2013 BENEFITS HANDBOOK for Texas Health Employees

Michelle Quiej RN, Cardiac ICU Texas Health Harris Methodist Hospital Fort Worth

BE AWARE, BE PROACTIVE, BE INSPIRED, BE HEALTHY. About This Employee Benefits Handbook

Texas Health Resources is committed •• There are no guarantees that the This Handbook is also available on to providing employees with a choice right to participate in benefits under the Texas Health employee portal of comprehensive, affordable, and the plans for employees or other www.MyTHR.org and on competitive benefits. Your benefits are covered persons will exist or remain MyTexasHealth. an important part of your compensation unchanged. from Texas Health. And, as part of your •• Texas Health intends to continue If you have questions concerning your total compensation, Texas Health pays a the plans indefinitely but reserves benefits that are not answered in this substantial portion of the benefit costs the right to change them at any time. Employee Benefits Handbook, please for eligible employees and their families. This includes the right to change any contact Human Resources. amounts contributed by Texas Health Texas Health is pleased to provide you or employees toward the cost of Texas Health Promise with this Employee Benefits Handbook. benefits, the level of benefits provided, The Texas Health Promise is “Individuals It is important for you to read this and the types of employees eligible for Caring for Individuals, Together. ” It is Handbook and keep it for reference benefits. ℠ throughout the year. It describes the a recurring theme throughout this 2013 •• Texas Health reserves the sole right to main features of the benefit plans, Benefits Handbook. Whether you are a alter, amend, modify, or terminate the explains how to use these benefits, and direct caregiver or support those who plans, any program described in this identifies resources for help when you provide patient care, living the Promise Handbook, or any part thereof at its need it. You should understand your enables everyone at Texas Health to discretion at any time, either in their Texas Health benefits and how they better serve those who entrust their entirety or with respect to any covered work—so you can select the benefits medical care to us. types of employees. From time to time, that best protect the needs of you and you may receive updated information Texas Health’s Promise is valued your family. concerning benefit changes. throughout our organization—and that Throughout this Handbook, the term •• In the event of a conflict between the includes providing you and your family “Texas Health” refers to Texas Health provisions of this Handbook and the great benefits. Texas Health covers over Resources and the other employers provisions contained in the legal plan 80% of the costs of medical coverage for that have adopted the benefits being documents, the legal plan documents all employees. described. A list of the employers that will govern. have adopted each plan is available from •• No employee of Texas Health is Mission the Benefits Department at Texas Health. responsible for advising you on the To improve the health of the people in tax effect of your participation in any the communities we serve. The following is important information plan described in this Handbook. about this Handbook: Because tax laws are complicated •• This Employee Benefits Handbook is and constantly changing, it is Vision the Summary Plan Description (SPD) recommended that you consult a Texas Health Resources, a faith-based for the Texas Health Flexible Benefits tax advisor if you have any questions organization joining with physicians, will Plan, the Texas Health Retirement about how participation in any of be the health care system of choice. Program, and other benefits offered these plans will affect your personal to employees of Texas Health. The tax situation. Values provisions of this Handbook apply to •• The plan administrator and in some eligible employees of Texas Health cases the claims administrator has Respect, Integrity, Compassion, and their eligible family members. the authority to interpret each plan. Excellence (RICE) •• Nothing in this Handbook says Any interpretation made by the or implies that coverage under plan administrator or the claims Texas Health Policies and or participation in any plan is a administrator will be conclusive. Procedures guarantee of continued employment A glossary of terms begins on page 161. For more information on Texas Health’s with Texas Health or other employers It defines many important terms for policies, go to MyTexasHealth. who have adopted the Texas Health understanding your benefits under the benefits program. Neither this plans. Handbook nor updated materials are contracts or assurances of compensation, continued employment, or benefits of any kind. Table of Contents Table of Contents

Welcome to Total Health, Where Wellness is a Way of Life!...... 1 Understanding the Texas Health benefits philosophy will help you make the most of your valuable benefits. Overview...... 2 These pages give you a snapshot of all the great Texas Health benefits, describe the choices, and tell you who can be covered. Participation...... 4 Learn who is eligible, how to enroll, and how you pay for benefits. Medical & Wellness...... 17 The Total Health Medical Plan and Be Healthy Wellness Programs offer so many great features. This section explains them. Dental & Vision...... 61 Dental and vision care are important to your overall health, and this section explains how your benefits work. Spending Accounts...... 78 The Health Care and Day Care Spending Accounts can save you money. This section tells you how. Income Protection...... 85 Read this section to learn how the disability, life insurance and accident coverages help you be financially prepared. Retirement...... 106 Be sure to understand how the Retirement Plan works so you can get the most from it. Time Off...... 124 Everyone needs some time away from work. This section tells you about Texas Health’s time off benefits and policies. Other Benefits...... 132 Tuition reimbursement and adoption assistance are available if you need them. Leaving Texas Health...... 139 Your coverage will end when you terminate, so be sure to understand your options. This section also explains Texas Health’s separation pay plan when a position is eliminated. Claims and Administration...... 148 Texas Health has provided important information about claims, your legal rights, Medicare, and your privacy. Resources...... 160 Here you will find a glossary, summary of the rates for coverage, and list of important contacts.

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org i More Information Where to Get More Information Online •• www.MyTHR.org: MyTHR is not only where you enroll in benefits each year, but also the location where you can view your paychecks, PTO balance and much more. •• MyTexasHealth: This is the Texas Health intranet located on your Internet Explorer home page at work. By Phone •• 1-877-MyTHRLink (1-877-698-4754): Calling this number gives you direct access to all of our benefits providers, including United Healthcare, Caremark (prescription), Aetna (dental), MHN (EAP), Weight Watchers, Tuition Reimbursement, and more. •• Health Advocate: If you are not sure who you need to talk to, call 1-877-MyTHRLink (1-877-698-4754) and select prompt 2 to reach a Health Advocate. The Health Advocate will help you find the resource to meet your needs. In Person •• Human Resources: Each location has a Human Resources office available to assist with your benefit questions. The last page of your 2013 Employee Benefits Guide lists the phone number for each Human Resources office.

ii 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Welcome to Total Health Welcome to Total Health, Where Wellness is a Way of Life! Texas Health’s employee benefit Get Rewarded for Getting For more information about Be Healthy philosophy focuses on helping our Healthy wellness programs, check your Benefits employees and their families optimize Guide or online at www.MyTHR.org or their health and well-being. We have Your 2013 Employee Benefits Guide see page 52 of this handbook. named our benefits program Total describes the Be Healthy wellness Health because of our focus on the incentives and tells you about the Your Coach Wants rewards you can earn. Be Healthy is a total person. Total Health provides one You to Win source for all your benefit needs— wellness program designed to inspire including information about medical, and motivate you to take the best Research has shown that people who dental, vision, life insurance, disability, possible care of yourself. Be Healthy have support in managing their health Paid Time Off (PTO), and 401(k) benefits. gives you important tools to help you are more successful than people who Optimizing your health and well-being better understand your health and try to manage their health alone. To by taking advantage of all the programs make wellness a way of life. help you succeed, Total Health provides and resources offered through Total you support through personal Health As a benefits-eligible employee, Health supports Texas Health’s mission to Coaches. you receive a reward each time you improve the health of our employees and complete an incented Be Healthy our community. Texas Health has carefully selected element. After you have completed companies that have professionals In addition to medical, prescription the requirements for a reward, you will specializing in helping you manage drug, dental, and vision coverage, your receive an email notifying you that the different health issues. These Texas Health Benefit Program includes amount is available in your rewards professionals—called Health Coaches— generous coverage for preventive care, a account. Your reward is redeemable for are nurses, counselors, dietitians, and robust wellness program which includes gift cards from more than 100 national fitness experts who will call you to offer a maternity support program, and other retailers, restaurants, entertainment, and support and resources. programs that help our employees and travel providers, or you can receive it in their families manage illnesses. the form of a Visa gift card. Based on your Health Assessment results or claims data, you may be eligible to In return for low medical premiums and Why does Texas Health offer these participate in the personalized Health quality coverage, Texas Health asks that generous rewards? Because we want Coaching program. The companies you actively work at being healthy. This you to participate in Be Healthy! Texas Health has selected to provide means participating in Be Healthy, using these services include Optum Health, As your employer, Texas Health spends your benefit resources, and making MHN EAP, Caremark Pharmacy, millions of health care dollars each ® wellness a way of life. Alere Tobacco Cessation, and year on illnesses that could have been UnitedHealthcare. Your personal Health FOR ANSWERS to your benefit prevented or managed better if each Coach will provide one-on-one coaching questions or to access of us had taken a more active role in and many other resources to help you Total Health program information: managing our health. Our choice is lead a healthier life. Call 1-877-MyTHRLink clear—we can improve our health (1-877-698-4754) or end up paying more for medical Participation is voluntary and your or go online to www.MyTHR.org or insurance and medical care. individual participation is completely MyTexasHealth confidential.

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 1 Overview Overview Texas Health provides eligible employees with a comprehensive Flexible Benefits Plan that includes Medical, Dental, Vision, Life, Overview Disability, Long Term Care Insurance, and Flexible Spending Accounts. These benefits help protect you and your family from the financial hardships of illness, injury, disability, and death. Read “Eligibility for Flexible Benefits” on page 5 to determine whether you meet requirements for participating in each plan.

Summary of Your Benefits As an eligible employee, you can choose the combination of benefits that best meets your needs. You also can enroll eligible family members in certain benefits, as described below.

FLEXIBLE BENEFITS

Plan Who Can Be Covered Choices Medical You and your eligible ••UHC Choice 500 High Rx family members (as ••UHC Choice 500 Low Rx defined on pages 5 – 6) ••UHC Choice 1000 High Rx ••UHC Choice 1000 Low Rx ••UHC Choice 1500 Plus High Rx ••UHC Choice 1500 Plus Low Rx Dental You and your eligible ••Aetna® Managed Dental Plan Dental Maintenance Organization family members (as (DMO®) defined on pages 5 – 6) ••Participating Dental Network (PPO; low option) administered by Aetna® ••Participating Dental Network (PDN; high option) administered by Aetna® Vision You and your eligible ••Superior Vision® Plan family members (as defined on pages 5 – 6) Short Term Disability You ••Coverage of 60% of your weekly base pay, up to $1,700 per week ••Choose either a 14-day or a 30-day waiting period Basic Long Term Disability 1 You ••Employer-paid coverage of 50% of your monthly base pay, up to a maximum benefit of $15,000 per month after 180 days of disability Additional Long Term You ••Coverage equal to 10% (for a total of 60%) of your monthly base Disability 1 pay, up to $15,000 per month (including Basic LTD) after 180 days of disability Basic Life Insurance You ••Employer-paid coverage of one times your annual base pay, up to $50,000 Additional Life Insurance You ••Coverage of one to six times your annual base pay, up to a maximum of $2,000,0002 including Basic Life Dependent Life Insurance Your eligible family ••Coverage for your spouse in $10,000 increments up to the total members (as defined on of your Basic and Additional Life coverage, but not more than pages 5 – 6) $50,000 ••Coverage for your eligible children of $10,000 per child up to age 25 Basic Accidental Death & You ••Employer-paid coverage of one times your annual base pay, up to Dismemberment (AD&D) $50,000 Insurance

1 Physicians employed by THPG are covered through separate policies and are not eligible for the Texas Health Long Term Disability Plan.

2 Medical underwriting or evidence of insurability is required for coverage over $1,000,000 (including Basic Life).

2 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Overview

FLEXIBLE BENEFITS (CONTINUED)

Who Can Be Plan Covered Choices

Additional AD&D Insurance You and your eligible ••You may elect either employee-only coverage or employee and Overview family members (as family coverage. defined on pages ••Employee coverage of one to 10 times your annual base pay, up to 5 – 6) $750,000 Depending on the makeup of your family, family coverage provides: ••Spouse-only coverage of 50% of your Additional AD&D coverage ••Spouse coverage of 40% of your Additional AD&D coverage, and 10% for each child ••Child-only coverage of 15% of your Additional AD&D coverage for each of your eligible children up to age 25 Health Care Spending Account You and your eligible ••You may contribute up to $2,500 per year before-tax. family members (as defined on pages 5 – 6) Day Care Spending Account Your eligible family ••You may contribute up to $5,000 per year before-tax. members (as defined on pages 5 – 6)

OTHER BENEFITS In addition to the Flexible Benefits listed above, you may also be eligible for the following benefits.

Plan Description Long Term Care Insurance ••Daily benefit amount $100, $200, or $300 with lifetime maximum for two, three or five years. ••You may cover yourself, your spouse, parents, grandparents, and in-laws. Retirement Program ••After one year of service, Texas Health matches up to the first 6% of pay you save (based on length of service) if you contribute at least 2% of your pay to the plan each pay period. You may join the plan as soon as you are hired by Texas Health. ••For 2013, the Texas Health 401(k) Retirement Plan allows you to save up to $17,500 per year ($23,000 if you are age 50 or older) of your pay. Paid Time Off (PTO) 1, 2 ••Full-time and part-time benefits-eligible employees accrue PTO per pay period, depending on years of service and your classification in Texas Health’s HR/Payroll system. ••You may sell some of your PTO two times a year for a cash payment (up to 80 hours per year). ••You may donate PTO for contribution to an approved charity anytime during the year (up to 80 hours per year). ••You may donate PTO to the Helping Hands Fund.

Conversion of Paid Time ••You may convert up to 80 hours of PTO earned in 2013 (in eight-hour increments) to pay for Off (PTO)1, 2 benefits; available only during open enrollment and only if you elect at least one Flexible Benefit.

Be Healthy ••Full-time and part-time benefits-eligible employees may earn rewards in the 2013 program year.

Additional Benefits ••Business Travel Accident Insurance ••Tuition reimbursement ••Adoption assistance ••Credit union ••MHN EAP ••Tobacco cessation program ••On-site child care (in certain locations) ••Employee Discount Program

1 The combined amount of PTO you sell, donate, and convert cannot be more than 100 hours per year. Donations of PTO to the Helping Hands Fund do not count toward the 100 hour annual maximum. 2 Physicians and physician extenders of THPG are not eligible for PTO. Time away from work is based on their contract.

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 3 Participation Eligibility for Flexible Benefits...... 5 Employees 5 Family Members 5 Appealing Eligibility Determination 8 Discrimination Prohibited 8 Misstatements of Facts 8 Documentation 8 Enrolling in Flexible Benefits...... 9 New Employee Enrollment 9 Open Enrollment 9 Participation Bridging of Service 10 Changing Your Coverage 10 Summary of Allowable Changes in Coverage 14 Paying for Your Flexible Benefits...... 15 Benefits Paid in Full by Texas Health 15 Benefits Paid by You and Texas Health 15 Benefits Paid in Full by You 15 Before-tax Benefits 15 After-tax Benefits 15 Benefits Base Rate 15 Payroll Deductions 15 Medical Subsidy 16 Converting Paid Time Off 16

4 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Eligibility for Flexible Benefits Eligibility for Flexible Benefits Your eligibility for Flexible Benefits is EMPLOYMENT STATUS CHANGE You will be required to reimburse Texas determined by your job status (full-time Health for all benefits the plan pays for If your job classification changes so or part-time benefits-eligible) and, in a spouse or child who did not meet the you are classified as full-time or part- some cases, by your length of service. definition of eligible family member time benefits-eligible, you can begin at the time the benefits were paid. You participating in Flexible Benefits on the Employees of Texas Health wholly may also be subject to corrective action first day of the pay period on the later of: owned or controlled affiliates are up to and including termination. eligible for benefits. Physicians employed •• The date your job classification by Texas Health Physician Group (THPG) changes or SPOUSE are not eligible to participate in the •• The date you have completed one Your eligible spouse is the person of following Texas Health plans: month of service. the opposite sex who is legally married • to you and who legally resides in the • Long Term Disability Participation •• Paid Time Off Family Members United States. In the case of a common •• Separation Pay. law marriage, you must have filed a If you are an eligible employee and you declaration of informal (common law) elect coverage under Flexible Benefits, Physician extenders employed by marriage with the county clerk on a you also can elect the following coverage THPG are not eligible to participate form provided by the Bureau of Vital for your eligible family members: in the Texas Health PTO Plan or the Statistics and provide a copy to Human Separation Pay Plan. •• Medical Resources. If your spouse is a common •• Dental law spouse, certification of common Employees •• Vision law marriage is required. Tax returns will not be accepted as documentation ELIGIBILITY REQUIREMENTS •• Dependent Life of your spouse's eligibility. •• Additional Accidental Death and Unless otherwise noted in this Dismemberment (AD&D). Handbook, eligibility for benefits is If Family Members Work for Texas Health determined by your classification You may enroll your eligible family in Texas Health’s HR/Payroll system, members for Dependent Life insurance No person can be covered as both an according to these categories: coverage even if you do not elect any employee and a dependent under the •• Full-time employee—an employee of Additional Life insurance coverage for same benefit plan. If you are eligible for Texas Health who is classified to work yourself. For all other Flexible Benefits, Texas Health’s benefit plans and your at least 64 hours per pay period you must have coverage for yourself to spouse, parent, or child also works for •• Part-time benefits-eligible employee— enroll your eligible family members. Texas Health and is eligible for benefits, an employee of Texas Health who is you will need to determine whether it Your eligible family members include classified to work 48-63 hours per pay is better for you to each elect coverage (eligibility is determined according to period. as an employee or whether it is more these categories unless otherwise noted cost-effective for one of you to cover the Your eligibility for benefits is based on in this Handbook): other as a dependent (if eligible). your classification in the HR/Payroll •• Your legal spouse (as defined on this •• If both spouses work for Texas Health, system—not the number of hours you page) only one of you may cover your actually work. For those with more than •• Your dependent children—including eligible children and grandchildren. 1 one job, benefit eligibility is determined biological children, children who •• If a parent and child work for Texas by the total combined hours from all have been adopted or placed for Health: active jobs. adoption, foster children, –– The child may be covered as the stepchildren , grandchildren 1, and Part-time benefits-ineligible employees parent’s dependent only if the child other qualified children (as defined (as defined in the glossary) and PRN meets the eligibility requirements on pages 6 – 7). employees are eligible to participate –– Only one of you may cover in the Texas Health 401(k) Retirement the grandchildren 1 (the child’s Plan, MHN EAP, and Alere Quit for Life children). Tobacco Cessation program. They are –– The parent cannot elect Dependent not eligible to participate in the Flexible Life Insurance coverage for that Benefits Plan or any other plan or child. program.

1 Footnotes are on the next page.

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 5 Eligibility for Flexible Benefits

CHILD Newborn Children Coverage will continue as long as the enrolled dependent is incapacitated To be eligible for coverage under the If you elect coverage under the and meets the definition of dependent, Total Health Medical Plan, a child must Medical Plan, your newborn child will unless coverage is otherwise terminated meet all the following criteria: automatically receive medical coverage under the terms of the plan. •• Be under 26 (or any age if unmarried for 31 days following birth. If you wish and physically or mentally incapable to extend coverage beyond the 31-day You must furnish UnitedHealthcare of self-support) period, you must enroll the newborn (UHC) with proof of the child’s online within 31 days of the child’s •• Live in the United States incapacity and dependency within birth. 31 days of the date coverage would To be eligible for dental, vision, or life otherwise have ended because the Stepchildren insurance coverage, a child must meet child reached a certain age. Before UHC all the following criteria: Your stepchildren are eligible for agrees to this extension of coverage, coverage under the Total Health •• Be under 252 (or any age if physically they may require that a physician Medical Plan only if they meet all the or mentally incapable of self-support) chosen by UHC examine the child. UHC requirements above and your spouse will pay for that examination. Participation •• Be unmarried (the child’s parent) is covered under 3 •• Live in the United States the plan as your dependent or as a UHC may continue to ask you for •• Have the same primary residence Texas Health employee. This provision proof that the child continues to meet as you and be a member of your does not apply to dental, vision or life these conditions of incapacity and household 3 insurance coverage. dependency. Such proof might include medical examinations at UHC’s expense. You may also cover a child who meets Child Placed for Adoption However, you will not generally be asked the above criteria if you can provide a A child under age 18 will be considered for this information more than once a copy of the court order signed by the placed with you for adoption if you year. judge showing one of the following: have assumed a legal obligation for You may add coverage for an •• You have adopted the child total or partial support of the child in incapacitated child only if the child meets •• The child has been placed in your anticipation of the adoption. In this the definition of eligible child (described home for foster care situation, you should provide Human on this page) and the definition of •• You have been appointed by the Resources with documentation (such as incapacitated child (described above) court as the child’s legal guardian or a signed court order) that the adoption and either: non-parent managing conservator. agency or other entity had legal custody of the child on the date the child was •• Your adult child who was not covered A child serving in the military or armed placed with you for adoption. by the plan becomes incapacitated or forces of any country is ineligible for •• You have an adult child who is coverage. Incapacitated Child incapacitated and are enrolling in the Texas Health Medical Plan as a new The employee’s child may be covered Coverage for an unmarried, employee. under a Qualified Medical Child incapacitated child does not end just Support Order (explained on the next because the child has reached a certain page) even if you do not claim the child age. You may extend the coverage for as a dependent on your federal income that child beyond the limiting age if both tax return. of the following are true. The child: •• Is not able to be self-supporting because of mental retardation or physical handicap and •• Depends mainly on you for support

1 To cover your grandchildren, you must provide documentation of court appointed legal guardianship or managing conservatorship to Human Resources before the enrollment deadline.

2 The dental and life insurance plans allow you to cover eligible children up to age 25, regardless of student or employment status. The vision plan allows you to cover unmarried dependent children up to age 25 who are not regularly employed on a full-time basis. 3 Under the life insurance plan, you may cover an eligible child who does not have the same primary residence as you or live in the U.S.

6 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Eligibility for Flexible Benefits

Qualified Medical Child Support The following information must be DOCUMENTATION FOR Order (QMCSO) included in the QMCSO: DEPENDENTS Dependent coverage will be offered to •• The name and the last known mailing You must provide the social security the extent it is required by a QMCSO, address of the participant and the number for all covered dependents who provided you continue to meet the name and mailing address of each are at least six months old. You will enter eligibility requirements of the medical child covered by the order those online when enrolling. plan and you are enrolled in the plan. •• A reasonable description of the type To ensure only eligible dependents are If you are not enrolled in a Total Health of coverage to be provided by the covered under our plans, Texas Health Medical Plan at the time the plan plan to each child, or the manner in requires you to provide documentation administrator receives the QMCSO, you which the type of coverage will be when adding a dependent to medical, and your child will be enrolled in the determined dental or vision coverage (for a new UHC Choice 500 High Rx Plan to comply •• The time period during which the hire, rehire, status change or during open with the court order and the applicable order applies, and premium will be deducted from your enrollment). If you are an employee •• Each plan to which the order applies. paycheck. The plan administrator will who left Texas Health and you were

rehired more than one year later, you are Participation determine whether an order or notice is A medical child support order is not required to resubmit documentation of a QMCSO. qualified by the plan administrator if it your dependents’ eligibility. requires a plan to provide any benefit A QMCSO ordering your spouse to not otherwise provided under the plan. provide coverage for your stepchildren Following are acceptable forms of documentation: is not binding on Texas Health. If your The plan administrator has the spouse is ordered to provide medical responsibility for determining whether •• Spouse: Both of the following need to coverage for his or her children (your a QMCSO exists. When a QMCSO is be provided for your spouse: stepchildren) under a QMCSO, you received, the plan administrator will –– Photocopy of marriage license, may cover them under a Total Health notify you and each child that the order marriage certificate provided by Medical Plan only if your spouse (the has been received. The notification your religious organization, most child’s parent) is also currently covered describes the procedures that will be recent tax return or certification under the plan and the child meets used to determine its qualification. of common law marriage (your the definition of eligible child on the tax return is not acceptable previous page. After the review process is completed, documentation of common law the plan administrator will notify marriage) and A QMCSO is any judgment, decree, you and your child(ren) of the –– Photocopy of driver’s license, most or order (including a settlement Administrator’s determination and, if recent tax return, bill or some other agreement) issued by a court of applicable, the appeal process that may documentation that shows both you competent jurisdiction that: be requested. and your spouse currently have the •• Provides for child support with respect You may request a free copy of the same address to a child of a participant under a procedures governing Qualified Medical •• Children: One of the following needs group health plan Child Support Order determinations to be provided for each child: •• Provides health benefit coverage to from the plan administrator. Any health –– Photocopy of birth certificate that a child pursuant to a state domestic benefits paid under a QMCSO as shows you and/or your spouse as relations law (including a community reimbursement for expenses paid by the parents or property law), and relates to benefits child or the child’s custodial parent or under the plan, or –– Photocopy of birth record from legal guardian will be paid to the child hospital that shows you and/or your •• Enforces a law (including a or the child’s custodial parent or legal spouse as parents or community property law) and relates guardian. to benefits under the plan, or law –– Photocopy of legal guardianship or relating to medical child support adoption papers or described in the Social Security Act –– Photocopy of Qualified Medical with respect to a group health plan. Child Support Order (QMCSO)

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 7 Eligibility for Flexible Benefits

You must send documentation to •• A description of any additional •• A statement of your right to review (upon your Human Resources office or material or information necessary request and at no charge) relevant fax documentation to the Benefits for you to validate the claim and an documents and other information Department at 682-236-6997 within explanation of why this information is •• If an internal rule, guideline, protocol, 31 days of your event (new hire, necessary or other similar criterion is relied on family status change, etc.). If you do •• Information on the steps you must in making the decision on review, a not provide complete and timely take to appeal the plan administrator’s description of that rule, guideline, documentation, your dependents will decision, including your right to protocol, or other similar criterion or not be added to your coverage. If your submit written comments and have a statement that it was relied on and dependent is dropped because of lack of them considered, your right to review that a copy will be provided free of documentation, premiums you have paid (upon request and at no charge) charge to you upon request, and will not be refunded. relevant information, and your right •• A statement of your right to bring suit to file suit under ERISA (where under ERISA §502(a) (where applicable). Appealing Eligibility applicable) with respect to any Determination adverse determination after appeal of Discrimination Prohibited

Participation your claim. If you believe you or your dependent is Eligibility under the Medical, Dental, eligible for coverage, within 60 days of APPEALS and Vision Plans will not be based on your eligibility date you may submit this a health-related factor, such as genetic If your claim is denied in whole or part, claim by emailing the plan administrator information or evidence of insurability. you (or your authorized representative) at [email protected] or Federal law prohibits any discrimination may request review by writing to the sending a written request to the plan in eligibility or cost of coverage because People and Culture Committee (the administrator at the address on pages of a health status-related factor. committee) who acts on behalf of 153 – 154 of this handbook. You must the plan administrator with respect to list the names of the people you believe appeals. Your appeal must be made in Misstatements of Facts are eligible to participate and explain writing within 180 days after you receive the reasons you believe they are eligible. Texas Health benefits are provided for the notice that the claim was denied. If You should include any documents you the exclusive benefit of Texas Health you do not appeal on time, you will lose would like to have considered. employees and their families, so the right to appeal the denial and the coverage is limited to eligible employees If your claim for eligibility is denied in right to file suit in court. Your written and their eligible family members. If you whole or in part, the plan administrator appeal should state the reasons you elect to cover an ineligible person or will notify you in writing within 15 days believe your claim should not have been do not accurately provide the correct after the date the plan administrator denied. It should include any additional information about that person—such receives your claim. (This time period facts and/or documents you believe as giving a false age, gender, marital may be extended for an additional support your claim. You will have the status or any other condition, you will be 15 days for matters beyond the plan opportunity to ask additional questions subject to corrective action, up to and administrator’s control including cases and make written comments, and you including termination and may result in in which a claim is incomplete. The plan may review (upon request and at no loss of coverage as explained on page administrator will provide written notice charge) the information relevant to your 140 under “When Coverage Ends.” Texas of any extension, including the reasons appeal. Health also reserves the right to recover for the extension and the date by which any overpayments made on behalf of a DECISION ON REVIEW the plan administrator expects to make person who is ineligible. a decision. If a claim is incomplete, the Your appeal will be reviewed and extension notice will also describe the decided by the committee or other Documentation required information and will allow entity designated by the plan in a you 45 days from receipt of the notice reasonable time not later than 60 days Texas Health has the right to request to provide the specified information. after the committee receives your complete documentation of dependent The extension suspends the time for request for review. The committee may, status, eligibility for coverage or change a decision on your claim until the in its discretion, hold a hearing on the in coverage, or of a claim for benefits. specified information is provided.) denied claim. If the decision on review Texas Health reserves the right to refuse affirms the initial denial of your claim, coverage or benefits if it does not Notification of a denied claim will you will be furnished with a notice that believe the facts are accurate. include: explains: •• A specific reason or reasons for the •• The specific reasons for the decision denial on review •• The specific plan provision on which •• The specific plan provisions on which the denial is based the decision is based

8 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Enrolling In Flexible Benefits Enrolling In Flexible Benefits You have the opportunity to enroll in If you miss the deadline for enrollment Open Enrollment Flexible Benefits as a new hire and or dependent verification and you during the open enrollment period each still want medical coverage, you must Current employees will receive year. You also may enroll or change contact Human Resources within 60 enrollment materials prior to the open your benefit elections during the year if days of your missed deadline. Only enrollment period. you experience a status change or have one medical plan option is available •• Carefully review these materials and special enrollment rights, as explained during this 60-day period—UHC Choice determine which benefits you will on pages 10 – 13. 500 High Rx plan paid on an after-tax choose for yourself and your eligible basis. You may not enroll in any other dependents. The benefit choices you make during benefits until the next open enrollment •• Enroll in Flexible Benefits during the open enrollment remain in effect for the period unless you have a qualified status open enrollment period typically held entire plan year unless you have a status change. Contact Human Resources in November. Your elections become Participation change or special enrollment rights as for information on how to make this effective January 1. described on pages 10 – 13. election. Your after-tax plan will be effective the first day of the following MISSED ENROLLMENT DEADLINE New Employee Enrollment pay period after complete forms and If you are not enrolled in medical documentation are received. •• New hires must enroll within 14 coverage and you miss the deadline for enrollment but you still want medical calendar days of hire date. If you do BASIC BENEFITS not enroll within 14 calendar days, coverage, you must contact Human Eligible employees are automatically your next opportunity to enroll will Resources within 60 days of your enrolled in the following employer-paid be the next open enrollment period. missed deadline. However, within the 60 Basic Benefits on the first day of the pay In this case, you will not have day period, you may choose only one period after one month of service: any Flexible Benefits (only Basic medical plan option — UHC Choice Benefits) unless you later enroll •• Basic Long Term Disability (LTD) 500 High Rx plan paid on an after-tax because you have a status change or •• Basic Life Insurance basis. You may not enroll in any other benefits until the next open enrollment qualify for special enrollment rights •• Basic AD&D Insurance period unless you have a qualified status as explained on pages 10 – 13. •• Business Travel Accident Insurance • change. Contact Human Resources • You may change your elections online •• Paid Time Off (PTO).1 as many times as you would like for information on how to make this election. within your 14 day enrollment period. FLEXIBLE BENEFITS Your benefits that take effect will be Benefits-eligible employees must enroll MISSED DEPENDENT the last elections you save. within the required time frames to VERIFICATION DEADLINE •• Your participation in Flexible Benefits receive the following Flexible Benefits: If you miss the deadline for dependent begins the first pay period after you verification and you still want medical complete one month of service. •• Medical coverage for your dependents, you •• You will be required to provide •• Dental must contact Human Resources prior documentation of all dependents you •• Vision to January 1. However, you may choose cover under medical, dental or vision •• Short Term Disability only one medical plan option — UHC as described on page 7. •• Additional Long Term Disability Choice 500 High Rx plan paid on an •• Additional Life Insurance after-tax basis. You may not enroll in •• Dependent Life Insurance any other benefits until the next open •• Additional AD&D Insurance enrollment period unless you have a •• Flexible Spending Accounts. qualified status change. Contact Human Resources for information on how to make this election.

YOU MUST provide documentation for your dependents.

1 You begin to accrue PTO on your date of hire.

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 9 Enrolling In Flexible Benefits

Bridging of Service STATUS CHANGE ELIGIBILITY Changing Your Coverage REHIRED EMPLOYEE If you regain eligibility for benefits You may add or drop certain coverages ENROLLMENT within 180 days of your loss of benefits when you experience a status change or If you are rehired by Texas Health due to a status change, you qualify for if you have special enrollment rights as within 180 days of your termination, you “bridging of service.” Bridging service described later in this section. qualify for “bridging of service.” Bridging means the time gap is closed and STATUS CHANGES service means the time gap is closed your PTO accrual picks up at the rate and your PTO accrual picks up at the when you lost benefits. Because your The Texas Health Flexible Benefits rate when you terminated. Because your service is bridged, you must continue Plan is regulated by federal laws and service is bridged, you must continue the same coverage in effect before you regulations that restrict when you may the same coverage in effect before you lost benefit eligibility. However, your change your elections. According to left. However, your reinstated benefits reinstated benefits are based on your these regulations, you may request are based on your new ABBR. The new ABBR. The rule to continue the changes to certain benefits during rule to continue the same coverage in same coverage in effect before you left the year only if you have a qualified does not apply to employees who go status change that affects eligibility or

Participation effect before you left does not apply to employees who go from full-time to from full-time to non-benefits-eligible coverage. term and then benefits-eligible part-time and then to benefits-eligible part-time or Qualified status changes include: or from benefits-eligible part-time to from benefits-eligible part-time to non- term then to full-time within 180 days. benefits-eligible then to full-time within •• You or your eligible family member Coverage is immediate if you previously 180 days. Coverage is immediate if you becomes covered by one of the satisfied the waiting period, unless you previously satisfied the waiting period, Total Health Medical Plans because were rehired in a different calendar year unless your status change occurs in a of special enrollment rights as than the year in which you terminated. different calendar year than the year explained beginning on page 12 (you In that case, you have 14 days to make in which you lost benefit eligibility. In may make changes only to medical new benefit elections. Those newly that case, you have 14 days to make new coverage levels, such as adding or elected benefits will take effect the first benefit elections. dropping family members, but you of the pay period following the date you may not change plans). If you regain eligibility for benefits submit new elections. •• Your marital status changes due more than 180 days after your loss of to marriage, death of your spouse, benefits due to status change, you will If you are rehired more than 180 days divorce, or annulment. after your termination, you will be be subject to a new waiting period and •• The number of your dependents for subject to a new waiting period and you you may make new benefit elections federal income tax purposes changes may make new benefit elections that that are effective for the remainder of due to birth, adoption, placement for are effective for the remainder of the the year. Those newly elected benefits adoption, or death. (If you gain a new year. Those newly elected benefits will will take effect the first of the pay dependent and already have family take effect the first of the pay period period following the date you submit coverage, you must go online within following the date you submit new new elections. 31 days of your change to add the elections. new dependent to your coverages. A new dependent is not automatically enrolled, even if you already have coverage for your family.) •• You or your eligible family member begins or ends employment that affects eligibility for benefits •• You or your eligible family member experiences a change in employment status that affects eligibility for benefits—for example, you switch between part-time and full-time, PRN and full-time, or part-time and PRN. •• You or your eligible family member takes or returns from an unpaid leave SEE PAGE 14 for a table that of absence that affects coverage. summarizes the changes you may make based on your life event.

10 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Enrolling In Flexible Benefits

•• Your family member becomes You may change or revoke your A loss of coverage means: eligible or loses eligibility for medical, previous election for the Day Care •• Your current option is being eliminated. dental or vision coverage due to age Spending Account during the year and •• Your network is no longer being (see page 6). make a new election (you must notify offered where you live. •• You or your eligible family member Human Resources, make your election, moves to a new home or work location and provide documentation within 31 In addition, the plan administrator (this applies only to dental DMO). days—if documentation is not provided may consider the following a loss of •• You or your family member becomes the election will be reversed) under coverage: entitled to coverage or loses coverage these circumstances: •• A substantial decrease in the number under Medicare, Medicaid, or state- •• The cost of dependent care of medical care providers available sponsored child health plan. significantly increases or decreases under an option •• A QMCSO (explained on page 7) (you can change or revoke your requires you or your former spouse previous election only if the provider •• A reduction in benefits for a specific to provide coverage for a dependent is not your relative, as defined in the type of medical condition or under a Texas Health welfare plan plan). treatment for which you, your spouse,

or dependent child is currently in a Participation and that coverage is, in fact, provided. •• You remove your child from a facility course of treatment •• Your spouse’s employer offers benefit •• You or your spouse quit working plans with a different plan year that •• You experience a qualified status You may also make a new election if the affects your coverage. change, as defined on pages 10 – 12. change is because of and corresponds If your status change allows you to add with a change in another employer- The plan administrator or its authorized one family member, you may enroll all sponsored plan (including your agent will determine whether your other eligible family members at this spouse’s plan), if the period of coverage requested change is consistent with time, as well. is different. your status change. Your new election must be consistent Requesting a Change in Coverage with your status change. Under the If you miss the deadline for your status and Your Responsibility for medical, dental, vision, STD, LTD, life, change or dependent verification and Notification you still want medical coverage (cannot and AD&D plans and the flexible To change your coverage, you must be previously enrolled), you must contact spending accounts, “consistent” means contact Human Resources within 31 Human Resources within 60 days of the change must result in the gain or days of your status change. When you your missed deadline. However, within loss of coverage by you, your spouse, initially notify Human Resources of the 60 day period, you may choose only or any of your dependent children, and your event, they will explain how to one medical plan option—UHC Choice the new election must reflect that gain enroll or discontinue coverage. After you 500 High Rx plan paid on an after-tax or loss. You may add or drop family enroll, you must provide documentation basis. You may not enroll in any other members, which may change your within 31 days of the event. Your benefits until the next open enrollment coverage level, but you may not change documentation must show your name, period unless you have a qualified status medical or dental plans (for example, the date of the change and, if applicable, change. Contact Human Resources for you cannot change from 500 High Rx to your new dependent’s name. 1000 High Rx, but you can change from information on how to make this election. employee only coverage to employee + You will be required to provide If your cost for benefits coverage children) when you experience a family documentation for dependents you significantly increases or decreases status change. However, if you change cover, as described on page 7. during the year, you will be allowed job status (for example, from benefits- to make a change in your elections. eligible part-time to full-time or full-time When you go online and make changes However, you may not change your to benefits-eligible part-time), you may based on spouse eligibility, you also election for the Health Care Spending change medical or dental plans. need to provide documentation to Account. Human Resources. If you, your spouse, or dependent child has a significant reduction in coverage during the year, you may be allowed to change your election. If the curtailment results in the loss of coverage, you would be permitted to either elect new SEE PAGE 14 for a table that coverage under another option or drop summarizes the changes you may future coverage if no similar coverage is make based on your life event. offered.

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 11 Enrolling In Flexible Benefits

You are also responsible for notifying The Benefits Department will review SPECIAL ENROLLMENT RIGHTS Human Resources when your divorce your elections and your documentation Under the Health Insurance Portability is final so coverage can be stopped. to ensure the status change and and Accountability Act of 1996 (HIPAA), If you notify Human Resources and elections entered meet the qualified you and your dependents may be provide documentation after 31 days, status change requirements. In the event entitled to enroll in a Total Health your dependent will be dropped from your effective date is changed because Medical Plan at times other than coverage. However, because of IRS of one of the above reasons, your the open enrollment period. Special regulations and plan rules, you will effective date will follow these rules: enrollment rights are available when continue to pay the premium for the rest •• If you do not submit your paperwork you lose coverage under another plan or of the plan year. You will not receive a within the same pay period that gain a new dependent. refund. you made the online elections, your effective date will be the first of the If you lose coverage, special enrollment Effective Date of Changes pay period following the date you rights are available for you and/or your When you request a change in status, sent the paperwork to the Benefits dependents if: you have 31 days from the date of the Department. • Participation • You or your dependents were event that resulted in the status change •• If your documentation shows a eligible but not enrolled under a to notify Human Resources, provide different date than what you entered Total Health Medical Plan, and you documentation and enter new benefit online, your effective date is the first or your dependents were covered elections. The online enrollment system of the pay period following the date under another health plan or had will show an effective date of coverage of your status change, provided you health insurance coverage at the time as the first of the pay period following made the change request within 31 coverage was previously offered to the date you enter your benefit elections days of the event date. online. This is your effective date you and provided you: If you do not make the request and •• You or your dependents who had lost coverage under the other health plan •• Notify Human Resources of your status complete all the steps listed above because it was COBRA coverage that change via the online enrollment within 31 days, you must wait until the was exhausted, or the coverage was system next open enrollment period. If you have not under COBRA and either: •• Provide appropriate documentation not completed one month of service at the time your job classification changes, –– The coverage was terminated as a •• Have been employed by Texas Health your benefits will be effective on the result of loss of eligibility for the for at least one month first payroll period after you make your coverage (including divorce, death, •• Enter your elections online with an new election and complete a month of termination of employment or accurate event date. service. reduction in number of hours of employment) or Your online elections will not When adding coverage because of the –– Employer contributions toward the become effective until you have sent birth or adoption of a dependent, your coverage were terminated. documentation supporting the event new coverage is effective as of the date of (such as your divorce decree in the the birth or adoption. The term “loss of eligibility” does not event of a divorce) to the Benefits include loss of coverage because of Department and your documentation failure to pay premiums on a timely basis has been approved. Your effective date or any termination of coverage for cause. provided by the enrollment system and/ or elections will be changed if: If you gain a new dependent, you and •• You submit the documentation after your dependents are eligible for special the pay period in which you make enrollment rights if: your online elections •• You are eligible for a Total Health •• You entered an event date that does Medical Plan but are not currently not correspond with the date shown enrolled, and in your documentation •• You acquire a new dependent •• The benefit changes you requested through marriage, birth, adoption, or online are not consistent with your placement for adoption. status change. You may enroll yourself and all your eligible dependents on account of your marriage or a child's birth, adoption, or placement for adoption with you.

12 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Enrolling In Flexible Benefits

You may add or drop coverage if Effective Date of Changes your dependent becomes eligible for The effective date for special enrollment premium assistance under Medicaid rights is the earlier of the first day of the SEE PAGE 14 for a table that or a state health plan (CHIP) or loses month or the first day of the pay period summarizes the changes you coverage under one of those plans as a after you notify Human Resources, may make based on your life result of loss of eligibility. provide the appropriate documentation, event. Requesting Special Enrollment and complete the enrollment (all of this must be done within 31 days of You must notify Human Resources and the event). If you are adding coverage provide documentation within 31 days because of the birth or adoption of of the event that caused your special a dependent, your new coverage is enrollment rights or you will lose your effective as of the date of the birth or special enrollment rights for that event. adoption. See pages 167 – 168 for the The plan administrator may require 2013 cost of coverage. documentation of the event.

If you do not request your change and Participation When you initially notify Human provide documentation within 31 days Resources of your event, they will of the qualifying event, you may elect explain how to enroll. After you enroll, to change your benefits only during you must provide documentation within the next open enrollment period or 31 days of the event. if you have special enrollment rights, as explained beginning on page 12. Your documentation must show your If you do not provide the required name, the date of the change and, if documentation after you have made applicable, your new dependent’s name, your elections, the election will be Social Security number, gender, and birth reversed or cancelled and premiums date. will not be refunded. You will also be required to provide documentation for the dependents you cover as described on page 7.

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 13 Enrolling In Flexible Benefits

Summary of Allowable Changes in Coverage The following table lists the changes you may be allowed to make for qualified status changes or special enrollment rights you may have. Boxes marked with a √ indicate when changes are allowed. The term “Dep” in the table means “Dependent.” The benefits you select must be consistent with your family status change.

Spouse & Add’l Health & Day Medical, Dental & Vision Add’l Life STD/LTD Child Life AD&D Care FSA Add Drop Add Drop Change Add Drop Add Drop Add Drop Add Drop Increase Decrease Event Plan Plan Dep Dep Plan Plan Plan Plan Plan Plan Plan Plan Plan Amount Amount Newly hired employee is eligible for √ √ √ √ √ √ √ benefits1 Spouse gets job with other coverage √ √ √ √ √ √ √ or becomes eligible for Medicare Spouse has a different enrollment √ √ √ √ √ √ √ √ √ √ √ √ period and change in coverage

Participation Employee is rehired 180 or more days √ √ √ √ 2 √ √ √ following termination1 Employee changes from part-time to √ √ √ √ √ 2 √ √ √ √ full-time Employee changes from full-time to √ √ √ √ √ √ √ √ 3 √ part-time Employee changes from PRN or √ √ √ √ 2 √ √ √ part-time (working less than 24 hours/week) to full-time or part-time (working more than 24 hours/week) 4 Employee goes on unpaid LOA √ √ √ √ √ √

Employee returns from unpaid LOA12 √ √ √ √ √ √

Employee marries √ 5 √ √ √ √ √ 2 √ √ √ √ √

Employee divorces √ √ √ √ √ 2 √ 6 √ √ √ √

Spouse dies √ √ √ √ √ 7 √ √ √ √ √

Employee gains a child due to birth, √ 5 √ √ √ 2 √ 8 √ √ √ adoption, marriage, etc. Child is no longer eligible due to other √ √ 9 √ 9 √ √ coverage, (CHIP, Medicaid or other insurance) divorce, death, reaching the age limit Spouse or child terminates employment, √ √ √6 √ 2 √6 √6 √ √ 10 or coverage offered by spouse’s or child’s employer changes significantly, resulting in loss of eligibility for the plans in which they were enrolled or resulting in a significant change in benefit cost or coverage Employee moves to location outside √ 11 √ 11 √ 11 the plan’s service area Cost of day care changes (and care is √ 10 √ 10 not provided by relative)

1 An employee who is rehired less than 180 days following termination will have 6 Spouse event only the same coverage as before termination, unless rehired in a new plan year or 7 Child life only unless the employee has changed to a different status. 8 If this is your first child, you may add Spouse Life, as well. 2 Pre-existing condition limitations apply. 9 You may not drop spouse life or AD&D and can only drop child life coverage for 3 If medical, dental or vision is dropped the affected child. 4 An employee who loses eligibility for benefits and again becomes eligible for benefits 10 Day Care FSA only within 180 days will have the same coverage as before the loss of eligibility. 11 Medical and Dental only 5 Employee can only add plan if adding dependents. 12 You are re-enrolled in your previous coverage if you request re-enrollment.

YOU ARE required to provide documentation for your dependents.

14 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Paying for Your Flexible Benefits Paying for Your Flexible Benefits You and Texas Health both pay the cost Before-tax Benefits Benefits Base Rate of your Flexible Benefits. Texas Health pays the total cost for some benefits, you You pay your portion of the cost for most Some of your premiums for benefits are pay the total cost for some benefits, and benefits with before-tax dollars. This based on your benefits base rate (as you and Texas Health share some costs, means your contributions for benefits defined in the glossary), which is your base as shown below. Your cost for benefits are deducted from your paycheck before pay on the latest of: is deducted from 26 paychecks of each federal income and Social Security taxes •• Your hire date are taken out. calendar year. Any missed premiums will •• Your rehire date be deducted from the next paycheck. You pay for the following benefits on a •• October 1 of the previous year before-tax basis: •• The date of your last change in job Benefits Paid in Full status (full-time to part-time, part-time •• Medical to full-time, benefits-eligible to non- Participation by Texas Health •• Dental benefits-eligible). •• Paid Time Off •• Vision •• Basic Life Insurance •• Additional AD&D Insurance Premiums that are based on your •• Basic AD&D Insurance •• Flexible Spending Accounts benefits base rate include: •• Basic Long Term Disability •• Medical Because you do not pay taxes on •• Business Travel Accident Insurance • the earnings you use to pay for these • Basic Life Insurance •• Tuition Reimbursement benefits, your total tax bill may be •• Additional Life Insurance •• Be Healthy wellness program reduced. •• Basic AD&D Insurance •• Adoption Assistance •• Additional AD&D Insurance After-tax Benefits •• Short Term Disability Benefits Paid by •• Basic Long Term Disability Your contributions for after-tax benefits You and Texas Health • are subject to federal income taxes and • Additional Long Term Disability •• Medical/Prescription Social Security taxes. Contributions are deducted from your paycheck after Payroll Deductions Benefits Paid in Full taxes have been taken out. Your after-tax You will pay for the benefits you elect by You benefits include: through payroll deduction. These •• Additional Life Insurance deductions are taken from 26 paychecks •• Dental •• Dependent Life Insurance during the year. •• Vision •• Short Term Disability •• Additional AD&D Insurance •• Additional Long Term Disability •• Flexible Spending Accounts •• Long Term Care Insurance •• Additional Life Insurance •• Dependent Life Insurance •• Short Term Disability •• Additional Long Term Disability •• Long Term Care Insurance

If you take an approved leave of absence, you must pay your portion of the cost for benefits bi-weekly to continue coverage during the leave. If you do not pay your premiums while on leave, your benefits will be canceled.

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 15 Paying for Your Flexible Benefits

Payroll deductions for medical, dental, Medical Subsidy Converting Paid Time Off* and vision benefits are based on the plan you elected and the family Because retirement can have a During open enrollment, you can elect members you elect to cover. Your cost significant financial effect on you and to convert up to 80 hours of Paid Time for medical coverage also varies by your family, Texas Health will provide Off (PTO) in eight-hour increments that which prescription drug coverage you a medical subsidy if you are age 55 or you will earn the following year to pay choose and by your benefits base rate, older and work part-time. This subsidy for your Flexible Benefits. To be eligible depending on whether you earn: (which is taxable), will make your net to convert PTO, you must elect at least cost for medical coverage the same one Flexible Benefit option (other than •• Less than $25,000 as for full-time employees earning the 401(k) Retirement Plan). •• $25,000 – $49,999 between $50,000 and $74,999 per year— •• $50,000 – $74,999 regardless of how much you actually You are limited to a combined total •• $75,000 – $99,999 earn. of 100 hours per year for conversion, selling and donating PTO. For example, •• $100,000 or more For example, if you elect medical if you elect to convert 40 hours of PTO Separate medical rates also apply to coverage under the Choice 500 Low to pay for 2013 benefits, you will have 60

Participation part-time employees. Rx plan for Employee + Spouse, the hours of PTO available to sell or donate part-time premium listed on page 167 is during 2013. See page 126 for details on Payroll deductions for other optional $216.16. This is the amount that will be converting PTO. benefits are based on the level of shown on your paycheck as a deduction coverage you select and, in some cases, for medical coverage. The premium for * Physicians and physician extenders are not eligible your age and earnings. full-time employees earning $50,000 for PTO conversion. Your 2013 costs are listed on pages – $74,999 is $90.60. The difference of 167 – 168. $125.56 will be shown on your paycheck as a medical subsidy from Texas Health.

$216.16 Part-time premium

Premium for full-time – $90.60 employees earning $50,000 – $74,999

Subsidy for part-time $125.56 employees over age 55

16 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Medical & Wellness Total Health Medical Plan...... 18 Overview 18 Choose Your Network 18 Choose Your Medical Coverage 19 Who Can be Covered 19 Pre-existing Conditions 19 2013 Medical Plan Comparison 20 Prescription Drug Comparison 23 UHC Choice Plan 24 UHC Choice Plus Plan 24 How the Plans Work 24 Covered Medical Expenses 28 Excluded Medical Expenses 35 Coordination of Benefits 38 Prescription Drug Benefits 39 Filing and Appealing Claims 41 Subrogation 49 When Coverage Ends 51 Retiree Medical Coverage 51 Be Healthy Wellness Program...... 52 Eligibility for Be Healthy 52 Be Healthy Incentives 53 Medical & Wellness Medical Online Health Assessment 54 Be Healthy Basics 54 Preventive/Wellness Exam 55 Health Advocacy 55 Maternity Support Program 56 Cancer Support Nurse 56 Health Coaches 56 Diabetes Management Program 57 Medical Nutrition Therapy 57 Tobacco Cessation 57 Weight Watchers 58 Fitness Memberships 58 Cancer Screenings 59 Employee Assistance Program (EAP) 60

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 17 Total Health Medical Plan Total Health Medical Plan Overview •• Health Advocacy—Whenever you Choose Your Network have questions about your health, Texas Health offers eligible employees a you can ask Health Advocacy. Texas The Total Health Medical Plans offer medical plan that allows you to choose Health gives you free access to Health UnitedHealthcare’s (UHC’s) Choice the network, medical coverage level, and Advocacy for information by phone and Choice Plus networks of doctors, prescription drug coverage that’s best for at 1-877-MyTHRLink (1-877-698-4754), hospitals, and other health care you and your family. option 2 or online at www.myuhc.com. providers. Both networks include the same in-network providers. The Health Advocacy offers a team of You have one source for all employee difference is that you are covered for specially trained individuals who help benefits needs—Total Health. out-of-network care only if you select the you navigate the health care system UHC Choice Plus network. Treating illness is only part of the way and gives you a trusted source for you protect your health. To truly protect health care information and support Regardless of which network you yourself, you need good medical 24 hours a day. choose, you have the opportunity to coverage and good resources so you can •• Be Healthy—supports you in save even more. To keep your out-of- take an active role in your health. optimizing and maintaining your pocket costs as low as possible, Texas health and well-being. Health encourages you to use Texas Here is what the Total Health Medical •• Preventive Care—is covered for you Health Preferred Hospitals. Texas Health Plans include: and each covered member of your Preferred Hospitals are not a separate •• Medical Coverage—gives you access family. The Total Health Medical Plans network. They are a select group of to UnitedHealthcare’s Choice and cover an extensive array of preventive hospitals within the UHC network. When Choice Plus network and your choice exams including, but not limited to, you use Texas Health Preferred Hospitals, of three different deductible and physicals, mammograms, pap smears, you will receive the highest level of coinsurance levels. You save money on prostate exams, and colonoscopies. benefit coverage and pay the lowest out- Medical & Wellness Medical your health care costs when you use You are encouraged to have these of-pocket costs. It is your responsibility Texas Health Preferred Hospitals. yearly check ups. Prevention is one of to verify whether a hospital is a Texas •• Prescription Drug Coverage—you the best ways to make wellness a way Health Preferred Hospital before you have two options that differ in the of life. receive care. percentage they pay for covered •• Maternity Support Program—offers prescription drugs. you personal support through all When you need medical care, first check to be sure your doctor, hospital or •• Complex and Chronic Patient stages of pregnancy and delivery and health care provider is part of the UHC Management (CCPM)—Working on rewards you for participating. Choice or Choice Plus network. By using behalf of Texas Health Resources, •• MHN Employee Assistance Program network providers, you can save money Total Health Nurses, who are skilled (EAP)—gives you free phone and on the cost of your care. These networks case managers, identify patients with Internet access to counselors and are large and include most medical complex and chronic conditions and information to help you cope with specialties you will need. build on in-office care to fill potential life challenges like stress, relationship care gaps with: issues, and financial concerns. It You are not required to choose a –– Coordination of multiple physicians includes up to six free face-to-face primary care physician (PCP), but the –– Access to community resources counseling sessions per issue per year. network copays are lower when you –– Longer-term condition support The EAP is available 24 hours a day, use a physician who specializes in seven days a week. –– Complex access general practice, family practice, internal •• Benefits for Mental Health and –– Care plan coordination medicine, or pediatrics. You may use Substance Abuse—Mental health and –– Psychosocial and knowledge needs. a network specialist without a referral substance abuse treatment must be from a primary physician, but you pay •• Transition Support Program— coordinated through United Behavioral the higher specialist copay. provides support to help improve your Health (UBH) if you are covered by the health care experience by providing Total Health Medical Plans. For a complete list of Texas Health support from the time you learn you Preferred Hospitals, log on to need to go to the hospital until after www.MyTHR.org. You can also get the you return home. list of Texas Health Preferred Hospitals on www.myuhc.com by entering “THR” as your user name and password.

18 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Total Health Medical Plan

Choose Your Medical Before making an election, you should OUT-OF-AREA FAMILY MEMBERS review all the plan options carefully Coverage If you want to cover a family member to determine which one is most who does not live in an area that has Regardless of which network or medical appropriate for you. Refer to the Medical UHC network providers, you may want plan you choose, all the plans cover the Plan Comparison table on pages 20 – 22. to select the UHC Choice Plus network same medical services. The differences are because it covers out-of-network care. in the premiums and the amount you pay Important terms that appear in this section are defined in the Glossary of out of your own pocket for medical care. To find out whether there are any UHC Terms beginning on page 161. network providers who practice in the If you select the UHC Choice network, location where your dependent lives, you have the option of: Who Can Be Covered logon to www.myUHC.com and enter •• Choice Plan 500 As a full-time or part-time benefits- THR as your user name and password. •• Choice Plan 1000. eligible employee or as a COBRA After you have logged in, you'll see the participant (as defined on page 5), you option to “Find Physicians and Facilities.” If you select the UHC Choice Plus may elect one of the following levels network, you have: If you elect the UHC Choice Plus Plan, of coverage under one of the medical your dependents may use any provider, •• Choice Plan 1500 Plus. plans: either in- or out-of-network. You must For a comparison of these plans, see •• You only submit claims for services received out- pages 20 – 22. •• You and your spouse of-network. •• You and your children Once you have chosen your medical •• You and your family. Pre-existing Conditions plan network and coverage, it is time to select a prescription drug coverage that Your dependents must be covered under Texas Health is proud that we do works best for you and your family. Two the same option as you are covered not have any pre-existing condition options are available: under. See page 6 for information on limitations under any of the medical plan options. This means if you are •• High Rx eligibility. newly enrolling in our plans, you do not •• Low Rx. & Wellness Medical You will be required to provide need to be concerned that our medical Both options cover the same medicines documentation that confirms the plans will not cover a condition that you and have the same copay for generic eligibility of dependents you cover, as or your dependent has at the time you drugs. The difference is in the percentage explained on page 7. enroll—so long as it is a condition that is of coinsurance you will pay for otherwise covered by our medical plan. preferred and non-preferred drugs. For a comparison of the plans, see page 23.

