retirees and certain family members of early retirees participating in the employment based plan. By law, the program expires on Jan. 1, 2014. Under the Early Retiree Reinsurance Program, your plan sponsor may choose to use any reimbursements it receives from this program to reduce or offset increases in plan participants premium contributions, co payments, deductibles, co insurance, or other out of pocket costs. If the plan sponsor chooses to use the Early Retiree Reinsurance Program reimbursements in this way, you, as a plan participant, may experience changes that may be advantageous to you, in your health plan coverage terms and conditions, for so long as the reimbursements under this program are available and this plan sponsor chooses to use the reimbursements for this purpose. A plan sponsor may also use the Early Retiree Reinsurance Program reimbursements to reduce or offset increases in its own costs for maintaining your health benefits coverage, which may increase the likelihood that it will continue to offer health benefits coverage to its retirees and employees and their families. If you have received this notice by email, you are responsible for providing a copy of this notice to your family members who are participants in this plan. Date of notice: Sept. 1, 2011 Name of entity/sender: Boy Scouts of America Contact position/office: BSA Benefits Center Address: P.O. Box 9735, Providence, RI 02940 Phone Number: 1 800 444 4416 11
HIPAA PRIVACY NOTICE THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This notice only pertains to the health benefits under the plans, sponsored by Boy Scouts of America, which are covered under the Health Insurance Portability and Accountability Act of 1996. These plans are: BSA Medical Plan the Choice Plus Basic, Choice Plus Buy up, Choice Plus High Deductible, Options PPO Basic, Options PPO Buy up, Options PPO High Deductible, and Medicare Supplement, including prescription drug coverage Dental Assistance Plan Vision Care Plan Employee Assistance Plan (EAP) As we work every day to operate your health plans, protecting the confidentiality of your personal medical information has always been an important priority. The plans have adopted policies to safeguard the privacy of your medical information and comply with federal law (specifically, the Health Insurance Portability and Accountability Act, known as HIPAA ). Note: We refers to the Boy Scouts of America group health plans listed above. You or yours refers to the Individual participants in the Plans. If you are covered by an insured health option under the plans, you may have or will also receive a separate notice from your insurer or HMO. This notice explains: How your personal medical information may be used and disclosed, and What rights you have regarding this information. How The Plans May Use and Disclose Your Information We are required by federal law to protect the privacy of your Individual Health Information (referred to in this notice as Protected Health Information ). We are also required to provide you with this notice regarding our policies and procedures regarding your Protected Health Information, and to abide by the terms of this notice, as it may be updated from time to time. Under applicable law, we are permitted to make certain types of uses and disclosures of your Protected Health Information, without your authorization for treatment, payment, and health care operations purposes. For treatment purposes, such use and disclosure may take place in providing, coordinating, or managing health care and its related services by one or more of your providers, such as when your primary care physician consults with a specialist regarding your condition. The plans may also disclose your Protected Health Information to a health care provider who renders treatment on your behalf. For example, if you are unable to provide your medical history as the result of an accident, the plans may advise an emergency room physician 12
about the types of prescription drugs you currently take. For payment purposes, such use and disclosure may take place to determine responsibility for coverage and benefits. For example, we may use your information when we confer with other health plans to resolve a coordination of benefits issue. We may also use your Protected Health Information for other payment related purposes, such as to assist in making plan eligibility and coverage determinations, or for utilization review activities. For health care operations purposes, such use and disclosure may take place in a number of ways involving plan administration, including quality assessment and improvement, vendor review, and underwriting activities. Your information could be used, for example, to assist in the evaluation of one or more vendors who support us or we may contact you to provide appointment reminders or information about Treatment alternatives or other health related benefits and services available under the Plans. We may share your Protected Health Information across the health plans covered by this notice for health care operations activities, since the health plans are maintained and managed by the same plan sponsor (Boy Scouts of America). We may disclose your Protected Health Information to Boy Scouts of America (the plan sponsor) in connection with these activities. If you are covered under an insured health plan, the insurer also may disclose Protected Health Information to the plan sponsor in