2015 Benefits Open Enrollment - East Longmeadow, MA

Town of East Longmeadow, 60 Center Square, East Longmeadow, MA 01028

Disclaimer: The Town retains the right to adopt rules and regulations as provided for under MGL Chapter 32B, Section 14. In accordance with

Chapter 150 E Massachusetts General Laws, health insurance and other benefit costs are subject to appropriation by the Town of East Longmeadow.

2015 Benefits

Open Enrollment For Employees and Non-Medicare Eligible Retirees and/or their dependents

April 28 – May 27, 2014 (July 1, 2014 to June 30, 2015 coverage)

HEALTH WELLNESS DENTAL

This document is available, upon request, in alternate formats including large print.

Please direct your request to: Corinne Tranghese, Benefits Administration Manager

(413)525-5400 extension 1007 or via email to [email protected]

This document is available on the Town’s website at www.eastlongmeadowma.gov/benefits

http://www.eastlongmeadowma.gov/benefits

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What to do during open enrollment?

1) Evaluate your current coverage and determine if you need to switch plans or enroll in our coverage. Complete benefits packet including Summaries of Benefits and Coverage, plan summary comparisons, and premiums can be obtained by attending the Benefits Fair at Birchland Park Middle School on May 15, 2014 - 11 am to 5 pm, contacting Corinne Tranghese at 525-5400 X 1007 or visiting www.eastlongmeadowma.gov/benefits. Hard copies can be picked up in the Selectmen’s office at the Town Hall.

2) If you do not make any changes your current coverage will continue. If you are covering a spouse, you must provide a copy of the first page of your most recent 1040 or 1040A tax form. If you are covering an ex-spouse you must provide a copy of the divorce decree stating you are responsible to cover their health insurance needs and a signed statement that neither of you have remarried. An ex-spouse of a retiree divorced or retired after 11/29/2011 is not eligible for coverage under the Town’s group health insurance. Documentation must be received by May 27, 2014 or their coverage will terminate on June 30, 2014.

3) If you are retiring this year contact Corinne Tranghese by May 31, 2014 to discuss what must be done to maintain your eligibility for coverage.

4) If your coverage is through retirement from the Town of East Longmeadow and you and/or your dependents are 65 years of age or older you must submit the letter from social security, which is dated January 2, 2014 through March 31, 2014 and states you are not eligible for premium free Medicare Part B retired from the Town of East Longmeadow otherwise you must submit a Medicare card with Parts A&B effective 07/2014 or earlier and you must submit an enrollment form in a Medicare Wrap/Supplement/Advantage plan by 05/27/2014.

5) If your coverage is through retirement from the Town of East Longmeadow and you and/or your dependents are approaching 65 years of age you must apply for Medicare Parts A&B. Contact Corinne Tranghese 4 months before your birthday for help.

Changes permitted to Health and Dental Coverage during Open Enrollment

1) Enroll yourself or your dependents for the first time - If you are regularly scheduled to work 20 or more hours per week and would like to add new coverage or add a dependent to existing coverage you must submit an enrollment form with all the appropriate documentation by May 27, 2014. Coverage will be effective July 1, 2014.

2) Terminate existing coverage for a dependent or your entire family - submit a termination form prior to May 27, 2014. Coverage will end June 30, 2014.

3) Switch plans – Terminate enrollment in your current plan and enroll in any of the other plans offered by submitting a termination form and an enrollment form with necessary documents.


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Necessary Documentation for Dependent Enrollment 1) Spouse – Copy of state issued marriage certificate (church or Justice of the Peace certificates

are not accepted) and a copy of the first page of your most recent 1040 or 1040A tax form. Financial figures may be blacked out. Federal Tax Return requirement does not apply to same-sex marriages (an affidavit will be provided if necessary).

2) Ex-spouse – Copy of health insurance provision language that states the subscriber must maintain coverage for ex-spouse from Divorce Decree and a copy of the first page of the divorce decree listing names of both parties and a signature page. A signed statement must also be provided stating that neither party has remarried. An ex-spouse of a retiree divorced or retired after 11/29/2011 is not eligible for coverage under the Town’s group health insurance.

3) Children to Age 26 – Copy of the state issued birth certificate for each child or a Court Order

documenting guardianship or adoption papers. Birth certificates must be the long form stating the names of both parents and cannot be an abstract or a hospital record.

What is New?

1) Dental - Effective 07/01/2014, our dental carrier is changing to MetLife. At a recent meeting with the Insurance Advisory Committee, it was decided to recommend to the Board of Selectmen to make this change. They are offering lower rates with as good as or better coverage than we currently have with a $2500/per person annual maximum. Adult dependents will be able to remain on our dental until 26 years of age. Current coverage will automatically transfer and new identification cards should be received soon!

2) Vision – Metlife is offering an affordable vision plan to help pay for vision needs including glasses and contacts not covered by health insurance.

3) Optional Life Insurance – Metlife is offering guaranteed issue optional life insurance. Coverage for spouses is available and coverage is effective July 1, 2014. Employees who sign up during open enrollment and retire in June can still take the coverage with them as a retiree and continue paying the group rates.

4) This is a good time to evaluate your needs for some of our other voluntary products from Boston Mutual, AFLAC, Colonial, Trustmark, UNUM, Mass Mutual deferred Comp and companies offering 403b plans.