Texas Health Preferred Hospitals

EVEN WHEN you use a doctor who is in the UHC Choice or Choice Plus network, you still need to be sure your doctor refers you to Texas Health Preferred Hospitals. You will pay more if you use a network hospital that is not a Texas Health Preferred Hospital. It is your responsibility to verify whether a hospital is a Texas Health Preferred Hospital before you receive care.

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 19 Total Health Medical Plan

2013 Medical Plan Comparison The following table compares the key features of the different medical options and the copays or coinsurance you must pay. All the plan provisions are subject to each plan’s copays, coinsurance and/or deductible amounts, as applicable. Some services require prior notification. Excluded medical expenses are described on pages 35 – 38.

DEDUCTIBLES AND OUT-OF-POCKET MAXIMUMS • Preferred Hospitals UHC Choice Network Out-of-Network 1 Plan Name Individual Family Individual Family Individual Family

Choice Plan 500 Annual Deductible $500 $1,500 $3,000 $9,000 Not covered Not covered Annual Out-of-Pocket Maximum 2 $3,000 $6,000 $12,000 $24,000 Not covered Not covered Choice Plan 1000 Annual Deductible $1,000 $3,000 $4,000 $12,000 Not covered Not covered Annual Out-of-Pocket Maximum 2 $5,000 $10,000 $15,000 $30,000 Not covered Not covered Choice Plan 1500 Plus Annual Deductible $1,500 $4,500 $4,000 $12,000 $5,000 $15,000 Annual Out-of-Pocket Maximum 2 $5,500 $11,000 $15,000 $30,000 $18,000 $36,000

YOUR COST FOR COVERED SERVICES The deductibles and out-of-pocket maximums are different under each of the three plan options. However, after you pay the annual deductible for your chosen plan, the coverage is the same under all plans. Only the Choice Plan 1500 Plus covers out-of-network care.

1

Medical & Wellness Medical Preferred Hospitals UHC Choice Network Out-of-Network (Covered only Under Choice Plan Plan Feature 1500 Plus) Outpatient Care

Office Visits for Illness or Injury $30 copay for primary physician 50% after deductible $50 copay for specialist Outpatient Diagnostic Lab & No additional charge if processed in No additional charge if processed 50% after deductible X-ray 3 (excluding MRI, CT, PET doctor’s office; 10% after deductible if in doctor’s office; 10% or 50% after scans) not in doctor’s office deductible if not in doctor’s office* Chemotherapy Treatment $50 copay for specialist 50% after deductible Radiation 10% after 10% or 50% 50% after deductible deductible after deductible* MRI, CT & PET Scans 3 10% after 10% or 50% 50% after deductible deductible after deductible* Outpatient Surgery Office visit copay applies; 10% after Office visit copay applies; 10% or 50% 50% after deductible with deductible if not in doctor’s office after deductible if notification4 not in doctor’s office* Emergency Room 10% after deductible Urgent Care Clinic $50 copay 50% after deductible * Coinsurance is 10% at a freestanding network facility and 50% at a hospital that is not a Texas Health Preferred Hospital.

OUT-OF-NETWORK CARE is not covered under Choice Plans 500 or 1000, unless it is for an emergency.

Footnotes are on page 22.

20 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Total Health Medical Plan

Preferred Hospitals UHC Choice Network Out-of-Network1 (Covered only Under Choice Plan 1500 Plan Feature Plus) Preventive Care Routine Physicals 6 $0 Not covered Well-woman/man exams 6 $0 Not covered (including pap test and PSA test) Well-child exams (including $0 Not covered immunizations) 6 Mammography 5 $0 Not covered Colonoscopy 6 $0 Not covered Maternity Care Office Visits for Pre- and $30 for initial office visit; 50% after deductible Post-natal Care no cost for additional visits In-hospital Delivery and Newborn 10% after deductible and only one 50% after deductible4 Nursery Care including all deductible applies to the mother and physician charges newborn child Inpatient Hospital Care Hospital Admission 7 10% after deductible 50% after deductible 50% after deductible with notification4 Family Planning Infertility Services—diagnostic 10% after deductible 50% after deductible testing 8 Sterilization (tubal ligation or Office visit copay applies; 10% after Office visit copay applies; 50% after 50% after deductible vasectomy) deductible if not in doctor’s office deductible if not in doctor’s office Mental Health Care and Substance Abuse Treatment Outpatient Mental Health Care $50 per visit 50% after deductible and Substance Abuse Treatment & Wellness Medical Inpatient Mental Health Care and 10% after deductible 50% after deductible 4 Substance Abuse Treatment Hearing Care Hearing Evaluation Office visit copay applies; 10% after Office visit copay applies; 50% after 50% after deductible deductible if not in doctor’s office deductible if not in doctor’s office Hearing Aids (one new pair every 10% after deductible 50% after deductible 36 months) Outpatient Therapy Acupuncture $50 per visit 50% after deductible (up to four treatments per year) Cardiac Rehabilitation $30 per visit $50 per visit 50% after deductible (up to 36 visits per year) Chiropractic and Spinal $50 per visit 50% after deductible Manipulation (20 visits) Pulmonary and Cardiac Therapy $30 per visit $50 per visit 50% after deductible (20 visits) Speech, Occupational, and $30 per visit $50 per visit 50% after deductible Physical Therapy (combined 60 visits) Care at Alternate Sites Home Health Care (up to 100 10% after deductible 50% after deductible 4 visits per year; one visit is up to four hours) Skilled Nursing Care 10% after deductible 50% after deductible 4 (up to 60 days per year) Hospice Care 10% after deductible 50% after deductible 4

Footnotes are on page 22.

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 21 Total Health Medical Plan

Preferred Hospitals UHC Choice Network Out-of-Network1 (Covered only Under Choice Plan 1500 Plan Feature Plus) Other Services Ambulance Covered in full with no deductible for a medical emergency. Transportation to nearest facility that can provide appropriate medical care and treatment. Allergy Tests and Treatment $30 primary physician 50% after deductible $50 specialist (or cost of serum if less) Cosmetic Surgery 9 10% after deductible 50% after deductible 50% after deductible 4 Durable Medical Equipment 10% after deductible 50% after deductible 4 (diabetic supplies are unlimited) 10 Glasses or Contacts 11 10% after deductible 50% after deductible Organ and Tissue 10% after deductible Not covered Transplants 12 Orthognathic and TMJ 13 10% after deductible 50% after deductible

Ostomy Supplies 10% after deductible 50% after deductible Bariatric Surgery 14 10% after deductible plus $4,000 50% after deductible plus $4,000 Not covered (must meet specific guidelines hospital copay hospital copay described on page 32 under “obesity” and be at least 18 years old) Medical Nutrition Therapy $0 copay per session (only at Texas Not covered (one initial assessment Health facilities) and up to three 30-minute sessions per year) 15 Diabetes Education 16 $10 copay Not covered Medical & Wellness Medical

OUT-OF-NETWORK CARE is not covered under Choice Plans 500 or 1000, unless it is for an emergency.

1 Whenever you use an out-of-network provider, you must pay for services at the time you receive them and file a claim for reimbursement of eligible expenses. 2 The annual out-of-pocket maximum does not include the annual deductible, medical copays, prescription copays, non-compliance penalties, or expenses that are not covered by the plan. 3 Whenever you have an X-ray or lab service, you incur two separate charges. One is for the service itself, and the other is for the radiologist or pathologist who interprets the results. The radiologist or pathologist must be in-network for charges to be covered under Choice 500 and Choice 1000. 4 $1,000 penalty for failure to provide notification. 5 One per year is covered in full; additional screenings are covered, however you pay the coinsurance after your deductible. 6 One well exam per year is covered in full if the claims administrator determines the physical is for preventive care. Additional screenings or services will be considered diagnostic services and will be covered after you pay the applicable copay or deductible and coinsurance. At the time of your preventive care visit, if other services are performed that are not preventive services, as determined by the claims administrator, they will not be paid at 100% even if they are submitted as part of a claim for preventive care. Some items require you to pay the appropriate copay or coinsurance, including electrocardiograms (EKGs), focused office visits, thyroid scans, breast MRI, vitamin D assays, and transvaginal ultrasounds. 7 Includes network providers for all of the following: inpatient doctor’s visits and consultations, surgeon, anesthesiologist, pathologist, and radiologist. 8 Infertility drugs, procedures to correct infertility, artificial insemination, GIFT, ZIFT, and other infertility treatments are not covered. 9 Coverage limited to accidental bodily injury, correction of a congenital anomaly, reconstructive breast surgery, or removal of breast implants (if deemed necessary by the claims administrator). 10 You must pre-notify UHC for durable medical equipment that costs more than $1,000. 11 Only covered when prescribed within 12 months following cataract surgery. 12 Coverage is limited to non-experimental transplants at approved hospitals, as explained on page 34. 13 No coverage for appliances and orthodontic treatment. Must meet specific guidelines. 14 Bariatric surgery can only be performed at Texas Health hospitals that are designated as a UHC Center of Excellence. 15 You must have a physician’s referral. 16 You must have a physician’s referral. If you visit a THR diabetes educator, you may receive free test strips.

22 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Total Health Medical Plan

Prescription Drug Comparison

Type of High Rx Low Rx Prescription Retail 17 Mail Order 18 Retail 17 Mail Order 18 Generic $10 copay $20 copay $10 copay $20 copay Preferred 25% of cost of 31-day supply ($20 25% of cost of 90-day 40% of cost of 31-day supply ($20 40% of cost of 90-day supply ($40 minimum and $100 maximum supply ($40 minimum and minimum and $150 maximum minimum and $300 maximum copay per prescription) $200 maximum copay per copay per prescription) copay per prescription) prescription) Non-Preferred 40% of cost of 31-day supply 40% of cost of 90-day supply 50% of cost of 31-day supply ($40 50% of cost of 90-day supply ($80 ($40 minimum with no maximum ($80 minimum with no maximum minimum with no maximum copay minimum with no maximum copay copay per prescription) copay per prescription) per prescription) per prescription) Annual Out- $2,000 per person if you earn $25,000 or more. $2,000 per person if you earn $25,000 or more. of-Pocket $1,000 if you earn less than $25,000. 20 $1,000 if you earn less than $25,000. 20 Maximum 19

17 Up to a 31-day supply 18 Up to a 90-day supply. Mail order is required for maintenance medications on the third time you fill it. Or you may purchase a 90-day supply at the retail pharmacy at Texas Health Dallas and Texas Health Plano, or any CVS pharmacy. Otherwise you pay double the retail charge. 19 Maximum combined for retail and mail-order prescriptions. Prescription drug annual out-of-pocket maximum is separate from medical annual out-of-pocket maximum. Copays for generic drugs, as well as coinsurance for drugs, apply toward the out-of-pocket maximum. The out-of-pocket maximum does not include the dispense as written (DAW) penalty explained on page 39. 20 Based on your base benefits rate. All COBRA participants will have a $2,000 annual out-of-pocket maximum. Medical & Wellness Medical

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 23 Total Health Medical Plan

UHC Choice Plan How the Plans Work Benefits will be paid as though you had used a Preferred Hospital only The UHC Choice Plan pays benefits only UHC Choice and Choice Plus Plan if the covered services or supplies when you use providers who are part network providers agree to charge for that condition are provided by or of the UHC Choice network. You pay a contracted rates for their services. You arranged by the designated facility or copay for doctor office visits and urgent must meet an annual deductible before other provider chosen by the claims care. For most other services, you must the plan pays benefits for services administrator. meet an annual deductible and pay requiring you to pay coinsurance. You your coinsurance before the plan pays are not required to satisfy a deductible YOUR COSTS benefits. You do not file any claims. This when a copay amount applies. All Individual Deductible plan generally pays no benefits if you medical treatment must be considered use out-of-network providers, except in a covered health service (as explained A deductible is the amount you must the event of an emergency (as defined on page 162) to be eligible for coverage pay each year from your pocket before on page 163). by the plan. The plan will not pay more the plan begins to pay benefits for than the eligible expenses. covered health services. Copays do not Advantages of this plan include: count towards the deductible. After you •• Lower deductible See pages 28 – 35 for a list of covered satisfy the deductible, the plan pays a medical expenses under the UHC percentage of eligible expenses. Your •• Lower out-of-pocket expenses Choice and Choice Plus Plans. prescription copays are not subject to •• Covered preventive care (such as deductibles. routine physical exams and well-child You may use any UHC Choice or Choice care) received from network providers Plus network provider or facility you Family Deductible •• No claims to file wish. However, if your UHC Choice After two covered family members meet •• Lower premiums. network doctor refers you to a network their individual annual deductibles, hospital that is not a Texas Health or more than two family members UHC Choice Plus Plan Preferred Hospital, you will pay more combined meet the family deductible, (50% of the cost of covered services) The UHC Choice Plus Plan offers you other covered family members are not than if you use a Texas Health Preferred the savings of the UHC Choice Plus required to satisfy individual deductibles Medical & Wellness Medical Hospital (10% of the cost of covered network—while giving you the flexibility for the year. The plan administrator services). If you choose a Texas Health to use non-network providers when you reserves the right to allocate the Preferred Hospital, the plan pays a want. You can receive care through a deductible and benefits to any covered higher benefit, which reduces your UHC Choice Plus network provider or persons. out-of-pocket costs. Because network through another provider of your choice. providers may change, you should How Deductibles Cross-apply If you receive care through an out- always verify that the hospital is in the If you participate in Choice Plan 500 or of-network provider, you pay higher network before receiving services. 1000, the Preferred Hospital and UHC out-of-pocket costs. You must file claims MyTexasHealth and www.MyTHR.org Choice Network deductibles count for out-of-network services. The plan provide a list of Texas Health Preferred towards each other. controls your expenses with an annual Hospitals. You can also use the Texas out-of-pocket maximum, which limits Health WellCall Center 1-877-THR-WELL If you participate in the Choice Plan the amount you must pay for covered (1-877-847-9355) to find a physician. 1500 Plus, the Preferred Hospital and services in one calendar year. UHC Choice Network deductibles If you have a medical condition that count towards each other. However, Advantages of the UHC Choice Plus Plan the claims administrator believes needs Texas Health Preferred and UHC Choice include: special services, they may direct you to Network annual deductibles do not •• The choice of using a network or a designated facility or other provider cross-apply to the out-of-network annual out-of-network provider each time you chosen by them. If you require certain deductible and the out-of-network need medical care complex covered health services for annual deductible does not cross-apply •• Higher benefit levels when you use which network expertise is limited, the to either the Texas Health Preferred network providers claims administrator may direct you to or UHC Choice Network annual •• Covered preventive care (such as an out-of-network facility or provider. deductibles. routine physical exams and well-child care) received from network providers •• No claims to file when you use network providers.

24 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Total Health Medical Plan

Coinsurance Annual deductibles, medical copays, Choice Plus Network non-notification penalties, prescription Coinsurance is the percentage of medical Network Benefits.Contracted rates with drugs, and non-covered medical expenses you are responsible for paying the provider. expenses do not count toward the out- after you meet the annual deductible. of-pocket maximum. Prescriptions have All services require coinsurance except Non-network Benefits. a separate out-of-pocket maximum listed generic prescriptions, office visits, routine on page 23. •• Negotiated rates agreed to by the non- physicals, urgent care, and ambulance network provider and either the claims service. You pay your coinsurance and Fee Limits administrator or one of its vendors, the plan pays the remaining percentage. affiliates or subcontractors, at the You must file claims for benefits that The UHC Choice and Choice Plus discretion of the claims administrator. require coinsurance when you use out-of- Plans pay in-network benefits based on •• If rates have not been negotiated, then network providers under the UHC Choice contracted rates. Out-of-network claims one of the following amounts: Plus Plan. for the UHC Choice Plus Plan will be paid at 140% of the Medicare allowable –– 140% of the published rates allowed Out-of-Pocket Maximum amount. This is the maximum amount the by the Centers for Medicare and plans will consider as an eligible expense Medicaid Services (CMS) for Under the UHC Choice and Choice Plus for a medical service or supply. By using Medicare for the same or similar Plans, you will not pay more than the the UHC Choice or Choice Plus network, service within the geographic annual out-of-pocket maximum in one you can keep your costs lower. Network market, or year for covered services when you use doctors and hospitals agree to keep their network providers. In-network services –– When a rate is not published by fees within the plan’s eligible expenses or have a separate out-of-pocket maximum CMS for the service, the claims allowable amount for your area. from out-of-network services in the administrator uses an available gap methodology to determine a rate for Choice Plus Plan. If you are covered under the UHC Choice the service as follows Plus and use an out-of-network provider After your coinsurance costs reach the –– For services other than physician- whose fees are more than the plan’s applicable out-of-pocket maximum, administered pharmaceutical eligible expenses or allowable amount, the plan pays the full cost of covered products, the claims administrator

you must pay any amount that exceeds & Wellness Medical expenses for the rest of the year. uses a gap methodology that uses a the limit, in addition to your deductible relative value scale, which is usually and coinsurance amounts. If you are in Choice Plan 500 or 1000, based on the difficulty, time, work, deductible and coinsurance amounts you Choice Network risk and resources of the service. pay for services provided by Texas Health The relative value scale currently Preferred and UHC Choice Network will Eligible expenses are charges for covered used is created by Ingenix. If the cross-apply to the annual deductibles health services that are provided while Ingenix relative value scale becomes and out-of-pocket maximums for both the the plan is in effect and are determined no longer available, a comparable Texas Health Preferred and UHC Choice as follows: scale will be used. The claims Networks. administrator and Ingenix are Eligible Expenses are related companies through common If you are in Choice Plan 1500 Plus, For: Based On: ownership by UnitedHealth Group. deductible and coinsurance amounts Network Contracted rates with –– For physician-administered you pay for services provided by Texas Providers that provider Health Preferred and UHC Choice pharmaceutical products, the Non- If you receive covered claims administrator uses gap Network will cross-apply to the annual network health services from a deductibles and out-of-pocket maximums Providers non-network provider methodologies that are similar to both the Texas Health Preferred and in an emergency, to the pricing methodology eligible expenses are used by CMS, and produces fees UHC Choice Networks. However, Texas the amounts billed by Health Preferred and UHC Choice the provider, unless the based on published acquisition Network expenses do not cross-apply to claims administrator costs or average wholesale price negotiates lower rates. the out-of-network annual deductible for the pharmaceuticals. These methodologies are currently created or out-of-pocket maximum and out-of- For certain covered health services, by RJ Health Systems, Thomson network expenses do not cross-apply to you are required to pay a percentage Reuters (published in its Red either the Texas Health Preferred or UHC of eligible expenses in the form of Book), or the claims administrator Choice Network annual deductible or coinsurance. out-of-pocket maximum. based on an internally developed pharmaceutical pricing resource.

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 25 Total Health Medical Plan

When a rate is not published by CMS for the service and a gap methodology does SITUATIONS REQUIRING Notification not apply to the service, or the provider does not submit sufficient information YOU MUST prenotify UHC in the following situations: on the claim to pay it under CMS ••Elective admissions—five business days before admission published rates or a gap methodology, ••Maternity (inpatient stays greater than 48 hours for regular delivery and the eligible expense is based on 50% 96 hours for Cesarean delivery) of the provider’s billed charge, except ••Skilled nursing/inpatient rehabilitation facilities that certain eligible expenses for mental ••Reconstructive procedures health and substance abuse services are based on 80% of the billed charge. ••Nonelective admissions—within one business day or the same day of admission The claims administrator updates the ••Emergency admissions—within two business days CMS published rate data on a regular ••Durable medical equipment costing $1,000 or more basis when updated data from CMS ••Home health care becomes available. Theses updates are ••Hospice care typically implemented within 30 to 90 ••Inpatient services for mental health or substance abuse conditions days after CMS updates its data. ••Dental/oral surgery (for an accident) ••Transplants For certain covered health services, • Congenital heart disease—as soon as it is suspected or diagnosed (in you are required to pay a percentage • utero detection, at birth, or as determined and before the time an of eligible expenses in the form of evaluation for CHD is performed) coinsurance. Eligible expenses are subject to the claims administrator’s IF YOU do not follow the plan's requirement for notification, as explained reimbursement policy guidelines. You below under “Your Responsibility for Notification” you may be subject to a may request a copy of the guidelines penalty. related to your claim from the claims administrator. Medical & Wellness Medical NOTIFICATION IS not a guarantee or a determination of benefits. RECEIVING CARE Preventive Care Emergency Care YOUR RESPONSIBILITY FOR The UHC Choice and Choice Plus Plans NOTIFICATION cover routine physicals when you use The plans cover emergency care network providers at 100%.* Routine worldwide. When you have a medical Prior notification is required before physicals include well-woman, well-man emergency (as defined on page 163), you receive certain covered services or and well-child exams. Routine physicals your visit to a hospital emergency room supplies. In general, network providers and well-child care are not covered is covered as shown in the table on page are responsible for notifying Personal SM out-of-network. See page 33 for more 20. Health Support before they provide information about preventive care. these services to you. However, you are In the event of an emergency, you may responsible for notifying Personal Health Urgent Care receive benefits at the Preferred Hospital SupportSM for certain network benefits. level when using an out-of-network If you need urgent care for symptoms provider if you call the toll-free number For mental health/substance abuse such as high fevers, flu, cuts that may on the back of your ID card within two services, you are responsible for require stitches, or sprains, call your business days after the emergency. notifying United Behavioral Health. primary physician or family doctor. He or she will direct you to the appropriate Care While Traveling If you elected Plan 1500 Plus and you place for treatment. Urgent care clinics receive certain covered services or If you have an emergency, acute illness, or centers (as defined on page 166) are supplies from non-network providers, you or injury while traveling, get medical listed in the UHC directory or on are responsible for notifying Personal attention immediately. Then, call your www.MyUHC.com. Health SupportSM before you receive doctor or the number on your plan ID these covered health services. You will be card within 48 hours of receiving care to subject to a $1,000 penalty if you do not be eligible for network benefits. pre-notify.

* One well exam per year is covered in full if the claims administrator determines the physical is for preventive care. Additional screenings or services will be considered diagnostic services and will be covered after you pay the applicable copay or deductible and coinsurance. At the time of your preventive care visit, if other services are performed that are not preventive services, as determined by the claims administrator, they will not be paid at 100% even if they are submitted as part of a claim for preventive care. Some items require you to pay the appropriate copay or coinsurance, including electrocardiograms (EKGs), focused office visits, thyroid scans, breast MRI, vitamin D assays, and transvaginal ultrasounds.

26 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Total Health Medical Plan

You are required to provide prior After you’re home, your nurse will HEALTH ADVOCACY notification for the services listed in the work with you face-to-face or by Coping with health concerns can be box on the previous page. phone to help you do all you can to time-consuming and complex. And, with prevent a return to the hospital. To notify Personal Health SupportSM so many choices, it can be hard to know Your Transition Support nurse will or United Behavioral Health, call the where to look for trusted information help you: telephone number on your ID card. and support. That’s why Health Advocacy –– Understand your condition and services were developed—to give you When you receive services from non- follow your discharge plan peace of mind with: network providers, you should confirm –– Avoid infection or other illness •• Immediate answers to your health and SM with Personal Health Support that the during your recovery wellness questions any time, from any services you plan to receive are covered. –– Make follow-up appointments with where—24 hours a day your doctor and other providers You must notify the claims administrator of •• Access to caring registered nurses –– Learn about medications, including hospital admissions as follows: who have an average of 15 years’ what they’re supposed to do, side clinical experience •• Elective admissions—five business effects and tips for making them •• Trusted, physician-approved days before admission more affordable information to guide your health care •• Nonelective admissions—within one –– Discover the best options for future decisions business day health care needs. •• Emergency admissions—within two •• Complex and Chronic Patient When you call 1-877-MyTHRLink business days. Management (CCPM): Employees (1-877-698-4754) prompt 2, a caring with complex and chronic conditions nurse can help you: UHC PERSONAL HEALTH have access to Total Health Nurses SUPPORTSM & CCPM •• Choose appropriate medical care who help ensure they understand –– Understand a wide range of UHC Personal Health Support provides their diagnosis and treatment symptoms you with support to help you improve recommendations. Total Health Nurses –– Determine if the emergency room, your health care experience. It can help will collaborate with you and your a doctor visit or self-care is right for you when you need to be admitted physician/care team telephonically, & Wellness Medical your needs to a hospital or have an outpatient by visiting your home, or by attending •• Find a doctor or hospital procedure. The program: doctor visits with you. They can help you: –– Find doctors or hospitals that meet •• Keeps decision-making between you your needs and preferences –– Understand your condition and and your doctors treatment plan options –– Locate an urgent care center and •• Helps you navigate the complexity other health resources –– Make lifestyle changes that will of the health care system to get the improve your health •• Understand treatment options services you need. –– Select the appropriate health care –– Learn more about a diagnosis Personal Health Support includes: resources –– Explore the risks, benefits and –– Discover the best options for future possible outcomes of your •• Notification: If you have a situation that health care needs treatment options requires notification (listed in the box •• Achieve a healthful lifestyle on the previous page), UHC makes your –– Learn about medications, including –– Get tips on how nutrition and experience easier by verifying eligibility, what they’re supposed to do, side exercise can help you maintain a confirming benefits, helping you effects and tips for making them healthful weight understand your benefits, and offering more affordable recommendations for network doctors, –– Make follow-up appointments with –– Learn about important health hospitals, and other health care providers. your doctor and other providers. screenings and immunizations •• Admission CounselingSM: Before a •• Reminder Programs: You’ll receive •• Ask medication questions scheduled hospital admission, you reminder letters about recommended –– Explore how to save money on may receive a call to answer your screening exams like mammograms, prescriptions questions or to explain what help you adolescent immunizations, cervical –– Learn how to take medication safely might need after you are discharged cancer screening, diabetes screening, and avoid interactions. from the hospital. and if you are over age 65, flu and While Health Advocacy is an excellent •• Transition Support: Your Transition pneumonia shots. information resource, it cannot diagnose Support nurse will talk with you or •• Dedicated Team of Nurses: A problems or recommend specific your caregiver, usually within 24 - dedicated team of nurses is available treatment. This service is not a substitute 48 hours of your admission to the to help you manage your pregnancy, for your doctor’s care. hospital or care facility. as well as chronic and complex conditions.

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TEXAS HEALTH WELLCALL HEALTH CARE LAWS The following items are considered CENTER AND CONSUMER WEB covered expenses if the claims Mental Health Parity Act SERVICES administrator determines that they are Texas Health offers you two resources According to the Mental Health Parity an eligible expense for diagnosis or to make it easier for you to use Texas Act of 1996, mental health benefits treatment of the patient’s condition. Health hospitals for your own health under the Texas Health Medical Plan are All services are subject to the excluded care—the WellCall Center and Consumer equal to medical and surgical benefits expenses listed on pages 35 – 38. under this plan. Web Services. •• Acupuncture—up to four visits per year Consumer Web Services Women’s Health Act •• Allergy treatment, testing and serum The Women’s Health and Cancer Rights Log on to www.TexasHealth.org for injections Act of 1998 requires that all health access to a wealth of online resources, •• Ambulance—for medical insurance plans that cover mastectomy including: emergencies to the nearest hospital also cover the following medical care: •• Pre-registration for elective surgery, where emergency health services • maternity stay, or outpatient surgery at • Reconstruction of the breast on which can be performed. Non-emergency Texas Health hospitals the mastectomy was performed coverage is available for non- • •• Information on family and community • Surgery and reconstruction of the emergency ambulance transport when education classes other breast to produce a symmetrical it is medically necessary. appearance •• Hospital bill payment •• Anesthesia •• Prostheses and treatment of physical •• Electronic get-well cards •• Anorexia and bulimia complications at all stages of the •• Medical encyclopedias in English and •• Attention Deficit Disorder (ADD) mastectomy, including lymphedemas. Spanish and Attention Deficit Hyperactivity Disorder (ADHD)—diagnosis •• Information about prescription drugs Newborn’s and Mother’s Health and treatment are covered. Other in English and Spanish Protection Act limitations described on page 31 Federal law (Newborn’s and Mother’s WellCall Center under “Mental health and substance

Medical & Wellness Medical Health Protection Act of 1996) prohibits abuse” also apply. You can access free Texas Health the plan from limiting a mother’s or •• Audiologists—includes charges by System information by calling newborn’s length of hospital stay to a licensed or certified audiologist 1-877-THR-WELL (1-877-847-9355). The less than 48 hours for a normal delivery for physician-prescribed hearing call center provides: or 96 hours for a Cesarean delivery or evaluations to determine the location •• Directory listing of physicians on the from requiring the provider to obtain of a disease within the auditory medical staff at Texas Health hospitals preauthorization for a stay of 48 or 96 system; for validation or tests to (Be sure the physician you select is in hours, as appropriate. confirm an organic hearing problem your UHC network.) However, federal law generally does •• Autism—plan will cover occupational, •• Physician referrals with information not prohibit the attending provider, physical, and speech therapy for matched to your specific needs such after consultation with the mother, from children up to age 18 with Autistic as specialty, clinical interest, insurance discharging the mother or her newborn Spectrum Disorder (ASD). Subject to accepted, and hospital privileges (Be earlier than 48 hours for normal delivery maximum limits per plan year of 60 sure the physician you select is in your or 96 hours for Cesarean delivery. visits combined. UHC network.) •• Bereavement counseling—for the •• Family and community class Covered Medical Expenses immediate family if the patient was information and registration receiving hospice care covered under •• Information on Texas Health hospital Covered medical expenses are services the medical plan departments and services. and supplies that are eligible under •• Birthing center the plan and that you or a covered •• Blood pressure cuffs—covered at You can call and speak to an operator dependent receives to diagnose or 100% with a doctor’s order. Contact between 8 a.m. and 5:30 p.m. Monday treat an illness or injury. The claims Personal Health Support® at through Friday. administrator has the discretion and 1-877-MyTHRLink (1-877-698-4754), authority to initially determine whether prompt 2 for more information. a treatment or supply is covered and •• Blood processing and administration how the eligible expense will be •• Breast implant removal—if due to a handled by the plan. See the plan medical condition comparison table on pages 20 – 22 for a summary of copays and coinsurance required for certain services.

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•• Breast prostheses and Each visit may include one spinal CHD services other than those listed reconstruction—internal or manipulation, one extra-spinal above are excluded from coverage external prostheses needed due to a manipulation and up to three unless Personal Health Support mastectomy modalities. Massage therapy is not determines the service is a proven •• Breast Pump—Preventive care covered. procedure for the involved diagnoses. benefits defined under the Children under 12 are covered for Contact Personal Health Support at Health Resources and Services manipulative therapy only for acute or 1-877-MyTHRLink (1-877-698-4754) Administration (HRSA) requirement repetitive musculoskeletal injuries, prompt 2, for information about CHD include the cost of renting one excluding birth trauma and scoliosis. services. breast pump per Pregnancy in •• Cochlear implant—for a person Notify Personal Health Support: conjunction with childbirth. Benefits who has been diagnosed with a As soon as CHD is suspected or for breast pumps also include the severe to profound sensorineural diagnosed (in-utero detection, at birth, cost of purchasing one breast pump hearing loss and severely difficult or as determined and before the time per Pregnancy in conjunction with speech discrimination or post-lingual an evaluation for CHD is performed). childbirth. Benefits are only available sensorineural deafness in an adult If you don’t notify Personal Health if breast pumps are obtained from a •• Colonoscopy—one per year covered if Support, benefits will be reduced to DME provider, Hospital or Physician. preventive* 50% of eligible expenses. •• Breast reduction—for certain •• Congenital heart disease services— •• Contact lenses—initial pair prescribed functional impairments but not to health services for congenital heart solely improve appearance or to and purchased within 12 months after disease (CHD) are covered when cataract surgery improve athletic performance ordered by a physician. CHD services •• Cornea transplant •• Cardiac rehabilitation services— may be received at a Congenital Heart •• Dental care/oral surgery—Prior up to 36 visits per calendar year Disease Resource Services program. notification is required. Failure to combined across all benefit levels for Benefits are available for the CHD prenotify will result in a $1,000 penalty. services that are expected to result services when they meet the definition Services must be performed by a in significant physical improvement of a covered health service and are doctor of dental surgery (DDS) or a in the patient’s condition within not an experimental or investigational Doctor of Medical Dentistry (DMD). & Wellness Medical two months of the start of treatment. service or an unproven service. Services must be performed by a Personal health support notification is licensed therapy provider under the required for all CHD services, direction of a physician. including outpatient diagnostic testing, •• Chemotherapy—including wigs for in-utero services and evaluation. alopecia following chemotherapy Covered services include: •• Chiropractic care/spinal –– Congenital heart disease surgical manipulation—up to 20 visits per interventions calendar year combined across –– Interventional cardiac all benefit levels. Benefits are paid catheterizations only for rehabilitation services that are expected to result in a –– Fetal echocardiograms significant physical improvement –– Approved fetal interventions in your condition. In addition, the You do not pay the copayment or claims administrator has the right annual deductible when the CHD to deny benefits for any type of service is received at a Congenital therapy, service, or supply for the Heart Disease Resource Services treatment of a condition that ceases program. to be therapeutic treatment and is instead administered to maintain a level of functioning or to prevent a medical problem from occurring or reoccurring.

* One well exam per year is covered in full if the claims administrator determines the physical is for preventive care. Additional screenings or services will be considered diagnostic services and will be covered after you pay the applicable copay or deductible and coinsurance. At the time of your preventive care visit, if other services are performed that are not preventive services, as determined by the claims administrator, they will not be paid at 100% even if they are submitted as part of a claim for preventive care. Some items that were previously covered as preventive care are no longer covered as preventive care and now require you to pay the appropriate copay or coinsurance, including electrocardiograms (EKGs), focused office visits, thyroid scans, breast MRI, vitamin D assays, and transvaginal ultrasounds.

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Covered expenses are limited to: •• Diabetes supplies—the Caremark •• Hearing care—hearing screening as –– Surgical treatment of fractures prescription drug plan covers oral part of a routine preventive office and dislocations of the jaw or for medications, insulin, syringes, blood visit; purchase of aid and hearing tests treatment of accidental injury to glucose monitors, test strips, lancets, associated with the purchase of an sound, natural teeth, including and chem strips. The medical plan aid, every 36 months. Bone anchored replacement of such teeth. The covers durable medical equipment, hearing aids are covered only for service must be started within three including external insulin pumps, covered persons: months and completed within supplies for your pump (infusion sets, –– Who have craniofacial anomalies 12 months after the date of an cartridges, batteries, and medical –– Whose abnormal or absent ear accident. tape), and glucagon emergency canals preclude the use of wearable –– Surgery needed to correct kits when ordered by the physician. hearing aids or accidental injuries to the jaws, External pumps that deliver insulin –– Whose hearing loss is of sufficient cheeks, lips, tongue, floor, and roof into the intraperitoneal cavity are not severity that it would not be of the mouth. Accidental injury covered. You can receive a glucose adequately remedied by wearable must be severe enough that the monitor free through Caremark. hearing aids. • initial contact with the physician or • Diagnostic X-ray and lab •• Home health care—up to 100 visits dentist occurred within 72 hours of •• Dialysis—when done on an outpatient per calendar year; prior notification the accident. basis, notification is not required by is required; each visit lasting for –– Treatment of a sound, natural tooth. UHC four hours or less is considered one The physician or dentist must certify •• Disposable or consumable medical visit; each visit must be ordered by a that the injury to the tooth was a supplies—covered only when a physician; part-time or intermittent virgin or unrestored tooth, has no doctor’s prescription is required. nursing care by a registered nurse, decay, no filling on more than two Elastic stockings are limited to two licensed practical nurse or licensed surfaces, no gum disease associated pairs per calendar year. Supplies vocational nurse; services of a with bone loss, no root canal that can be purchased without a certified social worker; medical therapy, is not a dental implant, and prescription are not covered, such as supplies, drugs and medicines functions normally in chewing and bandages, gauze, and dressings. prescribed by a physician, and Medical & Wellness Medical speech. •• Durable medical equipment—for laboratory services provided by or –– Removal of non-odontogenic equipment that costs $1,000 or more, on behalf of a hospital, but only to lesions, tumors or cysts by a Doctor prior notification is required. Benefits the extent that they would have been of Dental Surgery (DDS) or Doctor are available for the replacement of covered under the plan if you had of Medical Dentistry (DMD) durable medical equipment once remained in the hospital; services of –– Incision and drainage of non- every three calendar years. a licensed physical therapist; the care odontogenic cellulitis •• Emergency care—for medical cannot be for the purpose of assisting –– Surgical treatment of accessory emergencies (see page 163 for a with daily living activities sinuses, salivary glands, ducts, and definition). The plan administrator •• Hospice care—for people with tongue must be notified within 48 hours. terminal illness (diagnosed with six –– Treatment to correct a non- •• Enteral nutrition—the sole source months or less to live). Prenotification odontogenic congenital defect that of nutrition or when a nutritional is required. Covered expenses are results in a functional defect of a formula treats inborn error of limited to: covered dependent child. metabolism –– Room and board for confinement in •• Diabetes education—After a $10 •• Eyeglasses—initial pair of lenses and a hospice copay, the individual and group frames prescribed and purchased –– Ancillary charges furnished by the education sessions for both adult within 12 months following cataract hospice while you are confined, and pediatric diabetes patients surgery including rental of durable medical are covered 100% at Texas Health •• Family planning—covered services equipment that is used solely for Preferred Hospitals and UHC network include Norplant, IUD, diaphragms, treating an injury or illness providers but only with a physician’s Depo Provera and home birth; –– Medical supplies, drugs and referral. You are eligible to earn free marriage counseling is excluded (see medicines prescribed by the test strips for self-monitoring of your page 60 for services offered by the attending physician, but only to the blood glucose when you visit with MHN EAP). extent such items are necessary for Texas Health diabetes educators at •• Foot care—includes foot surgery or pain control and management of a least quarterly. diabetic care; excludes services for terminal condition corns, calluses, and ingrown toenails unless considered an eligible expense as determined by UHC

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–– Physician services and nursing care –– Half-day partial-hospital programs This also applies to diagnosis and by a registered nurse, a licensed provide services at least three hours treatment of Attention Deficit practical nurse, or a licensed per day, two or more days per week Disorder (ADD) and Attention Deficit vocational nurse –– Covered as an inpatient benefit with Hyperactivity Disorder (ADHD) and –– Home health aide services 5 days IOP = 1 day inpatient care Autism. –– Home care charges by a hospital or –– May be used as a point of entry Treatment Site Ratio home health care agency, under the into care, a step up from routine supervision of a registered nurse, a outpatient services, or a transition Residential 1.5 days = treatment 1 inpatient day licensed practical nurse, a licensed after acute inpatient, residential care Day treatment/ 2 days = vocational nurse, or a home health or a partial hospital program partial 1 inpatient day aide •• Laboratory charges—includes tests and hospitalization –– Medical social services by X-rays Structured 5 days = licensed or trained social workers, •• Mastectomy—includes reconstruction outpatient 1 inpatient day psychologists, or counselors of the breast on which the mastectomy Intensive Outpatient 5 days = –– Nutrition services by a licensed was performed or surgery and Program (IOP) 1 inpatient day dietitian. reconstruction of the other breast to Sober living/ 10 days = transitional living 1 inpatient day •• Hospital confinement—prior produce a symmetrical appearance notification is required; private room and prosthesis and physical Outpatient 6 days = psychotherapy visit 1 inpatient day at Texas Health hospitals or semi- complications in all stages of the private room at other facilities, board, mastectomy, including lymphedemas Any inpatient admission for mental and other necessary medical services •• Maternity care—includes prenatal health or substance abuse treatment and supplies, up to the usual and care, labor, delivery, hospitalization or that occurs more than 48 hours customary limit (or, for a hospital a birthing center, and newborn care; following discharge for such a without semi-private rooms, 90% of the maternity charges for dependent treatment is considered an additional most common private room rate.) children are covered, but the newborn admission. This applies regardless child of a dependent (grandchild Benefits are not payable for hospital of whether the covered person’s of the employee) may be covered admissions on a Friday, Saturday, or discharge is against medical advice. & Wellness Medical beyond 31 days after birth only if the Sunday unless surgery is performed Residential treatment for mental employee’s grandchild meets eligibility within 24 hours of admission, or the health care and substance abuse will requirements described on page 6; admission is an emergency; you must be covered if it meets the definition notification is required if the stay prenotify UHC before hospitalization of a covered health service, subject to is longer than 48 hours for vaginal except in emergencies. the same coverage and limitations as delivery and 96 hours for Cesarean inpatient care. •• Infertility treatment—coverage for delivery. In the event the newborn •• Midwife—services of a licensed diagnosis of underlying cause of stays longer than the mother, the state-certified midwife who is a infertility in a physician’s office or newborn will be treated as discharged registered nurse medical facility; excludes fertility from maternity and re-admitted as drugs, artificial insemination, in-vitro a sick infant. There is no newborn •• Multiple surgical procedures—when fertilization, gamete intra fallopian coverage after 31 days. performed at the same time as the primary surgical procedure, secondary transfer (GIFT), zygote intra fallopian •• Medical nutrition therapy—coverage procedures (excluding incidental transfer (ZIFT). for participants with body mass procedures or separate operative •• Injections—the lesser of the copay or index (BMI) of 28 or more; requires areas) are covered at 50% of the in- the cost of the injection physician referral; therapy covered only network negotiated rate or 50% of the •• Intensive care if provided by a Texas Health clinical allowable expense for each additional •• Intensive outpatient program (IOP) dietitian. You may receive one initial procedure. –– Designed for plan participants who 90-minute assessment and up to three •• Narcolepsy—diagnosis and treatment are recovering from severe and/or 30-minute sessions each year. of sleep apnea and narcolepsy chronic behavioral health conditions •• Mental health and substance abuse— •• Nutritional Counseling—for covered including mental health conditions treatment for inpatient care or for persons with a body mass index of 28, and substance abuse disorders that outpatient care. Prior notification to be provided by a registered dietitian occur at the same time is required for inpatient services. at a Texas Health preferred hospital. –– May include psychotherapy, Residential treatment for mental health Nutritional counseling is limited to an pharmacotherapy, and supportive/ and substance abuse will be permitted initial assessment of 90 minutes and up rehabilitative interventions if it is a covered health service, as to three 30 minute sessions. –– Provided in a freestanding or defined on page 162. hospital-based program

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•• Newborn care—coverage includes •• Occupational therapy—up to 60 •• Ostomy supplies—pouches, faceplates, routine nursery and pediatric care outpatient visits per calendar year belts, irrigation sleeves/bags, catheters, following birth, including room and (combined with speech therapy and and skin barriers board, professional services for well physical therapy); benefits are paid •• Outpatient hospital charges newborn, and circumcision; newborn only for rehabilitation services that •• Outpatient surgery—contact Personal must be enrolled for coverage within are expected to result in a significant Health Support when using an out-of- 31 days of birth to receive coverage improvement in your condition within network provider or facility after 31 days two months of the start of treatment. •• Panniculectomy—Removal of excess •• Obesity— nonsurgical or surgical In addition, the claims administrator skin will be covered if deemed treatment of morbid obesity (as has the right to deny benefits for any medically necessary by UHC if you defined by the claims administrator). type of therapy, service, or supply maintain a weight loss of at least 20% Nonsurgical treatment is covered only for the treatment of a condition that for at least two years by any means of when provided in a physician’s office. ceases to be therapeutic treatment weight loss. and is instead administered to To be eligible for surgical treatment •• Physical therapy—up to 60 outpatient maintain a level of functioning or (bariatric surgery), your medical visits per calendar year (combined to prevent a medical problem from records must document a body mass with speech therapy and occupational occurring or reoccurring. Therapy index (BMI) of 40 or higher for at therapy); benefits are paid only must be performed by a licensed least two years with documented for rehabilitation services that are therapist under a physician’s order. sleep apnea, diabetes, hypertension, expected to result in a significant • or immobility secondary to joint • Office visit—for medical diagnosis or physical improvement in your pain that is not responsive to medical treatment condition within two months of the intervention for at least six months. •• Orthognathic surgery—covered only start of treatment (except autism). In You must have participated in the for the following conditions: addition, the claims administrator has Healthy Weight Management Program –– A jaw deformity resulting from a the right to deny benefits for any type for six months. Counseling is required facial trauma or cancer of therapy, service, or supply for the before and after surgery. –– A skeletal anomaly of the jaw that treatment of a condition that ceases The surgery is covered only at Texas demonstrates a functional medical to be therapeutic treatment and is Medical & Wellness Medical Health hospitals that are designated as impairment, such as: instead administered to maintain a a UHC Center of Excellence, and only ŒŒ Being unable to chew solid food level of functioning or to prevent a for participants who are at least age ŒŒ Choking on solid food that has medical problem from occurring or 18. not been completely chewed reoccurring. You pay a $4,000 copay for the surgery ŒŒ Damaging soft tissue while •• Physician services—including care in addition to your plan’s deductible chewing in the office and hospital visits by and coinsurance. This copay does ŒŒ Having a speech impediment primary physicians and specialists not apply toward your annual out-of- caused by a jaw deformity •• Pre-admission testing pocket maximum. ŒŒ Suffering from malnutrition •• Prenatal care/postnatal care or weight loss because of Bariatric surgery may be repeated •• Prescription drugs—covered through inadequate intake as a result if you experience a significant Caremark (see page 39) of a jaw deformity complication or technical failure •• Orthoptic therapy—orthoptic requiring surgical revision of original (vision) therapy for the treatment procedure, provided you have been of convergence insufficiency in the compliant with the prescribed absence of accommodative disorder. nutrition and exercise program. Orthoptic therapy is not a covered Gastric bypass sleeve procedure and expense for treatment of reading or vertical banded gastrolasty (VBG) learning disabilities, or for vision- are covered, however adjustable related diagnoses other than those gastric band (AGB or lap band) is not listed as covered, because there is not covered. enough clinical evidence that these Panniculectomy may also be covered. are safe or effective in published, peer- (See Panniculectomy for more reviewed medical literature. THIS LIST is not information.) •• Orthotic Devices—covered when all-inclusive and linked with a medical diagnosis should not be used to such as wrist/hand, elbow, and lower determine whether extremity orthotics (excluding foot) you may receive treatment.

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•• Preventive care— The plan pays •• Private rooms—covered only at Texas Cosmetic surgery is covered only for benefits for preventive care services Health hospitals the following situations: provided on an outpatient basis •• Prosthetic devices— –– Repair of injuries caused by an at a physician’s office, an alternate –– Initial purchase and fitting of accident facility or a hospital. Preventive care external prosthetic which is –– Surgical correction of a congenital encompasses medical services that necessary to alleviate or correct birth defect in a child have been demonstrated by clinical sickness, injury, or congenital defect, –– Reconstructive breast surgery evidence to be safe and effective in to replace or substitute for a missing following mastectomy either the early detection of disease body part, limited to artificial arms –– Removal of breast implants if the or in the prevention of disease, have and legs and terminal devices such claims administrator deems it been proven to have a beneficial as a hand or hook; necessary effect on health outcomes and –– Devices may be evaluated for Services are considered cosmetic include the following as required replacement after five years due to procedures when they improve under applicable law: normal wear and tear; appearance without making an –– Evidence-based items or services –– Devices may be replaced before five organ or body part work better. that have a rating of “A” or “B” in the years for adults and children if it is The fact that a person may suffer current recommendations of the determined by medical review as psychological consequences from United States Preventive Services appropriate (for example defective the impairment does not classify Task Force or damaged) or if needed due to a procedure as a reconstructive –– Immunizations that have a normal body growth in children recommendation from the Advisory procedure. (Reshaping a nose with •• Psychological counseling—subject to a prominent “bump” is an example Committee on Immunization mental health treatment plan Practices of the Centers for Disease of a cosmetic procedure because it •• Pulmonary therapy—up to 20 Control and Prevention improves appearance without outpatient visits per calendar affecting a function like breathing.) –– With respect to infants, children and year combined across all benefit This plan does not provide benefits adolescents, evidence-informed levels; benefits are paid only for for cosmetic procedures. preventive care and screenings rehabilitation services that are Some services are considered & Wellness Medical provided for in the comprehensive expected to result in a significant cosmetic in some circumstances guidelines supported by the improvement in your condition within and reconstructive in others. (An Health Resources and Services two months of the start of treatment. example is upper eyelid surgery. At Administration Services must be provided by a times, this procedure will improve –– With respect to women, additional licensed therapy provider under the vision, while at other times, it only preventive care and screenings direction of a physician. In addition, improves appearance.) provided for in comprehensive the claims administrator has the •• Respiratory therapy—see Pulmonary guidelines supported by the right to deny benefits for any type therapy Health Resources and Services of therapy, service, or supply for the • Administration. treatment of a condition that ceases • Second surgical opinions –– Generic birth control prescriptions to be therapeutic treatment and is •• Short-term rehabilitation therapy— covered at 100% including pills, instead administered to maintain a Benefits can be denied or shortened implants and patches level of functioning or to prevent a for covered persons who are •• Preventive care—one well exam medical problem from occurring or not progressing in goal-directed per year is covered in full if the reoccurring. rehabilitation or if rehabilitation goals claims administrator determines •• Radiation therapy have been previously met. • the physical is for preventive care. •• Reconstructive procedures—services • Skilled nursing and rehabilitation—at Additional screenings or services will are considered reconstructive an in-network skilled nursing facility be considered diagnostic services procedures when a physical or long-term rehabilitation facility and will be covered after you pay impairment exists and the primary up to 60 days per year. Services are the applicable copay or deductible purpose of the procedure is to covered only for care related to the and coinsurance. At the time of your improve or restore physiologic injury or illness for which you are preventive care visit, if other services function for an organ or body part to confined. are performed that are not preventive make it work better. An example of •• Sleep disorders—therapy to treat sleep services, as determined by the claims reconstructive procedure is surgery apnea or narcolepsy administrator, they will not be paid on the inside of the nose so that a •• Specialist office visit at 100% even if they are submitted as person’s breathing can be improved or part of a claim for preventive care. restored.

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•• Speech therapy—up to 60 •• Support garments—covered if the Covered organ transplant services (combined with physical therapy and claims administrator determines them include the recipient’s medical, occupational therapy) outpatient to be necessary, subject to limitations surgical, and hospital services; visits per calendar year; covered only (see page 30 for disposable or inpatient immunosuppressive when the speech impediment or consumable medical supplies) medications; and costs for organ speech dysfunction results from injury, •• Surgeon’s services—includes assistant procurement: sickness, cancer, autism spectrum surgeon charges –– Blood/marrow/stem cell disorder, stroke or congenital anomaly, •• Temporomandibular joint syndrome –– Cornea or is required following the placement (TMJ) treatment—covered for –– Heart of a cochlear implant. Learning diagnostic and surgical treatment –– Heart/lung disabilities and developmental delays of conditions affecting the –– Intestine are excluded. temporomandibular joint when –– Kidney Services must be performed by a provided by or under the direction of –– Kidney/pancreas licensed therapy provider under the physician. Coverage includes necessary direction of a physician. Benefits diagnostic or surgical treatment –– Kidney/liver are available only for rehabilitation required as a result of accident, trauma, –– Liver services that are expected to result congenital defect, developmental –– Liver/intestine in significant physical improvement defect, or pathology. Dental services, –– Lung in the patient’s condition within including appliances and orthodontic –– Pancreas. two months of the start of treatment treatment, are not covered in any Coverage for organ procurement (except autism). In addition, the situation. The following charges are costs will be limited to costs directly claims administrator has the right covered: related to procurement of an organ to deny benefits for any type of –– Arthrocentesis for the treatment from a cadaver or a live donor and therapy, service, or supply for the of documented, symptomatic will consist of surgery necessary for treatment of a condition that ceases degenerative joint disease, organ removal, organ transportation, to be therapeutic treatment and is osteoarthritis or documented, and the transportation, hospitalization, instead administered to maintain a intracapsular soft tissue and surgery of a live donor. Medical & Wellness Medical level of functioning or to prevent a abnormalities (such as disc Compatibility testing undertaken medical problem from occurring or displacement or adhesions). before procurement is covered if UHC reoccurring. –– Arthroplasty for the treatment considers it to be an eligible expense; •• Sterilization—voluntary vasectomy of documented symptomatic the amount payable for donor’s or tubal ligation; does not cover osteophytes affecting the medical costs will be reduced by the sterilization reversal temporomandibular joint or amount payable for those costs from •• Substance abuse treatment—inpatient documented symptomatic any other plan; certain transplants treatment will be permitted if it meets intracapsular soft tissue abnormality are not covered, see Excluded Medical the definition of a covered health (such as disc displacement or Expenses. service, but is subject to the same adhesions) If you are the recipient, your covered coverage and limitations as inpatient –– Arthrotomy for the treatment of health services will include: care. intracapsular soft tissue abnormality –– The expenses (based on URN Any inpatient admission for mental (such as disc replacement or contracted rates) incurred to secure health or substance abuse treatment adhesions). the organ or tissue directly from a that occurs more that 48 hours However, arthroscopy is not covered cadaver or through an organ bank, following discharge for treatment is for treatment of TMJ because of and considered an additional admission. inadequate clinical evidence of its –– The medical expenses incurred by a This applies regardless of whether the safety and/or efficacy in published, living donor, but only if they are not covered person’s discharge is against peer-reviewed medical literature. covered by the donor’s own plan of medical advice. Residential treatment •• Termination of pregnancy—only if benefits for mental health care and substance it meets the definition of a covered If you are the donor, your covered abuse will be covered if medically health service health services will include the necessary, subject to the same •• Transplants—non-experimental medical expenses that you incur to coverage and limitations as inpatient human organ and tissue transplants donate the organ or tissue. care. covered only at facilities approved in •• Urgent care clinic or center advance by UHC; prior notification is required; includes donor’s expenses to the extent they are not covered by donor’s own medical benefits

34 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Total Health Medical Plan

•• Vision care—examinations by Excluded Medical Expenses Also excluded are extraction, a licensed ophthalmologist or restoration, replacement, medical optometrist and glasses, including To provide adequate medical coverage or surgical treatment of dental frames and one set of lenses and control costs, the medical plan sets conditions and services to improve (including contacts) within 12 months reasonable limits on the benefits for dental outcomes, dental implants, of cataract surgery; limited to one certain types of services and supplies. dental braces, dental x-rays, supplies diabetic retinal exam annually; does Benefits are not payable for services that and appliances, and all associated not include routine examinations the claims administrator determines expenses, including hospitalization required by an employer in do not meet the definition of a covered and anesthesia (except for connection with your employment health service (see page 162). In making transplant preparation, initiation a determination, the claims administrator •• Well-baby care and immunizations of immunosuppressives, the direct considers the condition and overall health —covered at 100%; no coverage for treatment of acute traumatic injury, of the patient. The following services are out-of-network providers cancer or cleft palate), and fluoride excluded under the medical plan: •• Wigs—for hair loss following preparations. chemotherapy •• Alternative medicine treatments— •• Developmental therapy for children •• X-rays—the use of X-ray, radium, or herbal, holistic and homeopathic •• Disposable or consumable supplies— radioactive isotopes and laboratory medicine, aromatherapy, rolfing, including orthotic devices for feet services to diagnose or treat an injury acupressure and other forms, as •• Duplicate coverage—dependent’s or illness defined by the office of Alternative expenses if he or she is receiving Medicine of the National Institute of benefits for the same expenses as a Health covered employee •• Behavior training •• Educational testing or training— •• Biofeedback therapy testing or training that does not •• Breast implant replacement—if the diagnose or treat a medical condition earlier breast implant was performed includes learning disabilities and as a cosmetic procedure treatment for hyperkinetic syndrome, •• Charges incurred before you were except ADD or ADHD Medical & Wellness Medical covered •• Ecological and environmental •• Chelation therapy—covered only to medicine treat heavy metal poisoning •• Emergency room visits for non- •• Claim forms—the plans will not pay emergencies the cost for anyone to complete your •• Experimental, unproven, or claim form. investigational treatment—any •• Cosmetic treatment or drugs— medical treatment, service, device, treatments or drugs solely for drug, or supply that is regarded by the cosmetic purposes (hair loss, acne claims administrator as experimental scars, liposuction, and sclerotherapy) or any research studies or any service including pharmacological regimens, or supply not considered legal in the nutritional procedures and treatments, U.S. scar or tattoo removal or revision •• Eye care—surgical procedure for procedures (such as salabrasion, the correction of a visual refractive chemosurgery or other skin abrasion problem, including radial keratotomy procedures) skin abrasion procedures or LASIK; the purchase or fitting performed as a treatment for acne of eyeglasses or contact lenses, •• Custodial care and convenience except the first pair prescribed and items—such as incontinence briefs, purchased within 12 months following liners, diapers when used for custodial cataract surgery purposes, beauty/barber shop •• Fetal reduction surgery •• Dental care/oral surgery—except as •• Fluoride preparations specifically described as a covered expense on pages 29 – 30. Treatment of congenitally missing, malpositioned, or supernumerary teeth is not covered, even if part of a congenital anomaly.