connection with payment, treatment or health care operations. Boy Scouts of America has designated a limited number of employees who are the only ones permitted to access and use your Protected Health Information for plan operations and administration. When appropriate, we may share two types of Health Information with other Boy Scouts of America employees: Enrollment/unenrollment data information on whether you and your dependents participate in the plans Summary Health Information summaries of claims from which names and other identifying information have been removed The Plans are prohibited from using or disclosing, and will not use or disclose, your information that contains genetic information for underwriting purposes. Other Permitted Uses and Disclosures In addition, we may use or disclose your Protected Health Information without your authorization under conditions specified in federal regulations, including: As required by law, provided the use or disclosure complies with and is limited to the relevant requirements of such law For public health activities Disclosures to an appropriate government authority regarding victims of abuse or neglect To a health oversight agency for oversight activities authorized by law In connection with judicial and administrative proceedings To a law enforcement official for law enforcement purposes For research purposes, as long as certain privacy related standards are satisfied To a coroner or medical examiner 13
To cadaveric organ, eye or tissue donation programs To avert a serious threat to health or safety For specialized government functions (e.g., military and veteran s activities, national security and intelligence, federal protective services, medical suitability determinations, correctional institutions and other law enforcement custodial situations), and For workers compensation or similar programs established by law that provide benefits for work related injuries or illness without regard to fault. In Special Situations We may disclose to one of your family members, to a relative, to a close personal friend, or any other person identified by you, Protected Health Information that is directly relevant to the person's involvement with your care or payment related to your care. In addition, we may use or disclose the Protected Health Information to notify a family member, your personal representative, another person responsible for your care, or certain disaster relief agencies of your location, general condition, or death. If you are incapacitated, there is an emergency, or you otherwise do not have the opportunity to agree to or object to this use or disclosure, we will do what in our judgment is in your best interest regarding such disclosure and will disclose only information that is directly relevant to the person's involvement with your health care and is otherwise permitted by state law. Other uses and disclosures will be made only with your written authorization, and you may revoke your authorization in writing at any time. Right to Request Restrictions You may ask us to restrict uses and disclosures of your Protected Health Information to carry out treatment, payment, or health care operations, or to restrict uses and disclosures to family members, relatives, friends, or other persons identified by you who are involved in your care or payment for your care. However, we are not required to agree to your request. You may exercise this right by contacting the individual or office identified at the end of this notice. They will provide you with additional information. Notwithstanding our right to otherwise not agree to your request to restrict Disclosures of your Protected Health Information, we will comply with the requested restriction if: Except as otherwise required by law, the disclosure is to a health plan for the purposes of carrying out payment or health care operations (and not for the purposes of carrying out treatment) and The Protected Health Information pertains solely to a health care item or service for which the health care provider has been paid out of pocket in full. You Rights Regarding Protected Health Information You have the right to request the following with respect to your Protected Health Information: Inspect and copy your Protected Health Information Amend or correct inaccurate information 14
Receive a paper copy of this notice upon request, even if you agreed to receive it electronically Receive a copy of your record in electronic format for a fee, to the extent we maintain an electronic record of your information Receive an accounting of certain disclosures of your information made by us However, you are not entitled to an accounting of several types of disclosures including, but not limited to: Disclosures made for payment, treatment or health care operations Disclosures you authorized in writing Disclosures made before April 14, 2003. You have the right to receive an accounting of disclosures of your Protected Health Information through an electronic health record by the plans to carry out treatment, payment and health care operations during the three (3) years prior to your request. This right applies to: Electronic health records held by the plans as of Jan. 1, 2009 disclosures made on or after Jan. 1, 2014, and Electronic health records acquired by the plans after Jan. 1, 2009 disclosures made after the later of Jan. 1, 2011 or the date the plans acquire the electronic health record. Right to Request