Information regarding all these plans can be obtained from the representatives by attending the Benefits Fair on May 15, 2014 from 11 am to 5 pm at Birchland Park Middle School – 50 Hanward Hill, East Longmeadow, MA 01028. This complete packet can be viewed at www.eastlongmeadowma.gov/benefits or by contacting Corinne Tranghese at 525-5400 X 1007.


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The Scantic Valley Regional Health Trust-Saving you Money The Scantic Valley Regional Health Trust (SVRHT), the joint purchase group through which the Town of East Longmeadow purchases health coverage, will offer FY15 health plan rates that are the same as Fiscal Year 2014 rates. The Trust meets regularly at the Wilbraham Town Office Building and meeting minutes are posted on the SVRHT website at www.scantichealth.org/. High Technology Imaging Services - The SVRHT voted to waive the co-pays for high technology imaging services when employees select from a list of non-hospital based imaging centers for scheduled services. Call the customer service number on the back of your health insurance card to find out if the imaging center you have been referred to will require a co-payment or where you may be able to go instead and not pay a co-payment. Wellness Program - SVRHT has hired a Wellness Coordinator, Lyn Hollinger, to manage an aggressive Wellness Program. The SVRHT Wellness Program offers employees and retirees and their families health promotion programs, disease screenings, and general behavior risk reduction programs, some with cash rewards. This is a long-term cost reduction strategy, rather than a cost shifting strategy. Participation in the Wellness programs is a Win-Win for employees and employers - improving quality of life while putting the SVRHT on track for reducing health costs for preventable conditions. Please consider participating in the SVRHT Wellness programs. For more information, please visit the SVRHT website at www.scantichealth.org or contact Lynn Hollinger at (413) 847-0249 or [email protected]. Fitness Benefits (i.e. Gym membership or Weight Loss program) - All three insurance providers (BC/BS, HNE and Tufts) offer cash reimbursement benefits on fitness programs (club membership or fitness classes) with their active employee health plans. Please contact your insurance provider directly. Abacus: Two Special Health Benefits Savings Programs - The following two programs, a free prescription drug program and a program for disease management including free diabetes medications and supplies, are offered through a contract between the SVRHT and Abacus Health Solutions, a firm specializing in the design and administration of incentive based health management programs. Your participation is voluntary and completely confidential. It is important to note that no medical or health information about you or your family will ever be shared with the Town of East Longmeadow. Employees and Retirees on our self-insured group plans and select Medicare wrap/supplement plans are eligible to participate in these programs. 1. Free Prescription Program - myMedicationAdvisor is a voluntary prescription medication safety

and savings program provided free of charge as part of the benefits package for employees who are enrolled in self-insured health plans. myMedicationAdvisor is primarily a web-based program but does have a paper-based ordering process and a customer-friendly telephonic component for those without computers. The program offers education in the area of medication management, and provides answers to confidential medication questions. In addition, the program offers selected maintenance medications free of charge which are purchased more cost efficiently from international vendors, and which are offered to employees. Medication lists are updated every

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three months and are posted on the SVRHT website at www.scantichealth.org. myMedicationAdvisor’s website is www.myMedicationAdvisor.com. Log on and start saving on prescription medications. If you would rather speak to somebody, please call toll free 1-877-467-3133. 2. Diabetes Care Rewards Program - The Good Health Gateway Diabetes Care Rewards Program offers free of charge diabetes medications and supplies for subscribers of self-insured health plans who complete program requirements. If you have ever been told you have diabetes, pre-diabetes, elevated or high blood sugar, hyperglycemia, or low insulin levels, and you are encouraged to find out about participating in the Diabetes Care Rewards Program and receive its benefits. The purpose of this program is to encourage good diabetes care by having important screenings and exams. In addition to better health, the reward for meeting the program requirements is FREE diabetes medications and supplies ($0 co-pays). To learn more, call their helpline at (800)-643-8028 or register online at www.GoodHealthGateway.com.

The Affordable Care Act (ACA) There are no benefit plan changes on the Active Employee and Non-Medicare Retiree Health Plans for FY 2015, and premium rates remain the same as in FY 2014. The Affordable Care Act (ACA), offers certain new coverage, payment limits and other provisions which the Scantic Valley Regional Health Trust (SVRHT) Board discussed and voted to include in their plans. These include: • Coverage of routine patient costs for services and items furnished in connection with clinical trials (health plans may not discriminate against individuals who participate in qualified clinical trials). • Coverage of wigs in certain circumstances. • Annual or lifetime dollar limits must be removed from all “essential health benefits” as defined by the ACA. • Beginning with plan years renewing on or after January 1, 2014, all group health plans need to include out of pocket maximums of no more than $6,350 for individuals and $12,700 for families. In 2014, all medical cost sharing must be applied to the out of pocket maximum. (Note: In 2015, all medical and pharmacy benefits must be applied to the out of pocket maximum). • Beginning with plan years renewing on or after January 1, 2014, group health plans cannot impose pre-existing condition exclusions, regardless of age. • For plan years beginning on or after January 1, 2015, employers will be prohibited from establishing waiting periods of more than 90 days for new enrollees. • Plans that require designation of a PCP, must permit each participant, beneficiary, and enrollee to designate any available participating PCP.