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•• Foot care—manipulative procedures •• Hospitalization primarily for –– Treatment for conduct and impulse for weak or fallen arches, flat or X-rays, laboratory, diagnostic study, control disorders, personality pronated foot, foot strain, orthopedic physiotherapy, hydrotherapy, medical disorders, paraphilias and other shoes, support devices and orthotics; observation, convalescent or rest mental illnesses that will not callus or corn paring or excision, care, or any medical examination or substantially improve beyond the toenail trimming, hygienic and test not connected with an illness current level of functioning or preventive maintenance, including or injury; admissions on a Friday, that are not subject to favorable cleaning and soaking feet, applying Saturday, or Sunday unless surgery is modification or management creams to maintain skin tone, or any performed within 24 hours according to prevailing national other service not performed to treat •• Hypnotherapy standards of clinical practice, as a localized illness, injury or symptom •• Immunization agents—prescriptions reasonably determined by United involving the foot, treatment of for immunization agents, biological Behavioral Health, the company subluxation of the foot products for allergy immunization, that administers mental health/ •• Foreign care—health services biological sera, blood, blood plasma substance abuse benefits under the provided in a foreign country, unless and other blood products or fractions Total Health Medical Plan required in an emergency and medications used for travel –– Services utilizing methadone •• Free care or treatment—care, prophylaxis treatment as maintenance, treatment, services, or supplies for •• Infertility treatment—includes in-vitro L.A.A.M. (L-Alpha-Acctyl-Methadol), which payment is not legally required fertilization, artificial insemination, Cyclazocine, or their equivalent or which the provider offers to waive gamete intra-fallopian transfer (GIFT), –– Treatment provided in connection •• Government-paid care—care, zygote intra-fallopian transfer (ZIFT), with or to comply with involuntary treatment, services, or supplies or any other procedure or drug commitments, police detentions, or provided or paid for by any intended to increase fertility other similar arrangements, unless governmental plan or law when •• IQ testing authorized by United Behavioral the coverage is not restricted to the •• Jawbone surgery—upper or lower Health government’s civilian employees and jawbone surgery except as required –– Residential treatment services their dependents (this exclusion does for direct treatment of acute traumatic •• Military service—illness or injury Medical & Wellness Medical not apply to Medicare or Medicaid) injury or cancer received while serving in the armed •• Grandchildren—medical expenses of •• Liposuction forces of any country an employee’s grandchild (the child of •• Maintenance care •• Missed or broken appointments— an employee’s unmarried dependent •• Marriage counseling charges for missing an appointment child) after 31 days following birth, with a health care provider •• Massage therapy—massage and unless the employee’s grandchild • soft-tissue therapy, regardless of who • Naturopath meets the eligibility requirements performs the service •• Nonmedical facility—charges for described on page 6 •• Medical records—charges for requests education, training, or bed and board •• Gynecomastia—treatment of benign of medical records while confined in an institution that is gynecomastia (abnormal breast mainly a school or other institution for •• Mental Health or Substance Abuse: enlargement in males) training or a place of rest, a place for –– Services performed in connection •• Home health care—services and the aged, or a nursing home with conditions not classified in the supplies not included in the home •• Nursing care, as it relates to: current edition of the Diagnostic health care plan recommended by –– Care, treatment, services, or supplies the attending physician; services of and Statistical Manual of the American Psychiatric Association that do not require the skills and your close relative or a person who training of a nurse ordinarily resides in your home; –– Services for mental health or –– A nurse who is a close relative services of any social worker unless substance abuse that extend (spouse, child, parent, brother, designated C.S.W.A.C.P; transportation, beyond the period necessary for sister, in-law) or lives in the same custodial care, housekeeping short-term evaluation, diagnosis, household •• Hospice—services or supplies not treatment or crisis intervention included in the hospice care program; –– Treatment for insomnia, dementia, services of a close relative or a person neurological disorders, and other who ordinarily resides in your home; disorders with a known physical curative or life-prolonging procedures; basis for any period not under the care of a physician

36 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Total Health Medical Plan

•• Nutritional therapy and •• Physical conditioning—programs •• Safety items—devices used supplements—megavitamin and such as athletic training, bodybuilding, specifically as safety items or to nutrition-based therapy, nutritional exercise, fitness, flexibility, diversion, affect performance in sports-related counseling for individuals or groups, general motivation, or any therapy to activities including weight loss programs, health improve general physical condition •• Scar or tattoo removal or revision clubs, and spa programs, enteral •• Physical examinations not required procedures (such as salabrasion, feeding and other nutritional and for health reasons—including chemosurgery and other skin abrasion electrolyte supplements, including employment, insurance, government procedures) infant formula, donor breast milk, license, court-ordered, forensic, or •• Sex changes or transsexual and dietary supplements, electrolyte custodial evaluations related operations and hormone supplements, diets for weight •• Physician fees for any treatment not therapies control or treatment of obesity rendered by or provided under the •• Sex-determination testing— (including liquid diets and food), supervision of a physician amniocentesis, ultrasound, or any food of any kind (diabetic, low fat, •• Prescription drugs—covered through other procedures requested solely for low cholesterol), oral vitamins and/ a separate prescription drug plan as sex determination of a fetus, unless it or minerals, except when the sole explained on page 39 meets medical criteria to determine source of nutrition or when certain •• Private-duty nursing the existence of a sex-linked genetic nutritional formula is used to treat a •• Prostheses—replacement for theft or disorder specific inborn error of metabolism loss, wear and tear, destruction, or any •• Sexual dysfunctions, deviations or •• Organ donation—expenses incurred biomechanical external prosthetic disorders—all drugs and treatment as an organ donor by a non-Texas device are excluded (except limited drugs for Health member •• Providers—services provided at free- erectile dysfunction) •• Organ transplants—experimental standing or hospital-based diagnostic •• Skin abrasion procedures performed transplants; artificial organ transplants; facility without a written order by a as a treatment for acne cross-species organ transplants; organ physician or other provider; services •• Sleep therapy—medical and surgical donor costs not directly related to that are self-directed to a free-standing treatment for snoring is not covered, organ procurement; transplants or hospital-based diagnostic facility, except when provided as part of performed at a facility not approved & Wellness Medical services ordered by a physician or treatment for documented obstructive by UHC other provider who was not actively sleep apnea; appliances for snoring • • Orthognathic surgery—not covered involved in your medical care before are not covered for the following conditions: ordering the service, or is not actively •• Smoking cessation aids—except –– Myofascial, neck, head, and shoulder involved in your medical care after for those covered by the wellness pain the service is received. This exclusion program as described on page 57 –– Irritation of the head or neck does not apply to mammography. •• Speech therapy—except as required muscles •• Relatives—treatment by a medical for treatment of a speech impediment –– Popping or clicking of the practitioner (including but not limited or speech dysfunction that results temporomandibular joints to: a nurse, physician, physiotherapist from injury, stroke, or congenital –– Potential for development or or speech therapist) who is a close anomaly. Not covered if: exacerbation of TMJ relative (spouse, child, brother, sister, –– Considered custodial and –– Teeth grinding parent, or grandparent of you or your educational spouse, including in-law and step Treatment of malocclusion is dental –– Therapy to improve speech relatives) or by a person who lives in and, therefore, not a covered medical skills not fully developed (non- the same household as the covered service. restorative) person –– To maintain speech communication •• Over-the-counter medications or • • Reproduction—surrogate parenting, or supplies—see page 165 fees or direct payments to a donor or –– To treat stuttering, stammering, or •• Penile prostheses doctor for sperm or ovum donations, other articulation disorders •• Personal comfort items, such as fees for maintenance or storage of charges for hospital television or frozen embryos (sperm or egg), health •• Termination of pregnancy—if elective telephone use services and associated expenses abortion •• Pharmacological regimens, nutritional for elective abortion, contraceptive •• Therapeutic devices procedures or treatments supplies and services •• Travel or transportation expenses— •• Reversal of sterilization or any form of even if prescribed by a physician. contraception not specifically covered Some travel expenses related to covered services may be reimbursed at the discretion of Texas Health.

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•• War-related—services or supplies Coordination of Benefits If payments should have been made received as a result of a declared or under this plan but have been made undeclared war or caused during Your medical plan is designed to under any other plan, the claims service in armed forces of any country integrate benefits with other group administrator has the right, in its sole or individual plans or policies or •• Weight reduction—except for the discretion, to pay to any insurance government programs, including diagnosis of morbid obesity, which is company or other organization or Medicare. If you are eligible, either as specifically covered by the plan person making such other payments any the insured or a dependent, to receive •• Wellness items—items that promote amounts it determines and to the extent medical benefits from another plan well-being and are not medical in of such payments, Texas Health and (including automobile insurance) or nature, such as massage therapy, the plan will be fully discharged from government program, the total benefits dehumidifiers, air filtering systems, liability. The benefits that are payable you are eligible to receive from all air conditioners, bicycles, exercise will be charged against any applicable plans will not be more than the benefits equipment, whirlpool spas, and health maximum payment or benefit of this that would be payable from the Total club memberships plan rather than the amount payable in Health Medical Plan if you had no other the absence of this provision. •• Work-related—treatment or drug for coverage. This applies whether or not any illness or injury that occurs during you file a claim under the other plan. If If you are enrolled in both the medical or as a result of work for pay or profit, needed, you must authorize the claims and dental plans and need treatment or for which the covered person is administrator to get information from that both plans will cover, the medical entitled to benefits under any worker’s the other plans. plan pays first. The dental plan pays compensation or occupational second, but only if it covers the same disease law or any such similar law If you are covered by two medical plans, service. one of the plans will be primary and the In addition to the items above, the plan other will be secondary. The primary If you or a dependent has active medical will not cover the following: plan pays benefits first. The following coverage through Texas Health and is •• Charges incurred before the effective criteria determine which plan is primary: covered under Medicare, your Texas date of coverage or after coverage is •• A plan without a coordinating Health coverage is primary and your terminated provision is always the primary plan. Medicare is secondary. Medical & Wellness Medical •• Charges for services or supplies that •• If all plans have a coordinating the claims administrator does not provision, the plan covering you consider a covered health service directly (rather than as a spouse or •• Charges for routine exams and dependent) is primary. immunizations, except those listed as •• If a child is covered by both parents’ covered expenses plans, the plan of the parent whose •• Charges that others are responsible for birth date falls first in the calendar paying year is primary. If the birth dates are •• Expenses covered by a mandatory the same, the plan of the parent who auto insurance policy written to has been covered under the plan the comply with a “no-fault” or uninsured- longest is primary. If the other plan motorist insurance law does not have these requirements, the •• Expenses for treatment provided or other plan will be primary. paid for by the government, unless the Total Health Medical Plan is required If your child is covered and you are to pay first divorced, then the plan of the parent with custody pays first, unless a court •• Charges resulting from or occurring order or decree specifies the other during the commission of a crime or parent’s plan pays first. The plan of a while engaged in an illegal act, illegal step-parent with whom the child lives occupation or aggravated assault pays second (if applicable). unless injuries result from a medical condition or domestic violence •• Charges in connection with any cosmetic surgery or treatment, unless specifically listed under covered expenses

38 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Total Health Medical Plan

Prescription Drug Benefits Maintenance medications are those In order to have coverage for medications that your physician prescriptions drugs in certain drug The Total Health Medical Plan offers prescribes for chronic or long-term classes, you must try a generic drug two prescription drug options—a High conditions (such as diabetes, high blood first. If you try (or have tried) a generic Rx and a Low Rx program (see page 23 pressure, heart conditions, allergies, drug and it does not work for you, then for details). Both are administered by thyroid conditions, etc.). If you are not you may receive coverage for a brand- Caremark and include a list of cost- sure if the prescription is for a chronic name drug. However, if you choose to effective generic and preferred drugs. condition, please check with your use a brand-name drug without trying pharmacist. a generic first or without getting prior Your cost for prescription drugs approval, coverage may be denied. depends on which option you choose PREVENTIVE DRUGS and whether the medication is generic, The following drug classes require use preferred, or non-preferred. When The Total Health Medical Plan Benefits covers preventive care medications at no of the generic step therapy program: possible, you may substitute a less ulcer, cholesterol, hypertension, urinary, expensive generic drug for a preferred cost to you. Preventive care medications are medications for which a prescription asthma, osteoarthritis, sleep aids, anti- or non-preferred drug and pay a lower inflammatory, migraines, and allergy. copay. If the prescribing physician from a physician is required under any of the following: Contact Caremark at 1-877-MyTHRLink specifies “dispense as written,” you may (1-877-698-4754), prompt 3 for more not make a substitution and will have to •• Evidence-based items or services that information. pay the applicable copay. have in effect a rating of "A" or "B" in the current recommendations of the CAREMARK RESOURCES The plan’s minimum and maximum United States Preventive Services Task It is important to understand your copays for preferred prescriptions and Force; the out-of-pocket maximum keep your pharmacy benefit options so you can •• With respect to infants, children and costs down by limiting the amount you make informed and cost-effective adolescents, evidence-informed must pay from your own pocket each decisions about your care. To give you preventive care and screenings time you fill a prescription. Generic access to the most up-to-date information provided for in the comprehensive copays apply toward the out-of-pocket Caremark provides a tool called “Check guidelines supported by the prescription maximum. DAW penalties Drug Costs” on www.caremark.com. & Wellness Medical Health Resources and Services do not apply towards the out-of-pocket “Check Drug Costs” is a tool that you Administration; or prescription maximum. This maximum is can use to learn about your options for •• With respect to women, such separate from the medical plan’s out-of- prescription medications. additional preventive care and pocket maximum. screenings as provided for in Before you fill a prescription, check to be Your annual out-of-pocket maximum is: comprehensive guidelines supported sure the medication is on the formulary by the Health Resources and Services list. Caremark updates the formulary list ABBR* Out-of-pocket Administration. each quarter. You can view the formulary Maximum list online at www.caremark.com. To find out whether a medication is Under $25,000 $1,000 considered to be a preventive care Over $25,000 $2,000 medication, sign in or register at www. *Annual Benefits Base Rate caremark.com and use the Check Drug Coverage and Cost tool or call 1-877-797- After the second time you fill a 9847. maintenance medication, you are required to have your maintenance NON-USE OF GENERICS medications filled with a 90-day If a generic drug is available and prescription or you will be penalized by you elect or your doctor prescribes a paying double the retail charge. You can preferred or non-preferred drug, you get a 90-day supply at retail pharmacies will pay a higher copay plus a “dispense located at Texas Health Dallas and Texas as written (DAW) penalty”—which Health Plano, Caremark mail order, or is the difference in cost between the any CVS pharmacy. preferred or non-preferred and generic drug. Certain prescriptions may require preauthorization. IF YOU have diabetes, you are eligible for free test strips when you receive regular follow-up with a diabetes educator at a Texas Health facility.

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 39 Total Health Medical Plan

COVERED DRUGS •• Hematinics, except Epogen or Procrit •• Prescription vitamins (other than prenatal vitamins), dietary Drugs that are covered include: •• Immunization agents, biological products for allergy immunization, supplements and fluoride products •• Birth control, oral contraceptives, biological sera, blood, blood plasma •• Replacement of lost or stolen and contraceptive devices (IUD or and other blood products or fractions prescriptions diaphragm) and implants (Norplant) and medications used for travel •• Smoking-deterrent medications •• Compounded medication of which at prophylaxis containing nicotine or any other least one ingredient is a prescription •• Infertility drugs smoking-cessation aids, all dosage legend drug •• Medication to be taken or forms (such as Nicorette, Nicoderm, •• Disposable insulin needles/syringes by administered, in whole or in part, etc.) except as covered under the prescription while a patient is in a licensed Tobacco Cessation program described •• Drugs that may only be dispensed hospital, rest home, sanitarium, beginning on page 57 upon the written prescription of a extended care facility, convalescent •• Therapeutic devices or appliances, physician or other lawful qualified hospital, skilled nursing facility, or including needles, syringes, support prescriber under the applicable state similar institution that operates on its garments (unless they are a covered law premises, or allows to be operated on health service, as defined on •• Glucose test strips and lancets its premises, a facility for dispensing page 162), and other nonmedical •• Growth hormones and releasing pharmaceuticals substances, regardless of intended use, agents, subject to Caremark’s •• Medications to enhance athletic are not covered unless specifically guidelines performance listed as covered items. •• Insulin by prescription •• Mineral supplements, except folic acid SPECIALTY MEDICATIONS •• Prenatal vitamins prescribed by a •• Obesity drugs If you take a specialty medication for a physician •• Over-the-counter medicines and chronic condition such as rheumatoid •• Prescription drugs and generic drugs, supplies—that do not require a arthritis or hemophilia, you may be except those drugs listed in the physician’s prescription and may be directed to a designated pharmacy to exclusions obtained over-the-counter, regardless obtain those medications. If you choose

Medical & Wellness Medical •• Smoking cessation drugs covered by of whether a physician has written not to obtain your specialty medications the wellness program a prescription for the item are not from a designated pharmacy, no benefits •• Tretinoin, all dosage forms (for covered except for diabetic supplies will be paid and you will be responsible example, Retin-A), for individuals age and prenatal vitamins for paying the full cost of your specialty 29 and under •• Prescription and nonprescription medication. supplies, devices, and appliances other DRUGS NOT COVERED than syringes used in conjunction MAIL ORDER Drugs that are not covered are: with injectable medications Caremark has its own mail order service. •• Prescription drugs or medications •• Charges for the administration or Please refer to your Caremark packet used for treatment of sexual injection of any drug are not paid as for your mail order prescription form, dysfunction, including but not part of the drug benefits mailing address and phone number. limited to erectile dysfunction, •• Charges incurred before a person was You may also get information and forms delayed ejaculation, anorgasmia and covered online at www.caremark.com. Mail decreased libido; however, up to six • order prescriptions are normally filled • Dental drugs pills a month are covered for drugs to and mailed within two weeks following •• DESI drugs (drugs determined by the treat erectile dysfunction receipt of the prescription. FDA as lacking substantial efficacy) •• Prescription drugs provided free of •• Drugs labeled “Caution-limited by charge from local, state, or federal NEW PRESCRIPTIONS federal law to investigational use,” or programs If your physician gives you a new experimental drugs, even though a •• Prescription drugs used for cosmetic charge is made to the covered person prescription for a maintenance purposes such as: drugs used to medication, you should ask him or her •• Drugs newly approved by the FDA, reduce wrinkles, drugs to promote for a 30-day prescription that you can fill prior to review by the applicable hair growth, drugs used to control immediately and a 90-day prescription Pharmacy and Therapeutics perspiration and fade cream products that you can fill for ongoing use. Committee •• Prescriptions provided without charge •• Hair replacement drugs for treatment under a worker’s compensation of alopecia (hair loss) including program Minoxidil (Rogaine) and Propecia are not covered unless the hair loss is a result of chemotherapy.

40 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Total Health Medical Plan

Take the 30-day prescription to your Filing and Appealing Claims You must submit the original local pharmacy to be filled. Then order itemized bill or receipt provided a 90-day supply of your prescription Benefits under the medical plan are self- by your physician, hospital, or other at the retail pharmacy at Texas Health funded, which means all claims are paid medical service provider, so you Presbyterian Hospitals at Dallas and from employee payroll deductions and should make copies for your own Plano, through Caremark mail order or at Texas Health’s general assets. UHC and records. Photocopies of receipts are any CVS pharmacy. Caremark provide claims services, but not accepted for claims. In addition, do not insure the plan. each bill or receipt must include the If you are currently taking maintenance CLAIMS following: medications, contact your physician and • ask for a 90-day prescription. UHC is the claims processor for the • Name of patient medical plan options. The following •• Date the treatment or service was summarizes how to file claims under provided UHC Choice and Choice Plus Plans. •• Diagnosis of the injury or illness for which treatment or service was given Whenever you file a claim, be sure to •• Itemized charges for the treatment or keep a copy of the claim and any other service information (such as itemized bills) that •• Provider’s name, address, and tax ID you include with the claim. number

Network Providers Most medical claims payments are sent When you use network providers, you to you along with an explanation of do not need to file claims. The provider benefits (EOB) explaining the amount will file the claim with UHC. For network paid. In some cases, payments may be benefits, if there is any difference sent directly to your physician, hospital, between the eligible expenses and the or other medical provider if your amount the provider bills, you are not provider accepts assignment of benefits responsible for paying the difference (as defined on page 161). In this case, Medical & Wellness Medical unless you agreed to reimburse the the EOB will be mailed to you and provider for such services. the payment mailed to your provider. For out-of-network benefits, you are Out-of-network Providers responsible for directly paying to the Out-of-network care is generally not out-of-network provider any difference covered under the UHC Choice Plan. between the amount the provider bills When you use out-of-network providers you and the amount UHC considers as under the Choice Plus Plan, you must file the eligible expense. a claim for reimbursement as follows: Prescription Drugs •• Complete a medical claim form You do not need to file claims for (available on the Internet at prescriptions purchased through www.myuhc.com) each time you network providers. You pay a copay or receive medical services. Be sure to coinsurance when you present your follow the instructions on the form. Caremark member ID card at a network •• Submit all itemized receipts from pharmacy or when you use the mail- your physician or other health care order prescription program. You may provider. A canceled check is not also use your Caremark member ID card acceptable documentation. at out-of-network pharmacies. •• Mail the completed claim form with the original itemized bills and receipts to UHC at the address on the claim form.

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 41 Total Health Medical Plan

NOTICE AND PROOF OF CLAIM Pre-service Claims If an ongoing course of treatment was previously approved for a specific You or your primary physician should On receipt of a pre-service claim, the period of time or number of treatments, file notice and proof of a claim on claims administrator will determine and your request to extend the treatment the proper claim form with the claims whether or not it involves urgent care. is an urgent care claim as defined above, administrator as soon as possible after If a physician with knowledge of your your request will be decided within 24 the claim is incurred and within the medical condition determines that a hours, provided your request is made time frames described in this section. claim involves urgent care, the claim will at least 24 hours prior to the end of The claim must be filed as soon as be treated as an urgent care claim. the approved treatment. The claims possible and in no event (except in the administrator will make a determination case of your legal incapacity) later than A claim is a pre-service claim if all on your request for the extended December 31 following the plan year or part of your right to the benefit is treatment within 24 hours from receipt in which the claim was incurred. For conditioned on receiving approval of your request. example, if a claim is incurred July 2013 before obtaining the medical care (such as preauthorization). This does not you have until December 31, 2014 to If an ongoing course of treatment was apply to a claim involving urgent care, as submit the claim. previously approved for a specific defined below. period of time or number of treatments, If there is a change in claims and you request to extend treatment in administrator, all claims incurred before Urgent Care Claims a non-urgent circumstance, your request the change in vendor must be received An urgent care claim is any pre-service will be considered a new request and by the old claims administrator by claim for medical care or treatment decided according to post-service or December 31 following the end of the when time periods that otherwise apply pre-service time frames, whichever year. to pre-service claims could seriously applies. jeopardize your life, health, or ability If the plan is terminated, all claims to regain maximum function or would, If your request for extended treatment incurred before the plan termination in the opinion of a physician with is not made at least 24 hours before must be received within 30 days after knowledge of your medical condition, the end of the approved treatment, the the plan’s termination or the claims will subject you to severe pain that cannot request will be treated as an urgent care

Medical & Wellness Medical not be paid. Any claims incurred after be adequately managed without the claim and decided according to the time termination of plan coverage for any care or treatment that is the subject of frames described on this page and the reason are not covered under the plan. the claim. next. If an ongoing course of treatment Each claim will be adjudicated was previously approved for a specific Post-service Claims (processed) in a way that ensures period of time or number of treatments, that the people involved in making A post-service claim is any claim for a and you request to extend treatment the decisions act independently and benefit that is not a pre-service claim or in a non-urgent circumstance, your impartially. For this reason, decisions an urgent care claim. request will be considered a new claim regarding hiring, compensation, and decided according to post-service termination, promotion, or other similar Concurrent Care Claims or pre-service time frames, whichever matters related to the individual who A concurrent care claim is one in which applies. is designated as the fiduciary for an the claims administrator approves internal appeal, or any health care a course of treatment over a period professional or other medical or of time or for a specified number of vocational expert involved in the claim treatments. However, a concurrent care or internal appeal, will not be based on claim may be reconsidered by the the likelihood that the individual will claims administrator and the initially support a denial of benefits. approved period of time or number of treatments may be either reduced, TYPES OF CLAIMS terminated, or extended. There are four different types of claims. The claim type is determined initially when the claim is filed. If the nature of the claim changes as it proceeds through claims processing, the claim may be re-characterized. For example, a claim may initially be an urgent care claim. If the urgency subsides, it may be re-characterized as a pre-service claim.

42 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Total Health Medical Plan

CLAIM AND APPEAL TIME FRAME Pre-Service Claims Post-Service Claims

1 Urgent Care Claims Action Timing Action Timing Action Timing If your claim is filed improperly If your claim is incomplete If your claim is incomplete UHC must notify you 5 days UHC must notify you 30 days within: within: UHC must notify you 24 hours within: If your claim is incomplete You must then provide 45 days completed claim after You must then provide 48 hours UHC must notify you 15 days information to UHC within: receiving completed claim after within: an information to UHC within: receiving You must then provide 45 days extension notice completed claim after notice 2 Notification of Determination information to UHC within: receiving If UHC denies your initial claim an UHC must notify you of extension UHC must notify you of 1 the benefit determination: notice the denial: ••If the initial claim is ••If the initial claim is If UHC denies your initial claim 30 days complete, within: 72 hours complete, within: UHC must notify you of ••After receiving the the denial: ••After receiving the completed claim (if completed claim (if 30 days the initial claim is 48 hours ••If the initial claim is the initial claim is incomplete), within: complete, within: 15 days incomplete), within: You must appeal a claim 180 days ••After receiving the You must appeal the claim 180 days denial no later than: after completed claim (if denial no later than: after receiving the initial claim is 15 days receiving the denial incomplete), within: the denial UHC must notify you of 72 hours You must appeal the claim 180 days the appeal decision within: after denial no later than: after UHC must notify you 30 days receiving receiving of the first level appeal after the appeal the denial decision within: receiving the first 1 You do not need to submit urgent care claims in UHC must notify you 15 days of the first level appeal after level writing. You should call UHC as soon as possible & Wellness Medical appeal to appeal an urgent care claim. decision within: receiving the first You must appeal the first 60 days level level appeal (file a second after appeal level appeal) within: receiving You must appeal the first 60 days the first level appeal (file a second after level level appeal) within: receiving appeal the first decision level UHC must notify you of 30 days appeal the second level appeal after decision decision within: receiving UHC must notify you of 15 days the the second level appeal after second decision within: receiving level the second appeal 3 level 2 appeal 3 UHC may require a one-time extension of no more than 15 days only if more time is needed due to 2 UHC may require a one-time extension of no more circumstances beyond their control. than 15 days only if more time is needed due to circumstances beyond their control.

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HOW TO FILE A CLAIM FOR •• In the case of an incorrectly filed The claims administrator will decide and BENEFITS urgent care claim, you should be notify you of an initial post-service claim Except for urgent care claims, a claim notified as soon as possible, but no within a reasonable time but no later for benefits is made when you (or your later than 24 hours after the claims than 30 days after receiving the claim. authorized representative) submit a administrator receives the incorrectly You may agree to voluntarily extend written claim form as follows. filed claim. The notice will explain that the request is not a claim and the above time frames. If the claims Medical claims administrator: describe the proper procedures for administrator is not able to decide UnitedHealthcare filing a claim. The notice may be a pre-service or post-service claim P.O. Box 30555 oral unless you specifically request within the above time frames for Salt Lake City, UT 84130-0555 written notice. reasons beyond its control, one 15- www.uhc.com day extension of the applicable time TIME FRAME FOR DECIDING frame is permitted, provided that you Prescription claims administrator: INITIAL BENEFIT CLAIMS are notified in writing before the end Caremark Claims Department The claims administrator will decide an of the initial time frame for the claim. P.O. Box 686005 initial pre-service claim and notify you The extension notice will include a San Antonio, TX 78268-6005 within a reasonable time appropriate to description of the reasons beyond the www.caremark.com the medical circumstances, but no later plan’s control that justify the extension than 15 days after receipt of the claim. and the date by which a decision is You can request a claim form from the expected. No extension is permitted for claims administrator for your plan. A The plan will decide an initial urgent urgent care claims. claim form is considered to be received care claim as soon as possible, taking by the plan on the date it is delivered to into account the medical urgency and If any information needed to process the applicable address shown above or notify you of the determination, whether a claim is missing, the claim will be the date that it is deposited in the U.S. or not adverse, but no later than 72 treated as incomplete. Mail for first-class delivery in a properly hours after the claim is received. stamped envelope containing the above If an urgent care claim is incomplete, name and address. The postmark will be If a claim is a request to extend a the claims administrator will notify Medical & Wellness Medical proof of the date of mailing. concurrent care decision involving you as soon as possible, but no later urgent care and it is made at least 24 than 24 hours following receipt of the Because of the expedited time frames hours before the end of the initially incomplete claim. The notification for a decision regarding urgent care approved time period or number of may be made orally to you, unless you claims, an urgent care claim may be treatments, the claim will be decided request written notice. It will describe submitted to the claims administrator at within no more than 24 hours after the the information necessary to complete the telephone number on your ID card. claim is received. Any other request to the claim and will specify a reasonable The claim should include at least the extend a concurrent care decision will time, no less than 48 hours, within which following information: be decided within the applicable time the claim must be completed. •• Your name frames for pre-service, urgent care, or The claims administrator will decide the post-service claims. •• A specific medical condition or claim as soon as possible, but not later symptom If the claims administrator notifies than 48 hours after the earlier of: •• A specific treatment, service, or you that an initially approved course •• Receipt of the specified information or product for which approval or of treatment will be reduced or payment is requested. •• The end of the period of time terminated, the notice will be provided provided to submit the specified These claims procedures do not apply sufficiently in advance of the reduction information. to any request for benefits that is or termination to allow you to appeal not made according to these claims the adverse decision and receive If a pre-service or post-service claim is procedures, except that: a decision on review under these incomplete, the claims administrator •• In the case of an incorrectly filed procedures before the reduction or may deny the claim or may take an pre-service claim, you should be termination. In the meantime, to the extension of time, as described above. notified as soon as possible but no extent required by applicable law, the If the claims administrator takes an later than five days after the claims plan will continue to provide coverage extension of time, the extension notice administrator receives the incorrectly to you with respect to ongoing course will include a description of the filed claim and of treatment pending the outcome of the internal appeal. missing information and specify a time frame, no less than 45 days, in which the necessary information must be provided.

44 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Total Health Medical Plan

The time frame for deciding the claim your opportunity to receive as •• The availability of, and contact will be suspended from the date you soon as practical upon request the information for, any applicable receive the extension notice until diagnosis and treatment codes (and office of health insurance consumer the date the missing information is their meanings) assistance or ombudsman established provided to the claims administrator. If •• The specific reasons for the under Section 2793 of the Public the requested information is provided, decision, the denial code and its Health Service Act to assist the plan will decide the claim within corresponding meaning, as well as individuals with the claims and the the period specified in the extension a description of the plan’s standard, plan’s internal appeal processes and notice. If the requested information is if any, that was used in denying the external review processes. not provided within the time specified, claim THE RIGHT TO INTERNAL APPEAL the claim may be decided without that •• References to the specific plan information. provisions on which the decision is You have the right to appeal an adverse based decision under these claims procedures. NOTIFICATION OF INITIAL Except for urgent care claims, discussed BENEFIT DECISION BY THE PLAN •• A description of any additional material or information necessary below, an appeal of an adverse benefit Written or electronic notification of to perfect the claim and why such decision is filed when you (or your the claims administrator’s decision information is necessary authorized representative) submit a on a pre-service or urgent care claim written request (go to www.myuhc.com •• A description of the plan procedures will be provided to you, whether or to print the member service request form and time limits for appeal of not the decision is adverse. A decision for medical appeal) for review to your the decision, the right to obtain is adverse if it is a denial, reduction, claims administrator: information about those procedures, or termination of a benefit, a failure the right to sue in federal court and to provide or make payment in UHC Appeals a description of the procedures to whole or in part, or a rescission of P. O. Box 30432 obtain an external review of the coverage. A rescission of coverage is Salt Lake City, UT 84130-0432 claim any retroactive termination of your •• A statement disclosing any internal Caremark Appeals coverage, except where you perform rule, guidelines, protocol or similar Caremark, Inc. an act of fraud or make or make an & Wellness Medical criterion that was used in making the Appeals Department intentional misrepresentation of a adverse decision (or a statement that MC 109 material fact. Retroactive termination such information will be provided P.O. Box 52084 of your coverage for failure to make free of charge upon request) and Phoenix, AZ 85072-2084 timely payment of your premiums Fax: (866) 689-3092 or contributions toward the cost of •• If the decision involves scientific or clinical judgment, it will disclose coverage is not a rescission. You should request a review in writing. either an explanation of the scientific A request for review will be treated Any new or additional evidence or clinical judgment applying the as received by the plan on the date it that was considered, relied upon, or terms of the plan to the covered is delivered to the applicable address generated in connection with the claim person’s medical circumstances or listed above or on the date that it is will be provided to you at no cost and a statement that such explanation deposited in the U.S. Mail for first-class in advance of the date of the notice of will be provided at no charge upon delivery in a properly stamped envelope adverse benefit determination. request. containing the above name and address. •• In the case of an adverse decision The postmark on any such envelope You will receive written or electronic concerning an urgent care claim, a will be proof of the date of mailing. notification of the adverse decision. description of the expedited review The notice will be written so you process. Notification of the plan’s You have the right to submit documents, can understand it, will be made in a adverse decision on an urgent care written comments, or other information culturally and linguistically appropriate claim may be provided orally, but in support of an appeal. The claims manner, and will include the following: written or electronic notification will administrator must provide you with •• Information sufficient to identify the be furnished not later than three days any new or additional evidence claim involved, including the date after the oral notice. considered, relied upon, or generated of service, the health care provider, by the plan (or at the direction of the claim amount (if applicable) the claims administrator or plan and either the diagnosis code and administrator) in connection with the its corresponding meaning and the claim and, if applicable, the rationale treatment code and its corresponding for the final internal adverse benefit meaning or a statement describing determination based on such new or additional evidence.

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The claims administrator or its delegate HOW THE APPEAL WILL BE The claims administrator will decide must provide this information as soon DECIDED the appeal of an urgent care claim as as possible and sufficiently in advance The appeal of an adverse benefit soon as possible, taking into account the of the date on which the notice of decision will be reviewed and decided urgent medical situation, but no later final adverse benefit determination is by the claims administrator because they than 72 hours after the plan receives the required so you will have an opportunity are the named fiduciary under the plan. request for review. to respond by, for example, presenting The person who reviews and decides an The claims administrator will decide the evidence and testimony, prior to that appeal will be a different individual than appeal of a post-service claim within date. the person who made the initial benefit a reasonable period, but no later than decision and will not be a subordinate of The appeal of a denied pre-service 60 days after receipt of the request for the person who made the initial benefit request for benefits, post-service claim review. decision. The claims administrator will or a rescission of coverage must be filed follow these procedures when deciding with the claims administrator within 180 The claims administrator will decide any appeal. days after you receive the notification of the appeal of a decision to reduce or terminate an initially approved course adverse benefit decision. The review by the claims administrator of treatment (under a concurrent care will take into account all information This communication should include: claim) before the proposed reduction or you submitted, whether or not it termination takes place. •• The patient’s name and ID number as was presented or available at the shown on the ID Card; initial benefit decision. The claims The claims administrator will decide the •• The provider’s name; administrator will give no deference to appeal of a denied request to extend •• The date of medical service; the initial benefit decision. a concurrent care claim in the appeal •• The reason you disagree with the time frame for pre-service, urgent care, or In the case of a claim that was denied on denial; and post-service claims described above, as the grounds of a medical judgment, the •• Any documentation or other written appropriate to the request. claims administrator will consult with information to support your request. a health professional with appropriate NOTIFICATION OF DECISION

Medical & Wellness Medical However, an appeal of the plan’s decision training and experience. The health care ON APPEAL professional who is consulted on appeal to reduce or terminate an initially Written notification of the decision will not be the same individual, if any, approved course of treatment (see regarding an appeal will be provided who was consulted regarding the initial definition of concurrent care decision) to you whether or not the decision is benefit decision or a subordinate of that must be filed within 30 days of your adverse. A decision regarding an appeal individual. receipt of the notification of the plan’s is adverse if it is either: decision to reduce or terminate. Failure Upon your request and free of charge, •• A denial, reduction, or termination of to comply with this important deadline you will have reasonable access to, and benefits or may cause you to forfeit any right to any copies of, all documents, records, and • further review of an adverse decision • A failure to provide or make all or part other information relevant to your claim under these procedures or in a court of of a payment for a benefit. for benefits. If the advice of a medical l a w. or vocational expert was obtained in You will receive written notification To initiate a pre-service urgent care connection with the initial benefit decision, of an adverse decision regarding an appeal, call 1-877-MyTHRLink the names of each expert will be provided appeal. It will include the following (1-877-698-4754) select prompt 2 and on your request, regardless of whether the information, written in a manner that ask for Care Coordination. The claim advice was relied on by the plan. you can understand, and in a culturally should include at least the following and linguistically appropriate manner All necessary information in connection information: according to applicable law: with an urgent care appeal will be •• Information sufficient to identify the •• Your name transmitted between the plan and you by claim involved, including the date •• A specific medical condition or telephone, fax, or email. of service, the health care provider, symptom TIME FRAMES FOR DECIDING the claim amount (if applicable), the •• A specific treatment, service, or BENEFITS APPEALS diagnosis code and its corresponding product for which approval or meaning, and the treatment code and payment is requested and The claims administrator will decide its corresponding meaning •• Any reasons why the appeal should be the appeal of a pre-service claim within processed on a more expedited basis. a reasonable time appropriate to the medical circumstances, but no later than 30 days after receiving the request for review.

46 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Total Health Medical Plan

•• The specific reasons for the appeal You will be deemed to have exhausted It will also include information about decision, the denial code and its the internal claims appeals process if the applicable rules, your right to corresponding meaning, as well as the plan or claims administrator fails to representation, the process for a description of the plan’s standard, adhere to the requirements described selecting the decision maker, and the if any, that was used in denying above and under applicable law. circumstances, if any, that may affect the the claim and a discussion of the impartiality of the decision maker, such decision VOLUNTARY APPEAL as any financial or personal interests •• A reference to the specific plan Within 180 days after the date you in the result or any past or present provisions on which the decision is receive written notice of the decision relationship with any party to the review based by the claims administrator regarding process. No fees or costs are imposed •• A statement disclosing any internal an appeal, you (or your authorized on you as part of the voluntary appeal. rule, guidelines, protocol or similar representative) may file a written You may file a lawsuit for benefits only criterion relied on in making the request for a review of your denied after you have exercised all appeals adverse decision (or a statement that claim. You (or your authorized described in this section (except the such information will be provided representative) may submit written voluntary appeal) and all or part of the free of charge on request) issues and comments to the Voluntary benefits you request on appeal have •• A statement of the right to sue in Review Process (VRP) Board. been denied. federal court and a description of The VRP Board will notify you of its the procedures to obtain an external EXTERNAL REVIEW PROGRAM decision in writing. Such notification review of the claim will be written in a manner that you can If you are not satisfied with the final • • A statement indicating you are understand and will contain specific determination after exhausting your entitled to receive reasonable access reasons for the decision, as well as internal appeals, you may choose to or copies of all documents, records specific references to pertinent plan to participate in the external review or other information relevant to provisions. The decision on review will program. the determination (on request and be made within 60 days after the VRP without change) and Board receives your request for review. This program applies only if the adverse •• If the decision involves scientific benefit determination is based on Medical & Wellness Medical or clinical judgment, either an If you do not request a voluntary appeal, issues of medical judgment, including explanation of the scientific or the plan cannot say that you failed to but not limited to those based on the clinical judgment applying the exhaust your administrative remedies. requirements for medical necessity, terms of the plan to your medical The time you spend pursuing your appropriateness, health care setting, circumstance or a statement that voluntary appeal does not shorten the level of care, or effectiveness of a such explanation will be provided at period within which you must file a covered benefit; or the determination no charge on request. lawsuit. that a treatment is experimental or •• The availability of, and contact investigational. You may submit a voluntary appeal information for, any applicable only after exhausting the appeal to the This external review offers an office of health insurance consumer claims administrator. independent process to review the assistance or ombudsman established denial of a requested service or under Section 2793 of the Public Upon your request, the claims procedure or payment for a service or Health Service Act to assist administrator will provide you sufficient procedure. Within four months after individuals with the claims and plan’s information relating to the voluntary receipt of a notice of an adverse benefit external review process. appeal to enable you to make an determination, you must request an informed judgment about whether Notification of an adverse decision external review of the claim for benefits. to submit a benefit dispute to the regarding an appeal of an urgent care If the last filing date would fall on a voluntary appeal. This information will claim may be provided verbally, but Saturday, Sunday, or federal holiday, the include a statement that your decision written notification will be furnished last filing date is extended to the next to submit a benefit dispute to the not later than three days after the oral day that is not a Saturday, Sunday, or voluntary appeal will have no effect on notice. federal holiday. You or your authorized your rights to any other benefits under representative may request an external You must exhaust the internal claims the plan. review by contacting the toll-free appeals process before you pursue number on your ID card or by sending any other legal or equitable remedy. A a written request to the address on your decision of your entitlement to benefits ID card. upon exhaustion of this process will constitute a final internal adverse benefit determination.

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Within five business days following Upon receipt of a completed and eligible •• Reports from appropriate health care receipt of your request, the claims request for external review, the plan must, professionals and other documents administrator will complete a in accordance with applicable law, assign submitted by the plan, you, or your preliminary review of the request an IRO to conduct the external review. treating provider; for external review to determine the Within five business days following the •• The terms of the plan, to ensure that following: date of assignment of the IRO, the plan the IRO’s decision is not contrary to •• Whether you are or were covered will provide to the IRO the documents the terms of the plan, unless the terms under the Plan at the time the health and any information considered are inconsistent with applicable law; care item or service was requested or in making the adverse benefit •• Appropriate practice guidelines, which provided; determination. If the plan fails to timely must include applicable evidence- provide the documents and information, •• Whether the adverse benefit based standards and may include any the IRO may terminate the external determination relates to the fact other practice guidelines developed review and make a decision to reverse that you do not meet the eligibility by the federal government, national or the adverse benefit determination. requirements to participate under the professional medical societies, boards, and associations; terms of the Plan; Within one business day after making •• Any applicable clinical review criteria •• Whether you have exhausted the the decision to terminate the external developed and used by the plan, Plan's internal claims procedures; and review and reverse the prior adverse unless the criteria are inconsistent •• Whether you have provided all the benefit determination, the IRO must with the terms of the plan or with information and forms required to notify you of its determination. The IRO applicable law; and process the request for an external will notify you, in writing, of the eligibility review of the claim for benefits. and acceptance of the claim for external •• The opinion of the IRO’s clinical review, and you may, within ten business reviewer or reviewers after considering If your request for external review days following the date of receipt of the information to the extent the is complete, but the claim is not such notice, submit, in writing, to the IRO information or documents are eligible for an external review, the additional information for the IRO to available and the clinical reviewer or claims administrator will, within one consider when conducting the external reviewers consider appropriate. business day following completion

Medical & Wellness Medical review of the claim for benefits. of its preliminary review, provide you Within forty-five days after the IRO with written notice of the reasons for Upon receipt of any information receives the request for the external the claim’s ineligibility for external forwarded by the IRO, the plan review, the IRO must provide you written review and the contact information may reconsider its adverse benefit notice of the final external review for the Employee Benefits Security determination that is the subject of the decision. If you requested an expedited Administration (toll-free number external review. Reconsideration by the external review, the IRO will provide 866-444-EBSA (3272)). plan will not delay the external review of notice of the final external review the claim for benefits. If the plan decides, decision to you as expeditiously as your If your request for external review is upon completion of its reconsideration, medical condition or circumstances incomplete, the claims administrator to reverse its adverse benefit require, but in no event more than or its delegate, within one business day determination and provide coverage or seventy-two hours after the IRO receives following completion of its preliminary payment, the external review of the claim your request for an expedited external review, will provide you with written for benefits may be terminated. review. Notice of the final external review notice describing the information or decision may be given orally, but only if materials needed to complete the In conducting its review, the IRO will the IRO furnishes you written notification request for external review. You must consider the information provided the of the final external review decision provide the information necessary by the plan and any additional information within forty-eight hours after the date of later of the applicable four-month filing and documents you timely submit. In providing the oral notice. period or the 48-hour period following reaching its decision, the IRO will review the receipt of the notification, whichever the claim de novo and is to be bound by is later. any decisions or conclusions reached during the plan’s internal claims process. The IRO may also consider: •• Your medical records; •• The attending health care professional’s recommendation;

48 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Total Health Medical Plan

The notice of the final external review You may request an expedited external Subrogation decision by the IRO should include the review at the time you receive: following: The plan may be entitled to recover, •• An adverse benefit determination through either or both of its rights to •• A general description of the reason that involves a medical condition for reimbursement or subrogation, the cost you requested an external review which the time frame for completion of certain benefits previously provided of the claim for benefits, including of an expedited internal appeal to you as a result of an illness, injury information sufficient to identify the would seriously jeopardize your life or condition for which a Responsible claim (including the date or dates or health or would jeopardize your Third Party is or may be held legally of service, the health care provider, ability to regain maximum function responsible. The following explains the claim amount (if applicable), the and with respect to which you have the circumstances under which the diagnosis code and its corresponding filed a request for an expedited plan will have these rights to recovery meaning, the treatment code and internal appeal; or and your obligations under such its corresponding meaning, and the •• An adverse benefit determination, circumstances. Please note that your reason for the previous denial); if you have a medical condition failure to comply with the requirements •• The date the IRO received the where the time frame for completion of this section may result in a loss of assignment to conduct the external of a standard external review coverage under the plan. review of the claim for benefits and would seriously jeopardize your the date on which the final external life or health or would jeopardize IMPORTANT DEFINITIONS review decision was made; your ability to regain maximum There are important terms used •• References to the evidence or function, or if the adverse benefit throughout this section, the definitions documentation, including the determination concerns an of which are provided below: specific coverage provisions admission, availability of care, •• “Reimbursement” refers to the and evidence-based standards, continued stay, or health care item repayment by you of expenses considered in reaching the final or service for which you received previously paid by the plan for an external review decision; emergency services, but have not illness, injury or condition for which •• A discussion of the principal reason been discharged from a facility. a responsible third party is or may be or reasons for the final external You may contact the claims held legally responsible. & Wellness Medical review decision, including the administrator at the toll-free number •• “Subrogation” refers to the rationale for the final external review on your ID card for more information substitution of you by the plan with decision and any evidence-based regarding your external appeal rights respect to your claim related to an standards that were relied on in and the independent review process. illness, injury or condition for which making the final external review a Responsible Third Party is or may decision; PAYMENT OF CLAIMS be held legally responsible. •• A statement that the determination Plan benefits are payable to you unless •• “Responsible third party” means is binding except to the extent that you give written direction, at the time any person other than the plan, other remedies may be available you file your claim, to directly pay including, but not limited to, any of under state or federal law; the health care provider or unless a the following: •• A statement that judicial review may Qualified Medical Child Support Order –– The party or parties who caused be available; and directs the payment to someone else. the illness, injury, or condition, •• Current contact information, If any benefit remains unpaid at your –– The insurer, guarantor, or other including phone number, for any death, if the covered person is a minor indemnifier of the party or parties applicable office of health insurance or legally incapable (in the opinion who caused the illness, injury, or consumer assistance or ombudsman of the claims administrator) of giving condition, established under Section 2793 of the a valid receipt and discharge for –– Your own insurer (for example, Public Health Service Act. payment, the claims administrator may, uninsured, underinsured, and no at its option, pay benefits to the spouse, Upon receipt of a notice of a final fault coverage), parent or child of the covered person. external review decision reversing the –– A worker’s compensation insurer, adverse benefit determination, the Plan Payment to the covered person’s and/or immediately must provide coverage relative constitutes a complete –– Any other person, entity, policy, or payment (including immediately discharge of the claims administrator’s healthcare plan or insurer that is authorizing or immediately paying obligation to the extent of the payment. liable or legally responsible for the benefits) for the claim. The claims administrator is not required illness, injury, or condition. to see the application of the money.

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 49 Total Health Medical Plan

GENERAL It is important to note that the plan’s lien All benefits paid by the plan with respect applies regardless of how the claims, to such illness, injury or condition will be If you receive payment or reimbursement awards, recoveries or amounts paid or added to the amount of the plan's lien, as of expenses from the plan, or you submit payable by or on behalf of a responsible described above. As a result, the plan will a claim to the plan for payment or third party are classified or characterized have the right to recover such amounts reimbursement of expenses, which relate by the parties, the courts or any other from the escrow account or directly from to the treatment of an illness, injury, or person or entity, including, for example, you. condition for which a responsible third amounts paid to or for your benefit party is or may be held liable or legally for general damages, and regardless of NO OFFSET OF COSTS responsible (for example, when the whether you are made whole for your plan pays claims for the treatment of an The plan will not pay, offset any recovery, losses and claims for benefits following illness, injury or condition caused by an or in any way be responsible for any the plan's recovery, and regardless of automobile accident or another person’s fees or costs associated with enforcing whether the Responsible Third Party is at negligence), the payment, reimbursement, its reimbursement or subrogation fault or has had made an admission of or claim, as applicable, will be subject to rights under the plan unless the plan fault. the plan’s rights of reimbursement and administrator, in its sole and absolute discretion, agrees to do so in writing. subrogation as further described in this REIMBURSEMENT OF PAID All costs and fees incurred by the section. EXPENSES plan to enforce its reimbursement and NOTICE TO PLAN Upon recovery of any amounts from a subrogation rights will be added to the responsible third party, you are required amount of the plan's lien, as described You are required to notify the plan of to reimburse the plan first from such above. any payment, reimbursement or claim recovery for the amount of benefits paid for expenses under the plan that relates by the plan, if any, for the illness, injury, or SUBROGATION OF RIGHTS AGAINST to the treatment of an illness, injury or condition to which the recovery relates, THIRD PARTIES condition for which a responsible third plus the costs and expenses incurred by The plan will be subrogated to and will party is or may be held liable or legally the plan in collecting such recovery from succeed to all claims, demands, actions responsible. you or the responsible third party. If you and rights of recovery (under all possible

Medical & Wellness Medical Notice can be provided directly to the fail to the reimburse the plan within thirty legal theories) that you may have against claims administrator by calling United days of receipt of such recovery, the plan any responsible third party with respect Healthcare between 8:00 a.m. and 5:00 may charge you interest on the amount to any illness, injury, or condition for p.m. Central time, or by logging on to you are required to reimburse the plan which such responsible third party may www.myuhc.com. in accordance with this provision. All be held liable or legally responsible. interest charged pursuant to this section CONDITIONAL BENEFIT PAYMENTS will be added to the amount of the plan’s This means the plan may, at its option, take over your right to pursue or receive The payment by or on behalf of the lien, as described above. payments from a responsible third party, plan of any claim for benefits for which PAYMENT OF FUTURE EXPENSES provided the plan’s recovery will not a responsible third party is or may be exceed the amount of the plan’s lien held liable or legally responsible is Upon recovery of any amounts from a described above. conditioned and contingent upon actual Responsible Third Party, future expenses incurred by you that relate to the same repayment to the plan in the event of a Upon such request, and prior to the illness, injury or condition with respect recovery from a responsible third party. plan’s receipt of an executed agreement, to which you received such recovery will any claim related to the illness, injury LIEN not thereafter be reimbursable from, or or condition that is the subject of the paid directly by, the plan, unless otherwise The plan will have a first priority lien reimbursement or subrogation rights of provided in a separate written agreement against, and will be entitled to recovery the plan will be pended and will not be signed by you and the plan administrator. of, the first dollars paid or payable to you processed or paid. or on your behalf by a Responsible Third Any funds paid or payable by a Party. PRESERVATION OF RIGHTS Responsible Third Party to or on behalf of you for future medical claims relating The plan administrator may, in its sole to the same illness, injury or condition for and absolute discretion, take any action which the Responsible Third Party is, or as it, in its sole and absolute discretion, may be, held liable or legally responsible determines necessary or appropriate are required to be set aside in an escrow to preserve the plan’s rights to account for your benefit. reimbursement and/or subrogation.

50 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Total Health Medical Plan

COOPERATION AND ASSISTANCE When Coverage Ends Eligible retirees must elect this coverage within 60 days of their retirement date You are required to cooperate Generally, coverage for you and your by completing the Retiree Medical in protecting the plan’s rights to covered dependents under the Total form. You are required to continue the reimbursement and subrogation, and Health Medical Plan ends on the last same medical coverage you had as an may not act (or fail to act) at any time day of the pay period in which you active employee. (Coverage for retirees or in any manner that prejudices the terminate employment. may change when coverage for active plan’s rights to reimbursement and/or employees changes.) subrogation (including but not limited However, there are certain situations to settling a claim with a responsible when it would end on a different date. Retirees can change medical options third party, without advance notice to For example, it would end on the date: during open enrollment, with coverage and approval of the plan administrator). •• The employee dies normally effective on the following You are required to provide all •• You divorce January 1. Individuals who drop information and sign and return all •• Your dependent reaches the plan's medical coverage after retirement will documents necessary for the plan to maximum age. not be eligible to re-enroll at a later date. exercise its rights to reimbursement and Retirees are required to pay the entire subrogation within five business days of See page 140 for more information. premium, including both the employee’s a request by the plan administrator. CONTINUATION OF MEDICAL and Texas Health’s portion of the cost for medical coverage, plus an additional WRITTEN AGREEMENTS COVERAGE cost for administration. As a condition to your continued In some cases, you and your covered participation under the plan, you dependents may be eligible for COBRA If a retiree reaches age 65 before his may be required to execute a written continued health coverage, as explained or her spouse (or dies before reaching agreement acknowledging the in “Coverage After Termination” on page age 65), the spouse may continue plan’s rights of reimbursement and 141. medical coverage until he/she turns age subrogation. Upon such request, 65, as long as the spouse was covered CERTIFICATE OF CREDITABLE and prior to the plan’s receipt of an under the plan at the employee’s date COVERAGE executed agreement, any claim related of retirement or death. Otherwise, the to the illness, injury or condition that Federal laws require Texas Health to spouse’s coverage ends when the & Wellness Medical is the subject of the reimbursement or provide a Certificate of Creditable retiree’s coverage ends. If the retiree subrogation rights of the plan will be Coverage outlining your medical dies, an eligible surviving spouse who pended and will not be processed or coverage and showing the dates you remarries may not add his or her new paid. were covered. spouse to the plan. If the covered spouse is older than the retiree, the spouse’s UHC will provide you with a Certificate FAILURE TO COMPLY coverage ends when the spouse turns of Creditable Coverage if your coverage Your benefits under the plan are age 65. For more information see the terminates under the plan: conditioned on your compliance booklet entitled “What To Do When You with the requirements related to the •• At the time of the qualifying event or Retire Before Age 65” which is available plan’s rights to reimbursement and other termination of coverage on MyTexasHealth. subrogation. If you do not reimburse the •• At the time your COBRA coverage plan such amounts, the plan may take ends. Texas Health reserves the right to amend any action the plan administrator deems or terminate retiree medical coverage You can also make a written request for at any time at its discretion. Contact appropriate, including but not limited to a Certificate of Creditable Coverage to the following: Human Resources for more information the claims administrator, provided that or to obtain a Retiree Medical form to •• Reducing future benefits that would your request is made within 24 months enroll before your planned retirement otherwise be payable for any illness after your coverage ends. date. or injury, •• Terminating coverage under the plan Retiree Medical Coverage You will also receive a packet explaining for you and your dependents. your right to elect COBRA continuation Employees who retire from Texas Health coverage. If you chose to elect COBRA at age 55 or older with a combined age continuation coverage, you will not and years of continuous service equal be eligible to elect retiree medical to or greater than 75 may continue coverage at a later date. medical coverage until age 65.

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 51 Wellness Program Be Healthy Wellness Program Texas Health offers the Be Healthy These professionals—called Health Dependents can access the Be Healthy wellness program that gives you the tools Coaches—are nurses, counselors, dietitians website, but are not eligible to earn most to focus on getting healthy and staying and fitness experts who will call you to offer rewards. COBRA participants are not healthy. This section describes those support and direct you to resources that can eligible for Be Healthy rewards. tools. help you achieve your wellness objectives. Be Healthy provides many opportunities Research has shown that people who have Benefits-eligible employees are all full- to improve your health—and your support in managing their health are more time and part-time employees who are life. Several of the program elements successful than people who try to manage classified to work 48 hours or more each also allow you to earn rewards for their health alone. To provide the support pay period. Your status as full-time or completing them. The table below you need, Texas Health has carefully part-time is based on your status in Texas describes your eligibility for each selected companies that have professionals Health’s HR/payroll system and not program. focusing on different health issues. based on the number of hours you work.

