SJC 2019 Benefits Guide (NM)

Your Benefits Medical Dental Vision Life & Disability Spending Accounts And more‌

Santa Fe Benefits Guide

2019

January 1st, 2019 - December 31st, 2019

2019 Benefits Guide

Introduction Table of Contents Introduction

2

Contacts

3

EONE

4

Medical Plans

5-8

Telehealth

9

Pharmacy

10

Dental and Vision

11

FSA

12

Life & Disability

13

Employee Assistance Program 14 Employee Contributions

15

Annual Notices

16-19

Employee Eligibility Employees new to St John's College are eligible for most benefits on their 90th day of employment. Employees who work over 17.5 hours (35 hour regular schedule); employees who work over 20 hours (40 hour regular schedule); and tutors that teach ½ time or more. Staff employees are eligible for life insurance and disability insurance on their date of hire. Staff employees are eligible for health, dental, and vision insurance on their 90th day of employment. Faculty and faculty associates are eligible for all benefits on their date of hire. St John's College offers comprehensive, cost effective benefits options. You must enroll within 31 days of your eligibility or you forfeit your right to enroll until the following open enrollment.

Changing Your Elections It is very important to consider your choices carefully before you make your benefit elections. The benefits you choose will be in place from your eligibility date through the end of the plan year, unless you have a qualifying event during the year such as: • Marriage, Divorce, Legal Separation, Birth or adoption of a child • Death of a spouse or child • You or one of your covered dependents gains or loses other benefits coverage due to a change in employment status Note: For additional information, Qualified Event Definition is determined by www.IRS.gov guidelines.

Dependent Eligibility • Legal spouse • Domestic Partner • A dependent child under the age of 26 (coverage terminates at the end of the month in which the dependent turns 26) Note: Under the Patient Protection and Affordable Care Act (PPACA), adult children enrolled under their parent’s medical plan may maintain their coverage until the age of 26.

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Contacts St John’s College

Aaron Young Director of Human Resources

(505) 984.6140

CareFirst Administrators, BCBS

Medical

www.cfablue.com (877) 889.2478

MDLive

Virtual Medical Visits

www.mdlive.com (800) 400.6354

United Concordia

Dental

www.ucci.com (800) 332.0366

Avesis

Vision

www.avesis.com (800) 828.9341

CIGNA

Life, AD&D, LTD and STD

Online Claim Filing: www.cigna.com/customer-forms 800.36.CIGNA (24462)

The Solutions Group

Employee Assistance Program

www.solutionsbiz.com (505) 254.3555

Discovery Benefits

Flexible Spending Accounts Health Savings Accounts

www.discoverybenefits.com (866) 451.3399

Employee ONE Benefit Solutions

Benefits Advocate Team ID Cards and Eligibility

mybenefits@employee1.net (410) 719.2222 (877) 719.EMP1 (3671)

If you have any questions regarding your benefits, please call Heath Advocate at 1-866-695-8622 (8:00 a.m. to 4:00 p.m. EST). Access Health Advocate online 24-hours a day, seven days a week.

Please Note: This booklet provides a summary of the benefits available, but is not your Summary Plan Description (SPD). St John’s College reserves the right to modify, amend, suspend, or terminate any plan at any time, for any reason without prior notification. The plans described in this book are governed by insurance contracts and plan documents, which are available for examination upon request. We have attempted to make the explanations of the plans in this booklet as accurate as possible. However, should there be a discrepancy between this booklet and the provisions of the insurance contracts or plan documents, the provisions of the insurance contracts or plan documents will govern.

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EONE Benefit Advocacy Team

Plan Information & Questions Get the answers you’re looking for, and get back to your life.

877-719-EMP1 (3671) or mybenefits@employee1.net Monday-Friday 6:30a – 3:00p MST

During open enrollment make sure to take advantage of all group communication materials such as: Benefits Guides and Open Enrollment Meetings. If you still have questions about your benefits after open enrollment, we’re here to help!

Provider Search If you’re having trouble navigating the carrier-specific Provider Search as indicated in this Benefits Guide, please give us a call! Remember to check your Benefits Guide for network information to help narrow your search.

ID Cards In most cases, you’re able to order and print your ID card (or temporary card) directly from the carrier website. Review your guide for information on how to register online with each carrier – it’s fast and easy!