Confidential Communications You have the right to request in writing that you receive your Protected Health Information by alternative means or at an alternative location regarding communications that your health plan initiates. For more information about exercising these rights, contact the office below. Complaints If you believe that your privacy rights have been violated, you may file a written complaint without fear of reprisal. Direct your complaint to the Plan Administrator at the address listed below under Contacting Us or to the Secretary of the Department of Health and Human Services, Hubert H. Humphrey Building, 200 Independence Avenue SW, Washington, DC 20201.You will for filing a complaint. About This Notice We reserve the right to change the terms of this notice and to make the new notice provisions effective for all Protected Health Information we maintain. If we change this notice, you will receive a copy of the new notice by distribution to active employees in the workplace. A copy of the current notice will be posted on the BSA Benefits Center Web site at all times. Contacting Us You may exercise the rights described in this notice by contacting the Boy Scouts of America office identified below. They will provide you with additional information. The contact is: Privacy Officer Boy Scouts of America 1325 West Walnut Hill Lane Irving, TX 75038 Phone: 972 580 2031 15
Complaints about our Health Plan privacy practices should be submitted in writing to the address above. Effective date of revised notice: Oct. 1, 2011 Keep this notice with your other important papers. You are not required to take any action at this time. 16
Medicaid and the Children s Health Insurance Program (CHIP) Offers Free or Low Cost Health Coverage to Children And Families If you are eligible for health coverage from your employer, but are unable to afford the premiums, some States have premium assistance programs that can help pay for coverage. These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer sponsored health coverage, but need assistance in paying their health premiums. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, you can 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, you can contact your State Medicaid or CHIP office or dial 1 877 KIDS NOW (543 7669) or www.insurekidsnow.gov to find out how to apply. If you qualify, you can ask the State if it has a program that might help you pay the premiums for an employer sponsored plan. Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, your employer s health plan is required to permit you and your dependents to enroll in the plan as long as you and your dependents are eligible, but not already enrolled in the employer s plan. This is called a special enrollment opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you live in one of the following States, you may be eligible for assistance paying your employer health plan premiums. The following list of States is current as of Jan 31, 2011. You should contact your State for further information on eligibility ALABAMA Medicaid http://www.medicaid.alabama.gov Phone: 1 800 362 1504 ALASKA Medicaid http://health.hss.state.ak.us/dpa/programs/medicaid Phone (Outside of Anchorage): 1 888 318 8890 Phone (Anchorage): 907 269 6529 ARIZONA CHIP CALIFORNIA Medicaid http://www.dhcs.ca.gov/services/pages/tplrd_cau _cont.aspx Phone: 1 866 298 8443 COLORADO Medicaid and CHIP Medicaid http://www.colorado.gov Medicaid Phone (In state): 1 800 866 3513 Medicaid Phone (Out of state): 1 800 221 3943 CHIP http:// www.chpplus.org CHIP Phone: 303 866 3243 http://www.azahcccs.gov/applicants/default.aspx Phone (Outside of Maricopa County): 1 877 764 5437 Phone (Maricopa County): 602 417 5437 17
ARKANSAS CHIP http://www.arkidsfirst.com Phone: 1 888 474 8275 GEORGIA Medicaid http://dch.georgia.gov Click on Programs, then Medicaid Phone: 1 800 869 1150 IDAHO Medicaid and CHIP Medicaid www.accesstohealthinsurance.idaho.gov Medicaid Phone: 1 800 926 2588 CHIP www.medicaid.idaho.gov FLORIDA Medicaid http://www.fdhc.state.fl.us/medicaid/index.shtml Phone: 1 877 357 3268 MISSOURI Medicaid http://www.dss.mo.gov/mhd/participants/pages/hip p.htm Phone: 573 751 2005 MONTANA Medicaid http://medicaidprovider.hhs.mt.gov/clientpages/clie ntindex.shtml Phone: 1 800 694 3084 CHIP Phone: 1 800 926 2588 INDIANA Medicaid http://www.in.gov/fssa Phone: 1 800 889 9948 IOWA Medicaid www.dhs.state.ia.us/hipp Phone: 1 888 346 9562 KANSAS Medicaid https://www.khpa.ks.gov NEBRASKA Medicaid http://www.dhhs.ne.gov/med/medindex.htm Phone: 1 877 255 3092 NEVADA Medicaid and CHIP Medicaid http://dwss.nv.gov Medicaid Phone: 1 800 992 0900 CHIP http://www.nevadacheckup.nv.org CHIP Phone: 1 877 543 7669 Phone: 1 800 792 4884 KENTUCKY Medicaid http://chfs.ky.gov/dms/default.htm Phone: 1 800 635 2570 NEW HAMPSHIRE Medicaid www.dhhs.nh.gov/ombp/index.htm Phone: 603 271 4238 18
