Room & Board Open Enrollment Guide

2021 Open Enrollment Guide

Introduction

Welcome to our 2021 Benefits Open Enrollment Welcome to our 2021 Benefits Open Enrollment

Our goal is to provide meaningful benefits that support your wellbeing and the wellbeing of your loved ones. In return, you are expected to take accountability for understanding and appropriately utilizing your benefits. We encourage you to take the time to learn about all of the benefits, review your current elections and make choices that are right for you and your family for 2021.

During Open Enrollment staff members can enroll in the following benefits: • Medical

• Dental

• Vision

• Voluntary Life

• Voluntary Accidental Death & Dismemberment (AD&D) • Flexible Spending Accounts (FSAs)

How to Enroll or Waive Benefits Coverage for 2021

Be sure to read this guide in its entirety as well as the other Open Enrollment resources on Worklife and UltiPro. Make your decisions and complete your enrollment or waive coverage in UltiPro. Keep in mind that the benefit elections you made for 2020 do not automatically carry over. Be sure to make active elections for 2021 benefits during Open Enrollment in order to not have a lapse in coverage. You will not be able to make changes during the year unless you experience a qualified life event.

2021 OPEN ENROLLMENT GUIDE

What’s New for 2021

New Medical Plan Option (Replacing the Moderate Deductible HRA Plan)

2021 Open Enrollment Dates November 2, 2020 – November 18, 2020 ENROLL HERE: https://roomandboard.ultipro.com Navigate to Menu > Myself > Open Enrollment

The Copay Plan • It has a lower deductible • You pay a flat $35 for each office visit ($75 copay for specialty visits) • Labs and x-rays are 100% covered • Prescriptions have a flat copayment Coverage Levels: • We have moved from a 3-tier cost structure to a 4-tier cost structure for our medical and dental plans. You have the opportunity for significant cost savings if you have a child(ren) on our plan CONTRIBUTIONS – BIWEEKLY and your spouse/partner can obtain coverage HIGH COPAY DEDUCTIBLE elsewhere.

PLAN YOUR PER PAYCHECK DEDUCTION

HSA PLAN YOUR PER PAYCHECK DEDUCTION

EMPLOYEE

$92.00

$62.00

EMPLOYEE + SPOUSE/PARTNER

$225.00

$152.00

EMPLOYEE + CHILD(REN)

$194.00

$130.00

FAMILY

$344.00

$248.00

Copay Plan

COVERAGE LEVEL IN-NETWORK

OUT-OF-NETWORK

EMPLOYEE (PER MEMBER)

$750 deductible amount $3,000 out-of-pocket maximum

$1,150 deductible amount $4,500 out-of-pocket maximum

FAMILY

$1,500 deductible amount $6,000 out-of-pocket maximum

$2,300 deductible amount $9,000 out-of-pocket maximum

DEDUCTIBLE AND OUT-OF-POCKET MAXIMUM AMOUNT

This information below shows the amount you are responsible for paying by type of care with copays and after the deductible is met.

Routine preventive care • Preventive care • Screening • Immunization Office Visits • Illness or injury • Mental/behavioral health, substance use disorder • Physical, Occupational and Speech therapy • Specialty visits

No charge

$35 copay $35 copay $35 copay $75 copay

50% coinsurance for eye exams 50% coinsurance for immunizations 50% coinsurance for other services

Deductible then you pay 50%

Online Care • Virtuwell • Doctor on Demand

No charge Up to a $59 copay for Doctor on Demand

Not covered

Emergency Care • Urgent care • Emergency care at hospital ER • Ambulance

$100 copay for urgent care $200 copay for ER 20% coinsurance for medical transportation

$100 copay for urgent care $200 copay for ER 20% coinsurance for medical transportation

Inpatient Hospital Care

Deductible then you pay 20%

Deductible then you pay 50%

Outpatient Care • Scheduled outpatient procedures • Outpatient MRI and CT scan

Deductible then you pay 20%

Deductible then you pay 50%

2021 OPEN ENROLLMENT GUIDE

Copay Plan CONTINUED

PRESCRIPTION DRUG SERVICES IN-NETWORK

OUT-OF-NETWORK

GENERIC

$10 copay

You pay 50%

FORMULARY (BRAND)

