FACILITY SPECIFIC BENEFIT INFORMATION FOR St. Rose Hospitals - Non-Union This document contains important information about your Medical, Dental, Vision, Life, Accidental Death & Dismemberment and Longterm Disability Plan options. It also describes the Default Plan and Rollover Plan, which are the package of benefits provided to you if you do not enroll by the enrollment deadline. If you have any questions, contact the Dignity Health HR Service Center at 855.475.4747 and press "1". ELIGIBILITY Minimum hours per pay period Waiting Period Eligibility Date 40 30 days 1st of the month following completion of waiting period Newborns are not automatically enrolled; you must elect coverage within 31 days of the birth by logging on to dignityhealthmember.org/totalrewards ELIGIBLE DEPENDENTS Dual coverage is not allowed in any medical, dental or vision plan Eligible dependents include the following: One adult from the following categories: - Spouse - Legally Domiciled Adult (LDA) - Adult Tax Dependent (ATD) Dependent Child(ren) For eligible dependents definitions, refer to the Dignity Health Summary Plan Description (SPD). MEDICAL PLAN OPTIONS DENTAL PLAN OPTIONS VISION PLAN OPTIONS HPN HMO A-5 HPN Premier DHMP Nevada EPO Delta Basic Delta 1200 Delta 2500 Dignity Health Vision Plan Dignity Health Vision Plan Plus 1 St Rose NC CY 2017 V1-010117
LIFE & AD&D INSURANCE OPTIONS LTD INSURANCE OPTIONS Life and AD&D coverage options include: Employee Life 1 x Pay 2 x Pay 3 x Pay 4 x Pay 5 x Pay $10,000 $50,000 Employee AD&D 1 x Pay 2 x Pay 3 x Pay 4 x Pay $10,000 Dependent Spouse $5,000 $10,000 $25,000 $50,000 Dependent Child $2,000 $5,000 $10,000 Long Term Disability coverage options include: 40% 50% 60% 2 St Rose NC CY 2017 V1-010117
HPN HMO A-5¹ Provider Network Calendar Year Deductible $0 Hospital Deductible $0 Medical Out-of-Pocket Maximum 2 Physician Office Visits Health Plans of Nevada HPN HMO Network $6,000 per person / $12,000 per family Primary Care: $5 copayment Specialist: $10 copayment Behavioral Health: $5 copayment Preventive Services 3 100% Hospital Facility Services Medical: $100 copayment Behavioral Health: $100 copayment Emergency Room Urgent Care PRESCRIPTION DRUG PROGRAM BENEFITS Prescription Drug Deductible $0 Prescription Drug Out-of-Pocket Maximum 2 FORMULARY Walk-up Mail Order NON-FORMULARY Walk-up Mail Order $75 copayment (waived if admitted) $20 copayment Included in the Medical Out-of-Pocket Maximum (30-day supply) Tier 1: $7 copayment Tier 2: $30 copayment; $30 copayment plus cost difference between brand and generic when generic is available. (90-day supply) Tier 1: $14 copayment Tier 2: $60 copayment; $60 copayment plus cost difference between brand and generic when generic is available. (30-day supply) Tier 3: $50 copayment (maintenance drugs only) (90-day supply) Tier 3: $100 copayment Note: During the year, your prescription may change between the formulary and non-formulary. Some prescription drugs are subject to monthly quantity limits. OTHER MEDICAL SERVICES INPATIENT Anesthesiologist 100% Hospital Facility Services Medical: $100 copayment Behavioral Health: $100 copayment Physician Visits Surgeon, Surgical Assistant Primary Care: $5 copayment Specialist: $10 copayment Surgeon: 100% Surgical Assistant: 100% 3 St Rose NC CY 2017 V1-010117
HPN HMO A-5¹ OUTPATIENT Diagnostic X-ray/Imaging Diagnostic Lab Hospital Facility Services Surgeon, Surgical Assistant OTHER SERVICES Acupuncture Allergy Injections and Services (includes serum) Ambulance Chemotherapy/Radiation Therapy $5 copayment $5 copayment Medical: $50 copayment Behavioral Health: $50 copayment Surgeon: 100% Surgical Assistant: 100% Not covered $10 copayment $50 copayment $10 copayment Chiropractic $10 copayment Durable Medical Equipment $100 or 50% of allowable (monthly rental or purchase at HPN's option. Purchases are limited to a single purchase of a type of DME, including repair or replacement, every 3 years) Hospice 100% Short -Term Therapy (Physical; Occupational; Speech and Respiratory) Outpatient: $5 copayment Inpatient: $100 copayment (limited benefit maximum of 120 days per calendar year, per condition) ¹ Subject to limitations and exclusions. A complete list of the limitations and exclusions (applicable to this medical plan) is provided in the Evidence of Coverage provided by the health plan. ² The Medical Out-of-Pocket Maximum includes the Prescription Drug Out-of-Pocket costs. ³ All preventive services defined by the Affordable Care Act are covered without having to pay a copayment or co-insurance or meet a. This applies only when services are delivered by a network provider. A complete list of preventive services can be found at www.healthcare.gov/coverage/preventive-carebenefits/. This is a basic summary of the medical plan benefits. If you have questions about coverage or costs under this plan, please contact the plan administrator at the number listed on your ID card or log on to the Total Rewards Portal to access plan resources. From "My Health" you can link to the administrator's website or review the plan's Evidence of Coverage (EOC) document. To view the EOC, select "Summary Plan Descriptions" from the "Resource" section under "Quick Links". 4 St Rose NC CY 2017 V1-010117
Tier 1 (HMO) Tier 2 (PPO) Tier 3 (Out-of-Network) Provider Network HPN HMO (Tier 1) Network Sierra Health and Life Network Any provider Calendar Year Deducible $0 $500 per person / $1,500 per family combined with Tier 3 $500 per person / $1,500 per family combined with Tier 2 Hospital Deductible $0 $0 $0 Medical Out-of-Pocket Maximum 2 $2,000 per person/$2,000 per family $2,000 per person / $6,000 per family $4,000 per person / $12,000 per family Physician Office Visits Primary Care: $10 copayment Specialists: $20 copayment Primary Care: $25 copayment Specialists: $45 copayment Primary Care: 60% of allowable after Specialist: 60% of allowable after Behavioral Health: $10 copayment Behavioral Health: $25 copayment Behavioral Health: 60% of allowable after Preventive Services 3 100% 100% 60% of allowable after Hospital Facility Services Medical: $300 copayment Medical: 80% after Medical: 60% of allowable after Behavioral Health: $300 copayment Behavioral Health: 80% after Behavioral Health: 60% of allowable after Emergency Room $75 copayment (waived if admitted) $75 copayment (waived if admitted) $75 copayment (waived if admitted) Urgent Care $20 copayment $20 copayment $20 copayment PRESCRIPTION DRUG PROGRAM BENEFITS Prescription Drug Deductible Prescription Drug Out-of- Pocket Maximum 2 FORMULARY Walk-up Mail Order NON-FORMULARY Walk-up Mail Order HPN Premier¹ (30-day supply) Tier 1: $5 copayment Tier 2: $20 copayment; $20 copayment plus cost difference between brand and generic when generic is available. (90-day supply) Tier 1: $10 copayment Tier 2: $40 copayment; $40 copayment plus cost difference between brand and generic when generic is available. (30-day supply) Tier 3: $40 copayment (maintenance drugs only) (90-day supply) Tier 3: $80 copayment Health Plans of Nevada Note: During the year, your prescription may change between the formulary and non-formulary. Some prescription drugs are subject to monthly quantity limits. $0 Included in the Medical Out-of-Pocket Maximum 5 St Rose NC CY 2017 V1-010117
OTHER MEDICAL SERVICES INPATIENT HPN Premier¹ Tier 1 (HMO) Tier 2 (PPO) Tier 3 (Out-of-Network) Anesthesiologist $100 copayment 80% after 60% of allowable after Hospital Facility Services Physician Visits Surgeon, Surgical Assistant OUTPATIENT Medical: $300 copayment Medical: 80% after Medical: 60% of allowable after Behavioral Health: $300 copayment Behavioral Health: 80% after Behavioral Health: 60% of allowable after Primary Care: $10 copayment $45 copayment 60% of allowable after Specialist: $20 copayment Surgeon: $25 copayment Surgeon: 80% after Surgeon: 60% of allowable after Surgical Assistant: $25 copayment Surgical Assistant: 80% after Surgical Assistant: 60% of allowable after Diagnostic X-ray/Imaging $10 copayment $10 copayment 70% of allowable after Diagnostic Lab $10 copayment $10 copayment 60% of allowable after Hospital Facility