Health and Life Benefits Summary Plan Description First Data Corporation January 2018
First Data Corporation (the Company or First Data ) is the plan sponsor of the First Data Corporation Health & Welfare Benefit Plan ( Plan ). The Plan incorporates the insurance contracts, benefits documents, and other documents that are described in this summary plan description (SPD). The SPD is being provided to you and it describes benefits provided to you by your Plan sponsor and your rights under the Plan. The SPD is based on official plan documents. It is not, nor is it intended to be, the official plan document, or a contract between First Data and any employee or contractor, or a guarantee of employment. Every effort has been made to ensure the accuracy of this information. In the unlikely event that there is a discrepancy between the SPD and the official plan documents, the official plan documents will control. First Data reserves the right to amend, suspend, or terminate the plan(s) or program(s) at any time. First Data has the discretionary authority to interpret the terms of the plan(s) summarized in this document and determine your eligibility for benefits under its terms. In some cases as indicated, that discretionary authority has been delegated to a third party. First Data participates in the Aon Active Health Exchange, a private online health insurance marketplace for employers that provides choice of medical plan coverage levels and medical carriers. For detailed information about medical (includes prescription drug benefits) benefits and claims procedures, contact the medical carrier directly. This SPD fills in the gaps that the carrier certificate or summary may be missing. The carrier certificates are intended to be read together with this document to constitute the complete SPD. In addition, there may be situations where the plan(s) provides different benefits to different employee groups. This SPD provides only those benefits that are applicable to you based on your employee group. This SPD is available to you online through the benefits website at www.firstdatabenefits.us, or through Your Benefits Resources website at http://resources.hewitt.com/firstdata (user name and passcode required). You have access and the ability to view the SPD on the websites, and print pages of this SPD from the websites. You also have the right to receive a paper copy of the SPD, free of charge, by going to the Your Benefits Resources website, (click on Health & Life Insurance, then Other Benefits, and then Forms and Materials, to request the H&L espd). Or, make your request by calling the First Data Health and Life Help Desk at 1.800.965.2238. If there are any discrepancies between the information on the website and your printed copy, the website version will control. The medical carrier Summary of Benefits and Coverage documents are also available on the Your Benefits Resources and at the www.firstdatabenefits.us websites. Medical carrier certificates of coverage area available directly from the medical carrier. While this SPD can be a useful tool, it is not your only information resource: Call First Data Health and Life Help Desk at 800.965.2238: o With questions about eligibility and enrollment, or for assistance with inquiries regarding group medical and dental plans and non-health 1
plans (vision, legal, life, disability, business travel accident, health savings account, flexible spending account). o To speak with Aon Advocacy services for assistance with how your medical plan works and resolving medical and pharmacy claim issues. At the Your Benefits Resources (YBR) website, you can enroll into First Data s Health and Life Benefit Plans, and review your benefit coverage and dependent information. You can access the YBR website at o http://resources.hewitt.com/firstdata, or at o www.firstdatabenefits.us,( click Enroll in Health and Life Benefits link). At the Make It Yours website (https://firstdata.makeityoursource.com) or via www.firstdatabenefits.us, you can preview the medical plan coverage options and carriers available to you based on your home zip code, use the medical pricing tool to determine per paycheck medical plan contributions, review the Reference Guide, and access contact information for medical carriers and other benefit carriers. Call PayFlex Systems, the claims administrator for the health savings accounts and flexible spending accounts at 1.800.284.4885. First Data Health and Life Benefits claims administrator and insurance carrier websites and toll-free telephone numbers are also important resources for information. They are available at www.firstdataabenefits.us in the Reference Guide. 2
Table of Contents Benefits Overview... 7 Annual Benefits Salary... 9 Employee Eligibility for Coverage... 10 Coverage You Receive Automatically... 11 Coverage You Need to Elect Optional Coverage... 11 When Coverage Begins... 12 Dependents You Can Cover... 14 Dependent Verification Requirements... 14 Spouse/Domestic Partner Coverage (Dual Coverage Exclusion)... 15 Domestic Partner Eligibility Rules... 15 Dependent Eligibility Rules... 16 Rules for Full-Time Students (Child Life and Voluntary AD&D Coverage)... 17 Rules for Disabled Children... 17 Qualified Medical Child Support Order... 18 Employees in the Same Family... 18 Enrollment... 20 Initial Enrollment... 20 Annual Enrollment... 20 Coverage Categories... 21 Changing Your Coverage... 23 When Eligibility Ends... 31 When Coverage Ends... 33 Coverage You Can Continue... 33 COBRA and Conversion Rules... 34 Continuing Coverage under COBRA... 34 COBRA Qualifying Events... 36 Qualified COBRA Beneficiaries... 37 Conversion Rules... 38 Certificate of Group Health Coverage... 40 Medical Plan Overview... 42 Medical Plan Options... 42 3