$50 copay

You pay 50%

NONFORMULARY (BRAND)

$90 copay

You pay 50%

$200 copay

You pay 50%

GENERIC

$30 copay

Not covered

FORMULARY (BRAND)

$150 copay

Not covered

NONFORMULARY (BRAND)

$270 copay

Not covered

RETAIL (UP TO A 31-DAY SUPPLY)

SPECIALTY MAIL ORDER (UP TO A 93-DAY SUPPLY)

BENEFITS OF THE COPAY PLAN • It has a lower deductible • You pay a flat $35 for each office visit ($75 for specialty care) • Labs and x-rays are 100% covered • Prescriptions have a flat copayment

2021 OPEN ENROLLMENT GUIDE

Click here to view the full Summary of Benefits and Coverage (SBC) for the Copay Plan.

High Deductible (HSA) Plan

COVERAGE LEVEL IN-NETWORK

OUT-OF-NETWORK

EMPLOYEE (APPLIES TO SINGLE ONLY)

$1,800

$3,600

FAMILY

$3,600

$10,800

EMPLOYEE

$3,000

$5,000

FAMILY

$6,000

$15,000

DEDUCTIBLE AMOUNT

OUT-OF-POCKET MAXIMUM

2021 ROOM & BOARD HSA CONTRIBUTIONS EMPLOYEE

up to $600

EMPLOYEE + SPOUSE/PARTNER

up to $900

EMPLOYEE + CHILD(REN)

up to $900

FAMILY

up to $1,200

STAFF MEMBER HSA CONTRIBUTIONS EMPLOYEE

up to $3,000

EMPLOYEE + SPOUSE/PARTNER

up to $6,300

EMPLOYEE + CHILD(REN)

up to $6,300

FAMILY

up to $6,000

2021 OPEN ENROLLMENT GUIDE

High Deductible (HSA) Plan CONTINUED

COVERAGE LEVEL IN-NETWORK

OUT-OF-NETWORK

The information below shows the amount you are responsible for paying by type of care after the deductible is met.

Routine preventive care • Preventive care • Screening • Immunization

No charge

40% coinsurance for eye exams 40% coinsurance for immunizations No charge for well child 40% coinsurance for other services

Office Visits • Illness or injury • Mental/behavioral health, substance use disorder • Physical, Occupational and Speech therapy

Deductible then you pay 20%

Deductible then you pay 40%

Online Care • Virtuwell • Doctor on Demand

Deductible then you pay 20%

Not covered

Emergency Care • Urgent care • Emergency care at hospital ER • Ambulance

Deductible then you pay 20%

Deductible then you pay 20%

Inpatient Hospital Care

Deductible then you pay 20%

Deductible then you pay 40%

Outpatient Care • Scheduled outpatient procedures • Outpatient MRI and CT scan

Deductible then you pay 20%

Deductible then you pay 40%

2021 OPEN ENROLLMENT GUIDE

High Deductible (HSA) Plan CONTINUED

PRESCRIPTION DRUG SERVICES IN-NETWORK

OUT-OF-NETWORK

Generic

Deductible then you pay 20%

Deductible then you pay 40%

Formulary (Brand)

Deductible then you pay 20%

Deductible then you pay 40%

Nonformulary (Brand)

Deductible then you pay 20%

Deductible then you pay 40%

Specialty

Deductible then you pay 20%

Deductible then you pay 40%

Generic

Deductible then you pay 20%

Not covered

Formulary (Brand)

Deductible then you pay 20%

Not covered

Nonformulary (Brand)

Deductible then you pay 20%

Not covered

Specialty

Deductible then you pay 20%

Not covered

RETAIL (UP TO A 31-DAY SUPPLY)

MAIL ORDER (UP TO A 93-DAY SUPPLY)

2021 OPEN ENROLLMENT GUIDE

How the Plans Work

How the Copay Plan Works: IN-NETWORK PROVIDERS PREVENTIVE CARE

DEDUCTIBLE

COINSURANCE

In-network preventive care such as annual check-ups, cancer screenings, well child care and immunizations are covered at 100%.

$750 lndividual $1500 Family

Once you meet your deductible, you pay 20% for services up to your out-of-pocket maximum.

