final open enrollment letter - lasalle network

KEYSOLUTIONTM

P L A N D E S I G N E D F O R

T H E E M P L O Y E E S O F

E N R O L L M E N T G U I D E

2015 Medical Plan Options and Enrollment Information

Benef t Effective Date: i 1/1/2015

Administered by Key Benef t Administrators, Inc. i

It’s time to choose... ... medical coverage or tax penalty?

TM

Why must i choose betWeen medical coverage

or paying a tax penalty?

What are the aca tax penalties for people

Without the required minimum coverage?

What exactly is “minimum essential coverage” as

defined by aca?

The Affordable Care Act (ACA) requires all individuals to have at least “minimum

essential coverage” as of January 1, 2014, and beyond. If you do not have this

minimum coverage, then you may have to pay a penalty tax. By purchasing a plan

with “minimum essential coverage” through your employer, you can prevent being

taxed the “Individual Mandate” penalty tax.

The tax penalty is the “greater of” the calculated percent of your adjusted household

income or the combined per person penalty for each person in your family. This

Individual Mandate tax penalty also increases each year, as shown in the chart below.

Year % of Income Per Adult Penalty + Per Child Penalty

2014 1% or $95 $47.50

2015 2% or $325 $162.50

2016 and after

2.5% or $695 $347.50

The government has issued a list of Preventive and Wellness Benefits that must be

covered at 100% when obtained from a network provider and 40% from a non-

network provider. There are over 60 preventive services in all. These services include

immunizations, blood pressure screenings, diabetes and cholesterol screenings,

prenatal visits, and more.

See the Additional Information section at the end of this Guide for a list of the “minimum essential” Preventive and Wellness Benefits.

WHAT COVERAGE IS BEING OFFERED FOR THIS YEAR'S ENROLLMENT?

LaSalle Network is offering Temporary Full Time Hourly Employees the following coverage which satisfies the federally mandated “minimum essential coverage” so you can avoid the ACA tax penalty:

MVP – Minimum Value Plan with Multiplan PPO

WHAT BENEFITS CAN I EXPECT WITH THIS COVERAGE?

An MVP plan not only contains the Preventive and Wellness Benefits required by ACA, but it also covers strategically selected medical benefits, including a nationally acclaimed patented Chronic Disease Management (CDM) program, prescription drug coverage, and online access to Explanations of Benefits, plan summaries, and much more.*

Your coverage also has the Multiplan Preferred Provider Organization (PPO) attached to it. When you use the Multiplan PPO, services covered under your plan will be reimbursed at the higher in-‐network percent. Also, all incurred charges will be discounted by Multiplan. So whether your claim is incurred in or out of network, or even if it isn’t covered by your plan…the charges will still be discounted.

*For more MVP information, see the Additional Information section later in this Guide. It contains the ACA-‐required Preventive and Wellness Benefits, a list of CDM's coverage for 25 chronic conditions, and important MVP plan exclusions. Other benefits and coverage levels can be found on the Schedule of Benefits beginning on the next page.

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MVP Schedule of Benef ts i

Plan Name MVP

PPO Network Multiplan

Minimum Essential Coverage

% Covered for Wellness and Preventive Benef ts iRequired by ACA to avoid individual tax penalty. See the Additional

Information section of this Guide for covered services..

Network

100%

Non-Network

40%

Minimum Value Benef ts i Network Non-Network

Deductible – Individual/Family $0 / $0 $500

Coinsurance 100% 40%

Out-of-Pocket Maximum – Individual/Family $1,850 / $12,700 N/A

Emergency Room Services - Covers emergency room services including hospital facility and physician charges. For MRIs

performed during emergency room visit, a separate copay will not be applied. If surgery, PT, or DME is required during emergency room

visit, they will be covered under emergency room benef t. i

$400 copay $400 copay

Primary Care Visit to Treat an Injury or Illness - Covers all physician visits including off ce, outpatient, and inpatient physician charges.i

Copays apply to physician visit charge only, and do not include other services rendered at time of visit.

$15 copay Ded/Coins

Specialist Visits - Covers physician visits in off ce, as outpatient.i Copays apply to visit charge only and do not include other services

rendered at time of visit. $25 copay Ded/Coins

Imaging - Covers charges for CT, PET scans, MRIs, and the charges for related supplies. $400 copay Ded/Coins

Laboratory Outpatient and Professional Services - Covers professional components of labs, including off ce, outpatient, andi

inpatient charges. A copay will apply to each lab charge. $50 copay Ded/Coins

X-rays and Diagnostic Imaging - Covers the professional components of labs, including the off ce, outpatient, and inpatient charges. Ai

copay will apply to each x-ray or imaging charge. $50 copay Ded/Coins

Chronic Disease Management — CDM - See the Additional Information section of this Guide for all covered 25 chronic

conditions and their minimum standards of care. 100% Ded/Coins

Generic Prescription Drugs $15 copay Ded/Coins

Preferred Brand Drugs $25 copay Ded/Coins

Non-Preferred Brand Drugs $75 copay Ded/Coins

Mail-order Drugs 2.5 x copay Ded/Coins

Employee Term Life - Except for groups domiciled in CA, CT, HI, NJ, NY $10,000

1. Abdominal Aortic Aneurysm one time screening for age 65-75

2. Alcohol Misuse screening and counseling 3. Aspirin use for men ages 45-79 and women ages

55-79 to prevent cvd when prescribed by a physician 4. Blood Pressure screening 5. cholesterol screening for adults 6. colorectal cancer screening for adults starting at age 50

limited to one every 5 years 7. depression screening 8. Type 2 diabetes screening