LOUISIANA Medicaid http://www.lahipp.dhh.louisiana.gov Phone: 1 888 342 6207 MAINE Medicaid http://www.maine.gov/dhhs/oias/publicassistance/index.html Phone: 1 800 321 5557 MASSACHUSETTS Medicaid and CHIP Medicaid & CHIP http://www.mass.gov/masshealth Medicaid & CHIP Phone: 1 800 462 1120 MINNESOTA Medicaid http://www.dhs.state.mn.us Click on Health Care, then Medical Assistance NEW JERSEY Medicaid and CHIP Medicaid http://www.state.nj.us/humanservices/dmahs/client s/medicaid Medicaid Phone: 1 800 356 1561 CHIP http://www.njfamilycare.org/index.html CHIP Phone: 1 800 701 0710 NEW MEXICO Medicaid and CHIP Medicaid http://www.hsd.state.nm.us/mad/index.html Medicaid Phone: 1 888 997 2583 CHIP http://www.hsd.state.nm.us/mad/index.html Click on Insure New Mexico CHIP Phone: 1 888 997 2583 Phone (Outside of Twin City area): 800 657 3739 Phone (Twin City area): 651 431 2670 NEW YORK Medicaid http://www.nyhealth.gov/health_care/medicaid Phone: 1 800 541 2831 NORTH CAROLINA Medicaid http://www.nc.gov Phone: 919 855 4100 NORTH DAKOTA Medicaid http://www.nd.gov/dhs/services/medicalserv/medicai d TEXAS Medicaid https://www.gethipptexas.com Phone: 1 800 440 0493 UTAH Medicaid http://health.utah.gov/upp Phone: 1 866 435 7414 VERMONT Medicaid http://www.greenmountaincare.org Phone: 1 800 250 8427 Phone: 1 800 755 2604 19
OKLAHOMA Medicaid http://www.insureoklahoma.org Phone: 1 888 365 3742 VIRGINIA Medicaid and CHIP Medicaid http://www.dmas.virginia.gov/rcp HIPP.htm Medicaid Phone: 1 800 432 5924 CHIP http://www.famis.org CHIP Phone: 1 866 873 2647 OREGON Medicaid and CHIP Medicaid & CHIP http://www.oregonhealthykids.gov Medicaid & CHIP Phone: 1 877 314 5678 PENNSYLVANIA Medicaid http://www.dpw.state.pa.us/partnersproviders/medic alassistance/doingbusiness/003670053.htm WASHINGTON Medicaid http://hrsa.dshs.wa.gov/premiumpymt/apply.shtm Phone: 1 800 562 3022 ext. 15473 WEST VIRGINIA Medicaid http://www.wvrecovery.com/hipp.htm Phone: 304 342 1604 Phone: 1 800 644 7730 RHODE ISLAND Medicaid www.dhs.ri.gov Phone: 401 462 5300 SOUTH CAROLINA Medicaid http://www.scdhhs.gov Phone: 1 888 549 0820 WISCONSIN Medicaid http://www.badgercareplus.org/pubs/p 10095.htm Phone: 1 800 362 3002 WYOMING Medicaid http://www.health.wyo.gov/healthcarefin/index.html Phone: 307 777 7531 To see if any more States have added a premium assistance program since January 31, 2011, or for more information on special enrollment rights, you can contact either: U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.gov/ebsa www.cms.hhs.gov 1 866 444 EBSA (3272) 1 877 267 2323, Ext. 61565 OMB CONTROL NUMBER 1210 0137 (EXPIRES 09/30/2013) 20
Important Notice From the Boy Scouts of America About Your Prescription Drug Coverage and Medicare For Active Employees Only Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with the Boy Scouts of America (BSA) and about your options under Medicare s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. Important Things to Know about Current Coverage and Medicare s Prescription Drug Coverage: 1) Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare prescription drug plan or a Medicare Advantage plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2) BSA has determined that the prescription drug coverage offered by the BSA Medical Plan is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare prescription drug plan. Joining a Medicare Prescription Drug Plan You can join a Medicare drug plan when you first become eligible for Medicare and each year from Oct. 15 through Dec. 7. However, if you lose your current creditable prescription drug coverage through no fault of your own, you will be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. Effect on Current Coverage When Joining a Medicare Prescription Drug Plan If you and/or your Medicare eligible dependent join a Medicare prescription drug plan, the BSA Medical Plan will be considered primary to Medicare, so the BSA Medical Plan will pay benefits first. Paying a Higher Premium (Penalty) When Joining a Medicare Prescription Drug Plan You should also know that if you are eligible for Medicare and drop or lose your coverage under the BSA Medical Plan and don t join a Medicare prescription drug plan within 63 consecutive days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare prescription drug plan later. If you go 63 consecutive days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1 percent of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go 19 months without creditable coverage, your premium may consistently be at least 19 percent higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following November to join. 21
For more information about this notice or about your current prescription drug coverage, contact the BSA Benefits Center at 1 800 444 4416 or at bsabenefits.mercerhrs.com. Note: You will receive this notice each year. You will also receive it before the next period you can join a Medicare prescription drug plan and if this coverage through BSA changes. You may also request a copy of this notice at any time. More Information About Your Options Under Medicare Prescription Drug Coverage More detailed information about Medicare plans that offer prescription drug coverage is in the Medicare and You handbook. You ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: Visit www.medicare.gov. Call your state health insurance assistance program. (See the inside back cover of your copy of the Medicare and You handbook for their telephone number) for personalized help. Call 1 800 MEDICARE (1 800 633 4227), TTY users should call 1 877 486 2048. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this help, visit Social Security online at www.socialsecurity.gov, or call them at 1 800 772 1213 (TTY 1 800 325 0778). Remember: Keep this creditable coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty). Date: Sept. 1, 2011 Name of Entity/Sender: Boy Scouts of America Contact Position/Office: BSA Benefits Center Address: P.O. Box 9735, Providence, Rhode Island 02940 Phone number: 1 800 444 4416 22