Note: HIPAA privacy regulations may require the completion of a pre-authorization form prior to releasing information regarding deductible amounts or specific medical conditions (once a HIPAA form is submitted, it may take up to 48 hours before information can be released). Bank account information (including: 401(k), HSA, HRA and FSA) is generally considered classified and we recommend you reach out directly to the account holder.

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Medical Plan Summary Standard PPO Plan Summary The CareFirst Administrators / BlueCross BlueShield Plan allows you to seek care from an in-network or out-of-network provider, If you seek care from an out-of-network provider, you are subject to higher out-of-pocket expenses and balance billing by that provider. This plan does not require you to select a Primary Care Physician (PCP) or obtain a referral from your PCP in order to see a specialist.

In-Network Out-of-Network Annual Deductible

$250 Individual | $500 Family

$1,000 Individual | $2,000 Family

$2,000 Individual | $4,000 Family

$3,000 Individual | $6,000 Family

Physicians Office Visit

$15 Copay

30% of allowed benefit after deductible

Specialists Office Visit

$20 Copay

30% of allowed benefit after deductible

Preventive Care Services Well-Child Care (exams & immunizations) Adult Physical Exam (routine GYN) Breast Cancer Screening Pap Test Prostate & Colorectal Cancer Screening

No Charge

30% of allowed benefit after deductible

Lab: $20 Copay | X-ray: $20 Copay

30% of allowed benefit after deductible

Other Diagnostic Tests (OP Facility)

10% coinsurance

30% of allowed benefit after deductible

Inpatient Hospital Facility Services

10% coinsurance after deductible is met

30% of allowed benefit after deductible

10% coinsurance

30% of allowed benefit after deductible

Annual Out-of-Pocket Maximum

Lab and X-ray

Outpatient Hospital Facility Services Emergency Room

$100 per visit (waived if admitted)

Urgent Care

$20 per visit

Rehabilitations Services (Physical, Occupational, Speech)

10% coinsurance after deductible is met

30% of allowed benefit after deductible

Outpatient Spinal Manipulation

$20 Copay

30% of allowed benefit after deductible

• Mental Health/Substance Abuse

• •

Inpatient Hospitalization: 10% coinsurance after deductible is met Office Visits: $20 Copay 30% of allowed benefit after deductible Outpatient Facility: 10% coinsurance after deductible is met

Prescription Drugs Rx Deductible Rx Out-of-pocket Maximum Tier I – Generic Tier II – Preferred Brand Tier III – Non-Preferred Brand Tier IV – Specialty 90 Maintenance Supply

$0 ($0 family) Shared with Medical $10 copay per script $20 copay per script $35 copay per script Preferred – Tier II / Non-Preferred – Tier III 2x Retail

$250 ($500 family) Shared with Medical Deductible, then $10 Copay Deductible, then $20 Copay Deductible, then $35 Copay Not Covered 2x Retail

Note: The information provided is only a partial, general description of plan benefits and does not constitute a contract. In case of a conflict between your plan documents and this information, the plan documents will govern.

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Medical Plan Summary HDHP PPO Plan Summary The CareFirst Administrators / BlueCross BlueShield Plan allows you to seek care from an in-network or out-of-network provider, If you seek care from an out-of-network provider, you are subject to higher out-of-pocket expenses and balance billing by that provider. This plan does not require you to select a Primary Care Physician (PCP) or obtain a referral from your PCP in order to see a specialist In-Network Out-of-Network Annual Deductible

$1,500 Individual | $3,000 Family

$3,000 Individual | $6,000 Family

Annual Out-of-Pocket Maximum

$3,000 Individual | $6,000 Family

$6,000 Individual | $12,000 Family

Physicians Office Visit

$30 Copay after deductible

30% of allowed benefit after deductible

Specialists Office Visit

$50 Copay after deductible

30% of allowed benefit after deductible

No Charge

30% of allowed benefit after deductible

Lab: Deductible | X-ray: Deductible

30% of allowed benefit after deductible

Other Diagnostic Tests (OP Facility)

$100 Copay after deductible

30% of allowed benefit after deductible

Inpatient Hospital Facility Services

$250 Copay after deductible

30% of allowed benefit after deductible

Outpatient Hospital Facility Services

$100 Copay after deductible

30% of allowed benefit after deductible

Preventive Care Services Well-Child Care (exams & immunizations) Adult Physical Exam (routine GYN) Breast Cancer Screening Pap Test Prostate & Colorectal Cancer Screening Lab and X-ray