For Dependents Not Living With You... 43 Special Rules for Maternity Admissions... 43 Health Savings Account... 44 How the Health Savings Account Works... 44 Limited-Purpose Health Care Flexible Spending Account... 48 Triple S Medical Plan Overview... 48 Own It - Your Health Wellness Program... 48 Employee Assistance Program... 49 Dental Plan Overview... 52 Dental Plan Options... 52 Dental Terms You Should Know... 52 Preferred Dentist Provider (PDP) Plans... 54 MetLife Preferred Dentist Provider Plan A Summary of Benefits... 55 MetLife Preferred Dentist Provider Plan B Summary of Benefits... 56 What's Not Covered MetLife PDP Plan A and Plan B... 56 Preventive and Diagnostic Services... 58 Basic Restorative Services... 58 Major Restorative Services... 59 Orthodontia Services... 60 Dental Deductible... 60 Dental Coinsurance... 61 Filing Dental Plan Claims... 62 How to Appeal Denied Claims... 63 Dental Maintenance Organization (DMO) Dental Option... 63 Vision Plan Overview... 64 How the Plan Works... 64 Vision Plan Benefits... 65 What's Not Covered... 67 Filing Vision Plan Claims... 68 How to Appeal Denied Claims... 68 Flexible Spending Account Overview... 69 How Flexible Spending Accounts Work... 69 Health Care Flexible Spending Account... 71 Eligible Health Care Expenses... 71 4
Limited Purpose Health Care Flexible Spending Account... 74 Day Care Flexible Spending Account... 74 Care$ Benefit... 75 Eligible Day Care Expenses... 76 Filing Claims for Reimbursement... 77 Flexible Spending Account Debit Card (PayFlex)... 78 How to Appeal Denied Claims... 79 Life and AD&D Insurance Overview... 80 Insurance Plan Coverage... 80 When Life and AD&D Insurance Benefits End... 81 Basic Life Insurance... 81 Supplemental Employee Life Insurance... 84 Spouse/Domestic Partner Life Insurance... 86 Child Life Insurance... 87 Basic Accidental Death and Dismemberment (AD&D) Insurance... 88 Voluntary Accidental Death and Dismemberment (AD&D) Insurance... 90 Additional Benefits (AD&D)... 92 Life and AD&D Insurance Beneficiaries... 98 Imputed Income... 99 Evidence of Insurability... 100 Filing Life and AD&D Insurance Claims... 101 Exclusions... 101 Reductions in Coverage Amount... 103 Business Travel Accident Insurance... 104 Who Is Covered... 105 Covered Business Travel... 105 Business Travel Accident Insurance - Additional Plan Benefits... 106 How the Plan Pays Benefits... 112 Business Travel Accident Claims... 113 Exclusions... 113 Disability Plans Overview... 114 How Disability Benefits Work... 114 Short-Term Disability (STD) Plan... 114 Short-Term Disability (STD) - Additional Plan Rules... 115 5
When Benefits End... 118 Exclusions... 119 Long-Term Disability (LTD) Plan... 119 Long-Term Disability - Additional Plan Rules... 121 Two or More Disabilities... 122 Disabilities Due to Mental or Nervous Disorders or Disease... 122 Disability Due to Alcohol, Drug or Substance Abuse or Addiction... 123 Disabilities Due to Neuromuscular, Musculoskeletal or Soft Tissue Disorder and Chronic Fatigue Syndrome and related conditions... 123 Accidental Dismemberment and Loss of Sight... 125 Definition of Disability... 125 Vocational Rehabilitation... 127 Applying for Benefits... 128 Exclusions... 132 Recovery from a Disability... 132 Adoption Assistance... 134 How the Program Works... 134 Tuition Reimbursement Policy... 136 For More Information... 139 Legal Plan... 140 Important Plan Information... 146 Plan Identification... 146 Benefit Plans Sponsor and Administrator... 149 Benefit Review Process - Disability and Non-Group Health Plans... 159 6
Benefits Overview The Health and Life Benefits are designed to promote health and wellness and protect you financially in case of illness, accident, or death. First Data offers a variety of plan options and coverage levels so you can choose the coverage that's right for you. Enrolling for Coverage You receive some coverage automatically, while other coverage you will need to actively enroll. If you do not enroll, you are assigned coverage which may mean no coverage in certain benefits. As a new employee, you can enroll for benefits which remain in effect for the rest of the current plan year (January 1 to December 31). You can then make changes during any annual enrollment period for the upcoming plan year. As a current employee, you can change your coverage during any annual enrollment period for the upcoming plan year. If you have a qualified change in status, you can make mid-year changes to your benefit coverage that are consistent with your status change. If You Have Other Coverage Available You may be eligible for coverage under more than one medical or dental plan. For example, your spouse/domestic partner may be able to cover you under his or her employer's plans. Having coverage under more than one medical or dental plan does not necessarily mean you get more benefits. Most plans coordinate benefits, which prevents duplication of coverage. Review information for other plans before making your benefit selections. Dual Coverage Exclusion - If your spouse or domestic partner is eligible for medical coverage from his/her employer regardless of whether he/she is enrolled in that coverage your spouse/domestic partner is not eligible to participate in First Data s medical plans. If no employer coverage is available for your spouse/domestic partner, you must annually certify spouse/domestic partner eligibility for First Data before enrolling him/her in your First Data medical plan. Paying for Coverage The company pays for certain benefits, while some plans require you to enroll and pay your share of the cost or all of the cost through payroll deductions. Your payroll deductions may be on a before-tax or after-tax basis, depending on the type of benefit. 7
Before-tax payroll deductions include: Medical (other than most domestic partner coverage) Dental (other than most domestic partner coverage) Vision (other than most domestic partner coverage) Health Savings Account Health Care Flexible Spending Account Day Care Flexible Spending Account Before-tax deductions are taken before income taxes are calculated, which means these "tax- free" dollars are not subject to federal, Social Security, and in most cases, state taxes. Since your income is lower, you pay less in income taxes. You can elect to pay for this coverage with after-tax dollars. If you wish to pay with after-tax dollars, contact the First Data Health and Life Help Desk at 800-965-2238 and follow the prompts for additional information. After-tax payroll deductions include: Voluntary Accidental Death and Dismemberment Insurance Supplemental Employee Life Insurance Spouse Life Insurance Child Life Insurance Voluntary Long Term Disability Insurance Legal Plan Critical Illness Insurance Accident Insurance Most domestic partner coverage for Medical, Dental and Vision Payroll deductions begin or change as soon as administratively possible. First Data Annual Medical Contribution Owner-associates earning less than $85,000, who elect a First Data medical plan, will automatically receive a $300 First Data Annual Medical Contribution deposited in their Health Savings Account when electing the Bronze, Bronze Plus, or Silver medical plan (or deposited in their paychecks throughout the year in equal amounts as taxable income when electing the Gold or Platinum) to help fund out-of-pocket health care expenses. Owner-associates earning less than $85,000 hired on or after January 1, 2018, who elect medical coverage, will have the contribution prorated quarterly and deposited in their Health Savings Account (or spread across their paychecks when electing Gold or Platinum) following benefit enrollment per this schedule: 8