Services Surgeon, Surgical Assistant OTHER SERVICES Medical: $50 copayment Medical: 80% after Medical: 60% of allowable after Behavioral Health: $50 copayment Behavioral Health: 80% after Behavioral Health: 60% of allowable after Surgeon: $10 copayment Surgeon: 80% after Surgeon: 60% of allowable after Surgical Assistant: $10 copayment Surgical Assistant: 80% after Surgical Assistant: 60% of allowable after Acupuncture Not covered Not covered Not covered Allergy Injections and Services $20 copayment 80% after 60% of allowable after (includes serum) Ambulance $50 copayment $50 copayment $50 copayment Chemotherapy/Radiation $20 copayment 80% after 60% of allowable after Therapy Chiropractic $20 copayment $45 copayment 60% of allowable after Durable Medical Equipment $100 copayment or 50% of allowable (monthly rental or purchase at HPN's option. Purchases are limited to a single purchase of a type of DME, including repair and replacement, every 3 years ) 80% after (monthly rental or purchase at HPN's option. Purchases are limited to a single purchase of a type of DME, including repair and replacement, every 3 years ) 60% of allowable after (monthly rental or purchase at HPN's option. Purchases are limited to a single purchase of a type of DME, including repair and replacement, every 3 years ) Hospice $300 copayment Covered under Tier 1 Covered under Tier 1 Short-Term Therapy (Physical, Occupational, Speech and Respiratory) Outpatient: $10 copayment Inpatient: $300 copayment 80% after (All inpatient and outpatient limited to 120 visits per calendar year; combined with Tier 3 ) 60% of allowable after (All inpatient and outpatient limited to 120 visits per calendar year; combined with Tier 2 ) 6 St Rose NC CY 2017 V1-010117
HPN Premier¹ Tier 1 (HMO) Tier 2 (PPO) Tier 3 (Out-of-Network) ¹ Subject to limitations and exclusions. A complete list of the limitation and exclusions (applicable to this medical plan) is provided in the Evidence of Coverage. 2 The Medical Out-of-Pocket Maximum includes the Prescription Drug Out-of-Pocket costs. 3 All preventive services defined by the Affordable Care Act are covered without having to pay a copayment or co-insurance or meet a. This applies only when services are delivered by a network provider. A complete list of preventive services can be found at www.healthcare.gov/coverage/preventive-care-benefits/. This is a basic summary of the medical plan benefits. If you have questions about coverage or costs under this plan, please contact the plan administrator at the number listed on your ID card or log on to the Total Rewards Portal to access plan resources. From "My Health" you can link to the administrator's website or review the plan's Evidence of Coverage (EOC) document. To view the EOC, select "Summary Plan Descriptions" from the "Resource" section under "Quick Links". 7 St Rose NC CY 2017 V1-010117
Provider Network Tier 1 Tier 2 Dignity Health Preferred Network (All Dignity Health Hospitals; Dignity Health Medical Group Nevada and other aligned providers) Sierra Healthcare Options (SHO) - in Nevada UHC Options PPO - outside of Nevada Calendar Year Deductible 2 $0 $500 per person / $1,500 per family Hospital Deductible $0 $0 Medical Out-of-Pocket Maximum³ Physician Office Visits 11 $6,000 per person / $12,000 per family combined with Tier 2 Primary Care 4 : $5 copayment Specialist: $20 copayment 6 (when referred by PCP) Behavioral Health: $5 copayment $6,000 per person / $12,000 per family combined with Tier 1 Primary Care 4 : $20 copayment Specialist: $50 copayment 6 (when referred by PCP) Behavioral Health: $20 copayment Preventive Services 10 100% 100% no Inpatient Hospital Facility Services 7 Medical: $100 copayment Medical: Not covered (unless service is not provided at a Tier 1 facility or an emergency) Behavioral Health: $100 copayment Behavioral Health: $100 copayment Emergency Room 5 $75 copayment (waived if admitted) $75 copayment (waived if admitted) Urgent Care $20 copayment $20 copayment PRESCRIPTION DRUG PROGRAM BENEFITS Prescription Drug Deductible