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Exchange Notification - Effective October 1, 2013, employers must notify their employees: About the Health Insurance Marketplace: • That, depending on their income and what coverage may be offered by the employer, they may be able to get lower cost private insurance in the Marketplace; and • That if they buy insurance through the Marketplace, they may lose the employer contribution (if any) to their health benefits. The notice in its entirety is included at the very end of this document. NOTICE: All health plans offered by the Town are considered affordable and meet minimum coverage standards according to federal definitions. Summary of Benefit and Coverage - Under the Affordable Care Act all Health Plans must provide a Summary of Benefits and Coverage for each health plan offered which follows a described format and contains information designed to assist consumers to evaluate and compare the plans. Summaries of Benefits and Coverage for each plan offered from BCBS, Health New England, and Tufts Health Plan are available online on our website at www.eastlongmeadowma.gov/benefits or in hard copy in the Selectmen’s Office. Dependent Coverage for Adult Children to Age 26 - The Affordable Care Act requires plans and issuers that offer dependent coverage to make the coverage available until a child reaches the age of 26. Both married and unmarried children qualify for this coverage. This rule applies to all plans in the individual market and to new employer plans. It also applies to existing employer plans. Beginning in 2014, children up to age 26 can stay on their parent's employer plan, even if they have another offer of coverage through their employer. To add a child to your insurance plan, you need: photocopy of town- or city-issued birth certificate (long form listing parents’ names, hospital records are not accepted), or Court Order documenting guardianship, or adoption papers. IMPORTANT: It is the responsibility of the employee to notify the employer of any changes in Adult Child status. If you do not notify the employer of changes, and if it is found that your Adult Child is ineligible, you could be responsible for all medical charges that he/she incurs. Massachusetts Health Care Reform - All Massachusetts residents have been required to maintain health insurance since passing of the Massachusetts Health Care Reform Act in 2006. Those who cannot show that they have health insurance have to pay a penalty on their Massachusetts income tax return. On June 28, 2012, the Supreme Court upheld the constitutionality of the Affordable Care Act, the federal health reform law passed in 2010. When the Affordable Care Act (ACA) takes effect


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in 2014, Massachusetts residents will face federal health insurance requirements as well as state requirements. As a result of the Affordable Care Act: • a MassHealth expansion will allow new categories of residents to qualify for MassHealth Standard benefits or new MassHealth CarePlus coverage • legally present low-income non-citizens who do not qualify for MassHealth coverage will be eligible for federally funded health insurance subsidies • the federal government will give health insurance tax credits and subsidies to low and moderate-income residents (up to 400% FPG) to help lower their health insurance costs • seniors with Medicare Part D prescription drug plans will pay less for prescription drugs during the coverage gap known as the donut hole, and the coverage gap will eventually be eliminated by 2020. (See HealthCare.gov for details.) • residents without health insurance may face federal penalties and state penalties To learn about how the Affordable Care Act changes might affect you, see MassResources.org. NOTICE: All group health plans offered by the Town of East Longmeadow meet Minimum Creditable Coverage Standards which satisfies the individual mandate requirement of the Massachusetts Health Care Reform Act (Chapter 58 of the Acts of 2006)

Children’s Health Insurance Program (CHIP) If you are eligible for health coverage from your employer, but are unable to afford the premiums, some States, including Massachusetts, have premium assistance programs that can help pay for coverage. If you or your dependents are already enrolled in Medicaid (Medicaid in Massachusetts is called MassHealth) or CHIP and you live in Massachusetts (or any of the other states that offer premium assistance), contact your State Medicaid or CHIP office to find out if premium assistance is available at http://www.mass.gov/MassHealth or by calling 1-800-462-1120. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, visit http://www.insurekidsnow.gov/state/mass/, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW to find out how to apply. If it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, your employer’s health plan is required to permit you and your dependents to enroll in the plan within 60 days of being determined eligible for premium assistance (not only during Open Enrollment!). For more information or to find out which states offer this program (if you do not live in Massachusetts), go to the Department of Labor U.S. Department of Health & Human Services

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Employee Benefits Security Administration Centers for Medicare and Medicaid Services website at www.dol.gov/ebsa, www.cms.hhs.gov or call 1-866-444-EBSA (3272) 1-877-267-2323 ext 61565.

Women’s Health and Cancer Rights Act- WHCRA-Notice The Women’s Health and Cancer Rights Act (WHCRA) helps protect many women with breast cancer who choose to have their breasts rebuilt (reconstructed) after a mastectomy. Mastectomy is surgery to remove all or part of the breast. This federal law requires most group insurance plans that cover mastectomies to also cover breast reconstruction. It was signed into law on October 21, 1998. The United States Departments of Labor and Health and Human Services oversee this law. The law applies to group health plans for plan years starting on or after October 1, 1998, and to group health plans, health insurance companies, and HMOs, as long as the plan covers medical and surgical costs for mastectomy. Under the WHCRA, mastectomy benefits must cover: Reconstruction of the breast that was removed by mastectomy Surgery and reconstruction of the other breast to make the breasts look symmetrical or balanced after mastectomy; Any external breast prostheses (breast forms that fit into your bra) that are needed before or during the reconstruction; Any physical complications at all stages of mastectomy, including lymphedema (fluid build-up in the arm and chest on the side of the surgery); Mastectomy benefits may have a yearly deductible and may require that you pay co-insurance. Co-insurance is when less than the full amount of the bill is paid by the insurance company and the patient must pay the difference.

