Benefit Summary for the Employees of Vantage Radiology and Diagnostic Services, A Professional Service Corporation Effective Date: September 1, 2014 to August 31, 2015 This memorandum has been prepared to help you review the key factors that are associated with our benefit plans. This memorandum does not provide all of the contractual provisions, limitations or exclusions included in our policies and should be considered only as a summary of our current benefits. If any differences exist between this summary and the official contracts, the contracts shall prevail. 20101110
Your Benefits Plan Vantage Radiology and Diagnostic Services, a professional service corporation is pleased to offer a comprehensive benefits program to our valued employees. In the following pages, you will learn more about the benefits Vantage Radiology and Diagnostic Services, a professional service corporation offers. You will also see how choosing the right combination of benefits can help protect you and your family s health and finances and your family s future. Benefit Medical Insurance Dental Insurance Group Life and AD&D Insurance Disability Insurance Eligibility Carrier Regence BlueShield Delta Dental of Washington Unum Unum Full-Time employees are eligible for benefits after completion of the waiting period. Children are eligible for benefits up to age 26 regardless of dependent, student or marital status. Spouses and domestic partners (same or opposite gender) are eligible for benefits. When Can You Enroll? You can sign up for Benefits at any of the following times: After completing initial eligibility period During the annual open enrollment period Within 30 days of a qualified family-status change If you do not enroll at the above times, you must wait for the next annual open enrollment period. Making Changes Generally, you can only change your benefit elections during the annual benefits enrollment period. However, you may be able to change some of your benefit elections upon the occurrence of certain change in status events, provided you properly notify your Employer. These changes in status events may include: Marriage Divorce or legal separation Birth or adoption of an eligible child Death of your spouse or covered child Change in your spouse s work status that affects his or her benefits Change in your work status that affects your benefits Change in residence or work site that affects your eligibility for coverage Change in your child s eligibility for benefits Receiving Qualified Medical Child Support Order (QMCSO) If you have a family status change, you must timely notify Human Resources and complete the necessary forms. For more information refer to your benefits booklet. 1
Medical Plans Vantage Radiology and Diagnostic Services, a professional service corporation offers a choice between two medical plans through Regence BlueShield. You can choose the HSA Healthplan or the Innova PPO Plan. Regence allows you to see any Preferred Provider without a physician referral. The level of benefits you receive is dependent upon your choice of a Preferred, Participating or Non-Participating provider. Significantly higher benefits will be received when you obtain care from a Preferred provider. Please see your Booklet or carrier Summary of Benefits and Coverage for more information. Preferred Benefits Regence HSA 2.0 Healthplan Regence Innova PPO Healthplan Calendar Year Deductible Per Person $1,500 $500 Maximum Per Family $3,000 aggregate $1,500 Calendar Year Maximum Out-of-Pocket (Includes Coinsurance, Deductible and Copays) Per Person $5,000 $3,000 Maximum Per Family $10,000 aggregate $6,000 Preventive Care 1 Preventive Office Visit 100%, Deductible waived 100%, Deductible waived Preventive Lab Tests 100%, Deductible waived 100%, Deductible waived Well-Child Care 100%, Deductible waived 100%, Deductible waived Routine Immunizations 100%, Deductible waived 100%, Deductible waived Preventive Mammograms 100%, Deductible waived 100%, Deductible waived Professional Office Visit Deductible then: 20% $30 copay, Deductible waived Inpatient Professional Services Deductible then: 20% Deductible then: 10% Hospital/Facility Inpatient Care Deductible then: 20% Deductible then: 10% Outpatient Facility Charges Deductible then: 20% Deductible then: 10% Mental Health/Substance Abuse Outpatient Deductible then: 20% $30 copay, Deductible waived Inpatient Deductible then: 20% Deductible then: 10% Rehabilitation Inpatient Limited to 30 days per calendar year Deductible then: 20% Deductible then: 10% Outpatient Limited to 25 visits per calendar year Deductible then: 20% Deductible then: 10% Other Services Acupuncture Limited to 12 visits per calendar year Deductible then: 20% Deductible then: 10% Ambulance (Ground) Deductible then: 20% Deductible then: 10% Diagnostic X-Ray and Lab Tests Deductible then: 20% First $400: 100%, Deductible waived (PCY) $401+: Deductible then: 10% (PCY) Emergency Room (Copay waived if admitted) Deductible then: 20% $100 copay, Deductible then: 10% Spinal Manipulations Limited to 10 visits per calendar year Deductible then: 20% Deductible then: 10% Vision Benefits Exam Limited to one exam per calendar year 100%, Deductible waived 100%, Deductible waived Materials/ Hardware Limited to $150 per calendar year 100%, Deductible waived 100%, Deductible waived Participating & Out-of-Network Benefits Calendar Year Deductible Shared with In-Network Shared with In-Network Coinsurance 40% 30% Calendar Year Out-of-Pocket Maximum Shared with In-Network Shared with In-Network Preventive Care Office Visit Participating 100%, Deductible waived Participating: 100%, Deductible waived Out-of-Network 40%, Deductible waived Out-of-Network: Deductible then: 30% Professional Care Office Visit Deductible then: 40% Participating: $45 copay, Deductible waived Out-of-Network: Deductible then: 30% Emergency Room Deductible then: 20% $100 copay, Deductible then: 10% Annual Maximum UNLIMITED UNLIMITED 1 Cost-Share reflected only applies for Preferred and Participating providers. Please refer to your Regence plan documents for Non-Participating/ Out-of-Network Cost share. PCY = Per Calendar Year 2
ORGAN TRANSPLANT WAITING PERIOD You may not be eligible for any transplant benefits until you have been covered under the plan for six consecutive months. This waiting period may be reduced by creditable coverage from a prior plan. Please see your benefit booklet for more details. OUT OF AREA BENEFITS The BlueCard Program enables access to providers across the country and around the world. When traveling outside the Regence service area, you can take advantage of lower rates the local Blue Plan has negotiated with providers in the area. For covered services, you should not be responsible for any amount above these negotiated rates and will only pay applicable out-of-pocket expenses. Please go to www.bcbs.com or call 800-810-BLUE (2583) to find a provider in the area. Prescription Drugs Below is a brief overview of what you can expect to pay for a prescription drug, depending on which tier category it falls under in the Preferred Drug List for your plan when using an In-Network Pharmacy. To find out what tier applies to a specific medication, see the Preferred Drug List at www.regencerx.com. If you have a Maintenance Drug, one you take every day, week or month, take advantage of the Mail Order Programs with your medical plan. See your packet or go online for details. Regence HSA 2.0 Health Plan Regence Innova PPO Health Plan Benefit Participating Retail Mail Order Participating Retail Mail Order Generic $10 copay $30 copay Formulary Brand Deductible then: 20% Deductible then:20% $35 copay $105 copay Non Formulary Brand $75 copay $225 copay Maximum Day Supply Up to 90 days (up to 30 days for injectables) Up to 30 days Up to 90 days Deductible Individual Family Maximum Out-of-Pocket Individual Family Applies to Medical Plan Deductible Applies to Medical Plan Deductible Applies to Medical Plan Coinsurance Maximum Applies to Medical Plan Coinsurance Maximum MANDATORY GENERIC SUBSITUTION (INNOVA PPO PLAN ONLY) If an equivalent generic medication is available and a brand-name medication is chosen, you will be responsible for paying the applicable brand-name copay plus the difference in price between the equivalent generic medication and the brand-name medication. Health Savings Account (HSA) An HSA is a tax-sheltered bank account that you own for the purpose of paying eligible healthcare expenses for you and your dependents. Your own HSA voluntary and contributions are tax-deductible. Unused funds and interest accumulate, without limit, from year to year. You own the HSA and it is yours to keep even when you change plans or retire. If you withdraw funds for non-eligible expenses, the withdrawal may be subject to income tax and possible penalty. Once you incur eligible expenses, you can request reimbursement from your account. Keep your receipts and Explanation of Benefits (EOBs) in the event that the IRS requests additional information on your transaction(s). After reaching age 65, you can use the funds for any purpose, without a penalty. Due to IRS regulations, you CANNOT enroll, contribute or submit expenses to a Health Savings Account if you are covered under a health plan that is not considered a Qualified High Deductible Health Plan (QHDHP). This could include coverage under your spouse s medical plan or if you or your spouse enrolls in a full Section 125 Healthcare FSA. (Enrollment in a Limited Purpose Healthcare FSA is allowed). In addition, HSA participants may not file a 1040EZ tax return for any tax year in which they participated in an HSA. Other important considerations may apply. Please consult your professional tax advisor to determine whether you should enroll in this plan. Eligible expenses include plan deductibles, coinsurance and other out-of-pocket medical, dental and vision healthcare expenses for you and your eligible dependents. An extensive list of eligible expenses as well as detailed information regarding Health Savings Accounts can be found at on the IRS website by referencing Publication 969 and Publication 502. 3