Benefit Eligibility Date First Data Medical Contribution 01/01/2018 03/31/2018 $300 04/01/2018 06/30/2018 $225 07/01/2018 09/30/2018 $150 10/01/2018 12/31/2018 $75 Imputed Income Group Health Benefits Group health benefits are generally tax-free to employees, spouses, and dependents, but because domestic partners are not considered spouses under the Internal Revenue Code (IRC), they may not receive tax-free health care benefits from employer benefits plans. So, any benefits received by a domestic partner must be taxed. The imputed income is calculated on the entire full premium benefit amount. The domestic partner coverage is considered after-tax because the imputed income is applied to the full premium amount. This amount is added to your total annual compensation reported to the IRS. It appears on your W-2 statement and is taxable at your regular income tax rate. Annual Benefits Salary Your annual benefits salary is used to calculate your coverage amount for these plans: Basic Life Insurance Basic Accidental Death and Dismemberment Insurance Business Travel Accident Insurance Short-Term Disability Basic Long-Term Disability Insurance Voluntary Long-Term Disability Insurance Your annual benefits salary is also used to determine medical plan contribution pricing, your eligibility for the CARE$ benefit program, and life and disability insurance pricing and coverage amounts. When you join First Data, your annual benefits salary for the plan year is calculated using your base salary, unless your pay is commission based, in which case your annual benefits salary is considered to be $30,001. If the base salary is greater than $30,001 and commission is part of the compensation, the base salary will be the annual benefits salary. After that, your annual benefits salary is determined as of the annual "salary freeze date" (usually in August of each year). If your salary increases or decreases during the year, your annual benefits salary and coverage amounts will be adjusted at the next salary freeze date, and will go into effect the following plan year 9
Your annual benefits salary includes: Your base salary (including your base compensation for the year, before any salary reduction for before-tax contributions to the savings plan, flexible spending accounts, and other health and insurance plans). Commissions earned from September August of the previous plan year. Annual benefits salary does not include: Overtime Bonuses Shift differential Any other form of compensation you might receive Employee Eligibility for Coverage Who Is Eligible You are eligible for coverage under Health and Life Benefit Plans if you are on the U.S. dollar payroll as a regular full-time employee regularly scheduled to work at least 30 hours per week. There may be situations where the plan(s) provide different benefits to different employee groups. First Data has no pre-existing condition exclusions for medical coverage that would prevent your eligibility during your initial enrollment. First Data is the sponsor of the Health and Life Benefit Plans. Certain subsidiaries and affiliates of First Data are also employers participating in the plans. And, certain employee groups of First Data, specifically, Clover (FFEIN27-3703012) and Gyft (FFEIN45-5316966), are not eligible to participate. Note: These are exceptions to the eligibility for coverage listed above. The Business Travel Accident Insurance Plan includes all global employees (fulltime and part-time), eligible guests and eligible interns on authorized First Data business travel. The Employee Assistance Program includes all U.S. based employees (full-time and part-time), their covered dependents, and their household members. Who Is Not Eligible If you are in one of these groups, you are not eligible for coverage under the plan: Employees scheduled to work less than 30 hours per week Employees not on the U.S. dollar payroll Temporary and/or seasonal employees including interns whether paid or unpaid Independent contractors (even if such person is later reclassified as an employee by any court or governmental agency for any reason). Persons rendering services pursuant to agreements describing them as independent 10
contractors or employees of a leasing organization or working on assignment through any other outsource arrangements, or persons who have waived eligibility, are also not eligible to participate in these plans. Leased employees Employees subject to a collective bargaining agreement that does not provide for your participation Any other third-party personnel who perform services for the company Any others not listed here who do not meet the eligibility requirements Exceptions to Eligibility Rules Eligibility for the Severance Policy, Adoption Assistance Plan, Business Travel Accident Insurance Plan, Employee Assistance Program and Tuition Reimbursement Plan is different, and explained in the applicable sections describing these plans. Automatic versus Elected Coverage If you meet the eligibility requirements: You receive some coverage automatically You can elect to participate in optional coverage You choose the coverage you want and the dependents you want to cover You pay part or all of the cost of this coverage Coverage You Receive Automatically Once you satisfy the applicable waiting period and complete the applicable eligibility requirements, you receive coverage in these plans automatically: Basic Life Insurance (one times your annual benefits salary up to a maximum of $1,000,000 in coverage) Basic Accidental Death and Dismemberment Insurance (one times your annual benefits salary up to a maximum of $1,000,000 in coverage) Business Travel Accident Insurance (4 times your annual benefits salary up to a maximum of $1,000,000 in coverage; certain plan limits apply) Short-Term Disability plan Voluntary Long-Term Disability Insurance (60% of your annual monthly benefits salary) which requires a payroll contribution made by you, the employee (during initial enrollment, you must affirmatively elect Basic LTD if you want it, which is at no cost to you). Employee Assistance Program Severance Policy Coverage You Need to Elect Optional Coverage After meeting the eligibility requirements, you can enroll in these plans: Medical (if you are covering a spouse/domestic partner the dual coverage exclusion applies see Spouse/Domestic Partner Dual Coverage Exclusion section below) 11