Eligibility for Be Healthy Wellness Programs

Benefits-eligible Benefits-eligible employees enrolled employees not enrolled in the Total Health in the Total Health Medical Plan Medical Plan PRN Program Name Employees Spouses Children Employees Spouses Children Employees Spouses Children Online Health Assessment √ √ √2 √ Be Healthy Basics √ √2 √2 √4 Medical & Wellness Medical Preventive/Wellness Exam √ √ √2 Age Appropriate Cancer Screenings ••Colorectal Cancer (Colonoscopy) √ √2 √2 ••Mammogram √ √2 √2 ••Prostate Exam √ √2 √2 Maternity Support Program √ √ √ Health Coaches √ √ √ √ Diabetes Management Program √ √ √ Cancer Support Nurse √ √ √ Tobacco Cessation Program √ √ √ √ √ √ √ √ √ Employee Assistance Program √ √ √ √ √ √ √ √ √ Health Advocacy √ √ √ √ √ √ √ √ √ Medical Nutrition Therapy (available √ √ √ to participants with a BMI over 28) Weight Watchers1 Not √ √ subsidized Fitness Memberships1 √ √ √ √ √ √ √3

1 Weight Watchers and fitness memberships are not included in the Total Health Medical Plan.

2 Dependents can participate in the program but do not receive an incentive.

3 PRN's are eligible for discounts at fitness centers through Globalfit but not at Texas Health fitness centers.

4 Employees getting their labs completed at their physician's office must use the “Health Provider Screening Form” found at https://register.wellness-inc.com/thr in order to receive an incentive.

52 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Wellness Program

Be Healthy Incentives The first time you access the wellness The reward notification will be sent to website, you will be required to register the address you provide in your profile To earn a reward, most of the 2013 and provide your email address so on the Be Healthy wellness website. Be Healthy program elements can be you can be notified whenever you completed anytime during the year. To have earned a reward. Your privacy is The IRS considers incentive rewards a be eligible for the reward for the Health protected in all parts of the Be Healthy part of your pay. That means you will Assessment, you must complete it during program. have to pay taxes on the rewards you the open benefits enrollment period or receive and your 401(k) contributions within 14 calendar days of your hire date After you have completed the will be deducted. The tax for your if you are a new employee, or within 31 requirements for a reward, you will reward will be shown on your paycheck calendar days of becoming benefits- receive an email notifying you that the as additional pay. On average, the tax on eligible. It may take 6 – 8 weeks for your amount is available in your rewards a $25 reward will be around $5. reward notification to arrive. account. Your reward is redeemable for gift cards from more than 100 national Be Healthy is administered by retailers, restaurants, entertainment, and ® UnitedHealthcare . UnitedHealthcare travel providers or you can receive it in also administers our wellness website. the form of a Visa gift card.

HOW TO PARTICIPATE IN THE BE HEALTHY INCENTIVE PROGRAM

Program Element1 When and How to Complete It Reward How to Get the Reward Health Log on to www.MyTHR.org to enroll. After you enroll, you’ll have the $75 Your completion of the Health Assessment 2 option to complete the Health Assessment. Assessment is reported ••Active employees: during open enrollment automatically. ••New employees: within 14 calendar days of your hire date ••Newly eligible employees: within 31 calendar days of becoming benefits-eligible Medical & Wellness Medical

Spouses enrolled in the Total Health Medical Plan: $25 Your spouse's completion of the Log on to www.BeHealthyTHR.org and complete a profile, then Health Assessment is reported complete the Health Assessment. automatically. ••Spouses enrolled in our medical plan in 2012: during open enrollment in November 2012 ••Spouses not enrolled in our medical plan in 2012: during open enrollment in November 2013

Be Healthy All benefits-eligible employees: get your Be Healthy Basics at your $50 If you participate through the Basics entity’s health fair or take the “Health Provider Screening Form” to health fair, UHC will report your your appointment with your doctor anytime during 2013. You must participation. If you get your Be meet certain requirements to earn this reward. See page 54 for Healthy Basics at your doctor’s details. office, your doctor will complete the form for you to fax back. Preventive/ You must be enrolled in the Total Health Medical Plan to receive $100 When your network doctor Wellness credit. You can complete this element anytime during 2013. files your claim, UHC will Exam automatically report your Spouses enrolled in the Total Health Medical Plan may complete this $25 participation. element anytime during 2013.

Cancer You must be enrolled in the Total Health Medical Plan to receive $25 When your network doctor Screenings credit. If you have a mammogram, prostate exam or colonoscopy files your claim, UHC will anytime during 2013, you are eligible. automatically report your participation. Maternity You must be enrolled in the Maternity Support Program by your 16th $100 It’s automatic if you’re a Total Support week and actively participate through the 12th week after your baby Health participant. Program is born. To enroll, call 1-877-MyTHRLink (1-877-698-4754), select prompt 2 between 8 a.m. and 5 p.m. Monday through Friday, or log on to www.myuhc.com.

1 One reward per element per year. 2 If you are a new hire or experience a status change between October 1 and the end of Open Enrollment each year, you will only complete the Open Enrollment Health Assessment.

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 53 Wellness Program

Online Health Assessment SPOUSE HEALTH ASSESSMENT •• If you do not have at least two Be Healthy Basics that fall within these Spouses enrolled in the Total Health When you log on to www.MyTHR.org ranges, you can still qualify for the Medical Plan are eligible to earn a $25 to enroll for your 2013 benefits, you $50 reward by completing one of the reward. They can complete the health also can complete an online Health following prior to December 31, 2013: Assessment after you’ve finished assessment during open enrollment by –– Weight Watchers your benefits enrollment. Most of the logging on to http://BeHealthyTHR. –– Health Coaching by phone. questions on the Health Assessment are org. about things you know right away—like Spouses covered by the Total Health You may get your Be Healthy Basics at how much you weigh and how many medical plan in 2012 were eligible for your entity’s health fair or your physician times a week you exercise. It will also ask the Health Assessment during open may order your lab panel between you to enter recent lab results such as enrollment in November 2012. Spouses January 1 and December 31, 2013. your cholesterol, blood sugar (glucose) added to coverage under the Total and blood pressure. Even if you don’t Health medical plan in 2013 may take If you attend your entity’s onsite health have lab results, you can still complete the health assessment during open fair, you can get a blood test and screen the Health Assessment. enrollment in November 2013. to find out your blood pressure, blood glucose, lipids, body mass index (BMI), The Health Assessment asks questions Eligible child dependents are not able and body fat percentage. Dependents and then gives you results in a to earn a reward but can complete cannot get a blood screen at the health confidential, personal report that helps the health assessment. Spouses and fair. you understand more about your eligible dependents must use their social health and your health risks. The more GETTING YOUR BASICS FROM security number when they register. complete and accurate information you YOUR DOCTOR The first time spouses take the Health provide, the more valuable the results Assessment, they should: To receive credit for getting your Be will be to you. Your personal report will Healthy Basics at your doctor’s office, explain how to improve your health and •• Click “Register.” here’s what you need to do: maintain a healthy lifestyle. •• Complete the required fields, then click “Continue.” Please note that a •• Go to https://register.wellness-inc. Medical & Wellness Medical Based on your Health Assessment results, Social Security Number should be com/thr. Select Health Provider you may be eligible to participate in used for the “Unique ID." Screening Form and then follow the a personalized Wellness Coaching •• After completing the registration, prompts. Step-by-step instructions are program. You can register immediately click on "I AM" then “Take the health available on MyTexasHealth. after you complete your Health assessment." •• Take your form to your appointment Assessment or a coach will contact you with your doctor. After your doctor by letter or a phone call to invite you to Be Healthy Basics completes the form, fax it to participate. Your personal Health Coach 877-457-2612. The forms are processed will provide one-on-one coaching and Be Healthy Basics are measures of daily. many other resources to help you reach your physical condition that provides If you are covered by a Total Health your health goals. clues about your health. They tell you Medical Plan, remember to use a UHC and your doctor about your current Choice or Choice Plus network lab. If you completed the Health Assessment health, identify health risks, and provide during the 2013 open enrollment period important information about managing ONE REWARD PER YEAR (November 1 – November 15) or within your health. Based on your results, you 14 days of your hire date if you are a new You may earn only one $50 reward per will be offered wellness opportunities to year for this element. It may take 6 – 8 employee, or within 31 days of becoming optimize your health and well-being. benefits-eligible, a 75$ reward will be weeks for your reward notification to arrive. If you had lab tests done at the mailed to your home after you select your There are two ways to earn this $50 same time as your preventive/wellness reward online. To complete the Health reward: Assessment go to www.MyTHR.org and exam, they are billed separately and your •• If at least two of the following Be select the Be Healthy link in the upper left rewards may arrive at separate times. Healthy Basics are within the healthy corner. range, you earn the $50 reward: –– Your total cholesterol is less than 200 mg/dl –– Your blood pressure is 130/80 or lower –– Your body mass index (BMI) is 25 or lower.

54 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Wellness Program

Preventive/Wellness Exam Because of administrative limitations, HOW A HEALTH ADVOCATE CAN only those enrolled in the Total Health HELP Getting regular check-ups is important Medical Plan are eligible to earn a Coping with health concerns can be for everyone—even if you are in good reward for a preventive/wellness exam. health. By getting a preventive/wellness time-consuming and complex. When you At this time, the administrator of the Be call, a Health Advocate can help you: exam, your doctor may be able to Healthy incentive program is not able identify your risk for future medical to receive information about physical •• Choose appropriate medical care problems, screen for diseases, encourage exams from any other medical plan. –– Understand a wide range of a healthy lifestyle, and update your symptoms vaccinations. Plus, it is important to have After your doctor files a claim for your –– Determine if the emergency room, a relationship with a doctor in the event exam and it is processed, a reward a doctor visit or self-care is right for of an illness in the future. notification will be mailed to your your needs home. It may take 6 – 8 weeks for it to •• Find a doctor or hospital To get the most from your exam, write arrive. If you had lab tests done at the –– Find doctors or hospitals that meet down important information to tell your same time as your preventive/wellness your needs and preferences doctor—like your personal and family exam, they are billed separately and –– Locate an urgent care center and medical history, symptoms you have your reward notifications may arrive at other health resources now and medicines you take. Even non- separate times. You may earn only one prescription and herbal remedies are $100 reward per year for the preventive/ •• Understand treatment options important for your doctor to know about. wellness exam. –– Learn more about a diagnosis Bring a pen and paper to make notes –– Explore the risks, benefits and while you talk to your doctor. Be sure you select a doctor who is possible outcomes of your part of the UHC Choice or Choice Plus treatment options It is important that your doctor’s office network and that they use one of the •• Achieve a healthy lifestyle codes your visit as a wellness exam and codes listed in the table. not a routine office visit so you will be –– Get tips on how nutrition and able to receive this reward. Health Advocacy exercise can help you maintain a healthy weight

This exam may be performed by your With so many health care choices and –– Learn about important health & Wellness Medical primary care physician or women so much information from many sources, screenings and immunizations can get a well-woman exam with their it can be hard to know where to look for •• Ask medication questions gynecologist. Be sure to take your Be trusted information and support. Health –– Explore how to save money on Healthy Basics with you and tell your Advocacy services were developed to prescriptions doctor about the Be Healthy wellness give you peace of mind. Texas Health –– Learn how to take medication safely programs available to you. employees have access to a team of and avoid interactions. specially trained individuals who help Based on the results of your preventive/ you navigate the health care system and wellness exam, your doctor may give you a trusted source for health care recommend that you participate in one information and support 24 hours a day. of them. ELIGIBILITY If you are enrolled in a Total Health Medical Plan, you will receive a $100 All employees and their eligible family reward for getting a preventive/wellness members are eligible to use the Health exam anytime during 2013. Spouses Advocacy Services. enrolled in the Total Health Medical Plan HOW TO PARTICIPATE are eligible to earn a $25 reward. Your completion of the wellness exam will be To speak to a Health Advocate, call automatically reported so you receive 1-877-MyTHRLink (1-877-698-4754) and the reward. select prompt 2.

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Maternity Support Program For more information or to enroll, call With your Health Coach, you evaluate 1-877-MyTHRLink (1-877-698-4754), select your lifestyle, identify opportunities for If you are pregnant or thinking about prompt 2 between 8 a.m. and improvement, and get support in making becoming pregnant and you are 5 p.m. Monday through Friday, or log on any changes you choose. enrolled in the Total Health Medical to www.myuhc.com for more details. Plan, you can get valuable educational The Health Coach Program includes information, advice, and comprehensive Cancer Support Nurse powerful online tools, educational case management by enrolling in the materials, and activities to help you Maternity Support Program. If you have been diagnosed with cancer change behavior. You may speak with a and you are enrolled in the Total Health Health Coach by phone or participate The program is designed to enhance medical plan, you can be assisted by online. The Health Coach can help you your pregnancy experience by assigning an experienced cancer nurse who is create a plan to change your behavior, a dedicated OB nurse to help you better dedicated to Texas Health employees. support you along the way, and help you understand your pregnancy. Your OB The nurse is available to help you and/or revise your strategy as your individual nurse will provide clinical and practical your dependents during active treatment needs change. advice and answer your questions for all forms of cancer. throughout your pregnancy. The Health Coach program by phone The cancer nurse focuses on patients consists of at least three calls with a To take full advantage of the program, at high risk of complications and side Health Coach. To enroll, call you are encouraged to enroll within the effects. The nurse will collaborate with 1-877-MyTHRLink (1-877-698-4754), first trimester of pregnancy. If you enroll your treating physicians to fill gaps in prompt 2. in the Maternity Support Program by your knowledge of the cancer you have. your 16th week and actively participate He or she works to prevent avoidable For some health conditions, you can through the 12th week after your baby is complications and side effects to keep also complete the program online. Each born, you will receive a $100 reward. you out of the hospital and emergency online module contains five levels and room. The nurse will also educate and each level takes a minimum of one week There is no cost to enroll in the program. empower you to actively participate in to complete. Some of the services include: your own treatment and recovery. And

Medical & Wellness Medical Examples of a Health Coach: •• Pre-conception health coaching in the case of terminal cancer, the nurse •• Toll-free information lines staffed by increases your awareness and choice of •• An online module that can help with experienced OB nurses palliative care and hospice services, when nutrition and fitness, meal planning, •• Your choice of a book: What to Expect appropriate. To reach the cancer nurse, and exercise planning When You’re Expecting, What to Expect call 1-877-MyTHRLink (1-877-698-4754) •• A personal Health Coach who can the First Year, or Baby Play and Learn and select prompt 2. provide support by phone during •• Printed and online educational weight loss and after you meet your resources covering a wide range of Health Coaches goals topics •• Referrals to specialists when being Start making wellness part of your •• First and second trimester risk overweight may be a risk factor for everyday life. Start by taking a good screenings other health problems. look at what you’re doing today, decide •• Identification and management of whether to make any changes, set goals This program is administered by at-risk or high-risk conditions that may and decide how to meet your goals. UnitedHealthcare and is available to all affect pregnancy benefits-eligible employees and their •• Pre-delivery consultation A Health Coach helps you develop a eligible dependents. •• Coordination with and referrals to personal wellness strategy. After you’ve other benefits and programs available completed the 2013 Health Assessment, To enroll, go to www.MyTHR.org and under the medical plan you will get a Personal Results report. click on the Be Healthy link in the upper •• Support after your baby is born, left corner, then click on the appropriate This is an online personalized health including a phone call from a nurse program under “I Do.” profile that reviews your lifestyle approximately two weeks after your practices and identifies health issues baby is born to answer your questions ALTERNATIVE TO BE HEALTHY that could be affected by your personal and give you information about BASICS choices. Because it’s an individualized newborn care, feeding, immunizations report, your strategy won’t be exactly like You may complete a Health Coaching and more anyone else’s. program by phone as an alternative to the •• Screening for postpartum depression. Be Healthy Basics. Your participation will be automatically reported to satisfy this Be Healthy Basics alternative.

56 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Wellness Program

Diabetes Management Tobacco Cessation –– Pharmacy co-pays apply to Program purchasing Chantix if you are Texas Health has retained Alere, a enrolled in the Total Health Texas Health offers a program that company specializing in tobacco medical plan – for those not in includes diabetes education and support. cessation for over 20 years, to provide the medical plan, there is a 40 Diabetes education for adults or children you with resources to help you stop percent copay. Chantix is available (not available at all locations) is covered using tobacco. This program is available with a prescription at any Caremark under the Medical Plan after a $10 copay at no charge to help all employees pharmacy (for those enrolled in the at a Preferred Hospital or UHC provider. (including PRNs) and their eligible Total Health medical plan) or through Coverage includes either individual or family members. Texas Health Dallas Apothecary, Texas group education sessions with a certified Health Dallas Prescription Shop and The Quit for Life™ program provides: diabetes educator. A physician’s referral Texas Health Plano Medicine Chest is required. •• An in-depth assessment with a (for those not enrolled in the Total personal Quit Coach™ including Health Medical Plan). Benefits-eligible employees and eligible five outbound calls. Coaches can dependents enrolled in the medical plan be called for extra support as many Now is the best time to take the first are eligible to earn free test strips for times as needed, any day of the week. step toward quitting. This free program self-monitoring of your blood glucose Your Quit Coach helps you create is available to all employees and their when you visit with a Texas Health a personal quitting plan that may eligible family members. Your chances diabetes educator at least quarterly. include treatments to help you with of quitting are six times better with the The prescription drug plan covers oral withdrawal. Quit For Life Program than trying to quit medications, insulin, syringes, blood •• Personalized Quit Guides with helpful on your own. glucose monitors, test strips, lancets, tips and information and chemical strips. You can receive a To participate in the Quit for Life •• Nicotine Replacement Therapy (NRT) free glucose monitor. The Medical Plan Program, call 1-877-MyTHRLink •• Participants can access one eight- covers durable medical equipment (1-877-698-4754) and choose option 4, week shipment of one type of NRT including insulin pumps, supplies for then press 2 or go online to (patch, gum or lozenges) through your pump (infusion sets, cartridges, www.MyTHR.org and click on the enrollment in Quit for Life. & Wellness Medical batteries, and medical tape), and Alere link. glucagon emergency kits, when ordered •• Prescription medication bupropion is by your physician. available at any Caremark pharmacy (for those enrolled in the Total Health medical plan) or through Texas Health Medical Nutrition Therapy Dallas Apothecary, Texas Health Dallas Members in the Total Health medical Prescription Shop and Texas Health plan with a BMI greater than 28 are Plano Medicine Chest (regardless eligible for the Medical Nutrition of whether you are enrolled in the Therapy program which provides one Total Health medical plan). Copays initial assessment and up to three are waived for this medication if the 30-minute therapy sessions per year at participant is enrolled in Quit for Life. no cost to you. To be covered, you need •• Prescription medication Chantix™ a physician referral and the therapy must is covered for participants enrolled be provided by a Texas Health clinical in Alere Tobacco Cessation program dietitian. if recommended by the Quit Coach. Chantix is a prescription medicine A registered dietitian will customize used to help adults quit smoking. a healthy eating plan that meets your Chantix contains no nicotine and specific health and wellness needs. You helps reduce the urge to smoke. can make an appointment for: •• A personal lifestyle assessment •• Personalized meal planning •• Behavior modification counseling to work on your personal challenges such as emotional eating, skipping TO ENROLL or find out about any meals, portion management, and of these programs, go to listening to hunger/fullness cues. www.MyTHR.org or MyTexasHealth.

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Weight Watchers® PARTICIPATION REQUIREMENTS WEIGHT WATCHERS ONLINE AND COST SUBSCRIPTION Texas Health offers the following Weight Watchers programs to all employees: Texas Health will pay for your With an online subscription you can follow the Weight Watchers plan step- •• Weight Watchers at Work participation in Weight Watchers, as follows: by-step online. It provides interactive meetings: A Weight Watchers leader tools and resources like a weight tracker, comes to your workplace to provide •• Weight Watchers at Work: Texas progress charts, restaurant guides and experienced guidance at weekly Health pays 100% of the membership much more. It is available in versions meetings that fit your busy work fees if you attend at least 10 meetings specifically designed for men and schedule. You benefit from the proven in a 3-month period. If you do not women with tailored content that speaks advantage of group support from attend at least 10 meetings in a directly to each audience. To sign up, call your coworkers. A meeting must have 3-month period, you will be required 1-877-MyTHRLink (1-877-698-4754), press at least 15 Texas Health employees to pay the entire membership fee prompt 4, then option 1. enrolled. through payroll deduction. If you miss •• Weight Watchers community an at-work meeting, you can make it Fitness Memberships meeting monthly pass: If you are up by going to a community meeting not able to attend a meeting at work, or another entity’s at-work meeting Discounted fitness memberships are you may receive a monthly pass, within the same week. available for benefits-eligible employees which offers the flexibility of attending •• Weight Watchers community and their dependents. Weight Watchers meetings in your meeting monthly pass: Texas Health •• Texas Health Fort Worth, Texas community. will pay 50% of the fees if you attend Health Dallas, Texas Health Arlington •• Weight Watchers online at least 10 meetings in a 3-month Memorial, Texas Health Burleson, subscription: Weight Watchers period. You pay your half directly by Texas Health Denton and Texas Health online is available for employees who credit card. Hurst-Euless-Bedford have convenient are not able to participate in Weight •• Weight Watchers online: Texas on-site fitness centers. Watchers at-Work or Weight Watchers Health will contribute 50% for a •• Global Fit, a fitness center provider, community meetings. Follow Weight Weight Watchers 3-month online will help you find a fitness center near Medical & Wellness Medical Watchers online with interactive tools membership. You pay your half by you at rates lower than retail. Visit and resources like the WeightTracker, credit card. www.globalfit.com/thrtotalhealth progress charts, restaurant guides, and or call 1-(800) 294-1500. hundreds of recipes, tips and meal HOW TO PARTICIPATE •• As a benefits-eligible employee, you ideas. Find out how to enroll for Weight can join the Cooper Aerobics Center ELIGIBILITY Watchers by searching for “Weight at Craig Ranch for $50 per month (a Watchers” on MyTexasHealth. $20 discount). You pay an additional All benefits-eligible employees are cost for family members. eligible for Weight Watchers at-Work, the ALTERNATIVE TO BE HEALTHY community meeting program, or Weight BASICS Watchers online. Your membership is You may attend Weight Watchers as non-transferable. PRN employees may an alternative to Be Healthy Basics. participate in these Weight Watchers To receive credit, you must enroll and options, but must pay for the entire attend at least 10 meetings in a 3-month program. period before December 31, 2013. To satisfy this Be Healthy Basics alternative, your participation will be automatically reported.

58 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Wellness Program

Cancer Screenings You may want to ask your doctor: If you believe you have symptoms related to cancer or you have an It is important to have regular screening •• Do you recommend that I have any cancer screenings? unexplained change in the way you feel, exams that can detect cancer or you should see your doctor right away. conditions that could lead to cancer. •• What will the screening exam feel Screening exams can help doctors like? While other cancer screenings are find and treat some types of cancer •• What are the risks of this exam? covered health services under the Total early—when they are often more easily •• How and when will I know the results? Health Medical Plan, only the screenings treated. For people who do not have any •• What would be the next step? in the table below are eligible for a specific symptoms and who are not in reward. You can earn a $25 reward for any high-risk group for a certain type of People who are at increased risk for each one you complete, limited to one cancer, the table on this page lists the certain types of cancer may need to be reward per screening per year. recommended cancer screenings. screened earlier or more often.

AGE APPROPRIATE CANCER SCREENINGS

Type of You pay cancer and Recommended under the screening Recommended follow-up Total Health exam Description first exam exams Medical Plan Colorectal This type of cancer can be successfully treated when Men and women Every 10 years Covered at cancer— detected early. It involves cancer cells that grow in starting at age 100% one time colonoscopy the colon, rectum, or both. According to the American 50 per year2 Cancer Society, 90% of cases are in people over age 50. Breast This type of cancer is the second leading cause of Women starting Every year Covered at 1 cancer— death among American women. But most women who at age 40 100% one time & Wellness Medical mammogram are diagnosed at an early stage survive and continue to per year2 live normal lives. Prostate One out of every six men get this type of cancer. It Men starting at Every year Covered at cancer— usually begins as a tumor in the prostate gland, but age 50 100% one time prostate exam it can spread. It is the second most common type of per year2 or PSA test cancer among American men.

1 While some health organizations are recommending other time frames for getting mammograms, the National Cancer Institute, American Cancer Society, and BreastCancer.org still recommend getting regular mammograms beginning at age 40 or based on the individual woman's breast cancer risk profile.

2 One well exam per year is covered in full if the claims administrator determines the physical is for preventive care. Additional screenings or services will be considered diagnostic services and will be covered after you pay the applicable copay or deductible and coinsurance. At the time of your preventive care visit, if other services are performed that are not preventive services, as determined by the claims administrator, they will not be paid at 100% even if they are submitted as part of a claim for preventive care. Some items now require you to pay the appropriate copay or coinsurance, including electrocardiograms (EKGs), focused office visits, thyroid scans, breast MRI, vitamin D assays, and transvaginal ultrasounds.

YOUR PRIVACY Is Protected

IT IS important for you to know that an independent company manages Be Healthy and provides summary reports to Texas Health. Texas Health uses this data to make decisions about what benefit programs we will offer to employees.

TEXAS HEALTH uses independent companies to operate Be Healthy and provide Health Coaching. These companies include OptumHealth, MHN EAP, Caremark Pharmacy, Alere Quit for Life™ tobacco cessation program, and UnitedHealthcare. They must take the necessary steps to protect your information and give you appropriate information and education.

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Employee Assistance CLINICAL SUPPORT Convenient and confidential solutions and support are available at no Program (EAP) Call the EAP to get help with emotional charge, 24 hours a day, seven days issues. An intake specialist will listen to OVERVIEW a week. Contact the EAP by dialing your needs and refer you to a licensed 1-877-MyTHRLink (1-877-698-4754) To help you manage life's challenges, professional who can help. The EAP is prompt 4, then 4 again. Texas Health offers the Employee available around the clock to help with: Assistance Program (EAP), administered •• Marriage, relationship and family WORK AND LIFE SERVICES by MHN. It includes free, unlimited issues phone and Internet access to counselors Your EAP also features services to help and information to help you resolve •• Problems in the workplace you make the best of life’s chores and personal issues. You can also receive up •• Domestic violence challenges. Online and telephonic to six face-to-face counseling sessions •• Alcohol and drug dependency guidance or referrals are available to per issue per year. •• Stress, anxiety and sadness help with childcare and eldercare, •• Changes in mood financial services, legal services, identity This program is available to all theft, daily living services and more. See •• Grief and loss employees (including non-benefits- a more complete list in the box below. • eligible) and their eligible dependents. • Response to traumatic events. Availability lasts during an employee's EAP WEBSITE Clinical support comes in three ways: tenure with Texas Health and for 12 MHN’s website has tools to help you •• Face-to-face counseling weeks after employment with Texas take charge of your wellbeing. You can Health ends. •• Telephonic consultations ask our expert an emotional health •• Web-video consultations question, make a change with self-help Face-to-face counseling is provided by programs, take advantage of interactive a professional (a marriage and family e-learning programs, access childcare therapist or psychologist, for example) and eldercare directories, and find from MHN’s network. You can get a articles and videos on emotional health, referral when you call or search for a physical health and making healthy Medical & Wellness Medical provider at www.members.mhn.com. choices. Visit www.members.mhn.com (enter company code “thr”). and enter the company code “thr” to access the site.

EXAMPLES OF WORK AND LIFE SERVICES YOUR EAP CAN HELP WITH

•• Legal services – Talk to a •• Identity theft recovery •• Financial services – Talk •• Daily living services – professional over the phone services – Get information to an advisor over the Need help with household or face-to-face about: on ID theft prevention, phone about: repairs? Planning an event –– Civil, consumer and plus an ID theft emergency –– Budgeting or a vacation? MHN will criminal law (medical response kit. If your identity –– Credit and financial track down businesses and malpractice cases and is stolen, a fraud resolution questions (investment consultants for you. (MHN disputes or actions specialist can help. advice, loans and bill does not cover the cost between members •• Childcare and payments not included) nor guarantee delivery of and their employers or eldercare assistance – A –– Retirement planning vendors’ services.) between members and representative will give you –– Tax issues MHN are excluded) names and numbers of –– Personal and family providers who can help you law, including adoption, care for children or elders divorce and custody in your life. issues –– Financial matters –– Business law –– Real estate –– Estate planning

60 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Dental & Vision Dental Plan...... 62 Overview 62 Who Can Be Covered 62 Aetna DMO® 62 Aetna PPO (Low Option) 62 What the PPO (Low Option) Covers 64 Participating Dental Network (PDN) (High Option) 66 What the PDN (High Option) Covers 68 Excluded Expenses 70 Filing and Appealing Dental Claims 71 When Coverage Ends 73 Vision Plan...... 74 Overview 74 Who Can Be Covered 74 Summary of Benefits 74 Network Providers 75 Covered In-network Expenses 75 Exclusions 75 Coordination of Benefits 76 Filing Claims 76 When Coverage Ends 77 Dental & Vision Dental

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 61 Dental Plan Dental Plan Overview Who Can Be Covered For more information on the managed dental plan, consult the schedule of Texas Health offers you a choice in As a full-time or part-time benefits- benefits available onMyTexasHealth . dental coverage so you may select eligible employee or as a COBRA the option that best meets your needs. participant, you may elect the following You have three dental options: one is a levels of coverage under the Texas Aetna PPO/PDN Max managed dental plan that pays benefits Health Dental Plan: (Low Option) only when you use network providers, •• You only Aetna Preferred Provider Organization and the other two are preferred dental •• You and your spouse offers a network similar to a medical networks that pay benefits both in- •• You and your unmarried dependent PPO that allows you to use either network and out-of-network. All dental children up to age 25, regardless of network or out-of-network providers. options cover preventive care, basic care, student status However, you receive greater benefits major care, and orthodontia. when you use network providers. •• You and your family. Your dental plan choices are: See pages 5 – 7 for more information on If you choose the PPO (Low Option), •• Aetna Dental Maintenance eligibility. which uses the Aetna network, you Organization (DMO®) don’t have to satisfy a deductible for •• Aetna Preferred Provider Organization Aetna DMO® preventive care, but you must satisfy Max (PPO) Low Option the deductible before the plan pays The Aetna DMO® provides dental •• Participating Dental Network (PDN) for other kinds of care. Dental network services through a network of dentists High Option. providers agree to charge discounted very similar to a medical HMO. To receive rates for their services. The managed dental plan, Aetna DMO® benefits, you must use a network dentist. is a fully insured plan underwritten by Although coverage is the same for Under this plan, you pay no deductibles Aetna Dental, Inc. It offers a network of network and out-of-network care, and most expenses for diagnostic and dentists and providers to help you save out-of-network providers may charge preventive care are fully paid by the on the cost of your dental care. higher fees than network providers, plan. For other dental expenses, you resulting in higher out-of-pocket The Aetna PPO (PPO) and the pay copays according to the plan’s expenses for you. You must file claims Participating Dental Network (PDN) schedule. The copays vary depending when using an out-of-network provider plans use the Aetna network and are on the services. For a detailed listing to receive benefits under the PPO. fully insured plans underwritten by of covered services and copays, go to Members may be responsible for the Aetna Life Insurance Company. These MyTexasHealth. COBRA participants can difference between Aetna's negotiated call 682-236-7236.

Dental & Vision Dental plans allow you to decide whether to fees and the out-of-network dentist's actual use network or out-of-network providers charge. When you enroll in the managed dental whenever you need dental care. They are plan, you (and each enrolled family described in more detail in this section. Advantages of the PPO include: member) select a network dentist •• Choice of using network or out-of- located in the state of Texas from the Aetna is the brand name used for network providers products and services provided by provider directory. Except for emergency •• Discounted services when you use one or more of the Aetna group of treatment outside the service area, you network providers companies. In case of a discrepancy must use the dentist you have selected •• 80% coverage for preventive services between this summary plan description to receive dental benefits. whether you use network or out-of- and the group insurance contracts Advantages of the managed dental plan network providers. issued by Aetna Dental Inc., or in case of include: any legal action, the terms of the group insurance contracts will prevail. •• No claims to file •• No annual deductible to meet For more detailed information on the •• Orthodontia coverage for children Aetna plans, refer to the schedule of and adults benefits available onMyTexasHealth . •• Ability to change dentists during the year •• No annual maximum benefit limits for most services.

62 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Dental Plan

PPO PLAN FEATURES –– The most appropriate supply SUMMARY OF BENEFITS or level of service that can be Dental coverage under the PPO is The table below briefly summarizes provided on a cost-effective basis. subject to the following features: how the PPO (Low Option) covers The fact that your network dentist dental expenses and shows what the •• Alternative treatment—If you prescribes services or supplies does undergo a more expensive treatment plan pays for your care. not automatically mean they are or procedure when a less expensive necessary and covered by the plan. alternative was available, the plan PPO •• Out-of-network—You receive the may pay benefits based on the (Low Option) lower level of benefits if you use a less expensive procedure that is Network or provider who is not a member of the consistent with good dental care. Out-of- PPO. Plan Feature network* •• Annual benefit maximum—The plan •• Predetermination of benefits—You pays a maximum benefit of $1,000 Deductible $50 per person should request a predetermination of $150 per family per covered person per year. benefits if your dentist recommends Preventive care 80% after •• Coordination of benefits—If you or a treatment expected to cost $350 or (Two visits per year) deductible a covered dependent has coverage more to find out how the plan may ••Routine checkups under any other group dental plan, cover the procedure before receiving ••X-rays this plan will coordinate benefits with treatment. Your dentist completes ••Cleaning and the other plan. a form listing the recommended polishing •• Deductible—You must meet the dental services and showing the ••Space maintainers individual or family deductible charge for each service. The claims before the plan pays benefits for administrator reviews the form and Basic care 60% after deductible non-preventive care. The annual informs the dentist of your estimated ••Fillings deductible for Basic and Major Care benefits. The dentist may be asked ••Extractions is $50 per person or $150 per family. to provide supporting X-rays or ••Anterior/bicuspid Only covered expenses for which no other diagnostic records before root canal therapy benefits are payable can be counted predetermination is made. toward the deductible. ••Oral surgery •• Reimbursement—The plan will •• Fee limit—The amount of benefits Major care 40% after deduct your coinsurance amount deductible paid for eligible expenses is based on from the total amount of your ••Bridges the contracted fee limit for a service reimbursement. ••Dentures or item provided by participating ••Crowns providers in the zip code area where ••Molar root canal the service is provided. therapy •• In-network—A group of dental ••Inlays and onlays providers in the PPO has agreed to Maximum annual $1,000 per benefit person

charge negotiated rates for services & Vision Dental and items. Orthodontic care 50% with no (For eligible adults deductible •• Necessary services and supplies— and dependent $1,000 lifetime Only dental services that are children) maximum necessary are covered by the plan. Cosmetic services are not covered, * You will have higher out-of-pocket expenses when except to repair accidental injuries you use out-of-network providers. not covered by the Total Health Medical Plan. The service must be: –– For the diagnosis or direct treatment of a dental injury or illness –– Appropriate and consistent with the symptoms and findings or diagnosis and the treatment of the covered person’s injury or illness –– Provided in accordance with generally accepted dental practice on a national basis

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What the PPO BASIC SERVICES •• Sequestrectomy for osteomyelitis or bone abscess, superficial (Low Option) Covers Basic services are covered at 60% after you meet the deductible and include •• Condylectomy of temporomandibular To be covered by a dental plan, a the following: joint dental expense must be necessary •• Meniscectomy of temporomandibular and provided by a duly qualified and Visits and Exams joint licensed dentist. Charges for covered •• Radical resection of mandible with items must be within the usual and •• Professional visit after hours bone graft customary fee limits. (payment will be made on the basis of services rendered or visit, •• Crown exposure to aid eruption PREVENTIVE SERVICES whichever is greater) •• Removal of foreign body from soft Preventive services are covered at 80% •• Emergency palliative treatment tissue and include the following: •• Frenectomy X-ray and Pathology •• Suture of soft tissue injury •• Office visits during regular office •• Single films (up to 13) hours, for oral examination (limited •• Injection of sclerosing agent into to two visits per year) •• Intra-oral, occlusal view, maxillary or temporomandibular joint mandibular •• Prophylaxis (cleaning) limited to two •• Treatment of trigeminal neuralgia treatments per year •• Upper or lower jaw, extra-oral by injection into second and third divisions •• Topical application of fluoride •• Biopsy and histopathologic examination of oral tissue (limited to one course of treatment Periodontics per year for children under age 16) Oral Surgery •• Emergency treatment (periodontal •• Bitewing X-rays (limited to once per abscess, acute periodontitis, etc.) year) •• Local anesthetics and routine •• Root planing and scaling, per •• Complete X-ray series or panoramic postoperative care quadrant (not prophylaxis), limited film including bitewings, if necessary •• Uncomplicated extractions to four separate quadrants every two (limited to once every three years) •• Uncomplicated surgical removal of years •• Vertical bitewing X-rays (limited to an erupted tooth •• Correction of occlusion related to one set every three years) •• Postoperative visit (sutures and complications) after multiple periodontal surgery—occlusal guards, Space Maintainers extractions and impaction one every three years •• Gingivectomy (including post-surgical •• No age limit (covered only for •• Surgical removal of impacted tooth visits) one per quadrant per site every premature loss of primary teeth) (soft tissue) three years •• Includes all adjustments within six •• Alveolectomy (edentulous) •• Gingivectomy, treatment per tooth months after installation •• Alveolectomy (in addition to removal (less than four teeth per quad) •• Fixed space maintainer (band type) of teeth) •• Post-surgical visits •• Alveoplasty with ridge extension

Dental & Vision Dental •• Removable acrylic with round wire rest only •• Removal of exostosis •• Removable inhibiting appliance to •• Excision of hyperplastic tissue correct thumb sucking •• Excision of pericoronal gingiva •• Fixed or cemented inhibiting •• Incision and drainage of abscess appliance to correct thumb sucking •• Removal of odontogenic cyst or tumor •• Sialolithotomy (removal of salivary calculus) •• Closure of salivary fistula •• Dilation of salivary duct •• Transplantation of tooth or tooth bud •• Removal of foreign body from bone (independent procedure) •• Maxillary sinusotomy for removal of tooth fragment or foreign body •• Closure of oral fistula of maxillary sinus

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Endodontics MAJOR SERVICES •• Dentures and partials—fees for dentures, partial dentures and relining •• Pulp capping Major services are covered at 40% after include adjustments within six •• Therapeutic pulpotomy (in addition you meet the deductible and include months after installation; specialized to restoration) the following: techniques and characterizations are •• Vital pulpotomy Restorative not eligible •• Remineralization (calcium hydroxide, –– Complete upper denture temporary restoration) as a separate •• Gold restorations and crowns— –– Complete lower denture procedure only covered only as treatment for decay –– Partial acrylic upper or lower with •• Root canals (devitalized teeth or traumatic injury and only when chrome cobalt alloy clasps, base, all only, other than molar root canal teeth cannot be restored with a filling teeth and two clasps therapy), including necessary X-rays material or when the tooth is an –– Additional clasps and cultures but excluding final abutment to a fixed bridge restoration •• Inlays and onlays (one or more –– Partial lower or upper with chrome cobalt alloy lingual or palatal bar •• Canal therapy (traditional or sargenti surfaces) and acrylic saddles, base, all teeth method), includes single rooted or •• Crowns and two clasps plus additional bi-rooted –– Acrylic clasps •• Local anesthetics when necessary –– Acrylic with gold –– Simple stress breakers, extra –– Acrylic with non-precious metal Restorative Dentistry –– Stayplate, base and additional –– Porcelain clasps •• Excludes inlays, crowns (other than –– Porcelain with gold –– Office reline, cold cure, acrylic stainless steel) and bridges –– Porcelain with non-precious metal –– Laboratory reline •• Multiple restorations in one surface –– Non-precious metal (full cast) –– Special tissue conditioning, per will be considered as a single –– Gold (full cast) restoration denture –– Gold (3⁄4 cast) •• Restorations (involving one, two or –– Denture duplication (jump case), –– Gold dowel pin three or more surfaces), includes per denture •• Adding teeth to partial denture to amalgam, silicate cement, plastic, and –– Adjustment to denture more than replace extracted natural teeth— composite fillings six months after installation teeth and clasps •• Pins (retention) when part of the •• Repairs to crowns and bridges Oral Surgery restoration used instead of gold or crown restoration •• General anesthesia, only when Prosthodontics •• Stainless steel crowns (when tooth provided in conjunction with a cannot be restored with a filling •• Bridge Abutments (See Inlays and surgical procedure material) Crowns above) Periodontics •• Recementation of inlay, crown, or •• Pontics bridge –– Cast Gold (sanitary) •• Osseous surgery (including flap & Vision Dental •• Full and partial denture repairs –– Cast non-precious metal entry and closure)—modifies the bony support of teeth by reshaping –– Broken dentures, no teeth involved –– Slotted facing the alveolar process to achieve a –– Partial denture repairs (metal) –– Slotted pontic more physiologic form. May include –– Porcelain fused to gold –– Replacing missing or broken teeth. removal of supporting bone or non- –– Porcelain fused to non-precious supporting bone and limited to one metal per quadrant every three years. –– Plastic processed to gold –– Plastic processed to non-precious Endodontics metal •• Molar root canal therapy. •• Removable Bridge (unilateral)—one piece casting, chrome cobalt alloy clasp attachment (all types) including pontics

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ORTHODONTIA EXPENSES Covered Orthodontia Expenses Participating Dental The PPO (Low Option) covers 50% The PPO (Low Option) will cover Network (PDN) of eligible orthodontia expenses expenses for orthodontia treatment, (High Option) for eligible adults and dependent up to the lifetime maximum, for the A PDN is similar to a medical PPO in children. The plan covers only the following charges: that you may use either network or orthodontic services and treatments out-of-network providers. However, you described below. The lifetime maximum •• Services or supplies furnished in receive greater benefits when you use orthodontia benefit is $1,000. connection with an orthodontic procedure and before the end of network providers. The PPO (Low Option) will not cover the estimated duration shown in the If you choose the PDN (High Option) expenses for orthodontia treatment orthodontic treatment plan (which uses the Aetna network) you begun or appliances installed before •• Active appliances inserted while you don’t have to satisfy a deductible for you or your eligible dependent became or your dependent is covered by the preventive care, but you must satisfy covered by the Total Health Dental Plan. PPO (Low Option) the deductible before the plan pays •• Orthodontic procedures needed to Orthodontic Treatment Plan for other kinds of care. Dental network correct one of these conditions: providers agree to charge discounted The plan defines orthodontic treatment –– Vertical or horizontal overlap rates for their services. as the use of active appliances to of upper teeth over lower teeth move teeth to correct faulty position of (overbite or overjet) Although coverage is the same for teeth (malposition) or abnormal bite –– Faulty alignment (either frontwards network and out-of-network care, (malocclusion). or backwards) of the upper and out-of-network providers may charge lower arches with each other higher fees than network providers, Before beginning treatment, the dentist resulting in higher out-of-pocket must submit a treatment plan to the –– Cross-bite expenses for you. When you use an claims administrator that: •• Services or supplies as part of an orthodontic treatment plan that, out-of-network provider, you must file •• States the class of malocclusion or before the procedure is performed, claims to receive benefits under the malposition have been: PDN. •• Recommends and describes the –– Sent to the claims administrator for required orthodontic treatment Out-of-network payments are based review on Reasonable & Customary charges •• Estimates the duration of the –– Returned by the claims using the 80th percentile of the FAIR treatment administrator to the dentist Health Benchmark database profile. •• Estimates the total cost for the showing estimated benefits. The database consists of provider treatment charge data collected from more than •• Includes cephalometric X-rays, 150 major contributors, including study models, and any other commercial insurance companies and supporting evidence that the claims third-party administrators. Members Dental & Vision Dental administrator may reasonably require. may be responsible for the difference between the R&C amount and the out- The plan will return an estimate of of-network dentist’s actual charge. your orthodontic benefits to the dentist. After your treatment plan Advantages of the PDN include: is approved, you begin paying your portion of orthodontia expenses in •• Choice of using network or out-of- equal installments over the duration network providers of treatment. The PPO (Low Option) •• Discounted services when you use pays expenses in equal quarterly network providers installments, beginning with the end of •• 100% coverage for preventive services the three-month period following the whether you use network or out-of- date the appliances are first inserted. network providers.

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PDN PLAN FEATURES The fact that your network dentist SUMMARY OF BENEFITS prescribes services or supplies does Dental coverage under the PDN is The table below briefly summarizes not automatically mean they are subject to the following features: how the PDN (High Option) covers necessary and covered by the plan. dental expenses and shows what the •• Alternative treatment—If you •• Out-of-network—You receive the plan pays for your care. undergo a more expensive treatment lower level of benefits if you use a or procedure when a less expensive provider who is not a member of the PDN (High alternative was available, the plan PDN. may pay benefits based on the Option) •• Predetermination of benefits—You less expensive procedure that is Network should request a predetermination of consistent with good dental care. or Out-of- benefits if your dentist recommends Plan Feature network* •• Annual benefit maximum—The plan a treatment expected to cost $350 or pays a maximum benefit of $1,500 Deductible $50 per person more to find out how the plan may $150 per family per covered person per year. cover the procedure before receiving Preventive care No cost to the •• Bitewing X-rays (limited to once per treatment. Your dentist completes (Two visits per employee. Plan year) a form listing the recommended year) pays 100% with •• Coordination of benefits—If you or dental services and showing the ••Routine no deductible. a covered dependent has coverage charge for each service. The claims checkups under any other group dental plan, administrator reviews the form and ••X-rays this plan will coordinate benefits with informs the dentist of your estimated ••Cleaning and polishing the other plan. benefits. The dentist may be asked ••Space •• Deductible—You must meet the to provide supporting X-rays or maintainers individual or family deductible other diagnostic records before Basic care 80% after before the plan pays benefits for predetermination is made. ••Fillings deductible non-preventive care. The annual •• Reimbursement—The plan will ••Extractions deductible for Basic and Major Care deduct your coinsurance amount is $50 per person or $150 per family. ••Anterior/ from the total amount of your bicuspid root Only covered expenses for which no reimbursement. canal therapy benefits are payable can be counted •• Usual and customary fee limit—The ••Oral surgery toward the deductible. amount of benefits paid for eligible Major care 50% after •• In-network—A group of dental expenses is based on the usual and ••Bridges deductible providers in the PDN has agreed to customary fee limit for a service or ••Dentures charge negotiated rates for services item in the geographic area where ••Crowns and items. you reside. The usual fee is the fee ••Molar root canal •• Necessary services and supplies— most frequently charged or accepted therapy Only dental services that are for covered expenses for dental care ••Inlays and

necessary are covered by the plan. or supplies by a physician or hospital. onlays & Vision Dental Cosmetic services are not covered, The customary fee is the fee charged Maximum annual $1,500 per person except to repair accidental injuries or accepted for covered dental care benefit not covered by the Total Health or supplies by those of a similar Orthodontic care 50% with no Medical Plan. The service must be: professional standing in the same (For eligible adults deductible $1,250 geographic area, as determined by and dependent lifetime maximum –– For the diagnosis or direct children) treatment of a dental injury or Aetna. illness * You will have higher out-of-pocket expenses when –– Appropriate and consistent with you use out-of-network providers. the symptoms and findings or diagnosis and the treatment of the covered person’s injury or illness –– Provided in accordance with generally accepted dental practice on a national basis –– The most appropriate supply or level of service which can be provided on a cost-effective basis

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What the PDN BASIC SERVICES •• Condylectomy of temporomandibular joint (High Option) Covers Basic services are covered at 80% after you meet the deductible and include •• Meniscectomy of temporomandibular To be covered by a dental plan, a the following: joint dental expense must be necessary •• Radical resection of mandible with and provided by a duly qualified and Visits and Exams bone graft licensed dentist. Charges for covered •• Crown exposure to aid eruption items must be within the usual and •• Professional visit after hours • customary fee limits. (payment will be made on the • Removal of foreign body from soft basis of services rendered or visit, tissue PREVENTIVE SERVICES whichever is greater) •• Frenectomy Preventive Services are covered at 100% •• Emergency palliative treatment •• Suture of soft tissue injury and include the following: •• Injection of sclerosing agent into X-ray and Pathology temporomandibular joint •• Office visits during regular office •• Single films (up to 13) •• Treatment of trigeminal neuralgia hours, for oral examination (limited •• Intra-oral, occlusal view, maxillary or by injection into second and third to two visits per year) mandibular divisions •• Prophylaxis (cleaning) limited to two •• Upper or lower jaw, extra-oral treatments per year Periodontics •• Biopsy and examination of oral tissue •• Topical application of fluoride, •• Emergency treatment (periodontal including prophylaxis (limited to Oral Surgery abscess, acute periodontitis, etc.) one course of treatment per year for •• Local anesthetics and routine •• Root planing and scaling, per children under age 16) postoperative care quadrant (not prophylaxis), limited •• Bitewing X-rays (limited to once per •• Uncomplicated extractions to four separate quadrants every two year) years •• Uncomplicated surgical removal of •• Complete X-ray series or panoramic an erupted tooth •• Correction of occlusion related to film including bitewings, if necessary periodontal surgery—occlusal guards, •• Postoperative visit (sutures and (limited to once every three years) one every three years complications) after multiple •• Vertical bitewing X-rays (limited to extractions and impaction •• Gingivectomy (including post-surgical one set every three years) visits) •• Surgical removal of impacted tooth •• Gingivectomy, treatment per tooth Space Maintainers (soft tissue) (less than four teeth per quad) •• Alveolectomy (edentulous) •• Includes all adjustments within six •• Post-surgical visits months after installation •• Alveolectomy (in addition to removal of teeth) •• Fixed space maintainer (band type) Endodontics •• Alveoplasty with ridge extension •• Removable acrylic with round wire •• Pulp capping • Dental & Vision Dental • Removal of exostosis rest only •• Therapeutic pulpotomy (in addition •• Excision of hyperplastic tissue •• Removable inhibiting appliance to to restoration) •• Excision of pericoronal gingiva correct thumb sucking •• Vital pulpotomy •• Incision and drainage of abscess •• Fixed or cemented inhibiting •• Remineralization (calcium hydroxide, • appliance to correct thumb sucking • Removal of odontogenic cyst or temporary restoration) as a separate tumor procedure only • • Sialolithotomy (removal of salivary •• Root canals (devitalized teeth calculus) only, other than molar root canal •• Closure of salivary fistula therapy), including necessary X-rays •• Dilation of salivary duct and cultures but excluding final •• Transplantation of tooth or tooth bud restoration •• Removal of foreign body from bone •• Canal therapy (traditional or sargenti (independent procedure) method), includes single rooted or •• Maxillary sinusotomy for removal of bi-rooted tooth fragment or foreign body •• Local anesthetics where necessary •• Closure of oral fistula of maxillary sinus •• Sequestrectomy for osteomyelitis or bone abscess, superficial

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Restorative Dentistry Prosthodontics Periodontics •• Excludes inlays, crowns (other than •• Bridge Abutments (see Inlays and •• Osseous surgery (including flap stainless steel) and bridges Crowns above) entry and closure)—modifies the •• Multiple restorations in one surface •• Pontics bony support of teeth by reshaping will be considered as a single –– Cast Gold (sanitary) the alveolar process to achieve a restoration –– Cast non-precious metal more physiologic form. May include removal of supporting bone or non- •• Restorations (involving one, two or –– Slotted facing supporting bone and limited to one three or more surfaces), includes –– Slotted pontic amalgam, silicate cement, plastic, and per quadrant every three years. –– Porcelain fused to gold composite fillings –– Porcelain fused to non-precious Endodontics •• Pins (retention) when part of the metal restoration used instead of gold or •• Molar root canal therapy. –– Plastic processed to gold crown restoration –– Plastic processed to non-precious ORTHODONTIA EXPENSES •• Stainless steel crowns (when tooth metal cannot be restored with a filling The PDN (High Option) covers 50% material) •• Removable Bridge (unilateral)—one of eligible orthodontia expenses piece casting, chrome cobalt alloy •• Recementation of inlay, crown, or for eligible adults and dependent clasp attachment (all types) including bridge children. The plan covers only the pontics orthodontic services and treatments •• Full and partial denture repairs •• Dentures and partials—fees for described below. The lifetime maximum –– Broken dentures, no teeth involved dentures, partial dentures and relining orthodontia benefit is $1,250. –– Partial denture repairs (metal) include adjustments within six –– Replacing missing or broken teeth. months after installation; specialized The PDN (High Option) will not cover techniques and characterizations are expenses for orthodontia treatment MAJOR SERVICES not eligible begun or appliances installed before you or your eligible dependent became Major services are covered at 50% after –– Complete upper denture you meet the deductible and include covered by the Texas Health Dental Plan. –– Complete lower denture the following: –– Partial acrylic upper or lower with Orthodontic Treatment Plan Restorative chrome cobalt alloy clasps, base, all The plan defines orthodontic treatment teeth and two clasps •• Gold restorations and crowns— as the use of active appliances to –– Additional clasps covered only as treatment for decay move teeth to correct faulty position of or traumatic injury and only when –– Partial lower or upper with chrome teeth (malposition) or abnormal bite teeth cannot be restored with a filling cobalt alloy lingual or palatal bar (malocclusion). material or when the tooth is an and acrylic saddles, base, all teeth abutment to a fixed bridge and two clasps plus additional Before beginning treatment, the dentist clasps must submit a treatment plan to the •• Inlays and onlays (one or more & Vision Dental surfaces) –– Simple stress breakers, extra claims administrator that: •• Crowns –– Stayplate, base and additional •• States the class of malocclusion or –– Acrylic clasps malposition –– Acrylic with gold –– Office reline, cold cure, acrylic •• Recommends and describes the –– Acrylic with non-precious metal –– Laboratory reline required orthodontic treatment –– Porcelain –– Special tissue conditioning, per •• Estimates the duration of the –– Porcelain with gold denture treatment –– Porcelain with non-precious metal –– Denture duplication (jump case), •• Estimates the total cost for the per denture –– Non-precious metal (full cast) treatment –– Adjustment to denture more than • –– Gold (full cast) • Includes cephalometric X-rays, six months after installation study models, and any other –– Gold (¾ cast) supporting evidence that the claims –– Gold dowel pin Oral Surgery administrator may reasonably require. •• Adding teeth to partial denture to •• General anesthesia, only when replace extracted natural teeth— provided in conjunction with a teeth and clasps surgical procedure •• Repairs to crowns and bridges

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The plan will return an estimate of Excluded Expenses •• Cosmetic treatment—Facings on your orthodontic benefits to the crowns or pontics behind the second dentist. After your treatment plan The following expenses are not eligible bicuspid will always be considered is approved, you begin paying your for benefits under the PPO (Low cosmetic. This does not apply if the portion of orthodontia expenses in Option) or PDN (High Option). treatment is needed as a result of equal installments over the duration •• Services not necessary or not accidental injuries sustained while of treatment. The PDN (High Option) customarily performed for the dental you are covered under the plan. pays expenses in equal quarterly care of a specific condition as •• Charges in connection with: installments, beginning with the end of determined by Aetna –– Replacement of lost or stolen the three-month period following the •• Services not furnished by a dentist. appliances date the appliances are first inserted. This does not apply if the service –– Appliances, restorations or is performed by a licensed dental procedures needed to alter vertical Covered Orthodontia Expenses hygienist under the direction of a dimensions or restore occlusion, The PDN (High Option) will cover dentist or is an X-ray ordered by a or for the purpose of splinting or expenses for orthodontia treatment, dentist. correcting attrition or abrasion up to the lifetime maximum, for the •• Charges for a service: •• Charges in connection with injury following charges: –– Furnished by or for the United arising out of, or in the course of, any •• Services or supplies furnished in States government or any other work for wage or profit (whether or connection with an orthodontic government, unless payment of the not with Texas Health) procedure and before the end of charge is required by law •• Charges in connection with a the estimated duration shown in the –– To the extent that the service, disease covered by any workers’ orthodontic treatment plan or any benefit for the charge, compensation law, occupational •• Active appliances inserted while you is provided by any law or disease law or similar law or your dependent is covered by the governmental plan under which •• Charges for a service to the extent it PDN (High Option) the patient is or could be covered. is more than the usual charge made •• Orthodontic procedures needed to This does not apply to a state plan by the provider for the service when correct one of these conditions: under Medicaid or to any law or there is no coverage plan when, by law, its benefits are –– Vertical or horizontal overlap •• Charges above the prevailing rate in addition to those of any private of upper teeth over lower teeth in the area for dental care of a insurance program or other non- (overbite or overjet) comparable nature. The area and the governmental program. –– Faulty alignment (either frontwards range are determined by the claims •• Implants or backwards) of the upper and administrator lower arches with each other •• Replacement or modification •• Charges for a service or supply of a partial or full removable –– Cross-bite furnished by a network provider in denture, removable bridge or fixed •• Services or supplies as part of an excess of the provider’s negotiated bridgework, or for adding teeth to any orthodontic treatment plan that, charge for that service or supply. A Dental & Vision Dental of these within five years after that before the procedure is performed, negotiated charge is the maximum denture, bridge, or bridgework was have been: a network provider has agreed to installed charge for a service or supply under –– Sent to the claims administrator for •• Replacement or modification of a the PDN. review crown or gold restoration within –– Returned by the claims five years after that crown or gold administrator to the dentist restoration was installed showing estimated benefits. •• Charges for any of the following services: –– An appliance, or modification of one, if an impression for it was made before you were covered under the plan –– A crown, bridge or gold restoration, if a tooth was prepared for it before you were covered under the plan –– Root canal therapy, if the pulp chamber for it was opened before you were covered under the plan

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Filing and Appealing Out-of-network Providers Pre-service claims Dental Claims When you use an out-of-network On receipt of a pre-service claim, the provider, you must file a claim (the form claims administrator will determine Benefits under all dental plans are fully is available online) for dental expense whether or not it involves urgent care. insured by Aetna. Aetna processes all benefits as follows: If a dentist with knowledge of your claims under these plans. Whenever medical condition determines that a you file a claim, be sure to keep a copy •• Complete the top portion of the claim involves urgent care, the claim of the claim and any other information dental expense claim form by will be treated as an urgent care claim. (such as itemized bills) that you include following the instructions that with the claim. accompany the form. Then, present If the plan requires you to obtain the form to your dentist, who AETNA DMO advance approval for a service, supply, completes the remaining portion. or procedure, your request for advance The Aetna DMO pays benefits only •• Submit all itemized receipts from approval is considered a pre-service when you use network providers, so you your dentist. A canceled check is not claim. The claims administrator will do not need to file claims for benefits. acceptable documentation. notify you of its decision no later than You pay a copay for services, your •• Mail the completed claim form 15 days after receiving your claim. provider files claims for you, and the with the original itemized bills and plan pays the rest of the cost. receipts to Aetna at the address on This does not apply to a claim involving the claim form. urgent care, as defined below. However, in an emergency, you may use a non-network provider and you or the You must submit the original itemized Urgent Care Claims provider would need to file a claim. bill or receipt provided by your dentist, If the plan requires advance approval Consult the plan materials for more so you should make copies for your for a service, supply, or procedure information on claims for benefits. own records. Photocopies of receipts before a benefit is payable, and the are not accepted for claims. In addition, DENTAL PPO AND PDN plan or your dentist determines that each bill or receipt must include the your claim is an urgent care claim, the Under the PPO and PDN plans, you may following: claims administrator will notify you of use network or out-of-network providers. •• Name of patient its decision no later than 72 hours after However, you receive greater benefits •• Date the treatment or service was receiving your claim. when you use network providers. provided Urgent care means services received •• Diagnosis Network Providers for sudden illness, injury, or condition •• Itemized charges for the treatment or When you use a PPO or PDN provider, that is not an emergency condition but service you must first satisfy a deductible requires immediate outpatient medical and pay a coinsurance for basic care, •• Provider’s name, address, and tax ID care that cannot be postponed. An major care, and orthodontia. Network number. urgent situation is one that is severe providers will normally file your claims enough to require prompt medical

All dental claims payments are sent & Vision Dental for benefits with Aetna PPO or PDN. attention to avoid serious deterioration to you along with an explanation of of your health. This includes a condition benefits (EOB) explaining the amount If plan benefits differ depending on that would subject you to severe pain paid. Payments may, however, be sent whether care is given by, or accessed that could not be adequately managed directly to your dentist or other dental through, a network provider, you may without prompt treatment. obtain, without charge, a listing of provider if your provider accepts network providers from your claims assignment of benefits. In this case, If the claims administrator does not administrator, or by calling the toll-free the EOB will be mailed to you and the have enough information to decide Member Services number on your ID payment mailed to your provider. the claim, they will notify you of the Card. A current list of providers in the information needed to complete the TYPES OF CLAIMS Aetna network is available through claim as soon as possible after receiving DocFind®, at www.aetna.com. There are four different types of claims. your claim but no more than 24 hours The claim type is determined initially later. The claims administrator will give when the claim is filed. If the nature you a reasonable time to provide the of the claim changes as it proceeds information but not less than 48 hours. through claims processing, the claim They will notify you of their decision may be re-characterized. For example, no later than 48 hours after the end of a claim may initially be an urgent care the additional time period, or after they claim. If the urgency subsides, it may be receive the information, if earlier. re-characterized as a pre-service claim.