Emergency Room

$150 Copay after deductible

Urgent Care

$30 Copay after deductible

30% of allowed benefit after deductible

Rehabilitations Services (Physical, Occupational, Speech)

$50 Copay after deductible

30% of allowed benefit after deductible

Outpatient Spinal Manipulation

$50 Copay after deductible

30% of allowed benefit after deductible

Inpatient Hospitalization: $250 Copay after deductible Office Visits: $50 Copay after deductible Outpatient Facility: $100 Copay after deductible

30% of allowed benefit after deductible

• Mental Health/Substance Abuse

• •

Prescription Drugs Rx Deductible Rx Out-of-pocket Maximum Tier I – Generic Tier II – Preferred Brand Tier III – Non-Preferred Brand Tier IV – Specialty 90 Maintenance Supply

Shared with Medical Shared with Medical $10 copay per script $30 copay per script $50 copay per script Preferred – Tier II / Non-Preferred – Tier III 2x Retail

Note: The information provided is only a partial, general description of plan benefits and does not constitute a contract. In case of a conflict between your plan documents and this information, the plan documents will govern.

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Medical Plan Comparison Availability of Summary Health Information As an employee, the health benefits available to you represent a significant component of your compensation package. They also provide important protection for you and your family in the case of illness or injury.

Choosing a health coverage option is an important decision. To help you make an informed choice, your plan makes available a Summary of Benefits and Coverage (SBC), which summarizes important information about any health coverage option in a standard format, to help you compare across options. A paper copy is available, free of charge, by contacting your Human Resources Department.

Standard PPO Plan In-Network

HDHP PPO Plan In-Network

Out-of-Network

Deductible Individual

$250

$1,000

$1,500

$3,000

Family

$500

$2,000

$3,000

$6,000

Individual

$2,000

$3,000

$3,000

$6,000

Family

$4,000

$6,000

$6,000

$12,000

Preventive Care

No Charge

30% of allowed benefit after deductible

No Charge

30% of allowed benefit after deductible

PCP Office Visit

$15 Copay

30% of allowed benefit after deductible

$30 Copay after deductible

30% of allowed benefit after deductible

Specialist Office Visit

$20 Copay

30% of allowed benefit after deductible

$50 Copay after deductible

30% of allowed benefit after deductible

No

No

No

No

Lab: $20 Copay X-ray: $20 Copay

30% of allowed benefit after deductible

Urgent Care Facility

$20 Copay

30% of allowed benefit after deductible

Hospital Emergency Room (copay waived if admitted)

$100 Copay

30% of allowed benefit after deductible

Hospital Facility Services

10% coinsurance after deductible is met

30% of allowed benefit after deductible

$0 Individual ($0 Family)

$250 ($500 family)

Share with Medical

Rx OOP Maximum

Shared with Medical

Shared with Medical

Shared with Medical

Tier I – Generic

$10 copay

$10 Copay

$10 copay

Tier II – Preferred Brand

$20 copay

$20 Copay

$30 copay

Tier III – Non-Preferred Brand

$35 copay

$35 Copay

$50 copay

Preferred – Tier II / NonPreferred – Tier III

Not Covered

Preferred – Tier II / Non-Preferred – Tier III

2 X Retail Copay

2 X Retail Copay

2 X Retail Copay

Out-of-Pocket Maximum

Referral required?

Diagnostic, Lab and XRay

Lab: $50 Copay after deductible 30% of allowed benefit X-ray: $50 Copay after deductible after deductible $30 Copay after 30% of allowed benefit deductible after deductible $150 Copay after deductible $250 Copay after deductible

30% of allowed benefit after deductible

Prescription Coverage Rx Deductible

Tier IV - Specialty 90-Day Maintenance

Note: The information provided is only a partial, general description of plan benefits and does not constitute a contract. In case of a conflict between your plan documents and this information, the plan documents will govern.

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How it Works You must meet the plan deductible before the plan will pay for most services. The steps below highlight how your plan works

Standard PPO Plan In-Network

Out-of-Network

HDHP PPO Plan In-Network

Out-of-Network

$1,500 Individual $3,000 Family

$3,000 Individual $6,000 Family

Step 1 Meet your deductible You’re responsible for the entire cost of services up to the amount of your deductible. Once your deductible is satisfied, your coverage $1,000 will become available to you. Some services, such as preventative $250 Individual Individual $500 Family services, don’t require you to meet a deductible first. $2,000 Family If more than one person is covered on your plan (once the deductible is satisfied) the plan will start to make payments for everyone covered.