You pay a copay for office visits, prescriptions and 100% of other covered medical costs until you meet your deductible.

OUT-OF-POCKET MAXIMUM $3000 lndividual $6000 Family

If your accumulated out-ofpocket expenses reach the above maximums, the plan pays 100% for the remainder of the year.

How the High Deductible HSA Plan Works: IN-NETWORK PROVIDERS USE YOUR HSA TO HELP PAY THESE EXPENSES IN-NETWORK PREVENTIVE CARE In-network preventive care such as annual check-ups, cancer screenings, wellchild care and immunizations are covered at 100%.

2021 OPEN ENROLLMENT GUIDE

DEDUCTIBLE

$1800 lndividual $3600 Family

$600 $900

HSA

$1200

You pay 100% of medical and prescription drug costs until you meet your deductible. Room & Board will make contributions to your HSA in an amount based on the tier of coverage you select.

(Single= $600, Single+1 =$900, Family= $1,200). You can withdraw these funds tax-free and put them towards meeting your deductible or save them to help offset future expenses.

COINSURANCE Once you meet your deductible, you pay 20% for services and prescriptions* up to your out-of-pocket maximum.

*For specialty drugs, you pay 20% up to $200 maximum of the cost per prescription per month.

OUT-OF-POCKET MAXIMUM

$3000 lndividual $6000 Family

If your accumulated out-ofpocket expenses reach the above maximums, the plan pays 100% for the remainder of the year.

Plan Considerations It’s important to consider your options when selecting your medical plan. Deciding on a plan is a personal decision for you and your family. When choosing the plan that’s right for you, it’s important to think about your total costs: Fixed costs (annual premium contributions) + Variable costs (out-of-pocket expenses) = Total costs Here are a few things to think about when choosing a medical plan: • Consider your per paycheck premium contribution. Since your maximum out-ofpocket exposure is the same on both plans, your premium contribution is an important consideration.

• How do you and your family use your health care? Consider the number of office visits you make in an average year, the number and cost of prescription drugs you use, and the number of foreseeable hospital visits you anticipate in the upcoming plan year (pregnancy, chronic conditions, etc.).

• If you are using prescription medications and you are currently a HealthPartners member you can use the Rx shopping tool by logging into your myHealthPartners account.

• Enrolling in our High Deductible Plan gives you access to a health savings account (HSA). HSA dollars can be used for qualified health care expenses including vision and dental for yourself and any tax dependents. Your HSA dollars will rollover year-to-year, giving you the ability to save for future health care expenses. To learn more about HSAs, go to www.optumbank.com.

• You may also make contributions to your HSA up to the IRS maximums: $3,600/single and $7,200/family.

• If you are age 55+, you are eligible to make an additional $1,000 “catch-up” contribution.

Be sure to factor in your Room & Board contribution with these limits. There are some tax advantages to contributing to a HSA; see right.

• If you enroll in our Copay Plan, you have the ability to open a Medical Flexible Spending Account that allows you to set aside pre-tax money from your paycheck to pay for eligible medical, vision and dental expenses. (See page 14 for more information.)

HSA TAX ADVANTAGES • Staff member contributions are tax-free, reducing your taxable income.

• Distributions of HSA funds are tax-free when used to cover qualified health care expenses.

• HSA balances grow tax free.

Vision Coverage The vision plan through EyeMed allows you and your covered family members to receive an eye exam at an EyeMed in-network provider for just a $10 copay.

You also receive a $150 allowance toward your choice of a complete pair of eyeglasses or contact lenses. There are also other great discount benefits as an EyeMed member when you go to an “Insight” in-network provider.

With EyeMed, you have access to independent providers, LensCrafters, Pearle Vision and Target Optical as well as online retailers contactsdirect.com, glasses.com, lenscrafters.com and rayban.com.