9. diet counseling10. hIv screening11. Immunizations vaccines (hepatitis A & B, herpes Zoster,

human Papillomavirus, Influenza (flu shot), Measles, Mumps rubella, Meningococcal, Pneumococcal, Tetanus, diptheria, Pertussis, varicella)

12. obesity screening and counseling13. sexually Transmitted Infection (sTI) prevention counseling14. Tobacco use screening and cessation interventions15. syphilis screening

Covered Preventive services for Adults (ages 18 and older)15

1. Anemia screening on a routine basis for pregnant women 2. Bacteriuria urinary tract or other infection screening for

pregnant women 3. BrcA counseling and genetic testing for women at higher risk4. Breast cancer Mammography screenings every year for

women age 40 and over 5. Breast cancer chemo Prevention counseling for women 6. Breastfeeding comprehensive support and counseling from

trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women.

7. cervical cancer screening 8. chlamydia Infection screening 9. contraception: Food and drug Administration-approved

contraceptive methods, sterilization procedures, and patient education and counseling, not including abortifacient drugs

10. domestic and interpersonal violence screening and counseling for all women

11. Folic Acid supplements for women who may become pregnant when prescribed by a physician

12. gestational diabetes screening 13. gonorrhea screening14. hepatitis B screening for pregnant women 15. human Immunodeficiency virus (hIv) screening and counseling16. human Papillomavirus (hPv) dnA Test: hPv dnA testing

every three years for women with normal cytology results who are 30 or older

17. osteoporosis screening over age 60 18. rh Incompatibility screening for all pregnant women and

follow-up testing19. Tobacco use screening and interventions

and expanded counseling for pregnant tobacco users20. sexually Transmitted Infections (sTI) counseling 21. syphilis screening 22. Well-woman visits to obtain recommended preventive services* *Includes routine prenatal visits for pregnant women.

22 Covered Preventive services for Women, Including Pregnant Women

1. Alcohol and drug use assessments 2. Autism screening for children limited to two screenings

up to 24 months 3. Behavioral assessments for children limited to 5 assessments

up to age 17. 4. Blood Pressure screening 5. cervical dysplasia screening6. congenital hypothyroidism screening for newborns 7. depression screening for adolescents age 12 and older 8. developmental screening for children under age 3, and

surveillance throughout childhood 9. dyslipidemia screening for children 10. Fluoride chemo Prevention supplements for children without

fluoride in their water source when prescribed by a physician 11. gonorrhea preventive medication for the eyes of all newborns 12. hearing screening for all newborns 13. height, Weight and Body Mass Index measurements

for children14. hematocrit or hemoglobin screening for children15. hemoglobinopathies or sickle cell screening for newborns

16. hIv screening for adolescents 17. Immunization vaccines for children from birth to age 18;

doses, recommended ages, and recommended populations vary: diphtheria, Tetanus, Pertussis, hepatitis A & B, human Papillomavirus, Inactivated Poliovirus, Influenza (Flu shot), Measles, Mumps, rubella, Meningococcal, Pneumococcal, rotavirus, varicella, haemophilus influenzae type b

18. Iron supplements for children up to 12 months when prescribed by a physician

19. lead screening for children 20. Medical history for all children throughout development

Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years

21. obesity screening and counseling22. oral health risk assessment for young children up to age 1023. Phenylketonuria (PKu) screening in newborns24. sexually Transmitted Infection (sTI) prevention counseling

and screening for adolescents 25. Tuberculin testing for children 26. vision screening for all children under the age of 5

26 Covered services for Children

meC Preventive and Wellness Benefits A l I s T o F T h e “ M I n I M u M e s s e n T I A l c o v e r A g e ” r e Q u I r e d B y A c A

AdditionAl informAtion

*The services listed above are the standard laboratory and diagnostic procedure for each chronic disease.