Step 2 Your plan will start to pay for services

Plan pays Plan pays 90% 100% Calendar Year Deductible. After each eligible family member You pay 10% Play pays 70% You pay copays Plan pays 70% meets their individual deductible, covered expenses for that member will be paid based on the coinsurance level specified by and/or copays in You pay 30% after the You pay 30% the plan. Or, after the family deductible has been met, covered some instances deductible in expenses for each member will be paid based on the coinsurance most instances level specified by the plan.

Step 3 Your out-of-pocket maximum Your out-of-pocket maximum is the max amount you pay during your benefit period. Your plan deductible, all copays and benefit deductibles contribute towards your out-of-pocket max. After each eligible family member meets his or her individual out of-pocket max, the plan will pay 100% of their covered expenses. Or, after the family out-of-pocket max has been met, the plan will pay 100% of each member’s covered expenses.

2019 Benefits Guide

$2,000 Individual $4,000 Family

$3,000 Individual $6,000 Family

$3,000 $6,000 Individual Individual $6,000 Family $12,000 Family

8

Telehealth and Virtual Visits $15 Copay on Standard PPO Deductible on HDHP PPO

Call 800-400-6354 or go online to www.mdlive.com

MDLive treats over 50 non-emergency conditions…      

Common cold Allergies Constipation Cough Diarrhea Ear Problems

     

Fever Flu Headache Insect Bites Nausea Vomiting

     

Pink Eye Rash Respiratory Problems Sore Throat UTI (Adult Females, 18+) And more…

Employee Assistance Program Employee Assistance Program

To access services, you will need click on EAP either in top beige bar on the right side, or on the bottom of the screen with the purple hands logo

2019 Benefits Guide

Employees, their dependents and household members have access to an Employee Assistance Program (EAP) through The Solutions Group. Members can call Toll-Free 24/7 help line staffed by Master's and PhD level counselors and can receive up to 6 face-to-face sessions per incident with a counselor and unlimited telephone and web access. 24/7 Online portal access available via www.solutionsbiz.com.

Services Include: • Emotional and Work/Life concerns • Video Counseling or In-person Counseling • Child care, elder care, adoption and family support resources • Work and career growth resources • Health and well-being resources • Legal and Financial assistance resources • Identity theft resources • Referrals to providers, specialists and resources • Online forums to connect with peers on many topics • Direct access to trained work-life specialists through the LiveCONNECT chat feature • Access to a comprehensive library of more than 4,000 timely support topics including parenting, wellness, career development, consumer tips and more • Online password is “sjc” all lowercase, click submit • Toll-free number (855) 231.7737

9

Pharmacy Benefits CVS/CareMark Pharmacy Benefit Manager

Anything that requires pre-authorization will need to go through this process with CVS. Start communicating with your doctors today.

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Dental PPO Regular dental care is essential to good health. St John's College provides preferred (PPO) dental coverage through United Concordia with access to their national Advantage Plus PPO network of dental providers. Search www.unitedconcordia.com to locate participating providers.

Plan Highlights

• • •

You can visit in-Network and out-of-network dentists Out-of-network providers can balance bill up to full charges National PPO network In-Network

Plan Year Deductible

Out-of-Network $50 Individual / $150 Family

Annual Plan Year Maximum Benefit Preventive Care (such as cleanings, exams, and x-rays) Regular Restorative Care (such as fillings, oral surgery, and root canals)

Major Restorative Care (such as dentures, bridgework and crowns) Orthodontia Care (children up to age 19 only) Lifetime Orthodontia Maximum (per child)

$1,500 No Charge

0% of allowable charge

20% after deductible

20% after deductible of allowable charge

50% after deductible

50% after deductible of allowable charge

50%; deductible waived

50% of allowable charges; deductible waived

$1,500

$1,500

Avesis Vision Vision coverage through Avesis provides access to the national network of vision care providers.

Search www.avesis.com to find participating providers.

Eye Exams (every 12 months) Collection Frames (every 24 months) Lenses (every 12 months) Contact Lenses

In-Network

Out-of-Network

$10 copay

Up to $35 Reimbursement

$130 Allowance

Up to $45 Reimbursement

$25 Copay

Up to $80 Reimbursement (depending on lens type)

$130 Allowance

Up to $110 Reimbursement

Up to an additional 20% discount on frames, progressive lenses, and lens options, with a valid prescription; offered savings does not apply to contact lens materials. Check with your Avesis Vision Network Provider for details.