Consolidated Omnibus Budget Reconciliation Act (COBRA)-Notice The federal Consolidated Omnibus Budget Reconciliation Act (COBRA) gives employees and qualified beneficiaries the right to continue health insurance coverage for up to 18 months (up to 36 months in certain circumstances) under the Town's group health plan when a "qualifying event" would normally result in loss of eligibility. Included are such events as resignation, termination of employment, a reduction in an employee's work hours, an unpaid leave of absence, divorce or legal separation, loss of dependent eligibility, or the death of an employee. Under COBRA the employee or beneficiary pays the full cost of the premium at the Town of East Longmeadow's group rate. Coverage is subject to timely premium payments to the Town of East Longmeadow. For more information please visit the website of the U.S. Department of Labor at: http://www.dol.gov/dol/topic/health-plans/cobra.html.

HIPAA Health Insurance Portability & Accountability Act of 1996 Special Enrollment Rights (HIPAA) - Employees eligible for health insurance have the right to decline health insurance coverage if they have other coverage and may in the future be able to enroll themselves and their dependents on a town sponsored plan if they request coverage within 30 days after their other coverage ends. In addition, if you have a new dependent as a result of marriage, birth

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or adoption, you may be able to enroll yourself and your dependents, provided that you request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption and provide proof (e.g., marriage certificate, birth certificate, adoption record) of this “qualifying event”. HIPAA limits the circumstances under which coverage may be excluded for preexisting medical conditions. Under the law, a pre-existing conditions exclusion generally may not be imposed for more than 12 months. It also provides for the right to receive a certificate of health coverage from your employer. For more information please visit the website of the US Department of Labor at http://www.dol.gov/ebsa/faqs/faq_consumer_hipaa.html. HIPAA Notice of Privacy Practices (HIPAA) - This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please be advised that the Town of East Lognmeadow is a member of the Scantic Valley Regional Health Trust (SVRHT), a joint purchasing group. SVRHT contracts with Group Benefits Strategies (GBS) to administer the health insurance program for the member communities. Even for self-insured plans, the Town of East Longmeadow does not directly pay for services and does not receive Private Health Information (PHI). Complete notice can be found at the end of this document.

Medicare MGL Chapter 32B Section 18A

In accordance with M. G. L. Chapter 32B, Section 18A, retirees, their spouses and dependents shall enroll in Medicare health benefits as soon as they are eligible. Failure to fully enroll in Medicaremay jeopardize future participation the Town’s contributory group health insurance plan. Upon enrollment in Medicare eligible retirees and their spouses and dependents will be eligible to enroll in supplemental coverage to Medicare. Retirees need to apply for Medicare to discover whether they are eligible or not. Retirees may be eligible through a current or former spouse. The only certain way to determine your eligibility is to apply for Medicare Benefits.

Medicare Modernization Act of 2003 – Medicare D The Medicare Modernization Act of 2003 requires all employers that offer prescription drug coverage to notify covered employees and retirees who are Medicare eligible, or who may be Medicare eligible, as to the value of the current prescription drug benefit compared to that of the optional Medicare Part D drug benefit that went into effect on January 1, 2006. NOTICE: All of the health plans offered through the Town of East Longmeadow provide prescription drug benefits that are at least as good as the standard Medicare Part D prescription drug benefit, and these plans are considered to be “creditable coverage”. This statement is based on reviews performed by qualified actuaries of the prescription drug benefits and spending by the employer on each health plan compared to what Medicare would pay. Therefore, if you plan to continue to be covered under the Town of East Longmeadow’s health benefit plans, you do not need to purchase Medicare Part D*. If in the future you should

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want to purchase Part D for whatever reason, because you have been covered by a plan that has benefits as good as or better than Part D benefits, you would not be charged the Part D late enrollment premium penalty for the time you were covered by one of our group plans.

Family and Medical Leave Act – FMLA

FMLA Section 109 requires covered employers to provide employees with notice of Employee Rights and Responsibilities Under the Family and Medical Leave Act. This notification can be found at the end of this document. For additional information: www.wagehour.dol.gov or call 1-866-4US-WAGE (1-866-487-9243) TTY: 1-877-889-5627.

Health Insurance Premiums

The health insurance rates and payroll deductions will remain the same as this past year. For

detailed information please go to the website www.eastlongmeadowma.gov/benefits.

Tier Monthly Premium Town Share Subscriber Share Individual 1569.00 784.50 784.50

Blue Care Elect Family 3828.00 1914.00 1914.00

Individual 611.00 427.70 183.30 Network Blue NE

Family 1514.00 1059.80 454.20

Individual 515.00 360.50 154.50 Health New England

Family 1286.00 900.20 385.80

Individual 657.00 459.90 197.10 Tufts

Family 1642.00 1149.40 492.60

Plan Benefit Comparison Charts Disclaimer: The following pages summarize benefits of the SVRHT plans and are prepared by Group Benefits Strategies, our third party Administrator. The Subscriber Certificate(s) & applicable riders define the terms & conditions of these benefits in greater detail. Should any questions arise, the certificate(s) & riders will govern. Registered users can access their plan documents on their carrier website for full and complete plan details. The carrier documents are the only documents that describe complete plan details.

http://www.wagehour.dol.gov/


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SVRHT Plan Benefit Comparison

These pages summarize benefits of the plan(s). The Subscriber Certificate(s) & applicable riders define the terms & conditions of these benefits in greater detail. Should any questions arise, the certificate(s) & riders will govern.