Annual Employer Contribution 2014 Maximum Annual Employee Contribution (includes Employer Contribution) 2015 Maximum Annual Employee Contribution (includes Employer Contribution) $1,500 / Employee $3,300 / Employee Only $6,550 / Family Enrollment $3,350 / Employee Only $6,650 / Family Enrollment Vantage Radiology & Diagnostic Services, a professional service corporation will contribute $125 per month into your HSA account. IMPORTANT: All contributions to your HSA are done on a post-tax basis as of September 1 st, 2014. Please speak to your tax advisor about tax advantages related to this type of account. Dental Plan **** Benefits eligible employees and their dependents may enroll in the dental benefits through Delta Dental of Washington Although you can go to any dentist you wish, your plan year maximum will stretch further if you go to a Preferred Provider who offers discounts on their usual fees. Benefits Delta Dental of Washington Dental PPO Calendar Year Maximum $1,500 Calendar Year Deductible Individual $25 Family Maximum $75 Preventive & Diagnostic Care 100%, Deductible waived Basic Restorative Care PPO Dentist 90% Premier or Nonparticipating Dentist 80% Major Restorative Care 50% TMJ Benefits 50% Annual Maximum $1,000 Lifetime Maximum $5,000 VOLUNTARY PRE-AUTHORIZATION In the event you need to have dental work estimated to cost $300 or more, we recommend you have your dentist submit the charges to Delta Dental of Washington for pre-authorization. Delta Dental of Washington will review the intended treatment plan and let your dentist know how much of the bill they will cover. We recommend this to avoid any billing issues. Group Life and AD&D Benefits Vantage Radiology and Diagnostic Services, a professional service corporation provides Group Life and AD&D insurance to all benefit eligible employees at no additional cost. Please be sure to select a beneficiary. Unum Group Life and AD&D Employee Life Benefit 1 X salary up to $50,000 AD&D In the event of an accidental death, the benefit may double. Please see your booklet for Accidental Death Benefit further details. In the event of an accidental dismemberment, a benefit is provided up to a scheduled Dismemberment amount corresponding to the loss. Please see your booklet for further details. BENEFIT REDUCTION Benefits begin to reduce at age 65. Please refer to your booklet for further details. BENEFICIARY DESIGNATION If you are married and living in a community property state, your insurance carrier may require that you designate your spouse (or in some cases a registered domestic partner) for at least 50% of the benefit unless you have a waiver notice on file from your spouse. Consult your legal or tax advisor for further guidance on this issue. 4
Voluntary Life and AD&D Benefits Vantage Radiology and Diagnostic Services, a professional service corporation provides Voluntary Life and AD&D insurance to all benefit eligible employees at the employee s cost. Please see the Unum Benefit Summary in your packet for rate information. Unum Voluntary Life/AD&D Employee Benefit Amount $10,000 increments up to 5x annual earnings (not to exceed $500,000) Guarantee Issue Amount $70,000 Spouse Benefit Amount 100% of employee amount in increments of $5,000 (not to exceed $500,000) Guarantee Issue Amount $25,000 Child(ren) Benefit Amount 100% of employee amount in increments of $2,000 (not to exceed $10,000) Guarantee Issue Amount Full Amount BENEFIT REDUCTION Benefits begin to reduce at age 65. Please refer to your booklet for further details. BENEFICIARY DESIGNATION If you are married and living in a community property state, your insurance carrier may require that you designate your spouse (or in some cases a registered domestic partner) for at least 50% of the benefit unless you have a waiver notice on file from your spouse. Consult your legal or tax advisor for further guidance on this issue. Voluntary Short Term Disability Benefits Vantage Radiology and Diagnostic Services, a professional service corporation provides Voluntary Short Term Disability coverage to all benefit eligible employees at the employee s cost. Please see the Unum Benefit Summary in your packet for rate information. Benefits Benefits Begins Weekly Benefit Maximum Benefit Maximum Benefit Duration Unum Short Term Disability (STD) After a 14-day waiting period 40%, 50% or 60% of salary $2,000 per week Up to 11 weeks In the event of a disability claim, payments received under this plan would not be considered taxable income. 5