Note: The information provided is only a partial, general description of plan benefits and does not constitute a contract. In case of a conflict between your plan documents and this information, the plan documents will govern.

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Health Savings Account A health savings account (HSA) combines high deductible health insurance with a tax-favored savings account. Money in the savings account can help pay the deductible. Once the deductible has been met, the insurance starts paying.

Money left in the savings account earns interest and is yours to keep. So, it’s different from a traditional health insurance package because it adds a new self-funding option — an HSA savings product, which many banks and credit unions offer. Most financial institutions offer a variety of investment options for HSAs, including stocks, bonds, mutual funds and money market funds.

With an HSA, you save in three ways: The money you put in your HSA account is not subject to income tax.

• Funds in your account grow tax-free.

• You don’t pay taxes on withdrawals (providing they are used for qualified medical expenses) • Any interest earned in the account is not taxed

2019 HSA Contribution Limits Individual: $3,500 | Family: $7,000 | Catch-up (age 55+): $1,000

HSA Advantages Your HSA can help you during certain financial hardships. For example, your HSA funds can be used if you’re between jobs and use them to pay your health insurance premiums without any penalty. You can also use them to pay for qualified long-term care premiums, as well as for Medicare insurance and expenses.

An HSA can help add to your retirement funds. That’s because any unused funds are rolled over and after you turn 65, you can withdraw funds from your HSA for any reasons without penalty. It does not have to be for a medical expense and could be for normal living expenses.

What an HSA and an HSA-Compatible Health Plan Pay For Here’s a simple way to look at the way the two products that make up how an HSA works to pay for covered medical expenses during a calendar year.

Your Health Plan Pays For:

Your HSA Funds Pay For:

Covered medical expenses after the deductible has been met

Covered medical expenses until your deductible is met

Adult Preventive care

Qualified expenses, such as vision and dental care

Benefits & coverage based on your policy's terms

Copayment, coinsurance, out-of-pocket costs after your deductible is met

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Flexible Spending Account Flexible Spending Accounts (FSAs) allow you to be reimbursed for medical and dependent care expenses on a tax-free basis. If you can anticipate your family’s health care and dependent care costs for the next plan year, you may lower your taxable income. Here is how it works. You agree to set aside a portion of your pre-tax salary in the account.

The money comes out of your paycheck over the course of the year. The amount you contribute to the FSA is not subject to Social Security (FICA), federal, state, or local income taxes—effectively adjusting your annual taxable salary. Depending on your tax bracket, you may realize significant savings.

Log in to your account for real time access to account balance information, pending claim status, reimbursement forms, email your account manager, calculator “what if” scenarios, and more

How it works Use It or Lose It Consider your expenses carefully before you decide how much to contribute to each FSA account. If your eligible expenses for the calendar year turn out to be less than the amount you contributed to your FSA account, federal law requires that the unused balance be forfeited (the “Use it or Lose it” rule). So do not contribute more than you are reasonably certain you will use.

Over-the-Counter (OTC) Drugs The IRS requires a doctor’s note or prescription for reimbursement of OTC products under the Health Care FSA. This requirement applies to items such as cough medicines and pain relievers. Submit a doctor’s prescription when you submit your claim.

Status Change Federal regulation prohibits you from changing your enrollment or the amount of your election during the plan year. You are only eligible to change your elections during the year if you have a status change. Only benefit changes consistent with the change in status are permitted. Status Changes that may warrant a change in benefit elections are described elsewhere in this benefit guide.

If You Leave the Company Your participation in the Flexible Spending Accounts will end on the date of your termination of employment. This means that you may submit for reimbursement any qualified expenses incurred on or before the date of your termination.

You have 90 days after the end of your plan year to file a claim for reimbursement of these expenses. Please refer to your Human Resource Representative for more details.

2019 Benefits Guide

Health Care Account You may pay for certain IRS approved medical care expenses not covered by your insurance plan with pre-tax dollars e.g. co-pays, deductibles, and other out-of-pocket expenses. Under this FSA, the maximum you may contribute each plan year is $2,700.

Dependent Care Account The Dependent Care FSA lets you use pre-tax dollars toward qualified dependent care. The annual maximum amount you may contribute to the Dependent Care FSA per calendar year is $5,000 or $2,500 if married and filing separate tax returns.