Prescription Drug Out-of-Pocket Maximum³ FORMULARY Walk-up Mail Order NON-FORMULARY Walk-up Mail Order DHMP Nevada EPO¹ (30-day supply) $7 copayment when filled with generic; $30 copayment when filled with brand name when no generic equivalent is available; $30 copayment plus cost difference between brand and generic when generic equivalent is available. (90-day supply) $14 copayment when filled with generic; $60 copayment when filled with brand if no generic available; $60 plus cost difference between brand and generic when generic is available. (30-day supply) $50 copayment (90-day supply) $100 copayment Note: During the year, your prescription may change from the formulary to non-formulary or vice versa. Some prescription drugs require prior authorization, compliance with step therapy and/or may be subject to monthly quantity limits. UMR $0 Included in the Medical Out-of-Pocket Maximum 8 St Rose NC CY 2017 V1-010117
OTHER MEDICAL SERVICES INPATIENT 6 DHMP Nevada EPO¹ Tier 1 Tier 2 Anesthesiologist 100% 100% no Hospital Facility Services 7 Medical: $100 copayment Medical: Not covered (unless service is not provided at a Tier 1 facility or an emergency) Behavioral Health: $100 copayment Behavioral Health: $100 copayment Physician Visits 100% 100% no Surgeon, Surgical Assistant Surgeon: 100% Surgeon: 50% after For surgical assistant, covered at 100%, no Surgical Assistant: 100% Surgical Assistant: 50% after For surgical assistant, covered at 100%, no OUTPATIENT Diagnostic X-ray/Imaging Diagnostic Lab Hospital Facility Services 7 Surgeon, Surgical Assistant OTHER SERVICES Acupuncture (limits combined between Tier 1 and Tier 2) X-ray: Outpatient Radiology Center or Provider's Office: $5 copayment; Dignity Health Hospital: $25 copayment. Imaging: Outpatient Radiology Center: $25 copayment; Dignity Health Hospital: $75 copayment. PET Scan: Must be performed at a Dignity Health Hospital: $100 copayment Outpatient Lab Center or Provider's Office: $5 copayment Medical: Outpatient Surgi-centers: $50 copayment Dignity Health Hospital: $100 copayment Behavioral Health: $50 copayment Surgeon: $50 copayment Surgical Assistant: $50 copayment $10 copayment; (Limited 20 visits per calendar year combined with Chiropractic; for treatment of illness, disease, or injury only) Outpatient Radiology Center/Hospital: Not Covered Providers Office: X-rays - 80% after ; Imaging/Pet Scans - Not Covered Outpatient Lab Center: Not Covered Providers Office: 80% after Medical: Not covered (unless service is not provided at a Tier 1 facility or an emergency) Behavioral Health: $50 copayment Surgeon: 50% after Surgical Assistant: $50 copayment 80% after ; (Limited 20 visits per calendar year combined with Chiropractic; for treatment of illness, disease, or injury only) Allergy Injections and Services (includes $10 copayment 80% after serum) Ambulance $50 copayment (per trip) $50 copayment (per trip) Chemotherapy/Radiation Therapy $10 copayment 80% after Chiropractic 8 (limits combined between Tier 1 and Tier 2) $10 copayment; (Limited 20 visits per calendar year combined with Acupuncture; for treatment of illness, disease, or injury only) Durable Medical Equipment 50% coverage up to a maximum of $100 patient responsibility 80% after ; (Limited 20 visits per calendar year combined with Acupuncture; for treatment of illness, disease, or injury only) 80% after 9 St Rose NC CY 2017 V1-010117
Hospice Short -Term Therapy 9 (Physical; Occupational; Speech and Respiratory) DHMP Nevada EPO¹ Tier 1 Tier 2 Inpatient: $100 copayment per admission Outpatient: 100% Outpatient: $5 copayment (limited benefit maximum of 120 days per calendar year, combined with Tier 2) 80% after Outpatient: 80% of allowable after. (limited benefit maximum of 120 days per calendar year, combined with Tier 1) ¹ Subject to limitations and exclusions. A complete list of the limitations and exclusions (applicable to this medical plan) is provided in the Medical Plan Document. ² Deductible is per person. The combined family maximum is three times the illustrated amount. Expenses incurred in Tier 1 and Tier 2 are credited separately to each limit. ³ The Medical Out-of-Pocket Maximum includes Prescription Drug Out-of-Pocket costs. ⁴ Primary Care visits: Family Practitioner, General Practitioner, Pediatrician, Internist, Nurse Practitioner, Physician Assistant and OB/GYN visits, including behavioral health. All other professional visits are considered Specialist. ⁵ Non-emergent care not covered. 