Tobacco-Surcharge when enrolling in a medical plan ;if you, and if applicable, your enrolled spouse/domestic partner does not certify as a nontobacco user, you will pay an annual $300 Tobacco Surcharge prorated across pay periods) Dental Vision Supplemental Employee Life Insurance Spouse Life Insurance Child Life Insurance Voluntary Accidental Death and Dismemberment Insurance Basic Long Term Disability Insurance Voluntary Long Term Disability Insurance (see above for more information) Legal Plan Health Savings Account Health Care Flexible Spending Account Day Care Flexible Spending Account Care$ Benefit (available to employees who meet both Day Care Flexible Spending Account and salary eligibility requirements) If you do not enroll during the initial or annual enrollment period, you will be enrolled in only the coverage that is provided automatically and you will not be enrolled in any of the optional coverages. During the year, you can only change your coverage if you have a qualified change in status. When Coverage Begins For Newly Eligible Employees As an eligible full-time employee, your coverage in the following plans becomes effective on the first of the month following or coincident with your date of hire. Medical Tobacco Surcharge (applies to medical plan) Dental Vision Basic Life Insurance Supplemental Employee Life Insurance Spouse Life Insurance Child Life Insurance Basic Accidental Death and Dismemberment Insurance Voluntary Accidental Death and Dismemberment Insurance Basic Long-Term Disability Insurance Voluntary Long-Term Disability Insurance Legal Plan 12
Health Savings Accounts Health Care Flexible Spending Account Day Care Flexible Spending Account Care$ Benefit (if applicable based on eligibility) Your coverage in Business Travel Accident Insurance Plan and the Employee Assistance Program begins your first day at work. Your coverage in the Short-Term Disability Plan begins on your 91st day at work. Eligibility Rules for Rehired Employees When you return to employment at the Company, the same eligibility rules that apply to new hires apply to you. If you have already met your waiting period, your eligibility will begin on your rehire date. Your coverage options depend on when you return to work. Within 31 days - If you return in the same plan year (January 1 to December 31) in which you terminated, you receive the same coverage you had when your employment ended. If you return in a different plan year, you have an opportunity to enroll for new coverage. After 31 days - If you return in the same plan year (January 1 to December 31) in which you terminated, you receive the same coverage you had when your employment ended. An exception is the Health Care and Day Care Flexible Spending Accounts, in which you will need to enroll if you want to participate in that plan year. After 5 years If you return five years or more after your prior period of First Data employment, you are treated as a new hire with regard to health and life benefit eligibility. At Annual Enrollment For current employees making new coverage choices during annual enrollment, your new coverage begins on the next January 1. For Mid-Year Coverage Changes If you change your coverage as a result of a qualified change in status within the time limits provided (31 days for birth or adoption with an allowable up to 60 days, and 31 days for all other changes in status), your new coverage begins on the date of your status change event - for example, on the date you get married. If you do not elect to participate within the applicable deadlines, you must wait until the next annual enrollment period to enroll or make changes to your coverage. 13
Dependents You Can Cover As an eligible employee, you can enroll your eligible dependents for coverage in these plans: Medical (spouse/domestic partner; see Dual Coverage Exclusion section) Dental Vision Spouse Life Insurance Child Life Insurance Voluntary Accidental Death and Dismemberment Insurance Employee Assistance Program (enrollment by dependent name is not required) As an eligible employee, you can enroll your domestic partner and same sex spouse for coverage in these plans only: Medical (spouse/domestic partner; see Dual Coverage Exclusion section) Dental Vision Spouse Life Insurance Your eligible dependents include: Your legal spouse Children that meet dependent eligibility rules (see Rules for Full-Time Students section) Domestic Partner Same Sex Spouse under any marriage certificate, civil union, or any other similar arrangement recognized under the state law of the state in which you reside. Ineligible Dependents include: Parents of employees Siblings of employees, unless they meet the age and dependent requirements as described in Dependent Eligibility Rules section below. All other relationships not specifically listed as an eligible dependent. If one or more of your dependents are eligible First Data employees, special rules apply (see the Employees in the Same Family section below). Dependent Verification Requirements After you enroll any dependent in First Data medical, dental or vision coverage, you will receive information regarding dependent verification. You will be required to provide specific documentation validating that your dependents meet eligibility requirements. 14