The IRS defines an eligible dependent as: • A child under the age of 13 • A dependent over the age of 13 who is physically or mentally incapable of self-care, claimed as a dependent on your income tax return Only the portion of expenses which enable you to remain employed are eligible. Educational expenses are not eligible.

Note: In order for your FSA contributions to be eligible for reimbursement, you must obtain a tax identification or social security number from your provider which will be reported on your federal income tax return.

13

Life & Disability Insurance Available for Full-time Employees Only

Employer Paid Life and AD&D Insurance St John's College provides Basic Life and Accidental Death and Dismemberment (AD&D) at no cost to you.

• Available to benefit eligible employees • Benefits are based on your earnings, with a maximum benefit of $50,000 • AD&D benefits will match the life insurance amount

Voluntary Life and AD&D Insurance St John's College sponsors a supplemental Life and AD&D plan which allows Employees the opportunity to purchase additional Life and AD&D for yourself, spouse and children at a discounted group rate.

Additional Life and AD&D Insurance for you: • Maximum benefit of 5x your salary up to $500,000 (available in $10,000 increments) • Initial guarantee issue amount of 5x salary up to $150,000 • Cost varies due to age • Evidence of Insurability may be required for late entrants or elections over the guaranteed amount Additional Life and AD&D Insurance for your spouse and children: • Max benefit of $500,000 ($5,000 increments not to exceed 100% of the Employee amount) • Initial guarantee issue amount of $25,000 or 100% of employee benefit, whichever is less • Evidence of Insurability may be required for late entrants or elections over the guaranteed amount • Benefits for your child(ren) aged 14 days to 6 months are available up to $500 • Child benefits available from 6 months to 26 years up to $10,000.

Employer Paid Short Term Disability St John's College provides Short Term Disability Insurance at no cost to you.

• This benefit replaces up to 100% of your weekly earnings for the first 4 months and 80% for the next 2 months should you become disabled • Available after 1 year of employment • Benefits would begin after 10 work days for Accidents and Sickness • Benefits may continue for up to 26 weeks • Pre-existing conditions may apply

Employee Paid Voluntary Long Term Disability St John's College provides you the ability to purchase Long Term Disability Insurance at a group rate with no underwriting • This benefit replaces up to 60% of your monthly earnings should you become disabled • Benefit available after 1 year of employment • The maximum monthly benefit you may receive is $6,000 • Benefits would begin after you have been disabled for 180 days • Premiums are paid on an after-tax basis therefore the benefit will be tax-free when received • Contains a pre-existing condition limitation for the first 12 months of coverage

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2019 Employee Contributions Medical Employee Only

Employee Child(ren)

Employee Spouse

Employee Family

Standard PPO (Under $40,000)

$114.86

$200.99

$258.43

$344.56

Standard PPO ($40,000 to $84,999)

$155.87

$272.78

$350.73

$467.63

Standard PPO ($85,000 and up)

$196.89

$344.57

$443.01

$590.78

HDHP PPO (Under $40,000)

$97.63

$175.73

$229.43

$307.52

HDHP PPO ($40,000 to $84,999)

$132.49

$238.49

$311.37

$417.36

HDHP PPO ($85,000 and up)

$167.36

$301.26

$393.30

$527.27

Monthly Amounts

Dental Monthly Amounts

United Concordia Dental PPO

Employee Only

Employee +1

Employee Family

$32.53

$67.52

$117.37

Vision Monthly Amounts

Employee Only

Employee Child(ren)

Employee Spouse

Employee Family

$4.86

$9.05

$9.70

$14.30

Avesis Vision PPO

Voluntary Long Term Disability Monthly Amounts; per $100 of Covered Payroll – maximum covered payroll is $10,000 per month 0-24 25-29 30-34 35-39

$0.047 $0.060 $0.115 $0.180

40-44 45-49 50-54 55-59

60-64 65-69 70 and up

$0.269 $0.362 $0.501

$0.561 $0.583 $0.598

$0.532

Voluntary Life and AD&D Insurance Monthly Amounts Age 0-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75 and up

2019 Benefits Guide

Employee Rates Per $1,000

Spouse Rates Per $1,000

Child Rate Per $1,000

AD&D Rates Per $1,000

$0.060

$0.060

$0.238

Employee $0.020

$0.077

$0.077

Spouse $0.020

$0.129

$0.128

Child $0.020

$0.223

$0.223

$0.334

$0.334

$0.557

$0.557

$0.634

$0.634

$1.106

$1.106

$1.808

$1.808

$5.974

$5.973

15

Commonly Used Terms Allowable charge – sometimes known as the "allowed amount," or "usual, customary, and reasonable (UCR)" charge, this is the dollar amount considered by a health insurance company to be a reasonable charge for services or supplies based on the rates in your area.