Effective 07-01-2014

BLUE CROSS BLUE SHIELD HEALTH NEW

ENGLAND TUFTS HEALTH PLAN Changes/clarifications in

red font

BENEFIT NETWORK BLUE

HMO

BLUE CARE ELECT PREFERRED PPO EXCLUSIVE

EPO Choice Copay EPO In-Network Out-of-Network

Deductible None None $400 Individual None None $800 Family

Out-of-Pocket (OOP) Maximum - Once your out-of-pocket expenses for applicable services reaches this amount, you pay $0 for remainder of plan year (July 1 to June 30). NOTE: Prescription co-pays do not count towards the OOP maximum.

$2,000 per member $2,000 per member $3,000 per member $2,000 per member $2,000 per member $4,000 per family $4,000 per family $4,000 per family $4,000 per family

Lifetime Benefit Maximum

None None None None None

INPATIENT YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY

General Hospital/Mental Hospital/Substance Abuse Facility (semi-private room and board and special services)

$500 copay $500 copay 20% coinsurance* $500 copay $500 copay

Nothing for emergency/accident admissions

Physician Services Nothing Nothing 20% coinsurance* Nothing Nothing

Nothing for

emergency/accident admissions

Skilled Nursing Facility Nothing to 100

days per calendar year benefit maximum

Nothing to 100 days per calendar year benefit maximum combined with out of network days

20% coinsurance* to 100 days per calendar year benefit maximum, combined with in-network days

Up to 100 days per calendar year, combined with inpatient rehabilitation

Nothing up to 100 days per calendar year

Rehabilitation Hospital Nothing to 60 days

per calendar year benefit maximum

Nothing to 60 days per calendar year benefit maximum

20% coinsurance* to 60 days per calendar year benefit maximum

Up to 100 days per calendar year, combined with inpatient rehabilitation

Nothing up to 100 days per calendar year

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ENGLAND TUFTS HEALTH PLAN

Changes/clarifications in red font BLUE CARE ELECT PREFERRED PPO


HMO In-network Out-of-network

EXCLUSIVE

EPO Choice Copay EPO

OUTPATIENT HOSPITAL

YOU PAY YOU PAY YOU PAY YOU PAY

Emergency Room Visits for Emergency or Accident Care

$100 copay (waived if admitted or for observation stay)



$100 copay, (waived if admitted)

$100 copay, (waived if admitted)

Emergency Room Visits for Medical Care




$100 copay, waived if admitted

$100 copay, waived if admitted

Surgery $150 copay $150 copay 20% coinsurance* $150 copay $150 copay

Radiation and Chemotherapy


Diagnostic X-ray and Lab


Routine Colonoscopy (without surgery)


High Cost Radiology (MRI, CT & PET)

$100 copay* - copay waived if received at non-hospital facilities

$100 copay* - copay waived if received at non-hospital facility

20% coinsurance* $100 copay* - copay waived if received at non-hospital facility

$100 copay* waived when there is an active cancer diagnosis

Hemodialysis $0 copay $0 copay 20% coinsurance* $0 copay $0 copay

Physical Therapy $20 copay to 60

visits per calendar year

$20 copay to 100 visits per calendar year

20% coinsurance* to 100 visits per calendar year

$20 copay (two months or 25 visits whichever is greatest)

$35 co-pay - 30 visits per year

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HMO In-network Out-of-network EXCLUSIVE Choice Copay EPO

EPO

PHYSICIAN'S OFFICE YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY

Surgery $20 PCP Office

$35 Specialists Office

$20 PCP Office $35 Specialists Office

20% coinsurance* $20 PCP Office $35 Specialists Office

$20 PCP Office $35 Specialists Office

Adult Preventative Exam

$0 copay $0 copay 20% coinsurance*

$0 copay $0 copay

(includes preventative lab tests)

PCP Medical Care/ Mental Health Care/ Substance Abuse Care


Well Child Care $0 copay $0 copay 20% coinsurance* $0 copay $0 copay (includes preventative lab tests)

Routine GYN Exam (one per calendar year, includes preventative lab tests)


Routine Mammogram $0 copay $0 copay 20% coinsurance* $0 copay $0 copay Routine Vision Exam $0 copay (once

every 12 months) $0 copay (once per calendar year)

All charges $0 copay (once per calendar year)

$20 copay (once per calendar year)

Specialist Office Visit $35 copay $35 copay 20% coinsurance* $35 copay $35 copay

OTHER OUTPATIENT YOU PAY YOU PAY YOU PAY YOU PAY YOU PAY

Visiting Nurse Home Health Care Nothing (Includes

Hospice Care) Nothing 20% coinsurance* Nothing Nothing

Durable Medical Equipment

Member pays 20%, plan pays 80% with no limit




Member pays 30%, plan pays 70% with no limit **breast, hand, arm and feet prosthetics Member pays 20%, plan pays 80%

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HMO In-network Out-of-network EXCLUSIVE

EPO Choice Copay EPO

Ambulance Nothing (for emergency or medically necessary transport)

Nothing (for emergency or medically necessary transport)