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Post-service Claims If you file a pre-service claim and If any benefit remains unpaid at your include the name of the patient, dental death, if the covered person is a minor A post-service claim is any claim for a condition, and service or supply for or legally incapable (in the opinion benefit that is not a pre-service claim or which approval is being requested but of the claims administrator) of giving an urgent care claim. For post-service you do not follow the plan’s procedures a valid receipt and discharge for claims, the claims administrator will for filing pre-service claims, the claims payment, the claims administrator may, notify you no later than 30 days after administrator will notify you of the at its option, pay benefits to the spouse, receiving your claim. proper procedures within five days parent or child of the covered person. Ongoing Care (or within 24 hours for an urgent care Payment to the covered person’s relative claim). The notification may be oral constitutes a complete discharge of A claim for ongoing care is one unless you request written notification. the claims administrator’s obligation to in which the claims administrator the extent of the payment. The claims approves a course of treatment over HOW TO FILE A CLAIM FOR administrator is not required to see the BENEFITS a period of time or for a specified application of the money. number of treatments. However, a claim Except for urgent care claims, a claim for ongoing care may be reconsidered for benefits is made when you (or your by the claims administrator and the authorized representative) submit a initially approved period of time or written claim form to: number of treatments may be either reduced, terminated, or extended. Aetna P.O. Box 14066 The claims administrator will notify Lexington, KY 40512-4066 you in advance if the plan intends www.aetna.com. to terminate or reduce benefits for a course of ongoing care so you will have COORDINATION OF BENEFITS an opportunity to appeal the decision If you have dental coverage through before the termination or reduction any other plan, the PDN Plans are takes effect. If the ongoing care involves coordinated with the other plan so that urgent care, and you request an you do not receive greater benefits than extension of the ongoing care at least the cost of covered services. 24 hours before it expires, the claims administrator will notify you of its CLAIM FILING DEADLINE decision within 24 hours after receiving You must submit all dental claims your request. within 90 days after the date the expenses were incurred. EXTENSION OF TIME PERIODS For pre-service and post-service claims, PAYMENT OF CLAIMS

Dental & Vision Dental the claims administrator may extend Plan benefits are payable to you, unless the time periods for up to an additional you give written direction at the time 15 days for circumstances outside you file your claim, to directly pay the the plan’s control. If an extension is dentist or unless a Qualified Medical required, you will be notified of the Child Support Order directs the extension before the end of the initial payment to someone else. 15- or 30-day period. For example, if you have not submitted sufficient You may request that the claims information for the claims administrator processor pay your dentist directly by to decide the claim, they will notify you assigning your benefits. You may assign of the specific information needed and benefits for eligible expenses incurred provide an additional period of at least for dental care only to the person or 45 days to furnish the information. The institution that provides the services or claims administrator will notify you of supplies for which these benefits are their decision no later than 15 days after payable. the end of the extended period, or after receipt of the information, if earlier.

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FILING AN APPEAL If you have the DMO plan and wish to When Coverage Ends obtain information or make a complaint: With the exception of urgent care claims, Generally, coverage for you and your you have 180 days to file an appeal •• You may call Aetna Dental Inc.’s toll- covered dependents under the Total after you receive an adverse decision. free telephone number at Health Dental Plan ends on the last day After the claims administrator receives 1-(877) 238-6200. of the pay period in which you terminate your appeal, they will notify you of their •• You may write to Aetna Dental Inc. at: employment. See page 140 for more decision no more than: Aetna Dental Inc. information. •• 15 days later for a pre-service claim One Prudential Circle Sugar Land, TX 77478 In some cases, you and your covered •• 30 days later for a post-service claim. •• You may call the Texas Department of dependents may be eligible for COBRA You may submit written comments, Insurance at 1-(800) 252-3439. continuation coverage, as explained on documents, records, or other information •• You may write the Texas Department page 141. relating to your claim, even if you did not of Insurance at: submit them with the initial claim. You P.O. Box 149104 may also request that the plan provide Austin, TX 78714-9104 copies of all documents, records, and Fax: (512) 475-1771 other information relevant to the claim. Web: http://www.tdi.state.tx.us Those copies will be provided free of Email: [email protected]. charge. tx.us. If your claim involves urgent care, you Should you have a dispute concerning may make an expedited appeal by calling your premium or about a claim you Aetna’s Member Services at the telephone should contact Aetna first. If the dispute number on your ID card. You or your is not resolved you may contact the Texas authorized representative may appeal an Department of Insurance. This notice urgent care claim denial either orally or is for information only and does not in writing. All necessary communication become a part or condition of the DMO will be made by telephone, facsimile, plan as described in the Handbook. or other similar method, including the appeal decision. You will be notified of the decision within 36 hours after your appeal is received.

If you are dissatisfied with the appeal decision on a claim involving urgent care, you may file a second-level appeal with Aetna. You will be notified of the decision no later than 36 hours after the & Vision Dental appeal is received.

If you are dissatisfied with a pre-service or post-service appeal decision, you may file a second level appeal with Aetna within 60 days of receipt of the first appeal decision. Aetna will notify you of the decision no later than 15 days (for pre-service claims) or 30 days (for post-service claims) after the appeal is received.

If you do not agree with the final determination on review, you have the right to bring civil action under Section 502(a) of ERISA, if applicable.

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 73 Vision Plan Vision Plan Overview Summary of Benefits You may elect coverage for vision care The following table summarizes how the plan pays benefits and your cost for certain through the Superior Vision Plan. The services and supplies. plan pays benefits for annual eye exams and corrective lenses. You pay a copay Feature Network Out-of-network for exams and materials (materials Comprehensive eye Covered in full after $10 copay Up to $42 for copayment applies to lenses and exam once every ophthalmologist (M.D.) frames, not contact lenses) the plan 12 consecutive or $37 for optometrist months (O.D.) pays benefits for frames and lenses up to certain limits. Under this plan you Standard lenses Covered in full after $10 copay Single vision—up to $32 once every 12 Bifocal—up to $46 may use network or out-of-network consecutive Trifocal—up to $61 vision care providers, but you receive months1 Lenticular—up to $84 greater benefits when you use network Contact lens fitting Covered in full after $35 copay Not covered providers. (standard)

The Superior Vision Plan allows you to Contact lens fitting Up to $50 retail allowance after a Not covered (specialty) $35 copay choose your eye care provider. You can choose a network provider or an out-of- Contact lenses Cosmetic elective—up to $140 Cosmetic elective—up to (per pair, in lieu allowance ($35 copay for contact $100 retail allowance network provider. Network providers file of eyeglasses) lens fitting exam) Medically necessary—up all claim forms. When you use an out-of- once every 12 Medically necessary—covered to $2102 network provider, you pay the full cost consecutive in full2 months1 of vision care expenses to the provider and submit a claim for reimbursement. Standard frames Up to $140 retail allowance Up to $53 retail once every 12 allowance Your reimbursement will be paid consecutive under the out-of-network schedule of months allowances, less any applicable copay Refractive surgery 5%—50% discount No benefit amounts. (LASIK, radial keratotomy, or photo-refractive Who Can Be Covered keratotomy) You may elect the following levels of Add-ons to covered lenses (covered in-network only) coverage under the Vision Plan: You receive 20% off retail, up to the dollar amount listed: ••Factory scratch coat – $133 •

Dental & Vision Dental • You only ••Ultraviolet coat – $153 •• You and your spouse ••Standard anti-reflective coat – $503 •• You and your unmarried dependent ••High index 1.6 – $554 children up to age 25 who are not ••Polycarbonate – $404 regularly employed on a full-time ••Standard transitions and other photochromic – $804 basis ••Glass coloring – $355 •• You and your family ••Plastic tints solid or gradient – $255 See pages 5 – 7 for more information on You receive 20% discount off retail for these add-ons to any type of lenses: eligibility. ••Power over 4.00D sphere, 2.00D cylinder and 5.00D prism ••Cosmetic finishing, beveling, edging, and mounting ••All other lens options or upgrades

1 The plan will pay for either contact lenses or eyeglass frames and lenses once every 12 consecutive months. You may not receive benefits for eyeglasses in the same consecutive 12 month period in which you receive benefits for contact lenses. 2 Must have prior approval and only certain medical eye conditions will be approved 3 Single-vision and standard lined multifocal lenses 4 Single-vision lenses only 5 Any type of lenses

74 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Vision Plan

Network Providers –– Objective refraction by retinoscopy •• Photochromic lenses or autorefractor •• Laminated lenses To find a list of network providers, visit •• Binocular function. •• Slab-off lenses www.superiorvision.com or call •• Prism lenses Superior Vision at 1-877-MyTHRLink Your vision benefits also include: (1-877-698-4754), prompt 6, press 4. When •• Coating on lenses (anti-scratch, anti- •• Standard lenses (plastic or glass) that you choose a Superior Vision Services reflective, sunglass colors, etc.) are clear—once every 12 consecutive network provider, you should identify •• Tints (except rose tint #1 and #2) months yourself as a member of the plan when •• Oversized charge for lenses larger making your appointment. Superior –– Single vision than 61 mm Vision Services will give the provider –– Bifocal •• Ultra-violet tint or coating an authorization number to verify –– Trifocal •• Retail charges for frames in excess of your benefits before you receive your –– Lenticular the retail frame allowance services. Although it is not required, •• Frames—once every 12 consecutive •• Additional cost for elective contact it is recommended that you present months lenses over the allowance. your ID card to the provider at the time •• Contact lenses—once every 12 You may also take advantage of many you receive services. This makes the consecutive months in lieu of eyeglass discounts through Superior Vision identification process easier. You can lenses and frames print additional cards by logging on to Plan—more information is available at –– Contact lens exam/fitting fee—Most www.superiorvision.com. www.superiorvision.com. providers charge a fee for fitting contact lenses. This $35 copay is When you receive care, pay only your Exclusions copay and any charges not covered separate from the comprehensive by the plan. The network provider will eye examination. Contact lens exam There is no benefit coverage for the handle claims for you. and fitting charges are not covered following products and services: out-of-network. •• Replacement frames and/or lenses To receive the discount for refractive –– Medically necessary—covered except at normal intervals when surgery, simply present your ID card to in full in-network, up to $210 services are otherwise available a participating refractive surgeon listed allowance out-of-network •• Nonprescription glasses/sunglasses or in the Superior Vision provider directory –– Elective—up to $140 allowance oversized lenses with the notation “RF” under services –– You may order contact lenses •• Orthoptics or vision training and any provided. online at www.svcontacts.com. associated supplemental testing • Covered In-Network OPTIONS AT AN ADDITIONAL COST • Frame cases •• Low (subnormal) vision aids Expenses The Superior Vision Plan is designed •• Eye exams required by your employer to provide your basic eyewear needs. You may receive benefits for a as a condition for employment Many lens upgrades and add-ons are comprehensive vision examination by •• Services and materials covered by

not covered or have limitations. If you & Vision Dental an ophthalmologist or optometrist once choose any of the options listed below, another vision plan every 12 consecutive months, which you will pay for the options in addition •• Conditions covered by workers’ must include: to the covered benefit. You will pay compensation •• Case history these additional charges directly to your •• Benefits provided under your medical •• Visual health evaluation, to include: provider at the time of service; however insurance –– Internal and external examinations discounts may apply. •• Medical or surgical treatment of with direct and indirect •• Progressive power lenses—The the eyes ophthalmoscopy provider’s charge for a standard –– Pupillary reflexes and motility trifocal is credited toward the charge evaluation for the style of progressive lens –– Biomicroscopy selected. You pay the provider the –– Visual fields testing difference between the two. –– Tonometry •• Blended (no-line) bifocal lenses •• Refractive state evaluation, to include: •• Faceted lenses –– Visual acuity uncorrected and best •• Polished bevel lenses corrected acuity •• Polycarbonate lenses –– Subjective refraction with •• Hi-index lenses accommodative function •• Polaroid lenses

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 75 Vision Plan

•• Professional services and/or materials Coordination of Benefits Filing Claims in connection with: The Vision Plan is designed to integrate Written notice of your claim must be –– Blended bifocals, no line benefits with other group or individual given to Superior Vision within twenty –– Compensated or special multi-focal plans or policies. If you are eligible (20) days of the date such loss begins. lenses either as the insured or a dependent Notice must be given to Superior Vision –– Plain (non-prescription) lenses to receive vision benefits from another with enough information to identify you –– Anti-reflective, scratch, UV400, or plan (including automobile insurance) or your dependents. Failure to file such any coating or lamination applied or government program, the total notice within the time required will not to lenses benefits you are eligible to receive from invalidate nor reduce any claim that was –– Subnormal visual aids all plans will not be more than the not reasonably possible to file notice –– Tints other than solid benefits that would be payable from the within such time. However, the notice –– Orthoptics, vision training and Total Health Vision Plan if you had no must be given as soon as reasonably developmental vision procedures other coverage. This applies whether or possible. Superior Vision will provide –– Polycarbonate lenses not you file a claim under the other plan. claim forms when you request or when If needed, you must authorize the claims Superior Vision receives notice of claim. •• Services rendered or materials administrator to get information from If the forms are not given within fifteen purchased outside the U.S. or Canada the other plans. (15) days, you can submit written proof •• Charges in excess of the usual, covering the occurrence, character and customary and reasonable charge for If you are covered by two vision plans, extent of loss for which claim is made. the professional service or materials one of the plans will be primary and the •• Experimental or non-conventional other will be secondary. The primary You or your network provider must treatment or device plan pays benefits first. The following provide written proof of your claim to •• Safety eyewear criteria determine which plan is primary: Superior Vision not later than ninety •• Services or materials rendered •• If only the other plan is not with (90) days after the date of such loss. by a provider other than an Superior Vision, then the Total Health Failure to give such proof within such Ophthalmologist, Optometrist, or Vision Plan is the primary plan. time will not invalidate nor reduce any claim if it was not reasonably possible Optician acting within the scope of his •• If both plans are with Superior to give proof within such time. However, or her license Vision, then the plan under which the such proof must be furnished as soon •• Any additional service required other insured is the member rather than a as reasonably possible, but in no event, than basic vision analyses for contact dependent, is primary. except in the absence of legal capacity lenses, except fitting fees •• If both plans are with Superior Vision of the claimant, later than one (1) year •• Services rendered after the date a and the insured is a dependent child, from the date of the claim. participant ceases to be covered, the father’s plan is primary. except when vision materials ordered Superior Vision, at its expense, has the If payments should have been made before coverage ended are delivered right to examine you regarding any under this plan but have been made and the services rendered to the claim when and as often as may be

Dental & Vision Dental under any other plan, the claims participant within 31 days from the reasonably required while the claim is administrator has the right, in its sole date of such order pending. •• Services rendered or materials discretion, to pay to any insurance ordered before the date coverage company or other organization or If you file a claim, be sure to keep a copy began. person making such other payments any of the claim and any other information amounts it determines and to the extent (such as itemized bills) that you include of such payments, Texas Health and with the claim. the plan will be fully discharged from liability. The benefits that are payable If you cover your dependent under will be charged against any applicable the Vision Plan and do not have legal maximum payment or benefit of this custody of that dependent, Superior plan rather than the amount payable in Vision may make benefit payments the absence of this provision. directly to the care provider at the request of the custodial parent. Superior Vision will be released from all further liability to the extent of the payments made.

76 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Vision Plan

Superior Vision has the right to contest GRIEVANCE PROCEDURE For purposes of this grievance the validity of your or your dependent’s procedure, a grievance is a written If a claim for benefits is wholly or coverage under the plan because of complaint submitted in accordance partially denied, you will be notified in inaccurate or false information about with the above grievance procedure writing of such denial and of your right eligibility for coverage. Superior Vision by or on behalf of you or a dependent to file a grievance and the procedure has two years from the effective date regarding dissatisfaction with the to follow. The notice of denial will state of your coverage to contest eligibility. administration of claims practices the specific reason for the denial of Only statements that are in writing or provision of services of this benefits. and signed by you or your covered panel provider plan relative to you. dependent can be used to contest Within 60 days of receipt of such written In situations requiring urgent care, coverage. notice a member may file a grievance grievances will be resolved within four and make a written request for review to: business days of receiving the grievance. If you, your covered dependent, or your vision care provider receives an National Guardian Life Insurance Superior Vision Services has final overpayment of benefits under the Company discretionary authority to determine all Vision Plan, you are required to repay c/o Superior Vision Services, Inc. questions of eligibility and status and to any excess benefits to the plan. P.O. Box 967 interpret and construe the terms of the Rancho Cordova, CA 95741 insurance policy. OUT-OF-NETWORK PROVIDERS Superior Vision will resolve the When you use an out-of-network grievance within 30 calendar days When Coverage Ends provider, you must file a claim for vision of receiving it. If Superior Vision is Generally, coverage for you and your reimbursement. unable to resolve the grievance within covered dependents under the vision Before you receive services, you should that period, the time period may be plan ends on the last day of the call Superior Vision Member Services extended another 30 calendar days if pay period in which you terminate at 1-877-MyTHRLink (1-877-698-4754), Superior Vision notifies in writing the employment. See page 140 for more prompt 6, press 4 to verify your eligibility person who filed the grievance. The information. and receive an authorization number. notice will include advice as to when In some situations you may continue After receiving services, obtain an resolution of the grievance can be vision coverage after you leave Texas itemized invoice or receipt and mail it expected and the reason why additional Health. See page 141 for information on to the Superior Vision Claims Unit for time is needed. You or someone on his/ electing COBRA continuation coverage. reimbursement. Your claim will be paid her behalf also has the right to appear under the out-of-network schedule of in person before the Superior Vision allowances, less any applicable copay grievance committee to present written amounts. or oral information and to question those people responsible for making The mailing address is: the determination that resulted in the grievance. You will be informed in Superior Vision Services & Vision Dental writing of the time and place of the P.O. Box 967 meeting at least seven calendar days Rancho Cordova, CA 95741 before the meeting. Reimbursements will be mailed to your home address along with an explanation of benefits (EOB) describing the amounts you have been paid. You must submit all vision claims within 12 months after the date the expenses were incurred.

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 77 Flexible Spending Accounts Spending Accounts Flexible Spending Accounts...... 79 Overview 79 “Use It or Lose It” 79 Health Care Spending Account 79 Day Care Spending Account 82 Filing Claims 83 When Coverage Ends 84 Spending Accounts

78 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Flexible Spending Accounts Flexible Spending Accounts Overview cannot exceed $5,000. If you are married Health Care and you file a separate income tax Spending Account Most people have medical expenses return, contributions cannot exceed that are not covered by any benefit $2,500 for each of you, with a $5,000 The Health Care Spending Account plan—things like deductibles, copays, total maximum (a minimum of $130 per can be used to pay for certain health coinsurance, or dental and vision year). care expenses that are not covered by expenses. And, if you have young insurance. Eligible expenses include children at home or are caring for a The annual amount you contribute medical, dental, and vision expenses not parent, you may have to pay someone to is divided into equal amounts and paid by your medical coverage, such as care for them while you work. deducted from each paycheck. deductibles, copays, coinsurance, and amounts above the usual and customary As a full-time or part-time benefits- For example, if you elected to contribute fee limits. eligible employee, you may be able to $1,430 during open enrollment, that use the Flexible Spending Accounts amount is divided by 26 pay periods to WHO CAN BE COVERED under the Total Health Flexible Benefits figure your per-pay-period deduction of The Health Care Spending Account Plan to pay these expenses with tax-free $55. If you enroll during the calendar allows you to receive tax-free dollars. You pay no federal income or year, the annual contribution you elect reimbursement of health care expenses Social Security taxes on the earnings you is divided by the number of pay periods for you and your eligible dependents, deposit in the accounts, meaning you remaining in the calendar year. even if you don’t cover them under the pay lower overall taxes on your income. Total Health Medical Plan. You may file The Health Care Spending Account “Use It or Lose It” claims for reimbursement of expenses (HCSA) allows you to set aside tax-free The IRS restricts how you may use incurred by: money through payroll deductions the funds in your Flexible Spending •• You to pay eligible health care expenses. Accounts. If you decide to contribute •• Your spouse Eligible expenses are amounts not to either or both accounts, you should •• Your dependent children reimbursed by any health coverage, carefully estimate your expenses for •• Anyone else you can claim as a including a spouse's plan, for the care the coming year. The law requires that dependent on your federal income tax of you, your spouse, your children, and the accounts operate on a “use it or return. other qualified dependents. lose it” basis. This means you forfeit any money remaining in your spending CHANGING YOUR ELECTIONS The Day Care Spending Account accounts after all eligible expenses If, as a result of a status change, you allows you to set aside tax-free money have been reimbursed according to stop your deposits during the year, you through payroll deductions to pay plan guidelines. All Flexible Spending may file claims and be reimbursed for eligible day care expenses. Eligible Account forfeitures are used to pay for eligible health care expenses incurred expenses include day care for your the plan’s administrative expenses. children under age 13 or a disabled before the change. These expenses will dependent of any age when the care Your expenses claimed for be reimbursed up to the original amount enables you (and your spouse, if you are reimbursement must be for health you elected to deposit. You will not be married) to work. care or day care services incurred reimbursed for expenses incurred after between January 1, 2013, and March you stop your elections. Any unused HOW MUCH YOU MAY CONTRIBUTE 15, 2014, and only during the months amount will be forfeited. If you reduce You may participate in either or both that you are eligible to participate. If your deposits as a result of a status accounts. During enrollment, you you participate in the Health Care and change, you may be reimbursed for decide how much to deposit on a Day Care Spending Accounts, keep in eligible health care expenses up to the before-tax basis for the year, up to: mind that the accounts are maintained amount of your revised deposit amount. Spending Accounts separately. You may not transfer money However, you are not allowed to reduce •• $2,500 per year into your Health Care between the accounts. All claims your deposit to less than the amount you Spending Account (a minimum of must be submitted by March 31 of have been reimbursed. For example, if $130 per year) the following year to be eligible for your original contribution was $1,000 •• $5,000 per year into your Day Care reimbursement. and you have been reimbursed $500, you Spending Account. If you are married could only lower your new contribution and your spouse’s employer offers a to $500. Dependent Care Spending Account, your combined total annual contribution

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REHIRES The debit card can only be used ELIGIBLE HEALTH CARE for expenses you actually incur. For EXPENSES If you terminate your employment or example, you may be asked to pay your lose eligibility and then you are rehired In general, your Health Care Spending provider’s portion of your newborn within 180 days of your termination, you Account can be used to pay any services by a certain month of your will be reinstated in the plan at the same unreimbursed health care expenses pregnancy. However, this amount cannot contribution rate. that the Internal Revenue Service (IRS) be paid using the debit card. When using would normally allow you to deduct HCSA DEBIT CARD your debit card, please remember that when you calculate your taxes. The list your FSA funds should be used as the You will receive a Benefits Card which below gives examples of the expenses final payer. The card cannot be used for is a MasterCard that provides you that qualify for reimbursement. For a pre-treatment or estimated charges. immediate access to your FSA funds more comprehensive listing of eligible expenses, refer to IRS Publication 502 at upon initial enrollment. You will not If you go to a retail pharmacy, your http://www.irs.gov/pub/irs-pdf/p502.pdf. receive a new card each year. Your new Benefits Card can be used for your Excluded expenses are listed on the annual election will be loaded on the prescription medication at any network next page. card each year. Until March 15, 2013, pharmacy that is set up to take the card. when you use your debit card, funds (Please note that not all participating •• Most medical and dental plan copays will be drawn from your 2012 account pharmacies will be able to accept the (such as for office visits), deductibles, balance. After you use all the money in card.) Mail order prescriptions can be and out-of-pocket expenses (but your 2012 account, when you use your processed without authorization from not medical or dental insurance card it will withdraw from your 2013 Caremark and you should be able to premiums) account. When you use your card after use your Benefits Card. You may also •• Hearing expenses including hearing March 15, 2013, it will withdraw from your purchase a 90-day supply at the retail aids, special instructions or training 2013 account and you will no longer be pharmacy at Texas Health Presbyterian for the deaf (such as lip reading), and able to access your 2012 account. Your Hospitals of Dallas and Plano. Benefits Card can be used for medical, the cost of acquiring and training a dental and vision expenses at eligible If your provider does not accept dog for the deaf merchants with a valid merchant code. MasterCard, or you use a pharmacy •• Vision expenses including eyeglasses, that is not set up to process your FSA contact lenses, ophthalmologist fees, When you use your debit card, you may payment, you will be required to pay at the cost of a guide dog for the blind, be required to provide documentation the time of service and file a paper claim and special education devices for the such as an Explanation of Benefits for reimbursement. blind, such as an interpreter from your medical/dental insurance carrier or itemized receipts showing If you have trouble using your card Examples of medical expenses that may the charges for the service and the at a physician’s office, pharmacy, be reimbursed if not covered by a Total amount of insurance payment (if any). dental or vision provider, you may still Health Medical Plan or other medical In addition, we may request additional submit paper reimbursement forms to coverage you may have include, but are information such as a statement of PayFlex and your eligible claims will be not limited to, the following: medical purpose from your doctor. reimbursed to you. •• Acupuncture that is not paid by the Your debit card will be deactivated if medical plan Go to www.healthhub.com to track your you provide documentation that shows •• Artificial insemination, including Health Care Spending Account expenses, your transaction is not an eligible FSA in-vitro fertilization expense, or your documentation is not balances, and statement of claims or to •• Bandages, support hose, or received within 60 days of the date of see a listing of your account activity. other pressure garments (when the letter. If you have other questions about your recommended by a physician to cure If you do not provide the required FSA, call PayFlex at 1-877-MyTHRLink a specific ailment) documentation showing that the (1-877-698-4754), select prompt 6, then •• Blood, blood plasma, or blood transaction amount is eligible under the press 6. substitutes

Spending Accounts IRS tax code governing FSA plans, you •• Braces, appliances, or equipment, COBRA PARTICIPANTS HCSA including procurement or use will need to repay the amount to your DEBIT CARD account. •• Car controls for the handicapped Upon termination, you will no longer •• Charges in excess of usual and be able to use your HCSA debit card. customary fee limits As a COBRA participant, to receive •• Chromosome or fertility studies reimbursement for eligible expenses, you will need to file claims as explained on •• Confinement to a facility primarily for page 141. screening tests and physical therapy

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•• Copays for covered medical expenses •• Medically necessary orthodontia •• Expenses for which you do not submit •• Experimental treatment expenses for adults or dependents the appropriate documentation •• Foot disorders and treatments for •• Myofunctional therapy •• Health club fees and exercise classes corns, bunions, calluses, and structural •• Orthodontia expenses •• Marriage and family counseling disorders •• Replacement of dentures or •• Massage therapy (unless prescribed •• Home health care, hospice care, bridgework less than five years old by a physician to treat a medical nursing care, or home health care •• Replacement of lost, stolen, or missing condition) aides dentures or orthodontic devices •• Medical, dental, or vision insurance •• Hypnosis for treatment of illness •• Tooth cleaning more than twice per premiums •• Immunizations year. •• Over the counter medications without •• Learning disability tutoring or therapy prescription Please note that effective January 1, •• Nursing home care •• Personal care items such as cosmetics 2011, over-the-counter medications sold •• Physical exams and toiletries without a prescription are no longer a •• Transportation expenses for the •• Physical therapy reimbursable expense under the flexible handicapped to and from work •• Prescription drug copays spending account. • •• Prescription eyeglasses and contact • Vacation travel for health purposes lenses EXCLUDED EXPENSES •• Vitamins and nutritional supplements •• Prescription vitamins Some health care expenses you may •• Weight loss programs—program •• Psychiatric or psychological incur are not eligible for reimbursement. fees are not eligible unless you have counseling These expenses should not be included a letter of medical necessity and diagnosis of obesity or hypertension. •• Radial keratotomies and LASIK in your budgeting to determine the Food and other costs are not procedures to correct nearsightedness amount you contribute to either reimbursable. •• Sexual dysfunctions or inadequacy spending account. Excluded expenses include: treatments HEALTH CARE SPENDING •• Smoking cessation program costs, if •• Medical expenses that have been ACCOUNT VS. TAX DEDUCTION prescribed, and prescription nicotine reimbursed through any other policy, If you pay eligible health care expenses withdrawal medications if prescribed plan, or program including Medicare through your Health Care Spending by a physician or any other federal or state program Account, you may not also take a •• Speech therapy •• Capital expenses deduction for these expenses on your •• Syringes, needles, injections –– Air conditioning units tax return. However, if you choose to take •• Transportation expenses to receive –– Structural additions or changes the tax deduction instead of using the medical care, including fares for –– Swimming pools account, you may deduct only expenses public transportation and private auto –– Whirlpools that are greater than 10% of your expenses (consult your tax advisor for –– Wheelchair ramps adjusted gross income, provided that you itemize deductions in your income tax the current IRS mileage allowance) •• Cosmetic medical treatments or return. •• Weight loss programs—program surgery, other than those that are fees only with a letter of medical medically necessary due to accident, Example necessity and diagnosis of obesity or trauma, disease or birth defect For example, if your adjusted gross hypertension •• Cosmetic prescriptions and cosmetic income is $20,000, only medical •• Work-related sickness or injury (not dental procedures such as cosmetic expenses of more than $2,000 can be covered by Workers’ Compensation). tooth bonding or whitening deducted on your income tax return: •• Electrolysis (unless prescribed Examples of dental expenses that may by a physician to treat a medical 10% of $20,000 = $2,000 be reimbursed if not covered by the condition) Total Health Dental Plan or other dental If you are in a combined 22.65% tax •• Expenses claimed as a deduction or coverage include, but are not limited to: bracket (15% income tax + 7.65% FICA

credit on your federal income tax Spending Accounts • tax), that means you pay $453 more in • Anesthesia return • taxes by not reimbursing these expenses • Charges in excess of usual and •• Expenses incurred before you customary fee limits through the Health Care Spending enrolled or after you terminated from Account: 22.65% of $2,5000 = $453. •• Drugs and their administration the plan •• Experimental treatment •• Expenses incurred before or after the •• Extra sets of dentures or other dental end of the calendar year for which the appliances account was established

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 81 Flexible Spending Accounts

Day Care Spending Account You must notify Human Resources, Because the IRS specifies that any make your election, and provide unused money in your Day Care Flexible The Day Care Spending Account can be documentation of the reason for the Spending Account is forfeited at the used to pay eligible child or dependent change within 31 days. If you do not end of the year, consider the following care expenses using before-tax dollars provide the documentation, your new guidelines when enrolling in this while you (and your spouse, if you are election will be reversed. program: married) are at work. HOW MUCH YOU MAY CONTRIBUTE •• Carefully determine the number of If you are married, your spouse must be weeks of dependent day care you will either: In general, you may contribute up to purchase. Estimate and deduct weeks $5,000 a year (a minimum of $130 that might include vacation, illness, •• Employed per year) to your Day Care Spending or occasions where your dependents •• A full-time student at an educational Account. If you are married and you might have free care. institution, or and your spouse are both contributing •• Don’t anticipate expenses you are •• Unable to care for himself or herself to a Day Care Spending Account not sure about, such as day care for a because of a mental or physical (regardless of whether your spouse child not yet born. Birth of a child is condition. works for Texas Health or another considered an eligible life event, so employer), you and your spouse have a WHO CAN BE COVERED you may start participating in a Day combined contribution limit of $5,000. Care Flexible Spending Account at You may claim day care expenses for (The limit is per married couple, not per that time. your eligible dependents, including: individual.) The annual amount you •• You must be actively at work to contribute is divided equally amount •• Children under age 13 claimed as contribute. your paychecks. Unlike your Healthcare dependents on your federal income Spending Account, which is credited tax return who spend at least eight at the beginning of the year with the hours a day in your home, and amount you have elected to contribute •• A person over age 13 (including your for the full year, your day care account is child, spouse or parent) if the person credited with each payroll deduction. meets all of the following criteria: –– Lives with you and depends on For example, if you elected to contribute you for more than half of his or her $2,600 during open enrollment, that financial support amount is divided by 26 pay periods to –– Is physically or mentally incapable figure your per-pay-period deduction of of self-care $100. If you enroll during the calendar –– Spends at least eight hours a day in year, the annual contribution you elect your home, and is divided by the number of pay periods –– Is claimed as a dependent on your remaining in the calendar year. federal income tax return. You cannot contribute more than your CHANGING YOUR ELECTIONS earned income or your spouse’s earned income, whichever is less. For example, You may change or revoke your previous if your spouse works part-time and earns election for Day Care Spending Account $2,000 a year, you can deposit no more during the year and make new election than $2,000 a year into this account. if you experience one of the following Please consult with a tax advisor to situations: determine the limitations that apply in this •• The cost of dependent care situation. significantly increases or decreases (you can change or revoke your previous election only if the provider Spending Accounts is not your relative, as defined in the plan). •• You remove your child from a facility •• You or your spouse quit working •• You experience a qualified status change, as defined on pages 10 – 12.

82 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Flexible Spending Accounts

ELIGIBLE DAY CARE EXPENSES •• Expenses claimed as a deduction or Filing Claims credit on your federal income tax To qualify for reimbursement, care must return The Health Care and Day Care Flexible be provided by a licensed day care Spending Accounts are administered facility or by an individual who is not •• Expenses incurred before you separately. You must submit claims to your dependent. enrolled or after you terminated from the plan PayFlex to receive reimbursement for Expenses paid to the following providers •• Expenses incurred before or after the eligible health care and dependent day may be reimbursed through your account end of the calendar year for which the care expenses. if you can provide their Social Security or account was established You may file claims for eligible expenses taxpayer identification number: •• Day care expenses that in any at any time during the plan year. calendar year are more than your •• A licensed child care center or adult Reimbursements are processed twice income or your spouse’s income day care center, including a church or each week. After your claim is approved, (whichever is less), unless you are non-profit center either a check will be mailed to your married and your spouse is a full-time •• A babysitter inside or outside your home address or your reimbursement student or mentally or physically home if the sitter does not care for will be direct deposited to your account. more than six children at a time (not disabled including the sitter’s own dependents) •• Expenses for which you do not submit HEALTH CARE SPENDING ACCOUNT •• A housekeeper whose duties include the appropriate documentation dependent day care •• Expenses for child care when your After you have made your first deposit •• A relative who cares for your spouse is not employed (unless your through payroll deduction, the entire dependents but is neither your spouse, spouse is a full-time student or is amount you have agreed to deposit your child, nor your dependent mentally or physically disabled). for the calendar year is available for reimbursement. Ongoing deposits •• Someone who cares for an elderly or DAY CARE SPENDING ACCOUNT will repay your account for earlier disabled dependent inside or outside VS. FEDERAL TAX CREDIT your home reimbursements you received. If you enroll Federal tax laws allow you to take a in the plan during the year, you are eligible •• Au pairs (foreign visitors to the U.S. tax credit for eligible dependent care for reimbursement only of expenses you who perform day care and domestic expenses. The tax credit is a percentage incur after becoming a plan participant. services in exchange for living of your dependent day care expenses, expenses), provided the au pair up to $3,000 for one dependent or Before filing a claim for reimbursement agency is a non-profit organization $6,000 for two or more dependents. You from your account: or the au pair obtains a U.S. Social may use both the dependent day care Security number for tax identification •• Pay your health care expense and tax credit and the Day Care Spending purposes submit a claim to the appropriate Account, but not for the same expenses. Medical, Dental, or Vision Plan. If you •• Facilities away from home, provided Amounts reimbursed from your account are not required to submit a claim for your dependent spends at least eight are to be deducted from your tax credit. benefits (for example, when you pay hours per day at home. a doctor’s office copay), keep your In some cases, using the Day Care receipt from the service provider. EXCLUDED EXPENSES Spending Account saves you more. In other • Some day care expenses you may incur cases, you may save more by taking the • If you have other coverage, such as are not eligible for reimbursement. credit on your tax return. Because tax laws through your spouse’s employer, you Therefore, these expenses should not be are complex and change from time to time, must first submit your claim to that included in your budgeting to determine you should consult a tax advisor or contact coverage and receive the other plan’s the amount you contribute to either the IRS to obtain Publication 503 at: explanation of benefits (EOB) before spending account. Excluded expenses http://www.irs.gov/pub/irs-pdf/p503.pdf. filing for reimbursement from your include: Health Care Spending Account. •• If you incur an eligible expense for • • Care provided by anyone you or your which you have no coverage, you spouse claim as a dependent on your may submit the expense directly for Spending Accounts income tax return reimbursement. •• Care by occasional baby sitters •• A facility or individual for whom you cannot provide a taxpayer identification or Social Security number

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 83 Flexible Spending Accounts

To submit a claim for eligible health care To file a claim: When Coverage Ends expenses: •• Complete a Flexible Spending •• Complete a Flexible Spending Account Claim Form and attach Coverage ends under the Flexible Account Claim Form (available from original documentation of your Spending Accounts at the end of the Human Resources and online at expenses, such as a receipt from your pay period in which you terminate www.healthhub.com). day care provider. Documentation employment with Texas Health or stop your contributions. You have until •• Attach documentation of your must include the dependent care March 31 of the following year to submit expenses, such as an original receipt provider’s name and the dependent's claims for dependent care and health from the medical service provider or age. A canceled check is not care expenses incurred before your your explanation of benefits (EOB) acceptable documentation. termination or before you stopped your from your plan. A canceled check is •• Mail, email or fax the completed claim contributions. not acceptable documentation. Each form and documentation to PayFlex bill or receipt must include: at the address or fax number on the You may continue to participate in –– Name of patient claim form. the Health Care Spending Account by –– Date the treatment or service was electing COBRA continuation coverage CLAIM FILING DEADLINE provided (see page 142). By making this election, –– Description of the treatment or You have until March 31, 2014 to submit you may extend your participation in the service given claims for health care or day care Health Care FSA. Although you would expenses incurred: –– Itemized charges for the treatment now make contributions on an after- or service •• Between January 1, 2013 and tax basis, by electing continuation of –– Provider’s name. March 15, 2014 coverage for this account you would still have the opportunity to file claims for •• Mail, email or fax the completed claim •• Before you stopped making reimbursement based on your account form with the original itemized bills, contributions because you balance for the year. Explanation of Benefits (EOB) and experienced a status change during receipts to PayFlex at the address or the year. fax number on the claim form. Filing and Appealing Health Care •• The claims processor will determine and Dependent Care Spending whether the expense is eligible for Account Claims reimbursement. Whenever you file a claim, be sure to DAY CARE SPENDING ACCOUNT keep a copy of the claim and any other Unlike the Health Care Flexible information (such as itemized bills) that Spending Account, you may be you include with the claim. A canceled reimbursed from the Day Care Account check is not acceptable documentation. only up to the amount you have actually You should file your spending account deposited at the time you submit the claims using the claim form found on claim (less any claims that have already MyTexasHealth and www.healthhub. been paid). If your account balance com and send claims to: is less than the amount you request, PayFlex Systems USA, Inc. your reimbursement will equal only Flex Dept. the amount in your account. However, P.O. Box 3039 unpaid amounts are automatically paid Omaha, NE 68103-3039 as additional deposits are made to cover Fax: (402) 231-4310 them. If you enroll in the plan during the www.healthhub.com year, you are eligible for reimbursement only for expenses you incur after You appeal spending account claims becoming a plan participant. in the same way you appeal medical

Spending Accounts claims (described beginning on page Pay your day care expenses to your 41) except you send a spending account provider and ask for a receipt. You will appeal to PayFlex at the above address. only be reimbursed for dependent day care expenses after the actual care has For information on how to appeal a been received. denied claim, see pages 44 – 49.

84 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Income Protection Disability Coverage...... 86 Overview 86 Summary of Disability Benefits 86 Definition of Disability 87 Coordination of Benefits 88 Short Term Disability (STD) 88 Long Term Disability (LTD) 90 Exclusions and Limitations 92 Filing STD and LTD Claims 93 When Coverage Ends 94 Converting Coverages 94 Life and Accident Coverage ...... 95 Overview 95 Summary of Benefits 95 Life Insurance 95 Accidental Death & Dismemberment (AD&D) Insurance 97 Business Travel Accident Insurance 100 Beneficiary Designation 102 Filing Claims 103 When Coverage Ends 104 Continuing Coverage 104 Long Term Care Plan...... 105 Overview 105 Who Can Be Covered 105 Summary of Benefits 105 Income Protection Income

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 85 Disability Coverage Disability Coverage Overview Summary of A pre-existing condition is any injury Disability Benefits or sickness for which you incurred Disability insurance coverage helps you expenses, received medical treatment, meet your financial obligations if you are The table on the next page summarizes care or services including diagnostic unable to work due to your own injury or the disability benefits available to measures, or took prescribed drugs or sickness. This coverage is an important eligible Texas Health employees. medicines within 12 months before your element in your financial planning most recent effective date of coverage. because it provides a continuing source To make your disability benefits go of income if you are unable to work further, you pay for disability coverage Examples of pre-existing conditions because of a disability. Before choosing on an after-tax basis so that any disability include, but are not limited to, the disability coverage, think about how benefits you receive are not taxable following; you and your family would manage income. •• Illness without your salary. Disability coverage is •• Chronic medical conditions provided by CIGNA. See pages 5 – 7 for Base pay is your hourly rate times the information on eligibility. number of hours you are classified in •• Pregnancy the HR/Payroll system to work and that •• Mental health conditions. To protect yourself and your family, you were receiving on your last day as full-time and part-time benefits-eligible an active employee before the date of This limitation does not apply to a employees (as defined on page 5) are disability. Base pay does not include shift period of disability that begins after eligible for the following: differentials, bonuses, overtime earnings, you have been covered for at least 12 commissions, or other compensation. months (counted from your most recent •• Short Term Disability (STD) with effective date of coverage or the effective a choice of a 14-day or 30-day You must have active disability coverage date of any added or increased benefits). elimination period on the date you become disabled to •• Basic Long Term Disability (LTD) receive benefits. If you are absent from If you have a disability that is caused by, •• Additional Long Term Disability. work due to sickness or injury on the contributed to, or the result of a pre- date your STD or LTD coverage would existing condition within the first 12 If you are a PRN, part-time benefits- otherwise become effective, coverage months after your coverage becomes ineligible employee (as defined on becomes effective only after you are effective under the disability plan, your page 165), or medical resident/intern, actively at work for one full day. benefits will be limited to 4 weeks (if you you are not eligible for STD, Basic LTD, were not covered by STD within 12 months or Additional LTD. Physicians employed PRE-EXISTING CONDITIONS before your disability began). by THPG are covered by the STD policy The Texas Health disability plan does not described in this section, but are covered LTD plan benefits will be paid for require evidence of insurability. However, through a separate LTD policy and are not any period of disability caused by, it does have certain limitations and eligible for the Texas Health Long Term contributed to, or resulting from a exclusions for pre-existing conditions Disability Plan. pre-existing condition. when you enroll for the plan during open enrollment or add the benefit after a status change. (New hire enrollment isn’t subject to pre-existing condition limitations). Income Protection Income

86 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Disability Coverage

Definition of Disability After the first 24 months that any You are not considered disabled if monthly disability benefit is payable, the you are able to earn more than 80% of STD LTD plan considers you to be disabled if your base pay. Base pay is your hourly The STD plan considers you to be you are not able to perform the material rate times the number of hours you disabled if you are not able to perform duties of any occupation for which you are classified to work in the HR/Payroll the material duties of your own are reasonably qualified by training, system. Base pay does not include shift occupation only because of disease or education, or experience and you are differentials, bonuses, overtime earning, injury. You could still meet this definition unable to earn 80% or more of your commissions, or any other compensation. if you are performing some of those earnings solely because of disease or It does not include PTO pay. If you duties, provided you are earning less injury. receive a lump sum payment, it will be than 80% of your pre-disability base pay prorated over the time it accrued or the only because of your disease or injury. You must be under the appropriate, period for which it was paid. regular care for your condition from a You must be under the appropriate, licensed physician who is not you or a regular care for your condition from a member of your family. licensed physician who is not you or a member of your family. If your occupation requires a professional or occupational license or certification of If your occupation requires a any kind, the LTD plan does not consider professional or occupational license or you to be disabled solely because you certification of any kind, the STD plan lose your license or certification. does not consider you to be disabled solely because you lose your license or The insurance carrier has the right to certification. ask you to undergo an examination by the physician of its choice to confirm LT D your disability. You are responsible From the date that you first become for providing documentation of your disabled and until monthly benefits are disability to the insurance carrier. payable for 24 months, the LTD plan You may be considered disabled during considers you to be disabled on any day if: and after the elimination period during •• You are not able to perform any week in which you are employed if the material duties of your own an injury or sickness is causing physical occupation solely because of disease or mental impairment that is severe or injury and enough that you are unable to earn •• Your work earnings are 80% or less of at least 80% of your base pay in any your adjusted pre-disability base pay. occupation for which you are qualified by education, training, or experience.

COMPARISON OF DISABILITY PLANS

Coverage When Benefits When Benefits End Amount of Benefit Begin Short Term Disability After 14 continuous See page 88 for a 60% of your base pay, up to 14-day elimination period calendar days of complete explanation $1,700 per week and reduced for disability certain earnings Short Term Disability After 30 continuous See page 88 for a 60% of your base pay, up to 30-day elimination calendar days of complete explanation $1,700 per week and reduced for period disability certain earnings Basic Long Term After 180 continuous See page 91 for a 50% of your base pay, up to Disability days of disability or complete explanation $15,000 per month after STD benefits end Additional Long Term The same date Basic The same date Basic 10% of your base pay, combined Disability LTD benefits begin LTD benefits end with Basic LTD for a total of 60% of your base pay, up to $15,000 per month Income Protection Income

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Coordination of Benefits Short Term Disability (STD) BENEFITS Your disability benefits are reduced Short Term Disability coverage is an Your STD benefits begin after the by other income you may receive. insurance benefit that replaces 60% of elimination period and continue for up Examples of other income include: your base pay, up to $1,700 per week if to 24 weeks following the 14 calendar day elimination period or for up to •• Any amounts you or your dependents you elect coverage under this plan and 22 weeks following the 30 calendar receive (or are assumed to receive) you become disabled while covered. day elimination period, provided you under any governmental program or You may choose: remain disabled for that period. You will coverage provided by statute, because 14 days 30 be required to provide proof of your of your disability Waiting Period days disability from time to time. •• Any Social Security disability or Maximum 24 22 retirement benefits you or your STD benefits are based on your base number of weeks weeks weeks dependents receive (or are assumed pay for which you paid premiums, as that benefits will to receive) for which you are eligible. reported to the insurance company. If be paid This does not include any Social you are disabled, you may receive a Security benefits you were receiving weekly benefit. STD benefits are paid before the date of your disability. Premium Costs More Less by the insurance company, not Texas than than •• Any proceeds payable under another the the Health. The weekly benefit is equal to group disability plan or similar plan. If 30-day 14-day 60% of your current base pay for one option option other insurance is payable, disability week, up to a maximum benefit of $1,700 per week, less other income benefits benefits under this plan will be paid You pay for STD coverage with after-tax you receive (as explained on page 88 on a prorated basis. payroll deductions. Your cost is based under “Coordination of Benefits”). Base •• Any benefit payable (or assumed on your benefits base rate as of October pay is determined on your last day as to be payable) under workers of the preceding year. compensation or similar law an active employee before the date of •• Any amounts paid because of loss of WHEN BENEFITS BEGIN disability. Base pay does not include shift differentials, bonuses, overtime earnings, earnings or earning capacity through You must meet all of the following commissions, or other compensation settlement, judgment, arbitration, or requirements to receive STD benefits: otherwise where a third party may be paid to you. Benefits are paid for each •• You have STD coverage in force on the liable, regardless of whether liability is week for which you are qualified. date you become disabled and on the determined. date the elimination period begins. Your STD benefits will begin only A dependent is anyone who receives •• You are receiving appropriate and after you have completed the 14 or 30 or is assumed to receive benefits under regular care for your condition from calendar day elimination period and any applicable law because of your a doctor who is someone other than your healthcare provider has submitted entitlement to benefits. you or your immediate family and necessary proof of medical care to whose specialty or expertise is the support the claim. You and your dependents, if applicable, most appropriate for your disabling CIGNA has a rigid time line for receipt of will be assumed to be receiving benefits condition(s) according to generally documentation from the provider. If you for which you are eligible from other accepted medical practice. income benefits. Your disability benefits miss the deadline, the claim is denied will be reduced by the amount it is The elimination period is the length of and you must go through the appeals estimated you are receiving from other time you must be continuously disabled process—adding even more time until income benefits. You must provide proof or partially disabled before you qualify benefits are paid if the late claim is that you have applied for other income to receive benefits (either 14 or 30 eventually approved. benefits and that all appeals have days). The elimination period begins on been exhausted. You must also provide the first day you are determined to be documentation that you have been denied either totally or partially disabled. Your other income benefits. disability must continue through the entire elimination period. You may be required to apply for Social Security benefits. If benefits you receive from other sources, including Social Security, result in an overpayment of your Texas Health disability benefits, you must repay CIGNA. Income Protection Income

88 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Disability Coverage

Weekly income benefits are paid for RETURN TO WORK INCENTIVE SUCCESSIVE DISABILITIES the period for which you qualified. You may receive STD benefits if you are A successive disability is a second Your weekly benefit is reduced by any disabled after the STD plan’s elimination disability due to the same cause as the disability retirement, unemployment period and continue working, or return first disability, that occurs less than 30 benefit paid by law or Social Security to work on a limited basis. The weekly days after you have returned to your disability or retirement benefits you or benefit is reduced only if the total of regular job from the first disability, and/ your dependents receive on your own your pay from working plus your STD or if during that 30-day period you earn behalf or for your dependents because benefit payable exceeds 100% of your less than 80% of your pre-disability pay of your disability. The weekly benefit pre-disability base pay. Periodically, the during at least one week. A successive will also be reduced by any disability insurance company will review your disability has: or unemployment benefits paid as a status and will require satisfactory proof result of employment with Texas Health •• No additional elimination period of earnings and continued disability. or as a result of membership with any •• The same maximum benefit period as group or organization or any retirement No disability benefit will be paid and the previous disability. benefits paid after age 65. benefits will end if CIGNA determines For any separate period of disability you are able to work under a modified CIGNA may help you apply for Social that is not considered continuous, you work arrangement and you refuse to do Security Disability Income (SSDI) will be required to complete a new so without good cause. benefits and may require you to file elimination period. an appeal if your request is denied. Rehabilitation During Disability If you refuse to cooperate with or WHEN STD BENEFITS END If CIGNA determines that you are a participate in the Social Security Your disability benefits will end on the suitable candidate for rehabilitation, Assistance Program, your disability earliest of the following events: benefits will be reduced by the amount CIGNA may require you to participate in •• You earn more than 80% of your CIGNA estimates you will receive. You a rehabilitation plan. CIGNA has the sole pre-disability base pay from any may receive Paid Time Off (PTO) or discretion to approve your participation occupation benefits from the Sick Leave Bank/EIB in a rehabilitation plan and to approve •• CIGNA determines you are not while receiving STD benefits, up to a a program as a rehabilitation plan. disabled combined total of 100% of your base CIGNA will work with you, your provider • p a y. and others, as well as with Texas Health • You reach the end of the maximum to perform the assessment, develop the benefit period During your 30-day or 14-day rehabilitation plan, and discuss return •• Your death elimination period, you may use Paid to work opportunities. •• You refuse, without good cause, Time Off (PTO) benefits. If you choose to fully cooperate in all required At CIGNA’s discretion, the rehabilitation to use PTO benefits while receiving an phases of the rehabilitation plan and plan may allow for payment of your STD benefit, it will not be offset with assessment expenses for medical care, education, the STD benefit. You may only receive a • moving, living accommodations or • You are no longer receiving PTO amount that, when combined with appropriate care STD benefit, does not exceed 100% of family care while you participate in the •• You fail to cooperate with CIGNA in your pre-disability earnings. program. the administration of the disability CIGNA has the right to recover any If you do not fully cooperate in all claim, including, but not limited overpaid benefits. To collect an required phases of the rehabilitation to, providing any information or overpayment, CIGNA may request plan and assessment without good documents needed to determine a lump sum payment, reduce any cause, no disability benefits will be paid, whether benefits are payable or the amounts payable under this plan, and/ and all coverage will end. actual benefit amount due. or take appropriate collection activity. Benefits may be resumed if you begin If you are disabled for part of a week, to fully cooperate in the rehabilitation your STD benefit will be prorated. plan within 30 days of the date benefits terminated.