Benefit — the amount payable by the insurance company to a plan member for medical costs.

Coinsurance — the amount you pay to share the cost of covered services after your deductible has been paid. The coinsurance rate is usually a percentage. For example, if the insurance company pays 80% of the claim, you pay 20%.

Coordination of benefits — a system used in group health plans to eliminate duplication of benefits when you are covered under more than one group plan. Benefits under the two plans usually are limited to no more than 100% of the claim.

Copayment — one of the ways you share in your medical costs. You pay a flat fee for certain medical expenses (e.g., $10 for every visit to the doctor), while your insurance company pays the rest.

Deductible — the amount of money you must pay each year to cover eligible medical expenses before your insurance policy starts paying.

Dependent — any individual, spouse or child, which is covered by the primary insured member’s plan.

Exclusion or limitation — any specific situation, condition, or treatment that a health insurance plan does not cover.

Exclusive Provider Organization (EPO) — a type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the EPO. It generally won't cover out-of-network care except in an emergency. An EPO may require you to live or work in its service area to be eligible for coverage. EPOs often provide integrated care and focus on prevention and wellness.

In-network provider — a health care professional, hospital, or pharmacy that is part of a health plan’s network of preferred providers. You will generally pay less for services received from in-network providers due to negotiated discounts for services in exchange for the insurance company sending more patients their way.

Medicare — the federal health insurance program that provides health benefits to Americans age 65 and older.

Signed into law on July 30, 1965, the program was first available to beneficiaries on July 1, 1966 and later expanded to include disabled people under 65 and people with certain medical conditions. Medicare has two parts; Part A, which covers hospital services, and Part B, which covers doctor services.

Network — the group of doctors, hospitals, and other health care providers that insurance companies contract with to provide services at discounted rates. You will generally pay less for services received from providers in your network.

Out-of-network provider — a health care professional, hospital, or pharmacy that is not part of a health plan's network of preferred providers. You will generally pay more for services received from out-of-network providers.

Out-of-pocket maximum — the most money you will pay during a year for coverage. It includes deductibles, copayments, and coinsurance, but is in addition to your regular premiums. Beyond this amount, the insurance company will pay all expenses for the remainder of the year.

Preferred provider organization (PPO) — a health insurance plan that offers greater freedom of choice than HMO (health maintenance organization) plans. Members of PPOs are free to receive care from both in-network or outof-network (non-preferred) providers, but will receive the highest level of benefits when they use providers inside the network.

Provider — any person (i.e., doctor, nurse, dentist) or institution (i.e., hospital or clinic) that provides medical care.

Waiting period — the period of time that an employer makes a new Employee wait before he or she becomes eligible for coverage under the company's health plan. Also, the period of time beginning with a policy's effective date during which a health plan may not pay benefits for certain pre-existing conditions

For a complete glossary of healthcare terms visit

www.healthcare.gov/glossary

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Annual Notices Right to Rescind Coverage PPACA requires group health plans to provide notice 30 days prior of group health plan termination. The rules prohibit rescissions except in very limited situations such as employees who commit fraud or make intentional misrepresentations. For example, if plan documents require employees enrolling family members to assert that these individuals meet plan eligibility requirements and to immediately notify the employer if their status changes, rescission might be possible for an employee who intentionally misrepresented marital status to obtain coverage for a friend. Prospective terminations of coverage and retroactive terminations for failure to pay premiums or contributions are not rescissions.

St John's College Group Health Plan the privacy rules under the Health Insurance Portability and Accountability Act (HIPAA) require the Group Health Plan (the “Plan”) to periodically send a reminder to participants about the availability of the Plan’s Privacy Notice and how to obtain a copy of this notice. The Privacy Notice explains participants’ rights and the Plan’s legal duties with respect to protected health information (PHI) and how the plan may use and disclose PHI. Mothers’ and Newborns’ Act 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 insurers may not, under federal law, require that a provider obtain authorization from the plan or issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

Medicare Information Attention Members who are Medicare eligible or who have Medicare eligible dependents—(or those who will soon be eligible). Coordination of benefits between the group plan and Medicare Parts A & B depends on specific criteria and reason for election of Medicare. Please contact the St John's College Human Resources department for more information in regards to these criteria and how the coordination of benefits would be determined.