You will receive dependent verification information in your home mail approximately 14 days after you enroll your dependents in coverage (medical, dental and/or vision). You must follow the instructions regarding the dependent verification process. If you do not comply with the dependent verification requests timely and accurately, your dependents will become ineligible for coverage. Specifically, any benefit coverage elected for the dependent(s) will be terminated on the date the dependent verification period expires. The dependent(s) will not be eligible to participate in the plans until the next annual enrollment period for the upcoming plan year, provided dependent verification of eligibility is completed. First Data may also conduct periodic dependent eligibility audits to ensure all dependents meet the eligibility qualifications. Employees found to be covering ineligible dependents will be subject to disciplinary action up to and including termination and coverage will be dropped for those dependents. Please note, that federal Medicare regulations require you to provide a Social Security number for each of your enrolled dependents. Dependents over the age of 1 will not be enrolled in the medical plan unless a valid Social Security number is provided to the dependent verification administrator. Spouse/Domestic Partner Coverage (Dual Coverage Exclusion) If your spouse/domestic partner is eligible for medical coverage through their employer (regardless of whether he or she is enrolled in that coverage) your spouse/domestic partner is NOT eligible for First Data medical coverage. If no employer coverage is available for the spouse/partner, you will be required to certify their eligibility for First Data coverage before you can enroll them in the medical plan coverage. You are required to annually certify their eligibility for First Data coverage before you can enroll him/her in your medical coverage. The Dual Coverage Exclusion does not apply when you and your spouse/domestic partner both work for First Data. Domestic Partner Eligibility Rules If you are benefit eligible, you can enroll your same sex or opposite sex domestic partner in coverage under the company's medical, dental, vision, and life insurance plans provided you and your partner meet certain requirements. If your domestic partner is eligible for medical coverage through his or her employer (regardless of whether he or she is enrolled in that coverage) your domestic partner is NOT eligible for First Data medical coverage. If no employer medical coverage is available to your spouse/domestic partner, you will be required to annually certify their eligibility for First Data coverage before you can enroll him/her in your medical coverage. To be eligible for coverage, you and your domestic partner must: 15
Have shared a continuous, committed relationship for no less than six months, intend to do so indefinitely, and have no such relationship with any other person; Are mutually responsible for each other's welfare and share financial obligations; e.g., joint home ownership, joint checking account, joint automobile ownership or life insurance policy designating the other as the primary beneficiary; Have shared a common household for at least six months and intend to do so indefinitely; are not related by blood to a degree of kinship that would prevent marriage; Are not in a federally or state recognized marriage either by law or common law, or legally separated; Are both over the age of 18, of legal age to contract; and If you reside in a state, such as California, which has a domestic partner registry, you have registered. When adding your domestic partner to coverage you will certify online that you and your domestic partner meet the above requirements. You will be subject to taxes on imputed income for the coverage you choose for your domestic partner. If you marry an opposite sex domestic partner, you will no longer be subject to any imputed income. If you marry your same sex domestic partner, you may not be subject to imputed income in certain states. In either event, you must inform the First Data Health and Life Help Desk at 800.965.2238 within 31 days following the date of your marriage so that we will be able to ensure that the proper tax treatment is being applied. Dependent Eligibility Rules Definition of Eligible Dependents Your eligible dependents include your children, even if he or she has coverage available through his or her own employer for medical, dental, vision, and life insurance programs. For child life, your eligible dependents include your dependent children who are not working full time that you claim as dependents for federal income tax purposes or the children of your eligible domestic partner. The definition of an eligible child includes: your biological children, stepchildren, legally adopted children, children placed for adoption, foster children, children for whom you are the legal guardian, children of your domestic partner, children who you claim as a tax exemption as a non-custodial parent, or children you must cover under a Qualified Medical Child Support Order (QMCSO). 16
Age Requirements You can cover your dependent children under Medical, Dental and Vision until the end of the month in which they reach age 26. For the Child Life Insurance and the Voluntary AD&D Insurance plans, you can cover a child until the end of the month in which he or she reaches age 19, or if they are a full-time student, until the end of the month in which he or she reaches age 23. You can cover a disabled child beyond the limiting ages above for as long as he or she remains eligible for coverage as defined in the corresponding benefit summary sections below. Please note, that federal Medicare regulations require you to provide a Social Security number for each of your enrolled dependents. Dependents over the age of 1 will not be enrolled in the Medical Plan unless a valid Social Security number is provided to the enrollment administrator (Health and Life Help Desk at 800.965.2238). Rules for Full-Time Students (Child Life and Voluntary AD&D Coverage) If an eligible child is a full-time student (according to the school's definition of full time), you can continue his/her Child Life Insurance and Voluntary AD&D Insurance benefits coverage after age 19. There will be no certification process for this coverage, however at the time the claim is submitted, if the child doesn t meet the eligibility requirements, the benefit will be denied. You can continue his or her coverage until the end of the month in which your child reaches age 23 as long as your eligible child continues to be a full-time student throughout the year. If your eligible full-time student graduates they are able to continue coverage through the end of the month in which they graduate unless they find full time employment Rules for Disabled Children A disabled child age 26 or older is eligible for medical, dental, and vision benefits if he or she meets all of these criteria: Became disabled before age 26 Was covered under a First Data coverage option on the day coverage would have otherwise ended or is the disabled child of a newly eligible employee who was covered under a prior medical plan, and the disability commenced before the limiting age 26 Is incapable of self-support because of a mental or physical disability And is financially supported by you A disabled child age 19 or older is eligible for child life and voluntary AD&D benefits if he or she meets all of these criteria: Became disabled before age 19 (or age 23 if a full-time student) 17