ChroniC diseAse serviCes

AsthmA 2 Office exams per plan year *spirometry

AtherOsclerOsis (PeriPherAl VAsculAr DiseAse) 1 Office exam per plan year *lipid Panel

AtriAl FibrillAtiOn 1 Office exam per plan year *eKG, *Prothrombin times

chrOnic ObstructiVe PulmOnAry DiseAse 2 Office exams per plan year *spirometry

chrOnic renAl insuFFiciency 2 Office exams per plan year *creatinine, *complete blood count (cbc), *electrolytes, *urine protein, *serum calcium, *serum phosphorus, *lipid panel

cOnGestiVe heArt FAilure 2 Office exams per plan year *bun, *creatinine, *Potassium

cOrOnAry Artery DiseAse 1 Office exam per plan year *lipid panel, *eKG, *cholesterol

DiAbetes 2 Office exams per plan year *Glycohemoglobins, *microalbumin, *lipid panel

ePilePsy 1 Office exam per plan year

humAn immunODeFiciency Virus inFectiOn 1 Office exam per plan year *t-cell/cD-4 counts, *PPD, *hiV quantifications, *complete blood count (cbc), *Pap smear (women only)

hyPerliPiDemiA 1 Office exam per plan year *lipid panel, *cholesterol

hyPertensiOn 2 Office exams per plan year

hyPerthyrOiDism 1 Office exam per plan year *thyroid stimulating hormone (tsh), *thyroxine (t4)

hyPOthyrOiDism 1 Office exam per plan year *thyroid stimulating hormone (tsh), *t4

metAbOlic synDrOme 1 Office exam per plan year *lipid panel, *Glucose Fbs or hemoglobin A1c (hgbA1c)

multiPle sclerOsis 2 Office exams per plan year

PArKinsOn’s DiseAse 2 Office exams per plan year

POlymyAlGiA rheumAticA 2 Office exams per plan year *erythrocyte sedimentation rate (esr) or c-reactive protein (crP) *complete blood count (cbc)

Pre-DiAbetes 1 Office exam per plan year *lipid panel, *Glucose Fbs or hemoglobin A1c (hgbA1c)

PulmOnAry hyPertensiOn (unrelated to cOPD) 2 Office exams per plan year

cOPD With PulmOnAry hyPertensiOn/ cOr PulmOnAle

2 Office exams per plan year *spirometry, *12 months of supplemental 02 tx

rheumAtOiD Arthritis 1 Office exam per plan year *complete blood count (cbc)

sleeP APneA 1 Office exam per plan year

chrOnic VenOus thrOmbOtic DiseAse 2 Office exams per plan year

ulcerAtiVe cOlitis (inflammatory bowel Disease) 1 Office exam per plan year *complete blood count (cbc), *lFt


MVP Chronic Disease Management C H R O N I C D I S E A S E S A N D T H E M I N I M U M S T A N D A R D S O F L A B O R AT O R Y A N D D I A G N O S T I C P R O C E D U R E S C O V E R E D B Y M V P P L A N S


MVP Exclusions E X C L U S I O N S A N D L I M I T AT I O N S O F A N M V P P L A N

There are Exclusions applicable to the Minimum Value Benef ts listed on the i MVP Schedule of Benef ts in this Guide...i per the list below.

If you choose an MVP plan, a plan document with detailed descriptions of all exclusions will be made available to you after enrollment.

Please refer to this plan document for Exclusion details.

1. Hospital inpatient services are not covered under the Minimum Value Benef ts of i an MVP only plan. Hospitalization is available only under an MVP Preferred or Preferred Plus plan.

2. Ambulatory Surgical Center services are not covered.

3. Specialty drugs are not covered.

4. Mental/Behavioral Health and Substance Abuse Disorder Outpatient services are not covered with the exception of services covered under the plan’s MEC benef ts. i

5. Rehabilitation Speech Therapy services are not covered.

6. Rehabilitative Occupational and Rehabilitative Physical Therapy services are not covered.

7. Skilled Nursing Facility services are not covered.

8. Outpatient Surgery Physician/Surgical services are not covered.

9. Charges that are not for the care or treatment of an accident or illness except as specif cally provided for in this plan. i

10. Treatment made necessary as the result of illegal use of narcotics or use of hallucinogens in any form unless prescribed by a physician or as provided herein.

11. Treatment made necessary by or a disability arising from war, declared or undeclared, or any act of war. An act of terrorism will not be considered an act of war, declared or undeclared.

12. Treatment or services provided by anyone other than a healthcare provider as def ned herein unless specif cally statedii in the plan.

13. Investigatory and experimental treatment, services, and supplies.

14. Organ transplants.

*Please refer to your plan document for a detailed description of all exclusions.

KEYSOLUTIONTM

Frequently Asked Questions »

Hourly Pay RateTotal Monthly

RateMonthly Employee

ContributionWeekly Employee

ContributionLess than $10.32 per hour $204.06 $127.50 $29.42

Between $10.33 & $11.00 per hour $204.06 $127.58 $29.44Between $11.01 & $12.00 per hour $204.06 $135.97 $31.38Between $12.01 & $13.00 per hour $204.06 $148.32 $34.23Between $13.01 & $14.00 per hour $204.06 $160.67 $37.08Between $14.01 & $15.00 per hour $204.06 $173.02 $39.93Between $15.01 & $16.00 per hour $204.06 $185.37 $42.78Between $16.01 & $16.52 per hour $204.06 $197.72 $45.63

Greater than $16.53 per hour $204.06 $204.06 $47.09

Covered Plan ParticipantsTotal Monthly

RateMonthly Employee

ContributionWeekly Employee

ContributionSingle/Spouse $320.26 $320.26 $73.91Single/Children $315.21 $315.21 $72.74

Family $437.73 $437.73 $101.01

Rates of Insurance for Single Coverage

Rates of Insurance for Coverage Including Spouse or Dependents

Rates are based on an employee's rate of pay. Please find your rate below and select your weekly cost for benefits.