Nothing for accident or emergency; 20% coinsurance* other medically necessary ambulance transport

$25 co-pay per member per day (included Chair Van services)

Nothing (for emergency or medically necessary transport)

Routine Pediatric

Nothing (covered services each six months)

All charges All charges Preventative dental only; no charge after $25 deductible per child per calendar year (for children under age 12)

Not Covered

Dental (through age 11)

Chiropractor Visits All charges $20 copay per visit

(up to 12 visits per calendar year)

20% coinsurance* (up to 12 visits per calendar year)

All charges (% discount through Optum Health)

$20 copay per visit (up to 12 visits per year)

Prescription Drugs Retail: (30 day

supply) Retail: (30 day supply)

Retail: (30 day supply)

Retail: (30 day supply) Retail: (30 day supply)

Tier 1: $10.00 copay

Tier 1: $10.00 copay Tier 1: $10.00 copay Tier 1: $10.00 copay Tier 1: $10.00 copay





Mail Order: (90 day supply)












Tier 3: $110.00 copay Tier 3: $110.00 copay

Express Scripts, Inc. (ESI) is the PBM



Catamaran is the PBM for retail and mail order.

CVS Caremark is the PBM

Fitness Benefit Up to $150

reimbursement toward membership or exercise classes at a health club. See plan details. $150 reimbursement per calendar year, WeightWatchers®

Up to $150 reimbursement toward membership or exercise classes at a health club. See plan details. $150 reimbursement per calendar year, WeightWatchers®

Up to $150 reimbursement toward membership or exercise classes at a health club. See plan details. $150 reimbursement per calendar year, WeightWatchers®

Up to $150 reimbursement per calendar year fitness club membership, Aerobic and Wellness classes, Personal Trainer fees and school and town sports registration fees. $150 reimbursement per calendar year, WeightWatchers®

Up to $150 fitness reimbursement per household, per calendar year $150 reimbursement per calendar year when enrolled in a weight loss program.

*After Deductible

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Summary of Benefits

Dental Insurance - PPO 99th UCR 2.5K

Voluntary Dental

Class Description All Active Full Time Employees (regularly scheduled 20 or more

hours/week) & COBRA Participants In-Network Out-of-Network

‡

Reimbursement Negotiated Fee

Schedule R&C

99th Percentile Type A – Preventive 100% 100% Type B – Basic 80% 80% Type C – Major 50% 50% Calendar Year Deductible applies to:

Individual

Family

B & C

$50 $150

Individual

B & C

$50 $150

Individual Calendar Year Maximum (applies to A,B,C services)

$2,500 $2,500

Orthodontia 50% 50% Orthodontia Lifetime Maximum

$1,000 $1,000

‡ Out of Network benefits are payable for services rendered by a dentist who is not a participating provider. The Reasonable and Customary charge is based on the lowest of (1) the dentist’s actual charge (the ‘Actual Charge’), or (2) the charge of most dentists in the same geographic area for the same or similar services as determined by MetLife (the ‘Customary Charge’). Services must be necessary in terms of generally accepted dental standards.

Voluntary Dental Rate per Employee

All Active Full Time Employees Employee Only $39.41

Employee + Spouse $77.69

Employee + Child(ren) $77.78

Employee + Family $116.01

Rates are guaranteed from July 1, 2014 - June 30, 2016 (24 months) Current dental subscribers will be automatically transferred to the Metlife plan unless a termination form is submitted. New subscribers must submit an enrollment form. Children will be eligible for coverage to age 26. If any of your children were terminated and you want them covered you must submit an enrollment form adding them to your coverage. All forms must be received by May 27, 2014 for the changes to be effective July 1, 2014.

Please note this is just a brief summary – complete plan documents and exclusions as well as enrollment forms can be found at www.eastlongmeadowma.gov/benefits. Plan representatives will be available at the Benefits Fair on May 15, 2014 at Birchland Park Middle School 11 am to 5 pm.


Board of Selectmen Town Administrator Paul L. Federici, Chairman Nick Breault

Angela Thorpe Telephone: (413) 525-5400 X 1100

Debra A. Boronski Fax: (413) 525-1025

Email: [email protected]

CT 09/20/2013

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

The Town of East Longmeadow and its health plans ("the Health Plans") are providing this notice to you as required by the Health Insurance Portability and Accountability Act (HIPAA) and the regulations promulgated thereunder.

This Privacy Notice describes how the Health Plans may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your right to access and control your protected health information. "Protected health information" is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

Disclosures Under the Privacy Rule Under the HIPAA Privacy Rule we may and do use and disclose protected health information without your prior written authorization for certain purposes. For example, we use protected health information in providing your health coverage. We use that information for treatment (for example, to help your providers coordinate and manage your health care), for payment (for example, to provide payment to your health care providers for the health care they provide to you) and for health care operations (for example, to conduct quality assessment and improvement activities). All of the above disclosures are made only for the purposes described in this Notice or as permitted by law.