Was covered under a First Data coverage option on the day coverage would have otherwise ended or is the disabled child of a newly eligible employee who was covered under a prior plan, and the disability commenced before the limiting age 19 (or 23 if a full-time student) Is incapable of self-support because of a mental or physical disability And is financially supported by you Contact the First Data Health and Life Help Desk at 1.800.965.2238 to learn how to certify his or her disability status with the claims administrator or insurance carrier. For your child's coverage to continue, you or your claims administrator/insurance carrier must contact the First Data Health and Life Help Desk when the disability status has been certified. Disabled child coverage will end for any of these reasons: o The child is no longer incapacitated o The child becomes self-supporting o Proof of continued capacity is not obtained o Coverage ends for reasons other than reaching the limiting age of the plan Qualified Medical Child Support Order Certain court orders could require First Data's health plans to cover your child. This is known as a Qualified Medical Child Support Order. The Company determines whether the court order is a Qualified Medical Child Support Order (QMCSO). If it is, the child gains eligibility for coverage. The child can also gain eligibility for coverage if the Company receives a National Medical Support Notice and determines it to be a QMCSO. In these situations, First Data can take deductions from your paychecks for your and the child's coverage. The plans cover the child from the first day of the month following the date the order is approved until the date or age stated in the order, but not beyond the normal eligibility age. The child is added to the coverage you are enrolled in. If a QMCSO requires someone other than you - for example, your ex-spouse - to provide health coverage for your child, you can drop coverage for that child if he or she actually becomes covered under the other person's plans. Contact the First Data Health and Life Help Desk at 1.800.965.2238 as soon as you are aware of any court proceedings that may affect your child's eligibility for coverage under the Company's plans. Employees in the Same Family You are not eligible to be an enrolled dependent in the plans if you are enrolled for coverage as an employee. If you and your spouse/dependent both work for First Data, neither the employee, spouse or dependent may enroll as both the employee and spouse/dependent for coverage. The coverage restriction is valid for 18
Supplemental Life, Spouse Life, Child Life, Medical, Dental, Vision, and Voluntary AD&D plans. If you enroll an ineligible person for any coverage, you will not be reimbursed for the cost of that coverage, and benefits under that coverage will be denied. Medical, Dental and Vision Coverage If you and your spouse/domestic partner are both benefit eligible First Data employees, you have these medical, dental and vision coverage options: You both can enroll for Employee Only coverage. One of you can enroll for Employee + Spouse (Domestic Partner) coverage. One of you can enroll for Employee Only coverage and the other can cover your eligible children by enrolling for Employee + Child(ren) coverage. One of you can enroll for Employee + Family coverage. If you and your eligible child are First Data employees, you have these medical, dental, and vision coverage options: You both can enroll for Employee Only coverage You can enroll for Employee + Child(ren) or Employee + Family coverage, as long as your dependent child meets the eligibility requirements. Employees of First Data can't be covered both as an employee and a dependent. Life and AD&D Insurance Coverage These rules apply to coverage under the life and accidental death and dismemberment (AD&D) insurance plans when both you and your spouse are eligible employees: Both of you can enroll in supplemental employee life insurance (if you are not also covering each other under spouse life insurance). Either you or your spouse, but not both, can purchase child life insurance and/or voluntary AD&D insurance for your eligible children. Health Savings Account & Flexible Spending Account Coverage These rules apply to coverage under the flexible spending accounts when both you and your spouse are eligible employees: Both of you can enroll in the Health Care Flexible Spending Account, and each can contribute the maximum annual amount allowed to individuals. Both of you can enroll in the Day Care Flexible Spending Account, but your combined contributions can't exceed the maximum annual amount allowed by the IRS. Both of you can enroll in the Health Savings Account, and each can contribute the maximum annual amount allowed to individuals. 19