6 Members need to obtain a referral to all specialists from a Tier 1 or Tier 2 PCP. If no specialist referral is obtained, the member will be responsible for a $100 copayment or the full contracted rate of the visit. 7 Requires precertification. For a detailed list of services that require precertification refer to the Medical Plan Document. 8 Includes spinal manipulation performed by MD, DO or other providers. 9 Must meet medical necessity criteria. 10 All preventive services defined by the Affordable Care Act are covered without having to pay a copayment or co-insurance or meet a. This applies only when services are delivered by a network provider. 11 In order to comply with the wellness program requirements, all members must designate a Tier 1 PCP (Family Practitioner, General Practitioner, Pediatrician, Internist). Women must designate a Tier 1 PCP, however are able to seek care from a Tier 1 or Tier 2 OB/GYN without a referral. This is a basic summary of the medical plan benefits. If you have questions about coverage or costs under this plan, please contact the plan administrator at the number listed on your ID card or log on to the Total Rewards Portal to access plan resources. From "My Health" you can link to the administrator's website or review the plan's Medical Plan Document (MPD) document. To view the MPD, select "Summary Plan Descriptions" from the "Resource" section under "Quick Links". 10 St Rose NC CY 2017 V1-010117
Delta Basic Delta Dental of California Network Delta Dental Providers Calendar Year Deductible $50 per person/$150 per family Calendar Year Maximum Benefit $800 per person Diagnostic and Preventive Services 80% Fillings, Extractions and Oral Surgery 80% after OTHER DENTAL SERVICES Crowns, Jackets and Cast Restorations 50% after Prosthodontic 50% after Orthodontics Not Covered This is a basic summary of the dental plan benefits. If you have questions about coverage or costs under this plan, please contact the plan administrator at the number listed on your ID card or log on to the Total Rewards Portal to access plan resources. From "My Health" you can link to the administrator's website or review the plan's Evidence of Coverage (EOC) document. To view the EOC, select "Summary Plan Descriptions" from the "Resource" section under "Quick Links". 11 St Rose NC CY 2017 V1-010117
Delta 1200 Delta Dental of California Network Delta Dental Providers Calendar Year Deductible $50 per person/$150 per family Calendar Year Maximum Out-of-Pocket $1,200 per person Diagnostic and Preventive Services 100% Fillings, Extractions and Oral Surgery OTHER DENTAL SERVICES Crowns, Jackets and Cast Restorations Prosthodontic Orthodontics 80% after 50% after 50% after 50% after (maximum lifetime benefit of $2,500 per person, combined with TMJ) This is a basic summary of the dental plan benefits. If you have questions about coverage or costs under this plan, please contact the plan administrator at the number listed on your ID card or log on to the Total Rewards Portal to access plan resources. From "My Health" you can link to the administrator's website or review the plan's Evidence of Coverage (EOC) document. To view the EOC, select "Summary Plan Descriptions" from the "Resource" section under "Quick Links". 12 St Rose NC CY 2017 V1-010117