COVERAGE LEVEL

2021 OPEN ENROLLMENT GUIDE

VISION CONTRIBUTIONS – BIWEEKLY

SINGLE

$3.79

SINGLE + CHILD(REN)

$7.59

EMPLOYEE + SPOUSE/PARTNER

$7.21

FAMILY

$11.16

Vision Plan

SUMMARY OF BENEFITS IN-NETWORK

OUT-OF-NETWORK

$10 copay

Up to $40

$40 10% off retail price

Not covered Not covered

$0 copay; 20% off balance over $150 allowance

Up to $105

$25 copay $25 copay $25 copay $25 copay $80 copay $110 copay $120 copay $135 copay $200 copay

Up to $30 Up to $50 Up to $70 Up to $70 Up to $50 Up to $50 Up to $50 Up to $50 Up to $50

EXAM SERVICES • Exam • Retinal Imaging

CONTACT LENS FIT AND FOLLOW-UP • Fit and Follow-up - Standard • Fit and Follow-up - Premium

FRAME • Any available frame at provider location

STANDARD PLASTIC LENSES • • • • • • • • •

Single Vision Bifocal Trifocal Lenticular Progressive - Standard Progressive - Premium Tier 1 Progressive - Premium Tier 2 Progressive - Premium Tier 3 Progressive - Premium Tier 4

Premium progressives and premium anti-reflective designations are subject to annual review by EyeMed’s Medical Director and are subject to change based on market conditions. Fixed pricing is reflective of brands at the listed product level. All providers are not required to carry all brands at all levels. Benefits are not provided from services or materials arising from: 1) Orthoptic or vision training, subnormal vision aids and any associated supplemental testing; Aniseikonic lenses; 2) Medical and/or surgical treatment of the eye, eyes or supporting structures; 3) Any eye or Vision Examination, or any corrective eyewear required by a Policyholder as a condition of employment; Safety eyewear; 4) Services provided as a result of any Workers’ Compensation law, or similar legislation, or required by any governmental agency or program whether federal, state or subdivisions thereof; 5) Plano (non-prescription) lenses; 6) Non-prescription sunglasses; 7) Two pair of glasses in lieu of bifocals; 8) Services or materials provided by any other group benefit plan providing vision care; 9) Services rendered after the date an Insured Person ceases to be covered under the Policy, except when Vision Materials ordered before coverage ended are delivered, and the services rendered to the Insured Person are within 31 days from the date of such order; 10) Lost or broken lenses, frames, glasses, or contact lenses will not be replaced except in the next Benefit Frequency when Vision Materials would next become available. Benefits may not be combined with any discount, promotional offering, or other group benefit plans. Standard/Premium Progressive lens not covered-fund as a Bifocal lens. Standard Progressive lens covered-fund Premium Progressive as a Standard. Benefit allowance provides no remaining balance for future use within the same benefit year. Fees charged for a non-insured benefit must be paid in full to the Provider. Such fees or materials are not covered.

2021 OPEN ENROLLMENT GUIDE

Dental Coverage Routine dental care can not only improve your oral health but your overall health as well. Delta Dental of Minnesota offers two networks — Delta Dental PPO and Delta Dental Premier — that work together to provide the greatest access to providers and help control your costs. Choosing a dentist in the Delta Dental PPO network may save you even more money.

Four out of five dentists nationally are Delta Dental Network dentists. You can choose to see a dentist outside of the network but your expenses may be higher and you may be responsible for submitting your own claim. To find a participating dentist, simply visit www.deltadentalmn.org and use the interactive ‘’Find a Dentist” tool or call Customer Service toll-free at 800.448.3815.

2021 OPEN ENROLLMENT GUIDE

CONTRIBUTIONS – BIWEEKLY YOUR PER PAYCHECK DEDUCTION EMPLOYEE

$7.25

EMPLOYEE + SPOUSE/PARTNER

$13.80

EMPLOYEE + CHILD(REN)

$16.15

FAMILY

$23.15

Dental Plan

SUMMARY OF BENEFITS DELTA DENTAL PPO

DELTA DENTAL PREMIER

NON-PARTICIPATING

$50 individual $150 family

$50 individual $150 family

$50 individual $150 family

Calendar Year Plan Maximum Per person

$1,500

$1,000

$1,000

Lifetime Ortho Maximum Per covered person

$2,000

$2,000

$2,000

Diagnostic & Preventive Services (deductible does not apply)