Enrollment Initial Enrollment You have 31 days from the date on your personalized enrollment worksheet to enroll for coverage. There are several resources available to provide you information about your health and life benefits and to help you complete your enrollment. Access the Make It Yours website prior to enrollment at www.firstdatabenefits.us or at http://firstdata.makeityoursource.com, to learn about the medical options, compare paycheck contributions, watch educational videos, visit medical carrier websites, view carrier telephone numbers, and access the Reference Guide Access the Your Benefits Resources website 24 hours a day, 7 days a week by connecting directly to http://resources.hewitt.com/firstdata, or through the benefits website at www.firstdatabenefits.us. Call the First Data Health and Life Help Desk at 1-800-965-2238 and follow the prompts with questions related to vision, legal, disability, life, AD&D, business travel accident, flexible spending accounts, and eligibility, enrollment, and adoption assistance. When you enroll, you need to provide personal information including the Social Security number for each dependent you want to cover. Based on the dependents you enroll in coverage you will be assigned a coverage category. If you do not enroll within the 31 day deadline date, you are assigned basic coverage automatically (see the Coverage You Receive Automatically section in Benefits Overview) however you will not be enrolled in any optional benefit coverage (except for Voluntary LTD Insurance Plan which you have to de-select during initial enrollment and affirmatively elect Basic LTD if you want it). Coverage will stay in effect until the next plan year (January 1 through December 31), unless you have a qualified change in status that allows you to change your coverage mid-year. Annual Enrollment Each fall, you ll be notified when it is time to enroll for the upcoming plan year. You must enroll during the annual enrollment period if: You want to cover a spouse/domestic partner in medical you must verify their eligibility for medical coverage per the terms of the spouse/domestic partner Dual Coverage Exclusion requirement (see Dual Coverage Exclusion section in the Benefits Overview). You want to change any of your dependents, or your dependent's current coverage. You want to enroll a new dependent (previously eligible but not covered). You want to contribute pre-tax payroll contributions to the Health Savings Account 20
You want to contribute pre-tax payroll contributions to the Health Care Flexible Spending Account or Day Care Flexible Spending Account for the upcoming year, and you are not a severed employee. You want to receive the Care$ benefit for the upcoming year and you are not electing in the Day Care Flexible Spending Account (for all eligible employees meeting certain requirements; if eligible for Care$ Benefit and you elect the Day Care FSA, you are automatically enrolled in the Care$ Benefit). You enroll in a medical plan and want to certify yourself and your enrolled spouse/domestic partner as a non-tobacco user or pay the $300 Tobacco Surcharge.. You are enrolled in a plan option that will no longer be offered and do not want to be automatically assigned coverage. The company offers a new benefit plan in which you want to enroll. If you do not enroll, your current options, if available, are carried over to the next plan year with some exceptions: Your flexible spending account contributions (including Care$ Benefit) are discontinued at the end of the current plan year. Some life insurance plans restrict the amount by which you can increase your coverage in a single year. You will be subject to evidence of insurability (EOI) if you increase your coverage or start coverage after previously declining. This will be completed online at the Your Benefits Resources enrollment website. Your spouse/domestic partner will be dropped from medical coverage if not re-certified as eligible for the new medical plan year (see Spouse/Domestic Partner Dual Coverage Exclusion section in the Benefits Overview). Other Enrollment Opportunities There are other times when you can enroll yourself or your eligible dependents for coverage. For example, if you or a dependent has a qualified change in status, you can change your coverage mid-year. Coverage Categories When you enroll for medical, dental or vision coverage, you enter information about the dependents you want to cover. They can include your spouse or domestic partner and/or any eligible children. After selecting which dependents to cover under the medical plans, you will then be assigned one of the following coverage categories for each plan: Individual Only (covering self-only) Family (covering self and one or more family members) After selecting which dependents to cover under the dental and vision plans, you will then be assigned one of the following coverage categories for each plan: Employee Only 21
Employee + Spouse (or domestic partner) Employee + Child(ren) Employee + Family You can have different coverage categories under the Medical, Dental, or Vision plans. All eligible dependents are covered automatically when you enroll in any of these plans: Spouse Life Insurance Legal Plan Voluntary Accidental Death and Dismemberment Insurance (if you elect family coverage) Employee Assistance Program (enrollment not required) You will select which dependents to cover under Child Life Insurance. If one or more family members are also eligible First Data employees, special rules apply (see Employees in the Same Family section in the Benefits Overview). At Other Enrollment Opportunities If you experience a qualified change in status, you may be eligible to change your coverage. If you don't submit new choices by the enrollment deadline (31 days for birth or adoption with an allowable of up to 60 days), and 31 days all other events, (and 60 days for Special Children s Health Insurance Program), no changes to your current elections will be made. If a change in residence to a location not covered by your current medical carrier or where your employee premiums for coverage changes, you must make an affirmative election within 31 days of the change in residence to enroll in a new medical plan coverage. If you move to a location where the employee premium cost changes for the same coverage and you take no action within the first 31 days of the change in residence, you will be defaulted to your current medical plan and medical carrier at the new contribution rate. If you move to a location where your current medical carrier is not available, you will default to the current type of medical plan coverage with the lowest cost carrier in your new location at the new contribution rate, provided you do not make an affirmative election within the first 31 days of the change of residence. If you move and your current dental option is not available in your new area, no coverage will be assigned under the Dental Plan. o You will have 31 days to elect dental coverage available in your new area. If you change from part time to full time and gain eligibility for a plan, and you do not enroll, you are assigned no optional coverage (see Coverage You Receive Automatically section in Benefits Overview). If you return from a leave that crossed plan years, you are assigned: Your current coverage under Long-Term Disability Insurance 22