WHAT ARE MY COSTS FOR THIS COVERAGE?

KEYSOLUTIONTM

H O W D O I K N O W I ' M E L I G I B L E T O E N R O L L F O R T H I S C O V E R A G E ? Employees who are eligible to enroll include: (1) temporary full time hourly employees who are expected at their hire date to work on average at least 30 hours per week (i.e., full-time) will be eligible to enroll after 90-days of employment, and (2) non-full time employees at their hire date who are determined to be a temporary full time hourly employee after completing a 12-month measurement period and subsequent waiting period will be eligible to enroll.

C A N I S I G N U P F O R C O V E R A G E AT A N Y T I M E ? Provided you are eligible for this coverage, you can enroll per the instructions given on the previous page under “How and When Can I Enroll for This Coverage.” If you do not elect coverage as explained, you will not be able to enroll until the next open enrollment period unless you experience a qualifying event.

H O W A R E M Y P R E M I U M S PA I D ? Premiums will be taken through payroll deductions. If you miss a payroll deduction as a result of absence or lack of work, you risk being terminated from the plan. If terminated, you will not be eligible to re-enroll until the next open enrollment period unless you experience a qualifying event.

C A N I C A N C E L M Y C O V E R A G E AT A N Y T I M E ? When premiums are paid with pre-tax dollars through payroll deductions as part of a Section 125 Savings Plan, you will not be able to change these elections until the next annual enrollment period, unless you have a qualifying event. However, when premiums are paid with post-tax dollars, you can cancel coverage at any time.

I F I D O E N R O L L , H O W D O I U S E M Y B E N E F I T S ? After enrollment, our claims administrator, Key Benef t Administrators (KBA), will send you a benef t kitii and an ID card. Simply present this ID card to your provider at the time of service. This card contains all the information your provider needs to submit your claims to KBA for processing. You can also use theinformation on this card to contact KBA for any questions you might have. KBA's contact information and website are on the back of this Guide.

W H E N W I L L K B A S E N D M E A B E N E F I T K I T A N D I D C A R D ? KBA will mail your benef t kit and ID card soon after you have enrolled and your f rst payment has beenii made.

W H AT O T H E R I N F O R M AT I O N I S AV A I L A B L E T O M E S O I U N D E R S T A N D M Y C O V E R A G E ? For further details on the coverage being offered, see the Additional Information section of this Guide.

FREQUENTLY ASKED QUESTIONS

KEYSOLUTIONTM

Customer Service Contacts K E Y S O L U T I O N ™ A C A - C O M P L I A N T P L A N S

Administered by KBA

Claims: Key Benef t Administrators, Inc. i

PO Box 129, Fort Mill, SC 29716

Website: kba.keyfamily.com

P P O N E T W O R K

Offered through Key Benef t Administrators, Inc. i

Multiplan PPO Network

1.888.342.7427 or www.multiplan.com

LaSalle Network MVP Health Plan: Key Benefit Administrators Coverage Period: 01/01/2015 – 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual or Family | Plan Type: PPO

Questions: Call 1-800-278-5488 or visit us at www.kbasolution.com If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at www.cciio.cms.gov/resources/files/Files2/02102012/uniform-glossary-final.pdf or call 800-278-5488 to request a copy. 1 of 7

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.kbasolution.com or by calling 1-800-278-5488.

Important Questions Answers Why this Matters:

What is the overall deductible?

Network $0; Non-network $500 Doesn’t apply to preventive care. Co-payments do not apply to the deductible.

You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible.

Are there other deductibles for specific services?

No. You don’t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers.

Is there an out-of-pocket limit on my expenses?

Yes. Network providers $1,850 person/$12,700 family; Non-Network providers no maximum

The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses.

What is not included in the out-of-pocket limit?

Premiums, balance-billed charges, penalties & health care this plan doesn’t cover. All co-pays apply to the out-of-pocket limit.

Even though you pay these expenses, they don’t count toward the out-of-pocket limit.

Is there an overall annual limit on what the plan pays?

No. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits.

Does this plan use a network of providers?

Yes. For a list of providers, see www.multiplan.com or call 888-342-7427.

If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.

Do I need a referral to see a specialist?

No. You don’t need a referral to see a specialist.

You can see the specialist you choose without permission from this plan.

Are there services this plan doesn’t cover?

Yes. Some of the services this plan doesn’t cover are listed on page 4. See your policy or plan document for additional information about excluded services.



Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.

Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible.

The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.)

This plan may encourage you to use participating providers by charging you lower deductibles, copayments and coinsurance amounts.