2019 Benefits Guide

Uniformed Services Employment and Reemployment Rights Act (USERRA) Health Insurance Protection if you leave your job to perform military service, you have the right to elect to continue your existing employer-based health plan coverage for you and your dependents for up to 24 months while in the military. Even if you don't elect to continue coverage during your military service, you have the right to be reinstated in your employer’s health plan when you are reemployed, generally without any waiting periods or exclusions except for service-connected illnesses or injuries.

Women’s Health and Cancer Rights Act of 1998 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 or 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 lymphedemas.

These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under the plan.

COBRA Under the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985, COBRA qualified beneficiaries generally are eligible for group coverage during a maximum of 18 months for qualifying events due to award termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage. COBRA coverage is not extended for those terminated for gross misconduct. Upon termination, or other COBRA qualifying event, the former fellows and any other beneficiary will receive COBRA enrollment information.

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Medicare Part D Notice Important Notice from the employer about Your Prescription Drug Coverage and Medicare Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage and your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.

There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage: Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. The employer has determined that the prescription drug coverage offered by the plan is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage.

Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.

When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th. If you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two month Special Enrollment Period (SEP) to join a Medicare drug plan.

What Happens To Your Current Coverage If You Decide To Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your group coverage will not be affected. You and your dependents can keep this coverage if part D is elected and the plan will coordinate with Part D. See pages 7- 9 of the CMS Disclosure of Creditable Coverage To Medicare Part D Eligible Individuals Guidance (available at http://www.cms.hhs.gov/CreditableCoverage/), which outlines the prescription drug plan provisions/options that Medicare eligible individuals may have available to them when they become eligible for Medicare Part D. If you do decide to join a Medicare drug plan and drop your current coverage, be aware that you and your dependents will be able to get this coverage back but you/they may have to wait until the next open enrollment plan.

When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current group coverage and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.

For More Information about This Notice or Your Current Prescription Drug Coverage. Contact your HR Department for further information. It is always best to discuss your personal situation with a Medicare expert when you are considering your options. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this group coverage changes.

You also may request a copy of this notice at any time. More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.

For more information about Medicare prescription drug coverage: Visit www.medicare.gov or call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1- 800-772-1213 (TTY 1-800-325-0778).

Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).

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New Health Insurance Marketplace Coverage Options PART A: General Information What is the Health Insurance Marketplace?

The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers “onestop shopping” to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace begins in November 2018 for coverage starting as early as January 1, 2019.

Can I Save Money on my Health Insurance Premiums in the Marketplace?

You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that doesn’t meet certain standards. The savings on your premium that you’re eligible for depends on your household income.

Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?

Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer’s health plan. However, you may be eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your employer that would cover you (and not any other members of your family) is more than 9.86% of your household income for the year, or if the coverage your employer provides does not meet the “minimum value” standard set by the Affordable Care Act, you may be eligible for a tax credit.

Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then you may lose the employer contribution (if any) to the employer- offered coverage. Also, this employer contribution – as well as your employee contribution to employer -offered coverage – is often excluded from income for Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis.

How Can I Get More Information?

For more information about your coverage offered by your employer, please check your summary plan description or contact your HR department. The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area.

Part B: Information about Health Coverage Offered by Your Employer This section contains information about any health coverage offered by your employer. If you decide to complete an application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the Marketplace application.

Employer Name

Employer Identification Number (EIN)

St John's College

85-0162247

Employer Address

Employer Phone Number

1160 Camino Cruz Blanca

505-984-6000

City

State

Santa Fe` NM Who can we contact about employee health coverage at this job?

Aaron Young Phone number (if different from above)

Zip Code 87505-4599

Email Address apyoung@sjc.edu

▪ Eligible members regularly scheduled to work more than 30 hours each week.

▪ Dependent coverage - eligible dependents are spouses and children (biological, adopted and step-children) ▪ Coverage meets minimum value standards, and the cost of this coverage to you is intended to be affordable, based on employee wages. ** Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount through the Marketplace. The Marketplace will use your household income, along with other factors, to determine whether you may be eligible for a premium discount. If, for example, your wages vary from week to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly employed mid-year, or if you have other income losses, you may still qualify for a premium discount. ***

If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Above is the employer information you’ll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower your monthly premiums.

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2019 Benefits Guide