Delta 2500 Delta Dental of California Network Delta Dental Providers Calendar Year Deductible $25 per person/$75 per family Calendar Year Maximum Benefit $2,500 per person Diagnostic and Preventive Services 100% Fillings, Extractions and Oral Surgery OTHER DENTAL SERVICES Crowns, Jackets and Cast Restorations Prosthodontic Orthodontics 80% after 60% after 60% after 50% after (maximum lifetime benefit of $2,500 per person, combined with TMJ) This is a basic summary of the dental plan benefits. If you have questions about coverage or costs under this plan, please contact the plan administrator at the number listed on your ID card or log on to the Total Rewards Portal to access plan resources. From "My Health" you can link to the administrator's website or review the plan's Evidence of Coverage (EOC) document. To view the EOC, select "Summary Plan Descriptions" from the "Resource" section under "Quick Links". 13 St Rose NC CY 2017 V1-010117
In-Network Network VSP Choice Providers Any Provider Out-of-Network Examination 1 $10 copayment Plan pays up to $45 after $10 copayment Lenses 1 $10 copayment $10 copayment then plan pays up to a maximum of: Single Vision: $45 Lined Bifocal: $65 Lined Trifocal: $85 Aphakic/Lenticular: $125 Frame 1 100% up to $125 retail allowance Plan pays up to $45 maximum 1, 2, 3 Contact Lenses Elective: Dignity Health Vision Plan 100% up to $105 maximum Medically Necessary: 100% VSP Elective: 100% to $105 maximum Medically Necessary: 100% up to $210 maximum ¹ Restrictions and limitations apply to type and freqency of coverage. Please refer to the Dignity Health Summary Plan Description for more details. ² Benefit is in lieu of glasses. ³ Contact lenses are medically necessary as opposed to elective when they meet one of the following additional standards: (1) glasses (lenses and frames) alone cannot correct a covered person s vision to 20/70 or better; (2) contact lenses are necessary following cataract surgery; (3) contact lenses are necessitated by certain conditions of keratoconus or anisometropia. Prior authorization from the Plan is required. This communication provides a basic summary of the vision plan benefits. Please refer to the Dignity Health Summary Plan Description (SPD) for more detailed benefit provisions. 14 St Rose NC CY 2017 V1-010117
In-Network Network VSP Choice Providers Any Provider Out-of-Network Examination 1 $10 copayment Plan pays up to $45 after $10 copayment Lenses 1 $10 copayment $10 copayment then plan pays up to a maximum of: Single Vision: $45 Lined Bifocal: $65 Lined Trifocal: $85 Aphakic/Lenticular: $125 Frame 1 100% up to $160 retail allowance Plan pays up to $45 maximum 1, 2, 3 Contact Lenses Elective: Dignity Health Vision Plan Plus 100% up to $150 maximum Medically Necessary: 100% VSP Elective: 100% up to $105 maximum Medically Necessary: 100% up to $210 maximum ¹ Restrictions and limitations apply to type and freqency of coverage. Please refer to the Dignity Health Summary Plan Description for more details. ² Benefit is in lieu of glasses. ³ Contact lenses are medically necessary as opposed to elective when they meet one of the following additional standards: (1) glasses (lenses and frames) alone cannot correct a covered person s vision to 20/70 or better; (2) contact lenses are necessary following cataract surgery; (3) contact lenses are necessitated by certain conditions of keratoconus or anisometropia. Prior authorization from the Plan is required. This communication provides a basic summary of the vision plan benefits. Please refer to the Dignity Health Summary Plan Description (SPD) for more detailed benefit provisions. 15 St Rose NC CY 2017 V1-010117
Employee Life Election Amounts¹ ² ³ 1X Pay 2X Pay 3X Pay 4X Pay 5X Pay $10,000 $50,000 Dependent Life Election Amounts Spouse: $5,000 $10,000 $25,000 $50,000 Dependent Child: $2,000 $5,000 $10,000 AD&D Election Amounts 1X Pay 2X Pay 3X Pay 4X Pay $10,000 Maximum Life/AD&D Benefit An employee can elect up to $1 million in life and/or AD&D coverage. Life Insurance Evidence of Insurability (EOI) Life Insurance Reduction of Benefit Dignity Health Life and Accidental Death & Dismemberment (AD&D) Insurance Prudential EOI is required when: an employee elects over $500,000 or three times pay during an initial enrollment. an employee increases coverage more than one times pay or over $500,000. $25,000 or more is elected for a spouse. A reduction in an