The Privacy Rule also permits disclosure of protected health information by a covered entity without the member's prior written authorization, and without providing the member the opportunity to agree or object, in the following situations:

1.) Where use or disclosure is required by law. 2.) To a public health authority that is authorized by law to collect or receive such information. 3.) To a governmental authority where there is a reasonable belief by the covered entity that the individual is a victim of abuse, neglect or domestic violence. 4.) To a health oversight agency for oversight activities authorized by law. 5.) In the course of certain judicial or administrative proceedings in response to a court order, subpoena, discovery request or other lawful process. 6.) To a law enforcement official for certain law enforcement purposes. 7.) To a coroner, medical examiner or funeral director for identification of a decedent and similar purposes. 8.) To organ procurement organizations or similar entities for the purpose of facilitating transplantations, etc. 9.) For medical research that has been approved by an institutional review board or similar medical panel. 10.) Where the covered entity in good faith believes the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public or is necessary for law enforcement authorities to identify or apprehend an individual. 11.) For certain specialized government functions including: certain military and veterans activities, certain national security and intelligence activities, protective services for the President and other leaders; certain medical suitability determinations by the Department of State; and certain correctional and law enforcement custodial situations. 12.) As authorized by and to the extent necessary to comply with laws relating to workers' compensation or other similar programs.

The conditions pursuant to which disclosures may be made for the above-listed purposes are more fully described at 45 CFR 164.512.

CT 09/20/2013

A covered entity is prohibited from using or disclosing genetic information for underwriting purposes.

Uses and disclosures of protected health information other than those listed, above, may only be made with your written authorization. You may revoke any such authorization by executing a Revocation of Authorization form, a copy of which is available from the Town's Health Benefits Office. Your Rights You have the right to inspect and copy your protected health information that is maintained in a designated record set by us. We will provide you with access to this information within thirty (30) days of receiving a written request for it. We will charge a reasonable fee for copying and mailing the records. Your rights with respect to the inspection and copying of records are more fully described at 45 CFR 164.524.

You have the right to request restrictions on certain uses and disclosures of protected health information (as provided at 45 CFR 164.522(a)) to carry out treatment, payment or health care operations. While we are not required to agree to a requested restriction, we will carefully consider any request.

You have the right to request that we allow you to receive communications of protected health information from us by alternative means or at alternative locations if you state that the disclosure of all or part of that information could endanger you. We will accommodate any such reasonable request.

You have the right, subject to certain limitations set forth at 45 CFR 164.526, to request that we amend protected health information, or a record that relates to you, in a designated record set for as long as that information is maintained in the designated record set. Your request to correct, amend, or delete information should be in writing. We will notify you if we make an adjustment as a result of your request. If we do not make an adjustment, we will send you a letter explaining why within 30 days. In the case of a denial, you may ask us to make your request part of your records, or you may file a statement of disagreement with us. You may also file a complaint with us or with the Secretary of Health and Human Services. If we make an amendment we will attempt to inform and provide the amendment within a reasonable time to anyone identified by you as possessing the subject protected health information as well as to persons who we know have the protected health information that has been amended.

You have the right to receive an accounting of the disclosures (if any) of your protected health information that we have made. This right to an accounting does not apply to uses or disclosures that were made in connection with treatment, payment or health care operations, nor does it apply to disclosures that you authorized or to other disclosures listed at 45 CFR 164.528(a). This right to disclosures is more fully described at Section 164.528.

You have the right to be notified when a breach of your unsecured protected health information has occurred.

You have the right to opt out of receiving any fundraising communications. Use or disclosure of your protected health information for marketing purposes requires your prior written authorization. A disclosure that constitutes the sale of protected health information requires your prior written authorization. You have the right to obtain upon request a paper copy of this notice from the Town's Health Benefits Office.

General The Health Plans are required by law to maintain the privacy of protected health information and to provide individuals with notice of the Health Plans' legal duties and privacy practices with respect to protected health information.

The Health Plans are required to abide by the terms of this notice. We reserve the right to change this notice. Any changes to this notice may be effective for all protected health information that the Health Plans maintain. A revised notice will be mailed to you within thirty (30) days of its effective date.

You may complain to us and to the Secretary of Health and Human Services if you believe your privacy rights have been violated. You may file a complaint with our Privacy Official: Nick Breault, Town Administrator (413) 525-1100. Please be assured that you will not be retaliated against for filing a complaint. You may also contact our Privacy Official to receive further information concerning our privacy policies.

New Health Insurance Marketplace Coverage Options and Your Health Coverage

PART A: General Information When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance: the Health

Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic

information about the new Marketplace and employmentbased health coverage offered by your employer.

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 "one-stop 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 October 2013 for coverage starting as early as January 1, 2014.

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 9.5% 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.1

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 .

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.

1 An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered

by the plan is no less than 60 percent of such costs.

Form Approved OMB No.

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.

3. Employer name

4. Employer Identification Number (EIN) 5. Employer address 6. Employer phone number 7. City 8. State 9. ZIP code 10. Who can we contact about employee health coverage at this job? 11. Phone number (if different from above) 12. Email address

Here is some basic information about health coverage offered by this employer:

• As your employer, we offer a health plan to:

All employees.

Some employees. Eligible employees are:

• With respect to dependents:

We do offer coverage. Eligible dependents are:

We do not offer coverage.

If checked, this coverage meets the minimum value standard, 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. Here's 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.

EMPLOYEE RIGHTS AND RESPONSIBILITIES UNDER THE FAMILY AND MEDICAL LEAVE ACT

Basic Leave Entitlement FMLA requires covered employers to provide up to 12 weeks of unpaid, job-protected leave to eligible employees for the following reasons:

• for incapacity due to pregnancy, prenatal medical care or child birth; • to care for the employee’s child after birth, or placement for adoption or foster care; • to care for the employee’s spouse, son, daughter or parent, who has a serious health condition; or • for a serious health condition that makes the employee unable to perform the employee’s job.