Group Long Term Disability Benefits Vantage Radiology and Diagnostic Services, a professional service corporation provides Group Long Term Disability insurance to all benefit eligible employees at no additional cost. Please be sure to select a beneficiary. Benefits Benefits Begin Monthly Benefit Maximum Benefit Benefit Duration Definition of Disability Pre-Existing Condition Limitation Unum After a 90-day elimination (waiting) period of continuous disability from the day your disabling condition occurs 66 2/3% of your covered pre-disability monthly earnings Up to $6,000 per month To age 65 / RBD Own Occupation and 20% earnings loss A pre-existing condition is a condition, regardless of cause, for which medical advice, diagnosis, care or treatment was recommended or received within the 3 months prior to your enrollment date. The plan will not pay benefits for any pre-existing conditions that result in disability during your first 12 consecutive months of coverage. In the event of a disability claim, payments would not be considered taxable income. Contact Information If you have any further questions concerning your benefits, please contact: Carrier Plan Website Phone Number Regence BlueShield Group #10001017 www.regence.com 888-344-6347 Delta Dental of Washington Group #03289 www.deltadentalwa.com 800-554-1907 Unum Life/AD&D & Long Term Disability #386611 Voluntary Life/AD&D #131970 Voluntary STD #B0345553 www.unum.com 877-225-2712 Benefit Resource Center The Benefit Resource Center is designed to provide you with a responsive, consistent, hands-on approach to benefit inquiries. Benefit Specialists are available to research and solve elevated claims, unresolved eligibility problems, and any other benefit issues with which you might need assistance. The Benefit Specialists are experienced professionals and their primary responsibility is to assist you. The Specialists in the Benefit Resource Center are available Monday through Friday 8:00 AM to 5:00 PM (Pacific Time). If you need assistance outside of regular business hours, please leave a message and one of the Benefit Specialists will promptly return your call or e-mail message by the end of the following business day. Phone: (866) 4ourBRC (468-7272) Email: 4ourBRC@kpcom.com Fax: (877) 678-5840 6
Confidentiality Disclosure These materials are produced by Kibble & Prentice for the sole use of its clients, prospective clients, and their representatives. Certain information contained in these materials are considered proprietary information created by Kibble & Prentice and/or their licensed and appointed insurance carriers. Such information and any insurance designs furnished by Kibble & Prentice are considered Confidential Material. Such information shall not be used in any way, directly or indirectly, detrimental to Kibble & Prentice and clients and/or potential clients and any of their representatives will keep that information confidential. IRS Circular 230 Disclosure: Kibble & Prentice Holding Co. does not provide tax advice. Accordingly, any discussion of U.S. tax matters contained herein (including any attachments) is not intended or written to be used, and cannot be used, in connection with the promotion, marketing or recommendation by anyone unaffiliated with Kibble & Prentice Holding Co. of any of the matters addressed herein or for the purpose of avoiding U.S. tax-related penalties. Also, the information contained in this benefit summary should not be construed as medical or legal advice. 7
Important Legal Notices Affecting Your Health Plan Coverage THE WOMEN S HEALTH CANCER RIGHTS ACT OF 1998 (WHCRA) If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for: All stages of reconstruction of the breast on which the mastectomy was performed; Surgery and reconstruction of the other breast to produce a symmetrical appearance; Prostheses; and Treatment of physical complications of the mastectomy, including lymphedema. These benefits will be provided subject to the same Deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan. Therefore, the following Deductibles and coinsurance apply: Preferred Benefits Regence HSA 2.0 Health Plan Regence Innova PPO Health Plan Calendar Year Deductible Per Person $1,500 $500 Maximum Per Family $3,000 aggregate $1,500 Calendar Year Coinsurance Maximum Per Person $5,000 $3,000 Maximum Per Family $10,000 aggregate $6,000 Professional Office Visit Deductible then 20% $30 copay, Deductible waived Inpatient Professional Services Deductible then 20% Deductible then 10% Hospital/Facility Inpatient Care Deductible then 20% Deductible then 10% Outpatient Facility Charges Deductible then 20% Deductible then 10% NEWBORNS ACT DISCLOSURE FEDERAL Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother s or newborn s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law, require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours). Any applicable state law provisions should be outlined in the Summary Plan Description and benefits booklet. NOTICE OF SPECIAL ENROLLMENT RIGHTS If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or 8