Your current coverage under Supplemental Employee Life Insurance provided that level of coverage is still available. If you become eligible to make new enrollment choices during the year, access the Your Benefits Resources website 24 hours a day, 7 days a week at www.firstdatabenefits.us. Please refer to the Initial Enrollment section above for ways to access the Your Benefits Resources enrollment website. Changing Your Coverage Rules for Changing Employee Coverage Federal laws set specific rules about the types of coverage changes employees can make during the year. After you enroll in (or decline) coverage, your choices generally stay in effect for the rest of the plan year (January 1 through December 31). In special circumstances, however, you can enroll in coverage or change your choices during the plan year, except for the Long-Term Disability, and Legal plan. During the plan year, you can start, increase, decrease or stop your Health Savings Account contributions at any time by contacting the Health and Life Help Desk.. Qualified Changes in Status During the plan year, you or your dependents can change your benefit coverage if a qualified change in status affects your or your dependents' eligibility under the First Data plans or another employer's plans. If you are eligible to make coverage changes, your changes must be consistent with the change in status. If you make a timely enrollment, (31 days for birth or adoption with an allowable up to 60 days, and 31 days for all other events, 60 days for Special Children s Health Insurance Program) your new coverage begins on the date of your status change event- for example, on the date you get married. These situations qualify as a change in status: Your legal marital status or domestic partnership changes o You get married or enter into a domestic partnership. o You get divorced, legally separated, or have your marriage annulled. o Your domestic partnership ends. o Your spouse or domestic partner dies. The number of your eligible children changes o You have or adopt a child. o Your child gains or loses eligibility for coverage under the Health and Life Benefits. o Your child dies You move to a new address Your benefits eligibility changes because: 23
o You take or return from a leave of absence. o You gain or lose eligibility as a result of a change in work schedule or status Your family member's benefits eligibility changes because of a change in his or her o Eligibility or coverage under another employer's plans: o He or she gains or loses eligibility as a result of a change in work schedule or status. o He or she gains a benefit option or loses coverage. o He or she makes new coverage choices during his or her employer's annual enrollment. You or your family member becomes entitled to or loses Medicare or Medicaid. You or your family member loses coverage under a government's or educational institution's plan. You gain or lose eligibility for another employer's group health plan. Please Note: Your newborn child is covered under the Medical Plan, if temporary eligibility is established upon request of a claim, for the first 31 days from the date of birth. The newborn child is dropped from the Medical Plan coverage on the 32nd day if you have not enrolled the child into the Medical Plan due to a qualified change in status (birth of a child). You have 31 days from the date of birth with an allowable of up to 60 days to enroll the child. You can enroll a newly eligible dependent on the Your Benefits Resources enrollment site at www.firstdatabenefits.us. Call the First Data Health and Life Help Desk for assistance at 1.800.965.2238. The Social Security number for the newborn child must be provided by the child s first birthday to continue coverage. Please Note: In addition to any qualified change in status, if your day care provider (other than a relative) significantly changes its periodic charge during the year, or if you switch providers to one whose charges are significantly different, you will be permitted to elect a corresponding change in your contributions to your Day Care Flexible Spending Account. If you experience a qualified change in status, or are able to change your coverage for any of the reasons described above, you can make a midyear coverage change. To do so, at the Your Benefits Resources website, go to the Life Events page and choose the reason for your change, or contact the First Data Health and Life Help Desk at 1.800.965.2238 for assistance. If You Get Married or Enter into a Domestic Partnership Allowable Changes: Medical, Dental and Vision Coverage: 24
Enroll yourself if you are not already covered Add coverage for your spouse or domestic partner (dual coverage exclusion applies) Add coverage for any eligible children Drop coverage for yourself if you become covered under your spouse's or domestic partner's plan Drop coverage for any eligible children if they become covered under your spouse's or domestic partner's plan Select a different option Life and AD&D Insurance Coverage (you can enroll into, increase, decrease or drop coverage): Supplemental Employee Life Insurance Voluntary Accidental Death and Dismemberment Insurance Spouse Life Insurance Child Life Insurance Long Term Disability Insurance Coverage Increase or decrease Flexible Spending Accounts (start, increase, decrease, or stop your contributions): Health Care Flexible Spending Account Day Care Flexible Spending Account, including Care$ Benefit (if eligible) Legal Plan Coverage You can enroll into but you cannot drop coverage mid-year If You Get Divorced Allowable Changes: Medical, Dental and Vision Coverage Enroll yourself, if you are not already covered. Drop coverage for your ex-spouse. If your children are no longer covered under your ex-spouse's plan, you may enroll them. If your children are no longer considered eligible dependents, you must drop their coverage. If your children become newly eligible under your ex-spouse's plan, you may drop their coverage under your plan. Select a different option Life and AD&D Insurance Coverage (you can enroll into, decrease or drop coverage) Supplemental Employee Life Insurance Voluntary Accidental Death and Dismemberment Insurance 25