100%

100%

100% of maximum allowable fee**

Basic Services

90%

80%

80% of maximum allowable fee**

Endodontics

90%

80%

80% of maximum allowable fee**

Periodontics

90%

80%

80% of maximum allowable fee**

Oral Surgery • Surgical/Nonsurgical extractions

90%

80%

80% of maximum allowable fee**

Major Restorative

60%

50%

50% of maximum allowable fee**

Prosthetic Repairs and Adjustments

60%

50%

50% of maximum allowable fee**

Prosthetics

60%

50%

50% of maximum allowable fee**

Orthodontics (dependent children only, age 8-18)

60%

50%

50% of maximum allowable fee**

EXAM SERVICES Deductible (calendar year)

No deductible for diagnostic and preventive service or orthodontics

This is a summary of benefits only and does not guarantee coverage. For a complete list of covered services and limitations/exclusions, please refer to the Dental Benefit Plan Summary. **Dentists who have signed a participating network agreement with Delta Dental have agreed to accept the maximum allowable amount as payment-in-full. Non-participating dentists have not signed an agreement and are not obligated to limit the amount they charge; the member is responsible for paying any difference to the non-participating dentists.

2021 OPEN ENROLLMENT GUIDE

Flexible Spending Accounts (FSAs) FSAs are voluntary accounts that allow you to use pre-tax funds to pay for certain expenses. You can set up three separate accounts — one for qualified health care expenses, one for qualified dependent care expenses and one for work-related parking/ transit expenses.

Medical Flexible Spending Account The Medical FSA provides a way to pay for your family’s eligible medical, vision and dental expenses with pre-tax money that is deducted from your paycheck.

Contributions You may make pre-tax contributions of up to $2,650 per year to your Medical FSA. If you have money left over at the end of the calendar year, you will be able to rollover up to $550 of your balance to the following calendar year.

Eligible Medical Expenses Eligible expenses can be found here through Discovery Benefits: https://www.discoverybenefits.com/ employees/eligible-expenses

2021 OPEN ENROLLMENT GUIDE

Limited Purpose Medical FSA

Contributions You may make pre-tax contributions of up to $2,650 per year to your Limited Purpose Medical FSA. If you have money left over at the end of the calendar year, you will be able to rollover up to $550 of your balance to the following calendar year.

Eligible Expenses Include: • Dental expenses • Vision expenses • Out-of-pocket medical expenses after you reach the federally-qualified High Deductible HSA Plan annual deductible ($1,400 for single coverage, $2,800 for family coverage).

Dependent Care FSA

Contributions You may contribute up to $5,000 per year, per family household, on a pre-tax basis to the Dependent Care FSA. This annual maximum applies to all contributions made by you and your spouse to a Dependent Care account.

Eligible Dependents You can be reimbursed for dependent care expenses if they are necessary to allow you or your spouse to work. The services must be provided by a qualified dependent care provider to care for your child, disabled spouse, elderly parent or other dependent who is physically or mentally incapable of self-care.

Commuter Expenses Staff members who incur work-related commuter expenses, including transportation or parking, may participate in this benefit. In 2021 you are able to deduct up to $270 per month pre-tax from your paycheck for transit expenses and $270 per month for parking expenses.

How Does the Commuter Benefit Work?

• You decide how much of your paycheck you want to deposit into your FSA each pay period.

• Your deduction will be loaded onto a debit card for you to pay for transit or parking expenses. You can also submit requests for reimbursements.

• Transactions or reimbursement requests cannot exceed the $270 IRS monthly maximums.

• Any amount remaining at the end of the calendar year will roll forward to the next calendar year.

Use it to Pay for Things Like:

• Bus passes, commuter van, light rail, train and subway fares • Parking ramps

2021 OPEN ENROLLMENT GUIDE

FSA Example

The following illustrates the tax benefits of a FSA. This example compares costs for single employee coverage. Your actual costs and tax savings will vary.

WITH FSA

WITHOUT FSA

Taxable income

$40,000

$40,000

Your FSA contribution

- $2,500

$0

Net taxable income

$37,500

$40,000

Less taxes

- $4,310

- $4,740

$0

- $2,500

$33,190

$32,760

$430

$0

Expenses paid after taxes Remaining income Your savings

Substantiation of Claims for all FSAs

We find great value in using our flex debit card to pay for claims at the time of service. The card gives you instant access to the funds in your account. The IRS regulations mandate that all claims incurred in a FSA must be substantiated. When a claim cannot be automatically substantiated (e.g. a prescription co-payment), Discovery Benefits will request documentation. It is imperative when asked for documentation that you provide it to Discovery Benefits as soon as possible. If documentation is not provided, the IRS requires you to pay back the plan.