If your STD coverage terminates during a period of disability that began while you were eligible for coverage, STD benefits will continue as long as you remain disabled up to the 180-day maximum. Income Protection Income

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 89 Disability Coverage

Long Term Disability (LTD) WHEN BENEFITS BEGIN The LTD benefit will be prorated for any period less than one month. Texas Health automatically provides LTD benefits begin after you have you with Basic LTD coverage on your been continuously disabled for 180 After 12 monthly LTD benefits payments, first day of eligibility. Basic LTD begins consecutive days or reached the end of your monthly benefit is increased on paying benefits if you remain disabled your STD benefits (whichever is later). each anniversary of the month you first after you have completed the 180-day This is called your elimination period. received an LTD benefit payment. The elimination period. LTD replaces 50% of amount of each increase will be the You must meet all of the following your base pay, up to $15,000 per month. lesser of: requirements: •• 10% of your indexed earnings (base You can increase your LTD coverage •• Your disability starts while you are pay plus any annual increase) from to a total of 60% of your base pay by covered under the LTD plan. the preceding year or purchasing Additional LTD. This plan •• Your disability continues during and •• The rate of increase in the Consumer pays an additional 10% of your base past the elimination period. pay in addition to Basic LTD, up to a Price Index (CPI-W) during the •• You meet the LTD plan’s eligibility combined total of $15,000 per month. preceding year. requirements described on page 86. LTD does not cover pre-existing •• You are under the appropriate care of RETURN TO WORK INCENTIVE a physician. conditions. A condition is considered If you are disabled after the LTD plan’s pre-existing if you incurred expenses, You must provide satisfactory proof of elimination period, you may continue received medical treatment, care or disability before benefits will be paid. working or return to work on a limited services including diagnostic measures, basis and also receive LTD benefits. or took prescribed drugs or medicines BENEFITS within 12 months before the effective During the first 24 months in which The basic monthly LTD benefit is equal date of your LTD coverage. A condition disability benefits are payable, the to 50% of your current base pay, up is not considered pre-existing if it disability benefit is reduced only if the to a maximum benefit of $15,000 per causes a disability that begins after the total of your pay from working plus your month, less other income benefits you LTD coverage has been in force for at LTD benefit payable exceeds 100% of are eligible to receive as described least 12 months or at least 12 months your pre-disability base pay. earlier in this section. If you purchase after the effective date of any added or Additional LTD coverage, your benefit increased benefits. After disability benefits are payable for will be equal to 60% of your base pay, 24 months, the monthly benefit payable Texas Health pays the full cost of Basic up to a combined maximum benefit is the monthly LTD benefit reduced by LTD coverage. You pay for Additional of $15,000 per month. Base pay does other earnings and 50% of your pay LTD with after-tax payroll deductions. not include shift differentials, bonuses, from working. Your cost is based on your benefits base overtime earnings, commissions, or rate as of October 1 of the preceding other compensation paid to you. Base Periodically, CIGNA will review your year. pay is determined on your last day as status and will require satisfactory proof an active employee before the date of of earnings and continued disability. Physicians employed by THPG are disability. covered by the STD policy described in If CIGNA determines you are able this section, but are covered through a The minimum monthly benefit payable to work under a modified work separate LTD policy and are not eligible is the greater of $100 or 10% of your arrangement and you refuse to do for the Texas Health Long Term Disability gross monthly benefit. Benefits are paid so without good cause, no disability Plan. at the end of each month for the period benefit will be paid and coverage will for which you qualified. end.

As described previously, your LTD benefit is reduced by other income benefits such as disability, retirement, or unemployment benefits for which you may be eligible due to your disability. This does not include any Social Security benefits you were receiving before your date of disability. Income Protection Income

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Rehabilitation During Disability To continue receiving benefits, you The 24-month limitation does not may be required to undergo a medical apply to a disability caused by If CIGNA determines that you are a examination by a physician or a schizophrenia or bi-polar disorder. suitable candidate for rehabilitation, functional capacities evaluation and you may be required to participate in •• Alcoholism and Drug Addiction continue to prove your disability. If a rehabilitation plan and assessment or Abuse: After 24 monthly disability you refuse, your disability benefits at CIGNA’s expense. CIGNA has the payments have been paid, no further will be temporarily discontinued until sole discretion to approve your benefits will be payable for any of the the required physical examination or participation in rehabilitation and to following conditions: evaluation has been completed. approve a program as a rehabilitation –– Alcoholism plan. CIGNA will work with you, your SUCCESSIVE DISABILITIES –– Drug addition or abuse. provider and others, as well as with THR If you are confined to a hospital for A successive disability is a second to perform the assessment, develop the more than 14 consecutive days before disability due to the same cause as rehabilitation plan, and discuss return reaching your lifetime maximum the first disability that occurs less than to work opportunities. benefit, the period of confinement six consecutive months after you have will not count against your lifetime At CIGNA’s discretion, the rehabilitation returned to your regular job from the limit. The confinement must be for plan may allow for payment of your first disability, and/or during that six the appropriate care of any of the expenses for medical care, education, month period you earn less than 80% above conditions. moving, living accommodations or of your pre-disability pay during at least family care while you participate in the one month. A successive disability has: SURVIVOR INCOME BENEFIT program. •• No additional elimination period If you die while disabled, a single, lump • If you fail to fully cooperate in all • The same maximum benefit period as sum benefit will be paid under this required phases of the rehabilitation the previous disability. provision if you have an eligible survivor plan and assessment without good (as defined below) and at least three For any separate period of disability cause, no disability payments will be monthly benefits have been payable to that is not considered continuous, you paid and coverage will end. you for a continuous period of disability. will be required to complete a new The survivor income benefit will equal DURATION OF BENEFITS elimination period. 100% of the sum of the last full disability If your disability starts before age 62, LIMITED BENEFITS benefit payable to you plus the amount it will end on the later of your 65th of any earnings from work by which •• Mental or Nervous Disorders: birthday or the date the 42nd monthly the benefit had been reduced for that Disability benefits will be provided benefit is payable. If your disability starts month. A single lump sum payment on a limited basis for disabilities on or after the date you reach age 62, equal to three monthly survivor income caused by or contributed to by it will continue for a certain number benefits will be payable. certain conditions. After 24 monthly of months of disability counted from LTD benefits have been paid, no The survivor income benefit will be the date you complete the elimination further benefits will be payable for paid to your spouse. If you do not have period, as shown in this table: any of the following conditions: a spouse, the benefit will be paid to –– Anxiety disorders your surviving children (including step- Maximum –– Delusional (paranoid) disorders children) who are unmarried, under age Duration of 21 and chiefly dependent on you for Age at Disability LTD Benefits –– Depressive disorders support and maintenance. If you do not –– Eating disorders 63 but less than 64 36 months have a spouse or eligible children, the –– Mental illness 64 but less than 65 30 months benefit will be paid to your estate. –– Somatoform disorders 65 but less than 66 24 months (psychosomatic illness) The benefit will be paid as soon as 66 but less than 67 21 months If you are confined to a hospital for CIGNA receives the necessary written 67 but less than 68 18 months more than 14 consecutive days before proof of your death and disability status. 68 but less than 69 15 months reaching your lifetime maximum If your monthly benefit payments is 69 and over 12 months benefit, the period of confinement more than you are entitled to receive, will not count against your lifetime the plan has the right to apply the Your LTD benefits will end sooner for limit. The confinement must be for overpayment towards the survivor the reasons listed on the next page. the appropriate care of any of the benefit. above conditions. Income Protection Income

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WHEN LTD BENEFITS END Exclusions and Limitations •• Substance abuse related disability (drug or alcohol) unless you are Your LTD benefits automatically end on Disability benefits will not be paid for a participating in a substance abuse the earliest of the following dates: disability resulting directly or indirectly treatment program approved by the •• You earn more than 80% of your from: state. The cost of the treatment must pre-disability base pay from any •• Suicide, attempted suicide, or self- be paid by you or another Texas occupation inflicted injury while sane or insane Health plan (if one is available and •• The insurance company determines •• War or any act of war, whether or not covers this type of treatment). In no you are not disabled declared event will LTD monthly benefits be •• The end of the maximum benefit •• Active participation in a riot paid for substance abuse beyond the earliest of the date you: period •• Commission of a felony –– Have received 24 LTD monthly •• You die •• The revocation, restriction, or non- benefit payments •• You refuse, without good cause, renewal of your license, permit, or to fully cooperate in all required certification necessary to perform the –– Have reached the maximum period phases of the rehabilitation plan and duties of your occupation unless due payable assessment solely to injury or sickness covered by –– Refuse to participate in an •• You are no longer receiving the disability insurance plan appropriate, available treatment appropriate care program or you leave the treatment •• You fail to cooperate with CIGNA in The following exclusions apply only to program before completing it the administration of the disability STD: –– Are no longer following the claim, including, but not limited •• Any cosmetic surgery or surgical requirements of your treatment to, providing any information or procedure that is not a covered plan under the program documents needed to determine health service. Benefits may be paid –– Complete the initial treatment whether benefits are payable or the if disability is caused by an organ plan, not including any aftercare or actual benefit amount due. donation in a non-experimental follow-up services. transplant procedure. Benefits may be resumed if you begin •• Work-related injury or sickness and/ to cooperate fully in the rehabilitation or one in which you are entitled to plan within 30 days of the date benefits benefits from workers compensation. are terminated. In addition, STD or LTD benefits will not be paid for any period of disability during which you are incarcerated in a penal or corrections institution.

The following exclusions and limitations apply only to the LTD plan: •• Disability beyond 24 months (after the elimination period) if it is because of certain mental disorders listed on the previous page. Confinement in a hospital or institution licensed to provide care and treatment for mental illness will not be counted as part of the 24-month limit. Income Protection Income

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Filing STD and LTD Claims For LTD, you must provide the claims AUTHORIZATION AND administrator with written proof of DOCUMENTATION To initiate your claim for STD or LTD your disability within 90 days after the benefits, you are responsible for You may be required to supply the end of your elimination period. If it is following: contacting the insurance carrier within 31 not possible to provide proof within days of the start of your leave of absence. 90 days, the claim is not affected if you •• Signed authorization for the claims Contact CIGNA at 1-(800) 36-CIGNA or give proof as soon as possible. However, administrator to obtain and release 1-(800) 362-4462. unless you are legally incapacitated, you all reasonably necessary medical, must provide proof no later than one financial, or other non-medical You, your medical provider, and year after it is due. Otherwise late claims information that supports your Texas Health will need to provide the will not be covered. disability claim. Failure to submit this insurance carrier or its authorized agent information may deny, suspend, or with required information on your claim See page 149 for information on what to terminate your benefits. as soon as possible. If you are not able do if your claim is denied. •• Proof that you have applied for to meet the filing deadline, through no all other applicable deductible fault of your own, your claim will be Your written description may include: income benefits such as Workers’ accepted if you file as soon as possible. •• The date your disability began Compensation or Social Security Unless you are legally incapacitated, •• The cause of your disability disability benefits late claims will not be covered if they •• The prognosis of your disability •• Objective medical findings that are filed more than one year after the •• Proof that you are receiving regular support your disability, such as tests, filing deadline. Contact the Texas Health and appropriate care for your procedures, or clinical examinations Integrated Disability Management condition from a doctor whose that are accepted as standard department for additional information specialty is most appropriate for your medical practice for your disabling on filing a disability claim. disabling condition according to condition generally accepted medical practice •• A description of the extent of your The STD, Basic LTD, and Additional (The doctor may not be a member of disability, including restrictions LTD plans are fully insured plans and your immediate family.) and limitations that are preventing benefits are paid by CIGNA. •• Objective medical findings that you from performing your regular occupation You may be asked for additional support your disability, such as tests, •• Appropriate documentation of your information about your disability. procedures, or clinical examinations base pay and, if applicable, regular You will be notified of the decision that are accepted as standard monthly documentation of your regarding your claim. Notification and/ medical practice for your disabling disability earnings or payment are made directly to you. condition •• A description of the extent of your •• The name and address of any hospital CLAIM FILING DEADLINE disability, including restrictions or health care facility where you have been treated for your disability You must call CIGNA at 1-(800) 36-CIGNA and limitations that are preventing or 1-(800) 362-4462 within 30 days of the you from performing your regular •• Notification to the claims date of disability for STD and within 30 occupation administrator when you are awarded days after you become disabled for LTD. •• Appropriate documentation of your other income benefits, including the base pay and, if applicable, regular nature of that benefit, the amount, the PROOF OF DISABILITY monthly documentation of your period for which the benefit applies, and the duration of the benefit if it is For STD, you must provide written proof disability earnings being paid in installments. of your disability before payment of •• The name and address of any hospital or health care facility where you have benefits can be approved. Your claim TIMING OF CLAIM PAYMENTS will be denied if you do not provide been treated for your disability. written proof in a timely manner. The claims administrator will begin CIGNA may request that you must paying benefits after your elimination provide the information listed below, period after receiving and approving at your expense, as part of your proof your claim. Benefits will continue as of disability. Failure to provide all of long as you continue to qualify up to this information may delay, suspend, or the maximum period. terminate your benefits. Your benefits are not assignable, which means you may not transfer your benefits to anyone else. Income Protection Income

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SUBROGATION When Coverage Ends LONG TERM DISABILITY COVERAGE The plan has the right to pursue all Generally, coverage for you under the rights of recovery you have against any STD Plan and the LTD Plan ends when If your coverage under the plan ends third party for any benefits provided you are no longer eligible for coverage, because your employment ends or you with respect to your disability. The term you do not elect coverage, you do not have been laid off, you may be eligible “third party” includes any party possibly pay your premiums, or you terminate to convert your Additional LTD coverage responsible for your injuries or illnesses employment with Texas Health. without any evidence of insurability. or your no-fault automobile insurance To be eligible to convert, you must: coverage. You must fully cooperate with Converting Coverages the plan’s efforts to recover benefits •• Have been covered by the LTD plan paid. You are required to notify CIGNA SHORT TERM DISABILITY and actively at work for at least 12 within 45 days of the date any notice is COVERAGE consecutive months given to any other party (including an You may not convert STD coverage •• Make application for conversion attorney) of any intention to pursue or to an individual policy when your insurance within 31 days after investigate a claim to recover damages coverage under the Texas Health STD coverage under the Texas Health due to injuries or illnesses that you Plan ends. group LTD plan ends. sustained. The plan’s subrogation Conversion coverage will be effective rights are a first priority claim against as of the date coverage ends under this all potential liable parties and are to plan. be paid before any other claim for your damages. This applies even if the If you apply more than 31 days after remainder of the payments from the coverage ends under this plan, you third party is insufficient to make you will be required to submit satisfactory whole or compensate you in part or in evidence of good health at your own whole for the damages you sustained. expense. Conversion coverage will be effective on the date CIGNA agrees in The claims administrator reserves any writing to insure you. and all rights to subrogation and/or reimbursement to the fullest extent The coverage under the conversion allowed by statute and customary plan will be those benefits offered at the practice. Neither you nor anyone time you apply. Premiums will be based else may do anything to prejudice on the rates in effect for conversion the claims administrator’s right to plans at that time. receive subrogation or reimbursement without the claims administrator’s prior You may not convert your Additional agreement. LTD coverage if: •• You are retired or age 70 or older; •• You are not in active service with Texas Health because of disability •• The policy is cancelled for any reason •• You are no longer in an eligible class of employees, even though you work for Texas Health. Income Protection Income

94 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Life and Accident Coverage Life and Accident Coverage Overview Summary of Benefits You rely on your paycheck to meet daily When you make your benefit decisions, you should consider those who living expenses. A severe accidental might be affected by your disability or death. injury or your death could jeopardize your family’s financial security. If Pays this death or injury occurs, your family If you: This policy: benefit: To: needs protection. Die Life Insurance Full benefit amount Your beneficiary Texas Health pays the full cost of the Die in an Life Insurance Full benefit amount Your following benefits for full-time and accident and AD&D beneficiary part-time benefits-eligible employees: Insurance Suffer a covered AD&D Percentage of total You •• Basic Life Insurance dismemberment benefit amount •• Basic Accidental Death and Dismemberment (AD&D) Insurance If you are absent from work because Life Insurance cost each year is based •• Business Travel Accident Insurance. of sickness or injury on the date your on your age as of January 1 and your Life and/or AD&D coverage or increase benefits base rate as of October 1 of the Coverage is effective on your first day of in coverage would otherwise become previous year. If you receive an increase eligibility (see page 5). effective, your effective date will be in your base pay during the year, your Full-time and part-time benefits-eligible deferred until you return to active service. Life Insurance coverage will increase employees may purchase the following at the same time. However, your cost for All Life and AD&D claims are calculated benefits: coverage will not increase until the next using your annual base pay at the time of open enrollment period. Your new rate • • Additional Life Insurance your loss. Annual base pay is your hourly for coverage will become effective the •• Dependent Life Insurance rate of pay times the number of hours you following January 1. •• Additional AD&D Insurance. are classified in the HR/Payroll system to work. Base pay does not include shift BASIC LIFE INSURANCE If you and your spouse both work for differentials, bonuses, overtime earnings, Texas Health pays the full cost of Basic Texas Health and are eligible for Flexible commissions, or other compensation Life Insurance coverage for full-time and Benefits, you cannot be covered both as paid to you. Benefit amounts are rounded part-time benefits-eligible employees. If an employee and a dependent on the to the next highest $1,000. you die, your beneficiary will receive a same plan. Also, only one of you may benefit equal to one times your annual cover your children. Life Insurance base pay, up to $50,000. If you have been If you and your benefits-eligible child Your financial plan should include diagnosed as terminally ill, you may also work for Texas Health, your child cannot tools to help your family deal not only qualify for Terminal Illness Benefit, as be covered as an employee and a with your own death, but also with explained later in this section. dependent on the same plan. Therefore, the death of a spouse or child. Texas ADDITIONAL LIFE INSURANCE you cannot cover this child for child life Health provides Basic Life coverage for insurance or family AD&D. you, and you can purchase coverage If you are a full-time or part-time for your spouse and children. You may benefits-eligible employee, you may elect If your spouse is a former Texas Health also increase your own coverage by Additional Life Insurance for yourself employee approved for premium waiver purchasing Additional Life Insurance. in addition to the Basic Life Insurance life insurance through Texas Health, provided by Texas Health. Your cost for you can not cover your spouse as a Additional Life Insurance is based on dependent. your benefits base rate, your age, and the amount of coverage you select. You pay for Additional Life coverage on an after-tax basis. Income Protection Income

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When you first become eligible, you Child life coverage for your fully Your request to change the amount may choose coverage of one, two, three, handicapped dependent child may of coverage may be delayed if the four, five or six times your annual base be continued past maximum age for dependent was in the hospital or pay, up to a combined maximum of a dependent child. Your child is fully disabled due to illness or injury on the $2,000,0001 for Basic and Additional handicapped if he or she is: effective date of the initial enrollment Life coverage. Each open enrollment •• Incapable of self-sustaining or increase. period after your initial enrollment, you employment because of a mental or If your covered spouse has been may increase your coverage by only physical handicap one level, but you may decrease your diagnosed as terminally ill, he or she •• Primarily supported by you. coverage to any level. may also qualify for a Terminal Illness Benefit, as explained later in this You must submit proof of the child’s Employees are guaranteed issue of section. condition and dependence to CIGNA coverage up to $1,000,000. Coverage within 31 days after your child reaches amounts over the $1,000,000 guaranteed EXCLUSIONS the maximum age. During the next two issue amount require employees complete There are no exclusions for Basic Life years, CIGNA may, from time to time, an Evidence of Insurability insurance coverage. require proof of the continued condition application, which contains health related and dependence. After that, CIGNA may questions. The forms must all be returned If an insured commits suicide, while require proof no more than once a year. to Cigna (at the address listed on the sane or insane, within two years from the date his or her insurance under the form) within 60 days of the enrollment. You may cover your dependents for the policy becomes effective, additional Sending the forms to Cigna ensures your following amounts: privacy because Texas Health will never life and dependent life insurance will • —You may elect coverage for see the completed form with employee • Spouse be limited to a refund of the premiums your spouse in $10,000 increments, up responses. When an employee elects a paid on the insured’s behalf. If a to the total amount of your Basic and coverage amount over $1,000,000, the dependent child commits suicide and Additional Life coverage, but no more amount over is placed in a pending is survived by other dependent children than $50,000. Each open enrollment status. Employees only pay premiums on covered under the same certificate, period after your initial enrollment the $950,000 ($1,000,000 - $50,000 Basic) no refund of premiums will be paid. you may increase your spouse’s guaranteed amount until the additional The suicide exclusion applies from the coverage by one level, up to $50,000. pended amount is approved by Cigna. effective date of any additional benefits The cost of spouse coverage is based Once approved, coverage for the total or increases in life insurance benefits. on the employee’s age as of January 1. amount goes into effect as of the approval WAIVER OF PREMIUM FOR date and employees will start paying the •• Each child—You may elect coverage DISABILITY new premium the following pay period. of $10,000 for your eligible children. Newborns may be covered from the If you submit satisfactory proof that you If you have been diagnosed as date of live birth. You pay the same have been continuously disabled for terminally ill, you may also qualify for premium amount for Child Life nine months from the date you were a Terminal Illness Benefit, as explained regardless of the number of children no longer working as a result of the later in this section. covered. disability, coverage will be extended up to age 65. Dependent coverage is not DEPENDENT LIFE INSURANCE Your cost for Dependent Life is based eligible for waiver of premium. If you are a full-time or part-time on which family members you choose benefits-eligible employee, you may to cover. The options for dependent You must submit this proof to CIGNA elect Dependent Life Insurance coverage are spouse only, children only, no later than three months after the coverage for your eligible dependents, or spouse and children. You purchase date the nine month waiting period as defined on pages 5 – 7. To be Dependent Life through payroll ends. Premiums will be waived from eligible for Dependent Life Insurance deductions on an after-tax basis. the date CIGNA agrees in writing to coverage, your dependents do not have waive your premiums. After premiums Dependent life coverage will be delayed to reside with you, be a U.S. citizen, or have been waived for 12 months, they if, on the date the insurance would live in the U.S. Dependent Life coverage will be waived for future 12-month otherwise be effective, the dependent is pays a benefit to you if your covered periods if you remain disabled and confined to his or her home under the dependent dies. submit satisfactory proof that disability care of a physician or is an inpatient continues. Satisfactory proof must You may cover your unmarried in a hospital, hospice, rehabilitation or be submitted to CIGNA three months dependent children from live birth or convalescence center, or custodial care before the end of the 12-month period. older but under age 25, regardless of facility. Coverage will be effective on the student status. date he or she is no longer an inpatient in these facilities or confined at home. 1 Coverage over $1,000,000 (including basic) is subject to evidence of insurability. Income Protection Income

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Amount of Insurance For the purpose of determining the •• Are not currently able to perform existence of a terminal illness, CIGNA all of the activities of daily living If you die while disabled and while will require you to submit the following including eating, transferring, dressing, coverage is continued under this proof: toileting, bathing, and continence, provision, CIGNA will pay a death benefit without human supervision or equal to the amount of coverage in •• A written diagnosis and prognosis by assistance. effect on the date you became disabled. two physicians licensed to practice in However, the life insurance benefit will the United States If a death benefit is payable, it will be be subject to a reduction of coverage •• Supportive evidence satisfactory to reduced by any other paid or unpaid amount because of age, retirement, CIGNA, including but not limited to accidental dismemberment loss. To pay or payment of an accelerated benefit. radiological, historical, or laboratory the death benefit, the insurance company Automatic increases in life insurance reports documenting the terminal must receive written notice of your death benefits will not apply while premiums illness. within 12 months of your death. are waived. CIGNA will pay benefits only if proof of your continuous disability is CIGNA may require, at its expense, an You may be required to undergo a received within one year of the date of examination of you or your dependent physical examination to provide proof the loss. and a review of the documented of your loss before AD&D benefits will evidence by a physician of its choice. be paid. Termination of Waiver Any Terminal Illness Benefit paid will If you experience more than one loss as If premiums are waived, your insurance be deducted from the amount of life a result of the same accident, the plan will end on the earliest of the following insurance payable upon your death or pays benefits for the largest loss amount, dates: your dependent’s death. up to 100% of the total coverage amount. •• The date you are no longer disabled. •• The date you refuse to submit to any Accidental Death & Loss Benefit1 physical examination required by Dismemberment (AD&D) CIGNA. Life 100% Insurance •• The last day of the 12-month period Two hands, two feet, or 100% one hand and one foot of disability during which you fail In addition to Life coverage, you can to submit satisfactory proof of protect yourself and your family Sight of both eyes 100% continued disability. members from the financial hardship One hand or foot 100% •• The date following your 70th birthday. of certain accidental injuries or death and sight in one eye with AD&D coverage. AD&D provides Hearing in both 100% “Disability” or “disabled” means because broad 24-hour protection year round, ears and speech of injury or sickness, you are unable to including coverage during travel. Quadriplegia 100% perform all the material duties of any The plan pays benefits to you if you One burn covering 75% or 100% occupation which you may reasonably have a serious accidental injury, and more of person’s body become qualified based on education, it pays your beneficiary if you die as Paraplegia 75% training or experience. the result of an accident. Death or One burn covering 75% dismemberment must occur as result 50 – 74% of person’s body TERMINAL ILLNESS BENEFIT of, and within 365 days following, the Hemiplegia 50% accident. If you or a covered spouse has a One hand or one foot 50% terminal illness, you may be eligible If you or a covered dependent Sight in one eye 50% to receive up to 75% of your Basic Life becomes totally disabled as a result Speech 50% and Additional Life or Dependent Life of an accident and that disability Hearing in both ears 50% Insurance benefit (to a maximum of is continuous from the date of the $500,000) during your lifetime under accident until your death, your Third degree burn 50% the Terminal Illness Benefit. covering 25 – 49% of beneficiary will receive the amount person’s body of your Principal Sum. Total disability You must be terminally ill (for example, Thumb and index 25% means you: have a prognosis of 12 months or less to finger of the same hand live), as diagnosed by a physician. This •• Are not currently employed to do All four fingers of 25% money can be used to defray medical any type of work for which you are or the same hand expenses or replace lost income during may become qualified by reason of Uniplegia 25% the last months of an illness. education, training or experience or All the toes of 20% the same foot

1 Benefit as a percentage of annual base pay. Income Protection Income

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BASIC AD&D INSURANCE If you AD&D SPECIAL FEATURES Texas Health pays the full cost of Basic have these Seat Belt Benefit AD&D Insurance coverage for full- family Family coverage Basic AD&D coverage provides a seat time and part-time benefits-eligible members: will be: belt benefit for you and your covered employees. Spouse only 50% of your Additional family members. AD&D coverage If you are injured or killed as a result Spouse and ••Your spouse’s If you or your covered family member of an accident, you or your beneficiary children coverage is 40% of dies in an accident as the driver or will receive a benefit based on the your Additional AD&D passenger of a private automobile, extent of the injury as shown in the coverage. and the covered person was properly table on page 97. The maximum benefit ••Each child’s coverage is 10% of your wearing a seat belt at the time of is one times your annual base pay, up to Additional AD&D the accident (as verified in a police $50,000. Benefit amounts are rounded coverage. accident report), a benefit will be to the next highest $1,000. Children Each child’s coverage is payable. If an airbag is activated as only 15% of your Additional Base pay is your hourly rate times the AD&D. a result of the same accident, an number of hours you are classified additional benefit will be payable. The in the HR/Payroll system to work. Here is an example: plans pay an additional $10,000 for use Base pay does not include shift Your base pay = $30,000. of seat belt and an additional $5,000 if differentials, bonuses, overtime earnings, an airbag is activated under the Plan. You elect coverage of 2 times base commissions, or other compensation. pay for family = $60,000. If the police report is not available or it is unclear whether the covered person Basic AD&D Insurance pays benefits Your family includes you and children. in addition to any other benefits you was wearing a seatbelt or positioned in may receive under your Life Insurance Your child loses sight of one eye. a seat protected by an airbag, CIGNA will pay a default benefit of $1,000. coverage if you die as a result of an Benefit payable on basic table on accident. Benefits are paid in a single page 97 = 50% of $60,000 = $30,000. No benefit will be paid if the covered lump sum payment. The percentage of child coverage in person was under the influence of ADDITIONAL AD&D INSURANCE the above table = 15% of $30,000. drugs or any intoxicant while operating $4,500 is the amount payable in this the automobile. If you are a full-time or part-time example. benefits-eligible employee, you may Other Special Features purchase Additional AD&D Insurance. If You purchase Additional AD&D through Basic and Additional AD&D coverage you elect Additional AD&D for yourself, payroll deduction on a before-tax basis, also provides the following special you can also elect AD&D coverage for so the premium reduces your taxable benefits for you and your covered your family. Additional AD&D coverage income. Your cost for Additional AD&D dependents: pays benefits in addition to any other is based on the amount of coverage and benefits you may receive under your coverage level you select. •• Coma Benefit—If you or a covered Life or Dependent Life coverage if death dependent becomes comatose as occurs as a result of an accident. the result of an accident, you receive 1% per month of the principal sum You may elect Additional AD&D coverage less any benefits already paid out or for yourself of one to 10 times your payable for up to 11 months. After annual base pay, up to $750,000. If you 12 months of continuous coma, the elect coverage for your family, all eligible full principal sum is payable less members of your family are covered. any benefit amount paid or payable because of the same accident. If your covered spouse or child is injured or dies as a result of an accident, Monthly benefit payments will cease you will receive a benefit based on the on the earliest of the date all monthly extent of the injury as shown in the payments have been made; the full table for Basic AD&D on page 97 and principal sum is paid; the coma then applying the percentages in the ceases; failure to have any required table in the next column. exam or to give proof of continuous coma; or the policy terminates. Income Protection Income

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•• Day Care Benefit—If you or your Additional AD&D Features •• Rehabilitation Benefit—CIGNA will spouse dies as the result of an pay a Rehabilitation Benefit of 5% •• Bereavement and Trauma accident and your child age 13 or of the principal sum (up to $10,000), Counseling Benefit—CIGNA will under is covered by AD&D and was subject to conditions and exclusions, pay up to $50 per session for up enrolled or does enroll in a child care when the covered person requires to five counseling sessions, up to center within 90 days from the date of rehabilitation after sustaining a $250 and subject to conditions and the accident, the plan pays an annual loss resulting from an accident. exclusions, when the covered person benefit of 3% of your total coverage The covered person must require or immediate family member requires amount (up to $2,000 per child, per rehabilitation within two years after bereavement and trauma counseling year) for the cost of the surviving the date of the loss. because the covered person suffered child’s care in a licensed child care a loss that resulted from an accident. center. This benefit is payable for up Contact Human Resources for more •• HIV Occupational Accident Benefit— to four years from the date of death or information on these special AD&D CIGNA will pay the benefit of 10% until the child turns 13. features. of the principal sum to a maximum •• Dependent Education Benefit—If of $25,000, subject to the conditions COVERED LOSSES you die as the result of an accident, and exclusions, when the employee the plan pays 5% of your total The AD&D plan pays a benefit if you or suffers an injury resulting from coverage amount (up to $5,000 per a covered dependent has a loss within an accident. The accident must year) to each dependent child for 365 days of an accidental injury. The occur during the performance of education. This benefit is payable following table explains when an injury occupational duties and result in to your surviving spouse for up to is covered as a loss. the covered employee acquiring four consecutive years, as long as the and testing positive for Human child: If injury is Immunodeficiency Virus (HIV) to: It must be: –– Enrolls as a full-time student at antibodies within one year of the an accredited school of higher Hand or foot Severed through or covered injury. above the wrist or learning before reaching age 25; •• Hepatitis C Occupational Duties ankle joint –– Continues his or her education as a Accident Benefit—CIGNA will pay Thumb and Severed through full-time student; and the benefit of 10% of the principal index finger or above the –– Incurs expenses for tuition, or four metacarpophalangeal sum, to a maximum of $25,000, fingers of joint fees, books, room and board, subject to conditions and exclusions, same hand transportation and any other costs when the covered person suffers an Sight, speech Entire and payable directly to or approved and injury resulting from an accident. The or hearing irrecoverable loss certified by the school. accident must have occurred during Movement Complete and the performance of occupational of limbs irreversible paralysis This benefit is payable for your duties and resulted in the covered of limbs surviving spouse for up to four person acquiring and testing positive Toes Severed through the consecutive years, as long as your for Hepatitis C within one year of the metacarpophalangeal spouse: joint injury. –– Enrolls in any accredited school to Paralysis Total loss of use of •• Home Alteration and Vehicle limbs with physician retrain or refresh skills needed for Modification Benefit—CIGNA will determination that the employment within one year of the pay the Home Alteration and Vehicle loss is complete and irreversible date of the employee’s accident; Modification Benefit of 10% of the –– Remains enrolled in an accredited principal sum, to a maximum of school; and $25,000, subject to conditions and –– Incurs expenses payable directly to, exclusions, when as a direct result of or approved by the school. the loss, the covered person requires adaptive devices or adaptation of If the dependent child(ren) or residence and/or vehicle to maintain surviving spouse does not qualify for an independent lifestyle. the special education benefits within 365 days of the employee’s death, CIGNA will pay the default benefit of $1,000 to your beneficiary. Income Protection Income

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EXCLUSIONS FOR AD&D •• Sickness, disease, bodily or mental Business Travel Accident COVERAGE infirmity, bacterial or viral infection or Insurance AD&D benefits do not cover injury or medical or surgical treatment, except Texas Health pays the full cost of death caused or contributed to by the for any bacterial infection resulting Business Travel Accident (BTA) following: from an accidental external cut or wound or accidental ingestion of Insurance coverage for all eligible •• Intentionally self-inflicted injury, contaminated food; employees (as defined on page 5). BTA suicide or attempted suicide or self- •• Travel in any aircraft owned, leased or provides coverage if you die or lose a injury while sane or insane; controlled by Texas Health, or any of its body part as the result of an accident •• Commission or attempt to commit a subsidiaries or affiliates. An aircraft will while traveling on Texas Health business. felony or an assault; be deemed to be “controlled” by Texas BTA pays a benefit if you lose part of •• Commission of or active participation Health if the aircraft may be used as your body as the result of an accident in a riot, insurrection or terrorist act; Texas Health wishes for more than 10 while traveling on business for Texas •• Bungee jumping, parachuting, consecutive days, or more than 15 days Health according to the following table: skydiving, parasailing, hang-gliding; in any year; •• Declared or undeclared war or act of •• An accident that occurs while engaged war; in the activities of active duty service Loss Benefit1 •• Flying in, boarding or alighting from in the military, navy or air force of any Life 100% an aircraft or any craft designed to fly country or international organization. Two hands, two feet, or 100% above the Earth’s surface, except as a Accidents that occur while engaged one hand and one foot passenger on a regularly scheduled in Reserve or National Guard training Sight of both eyes 100% commercial airline. This includes an are not excluded until training extends aircraft: beyond 31 days; One hand or foot 100% and sight in one eye –– Being flown by the covered person •• Operating any type of vehicle while Hearing in both 100% or in which the covered person is a under the influence of alcohol or ears and speech member of the crew; any drug, narcotic or other intoxicant Quadriplegia 100% –– Being used for: including any prescribed drug for Paraplegia 75% ŒŒ Crop dusting, spraying or seeding, which the covered person has been Hemiplegia 50% giving and receiving flying provided a written warning against instruction, fire fighting, sky operating a vehicle while taking it. One hand or one foot 50% writing, sky diving or hang-gliding, Under the influence of alcohol, for Sight in one eye 50% purposes of this exclusion, means pipeline or power line inspection, Speech 50% aerial photography or intoxicated, as defined by the law of the Hearing in both ears 50% exploration, racing, endurance state in which the accident occurred; tests, stunt or acrobatic flying; or •• Voluntary ingestion of any narcotic, Thumb and index 25% finger of the same hand ŒŒ Any operation that requires a drug, poison, gas or fumes, unless prescribed or taken under the direction All four fingers of 25% special permit from the FAA, even the same hand if it is granted (this does not of a physician and taken in accordance Uniplegia 25% apply if the permit is required with the prescribed dosage; only because of the territory •• In addition, benefits will not be paid All the toes of 20% the same foot flown over or landed on); for services or treatment rendered by –– Designed for flight above or beyond a physician, nurse or any other person 1 Benefit as a percentage of annual base pay the Earth’s atmosphere; who is: Base pay is your hourly rate times the –– An ultra-light or glider; –– Providing homeopathic, aroma- number of hours you are classified –– Being used for the purpose of therapeutic, or herbal therapeutic in the HR/Payroll system to work. parachuting or skydiving; services; Base pay does not include shift –– Being used by any military authority, –– Living in the covered person’s differentials, bonuses, overtime earnings, except an aircraft used by the Air household; commissions, or other compensation. If Mobility Command or its foreign –– A parent, sibling, spouse or child of your base pay changes, the amount of equivalent; the covered person. your coverage will change on the date your pay changes.

To be eligible for benefits, the loss must meet the plan’s definition according to the table at the top of the next column. Income Protection Income

100 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Life and Accident Coverage

Coverage is effective when you leave The seat belt benefit equals 10% of your If injury is your home or regular work location annual base pay up to a maximum of to: It must be: (whichever occurs later) to begin a $10,000. If you were in a seat that has Hand or foot Severed through or business trip. It ends when you return a working airbag that inflates upon above the wrist or ankle joint home or to your regular work location impact, a benefit of 5% of annual base Thumb and Severed through (whichever occurs first). Everyday travel pay will be paid, to a maximum of index finger or above the to and from work is not covered. Death $5,000. metacarpophalangeal or dismemberment must occur as result joint of, and within 365 days following, the EXCLUSIONS FOR BTA COVERAGE Sight, speech Entire and accident. BTA benefits do not cover injury or or hearing irrecoverable loss death resulting from the following: Movement Complete and BTA coverage has aggregate maximums. of limbs irreversible paralysis The maximum total benefit payable for •• Commuting to and from work of limbs the same accident, regardless of the •• Suicide or intentionally self-inflicted injury, whether sane or insane If you die as the result of an accident while number of employees injured or killed, traveling on business for Texas Health, your is $3,250,000 per accident (except •• Commission of or attempt to commit beneficiary will receive a benefit of one accidents on company owned or leased an assault or felony times your base pay, up to $800,000. aircraft). BTA coverage pays benefits in •• Commission of or active participation addition to any other benefits you may in a riot or insurrection You may be eligible for a benefit if receive under your Life and/or AD&D •• Sickness, disease, bodily or mental you become comatose within 30 days coverage. Benefit amounts are rounded infirmity, bacterial or viral infection of a covered accident while traveling to the next highest $10,000. or medical or surgical treatment on business for Texas Health and of these; exposure (whether or not Benefits are paid in a single lump-sum remain in a coma for 60 consecutive accidental) to viral, bacterial or payment, with the exception of the days. The monthly coma benefit is chemical agents; unless the bacterial coma benefit. 1% of annual base pay, payable for 11 infection results from an accidental months at the end of each month that If you have a covered injury resulting external cut or wound or accidental you are in a coma. A lump sum benefit from an accident while on a business ingestion of contaminated food of 100% of your annual base pay will trip that is approved in advance, you will •• Voluntary ingestion of a narcotic, be paid at the beginning of the 12th be entitled to an additional benefit if drug, poison, gas or fumes, unless month. You must be diagnosed and either: prescribed or taken under the regularly treated by a physician. A direction of a physician and in the •• The loss is the result of unavoidable benefit is not payable for any state of prescribed dosage unconsciousness intentionally induced exposure to the elements because of •• Injury sustained while in the armed during the course of treatment, unless a forced landing, stranding, sinking, or forces of any country or international the state of unconsciousness results wrecking of the form of transportation authority from the administration of anesthesia in which you were traveling at the •• Any act of war, declared or in preparation for surgical treatment of time of the accident or undeclared injuries sustained in a covered accident. •• Your body has not been found within one year of the date that the form •• Travel or flight as a pilot or crew Benefits are reduced if you are over 70 of transportation in which you were member in any kind of aircraft when the accident occurs, as shown in traveling disappeared, made a forced •• Flight in, boarding or alighting from this table. landing, sank, or was wrecked. an aircraft or any craft designed to fly above the Earth’s surface, except as a Benefits will BTA SPECIAL FEATURES fare-paying passenger on a regularly If your age is: be reduced to: BTA pays additional benefits if the scheduled commercial or charter 70 but less than 75 65% loss occurs in an automobile while airline 75 but less than 80 45% properly using a seat belt. Seat belt use •• Operating any type of vehicle while under the influence of alcohol or 80 but less than 85 30% must be verified in the police accident report or, if not mentioned in the police any drug, narcotic or other intoxicant 85 or over 15% accident report, by a signed statement including any prescribed drug for which you have been provided a If you experience more than one loss as from a doctor, paramedic, police officer, written warning against operating a a result of the same accident, the plan coroner, or other person of competent vehicle while taking it pays benefits for the largest loss amount, authority who was at the scene of the • up to 100% of the total coverage amount. accident. • Travel to a location where you are expected to be assigned for more than 60 days Income Protection Income

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•• Any activity not authorized or To name a beneficiary, logon towww. Unless prohibited by law, your life organized, or not reimbursable, by MyTHR.org and click on My Benefits. insurance benefits are distributed Texas Health A new Benefits website will open, click as indicated by your beneficiary •• Any activity not related to the View/Edit Benefits. Next click My Benefits designation. For this reason, you should purpose of the business trip that you to see a list of your current benefits. periodically review your beneficiary do while traveling for business Scroll down the page to #6 Life and designation, especially if you get •• Driving any vehicle or automobile for click View/Edit Information. Under the married or divorced or have or adopt pay or hire. sections titled Life and Voluntary Life is a a child. If there is no living designated Beneficiaries section. Click the word Edit beneficiary at the time of your death, BTA does not provide any benefits and you are ready to add/edit/remove benefits will be paid in accordance while you are performing job duties your beneficiaries. After adding your life with the applicable policy provision. during work hours in a residence work insurance beneficiaries, scroll down to area, as specified in the Texas Health #7 Accident and follow the same steps as If you elect life insurance coverage written telecommuting policy. before. Be sure to enter a beneficiary for for your spouse or children, you are the Basic plans and the additional plans if automatically the beneficiary for their In addition, benefits will not be paid for you elected coverage. insurance benefits. services or treatment rendered by you or any person who is either: The beneficiary you name for Basic Life If more than one person is named as beneficiary, the interests of each will •• Employed by Texas Health Insurance will also be your beneficiary for the Business Travel Accident plan. If you be equal unless you specify otherwise. •• Living your household or do not name a beneficiary designation for The share of any beneficiary who •• The parent, sibling, spouse, or child of each benefit, the beneficiary designation does not survive you will pass equally you or your spouse. you entered for Basic Life will apply to any surviving beneficiaries unless otherwise specified. If there is no named Beneficiary Designation to the other benefits. For example, if you designate a beneficiary in Basic beneficiary or surviving beneficiary, or In the event of your death, benefits for Life but not Additional Life, then the if you die while benefits are payable to Basic and Additional Life, Basic and Basic Life beneficiary will be applied to you, the remaining benefits will be paid Additional AD&D, and Business Travel Additional Life. If both Basic AD&D and to the first surviving class: Accident coverage are paid to your Additional AD&D are missing beneficiary •• Spouse named beneficiaries. To ensure that designations, the Basic Life Beneficiary •• Child or children benefits are paid according to your wishes will apply to those benefits as well. •• Parents in the event of your death, you should go •• Siblings online to designate a beneficiary which You may name anyone as your can be done at any time. beneficiary. However, Life, AD&D, and •• Your estate. BTA insurance proceeds cannot be paid In the event of a covered accidental You may name a different beneficiary to a minor child until the earlier of the injury, AD&D coverage pays benefits to: for each plan or combination of plans if date: you wish. You may name more than one •• You in the case of certain accidental •• The child reaches the age of majority beneficiary for each plan, such as your injuries (age 18 in Texas) or spouse and adult children. Beneficiary •• Your named beneficiary in the event •• A court has appointed a legal information cannot be given or changed of your death. guardian of the minors’ estate. This over the phone. appointment process can be costly, and state law may limit who may be named a guardian of an estate.

As an alternative to naming a minor child as your beneficiary, you can establish a trust for your child and designate the trust as your beneficiary. The trust would receive and manage your life insurance proceeds on your child’s behalf. You should obtain legal advice to determine the best way to set up the trust under Texas laws. Income Protection Income

102 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Life and Accident Coverage

Filing Claims Claim Filing Deadline Claim Filing Deadline Texas Health’s Life Insurance program is In addition to filing a life insurance In addition to filing a life insurance fully insured by CIGNA Group Insurance. claim, your family should notify the claim, you or your family should notify Business Travel Accident is fully insured Texas Health Benefits Specialist of the Texas Health Benefits Specialist of by Life Insurance Company of North your death. They must submit all life the death. Before benefits can be paid, America. They also process all claims. insurance claims within one year of the claims administrator must receive a The following summarizes the procedure your death and provide a certified copy certified copy of death certificate along for filing a claim for life insurance of your death certificate before benefits with all life insurance claims within benefits. can be paid. Claims submitted more one year of the death. Claims submitted than one year after death will not be more than one year after death will not For information on what to do if your considered for payment. be considered for payment. claim is denied, refer to page 149. Send your life insurance or AD&D appeal to: DEPENDENT LIFE INSURANCE ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE CIGNA Group Insurance If your covered dependent dies, contact P.O. Box 22328 the Texas Health Benefits Specialist If you or your covered dependent is Pittsburgh, PA 15222-0328 listed above as soon as possible for injured as the result of an accident, you 1-(800) 238-2125 assistance with the documents needed must contact the Benefits Specialist for processing the claim. You are the at Texas Health, who will help you file Send your BTA appeal to: sole beneficiary for your spouse’s or an AD&D claim. If you or your covered child’s life insurance. When the Texas dependent dies, you must submit CIGNA Group Insurance an original death certificate before Life Insurance Company of North Health benefits department receives benefits can be paid. Benefits will be America notification of a death, they will make paid in a single lump sum payment as Claims Administration appropriate changes in coverage and soon as possible after all information P.O. Box 22328 send you confirmation of the changes. is received. You should consult a tax Pittsburgh, PA 15222-0328 You must submit an original death advisor to be sure you understand the EMPLOYEE LIFE INSURANCE certificate before benefits can be paid. tax consequences of the life insurance Benefits will be paid in a single lump proceeds. If you die, your beneficiary should sum payment if less than $5,000. If the contact Texas Health as soon as payment is $5,000 or more, a checkbook Claim Filing Deadline possible for information about the is issued as soon as possible after all For a covered dismemberment, you benefits payable and the form of information is received. You should must file the claim and provide proof payment. Your beneficiary will receive consult a tax advisor to be sure you of the loss within 20 days of the loss or help with the documents needed for understand the tax consequences of life death. If it is not reasonably possible to processing the claim. Contact: insurance proceeds. provide proof within 20 days, you must Benefits Specialist provide it as soon as possible, but no Terminal Illness Benefit Texas Health Benefits Department later than one year after the loss. For 682-236-7237 To file a claim for a Terminal Illness a covered accidental death, you (or Benefit, you or your covered dependent your beneficiary) must submit all life The Benefits Specialist will send the must be totally disabled and terminally insurance claims within one year of claim form to your beneficiary, which ill (not expected to live more than 12 the death and provide a certified copy must be returned to the Benefits months). Two physicians must certify of the death certificate before benefits Specialist with an original death the terminal status of the covered can be paid. Claims submitted more certificate before the claim can be paid. person. Contact the Benefits Specialist than one year after death will not be at Texas Health to file a claim for a If the payment to one individual is less considered for payment. Terminal Illness Benefit. than $5,000, benefits are paid in a single lump sum payment. If the payment is $5,000 or more, your beneficiary will receive a checkbook that can be used to withdraw the proceeds.

In either case, payment will be made as soon as possible after all information is received. Income Protection Income

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BUSINESS TRAVEL ACCIDENT Continuing Coverage Benefits for Children Who Are No INSURANCE Longer Eligible Dependents PORTABILITY OPTIONS If you die or are injured in an accident A dependent child who is insured and while traveling on Texas Health You or your covered dependents is at least 19 years of age may choose to business, you or your dependents can choose to continue the elected continue life insurance. The dependent should contact Texas Health as soon as additional life insurance amount after child must apply with CIGNA and pay possible. Human Resources will help your benefit ends with Texas Health the required premium within 31 days your beneficiary with the forms and due to termination of employment after the date he or she reaches ages 19 documents needed for processing the or loss of benefit eligibility. You and/ or no longer qualifies as a dependent claim. If you die, your beneficiary must or your dependent may choose to child. provide a certified copy of your death continue life insurance coverage with certificate before benefits can be paid. no proof of insurability by submitting CONVERSION OPTIONS your application and payment to CIGNA Benefits are usually paid in a single You or a covered dependent may within 31 days of the date coverage lump sum payment as soon as possible convert all or any portion of your ends with Texas Health. The portability after all information is received. life insurance that would end due to application may be requested from termination of employment or loss of the Texas Health Benefits Department Claim Filing Deadline eligibility. You may apply for any type of by calling 682-236-7237 or emailing For a covered injury, you must file the life insurance CIGNA offers to persons [email protected]. The claim and provide proof of your loss of the same age in the amount applied coverage will be at the same level within 30 days of the first loss. If it is for, except you may not: as when coverage ended. Coverage not reasonably possible to provide continues to age 70 or until the end of •• Choose term insurance; proof within 30 days, you must provide period for which premiums are paid. •• Apply for an amount of insurance it as soon as possible, but no later than greater than the coverage amount one year after the loss. Before benefits Benefits for You at the time of termination. (Also, the can be paid for a covered accidental conversion policy will not provide death, your beneficiary must provide a If your coverage ends prior to age 70 accident, disability, or other benefits.) certified copy of your death certificate due to termination of employment or loss of benefit eligibility, you may and submit all life insurance claims To apply for conversion, you or your choose to continue the same level within one year of your death. Claims covered dependent must, within 31 of coverage you had as an active submitted more than one year after days after coverage ends, submit an employee at a rate similar to the group death will not be considered for application to CIGNA and pay the rate you paid at the time your Texas payment. required premium. The conversion Health coverage ended. application may be requested from When Coverage Ends If you choose to continue coverage, the Texas Health Benefits Department by calling 682-236-7237 or emailing Your Life, AD&D, and Business you may also elect to continue spouse [email protected]. Evidence Travel Accident coverage, including and child coverage. Employee and of insurability is not required. dependent coverage, will end on the Spouse coverage ends when you (the employee) reach age 70. Coverage for earlier of the date: Contact Human Resources for more a dependent child ends when the child information or to request a form. •• Your employment ends no longer qualifies as a dependent •• You are no longer an eligible child. employee •• You fail to make any required Benefits for Your Former Spouse premium payments A spouse who is legally separated, •• The plan terminates divorced, or widowed from an insured •• Your dependents are no longer employee may choose to continue eligible their life insurance. If your spouse •• Coverage becomes effective after an continues coverage, coverage may also open enrollment period in which you be continued coverage for dependent fail to enroll. children. Dependent child coverage ends when he or she no longer qualifies See page 140 for additional information. as a dependent child. Income Protection Income

104 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Long Term Care Insurance Long Term Care Insurance Plan Overview Who Can Be Covered PORTABILITY You may apply for long term care You may elect coverage for yourself and You may continue coverage after you insurance coverage through Genworth any of the following family members end your employment with Texas Life Insurance Company (Genworth who are ages 18 - 79: Health by paying premiums directly to Genworth Life. Life). Long Term Care (LTC) is not one •• Your spouse service, but many different services that •• Your parents HOW TO ENROLL can help people who have physical or •• Your in-laws cognitive impairments and are unable Although Texas Health makes this to care for themselves for an extended •• Your grandparents/grandparents program available to employees at period of time. Services might include in-law. attractive group rates, Texas Health does assistance in the home for day-to-day not administer the LTC plan. Genworth If you enroll in LTC insurance when first activities or care services in a nursing Life provides complete administrative eligible (as a new hire, or newly benefit home. services for the LTC program, so you eligible employee), you must complete must contact Genworth Life directly to a short application. If you apply If you apply for LTC insurance, request more information or to enroll. Genworth Life will provide you with an during another time, you must provide outline of coverage. This information additional evidence of insurability Call 1-800-416-3624 to speak to a Long from Genworth Life will describe the before coverage becomes effective. Term Care Specialist or go to eligibility, benefits, and terms and https://www.genworth.com/groupltc. Family members must complete a long conditions applicable to LTC insurance Enter “THR” as the group name and enter application with medical information benefits. Genworth Life’s outline governs “groupltc” as the password. The website and be approved before coverage your benefits and takes precedence provides complete details of the program, begins. Your spouse may use the short over any materials that Texas Health including costs, benefits, exclusions and form if he or she is under age 66. provides, including this Handbook. limitations and how to enroll. The following information provides a brief overview of the types of benefits Summary of Benefits available under the LTC insurance plan. You select coverage for a daily benefit amount and lifetime maximum benefit You select coverage for a daily benefit as shown in this table: amount, lifetime maximum benefit and increase option. Key features of the LTC insurance plan are: Daily Benefit •• You can choose a feature that will Amount Lifetime Maximum Benefit increase your daily benefit amount Up to Up to Up to and lifetime maximum benefit to 2 years 3 years 5 years help keep pace with the rising cost of $100 $73,000 $109,500 $182,500 long term care without requiring you to provide evidence of insurability. $200 $146,000 $219,000 $365,000 •• As an employee, if you apply when $300 $219,000 $328,500 $547,500 first eligible, you may use the short enrollment form and answer only a PREMIUMS few medical questions when applying. Your contributions for the cost of You must be approved for coverage. LTC insurance coverage for you and •• There is a 90-day waiting period your spouse may be deducted from before benefits begin. your paycheck on an after-tax basis. •• Coverage is guaranteed to be However, premiums for coverage of all renewable. other covered family members must be paid directly to Genworth Life. Payments must be made in advance. Income Protection Income

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Retirement Texas Health 401(k) Retirement Plan...... 107 Overview 107 Texas Health 401(k) Retirement Plan 107 Contributions 108 Matching Contributions 110 Changing Your Contributions 111 Investing Your Retirement Accounts 112 Plan Loans 114 Plan Withdrawals 115 Plan Distributions 116 Other Provisions 119 Other Texas Health Retirement Plans...... 121 Frozen PHS and HMHS 403(b) Annuity Plan 121 Frozen PHS and HMHS 401(k) Plan 121 Frozen PHS 401(a) Plan 122 Frozen Prior Employer 401(k) Plan 123

106 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Texas Health 401(k) Retirement Plan Texas Health 401(k)Retirement Plan Retirement Overview The members of the People and Culture HOW MUCH YOU MAY Committee are listed on page 153. CONTRIBUTE The Texas Health 401(k) Retirement You may contribute from 1% to 100% of Plan is designed to help you save for The People and Culture Committee your pay, in whole percentages, to your your future. Through contributions to has contracted with JPMorgan to Texas Health 401(k) account, subject to your account, you build income for provide many of the day-to-day limits explained later in this section. For retirement. You can choose from a administrative functions for the Texas example, if you earn $50,000 during 2013, variety of investment options offered by Health Retirement Program, including you can contribute the full $17,500 (see the plan to help meet your goals and recordkeeping. personal investment style. “Legal Limits” on the next page) to the plan by electing a 35% contribution rate. When it was formed in 1997, Texas Texas Health 401(k) Your contributions are automatically Health assumed responsibility for the Retirement Plan taken out of each paycheck and added retirement plans that had previously WHO IS ELIGIBLE to your account in the Texas Health been sponsored by Harris Methodist 401(k) Retirement Trust. All employees of Texas Health are Health System (HMHS) and Presbyterian eligible to participate in the plan. A Healthcare System (PHS) and If you work for more than one person who is treated by Texas Health established the Texas Health 401(k) employer that has adopted the Texas as an independent contractor but who Retirement Plan effective January 1, 1998. Health 401(k) Retirement Plan, your is later determined to be an employee, The plans previously sponsored by HMHS contribution election will apply to your will not be an eligible employee for and PHS are now frozen, meaning that pay from all employers. Certain limits any part of any plan year in which the you can no longer make contributions may apply to your contributions, as person was treated as an independent to them, but they do continue to have described under “Legal Limits.” contractor despite any retroactive investment gains or losses with the recharacterization. CATCH-UP CONTRIBUTIONS market. However, if you had funds in If you are age 50 or older during the one or more of these plans, you may be Contract medical directors are not plan year, you may contribute an able to take loans or withdrawals under eligible to participate in the plan. certain circumstances. additional “catch-up” contribution to WHEN PARTICIPATION BEGINS the plan. The “catch-up contribution” for Together, the Texas Health 401(k) 2013 is $5,500, giving you a contribution Retirement Plan and the frozen plans You are eligible to participate in the maximum of $23,000 for 2013 (annual make up the Texas Health Retirement plan as a new hire. There is no waiting maximum contribution of $17,500 plus Program. Refer to the section “Other period. catch-up contribution of $5,500). Texas Health Retirement Plans” If you have a Texas Health email beginning on page 121 for more address, J.P. Morgan Retirement Plan information on the frozen plans. The Services will send you an email with following sections describe the current a link to a Welcome Guide within two Texas Health 401(k) Retirement Plan. weeks of your hire date. It will contain Texas Health is the plan administrator detailed information about the plan for the Texas Health Retirement Plan. and instructions on how to enroll, along The People and Culture Committee acts with information on rolling accounts on behalf of Texas Health in its capacity over from other qualified plans. as plan administrator. The People and If you do not have a Texas Health email Culture Committee can be contacted at: address, your Welcome Guide will be People and Culture Committee mailed to your home address within two Attn: Executive Vice President, People weeks of your hire date. After you have & Culture received your kit, you can enroll in the THE 401(K) Retirement Plan can Texas Health plan by calling JPMorgan at help provide the financial security 612 E. Lamar Blvd., Suite 900 1-800-345-2345 or online at you will need when you retire. Arlington, Texas 76011 www.retireonline.com. 682-236-7900

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 107 Texas Health 401(k) Retirement Plan

DEFINING YOUR PAY If you exceed these limits, the plan will You can make one or both types return the excess (plus any earnings of contributions. However, your For purposes of making contributions and minus any losses) to you during the combined before-tax and Roth 401(k) to the Texas Health 401(k) Retirement following year. In addition, to comply contributions cannot exceed the IRS Plan, your pay is your W-2 Social

Retirement with IRS rules, Texas Health may change contribution limit for the year. (The limit Security earnings plus your before- the amount of your contributions and for 2013 is $17,500 or $23,000 if you’re tax contributions under the Flexible may be required to return some of your age 50 or older.) Benefits Plan and the Texas Health contributions to you. You may forfeit 401(k) Retirement Plan and certain employer matching contributions, if any, Because you save a percentage of your executive tax-deferred plans. W-2 Social on your refunded contributions. You pay, your contributions automatically Security earnings include, but are not will be notified if the plan administrator adjust when your pay changes. For limited to, your base pay, overtime, shift makes any adjustments to your account. example, if you receive a pay raise, the differentials, Paid Time Off (PTO), and amount you save will automatically PTO cash-out. Federal law limits eligible In addition to the limits noted increase while the percentage of pay wages for 401(k) contributions and the previously, federal law imposes certain saved remains the same. Or, if you work employer match to $250,000 for 2013. discrimination tests that can limit fewer hours than anticipated and earn This limit may be adjusted annually. the amount that highly compensated less than expected, you will save a employees (as defined by the IRS) smaller amount while the percentage of All bonuses, incentive payments, can contribute and receive. Generally, pay saved remains the same. prizes and similar compensation employees earning more than are excluded from the definition of $115,000 in 2013 are considered highly Your individual circumstances will help pay in determining eligible before- compensated employees. The amount you decide whether before-tax or Roth tax contributions and matching of pay that determines whether you 401(k) or a combination of the two are contributions. Payments from the are considered highly compensated is best for you. Separation Pay Plan are not part of indexed for inflation. eligible pay under this plan. BEFORE-TAX CONTRIBUTIONS If you are affected by these limits, the LEGAL LIMITS Your 401(k) contributions are not plan will return the excess (plus any subject to federal income tax at the time Federal law limits the amount you may earnings and minus any losses) to you they are made, but they are subject to contribute to the Texas Health 401(k) during the following year. If you are Social Security and Medicare taxes. You Retirement Plan each year. For 2013, likely to be affected, you will be notified generally pay income taxes when you your total annual contributions (both by the plan administrator. receive money from the plan if you are before-tax and Roth) are limited to not rolling over your account to another $17,500 of your W-2 pay. The $17,500 Contributions qualified plan or IRA. However, before limit also includes contributions you making any withdrawal or taking a You may contribute to the plan in may have made to a similar plan payment from the plan, you should seek before-tax dollars and/or make Roth through another employer during the the advice of a professional tax advisor. same year. 401(k) after-tax contributions to the plan. ROTH 401(K) CONTRIBUTIONS Rollover contributions from a previous Before-tax contributions help you employer’s qualified plan do not count reduce your federal income tax The Roth 401(k) allows you to save on toward these limits. liability immediately. At retirement an after-tax basis, accumulate tax-free your contributions, the matching investment returns, and receive tax-free The 2013 catch up amount for contributions and any earnings are qualified distributions. employees age 50 or older is $5,500. taxable. In addition to these limits on your You must meet two conditions to have a contributions, all contributions, Roth 401(k) contributions are made “qualified distribution” that allows you including your total annual after tax. If they meet certain criteria to receive your Roth 401(k) investment contributions (both before-tax and when you withdraw them, your returns tax-free. (Your Roth 401(k) Roth) and the employer matching contributions and their earnings could contributions are always distributed contributions made on your behalf, be tax free (company match is taxable). tax-free.): are limited to 100% of your annual •• You must have had your Roth 401(k) gross pay or $49,000, whichever is account for five years. less. You may designate your catch-up •• Your distribution must be made contributions as before-tax, Roth 401(k) due to termination, death, disability, contributions, or a combination of both. hardship, or termination of the plan.