your dependents other coverage). However, you must request enrollment within 60 days after your or your dependents other coverage ends (or after the employer stops contributing toward the other coverage). In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 60 days of marriage or within 60 days of birth, adoption, or placement for adoption. Further, if you decline enrollment for yourself or eligible dependents (including your spouse) while Medicaid coverage or coverage under a State CHIP program is in effect, you may be able to enroll yourself and your dependents in this plan if: coverage is lost under Medicaid or a State CHIP program; or You or your dependents become eligible for a premium assistance subsidy from the State. In either case, you must request enrollment within 60 days from the loss of coverage or the date you become eligible for premium assistance. To request special enrollment or obtain more information, contact person listed at the end of this summary. CONTACT INFORMATION Questions regarding any of these rights can be directed to: Beth Williams, Executive Director 533 S 336 th St, Suite C Federal Way, WA 98003 253-661-1700 ext 1105 9
STATEMENT OF ERISA RIGHTS As a participant in the Plan you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 ( ERISA ). ERISA provides that all participants shall be entitled to: Receive Information about Your Plan and Benefits Examine, without charge, at the Plan Administrator s office and at other specified locations, the Plan and Plan documents, including the insurance contract and copies of all documents filed by the Plan with the U.S. Department of Labor, if any, such as annual reports and Plan descriptions. Obtain copies of the Plan documents and other Plan information upon written request to the Plan Administrator. The Plan Administrator may make a reasonable charge for the copies. Receive a summary of the Plan s annual financial report, if required to be furnished under ERISA. The Plan Administrator is required by law to furnish each participant with a copy of this summary annual report, if any. Continue Group Health Plan Coverage If applicable, you may continue health care coverage for yourself, spouse or dependents if there is a loss of coverage under the plan as a result of a qualifying event. You and your dependents may have to pay for such coverage. Review the summary plan description and the documents governing the Plan for the rules on COBRA continuation of coverage rights. You should be provided a certificate of creditable coverage, free of charge, from your group health plan or health insurance issuer when you lose coverage under the plan, when you become entitled to COBRA continuation of coverage, when COBRA continuation of coverage ceases, if you request before losing coverage or if you request it up to 24 months after losing coverage. Prudent Actions by Plan Fiduciaries In addition to creating rights for participants, ERISA imposes duties upon the people who are responsible for operation of the Plan. These people, called fiduciaries of the Plan, have a duty to operate the Plan prudently and in the interest of you and other Plan participants. No one, including the Company or any other person, may fire you or discriminate against you in any way to prevent you from obtaining welfare benefits or exercising your rights under ERISA. Enforce your Rights If your claim for a welfare benefit is denied in whole or in part, you must receive a written explanation of the reason for the denial. You have a right to have the Plan review and reconsider your claim. Under ERISA, there are steps you can take to enforce these rights. For instance, if you request materials from the Plan Administrator and do not receive them within 30 days, you may file suit in federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent due to reasons beyond the control of the Plan Administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, and you have exhausted the available claims procedures under the Plan, you may file suit in a state or federal court. If it should happen that Plan fiduciaries misuse the Plan s money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a federal court. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have sued to pay these costs and fees. If you lose (for example, if the court finds your claim is frivolous) the court may order you to pay these costs and fees. Assistance with your Questions If you have any questions about your Plan, this statement, or your rights under ERISA, you should contact the nearest office of the Employee Benefits and Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits and Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. 10