Common

Medical Event Services You May Need

Your Cost If You Use Limitations & Exceptions

Network Provider Non-Network

Provider

If you visit a health care provider’s office or clinic

Primary care visit to treat an injury or illness Minimum annual care requirements for 25 chronic diseases

$15 co-pay/visit No charge

60% co-insurance 60% co-insurance

Co-pay applies to the office visit charge only.

Services are limited to those stated in the plan document.

Specialist visit Minimum annual care requirements for 25 chronic diseases

$25 co-pay/visit No charge


Co-pay applies to the office visit charge only.


Other practitioner office visit No coverage for chiropractor or acupuncture

No coverage for chiropractor or acupuncture

-none-

Preventive care/screening/ immunization

No charge 60% co-insurance Services are limited to those mandated by the Patient Protection Affordable Care Act.

If you have a test

Diagnostic test (x-ray, blood work) Minimum annual care requirements for 25 chronic diseases

$50 co-pay/service No charge


-none-


Imaging (CT/PET scans, MRIs) $400 co-pay/image 60% co-insurance -none-



Common




Provider

If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.caremark.com

Generic drugs $15 co-pay retail & $37.50 co-pay mail order

Not covered Limit of 34 day supply retail & 90 day supply mail order.

Preferred brand drugs $25 co-pay retail & $62.50 co-pay mail order


Non-preferred brand drugs $75 co-pay retail & $187.50 co-pay mail order


Specialty drugs Not covered Not covered -none-

If you have outpatient surgery

Facility fee (e.g., ambulatory surgery center)

Not covered Not covered -none-

Physician/surgeon fees Not covered Not covered -none-

If you need immediate medical attention

Emergency room services $400 co-pay/visit $400 co-pay/visit Co-pay applies to network out-of-pocket. Non-network subject to network out-of-pocket.

Emergency medical transportation Not covered Not covered -none-

Urgent care Primary care physician $15 co-pay/visit; Specialist $25 co-pay/visit

60% co-insurance Co-pay applies to the office visit charge only.

If you have a hospital stay

Facility fee (e.g., hospital room) Not covered Not covered -none-

Physician/surgeon fee Primary care physician $15 co-pay/visit; Specialist $25 co-pay/visit

Not covered Surgeon fees are not covered.

If you have mental health, behavioral health, or substance abuse needs

Mental/Behavioral health outpatient services


Mental/Behavioral health inpatient services


Substance use disorder outpatient services




Common




Provider

Substance use disorder inpatient services


If you are pregnant Prenatal and postnatal care 0% co-insurance 60% co-insurance No charge for routine prenatal.

Delivery and all inpatient services Not covered Not covered -none-

If you need help recovering or have other special health needs

Home health care Not covered Not covered -none-

Rehabilitation services Not covered Not covered -none-

Habilitation services Not covered Not covered -none-

Skilled nursing care Not covered Not covered -none-

Durable medical equipment Not covered Not covered -none-

Hospice service Not covered Not covered -none-

If your child needs dental or eye care

Eye exam Not covered Not covered -none-

Glasses Not covered Not covered -none-

Dental check-up Not covered Not covered -none-

Excluded Services & Other Covered Services:

Services Your Plan Does NOT Cover (This isn’t a complete list. Check your policy or plan document for other excluded services.)

Acupuncture

Bariatric surgery

Chiropractic care

Cosmetic surgery

Dental care (Adult)

Hearing aids

Infertility

Long-term care

Non-emergency care when traveling outside the U.S.

Private duty nursing

Routine eye care (Adult)

Routine foot care

Other Covered Services (This isn’t a complete list. Check your policy or plan document for other covered services and your costs for these services.)

Weight loss programs (PPACA services only)



Your Rights to Continue Coverage:

If you lose coverage under the plan, then depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply.

For more information on your rights to continue coverage, contact the plan at 800-278-5488. You may also contact your state insurance department, the US Department of Labor, Employee Benefits Security Administration at 866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human Services at 877-267-2323 x61565 or www.ciio.dms.gov.

Your Grievance and Appeals Rights:

If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: Key Benefit Administrators at 800-278-5488 or Employee Benefits Security Administration at 1-866-444-3272. www.dol.gov/ebsa/healthreform

Does this Coverage Provide Minimum Essential Coverage?

The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coverage.

Does this Coverage Meet the Minimum Value Standard?

The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. This plan does not prevent an otherwise qualified individual from obtaining a premium tax credit through the Health Care Marketplace.

Language Access Services: SPANISH (Español): Para obtener asistencia en Español, llame al 800-278-5488.

TAGALOG (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 800-278-5488.

CHINESE (中文): 如果需要中文的帮助， 800-278-5488.

NAVAJO (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 800-278-5488.

––––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next page.––––––––––––––––––––––

http://www.dol.gov/ebsa

http://www.ciio.dms.gov/

http://www.dol.gov/ebsa/healthreform

LaSalle Network MVP Health Plan: Key Benefit Administrators Coverage Period: 01/01/2015 – 12/31/2015 Coverage Examples Coverage for: Individual or Family | Plan Type: PPO


Having a baby (normal delivery)

Managing type 2 diabetes (routine maintenance of

a well-controlled condition)

About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans.