108 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Texas Health 401(k) Retirement Plan

Roth 401(k) contributions are added •• If your tax rate in retirement will be So you may need to reduce your Roth to the before-tax contributions, and the lower than in your working years, you 401(k) contribution rate, which can IRS limit applies ($17,500 for 2013, or may come out ahead with before-tax affect your final outcome. However, $23,000 if you are age 50 or older). contributions. qualified distributions from your Roth

•• If your tax rate in retirement will be account will be tax-free (compared to Retirement YOUR CONTRIBUTION OPTIONS higher than in your working years, fully taxable distributions from your As you consider Roth 401(k) Roth contributions may provide more before-tax account), and this may more contributions in addition to or instead income in retirement. than make up for the impact on your of your before-tax contributions, it’s paycheck. important to understand how they differ. However, no one can predict future tax rates due to changes in tax policy and One factor is your current tax rate your individual circumstances. Another compared to your expected tax rate at factor is whether you’ll keep your retirement. contribution rate the same if you begin •• If you expect that your tax rate will making Roth 401(k) contributions. remain the same, there may be Because Roth 401(k) contributions no significant difference between are taken from your paycheck after making Roth and before-tax taxes are deducted, if you elect the contributions. same contribution percentage, your take-home pay will be lower with Roth 401(k) contributions than before-tax contributions.

Before-tax Roth 401(k) Contributions taxed when made No Yes

Contributions taxed when distributed Yes No Investment returns taxed when distributed Yes No, if you take a qualified distribution Eligible for company match* Yes Yes 10% early distribution penalty Yes Yes (on taxable investment returns if the distribution is not a qualified distribution)

Distribution options if you leave the ••Keep your money in the plan** ••Keep your money in the plan** company ••Roll over your money to new ••Roll over your money to new employer’s employer’s plan Roth 401(k), if available ••Roll over your money to an ••Roll over your money to a Roth IRA Individual Retirement Account (IRA) ••Take your money as cash (if money does ••Take your money as cash not remain in Roth 401(k) for at least 5 years, your returns will not be tax-free)

* Company match is before-tax. ** If your balance is over $5,000.

ROLLOVERS FROM OTHER PLANS You may also roll over Roth 401(k) After you log on, click “Texas Health balances into the Texas Health 401(k) 401(k) Retirement Plan,” click “Forms You may be eligible to roll over before- Retirement Plan. and Publications” on the left side in the tax balances from a previous employer’s gray box under Account Detail. 401(k) plan, 403(b) plan, or other To make a rollover from your prior qualified defined contribution plan or employer’s qualified plan into the Texas conduit IRA into the Texas Health 401(k) Health 401(k) Retirement Plan, you Retirement Plan. The rollover must be a must complete a Rollover Application lump-sum distribution of your before-tax and your prior employer must sign off balances from a previous employer’s on the Eligible Rollover Distribution plan or conduit IRA. To avoid tax Certification. These forms are available consequences, you must make a rollover by calling JPMorgan and requesting a contribution within 60 days of the time Rollover Kit or going online to you receive the distribution from your www.retireonline.com. previous employer’s plan.

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 109 Texas Health 401(k) Retirement Plan

If you terminate employment when you Matching Contributions 2013 Employer Match Limits* are partially vested in your matching Texas Health will match a portion of Less than 5 Years $11,250.00 contributions, you will forfeit the non- of Service each dollar you save, up to the first 6% vested portion of your employer match of pay. The match is made each pay 5 Years of Service, $ 15,000.00

Retirement on the earlier of the date you: period and depends on your length but less than 10 Years of Service of service. To receive the match, you •• Have a five-year break in service, or must contribute at least 2% of your 10 or more 10 $ 18,750.00 •• Receive your vested amounts. Years of Service pay each pay period. To receive the A five-year break in service occurs if maximum match, you must contribute *The employer match limit is calculated using the you are not employed by Texas Health at least 6% of your pay each pay current IRS maximum eligible compensation limit of $250,000, then applying the match formula for 60 consecutive months. period. based on years of service. The maximum eligible compensation limit is subject to change due to IRS If you return to work for Texas Health You are eligible to immediately begin regulations. before you incur five consecutive receiving the employer match if you one-year breaks in service, you may were hired before January 1, 2010, or if VESTING have your forfeited amounts restored. you were hired on or after January 1, Vesting refers to your ownership of the Restoration will occur only if you repay 2010, and you have completed one year money in your account. You are always the matching contributions that were of service. Texas Health does not match 100% vested in your own contributions distributed to you by the plan before rollover distributions from a previous (both before-tax and Roth), rollovers the earlier of: employer’s plan. from other employer plans or conduit IRA, and investment returns on these •• Your fifth anniversary of The following table shows the amount amounts. re-employment, or of employer matching contributions you •• The date you incur five consecutive receive based on your years of service You become vested in Texas Health’s one-year breaks in service. with Texas Health. The table assumes matching contributions, any forfeitures that you contribute at least 2% of your allocated to your account, and LENGTH OF SERVICE pay each payroll period. the investment returns on those Your length of service with Texas Health contributions based on your years of determines: If your years For each $1 service as follows: of service with you contribute, •• Your eligibility to receive the match made by your employer Texas Health Texas Health If your years Your vesting 1 2 •• The amount of the matching equal : adds : of service with in the Texas contribution 1 but less than 5 $0.75 Texas Health Health match •• Your vesting. 5 but less than 10 $1.00 equal: is: 10 or more $1.25 Less than 2 None You generally will receive credit for 2 but less than 3 25% one year of service for each 365-day 1 You are eligible for company matching contributions if have completed one year of service. 3 but less than 4 50% period (whether or not consecutive) that you are employed by Texas Health 2 Up to 6% of your eligible pay. 4 but less than 5 75% or another employer that participates 5 or more 100% Federal law limits eligible wages for in the Texas Health 401(k) Retirement the 401(k) employer match which may A year of service is explained below Plan. This period is measured from be adjusted annually. For 2013 it is under “Length of Service.” You become either your first day of employment or $250,000. The table at the top of the next fully vested in your account (regardless your anniversary date of employment column shows the maximum employer of your years of service) in the event during 1997, whichever is later. match that may be received in 2013. of your normal retirement (at age 65), disability, or death. If you reach the employee IRS contribution limit before the end of the How Termination Affects Vesting year, you may not receive the highest If you terminate employment when you possible match from Texas Health are 0% vested in the Texas Health match, because you receive the match only you will forfeit the entire employer when you make a contribution. match. Forfeited amounts are generally

used to reduce Texas Health matching contributions and to pay expenses of the plan.

110 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Texas Health 401(k) Retirement Plan

Service Credit From Other Plans REHIRED EMPLOYEES AUTO-INCREASE FEATURE Your service that was credited to you If you terminate employment with Texas A smart way to make investing for your under the HMHS Plans and the PHS Health and are later rehired, you are retirement easier and more efficient is Plans may also be counted under the immediately eligible to begin making to take advantage of the Texas Health

Texas Health 401(k) Retirement Plan contributions to the Texas Health 401(k) Retirement Plan’s automatic Retirement for purposes of determining the rate 401(k) Retirement Plan. If your break in contribution increase feature. This of matching contribution and vesting service is less than one year, you retain online tool allows you to automatically service. You will be credited with your the vesting date you had. If you are not increase your contribution percentage years of service under the HMHS Plans vested in the matching contribution each year. You decide what percentage and the PHS Plans unless as of the later when you terminate and are rehired and which month you wish the increase of January 1, 1998, or your most recent after you have five consecutive breaks to happen on an annual basis. Your date of employment, your breaks in in service, you will not be credited with automatic increase will occur each year service equal or exceed the greater of your prior vesting service. If you were until you choose to stop the increase or five years or your years of service under employed by Harris Methodist Health you reach the annual plan or IRS limit these plans. System or Presbyterian Healthcare (whichever is lower). You can stop the Resources before August 1, 1997, but automatic increases at any time. Years of service under the HMHS were not credited with any years of and PHS Plans will be based on the service under any of the HMHS or PHS You might consider having your definitions of years of service contained Plans, your service for purposes of the automatic increase occur when you in those plans. Texas Health 401(k) Retirement Plan receive pay increases. It’s a great way will begin on your 1997 anniversary date. to contribute an extra percentage Your service credited to you under You will not be credited with any service automatically, and you won’t notice the pension plan sponsored by before your 1997 anniversary date. the difference in your paycheck. Take Arlington Memorial Hospital may also a look at the graph below to see how a be counted under the Texas Health Changing Your 1% increase each year can make a huge 401(k) Retirement Plan for purposes difference down the road. of determining the rate of matching Contributions contributions and vesting service. To sign up for this service or make any You may change or stop your contributions changes to your account, log on to to the Texas Health 401(k) Retirement If you were employed by Presbyterian www.retireonline.com. Click on your Plan at any time and as often as you would Hospital of Denton on May 30, 2009, plan name, then click on “Contribution like during the plan year. To change or you will receive credit for your years Amount” under Account Management. stop your contributions, simply contact of service with them under the Texas Select the “Auto-Increase” tab to make JPMorgan at 1-800-345-2345 or online at Health 401(k) Retirement Plan. If you your selections. You also may call www.retireonline.com. were employed by Texas Health Partners JPMorgan at 1-800-345-2345. on January 1, 2009, or by Medical Edge/ Your election to change or stop PhyServe on December 31, 2010, you contributions will be effective as soon as will receive credit for all your years administratively practical after JPMorgan of service. Certain acquisitions of the receives your change. Texas Health Physician Group also receive credit for all years of service. Contact the plan administrator for more information. Take a look at what a difference Assumes starting salary of $30,000 with a A break in service is generally a period 1 percentage point could make: 3% annual wage inflation. Contributions of greater than 12 months in which you are made at the end of each month starting at age 22 and continuing until age 65. were not employed by an employer who 3% contribution Annual rate of return is 8% compounded annually. This material has been prepared for has adopted the Texas Health 401(k) 3% contribution increasing at 1% until informational and educational purposes only. Retirement Plan. reaching 6% It is not intended to provide, and should not  be relied upon for, investment, accounting, 3% contribution $443,900 increasing at 1% until legal or tax advice. reaching 10%  The assumptions are for illustrative purposes $842,000 only and are not representative of the  performance of any security. There is no assurance similar results can be achieved, $1,278,500 and this information should not be relied upon as a specific recommendation or an offer to buy or sell securities.

0 300,000 600,000 900,000 1,200,000 1,500,000

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 111 Texas Health 401(k) Retirement Plan

Investing Your Retirement To help you in the investment process, Mutual Fund Choices the Retirement Plan Welcome Guide Accounts You may select any combination of the you receive includes an investment mutual funds offered under the plan. A The Texas Health 401(k) Retirement description of each fund. If you would variety of funds are offered to allow you Plan offers a variety of funds which you

Retirement like more detailed information about to diversify your investment selections may select for the investment of your the individual funds, you can contact to create an investment portfolio account under the Texas Health 401(k) JPMorgan and request a prospectus for consistent with your personal savings Retirement Plan. Each fund invests any of the funds. objectives. Mutual funds typically in specific types of securities and, exhibit a specific style of investing therefore, has different degrees of risk These prospectuses have been prepared which falls into the categories listed and potential reward. by JPMorgan and other investment firms whose funds are offered and have below: The plan trustees may change the neither been reviewed nor endorsed •• Money Market Funds—Managed to investment funds available to you at any by Texas Health. Texas Health does not maintain a stable share price, these time. The plan trustees may also direct guarantee the performance of any of the funds pay a variable rate of monthly that any amounts currently invested in a investments offered under the plan. income based upon the interest fund that is no longer offered under the returns of the fund’s investments. Texas Health 401(k) Retirement Plan Additional information about the These are the most conservative type be reinvested in a new fund. You will be mutual funds currently offered under of mutual funds. the plan is available through notified if the available funds change •• Income or Bond Funds—These seek www.retireonline.com. and of any mandatory reinvestment to offer a high rate of current income. of amounts held in your retirement If you do not choose any investment Both the yield and share price of account. Make your investment choices these funds will fluctuate up or down by contacting JPMorgan. elections, your contributions will automatically be invested in the with changing market conditions. If you do not direct the investment of JPMorgan Smart Retirement Target Date •• Equity or Stock Funds—These funds your account, the plan trustees will Fund dated closest to the year you turn seek to capture the investment invest your contributions on your behalf 65. returns of the various segments of the in the JPMorgan Smart Retirement economy. Typically, individual funds Target Date Fund dated closest to the JPMorgan Smart Retirement are characterized by investments Target Date Funds year you turn 65. in companies of a particular You may select from among the mutual capitalization range (for example, size CHOOSING YOUR INVESTMENT funds described below in “Mutual Fund of the company) and the following OPTIONS Choices” to create your own investment investment styles. The share price Before deciding how to invest your mix. Or you may choose from the target of all of these funds will fluctuate contributions you should take into date funds, or a combination of both. up or down with changing market account your age, earnings from all Target date retirement funds are made conditions. sources, tax bracket, existing savings, up of multiple asset classes. They are –– Growth Funds—Attempt to and future spending needs. Your professionally managed and offer a invest in companies with above investment decisions are your own. No diversified investment in a single fund. average growth prospects. employee or officer of Texas Health Typically, investments are made or your employer is authorized to give These funds are meant to align with in companies that have exhibited investment advice. an expected retirement date. The consistent above average growth, investment allocation will change and/or companies which are Consider all of your options carefully over time. The funds will become expected to exhibit above average before making an investment choice. increasingly more conservative as the growth in the near future. Also keep in mind that any investment target retirement date approaches. –– Value Funds—Attempt to invest in carries a degree of risk. Investments Participants may choose to invest in any companies with a stock price that can go down as well as up in value. If of the other target retirement funds or is considered undervalued relative that happens, as it probably will from any other investments in the lineup. As to the market. time to time, the dollar value of the with all investments, the principal value funds invested in stocks or bonds will of the fund(s) is not guaranteed at any decrease/increase with the market. time, including at the target date.

112 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Texas Health 401(k) Retirement Plan

–– Index Funds—Seek to match, Personal Online Advisor1 If you choose the JPMorgan Personal Asset as closely as possible, the Manager, you pay a fee of 0.6% of your If you prefer to take an active approach investment results of the S&P 500 account balance per year. For example, to managing your account and Composite Stock Price Index, if you have $10,000 in your account, you are looking for more direction or

which emphasizes stocks of receive professional management for Retirement investment advice, Personal Online large U.S. companies by using about $5 a month.2 The fee is deducted Advisor might be the right solution for a passive investment approach. directly from your retirement plan you. Personal Online Advisor, offered Typically, investments replicate the account, so there is no bill to pay and by J.P. Morgan Institutional Investments companies and weightings of a no reduction in your take-home pay. Inc. (JPMII) and powered by Financial style specific index. For more information about JPMorgan Engines®, is a web-based service Personal Asset Manager or to enroll in the –– Global Funds—Invest in common offering a step-by-step action plan program, contact JPMorgan. stocks and other types of securities for selecting investments, deciding of U.S. and/or foreign based how much to save, when to consider CHANGING YOUR INVESTMENT companies, typically with a higher retirement and more. You still control OPTIONS degree of risk and price fluctuation all investment decisions, and you can You may change your investment than domestic, U.S. equity funds. check back regularly for any updated fund elections for existing balances –– International Funds—Invest recommendations. This service is and future contributions (both exclusively in common stocks and available at no cost to you. You can employee and employer) at any time other securities of foreign-based access Personal Online Advisor on by contacting JPMorgan at the phone companies, typically with a higher www.retireonline.com. Simply logon, number or website listed on the inside degree of risk and price fluctuation click the plan name, and then click the back cover. Changes made by 3:00 p.m. than domestic, U.S. equity funds. green “Get advice” button. take effect the same day. Changes made •• Brokerage Account—Allows you to invest a portion of your account in an J.P. Morgan Personal Asset after 3:00 p.m. will take effect the next 1 unlimited number of mutual funds, Manager business day. stocks, and bonds. All fees associated If you don’t have the time or interest A confirmation letter will be sent to you with brokerage accounts will be paid to invest and manage your account, after JPMorgan processes the change. by participating employees. For more consider enrolling in the J.P. Morgan You do not need to complete any information, you can speak with a Personal Asset Manager program, paperwork. Before making any change, Retirement Consultant by calling also offered by JPMII and powered you should review the prospectus of the 1-800-776-6061. by Financial Engines. In this program, funds that you wish to select. Contact investment professionals choose JPMorgan to request the prospectus. your investments and manage your account for you. Fees are based on If you were employed before 1997 or your managed account balance. The were part of an acquisition, you may program uses financial models and have other accounts in addition to the research to create and monitor an Texas Health 401(k) Retirement Plan. investment strategy for you. You can When making investment changes, you access J.P. Morgan Personal Asset are able to designate changes for each Manager and relevant information individual plan. regarding fees on www.retireonline. com. Simply logon, click the plan name, In adherence with securities laws that and then click the green “Get advice” are applicable to mutual funds, Texas button. Health began complying with Rule 22c-2 as of October 1, 2006. This rule is intended to identify and control abusive short-term trading activity in retirement plans with mutual funds.

1 J.P. Morgan Institutional Investments Inc. (JPMII) has hired Financial Engines Advisors L.L.C. (“FEA”) to provide sub-advisory services. JPMII is a federally registered investment advisor. FEA, a federally registered investment advisor and wholly owned subsidiary of Financial Engines Inc., is an independent company that is not affiliated with J.P. Morgan Retirement Plan Services LLC or JPMII. Neither JPMII, FEA, nor their affiliates guarantee future results. Financial Engines® is a registered trademark of Financial Engines, Inc. All other marks are the exclusive property of their respective owners. ©2005-2012. Financial Engines, Inc. All rights reserved. Used with permission. J. P. Morgan Retirement Plan Services provides plan recordkeeping and administrative services. 2 Discounts may apply for accounts over $100,000. Call 1-800-345-2345 for details.

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 113 Texas Health 401(k) Retirement Plan

JPMorgan monitors potential short-term ACCOUNT STATEMENTS Plan Loans abusive trading activity for our funds. Your first-, second-, and third-quarter You will be notified if your account is The Texas Health 401(k) Retirement statements are available only online. identified as having short-term abusive Plan allows you to borrow money from Your fourth-quarter statement will your participant contributions and

Retirement trading activity. Contact JPMorgan for be mailed to your home. Statements specific trading activity rules allowed rollovers in your account. The amount should be available online 10 to 15 for each fund. you may borrow includes 50% of your days after the end of the quarter. (To contributions and the investment QUARTERLY REBALANCING view your statement online, log on returns on those contributions, plus ELECTION to www.retireonline.com, select any rollovers from other plans. You are the account from which you want to The quarterly rebalancing election charged interest for your 401(k) loan print a statement, then click “Account allows you to keep the same investment and must repay your own account. Statements” in the left column. If you allocation percentages over time that prefer to continue receiving quarterly The amount you may borrow is subject you initially selected. If you elect the paper statements, you can opt out of to certain limits. You must borrow a rebalancing feature, each quarter electronic statement delivery anytime minimum of $1,000. The maximum you JPMorgan will automatically buy or sell by contacting JPMorgan. can borrow is the lesser of: shares of mutual funds in your account •• 50% of your contributions and so your investment mix is rearranged to If you were employed before 1997 or rollovers (including investment produce an investment mix that reflects were part of an acquisition, you may returns) or the percentages you originally selected. have other accounts in addition to the Texas Health 401(k) Retirement Plan. •• $50,000—less your outstanding loan For example, you initially invest 40% When making investment changes, you balance during the previous 12- of your account in a bond fund and are able to designate changes for each month period. 60% of your account in a growth fund. individual plan. At the end of a quarter, changes in the You may take only one loan per plan relative value of your investments result Your quarterly statement will show your per calendar year, and may have only in an investment mix that is 45% bond activity for the previous three months one loan per plan outstanding at a time. fund and 55% growth fund. If you select with account balances in the retirement The interest you pay on your loan is the rebalancing feature, JPMorgan will plan based on the last business day of fixed for the period of the loan at a rate automatically sell interests in the bond the quarter. Your account balance is established by the plan administrator. fund and buy interests in the growth the sum of contributions (employee Currently, the loan interest rate is the fund to reestablish your initial 40/60 and employer match) if any, allocated prime interest rate plus 1% as of the investment mix. to your account, plus your investment first of the month when your request gains or losses on those contributions. is received. The loan is secured by the If you were employed before 1997 or Your accounts will reflect gains and remaining 50% of your account balance. were part of an acquisition, you may losses as of the end of the previous have other accounts in addition to the Most employees repay loans through business day. Texas Health 401(k) Retirement Plan. after-tax payroll deductions. When you When making investment changes, you If you want more detailed information take a loan, you choose the repayment are able to designate changes for each about your account statement or the period. Your choice will affect the individual plan. balances of your accounts between amount of your loan payment. The quarterly statements, contact JPMorgan repayment period available for your For more detailed information on or view your information online at loan depends on your reason for taking rebalancing, contact JPMorgan. www.retireonline.com. the loan: •• For a general purpose loan, you can elect a repayment period of up to five years •• For a loan to purchase your primary home, you can elect a repayment of up to 20 years. You must provide documentation of your home purchase.

Choosing Pre-tax or Roth 401(k) Contributions

VISIT WWW.RETIREONLINE.COM for help in making the decision between pre-tax and Roth 401(k) contributions using the Roth 401(k) Planner located under the Financial Tools tab.

114 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Texas Health 401(k) Retirement Plan

Generally, you do not pay taxes on a If the loan is not paid off in full by The following reasons are defined as loan unless you do not repay the loan in the end of default period, it will be hardships: a timely manner. In these cases, the loan defaulted and the balance left on the •• Cost related to the purchase of a may be treated as a taxable distribution, loan will be considered income for the primary residence (not including and if you are under age 59½, a 10% current year. JPMorgan will issue a 1099- mortgage payments) Retirement premature distribution penalty may R form that you will use when filing •• Payment of medical expenses apply. If you terminate employment your taxes. incurred by you, your spouse, or your while the loan is outstanding, your loan dependents that would be deductible will be due in full on the earlier of the Plan Withdrawals on your federal income tax return date you take a distribution or 30 days •• Payment of tuition and board for the after you terminate. If you do not repay Under certain circumstances, federal next 12 months of post-secondary your loan in full by this date, your loan law allows you to make a withdrawal of education for you, your spouse, or is in default. your vested contributions from the Texas Health 401(k) Retirement Plan while your dependents A loan is considered in default if the you are an active Texas Health employee. •• Prevention of your eviction from full amount of any payment is not paid You may make withdrawals when you or foreclosure on your primary by the end of the quarter immediately reach age 59½ or later, or during a time residence following the quarter in which it was of serious financial hardship. Each •• Funeral expenses for your parent, due. In case of default, your account option is explained below. spouse, children or other dependents balance will be reduced by the amount •• Expenses for the repair of damage to IN-SERVICE WITHDRAWALS of the outstanding loan balance that your principal residence that would AFTER AGE 591⁄2 was defaulted. Please consult your tax qualify for a casualty loss deduction. advisor on the consequences of taking You may withdraw all or a part of your a loan from your account. vested account from the Texas Health You will be required to submit proof of 401(k) Retirement Plan without penalty your hardship. Other limitations or rules may restrict while you are an active employee after your ability to borrow from the Texas The amount of hardship withdrawal you reach age 59½. If you do not roll Health 401(k) Retirement Plan. For you receive will be subject to federal the account over, the distributions will additional information or to apply income tax. In addition, if you are be subject to federal income tax, but for a loan, call JPMorgan at 1-800-345- younger than 59½, you must also pay no tax penalties. You may continue 2345. A $50 loan processing fee will be a 10% tax penalty on the amount of contributing to the plan after you take a deducted from your account for each the hardship withdrawal. You do not withdrawal. new loan you take. have to pay the penalty if the hardship To request an in-service withdrawal, go withdrawal is being made to pay LOANS WHILE ON LOA online to www.retireonline.com or deductible medical expenses or if you Employees on a leave of absence (LOA) contact JPMorgan by phone. meet the IRS definition of disability. may make loan payments directly to JPMorgan while on leave. If employees HARDSHIP WITHDRAWALS By federal law, you cannot make contributions to the plan and on a leave of absence do not send their While you are an active Texas Health cannot receive employer matching missed payments directly to JPMorgan, employee (regardless of your age), contributions for six months after you their loan will automatically be re- you may withdraw some or all of your make a hardship withdrawal. amortized when they return to work to contributions, but not the investment bring the loan current. returns on them if you have an If you want to take a hardship immediate and heavy financial need as If your loan reaches maturity while on withdrawal, contact JPMorgan at defined by the IRS. leave, the entire balance will be due in 1-800-345-2345. full based on the default period, which The distribution cannot be more than is the end of the quarter following the the amount of your immediate financial quarter the last payment was made. If need (including applicable taxes) and this occurs, you will need to contact you must already have received all JPMorgan to get the exact balance distributions and all non-taxable loans due and send a manual payment to from this plan and other plans of your JPMorgan to pay off the loan in full employer. before the default period is reached.

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 115 Texas Health 401(k) Retirement Plan

Plan Distributions You will be required to take a minimum RETIREMENT distribution beginning the year you Your normal retirement date under the The Texas Health 401(k) Retirement reach age 70½ if you are no longer Texas Health 401(k) Retirement Plan is Plan generally distributes your full actively at work. If you roll your Roth vested account balance to you when your 65th birthday. You may continue

Retirement money into a Roth IRA, you can avoid to participate in the plan after age 65 if your participation in the plan ends minimum distribution requirements, you are still employed by Texas Health. because you experience one of the have the ability to take out as much or If you continue to work for Texas Health following events. Either you: as little as you like, and leave it to your after age 65, a distribution of your total •• Retire at age 65 or later beneficiaries. account balance (less any outstanding •• Terminate employment with Texas You must meet two conditions to have a loan balance) will automatically be Health “qualified distribution” that allows you made by April 1st following the plan •• Become disabled (as determined by to receive your Roth 401(k) investment year in which you actually retire from the plan administrator) returns tax-free. (Your Roth 401(k) Texas Health. • • Die. contributions are always distributed tax-free.): You can request a distribution by calling JPMorgan at 1-800-345-2345 or •• You must have had your Roth 401(k) by going online to www.retireonline. account for five years. com. The table on this page indicates •• Your distribution must be made the ways you can request a distribution, due to termination, death, disability, depending on the reason for the hardship, or termination of the plan. distribution. A Roth account is separate from the If you request a distribution, your employer match and employee before- account will be valued on the day your tax contribution accounts. distribution is processed by JPMorgan. If you are concerned that your When you take a distribution from a account balance will fluctuate during Roth account, you will receive two the distribution processing period, checks. One check will be for your Roth you may want to consider changing contributions and the other will be for your investment choices to a more the earnings on your Roth account, your conservative investment option. employer match, and employee before- tax contributions, if applicable.

DISTRIBUTION OPTIONS Type of distribution Online at By phone with Request paper form www.retireonline.com JPMorgan from JPMorgan and (800) 345-2345 return to JPMorgan Distribution due to termination X X PHS 401(a) distribution X Hardships X In-service - active employee over age 59 1/2 X X QDROs X* X* Beneficiary distribution (upon employee's death) X* *You must also complete an IRS Form W-9, available online at www.irs.gov.

116 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Texas Health 401(k) Retirement Plan

TERMINATION If you elect to have your vested account You should consult with your tax balance paid in the form of a lump sum, advisor regarding the tax consequences Generally, within two weeks of your the law requires the plan to withhold of any distributions. termination from Texas Health, 20% of your distribution for income JPMorgan will be notified of the If you worked for the company before

taxes. If you are younger than 59½, a Retirement event. At that time, you may request 10% penalty for early withdrawal may 1998, the above information also a distribution from your account by apply. After you return your distribution applies to the Frozen PHS and HMHS logging on to www.retireonline.com form and elect to roll over your account, 401(k), the Frozen PHS and HMHS or by contacting JPMorgan. you will have 60 days from the time 403(b), and the Frozen PHS 401(a). However, you may leave money in Following are restrictions on how your you receive the check to roll over your those plans until April 1 following the account can be distributed. distribution to another employer’s plan or individual retirement account. You year in which you reach age 70½. The If Your Balance is Greater should consult with your tax advisor above information also applies to the than $5,000 regarding the tax consequences of any Frozen Prior Employer 401(k) Plan. distributions. You may leave your money in the Texas Direct Rollovers Health 401(k) Retirement Plan until you If Your Balance is $1,000 or Less reach age 65 while your vested balance You may elect to take all or part of remains $5,000 or more. When you turn If you do not initiate a distribution of your vested account balance as a age 65, JPMorgan will send notification that your account by the end of the quarter direct rollover. A direct rollover is the you are now required to take a distribution. following the quarter in which you payment by the Trustee of your vested terminated, and your vested account account balance to another employer’s If you request a distribution of balance is $1,000 or less (including qualified retirement plan or an IRA. your account after you terminate any rollover account balances), your You can make a direct rollover of part employment, you immediately forfeit vested account will be automatically of your balance and receive the rest of the non-vested portion of your account. distributed to you and you will forfeit it as a direct lump-sum distribution. By If you do not elect a direct rollover the non-vested portion of your account. making a direct rollover to an Individual of your vested account balance, the Retirement Account (IRA) or to an law requires the plan to withhold The law requires the plan to withhold employer’s qualified plan, you avoid 20% of your distribution for income 20% of your distribution for income tax withholding and penalties that you taxes. If you are younger than 59½, a taxes. If you are younger than 59½, a 10% would pay if you received a distribution 10% penalty for early withdrawal may penalty for early withdrawal may apply. payable to you. apply. You should consult with your tax advisor regarding the tax consequences. If you terminate employment and You can also rollover your Roth 401(k) take a distribution in or after the year contributions as long as your new If Your Balance is More Than in which you reach age 55, the 10% employer’s plan accepts rollovers of $1,000, but not More Than $5,000 penalty does not apply. It also does not Roth amounts. If not, you may roll your apply for distributions that are paid Roth 401(k) into a Roth IRA or leave the If you do not initiate a distribution of due to disability, beneficiary claims or money in the Texas Health Retirement your account after termination and Qualified Domestic Relations Orders. Program if it meets the minimum your vested account balance is more balance requirements. than $1,000, but not more than $5,000, If you have an account balance of your vested account balance (and $1,000 or less, you have not elected a any rollover account balances) will direct rollover, and you have not settled be directly rolled over to an individual payment within 180 days of distribution retirement account (IRA) designated by or cannot be located within 180 days the plan administrator. You will forfeit after your account becomes payable, the non-vested portion of your account. the plan administrator will treat your You will be informed of the automatic account as a forfeiture. Your account rollover by JPMorgan in March, June or will be restored if you make a claim September depending on your date of after the account is forfeited. termination. You will be notified of the financial institution that holds your IRA after the rollover is complete.

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REHIRED EMPLOYEES Naming a Beneficiary Unless otherwise designated in writing on a form provided by the plan If you receive your vested account As part of the enrollment process, you administrator, the beneficiary you balance when you terminate and then should complete a Designation of name to receive your accounts under are rehired by Texas Health before you Beneficiary Form. Your beneficiary is

Retirement the Texas Health 401(k) Retirement have a five-year break in service (as the person who will receive the value Plan will also be the beneficiary described under “Rehired Employees” of your Texas Health 401(k) Retirement designated for any other retirement on page 111), the amount of your Plan account(s) upon your death. You plan included in the Texas Health account that was forfeited will be may change your beneficiary at any time Retirement Program. reinstated if you repay the amount of by completing a new beneficiary form. your distribution before either your If you completed a beneficiary Designation of Beneficiary Forms are fifth anniversary of reemployment or designation under the Harris Methodist available online at MyTexasHealth, the date you incur a five-year break in Health System Retirement Plan or www.retireonline.com and at service, whichever occurs first. If you do the Presbyterian Healthcare System your Human Resources office. The not repay the amount of the distribution, Employees’ Retirement Plan before completed form should be sent to: your forfeited account balance will not 1998 and did not complete a new be reinstated. Texas Health form after January 1, 1998, the people DISABILITY Attn: Retirement Administrator named in the designation will be the 612 E. Lamar Blvd. beneficiaries only for those plans If the plan administrator determines Suite 400 and not for the Texas Health 401(k) that you meet the plan’s definition of Arlington, TX 76011 Retirement Plan. disability, you can receive a distribution of your full account balance (less According to federal law, if you are any outstanding loan balance) as married you must have your spouse’s soon as administratively practical. The written consent to designate a distribution will be made according beneficiary other than your spouse. to the procedure described above for Your spouse’s signature on the termination of employment. Designation of Beneficiary Form must be witnessed by a notary public. If If the plan administrator receives you name a beneficiary other than satisfactory evidence that you your spouse but the waiver form has are physically unable or mentally not been signed by your spouse and incompetent to receive the distribution, notarized, your designation is invalid. the plan administrator may make payments on your behalf to your spouse, If you list more than one beneficiary, a relative, or your custodian. the people you name will share your account equally unless you specify DEATH different percentages. You may In the event of your death, your full name both primary and contingent account balance (less any outstanding beneficiaries. A contingent beneficiary loan balance) will be paid as a will receive proceeds only if all of lump sum to your spouse if you the primary beneficiaries die before are married, or to any beneficiary payment is made. you have designated on a properly completed Designation of Beneficiary If you have named your spouse as your Form. Payment will be made as soon beneficiary and later you divorce, the as possible following your death, but designation of your spouse will be no later than the end of the plan year deemed to be revoked if written notice following the plan year of your death. of the divorce is received by the plan administrator before payment has been made.

118 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Texas Health 401(k) Retirement Plan

Other Provisions CLAIMS PROCEDURES NO PBGC COVERAGE QUALIFIED DOMESTIC RELATIONS For information on how to file a claim While a government agency known ORDERS or appeal a claim that has been denied, as the Pension Benefit Guaranty see “Claims Information” beginning on Corporation (PBGC) insures benefits Generally, you cannot pledge or assign page 149. payable under certain types of Retirement your account balance in the Texas retirement plans, it does not insure any Health 401(k) Retirement Plan or any UNCLAIMED BENEFITS of the benefits provided under the Texas other plan that is part of the Texas Health Retirement Program because Health Retirement Program. The plan When you or your beneficiary become each participant’s benefits depend may be required by law to recognize entitled to payment of a benefit, the upon his or her account balance obligations you incur as a result of plan administrator will send you or under the particular plan at the time court ordered child support, agreed your beneficiary a notice of the right to of payment. The PBGC insures only alimony, or as a result of the division of receive the benefit. The notice will be benefits payable under those plans that your community property interest in sent to the last known address of the provide for fixed and determinable your account balance in connection person as shown on the plan’s records. (defined benefit) retirement plans. with your divorce. To bind the plan If the benefit is not claimed within administrator, the court order must be six months after the date the notice NO FIXED BENEFIT AMOUNT a Qualified Domestic Relations Order is mailed (or if the plan is being (QDRO). If you are in the process of ERISA classifies the Texas Health terminated before the effective date of a divorce, the plan administrator can 401(k) Retirement Plan as a “defined the plan’s termination), the benefit may provide you with acceptable language contribution plan.” This means the plan be segregated in an interest-bearing for your court order. does not provide a fixed dollar amount account in your name while the plan of benefit. Your actual benefit will By law the plan must recognize a QDRO, administrator attempts to locate you or depend on the fair market value of your which is a decree or order issued by your beneficiary. account balances under a particular a court that obligates you to pay child plan at the time of distribution. The segregated account will not receive support or agreed alimony, or otherwise Your account balances will reflect allocations of investment returns. It will, allocates a portion of your account contributions and investment earnings however, be entitled to all investment balance to an alternate payee, who may on those contributions. returns it earns as a separate account be your spouse, former spouse, child, and will separately bear all expenses or LIMITATIONS ON EMPLOYMENT or other dependent. If such an order is losses related to its operation. received by the plan, all or a portion of The plan does not give you the right to your account will be used to satisfy the If the benefit is not claimed within continue to be employed by any of the obligation. five years, it will be forfeited. Your participating employers or diminish benefit will be restored after you or your employer’s right to terminate you The plan administrator is responsible your beneficiary is located. You should at any time. for determining whether a QDRO exists. make sure Texas Health always has your When a QDRO is received, the plan AMENDMENT OF THE PLAN current address and the current address administrator will notify the participant of your beneficiary. Texas Health has the right to amend the and each alternate payee and explain Texas Health 401(k) Retirement Plan at the procedures that will be used to If you terminate when your vested any time and for any reason. However, determine its qualification. After the account balance is $1,000 or less no amendment to the plan may: review process is completed, the plan (including any rollover account •• Authorize or permit any part of the administrator will notify the participant balances), you must take a distribution plan’s assets to be used for purposes and each alternate payee of the plan of your account. See page 117 for more other than the payment of benefits administrator’s determination and, if information. applicable, the appeal process that may and the payment of reasonable plan be requested. expenses •• Reduce the amount of your account You may request a free copy of the balance or the vested portion thereof QDRO determination procedure from •• Cause any plan assets to revert to any the plan administrator. employer.

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PLAN TERMINATION WITHDRAWAL BY PARTICIPATING YOUR RIGHTS UNDER THE PLAN EMPLOYER Texas Health has the right to terminate Except for Texas Health’s contributions the Texas Health 401(k) Retirement A participating employer may being conditioned upon the initial Plan at any time and for any reason. withdraw from the Texas Health qualification of the plan, there are no

Retirement Upon termination of the plan, you will 401(k) Retirement Plan at any time. specific plan provisions that provide become 100% vested in all amounts Texas Health, as the sponsor, may also for a disqualification of your status as a credited to your account under terminate the employer’s participation participant under the plan or for denial the plan. Texas Health has certain in the plan at any time. Either way, the or loss of vested plan benefits. options upon termination of the plan participating employer may continue concerning when your benefits will the plan on its own. YOUR ERISA RIGHTS be distributed, and the fact that the See “Your ERISA Rights” on page 152 for TEXAS HEALTH CONTRIBUTIONS plan has been terminated does not more information. CONDITIONED necessarily entitle you to immediate payment of your benefits. Termination Contributions to the Texas Health procedures adopted by Texas Health 401(k) Retirement Plan by Texas Health will be explained to you upon or your employer are conditioned upon termination of a plan. the initial qualification of the plan for federal income tax purposes and the deductibility of the contribution for federal income tax purposes (for for-profit companies). Such conditional contributions can be returned to Texas Health or your employer if these conditions are not satisfied.

120 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Other Texas Health Retirement Programs Other Texas Health Retirement Plans

When Harris Methodist Health System Frozen PHS and HMHS You may receive a distribution of your Retirement (HMHS) and Presbyterian Healthcare 403(b) Annuity Plan full account from the Frozen PHS and System (PHS) formed Texas Health HMHS 403(b) for the same reasons in 1997, Texas Health assumed On October 1, 2001, the following plans (retirement, termination, disability, and responsibility for the HMHS and PHS were merged to form the Frozen PHS/ death) at the same time, and in the Retirement Programs. The former HMHS HMHS 403(b) Plan: same way as described for the Texas and PHS retirement plans were frozen on •• Harris Methodist Health Retirement Health 401(k) Retirement Plan on pages December 31, 1997, which means that no Plan—HMHS 403(b) Plan 116 – 117 except that you may delay one is eligible to become a participant, •• Presbyterian Healthcare System the distribution of your account until no additional contributions may be Section 403(b) Annuity Plan—PHS April 1 following the year in which you made, and all participants are 100% 403(b) Plan. reach age 70½ if your account balance vested. Many of the provisions previously is $5,000 or greater. At that time, your described under the Texas Health 401(k) VESTING account will be distributed in the form Retirement Plan also apply to the frozen of a lump sum to you. You are 100% vested in all contributions PHS and HMHS retirement plans. These made on your behalf. provisions are: Frozen PHS and HMHS •• Investing Your Retirement Accounts— INSURANCE INVESTMENTS 401(k) Plan see page 112 You may have part of your contributions On October 1, 2001, the following plans •• Choosing Your Investment Options— invested in an insurance company were merged to form the Frozen PHS/ see page 112 contract or an annuity contract. You may HMHS 401(k) Plan: •• Changing Your Investment Options— direct the plan administrator to transfer see page 113 all or a portion of these contributions •• Harris Methodist Health System 401(k) Retirement Plan—HMHS 401(k) Plan •• Quarterly Rebalancing Election—see to one or more of the investment funds page 114 available in the Texas Health Retirement •• Harris Methodist Health System Productivity Sharing Plan and Trust— •• Account Statements—see page 114 Program. If you would like to transfer your contributions, please contact HMHS 401(a) Plan •• Plan Loans—see page 114 (not Human Resources. You are 100% vested •• Harris Methodist Health System Thrift applicable to the Frozen PHS in all contributions made on your behalf. Savings Plan—HMHS 401(m) Plan 401(a) Plan •• Presbyterian Healthcare System •• Plan Withdrawals—see page 115 (not Pre-1989 Contributions Section 401(k) Retirement Plan—PHS applicable to the Frozen PHS 401(a) If you were a participant in the HMHS 401(k) Plan. Plan) 403(b) Plan before January 1, 1989, •• Naming a Beneficiary—see you may withdraw any of the savings VESTING page 118 and earnings credited to your account You are 100% vested in all contributions •• Qualified Domestic Relations before January 1, 1989. You may make a made on your behalf. Orders—see page 119 withdrawal for any reason regardless of •• Claims Procedures—page 119 your age or financial need if the savings You may receive a distribution of your •• Unclaimed Benefits—see page 119 were always held in an annuity contract full account from the Frozen PHS and •• No PBGC Coverage—see page 119 maintained by an insurance carrier. HMHS 401(k) for the same reasons •• Limitations on Employment—see You cannot withdraw matching funds, (retirement, termination, disability, and page 119 however. Amounts held by JPMorgan death) at the same time, and in the same way as described for the Texas •• Amendment of the Plan—see are not eligible for withdrawal. You Health 401(k) Retirement Plan on pages page 119 must withdraw eligible contributions 116 – 117, except that you may delay •• Plan Termination—see page 120 (those made before January 1, 1989) and earnings before making any financial the distribution of your account until •• Your Rights Under the Plan—see hardship withdrawal. April 1 following the year in which you page 120 reach age 70½ if your account balance •• Your ERISA Rights—see page 152. is $5,000 or greater. At that time your account will be distributed in the form of a lump sum to you.

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Frozen PHS 401(a) Plan If you are not married on the date your If your spouse has validly waived the benefits are to begin, you will receive right to the death benefit or you are On October 1, 2001, the PHS 401(a) Plan a life annuity unless you elect to waive not married at the time of your death was renamed the Frozen PHS 401(a) Plan. this form of distribution. Under a life and have not begun receiving benefits

Retirement VESTING annuity, you will receive equal monthly under the plan, then your death benefit payments for as long as you live. will be paid to the beneficiary of your You are 100% vested in all contributions choice in a single lump sum. You may made on your behalf. You may elect not to receive the designate a beneficiary using a form automatic form of distribution and available from Human Resources (see PLAN WITHDRAWALS WHILE to receive a lump sum distribution EMPLOYED BY TEXAS HEALTH page 118 for more information). by contacting JPMorgan to request a You may not make any withdrawals distribution form. If you are married, If you die with an account balance from the 401(a) Plan, including your spouse must consent in writing on greater than $5,000, your account hardship withdrawals, while you are a notarized waiver if the value of your balance will be distributed to your working for Texas Health. account is more than $5,000. You may spouse if you are married, unless revoke your waiver election, but your you have elected otherwise with PLAN LOANS spouse may revoke his or her waiver your spouse’s consent in writing on The PHS 401(a) Plan does not permit only if you revoke yours. a form furnished to you by the plan loans. administrator. Your account balance Disability will be paid to your spouse in the form PLAN DISTRIBUTIONS If the plan administrator determines of a survivor annuity—that is, periodic You may receive a distribution of that you meet the plan’s definition of payments for the life of your spouse. your full account from the Frozen disability, you can receive a distribution The size of the monthly payments will PHS 401(a) Plan for the same reasons of your full account balance (less any depend upon the value of your account (retirement, termination, disability, and outstanding loan balance) as soon balance at the time of your death. death), at the same time as described as administratively practicable. The The plan administrator may, however, for the Texas Health 401(k) Retirement distribution will be made according distribute the benefit in a single lump Plan on pages 116 – 117 by contacting to the procedure described above sum, provided your spouse consents in JPMorgan to request a distribution form, for termination of employment. To writing on a notarized form. except as described below. You may request a disability distribution, contact If your spouse consents, you may waive delay your distribution until April 1 JPMorgan. 1 the survivor annuity at any time after the following the year you turn 70 ⁄2. If the plan administrator receives first day of the plan year in which you Distributions Other Than satisfactory evidence that you reach age 35. If your spouse has validly On Death are physically unable or mentally waived the right to the death benefit, or you are not married at the time of your If you are married on the date incompetent to receive the distribution, death and have not begun receiving your benefits are to begin, you will the plan administrator may make your plan benefits, then your death automatically receive a joint and payments on your behalf to your spouse, benefit will be paid to the beneficiary survivor annuity unless you elect to a relative, or your custodian. of your choice in a single lump sum. waive this form of distribution. Under Death a joint and survivor annuity when you If you are not married, your account If you die and your account balance is die, your spouse will receive a monthly will be paid to the beneficiary you $5,000 or less, it will be automatically benefit for the remainder of his or designate in one of the forms described distributed to your spouse (if you are her life equal to 50% or 75% of the above. You may designate a beneficiary married) in a lump sum balance as benefit you were receiving while both on a form available from Human soon as administratively practicable, of you were alive. If your spouse dies Resources (see page 118 for more unless you have elected otherwise before you do, your benefit will not information). be reduced and you will continue to with your spouse’s consent in writing receive the same monthly benefit you on a form furnished to you by the plan were receiving while both you and your administrator. spouse were alive. Although the total value is equivalent to other forms of payment, a joint and survivor annuity may provide a lower monthly benefit amount than other forms of payment.

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Termination Many of the provisions described under Vesting the Texas Health 401(k) Retirement Plan When you leave Texas Health before You are 100% vested in all contributions also apply to the Frozen Prior Employer age 65, you will receive a description made on your behalf. 401(k) Plan. These provisions are: of the annuity distribution and the lump sum option available to you. •• Investing Your Retirement Accounts— Plan Withdrawals While Employed Retirement This information is included with see page 112 by Texas Health the distribution paperwork. You will •• Choosing Your Investment Options— You may receive a distribution of your indicate your choice of the method see page 112 full account from the Frozen Prior of distribution on the form. The tax •• Changing Your Investment Options— Employer 401(k) Plan for the same consequences of the distribution option see page 113 reasons (retirement, termination, may vary, and you should consult with a •• Quarterly Rebalancing Election—see disability, or death) at the same time, tax advisor before making any elections. page 114 and in the same way as described for •• Account Statements—see page 114 the Texas Health 401(k) Retirement Plan on pages 116 – 117. You may Frozen Prior Employer •• Plan Loans—see page 114 also withdraw all or any portion of 401(k) Plan •• Plan Withdrawals—see page 115 your rollover contributions and any The plans sponsored by the companies •• Naming a Beneficiary—see page 118 earnings allocated on them at any time, listed below were transferred to the •• Qualified Domestic Relations regardless of whether you have reached Frozen Prior Employer 401(k) Plan on Orders—see page 119 age 59½. the date indicated. If you were working •• Claims Procedures—see page 119 for one of these companies on the date •• Unclaimed Benefits—see page 119 indicated, your retirement account may •• No PBGC Coverage—see page 119 have been transferred to the Frozen •• Limitations on Employment—see Prior Employer 401(k) Plan: page 119 •• Texas Health Partners, transferred on •• Amendment of the Plan—see page October 19, 2009 119 •• Presbyterian Plan Center for •• Plan Termination—see page 120 Radiation Services, PPCRS, transferred •• Your Rights Under the Plan—see page February 1, 2010 120 •• AMH Cath Lab, transferred on April 1, •• Your ERISA Rights—see page 152. 2010 •• Health First, transferred on May 1, 2010.

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 123 Time Off Time Away From Work...... 125 Paid Time Off 125 Who Is Eligible 125 Accruing PTO 125 Using PTO 126 Converting PTO 126 Selling PTO 127 Donating PTO to Charity 127 Donating PTO to the Helping Hands Fund 128 Receiving PTO from the Helping Hands Fund 128 Time Off Time Receiving PTO as an Incentive 128 Extended Illness Bank/Sick Bank 128 Bereavement Pay 129 Community Time Off 129 Jury Duty 130 Leaves of Absence 130 Benefits During Family and Medical Leave 130

124 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Time Away From Work Time Away From Work Paid Time Off (PTO) PRNs and part-time benefits-ineligible PART-TIME EMPLOYEES employees (as defined on page 165), If you are a part-time benefits-eligible Texas Health recognizes that time away medical residents/interns/fellows are employee (as defined on page 5), you from work is important and necessary not eligible for PTO. Time away from will accrue a percentage of the 80-hour for you to balance work with the rest work for contract medical directors, PTO schedule. For example, if you are of your life. Texas Health offers a Paid physicians and physician extenders classified in the HR/Payroll system Time Off program to help you continue employed by THPG is based on their to work 48 hours per pay period, you receiving pay when you take time contract. off. The primary purpose of the PTO will accrue 60% of the 80-hour PTO program is to provide you pay while you schedule. are away from work due to: Accruing PTO NEWLY HIRED EMPLOYEES Off Time •• Vacation You accrue PTO each pay period beginning on your date of hire. New hires who are eligible for PTO •• Holidays will begin accruing PTO on their date •• Illness or injury FULL-TIME EMPLOYEES of hire. New hires may use PTO as it •• Leave of absence The table below shows the annual is accrued and available, subject to •• Family and Medical Leave. PTO accrual schedule for a full- supervisor approval. time employee. If you are a full-time Paid time off (PTO) is a combination EMPLOYEES ON LEAVE OF employee (as defined on page 5), you of vacation, holiday, and sick time. You ABSENCE accrue PTO as a percentage of the receive PTO based on your employment following schedule. You do not accrue PTO while on paid status, position, and length of service, as or unpaid leave of absence. described below. If you miss work for Annual PTO Accrual more than three consecutive calendar MAXIMUM PTO Positions days due to a medical condition (your You may accrue up to 600 hours of Years of Below Director own or an immediate family member’s), PTO. You will forfeit hours in excess of Service Director & Above you must contact Integrated Disability the maximum accrual. You may carry Management at 1-877-MyTHRLink Less than 2 192 hours 232 hours over up to 600 PTO hours to the next (1-877-698-4754), prompt 6, press 1 to 2 but less 208 hours 248 hours calendar year. Your year-to-date PTO discuss eligibility for leave of absence. than 4 accrual is shown on each paycheck. Although PTO provides pay for a brief 4 but less 232 hours 272 hours illness, to be sure you have protected than 9 your income in case of a longer illness 9 but less 256 hours 296 hours or injury, it is important to consider than 14 Short Term Disability coverage as 14 but less 280 hours 312 hours explained on pages 88 – 89. than 20 20 or more 296 hours 328 hours It is important to manage your PTO bank like a savings account. You want If you are a full-time employee classified to make sure there is enough PTO for in the HR/Payroll system to work vacations and holidays; but also have 64 - 79 hours per pay period, you will some set aside in case you have to miss accrue a percentage of the 80-hour work due to illness or disability. PTO schedule. For example, if you are classified in the HR/Payroll system Who Is Eligible to work 64 hours per pay period, you will accrue 80% of the 80-hour PTO Both full-time and part-time benefits- schedule (64 hours is 80% of 80 hours). eligible employees (as defined on page 5) are eligible to receive PTO.