Voluntary Life and AD&D Insurance Voluntary Life Insurance Room & Board pays for basic term life insurance in the amount of 2 ½ times the annual salary for all staff members who work 20 hours or more per week. Depending on your situation, you may find that you need additional coverage.

You can elect Voluntary Life Insurance through VOYA for you, your spouse or domestic partner, and your dependent children, up to the benefit maximums listed below.

How it Works

You can elect coverage for yourself up to five times your annual salary in increments of $10,000 to a maximum of $500,000. You can cover your spouse, domestic partner and/ or child(ren) only if you elect coverage for yourself. For your spouse/domestic partner, you can elect up to 100% of your coverage in increments of $5,000 up to $500,000.

If you are currently enrolled in coverage, you will be able to increase your election by $20,000 during Open Enrollment without Evidence of Insurability. If this is your first time enrolling, you can elect up to $20,000 of coverage for yourself at Open Enrollment and $10,000 for your spouse/partner.

Child coverage is available in amounts of $5,000 or $10,000. You can cover unmarried children up to age 26.

2021 OPEN ENROLLMENT GUIDE

Voluntary Accidental Death and Dismemberment (AD&D) Insurance Room & Board pays for basic term AD&D insurance in the amount of 2½ times the annual salary for all staff members who work 20 hours or more per week. You may also elect additional AD&D insurance for yourself and eligible dependents. If elected, this benefit is paid in addition to the life benefit if you or a covered dependent dies in a covered accident. If you survive a serious accident, it can pay you a benefit for certain severe injuries such as loss of vision, hearing and limbs.

How it Works

You can choose a benefit amount up to five times your annual salary in increments of $10,000 to a maximum of $500,000. You can purchase coverage for your spouse/ domestic partner in amounts of $5,000 up to a maximum of $500,000, and coverage for dependent children in amounts of $5,000 and $10,000. AD&D rates are $.02 per $1,000 coverage for staff members and covered dependents. This coverage is not subject to Evidence of Insurability.

Voluntary Life Insurance Coverage Rates

Rates are shown as your biweekly deduction. Your rate will increase as you move to the next age group.

AGE BAND

RATE PER $10,000 BENEFIT

< 24

$0.231

25-29

$0.277

30-34

$0.369

35-39

$0.415

40-44

$0.554

45-49

$0.923

50-54

$1.569

55-59

$2.538

60-64

$3.415

65-69

$5.862

70-74

$9.60

75+

$16.246

Contact Information BENEFIT

MEDICAL

CARRIER OR ADMINISTRATOR

HealthPartners

GROUP #

2353

PHONE NUMBER

WEBSITE

952-883-5000 or 1-800-883-2177 Monday – Friday 7 a.m. - 7 p.m. CST

www.healthpartners.com/ roomandboard

Española: 1-866-398-9119 FLEXIBLE SPENDING ACCOUNT (FSA) HEALTH SAVINGS ACCOUNT (HSA)

Discovery Benefits

NA

1-866-451-3399 Monday-Friday 6 a.m. - 9 p.m. CST

www.discoverybenefits.com

Optum

NA

1-866-234-8913 Monday–Friday 7 a.m. - 7 p.m. CST

www.optumbank.com

1-800-448-3815 Monday–Friday 7 a.m. - 7 p.m. CST

www.deltadentalmn.org

1-866-804-0982

www.eyemed.com

DENTAL

Delta Dental of MN

VISION

EyeMed

Room & Board Wellness Team

Email: wellness@roomandboard.com Megan Barta, Benefits Associate 612-629-2172 Skye Seesz, Wellness Manager 612-629-2164

2021 OPEN ENROLLMENT GUIDE

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Resources

Room & Board Benefit Enrollment and Payroll Site 2021 Benefits Enrollment Guide HealthPartners Resources EyeMed Information Legal Notices