Amount owed to providers: $7,540 Plan pays $190 Patient pays $7,350 Sample care costs:

Hospital charges (mother) $2,700

Routine obstetric care $2,100

Hospital charges (baby) $900

Anesthesia $900

Laboratory tests $500

Prescriptions $200

Radiology $200

Vaccines, other preventive $40

Total $7,540

Patient pays:

Deductibles $0

Copays $640

Coinsurance $0

Limits or exclusions $6,710

Total $7,350

Amount owed to providers: $5,400 Plan pays $3,160 Patient pays $2,240

Sample care costs:

Prescriptions $2,900

Medical Equipment and Supplies $1,300

Office Visits and Procedures $700

Education $300

Laboratory tests $100

Vaccines, other preventive $100

Total $5,400

Patient pays:

Deductibles $0

Copays $890

Coinsurance $0

Limits or exclusions $1,350

Total $2,240

Note: These numbers assume the patient is participating in our diabetes wellness program. If you have diabetes and do not participate in the wellness program, your costs may be higher. For more information about the diabetes wellness program, please contact: 800-352-5071.

This is not a cost estimator.

Don’t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different.

See the next page for important information about these examples.

LaSalle Network MVP Health Plan: Key Benefit Administrators Coverage Period: 01/01/2015 – 12/31/2015 Coverage Examples Coverage for: Individual or Family | Plan Type: PPO


Questions and answers about the Coverage Examples:

What are some of the assumptions behind the Coverage Examples?

Costs don’t include premiums.

Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren’t specific to a particular geographic area or health plan.

The patient’s condition was not an excluded or preexisting condition.

All services and treatments started and ended in the same coverage period.

There are no other medical expenses for any member covered under this plan.

Out-of-pocket expenses are based only on treating the condition in the example.

The patient received all care from in-network providers. If the patient had received care from out-of-network providers, costs would have been higher.

What does a Coverage Example show?

For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn’t covered or payment is limited.

Does the Coverage Example predict my own care needs?

No. Treatments shown are just examples.

The care you would receive for this condition could be different based on your doctor’s advice, your age, how serious your condition is, and many other factors.

Does the Coverage Example predict my future expenses?

No. Coverage Examples are not cost

estimators. You can’t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your

providers charge, and the reimbursement your health plan allows.

Can I use Coverage Examples to compare plans?

Yes. When you look at the Summary of

Benefits and Coverage for other plans, you’ll find the same Coverage Examples. When you compare plans, check the “Patient Pays” box in each example. The smaller that number, the more coverage the plan provides.

Are there other costs I should consider when comparing plans?

Yes. An important cost is the premium

you pay. Generally, the lower your premium, the more you’ll pay in out-of-pocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses.

General Notice of COBRA Continuation Coverage Rights

Introduction

You’re getting this notice because you recently gained coverage under a group health plan. This

notice has important information about your right to COBRA continuation coverage, which is a

temporary extension of coverage under the Plan. This notice explains COBRA continuation

coverage, when it may become available to you and your family, and what you need to do

to protect your right to get it. When you become eligible for COBRA, you may also become

eligible for other coverage options that may cost less than COBRA continuation coverage.

The right to COBRA continuation coverage was created by a federal law, the Consolidated

Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can

become available to you and other members of your family when group health coverage would

otherwise end. For more information about your rights and obligations under the Plan and under

federal law, you should review the Plan’s Summary Plan Description or contact the Plan

Administrator.

You may have other options available to you when you lose group health coverage. For

example, you may be eligible to buy an individual plan through the Health Insurance

Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs

on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a

30-day special enrollment period for another group health plan for which you are eligible (such

as a spouse’s plan), even if that plan generally doesn’t accept late enrollees.

What is COBRA continuation coverage?

COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end

because of a life event. This is also called a “qualifying event.” Specific qualifying events are

listed later in this notice. After a qualifying event, COBRA continuation coverage must be

offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent

children could become qualified beneficiaries if coverage under the Plan is lost because of the

qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation

coverage must pay for COBRA continuation coverage.

If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the

Plan because of the following qualifying events:

• Your hours of employment are reduced, or

• Your employment ends for any reason other than your gross misconduct.

If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your

coverage under the Plan because of the following qualifying events:

• Your spouse dies;

• Your spouse’s hours of employment are reduced;

• Your spouse’s employment ends for any reason other than his or her gross misconduct;

• Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or

• You become divorced or legally separated from your spouse.

Your dependent children will become qualified beneficiaries if they lose coverage under the Plan

because of the following qualifying events:

• The parent-employee dies;

• The parent-employee’s hours of employment are reduced;

• The parent-employee’s employment ends for any reason other than his or her gross

misconduct;

• The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both);

• The parents become divorced or legally separated; or

• The child stops being eligible for coverage under the Plan as a “dependent child.”

When is COBRA continuation coverage available?