employee's life insurance coverage occurs when an employee reaches: age 70 age 75 LTD Election Amounts ¹ ² Plan Limits Elimination Period Prexisting Condition Long-Term Disability (LTD) Insurance Liberty Mutual 40% of annual base pay 50% of annual base pay 60% of annual base pay $15,000 is the maximum monthly benefit. An employee may only increase coverage by one level each year. LTD payments may begin after you have been disabled 180 days. An employee is considered to have a prexisting condition if medical treatment was received within 90 days from the effective date of LTD coverage. Benefits will not be paid when a disability is related to a prexisting condition and begins in the first year of LTD coverage. ¹ Annual base pay is defined as an employee's hourly base rate times his/her regularly scheduled hours per pay period times number of pay periods. ² To qualify for insurance or to receive an increase in life insurance amount, the employee must be actively at work performing his/her regular duties at Dignity Health s normal place of business, a work site approved by Dignity Health, or at other places Dignity Health requires him/her to travel. ³ Nonsmokers are offered reduced Employee Life Insurance rates. To qualify as a nonsmoker and receive the reduced rate, an employee must have not smoked in the last 12 months. This communication provides a basic summary of the life, AD&D and LTD plan benefits. Please refer to the Dignity Health Summary Plan Description (SPD) or the plan Certificate of Insurance for more detailed benefit provisions. To view these documents, select "My Health" and click the "Summary Plan Descriptions" link in the Resources section of Quick Links. 16 St Rose NC CY 2017 V1-010117
Default Plan/Rollover Plan In general, the Default plan provides minimal or, in some cases, no coverage, and you will forfeit any waive dollars if you do not complete your initial benefit enrollment. The Rollover Plan provides a comparable level of benefits and coverage to match your current elections excluding participation in the Health Care and/or Dependent Care Spending Accounts. The chart below provides default and rollover information specific to newly eligible and open enrollment elections. The affect on benefit elections due to an employment status change or transfer can vary based on the plan options available and the nature of the employment change. You will need to log on to the Dignity Health Total Rewards Portal during your enrollment window to determine what enrollment options are available to you. What happens if I do not make an election as a newly eligible employee? When you are a newly eligible employee you will be given the opportunity to elect benefits best suited to meet your needs. If you do not elect benefits, you will have the following coverage options chosen for you: Medical Plan Dignity Health HPN HMO A-5 with Employee Only coverage Dental Plan Waived Coverage Vision Plan Waived Coverage Employee Life $10,000 or 1 times pay; whichever is less Dependent Life-Spouse Waived Coverage Dependent Life-Child(ren) Waived Coverage Accidental Death & Dismemberment Waived Coverage Long-Term Disability 40% of pay Health Care Spending Account No pretax amount elected Dependent Care Spending Account No pretax amount elected What happens if I do not make an election during annual open enrollment? Your current elections will rollover into the new plan year with comparable coverage for the following: You must elect annually a contribution amount for the following Flexible Spending Accounts (FSA): Medical Plan - If you are currently enrolled in the HPN Choice Plan, your rollover coverage will be the HPN HMO A-5 with comparable coverage if you do not make an election during annual open enrollment. Dental Plan Vision Plan Employee Life Dependent Life-Spouse Dependent Life-Child(ren) Accidental Death & Dismemberment Health Care Spending Account Dependent Care Spending Account If your current election is "waived" coverage, it will continue to be waived for the new plan year. 17 St Rose NC CY 2017 V1-010117