Military Family Leave Entitlements Eligible employees whose spouse, son, daughter or parent is on covered active duty or call to covered active duty status may use their 12-week leave entitlement to address certain qualifying exigencies. Qualifying exigencies may include attending certain military events, arranging for alternative childcare, addressing certain financial and legal arrangements, attending certain counseling sessions, and attending post-deployment reintegration briefings. FMLA also includes a special leave entitlement that permits eligible employees to take up to 26 weeks of leave to care for a covered service-member during a single 12-month period. A covered servicemember is: (1) a current member of the Armed Forces, including a member of the National Guard or Reserves, who is undergoing medical treatment, recuperation or therapy, is otherwise in outpatient status, or is otherwise on the temporary disability retired list, for a serious injury or illness*; or (2) a veteran who was discharged or released under conditions other than dishonorable at any time during the five-year period prior to the first date the eligible employee takes FMLA leave to care for the covered veteran, and who is undergoing medical treatment, recuperation, or therapy for a serious injury or illness.*

*The FMLA definitions of “serious injury or illness” for current servicemembers and veterans are distinct from the FMLA definition of “serious health condition”.

Benefits and Protections During FMLA leave, the employer must maintain the employee’s health coverage under any “group health plan” on the same terms as if the employee had continued to work. Upon return from FMLA leave, most employees must be restored to their original or equivalent positions with equivalent pay, benefits, and other employment terms. Use of FMLA leave cannot result in the loss of any employment benefit that accrued prior to the start of an employee’s leave. Eligibility Requirements Employees are eligible if they have worked for a covered employer for at least 12 months, have 1,250 hours of service in the previous 12 months*, and if at least 50 employees are employed by the employer within 75 miles.

*Special hours of service eligibility requirements apply to airline flight crew employees. Definition of Serious Health Condition A serious health condition is an illness, injury, impairment, or physical or mental condition that involves either an overnight stay in a medical care facility, or continuing treatment by a health care provider for a condition that either prevents the employee from performing the functions of the employee’s job, or prevents the qualified family member from participating in school or other daily activities. Subject to certain conditions, the continuing treatment requirement may be met by a period of incapacity of more than 3 consecutive calendar days combined with at least two visits to a health care provider or one visit and

a regimen of continuing treatment, or incapacity due to pregnancy, or incapacity due to a chronic condition. Other conditions may meet the definition of continuing treatment.

Use of Leave An employee does not need to use this leave entitlement in one block. Leave can be taken intermittently or on a reduced leave schedule when medically necessary. Employees must make reasonable efforts to schedule leave for planned medical treatment so as not to unduly disrupt the employer’s operations. Leave due to qualifying exigencies may also be taken on an intermittent basis.

Substitution of Paid Leave for Unpaid Leave Employees may choose or employers may require use of accrued paid leave while taking FMLA leave. In order to use paid leave for FMLA leave, employees must comply with the employer’s normal paid leave policies. Employee Responsibilities Employees must provide 30 days advance notice of the need to take FMLA leave when the need is foreseeable. When 30 days notice is not possible, the employee must provide notice as soon as practicable and generally must comply with an employer’s normal call-in procedures. Employees must provide sufficient information for the employer to determine if the leave may qualify for FMLA protection and the anticipated timing and duration of the leave. Sufficient information may include that the employee is unable to perform job functions, the family member is unable to perform daily activities, the need for hospitalization or continuing treatment by a health care provider, or circumstances supporting the need for military family leave. Employees also must inform the employer if the requested leave is for a reason for which FMLA leave was previously taken or certified. Employees also may be required to provide a certification and periodic recertification supporting the need for leave. Employer Responsibilities Covered employers must inform employees requesting leave whether they are eligible under FMLA. If they are, the notice must specify any additional information required as well as the employees’ rights and responsibilities. If they are not eligible, the employer must provide a reason for the ineligibility. Covered employers must inform employees if leave will be designated as FMLA-protected and the amount of leave counted against the employee’s leave entitlement. If the employer determines that the leave is not FMLA-protected, the employer must notify the employee. Unlawful Acts by Employers FMLA makes it unlawful for any employer to:

• interfere with, restrain, or deny the exercise of any right provided under FMLA; and• discharge or discriminate against any person for opposing any practice made unlawful by FMLA or for involvement in any proceeding under or relating to FMLA.

Enforcement An employee may file a complaint with the U.S. Department of Labor or may bring a private lawsuit against an employer. FMLA does not affect any Federal or State law prohibiting discrimination, or supersede any State or local law or collective bargaining agreement which provides greater family or medical leave rights.

FMLA section 109 (29 U.S.C. § 2619) requires FMLA covered employers to post the text of this notice. Regulation 29 C.F.R. § 825.300(a) may require additional disclosures.

For additional information:1-866-4US-WAGE (1-866-487-9243) TTY: 1-877-889-5627

WWW.WAGEHOUR.DOL.GOV

U.S. Department of Labor Wage and Hour DivisionWHD Publication 1420 · Revised February 2013

2015 Benefits Open Enrollment - East Longmeadow, MA

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