The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan

Administrator has been notified that a qualifying event has occurred. The employer must notify

the Plan Administrator of the following qualifying events:

• The end of employment or reduction of hours of employment;

• Death of the employee;

• The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both).

For all other qualifying events (divorce or legal separation of the employee and spouse or a

dependent child’s losing eligibility for coverage as a dependent child), you must notify the

Plan Administrator within 60 days after the qualifying event occurs. You must provide

this notice to: Key Benefits Administrators.

How is COBRA continuation coverage provided?

Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA

continuation coverage will be offered to each of the qualified beneficiaries. Each qualified

beneficiary will have an independent right to elect COBRA continuation coverage. Covered

employees may elect COBRA continuation coverage on behalf of their spouses, and parents may

elect COBRA continuation coverage on behalf of their children.

COBRA continuation coverage is a temporary continuation of coverage that generally lasts for

18 months due to employment 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.

There are also ways in which this 18-month period of COBRA continuation coverage can be

extended:

Disability extension of 18-month period of COBRA continuation coverage

If you or anyone in your family covered under the Plan is determined by Social Security to be

disabled and you notify the Plan Administrator in a timely fashion, you and your entire family

may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a

maximum of 29 months. The disability would have to have started at some time before the 60th

day of COBRA continuation coverage and must last at least until the end of the 18-month period

of COBRA continuation coverage. Second qualifying event extension of 18-month period of continuation coverage

If your family experiences another qualifying event during the 18 months of COBRA

continuation coverage, the spouse and dependent children in your family can get up to 18

additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is

properly notified about the second qualifying event. This extension may be available to the

spouse and any dependent children getting COBRA continuation coverage if the employee or

former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both);

gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as

a dependent child. This extension is only available if the second qualifying event would have

caused the spouse or dependent child to lose coverage under the Plan had the first qualifying

event not occurred.

Are there other coverage options besides COBRA Continuation Coverage?

Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options

for you and your family through the Health Insurance Marketplace, Medicaid, or other group

health plan coverage options (such as a spouse’s plan) through what is called a “special

enrollment period.” Some of these options may cost less than COBRA continuation coverage.

You can learn more about many of these options at www.healthcare.gov.

If you have questions

Questions concerning your Plan or your COBRA continuation coverage rights should be

addressed to the contact or contacts identified below. For more information about your rights

under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient

Protection and Affordable Care Act, and other laws affecting group health plans, contact the

nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits

Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone

numbers of Regional and District EBSA Offices are available through EBSA’s website.) For

more information about the Marketplace, visit www.HealthCare.gov.

Keep your Plan informed of address changes

To protect your family’s rights, let the Plan Administrator know about any changes in the

addresses of family members. You should also keep a copy, for your records, of any notices you

send to the Plan Administrator.

Plan contact information

KEY BENEFIT ADMINISTRATORS

PO BOX 1901

FORT MILL, SC 29716

-or

Sirmara Campbell Twohill

Chief Human Resources Officer

p. 312.419.1700 | d.312.496.6564

[email protected]

Statement of HIPAA Portability Rights

IMPORTANT — KEEP THIS CERTIFICATE. This certificate is evidence of your coverage under

this plan. Under a federal law known as HIPAA, you may need evidence of your coverage to reduce a

preexisting condition exclusion period under another plan, to help you get special enrollment in another

plan, or to get certain types of individual health coverage even if you have health problems.

Preexisting condition exclusions. Some group health plans restrict coverage for medical conditions

present before an individual’s enrollment. These restrictions are known as “preexisting condition

exclusions.” A preexisting condition exclusion can apply only to conditions for which medical advice,

diagnosis, care, or treatment was recommended or received within the 6 months before your “enrollment

date.” Your enrollment date is your first day of coverage under the plan, or, if there is a waiting period,

the first day of your waiting period (typically, your first day of work). In addition, a preexisting condition

exclusion cannot last for more than 12 months after your enrollment date (18 months if you are a late

enrollee). Finally, a preexisting condition exclusion cannot apply to pregnancy and cannot apply to a

child who is enrolled in health coverage within 30 days after birth, adoption, or placement for adoption.

If a plan imposes a preexisting condition exclusion, the length of the exclusion must be reduced by the

amount of your prior creditable coverage. Most health coverage is creditable coverage, including group

health plan coverage, COBRA continuation coverage, coverage under an individual health policy,

Medicare, Medicaid, State Children's Health Insurance Program (SCHIP), and coverage through high-risk

pools and the Peace Corps. Not all forms of creditable coverage are required to provide certificates like

this one. If you do not receive a certificate for past coverage, talk to your new plan administrator.

You can add up any creditable coverage you have, including the coverage shown on this certificate.

However, if at any time you went for 63 days or more without any coverage (called a break in coverage) a

plan may not have to count the coverage you had before the break.

� Therefore, once your coverage ends, you should try to obtain alternative coverage as soon as

possible to avoid a 63-day break. You may use this certificate as evidence of your creditable

coverage to reduce the length of any preexisting condition exclusion if you enroll in another plan.

Right to get special enrollment in another plan. Under HIPAA, if you lose your group health plan

coverage, you may be able to get into another group health plan for which you are eligible (such as a

spouse’s plan), even if the plan generally does not accept late enrollees, if you request enrollment within

30 days. (Additional special enrollment rights are triggered by marriage, birth, adoption, and placement

for adoption.)

� Therefore, once your coverage ends, if you are eligible for coverage in another plan (such as a

spouse’s plan), you should request special enrollment as soon as possible.

Prohibition against discrimination based on a health factor. Under HIPAA, a group health plan may

not keep you (or your dependents) out of the plan based on anything related to your health. Also, a group

health plan may not charge you (or your dependents) more for coverage, based on health, than the amount

charged a similarly situated individual.

HIPAA Notice of Special Enrollment Rights

If you are declining enrollment for yourself or your dependents (including your spouse) because

of other health insurance or group health plan coverage, you may be able to enroll yourself and

your dependents in this plan if you or your dependents lose eligibility for that other coverage (or

if the employer stops contributing towards your or your dependents' other coverage). However,

you must request enrollment within 30 days after your or your dependents' other coverage ends

(or after the employer stops contributing toward the other coverage).

If you have a new dependent as a result of marriage, birth, adoption, or placement for adoption,

you may be able to enroll yourself and your dependents. However, you must request enrollment

within 30 days after the marriage, birth, adoption, or placement for adoption.

If you decline enrollment for yourself or for an eligible dependent (including your spouse) while

Medicaid coverage or coverage under a state children's health insurance program is in effect, you

may be able to enroll yourself and your dependents in this plan if you or your dependents lose

eligibility for that other coverage. However, you must request enrollment within 60 days after

your or your dependents' coverage ends under Medicaid or a state children's health insurance

program.

If you or your dependents (including your spouse) become eligible for a state premium assistance

subsidy from Medicaid or through a state children's health insurance program with respect to

coverage under this plan, you may be able to enroll yourself and your dependents in this plan.

However, you must request enrollment within 60 days after your or your dependents'

determination of eligibility for such assistance.

To request special enrollment or obtain more information, contact:

Sirmara Campbell Twohill

Chief Human Resources Officer

p. 312.419.1700 | d.312.496.6564

[email protected]

Right to individual health coverage. Under HIPAA, if you are an “eligible individual,” you have a right

to buy certain individual health policies (or in some states, to buy coverage through a high-risk pool)

without a preexisting condition exclusion. To be an eligible individual, you must meet the following

requirements:

• You have had coverage for at least 18 months without a break in coverage of 63 days or more;

• Your most recent coverage was under a group health plan (which can be shown by this certificate);

• Your group coverage was not terminated because of fraud or nonpayment of premiums;

• You are not eligible for COBRA continuation coverage or you have exhausted your COBRA benefits

(or continuation coverage under a similar state provision); and

• You are not eligible for another group health plan, Medicare, or Medicaid, and do not have any other

health insurance coverage.

The right to buy individual coverage is the same whether you are laid off, fired, or quit your job.

� Therefore, if you are interested in obtaining individual coverage and you meet the other criteria to

be an eligible individual, you should apply for this coverage as soon as possible to avoid losing

your eligible individual status due to a 63-day break.

State flexibility. This certificate describes minimum HIPAA protections under federal law. States may

require insurers and HMOs to provide additional protections to individuals in that state.

For more information. If you have questions about your HIPAA rights, you may contact your state

insurance department or the U.S. Department of Labor, Employee Benefits Security Administration

(EBSA) toll-free at 1-866-444-3272 (for free HIPAA publications ask for publications concerning

changes in health care laws). You may also contact the CMS publication hotline at 1-800-633-4227 (ask

for “Protecting Your Health Insurance Coverage”). These publications and other useful information are

also available on the Internet at: http://www.dol.gov/ebsa, the DOL’s interactive web pages - Health

Elaws, or http://www.cms.hhs.gov/HealthInsReformforConsume.

25915-051-1306

WOMEN’S HEALTH AND CANCER RIGHTS ACT NOTICE

The Women's Health and Cancer Rights Act of 1998 (WHCRA) was signed into law on October 21, 1998. The WHCRA which amends ERISA, requires group health plans that provide coverage for mastectomies to also provide coverage for reconstructive surgery and prostheses following mastectomies. Because your group health plan offers coverage for mastectomies, WHCRA applies to your plan. The law mandates that a participant who is receiving benefits, on or after the law's effective date, for a covered mastectomy and who elects breast reconstruction in connection with the mastectomy will also receive coverage for: 1. Reconstruction of the breast on which the mastectomy has been performed 2. Surgery and reconstruction of the other breast to produce a symmetrical appearance;

and 3. Prosthesis and treatment of physical complications of all stages of mastectomy, including

lymphedemas This coverage will be provided in consultation with the patient and the patient’s attending physician and will be subject to the same annual deductible, coinsurance and/or copayment provisions otherwise applicable under the policy/plan.

final open enrollment letter - lasalle network

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