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 125 Time Away From Work

Using PTO EXEMPT EMPLOYEES Converting PTO PTO provides you with pay while you If you are an exempt employee, you By converting PTO, you can use some take time off from work for vacation, must use PTO in full-day increments of the PTO pay you earn in the current holiday, illness, or disability. Your annual based on your schedule for the day, year to instead pay for Flexible Benefits PTO accrual is based on your standard unless you are on an intermittent during this year. During annual benefit hours in the HR/Payroll System and FMLA leave. If you are on an approved enrollment, most employees can elect to your years of service. Subject to your intermittent FMLA leave and you convert up to 80 hours of PTO (in eight- supervisor’s approval, you can use your choose to use your PTO for the portion hour increments) that you will earn PTO as soon as it is accrued, up to the of the day not worked, you must use next year to pay for next years Flexible amount that matches your scheduled PTO in hourly increments. If you are Benefits. The value of PTO hours you hours in the HR/ Payroll system. If an exempt employee who is not on elect to convert will be deducted from you are a full-time employee, you are intermittent FMLA and you miss a your paycheck over 26 pay periods encouraged to take at least 10 days (80 portion of a scheduled day, you are paid based on your hourly rate of pay at the hours) of PTO each year. for the full day without the addition of time the PTO is converted. To be eligible Time Off Time PTO. to convert PTO, you must elect at least You may use PTO when you are away one Flexible Benefit option (Medical, NON-EXEMPT EMPLOYEES from work on a regularly scheduled day, Dental, Vision, Additional Life, Additional unless it would cause you to exceed the If you are a non-exempt employee and AD&D, Short Term Disability, Additional number of hours you are classified in do not work your regularly scheduled Long Term Disability, Dependent Life the HR/Payroll system to work. However, hours, you can decide whether to use Insurance, or a Flexible Spending there are some exceptions. PTO to bring you up to the hours for Account) during the open enrollment the week according to your Full-time period. The hours you convert are You cannot use PTO if: Equivalent (FTE) defined in the HR/ included in the 100-hour annual •• Your absence is due to jury duty. Payroll system. maximum for the selling, converting, •• You are receiving bereavement pay. and donating of PTO. You may convert For example, if your FTE is 100% (40 a maximum of 80 hours per year. PTO You may use PTO, but are not required hours per week) and you work 36 hours conversion is suspended while you are to use it if: during the week, you may use four on a leave of absence. hours of PTO or choose to be paid for •• You have not worked the hours you 36 hours. You may not use PTO during are regularly scheduled to work any pay week if using it would cause according to your status in the HR/ you to exceed the number of hours Payroll system you are classified in the HR/Payroll •• You are on military reserve training system to work. If you do not notify your or duty. supervisor of your choice, no PTO hours •• You are not at work or are sent home will be added. because of low census or other business reason. •• You are on a leave of absence.

Exempt employees must use PTO in full- day increments unless on intermittent FMLA.

If you are receiving STD or workers’ compensation temporary income benefits, you have the option of receiving PTO to make up the difference between your regular weekly base pay and your STD or workers’ compensation benefits. However, the combined amounts cannot be more than 100% of your normal base pay.

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Selling PTO TERMINATING EMPLOYMENT Donating PTO to Charity The primary purpose of the PTO If you leave Texas Health, you will be paid You may sell your PTO hours to Texas program is to provide you with pay while for 100% of your accrued and unused Health and direct that the net after-tax you are away from work for vacation, PTO hours (up to 600 hours), provided proceeds from the sale be donated to illness, or disability. However, there may you continue to work for at least two one or a combination of the following be times when you need additional weeks (four weeks for management charities: employees and supervisors) after giving income for an unexpected expense. •• Community Giving written notice of your intent to resign. You may sell PTO two times a year, up If you do not give proper written notice, –– United Way to an annual total of 80 hours anytime your PTO will be reduced to offset the –– American Cancer Society during each calendar year, based on pay- amount of notice not given. PTO hours –– American Heart Association period ending dates. You must maintain may generally be used only during the –– March of Dimes at least 80 hours of PTO after the sale. notice period for PTO scheduled and –– Susan G. Komen for the Cure Each hour of PTO is valued at your approved by your supervisor before Foundation Time Off Time regular hourly pay rate. You may sell a you give notice. You may not use PTO to •• Texas Health Associates maximum of 80 hours per year. extend pay or benefits after your last day –– Arlington Memorial Hospital, Inc. of work. The hours you sell are included in the –– Harris Methodist Health 100-hour annual maximum for selling, If you switch to a status that is not Foundation converting, and donating PTO. For eligible for benefits (such as full-time to –– Presbyterian Healthcare example, if you converted 40 hours PRN), you will be paid for 100% of your Foundation. during open enrollment and have accrued and unused PTO, up to 600 not sold any PTO this year, you have hours, within two or three pay periods You may sell up to 80 hours of PTO for 60 hours that can be sold or donated after your change. Your PTO cash-out charity any time during the year, as long during 2013. However, if you have will be subject to applicable payroll as you maintain at least 80 hours of PTO donated 40 hours and converted 40 taxes and 401(k) deductions if you are after the sale. The hours you donate hours this year, you only have 20 hours enrolled in the 401(k) Plan. are included in the 100-hour annual available to sell during 2013. maximum for the selling, converting, CHANGING EMPLOYERS and donating of PTO. When you sell PTO, you will receive 80% If you work in a department, division, of the value of your sold PTO hours When you sell your PTO for donation or operating unit or an affiliate or as a cash payment, less the applicable to a charity, the proceeds are reported subsidiary that Texas Health sells or payroll taxes. The 20% penalty is as taxable income to you. Your PTO otherwise transfers to a third party and imposed for tax-related reasons. If you donation will be subject to applicable you are employed by the new owner, participate in the Texas Health 401(k) payroll taxes and 401(k) deductions (if your PTO will be transferred to your Retirement Plan, your contribution to you are enrolled in the 401(k) Plan). new employer if Texas Health and the 401(k) Plan will also be deducted the new owner agree to the transfer You may be able to claim the net from the PTO payment. before the date you are employed by after-tax proceeds of the sale as a tax- Contact Human Resources if you are the new owner. If the new owner does deductible charitable contribution if interested in selling PTO. You cannot be not agree to the transfer, you will be you itemize tax deductions when you suspended at the time you choose to paid your PTO as if you had terminated file your income tax return. sell PTO or when the payment is made. employment, as explained above. BENEFICIARY Due to IRS regulations, the combined amount of PTO you convert, sell, and In the event of your death, your PTO donate must be less than 100 hours balance will be paid to the beneficiary per year. Each plan has an individual you named for Basic Life Insurance. maximum, as well. This maximum does not apply to Helping Hands donations.

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Donating PTO to the Receiving PTO from the Receiving PTO as an Helping Hands Fund Helping Hands Fund Incentive The Helping Hands Fund is a program To be eligible to receive PTO benefits You cannot receive extra PTO as an that gives Texas Health employees a way from the Helping Hands Fund, you must: incentive to participate in philanthropic to help other employees. •• Be missing time from work events or activities. PTO can only be earned through the normal accrual process. You may donate PTO to the Helping •• Be an active, benefits-eligible 1 employee with at least 90 days of Hands Fund. Then, an employee who Extended Illness Bank/ must miss work due to a personal/ service family illness or a catastrophic event •• Have already applied for short-term Sick Bank and has used all of his or her PTO can disability benefits (if applicable) Before the formation of Texas Health, apply and, if approved, receive PTO •• Have exhausted all other means of some employers had an Extended Illness hours from the fund. help, including using all of your PTO Bank (EIB) or Sick Bank program to •• Not currently be receiving income provide paid time off for illness or injury. Time Off Time A central system-wide Helping Hands benefits from another source such These programs are now frozen and Committee administers distributions as short-term disability or workers’ no longer accrue hours, but employees from the fund. They will consider compensation may use their previously accrued hours the nature of the catastrophic event, •• Have not given away work shifts, etc. under certain circumstances until their employee’s economic circumstances, •• Demonstrate that an unpaid leave will accounts are depleted. the estimated length of absence from create a financial hardship work, and the amount of PTO requested. Employees with hours credited to the •• Not have received more than 80 former Presbyterian EIB or the Harris To be an employee donor, you: hours of PTO from the Texas Health Methodist Sick Bank before January 1, Helping Hands Fund in the same •• Must be an active, benefits-eligible 1998, or the Arlington Memorial Hospital calendar year employee with at least one year of Sick Bank before January 1, 2000, or service •• Be in good standing at your entity Presbyterian Hospital of Denton EIB and are not under any type of •• May make a single donation of PTO before May 1, 2009, can access them disciplinary action program. (in one hour increments), or you can after three consecutive days of absence due to illness or injury. If your schedule sign up to make regular donations of The PTO you receive is considered is 12 hours a day, you will have to take PTO each pay period. taxable income and will have other 36 hours of PTO before you are eligible •• Have enough PTO in your bank that deductions taken from it, such as your to use EIB. You may use PTO time, if you will have at least 80 hours left 401(k) contribution. You can receive a 2 available, during the three-day waiting after making the donation. maximum of 80 hours of donated PTO period. You cannot substitute EIB or Sick in a calendar year. Because the PTO that you donate to the Bank to replace the three days of PTO. Helping Hands Fund is actually used by The Helping Hands Fund is not You may use EIB/Sick Bank hours for an other employees to take time off, there intended to act as an income approved FMLA leave of absence. You is no maximum donation and it does replacement fund or to help people cannot transfer EIB or Sick Bank time not count toward the 100 hour annual who don’t have catastrophic situations. maximum that includes PTO you sell, between accounts or exchange them for donate, or convert. Because no taxes When you apply for the Helping Hands PTO. Unused time will not be paid out have been withheld from the PTO you Fund, you will also be referred to the upon your termination of employment donate, the donation itself is not tax MHN EAP (see page 60) to identify other or change in status to benefits-ineligible deductible. To donate PTO, complete the community resources and services that regardless of your years of service. PTO donation form on MyTexasHealth may be of additional help to you. Contact If you terminate or have a change in or go to Human Resources. Human Resources to request a donation status to benefits-ineligible (such as PRN from the Helping Hands Fund. or part-time benefits-ineligible as defined on page 165) you will forfeit your EIB or Sick Bank time even if you are later rehired or move back into a benefits- eligible status.

1 You cannot donate PTO from frozen accounts. 2 The 80-hour minimum does not apply to chaplain residents.

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Bereavement Pay To receive bereavement pay while on •• Hours may be taken incrementally as any of the eligible leave types you must approved by a manager. If you are a full-time or part-time do the following: •• CTO hours are categorized as benefits-eligible employee (based on productive paid time so the CTO the employee’s eligibility requirements •• Integrated Disability Management hours worked count toward the as defined on page 5) in an active status, (IDM) must be notified by the calculation of overtime. when a family member dies you can employee, the manager, or Human •• Both exempt and non-exempt take days off with pay to grieve, attend Resources of the death of the eligible employees should report CTO time the funeral, make funeral arrangements, family member and the expected to their department time keeper for or settle the estate. The time off does not amount of days off as listed in the tracking on THR’s annual Community need to be consecutive. table on this page. •• The IDM department will inform Benefit report. THR does many You are paid at your base pay for the employee of the required activities in and for the community each hour you are away from work for documentation (a copy of the and we want to make sure that the bereavement, to the amount based on death certificate, obituary or funeral hours you work in this capacity are the number of hours you are classified program). Upon the receipt of the tracked in this report each year. Off Time to work in the HR/Payroll system. You documentation, the IDM department •• Exempt employees do not receive may be eligible for bereavement pay for will send a request to the applicable additional compensation for the following: Payroll Department for payment of participating in CTO projects. bereavement. •• Non-exempt employees must be paid Amount Relationship to •• The applicable Payroll Department for all CTO hours worked. of Days Employee* will process the request via a pay •• Managers may flex a non-exempt sheet. employee’s hours to compensate for Up to ••Spouse CTO to avoid placing the employee in three ••Child or step-child days You will be paid only for the number of overtime. ••Grandchild hours you were classified to work in the •• CTO cannot be donated. ••Sibling, step-sibling, HR/Payroll system. or spouse’s sibling •• CTO cannot be used to solicit funds ••Parent, step-parent, Community Time Off or donations from employees and or spouse’s parent is to be used strictly for community ••Grandparent Each full-time and benefits-eligible volunteerism. ••Great-grandparent part-time employee is eligible for up Your responsibilities: ••Son- or daughter-in- to one regularly scheduled workday law of paid time off per year to volunteer •• Log on to Employee Volunteer Tool ••Brother or sister-in- at a hospital/entity/system sponsored located at www.TexasHealth.org/ law community benefit event and/or TexasHealthGives. ••Niece or nephew for a non-profit organization in the •• Complete your employee profile. Up to ••Aunt or uncle of community. Hours may be taken •• Read the CTO policy. one day employee incrementally, as approved by your •• Join an existing project or propose • Spouse of grandchild • manager. CTO hours are non-productive a new project and submit your ••Brother- or sister- paid time that counts toward hours CTO request two weeks prior to the in-law of employee’s worked, however is not meant to place spouse volunteer project. an employee into overtime. ••Niece or nephew of •• Your supervisor will receive an email employee’s spouse Guidelines for the program are: requesting approval of your CTO ••Great-grandchild project. • • Full-time and benefits-eligible part- •• If your project is approved by your * Applies to current step relationships only. time employees receive one full, supervisor, report CTO hours to scheduled workday per year for CTO You may not receive bereavement pay department personnel responsible •• The activity must be within the Texas during any pay week if using it would for payroll entry (CTO payroll code) Health service area. cause you to exceed the number of before payroll Monday. hours you are classified to work in the •• It must benefit a charitable 501(c)3 or HR/Payroll system. 170c-1 (school) organization. •• The activity utilizes Texas Health paid An employee on any approved leave of time. absence (paid or unpaid) may receive •• Your manager’s approval is required bereavement pay. prior to using CTO and is contingent on business and operational needs.

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Qualifying charitable organization is You may not use jury duty leave during •• Voluntary AD&D one that is tax-exempt under section any pay week if using it would cause •• Long Term Care (LTC) 501(c)3 or 170c1: you to exceed the number of hours you •• Health Care Flexible Spending •• Healthcare organization/ are classified to work in the HR/Payroll Account. social services—all health care system. You may not participate in the Day Care organizations qualify, including Flexible Spending Account during a community health activities that Texas Leaves of Absence leave of absence. Health may organize that benefit the Full-time and part-time benefits-eligible community at large. CTO is not for employees (as defined on page 5) may If you continue coverage during your personal benefit such as visiting a take the following types of leave: leave, you will pay the same cost of sick relative or friend. •• Family and Medical Leave coverage as active employees pay. If you •• Faith organizations—all faith do not pay your premiums, your benefits •• Military Leave organizations qualify for CTO as will be canceled. long as it is used to promote the •• Medical Leave (non-FMLA) Time Off Time health and well being of the faith •• Personal/Educational Leave. For more information, contact the organization members or the Integrated Disability Management community at large. An example Depending on the reason for the leave Department at 1-877-MyTHRLink (1-877- includes participating in faith and the amount of PTO you have 698-4754), prompt 6, press 1. You may community activities that feed the accumulated, you may be paid during view the Texas Health Leave of Absence homeless. your leave of absence. policy on MyTexasHealth or email at [email protected]. •• Schools—all public and private You do not accrue PTO while on a paid schools are qualifying organizations or unpaid leave of absence. as long as CTO is used to further Benefits During Family and education through the support of During your leave, you may keep your Medical Leave academic programs. Examples would coverage effective under the Texas include mentoring, tutoring and Health benefits plans by paying your BASIC FAMILY AND MEDICAL LEAVE science fairs. Examples of ineligible share of the premiums. Your cost will activities would be watching a be the same as active employees pay. If FMLA is a federal law that gives you the school performance, parent-teacher you are receiving PTO and/or EIB, your opportunity to take up to 12 work weeks conferences, field trip, or driving a premiums will be deducted from your of unpaid leave during any 12-month child to a school event. check. If you are not receiving PTO and/ period for the following reasons: or EIB for all of your leave, you must pay • Non-qualifying organizations • The birth and care of your newborn your share of the premiums by check or child include political organizations and credit card each pay period. If you do •• The placement of a child with you for organizations that may compete with not pay your premiums, your benefits adoption or foster care Texas Health. will be canceled. •• The care of your spouse, child (under For more information contact If you have LTC coverage, Genworth age 18 or incapable of caring for Texas Health Community Affairs Life will bill you directly for LTC him- or herself because of physical or Department at 682-236-7619 or email premiums. If you have a 401(k) loan, mental disability) or parent who has [email protected]. during an approved leave of absence, a serious health condition you may request that loan payments •• Your own serious health condition Jury Duty be suspended during your leave. If you that makes you unable to perform the suspend payments during a leave of essential functions of your job. If you are a full-time or part-time absence, the loan will be reamortized benefits-eligible employee, you will be upon returning to work. paid for each hour you are away from work to perform jury duty or serve as a You may continue the following Texas subpoenaed witness on behalf of Texas Health benefits during an unpaid leave Health. Jury Duty pay is equal to your of absence: hourly base pay rate. The maximum pay per day is based on the number of hours •• Medical you are classified to work in the HR/ •• Dental Payroll system. •• Vision •• Short Term Disability (STD) •• Long Term Disability (LTD) •• Life Insurance

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MILITARY FAMILY LEAVE QUALIFYING FOR FMLA If you have a qualifying change in family status (such as the birth of a If you have a spouse, son, daughter, or To qualify for FMLA you must have child, marriage, etc.) during your leave, parent who is an active duty member of been employed by Texas Health for 12 you must contact Human Resources the military who is deployed to a foreign months and worked at least 1,250 hours and make the change within 31 days of country or on active duty or called to in the 12-month period before the leave. your status change (see “Status Changes” active duty status in the National Guard on pages 10 – 12). or Reserves in support of a contingency During your leave, you are entitled to keep in effect your coverage under the operation, you may use your 12 weeks You should refer to the Texas Health Texas Health benefit plans. You must of FMLA to address certain qualifying Leave of Absence Policy to get more pay your share of the premiums. If you exigencies. Examples of qualifying information about your rights under are receiving PTO, your premiums will exigencies include attending certain FMLA. You may also contact the be deducted from your check. If you military events, arranging for alternative Integrated Disability Management are not receiving PTO for all of your childcare, participating in certain department at 1-877-MyTHRLink (1-877- leave, you must pay by check your share counseling sessions, and attending post- 698-4754), prompt 6, press 1. deployment reintegration briefings. of the premiums. If you do not pay Off Time your premiums, your benefits will be Another special FMLA leave permits canceled. eligible employees to take up to 26 weeks of leave to care for a covered You may also revoke your election service member who has been injured of coverage under any of the above in the line of duty and is unfit to plans before your leave or during perform his or her duties or who is a your leave, as long as it’s within 31 veteran undergoing medical treatment, days of beginning of unpaid leave. recuperation, or therapy for a serious You also have the right to revoke or illness or injury and who was a member change elections under the same terms of the Armed Forces (including the and conditions as are available to National Guard or Reserves) at any time employees participating in the plan who during the five years preceding the date are not on leave (see “Status Changes” the veteran undergoes treatment. on pages 10 – 12).

If you are the spouse, son, daughter, If your coverage under one of the plans parent, or next of kin of a service has been terminated, you may choose member, you may be eligible to take up to be reinstated on your return to work to 26 weeks of FMLA leave in a single after your leave on the same terms as 12-month period to care for the service before the leave (including family and member. dependent coverage). If your coverage under a plan terminates while you are on FMLA leave, you are not entitled to receive reimbursements for claims incurred during the period when the coverage was terminated. If you later elect to be reinstated in a plan upon return from FMLA leave for the reminder of the plan year, you may not retroactively elect coverage for claims incurred during the period when the coverage was terminated.

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 131 Other Benefits Tuition Reimbursement ...... 133 Adoption Assistance Program ...... 138 Other Benefits

132 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Other Benefits Other Benefits Tuition Reimbursement The table below explains the program This section gives you important and shows the benefits available to information about your Texas Health Attending school can open many doors eligible employees. To access the Tuition Tuition Reimbursement Program so you for your career, but paying for it can be Reimbursement application go to www. can make informed decisions. Here is a a big challenge. Texas Health offers the MyTHR.org. If you have questions, checklist of key actions you need to take: Tuition Reimbursement Program to help call 1-877-MyTHRLink (1-877-698-4754), you further your education. Through •• Verify that you are eligible to participate prompt 6, press 2 or send an email to in the Tuition Reimbursement Program. the Tuition Reimbursement Program, THRTuitionReimbursement@texashealth. Texas Health will reimburse tuition and •• Determine if your coursework or field org. of study is eligible for reimbursement some recurring fees for approved degree through the program. plans that benefit Texas Health or your To submit reimbursement forms and •• Submit an online application before position at Texas Health (certificate documentation, either fax them to the beginning of each semester or set programs are not eligible for tuition (682) 236-7291, email of courses. reimbursement). Courses must be taken THRTuitionReimbursement@texashealth. •• Submit your request for at universities, colleges and vocational org or mail or deliver copies to: reimbursement no later than 60 days tech schools in the U.S. that have been Texas Health Tuition after completing the courses. accredited by specific nationally Reimbursement Program recognized accrediting agencies as 612 E. Lamar Blvd. defined in the table on the next page. Suite 400 The Texas Health Benefits Department Arlington, TX 76011-4014 administers the Tuition Reimbursement Program. Other Benefits

ELIGIBILITY

Topic Description Eligibility Full-time and part-time benefits-eligible employees (as defined on page 5) may participate. The following are not eligible: ••Medical directors employed under contract ••Medical residents or interns ••Administrative residents or interns ••Fellows or interns ••Dependents of employees.

To be eligible for the Tuition Reimbursement Program, you must have six or more months of service before the start of the courses. (This rule is waived for employees pursuing clinical degrees.) You may be on a leave of absence while taking the courses, but you must be actively at work when any of the following occur: ••You submit your application ••Your application is approved ••You submit your reimbursement request ••Your grades and itemized statements are processed for payment. Exceptions are made for employees on military leave.

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ELIGIBILITY (CONTINUED)

Topic Description Approved accrediting All Degrees agencies To be eligible, courses must be taken from a university, college, vocational or technical school in the U.S. that is accredited by one of the following associations: ••Southern Association of Colleges and Schools (SACS) ••Middle States Association of Colleges and Schools (MSA-CHE) ••New England Association of Schools and Colleges (NEASC-CIHE) ••North Central Association of Colleges and Schools (NCA-HLC) ••Northwest Commission on Colleges and Universities (NWCCU) ••Western Association of Schools and Colleges — Senior Colleges (WASC-ACSCU) ••Western Association of Schools and Colleges — Junior Colleges (WASC-ACCJC) ••Association of Biblical Higher Education (ABHE) ••Accrediting of the Association of Theological Schools (ATS) (recognized at the undergraduate level only) This list of associations is not all-inclusive. If your school or university is not accredited by one of these associations, contact Tuition Reimbursement.

Clinical Degrees In addition to one of the above accreditations for all degrees, clinical courses must be taken from a school that is accredited by one of the following associations:

Nursing ••National League for Nursing Accreditation Commission (NLNAC) — All levels of nursing education ••American Association of Colleges of Nursing — Commission on Collegiate Nursing Education — BSN or higher degree programs Allied Health Professions ••Radiologic Science — Joint Review Committee on Education Radiologic Technology (JRCERT)

Other Benefits ••Clinical Lab Sciences — National Accreditation Association for Clinical Lab Sciences (NAACLS) ••Commission on Accreditation of Allied Health Education Programs (CAAHEP) ••Speech Language Pathologist — American Speech Language Hearing Association (ASHA) ••Physical Therapy — Commission on Accreditation of Physical Therapy Education (CAPTE) ••Occupational Therapy — Accreditation Council for Occupational Therapy Education (ACOTE)

ELIGIBLE DEGREES AND COURSEWORK

Topic Description Clinical degrees Employees are eligible for reimbursement of coursework for clinical degrees including all registered nursing positions, respiratory therapist, radiographer, pharmacist, social work, PT, OT, ST, pre-med students and other licensed or professional health care positions for which Texas Health typically hires. Reimbursement of clinical coursework, up to: ••$5,250 per year for full-time employees and part-time benefits-eligible employees who are considered full- time students under their degree plan (usually 12 credit hours per semester) and enrolled in clinical courses ••$2,625 per year for part-time employees. In addition to tuition, you may submit receipts for reimbursement of textbooks (books purchased from individuals are not covered) and an invoice for recurring mandatory fees not to exceed the allowable maximum reimbursement amount. Books for clinical nurse leader programs are not eligible for reimbursement. Recurring fees do not include fees for parking, insurance, or transportation fees. We may request verification of your degree plan prior to approval of your tuition application or reimbursement request. Non-clinical Benefits-eligible employees who have completed six months of service are eligible for tuition, up to the degrees following maximums: •• $4,000 per year for full-time employees •• $2,000 per year for part-time employees. Textbooks are not reimbursable for non-clinical degree plans, however recurring mandatory fees are eligible to be paid. Graduate Benefits-eligible employees are eligible for reimbursement of expenses related to completing a high school Equivalency education through a Graduate Equivalency Diploma (GED). Diploma (GED) Online courses Clinical degrees may be earned online. If you do not already possess a license or are not already registered, you must have approval in advance of attending these courses. Contact Tuition Reimbursement for additional qualification information. Online courses for non-clinical degrees are covered for approved degrees taken at a school that is accredited by one of the agencies listed above.

134 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Other Benefits

HOW THE PROGRAM WORKS

Topic Description Minimum grade To be eligible for reimbursement of a course, you must earn a grade of C or better (or passing grade in a requirements pass/fail course). How to apply You must submit an online application before beginning every semester (or a new set of classes if your school is not on a semester plan). After classes begin, you have 10 calendar days for late applications to still be considered for approval. You must be an active benefits-eligible Texas Health employee when you submit your application. All repeated courses require a new application prior to the course start date. ••Log on to www.MyTHR.org. ••Scroll down to Tuition Reimbursement and click “To access Tuition Reimbursement (new applications, application status, submit grades or reimbursement requests), click here.” ••Click “Yes” to the security question and answer the questions regarding your degree plan (if applicable). ••Select your school name and number of courses you are taking from the dropdown boxes. ••Click “Create a new application”, then follow directions on the form and click “Submit.” You will receive an email acknowledging submission of this form and a second email once the form is reviewed for approval. If you have submitted your tuition reimbursement application and do not receive one of these notifications in 3 – 5 business days, please contact the Tuition Reimbursement department at 1-877-MyTHRLink (1-877-698-4754), prompt 6, press 2, or at [email protected]. If you have a change in your classes, you must submit a revision to your original application online or contact the Tuition Reimbursement department by email at [email protected] or call 1-877-MyTHRLink (1-877-698-4754), prompt 6, press 2. If you are participating in a clinical degree program, when you apply for tuition reimbursement you may submit an estimate of the cost of textbooks before the start of the course and then edit the application once books are purchased. Books purchased from individuals are not covered. How you are You must have an approved Tuition Reimbursement application on file and be actively at work in a reimbursed benefits-eligible position at the time you submit your reimbursement request and at the time your reimbursement is processed. If your job is eliminated during your semester, you are eligible to receive Tuition Reimbursement if you meet all other requirements of the program.

Within 60 days after completing the courses, you must submit your grades with your name pre-printed Other Benefits on the grade notification and itemized receipts (including receipts for textbooks, if enrolled in a clinical program) along with the Reimbursement Request Form. Always include your name and ID number on all documents. To request reimbursement for tuition: ••Log on to www.MyTHR.org ••Scroll down to Tuition Reimbursement and click “To Request Reimbursement, click here.” ••Scroll down to the application from which you are requesting reimbursement. ••Click the “Reimbursement” tab and answer the questions regarding your degree plan (if applicable). ••Input your correct email address. ••Input the amounts for requested Tuition, Lab/Fees and books if applicable and click “Submit.” ••Print the form. ••Read, sign, date, and fax or email the form along with an invoice from the school, a letter grade report with your name preprinted on it to (682) 236-7291. If you are in a clinical degree plan and are requesting book reimbursement, please send an itemized book receipt along with the other requested documents. Upon submitting the form, you will receive a confirmation email and an acknowledgment email once the faxed copies have been received by our office. Please allow 3 – 5 business days for an acknowledgment email to be sent. Reimbursements are usually processed within 1 – 2 pay periods. If a career development plan (CDP) is required, you will receive an email from the Center for Learning after you have an approved application on file. This email will include instructions on how to complete your CDP. Your reimbursement will not be processed until our records indicate that you have an approved CDP on file. Contact the Center for Learning at 682-236-6161 for additional information. Please note that you do not need to submit a CDP each semester.

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HOW THE PROGRAM WORKS (CONTINUED)

Topic Description How to submit your Either fax them to 682-236-7291, email to [email protected], mail or deliver reimbursement forms copies to: and documentation Texas Health Tuition Reimbursement Program 612 E. Lamar Blvd., Suite 400 Arlington, TX 76011-4014

Requesting advance You may request advance tuition assistance if you are a full-time employee with an annual base benefits funds pay of $25,000 or less or a part-time benefits-eligible employee with an annual base benefits rate of pay of less than $12,250. All eligibility, maximums, and other policy requirements apply to advances.

More information about advance funds is provided later in this section.

Expenses that are The Tuition Reimbursement Program does not reimburse charges for professional meetings, workshops, not covered drop fees, exam fees, late fees, supply kits, conventions, licensures, room and board, parking fees, uniforms, drug screen, background check, professional certification courses, CEUs, shipping and handling, supplies, lab packs, laptops, software, nurse skills pack, insurance costs, review courses, tests or preparation for tests (such as NCLEX, GMAT, LMAT, MCAT, and TASP), or fees to CLEP. Books purchased from individuals. Tuition and fees for degree plans that do not benefit Texas Health or your position at Texas Health.

Taxation of tuition Reimbursements of up to $5,250 per tax year are not taxable income. Any paid reimbursement that reimbursement exceeds $5,250 in a calendar year will be taxed even if the payment was for the prior benefit year.

CHANGES IN EMPLOYMENT

Topic Description If you are hired by Non-clinical employees who currently participate in the Tuition Reimbursement Program may qualify for Texas Health in a a $4,000 transition assistance if they are hired by Texas Health in a clinical position (if they are .8 FTE or

Other Benefits clinical position more) within six months of graduation. The assistance, which is taxable income, is intended to help with the transition into the work setting and cover expenses such as housing deposits and relocation costs. If you leave Texas Health or transfer to a non-clinical position or non-benefits-eligible position before completing two years employment in a full-time clinical position, you are required to repay the full $4,000. Texas Health will make every effort to recover all outstanding Tuition Reimbursement funds (including transition assistance). This includes deducting any amount due from available funds in the possession of Texas Health (payroll checks, PTO), as well as utilizing outside collection agencies. After two years of service in a full-time clinical position with Texas Health, the assistance will be completely forgiven. Employees must apply for the assistance within one year of being hired by Texas Health in a full-time clinical position. You can obtain a transition assistance application from Human Resources. Assistance will not be paid until you provide proof that you have passed your boards and you are actively at work in a clinical position at the time the assistance is requested and processed.

If your employment If your employment terminates or you change to a non-benefits-eligible status (such as PRN or part- status changes time benefits-ineligible, as defined on page 165) within 12 months of completing the courses, you will be required to repay the reimbursed funds paid on your behalf (including transition assistance and educational assistance payments) to Texas Health. However, if your position is eliminated and you are eligible for separation pay or if your position is changed to non-benefits-eligible status, you will not be required to repay the funds as long as you searched for a position and did not turn down a reasonable offer. If you terminate or give notice that you will terminate or change to a non-benefits-eligible position before completing the course, you will not receive the tuition reimbursement for your courses, even if you have prior approval. All advance funds paid to you or your school could be deducted from your final regular paycheck (this includes any PTO payout you might receive). You will be responsible to reimburse Texas Health for any uncollected amounts.

136 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Other Benefits

ADVANCE FUNDS If your final grade is not a C or above (or MAKE THE MOST OF TUITION passing in a pass/fail class) or you do REIMBURSEMENT If you are a full-time employee with an not submit your grades within 60 days annual benefits base rate of $25,000 or Texas Health’s Tuition Reimbursement after completing the course, the advance less or a part-time employee with an Program is designed to encourage you funds and book reimbursement that annual benefits base rate of $12,250 or to further your education. Whether Texas Health paid in advance will be less, you qualify for advance funds. Texas you are pursuing a clinical or non- deducted from your pay over a number Health will pay for your coursework clinical degree or a GED, Texas Health of pay periods, listed in the table below. in advance once your application encourages you to participate in this generous program. is approved. You will need to print a If you received advance funds and you voucher and give it to the school as your are required to repay Texas Health, your source of payment. If you have questions call payments will be deducted from your 1-877-MyTHRLink (1-877-698-4754), pay over a number of pay periods based If you have already paid for your classes prompt 6, press 2 or send an email on the amount you owe Texas Health. and want to request advance funds, you to THRTuitionReimbursement@ may ask for immediate reimbursement texashealth.org. If you owe Your repayments of the payment by submitting your class this amount: will be over: PROGRAMS SPONSORED BY THE schedule and paid invoice itemizing the CENTER FOR LEARNING cost of tuition and recurring mandatory $2,000 or more 15 pay periods fees. Recurring fees do not include fees $1,000 – $1,999 10 pay periods If you are in a clinical program for parking, insurance, or transportation $500 – $999 8 pay periods sponsored by the Center for Learning, fees. Fax these documents, along with you may be eligible for advancement $300 – $499 6 pay periods the Reimbursement Request Form. Write of funds for books at beginning of the $200 – $299 4 pay periods “Advance Funds Requested” in large letters semester. Reimbursement will be made on the form and fax it to 682-236-7291. $199 or less $50 a pay period directly to the book distributor. You must have an approved tuition reimbursement If you are in a clinical degree plan and Payroll deductions will be at least $50. application on file at the beginning of However, the final deduction may be eligible for advance funds, you may also the semester or start of courses. If you Other Benefits request advance reimbursement for your lower if you owe less than $50. You are withdraw or do not pass the course, textbooks. Buy your books and submit a not eligible for further advance funds you will be required to reimburse Texas copy of the itemized book receipt listing until you have completely repaid the Health for the advanced amounts. the names of the books along with a amount you owe. If you terminate your Tuition Reimbursement Request form. employment with Texas Health, the Prodigy students who remain in a amount you still owe to Texas Health will benefits-eligible status will be eligible for be deducted from your final paycheck Tuition Reimbursement of up to $5,520 (this includes any PTO payout you might per year regardless of student status. receive). If your final paycheck is less than the amount you owe, you must repay If you are in a Texas Health sponsored Texas Health for any remaining balance. accelerated clinical degree program, you may be eligible for a $4,000 educational allowance if you meet the requirements of the program. Contact your career counseling specialist in The Center for Learning at 682-236-6161 for additional information.

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Adoption Assistance WHO IS ELIGIBLE Program Full-time and part-time benefits-eligible employees (as defined on page 5) are You may receive reimbursement of costs eligible for this benefit. You must have for legally adopting a child under age 18, at least one year of service and be in unless mentally impaired, while you are a benefits-eligible position at the time employed at Texas Health. The Adoption you make the application and the child Assistance Program will reimburse you is placed in your home. You must be in up to $2,000 per adoption, per year, per benefits-eligible active status in the HR/ family, after you submit the necessary Payroll System at the time payment is documentation to Human Resources and made. the adoption is final. You must submit your request within 90 days of the date of You may not be reimbursed for adoption adoption. expenses for one spouse to adopt the other spouse's children (for example, You must include the final Decree of children from a previous marriage). Adoption, a Letter of Possession (if applicable) and a copy of itemized bills along with the adoption assistance application found online at www.MyTHR.org. The amount you are reimbursed will not exceed the actual expenses you have incurred. Other Benefits

138 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Leaving Texas Health When Coverage Ends...... 140 Coverage After Termination...... 141 What is COBRA? 141 Who Is Eligible 141 Your Responsibility for Notifying the COBRA Administrator 141 When Continuation Coverage Is Effective 141 How to Elect COBRA Continuation 142 HCSA Continuation 142 Paying for Continuation Coverage 142 How Long Coverage Continues 142 Changing Your Coverage 143 If You Gain a New Dependent 143 If Your Address Changes 143 When Continuation Coverage Ends 144 If You Have Questions 144 Separation Pay Plan...... 145 Overview 145 Who Is Eligible 145 When a Position Is Eliminated 145 Transition Plan 145 Notice 145 Resignation During Notice Period 145 Reasonable Offer 145 Leave of Absence 146 Failure to Investigate, Apply or Interview 146 Transfer Pay Guidelines 146 Separation Pay 147 Employment and Consulting 147 Payment 147 Leaving Texas Health Texas Leaving

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 139 When Coverage Ends When Coverage Ends

Coverage for you and your covered •• Commit an act, practice, or Coverage for your dependents also ends dependents under the Texas Health omission that constitutes fraud, or when: Medical, Dental, Vision, STD, LTD, Life an intentional misrepresentation •• The dependent no longer meets the Insurance, AD&D, and Flexible Spending of a material fact including, but not eligibility requirements or dies Accounts Plans ends when you: limited to, false information relating •• You have failed to provide timely to another person’s eligibility or •• No longer meet the eligibility documentation of your dependent’s status as a dependent. Texas Health requirements (see page 5) eligibility has the right to request complete •• Terminate employment (Texas Health •• You terminate employment or cease documentation of dependent status, Medical, Dental, and Vision coverages, to be eligible for coverage eligibility for coverage or change in as well as participation in FSA, end coverage or of a claim for benefits. •• The plan no longer covers on the last day of the pay period in • dependents which you terminate.) • Knowingly provide incorrect information or submit false or •• The dependent knowingly provides •• Die fraudulent claims information incorrect information or submits a •• Retire (termination is retroactive to the false or fraudulent claim, in which •• Cancel or drop coverage (includes first day of coverage). Texas Health case coverage ends retroactively failing to re-enroll) has the right to request complete •• The dependent fails to comply with •• Become a full-time, active-duty documentation of dependent status, the plan’s subrogation provisions. member of the armed forces of any eligibility for coverage or change in In some cases, you and your covered country for more than 30 days. The coverage or of a claim for benefits. dependents may be eligible for COBRA disability plan extends coverage Texas Health reserves the right to continuation coverage, as explained on for up to two months if you pay the refuse coverage of benefits if we don’t the next page. premium. believe the facts are accurate •• Fail to make the required For 12 weeks following your contributions termination, you and your eligible •• Fail to comply with the plan’s covered dependents may continue to subrogation provisions. use the Employee Assistance Program. The program is explained on page 60. Coverage for you and your dependents will also end on: •• The date the plan is terminated •• The date the plan is modified,

Leaving Texas Health Texas Leaving eliminating any benefits for your employment classification.

140 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Coverage After Termination Coverage After Termination Under certain circumstances, you may Who Is Eligible? Your dependent children will become have the right to request a temporary qualified beneficiaries if they lose extension of coverage under Texas If you and/or your covered family coverage under the plan because: members would otherwise lose Health’s medical, dental, and vision •• You (the parent-employee) die plans and the health care spending coverage under the plan after •• You no longer meet the eligibility account. This section describes that a qualifying event, each person requirements for benefits, as right to continuation coverage. It considered a qualified beneficiary explained on page 5 generally explains when continuation (including you, your spouse, and your •• Your employment ends for any reason may become available to you and your dependent children) may elect COBRA. other than your gross misconduct family and what you need to do to If you are an employee of Texas Health, protect the right to receive it. •• You become entitled to Medicare you will become a qualified beneficiary benefits (Part A, Part B, or both) if you lose your coverage under the plan The Consolidated Omnibus Budget •• You and your spouse divorce because you experience one of these Reconciliation Act of 1985 (COBRA) is •• The child stops being eligible for qualifying events: a federal law that requires Texas Health coverage as a dependent child under to offer continuation coverage. •• Your hours are reduced to part-time, the plan. non-benefits-eligible What is COBRA? •• Your employment ends for any reason Sometimes, filing a proceeding in other than your gross misconduct bankruptcy under Title 11 of the United COBRA continuation coverage is States Code can be a qualifying event. •• Texas Health begins bankruptcy. coverage under Texas Health’s medical, If Texas Health files a bankruptcy dental, and vision plans and the health Your spouse will become a qualified proceeding that results in the loss of care spending account that may be beneficiary if he or she loses your coverage for retired employees covered available if your coverage would coverage under the plan because you under the plan, the retired employee, otherwise end because you experience experience one of these qualifying employee’s spouse, and dependent a qualifying event (described under events: children also become qualified “Who Is Eligible” on this page). beneficiaries. Depending on the event, you and your •• You die covered dependents may be eligible for •• You no longer meet the eligibility Your Responsibility for COBRA continuation coverage. After a requirements for benefits, as qualifying event, COBRA continuation explained on page 5 Notifying the COBRA coverage must be offered to each •• Your employment ends for any reason Administrator person who is a “qualified beneficiary.” other than your gross misconduct For some qualifying events, you must You must elect the same coverage when

•• You become entitled to Medicare notify Texas Health within 31 days after Health Texas Leaving you initially elect COBRA. benefits (under Part A, Part B, the event occurs. You must provide or both) All rules and procedures for filing this notice to the Human Resources claims and determining benefits under •• You and your spouse divorce. Department at your entity if: the plan for active employees also apply You will be notified of your rights to •• You and your spouse divorce to continuation coverage. COBRA continuation coverage only •• A dependent child loses eligibility for Qualified beneficiaries who elect after the COBRA administrator has been coverage as a dependent child. COBRA continuation coverage must pay notified that one of the above qualifying for the coverage. events has occurred. Texas Health must When Continuation notify the COBRA administrator of these Coverage Is Effective qualifying events. If you or your dependents elect to continue coverage, after the COBRA administrator receives your premium payment, the coverage becomes effective on the date coverage would otherwise end.

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How to Elect COBRA HCSA Continuation How Long Coverage Continuation If you have the Health Care Spending Continues You will automatically receive a letter Account (HCSA) plan as an active After the COBRA administrator and election form from Texas Health’s employee, you can elect to continue this receives notice of a qualifying event, COBRA administrator after your plan under COBRA until the end of the they will send information about employment with Texas Health ends plan year (which ends December 31). electing COBRA to each qualified or you lose coverage because of a However, you may not elect the HCSA beneficiary. Each qualified beneficiary reduction in scheduled work hours. The during Open Enrollment. If you elect will have an independent right to letter will explain the available COBRA to continue the health care spending elect COBRA continuation coverage. coverage and cost to continue coverage. account, you must continue making the Covered employees may elect COBRA full contribution to the account. continuation coverage on behalf of If you divorce or your dependent child their spouses, and parents may elect Although your contributions will be no longer meets the requirements of COBRA continuation coverage on on an after-tax basis, you will still a “dependent” under the plans, you, behalf of their children. your spouse, your dependent, or your have the opportunity to file claims representative will receive a letter and for reimbursement based on your COBRA continuation coverage is election form from PayFlex after you account balance for the year. Continued temporary. go online to drop the dependent from coverage under the health care account coverage. will last until March 15 following the 18 MONTHS end of the plan year. The use it or lose You, your spouse, and dependent If your entity’s Human Resources it rule will continue to apply, so any children may elect continuation Department does not receive notice unused amounts will be forfeited and coverage for up to 18 months if: within 60 days of the event, your coverage will terminate at the end of dependent will not be offered the plan year. •• You end your employment with Texas continuation coverage. Health Paying for Continuation •• You no longer meet the eligibility When Human Resources receives notice requirements for benefits as that a qualifying event has occurred, it Coverage explained on page 5. will advise the COBRA administrator. To keep your COBRA continuation 36 MONTHS You and/or your dependents will be coverage, you must pay the full notified by the COBRA administrator cost of continuation coverage on Your spouse and dependent children (at the address on record if you have time, including any additional may elect continued coverage for up not provided an updated address expenses permitted by law. If you to 36 months if: using the Benefits Change Form) of elect continuation coverage, you will •• You die your right to continue coverage. You receive a statement from the COBRA •• You become entitled to Medicare should receive the paperwork to elect administrator indicating when each benefits (under Part A, Part B, continuation coverage within 44 days payment is due. or both)

Leaving Texas Health Texas Leaving of your qualifying event. Within 60 days The cost of continuation coverage is of the postmark date on the notice, you •• Your and your spouse divorce typically 102% of the total premium (the or your dependent must inform the •• Your dependent child loses eligibility employee’s and the company’s combined COBRA administrator if you want to as a dependent child. cost, plus a 2% fee for administrative purchase continuation coverage. expenses). However, if continuation If you become entitled to Medicare If you do not elect to continue coverage coverage is extended from 18 months benefits less than 18 months before the within the 60-day time limit, your to 29 months due to disability, the cost end of employment or before you lose benefits under the medical, dental, and increases to 150% of the total premium. eligibility for benefits (as explained vision plans will end on the date of the on page 5) qualified beneficiaries qualifying event. You or your dependent (other than the employee) may elect cannot later elect to continue coverage. continuation coverage for up to 36 months after the date of Medicare entitlement.

142 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Coverage After Termination

For example, if your employment ends You must make sure that the COBRA If You Gain a New eight months after you become entitled administrator is notified in writing of the Dependent to Medicare, your spouse and children second qualifying event within 60 days can continue coverage for up to 28 of that event. This notice should include If you elect continuation coverage months after the date of the qualifying a death certificate or divorce decree, if for yourself and later marry, a child is event (36 months minus 8 months). applicable. You may mail, fax, or hand- born to you, or you adopt a child while deliver the notice. covered by continuation coverage, EXTENDING COBRA FOR you may elect coverage for your newly DISABILITY This extension may be available to acquired dependents after the qualifying In case of disability, you and your entire your spouse and dependent children if event. To add your dependents, notify the family may be entitled to receive up the event would have caused them to COBRA administrator within 60 days of to 11 additional months of COBRA lose coverage under the plan if the first the marriage, birth, or adoption. qualifying event had not occurred. continuation coverage (for a maximum If you get married after your COBRA of 29 months). Your spouse and any dependent children coverage takes effect, you may only add coverage under the Total Health Medical The disability must have started before may receive an extension if you (the Plan for your stepchild(ren) if you also the 60th day of the COBRA continuation employee or former employee): elect coverage for the child’s parent coverage and must last at least until •• Die (your spouse). This provision does not the end of the 18-month period of •• Become entitled to Medicare benefits apply to dental and vision. continuation coverage. (under Part A, Part B, or both) A new dependent may be a participant •• Become divorced. To qualify for the extension, you must under this coverage for the remainder timely notify the COBRA Administrator A dependent child may also receive of your continuation period (18, 29, or in writing and provide documentation an extension if he or she stops being 36 months, depending on the qualifying of the disability from the Social Security eligible under the plan as a dependent event). This new dependent will not have Administration within 60 days of the later child and Texas Health is notified timely. the right to continue coverage on his of the following: or her own if a divorce or other event •• The date of the Social Security Changing Your Coverage causes loss of coverage. disability determination, When you elect COBRA continuation If Your Address Changes •• The date the qualifying event occurs, coverage, you must keep the same •• The date you lose (or would lose) plan you had as an active employee or To protect your family’s rights, you should coverage as a result of the qualifying dependent of an employee. For example, keep the plan administrator informed of event, or if you elected the Choice Plan 500 any address changes of family members. •• The date you receive the general High as a benefits-eligible employee You should also keep a copy, for your COBRA notice. with Texas Health, you must continue records, of any notices you send to Texas that plan under COBRA. You have an Health or the COBRA administrator. EXTENDING COBRA FOR A SECOND opportunity to change your plan during QUALIFYING EVENT

open enrollment, which is generally in Health Texas Leaving If your family experiences another November. qualifying event while receiving 18 Prior to open enrollment, an enrollment months of continuation coverage, guide is mailed to the home of a COBRA your spouse and dependent children participant explaining the plan changes can get up to 18 additional months of beginning January 1 of the next year. continuation coverage—for a maximum Also included with the guide is an of 36 months if the plan receives proper enrollment form. If you want to keep the notice of the second qualifying event. same plan, you do not need to complete the form. To change your plan, you need to complete the form and mail it to PayFlex by the deadline for open enrollment. Your new election will take effect on January 1. You may not re-enroll in an HCSA.

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When Continuation If You Have Questions Coverage Ends Questions concerning your plan or Coverage automatically ends on the your COBRA continuation coverage earliest of the following dates: rights should be addressed to the plan administrator, Texas Health, or •• The maximum continuation period the COBRA administrator (PayFlex) . (18, 29, or 36 months) expires. Their addresses and phone numbers •• Full premium payment for are listed on the back cover of this continuation coverage is not received Handbook. You may also contact them by the COBRA administrator within for information about your rights and 30 days after the payment due date. obligations under each plan and under Partial payment or checks returned federal law. for non-sufficient funds (“NSF” or “bounced”) are considered non- For more information about your payment of premium. rights under ERISA, including COBRA, •• The person who is continuing the Health Insurance Portability and coverage becomes covered under Accountability Act (HIPAA), and any other group medical, dental, or other laws affecting group health vision plan, unless that plan contains plans, contact the nearest Regional or a pre-existing condition limitation District Office of the U.S. Department that affects the plan participant. In of Labor’s Employee Benefits Security that event, the participant is entitled Administration (EBSA) or visit the EBSA to continuation coverage up to the website at www.dol.gov/ebsa. (The maximum time period. address and phone number of Regional •• The person continuing coverage and District EBSA Offices are available becomes entitled to Medicare. on the website.) •• Texas Health no longer provides the coverage for any of its employees or their dependents. •• The person continuing coverage is no longer disabled after he or she has already received 18 months of continuation coverage. Leaving Texas Health Texas Leaving

144 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Separation Pay Plan Separation Pay Plan Overview When management anticipates the Resignation During Notice need for a transition plan, they will Period The Texas Health Separation Pay Plan consult with Human Resources to is designed to provide a consistent develop a plan that includes a summary If you resign during the 30-day notice process to help employees whose of the need for transition, as well as the period, you will not be entitled to positions have been eliminated as a names and other information regarding separation pay or pay for the remainder result of a restructuring, redesign, the employees who are potentially affected. of the notice period. sale/divestiture of a company or entity, or other changes in operations or Reasonable Offer business conditions. Notice If your position is eliminated, as If, during the 30-day notice period, Who is Eligible defined under the plan, you will you fail to apply for a full-time or part- receive notification and transition time position or refuse or decline one The Separation Pay Plan applies to information when management and reasonable offer from Texas Health full- and part-time benefits-eligible Human Resources have evaluated or an acquiring employer, you will be employees (as defined on page 5) each employee’s specific information. treated as having voluntarily separated whose positions are eliminated. PRN Options that may be available include and will not be eligible for separation and part-time benefits-ineligible transfer opportunities, career center p a y. employees, administrative residents/ services and, in certain situations, Reasonable offer from Texas Health interns/fellows, medical directors, separation pay (as defined in the plan). medical residents/interns, interns, means an offer in which the employee THPG physicians, and employees under Generally, you will be given a minimum meets minimum qualifications of the contract are not eligible for the plan. of 30 calendar days’ notice before position (some additional training Employee status, base pay, and years your position is eliminated. During may be necessary) and the midpoint/ of service are determined by Texas this period, if you are in a staff or marketpoint of the salary range for Health’s HR/Payroll system. management position (not directors the new position is 80% or more of the or officers) you will continue in your salary range midpoint/marketpoint When a Position Is current position while pursuing other (based on the employee's hourly rate) Eliminated employment opportunities. You are for the employee’s current position. required to actively search for other An offer of a PRN position is not Under this plan, you are considered to positions within Texas Health during the considered a reasonable offer. have your position eliminated if you are notice period, regardless of work status. involuntarily separated because all or A reasonable offer may include an offer part of an entity, department, division, If you are a director or officer, you are that involves a change in your benefits operating unit, or function is being not eligible for the notice period. In this status. You incur a change in benefits Health Texas Leaving outsourced, restructured, or closed. case, your separation will be on the date status if—before the elimination of Employees who are terminated for agreed by your manager and Human your position you are full-time benefits- cause (such as poor performance or Resources. eligible—and after the elimination your violation of policy) will not be eligible new position will be: In certain situations, with the approval for Separation Pay. •• Part-time benefits-eligible or of the entity Human Resources Director, •• Part-time not benefits eligible. management may deem it necessary Transition Plan to separate an employee immediately. You incur a change in benefits status A transition plan is required whenever The employee will cease to be an active if—before your position was eliminated, positions are being eliminated because employee as of the date of separation. you were part-time benefits-eligible— of outsourcing, restructuring, or closing and after the elimination in the new of an entity, department, division, position will be part-time not benefits- operating unit or function. The plan eligible. helps determine what will happen to the affected employees.

MARKETPOINT: a data point representing the 50th percentile of the market for a specific position

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If you incur a change in your benefits •• To whom all or part of an entity, If you are on a leave of absence of status but you received an offer from department, division, operating unit or any kind, other than a protected leave Texas Health which meets the salary function is outsourced of absence, your position may be requirement, you have received a •• That purchases or acquires all or part eliminated or terminated and you will reasonable offer for purposes of the of the assets of an entity, department, not be entitled to notice or separation Separation Pay Plan. In this case, you division, operating unit or function to p a y. may be eligible for transition pay. If you which the employee’s job relates A “protected leave of absence” is an accept a PRN position (after researching •• That performs the functions of the approved military leave or Family and and applying for full-time or part-time entity, department, division, operating Medical Leave Act leave at the end of positions), you will not receive transition unit or function; or which the employee has the right to pay, but may be eligible for separation •• That contracts with Texas Health be reemployed according to federal p a y. to offer employment to employees law. Any other type of leave of absence whose positions have been Transition pay is a percentage of the is not considered a protected leave of eliminated. separation pay you would have received absence. if you had not received a reasonable A reasonable offer (either type) may offer from Texas Health. The percentage also include a shift change, schedule Failure to Investigate, is determined by a fraction: change, or reassignment to a different Apply or Interview department or operating unit if that •• The numerator is the difference operating unit is located no more than During the notice period, you are between: 49 miles from the employee’s current expected to actively pursue job –– The number of assigned hours work location. opportunities within Texas Health for before the position was eliminated which you are qualified and that may –– The number of assigned hours after The Career Center assists employees result in a reasonable offer. If you fail the position was eliminated in identifying job opportunities for to investigate, apply or interview for •• The denominator is the number of which they may be qualified. Employees open positions that could result in a assigned hours before the position are expected to actively pursue reasonable offer, you will not be eligible was eliminated. reasonable opportunities for which for separation pay. they are qualified. If, during the 30-day The percentage is based on the change notice period, an employee fails to, Transfer Pay Guidelines in your assigned number of hours as does not or refuses to interview for an classified in the HR / Payroll system. open position with Texas Health or an If an employee accepts an offer within Pay for the notice period is not taken acquiring employer, he or she will not the Texas Health system, his or her pay into account in determining transition be eligible for separation pay. will be determined as follows: pay. An employee receiving transition •• If an employee accepts a position pay is not entitled to the notice period. Employees who continue working with the same or higher salary Transition pay is paid over a maximum through their 30-day notice period are grade, Texas Health’s compensation period of six months with your regular expected to meet and maintain all guidelines concerning lateral or

Leaving Texas Health Texas Leaving paycheck. If you leave before the end of conditions of performance for their promotional transfers will apply. the six month period, you will lose the assigned job. Failure to do so may •• If an employee accepts a position remainder of the transition pay. result in immediate separation with no that is in a lower salary grade, and separation pay. If you are receiving transition pay and the employee’s current base pay change to full-time benefits eligible Leave of Absence falls within the salary range for the employment status during the six-month position, the employee’s base pay will period, you will stop receiving transition If you receive a reasonable offer from not change. p a y. an acquiring employer, your position •• If the employee’s current base pay may be eliminated even if you are on a is above the maximum of the new A reasonable offer from an acquiring protected leave of absence. If you are salary grade range, the employee’s employer means an offer for a position on a protected leave of absence and do base pay will be adjusted to equal the for which the employee meets the not receive a reasonable offer from an maximum of the new salary range. minimum qualifications (some acquiring employer, your position may additional training may be necessary) not be eliminated during the leave. If Benefits base pay will be adjusted and the base pay offered is 95% or more your position is eliminated before you according to the terms of the applicable of the employee’s current base pay (as begin your protected leave of absence, benefits plan. defined on the next page). the notice period will be extended by the time period of the protected leave “Acquiring employer” for purposes of of absence. the plan, is an entity or person:

146 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Separation Pay Plan

Separation Pay Employment and Consulting Employees who have been unsuccessful in securing a new position may be You will be required to repay all or part eligible for separation pay (based on the level of the affected position and the of your separation pay if you receive employee’s years of service) and internal Career Center services if he or she does separation pay from Texas Health and not: then are either employed or engaged to do consulting work for Texas Health, the •• Have a new position at the end of the 30-day notice period or acquiring entity, or any entity that was •• Receive one reasonable offer from Texas Health or a Texas Health entity or part of the transaction that resulted in the •• Receive a reasonable offer from an acquiring employer. elimination of your position.

An employee who meets all the requirements of the Separation Pay Plan will be The amount you will be required to repay entitled to separation pay according to the following table. is described in the Separation Pay Plan and is based on the number of weeks of Employee’s Base Pay Amount of Separation Pay separation pay you received and when you began employment or consulting. Less than $45,000 1 week of base pay per year of service The Executive Vice President of People & ••4 weeks of base pay minimum Culture must approve all exceptions to the ••12 weeks of base pay maximum requirements of this section. $45,001 to $70,000 2 weeks of base pay per year of service ••4 weeks of base pay minimum You are not required to repay any part of ••26 weeks of base pay maximum the separation pay if you are employed in a $70,001 to $100,000 4 weeks of base pay per year of service PRN position, provided you are accurately ••8 weeks of base pay minimum classified as a PRN. This determination will be at the discretion of the Executive Vice ••52 weeks of base pay maximum President of People and Culture. $100,001 to $150,000 12 weeks of base pay per year of service ••26 weeks of base pay minimum Payment ••78 weeks of base pay maximum After you satisfy all of the conditions of Over $150,000 12 weeks of base pay per year of service the Separation Pay Plan, you will receive ••52 weeks of base pay minimum separation pay in a lump sum, less ••104 weeks of base pay maximum applicable withholding, within 90 days of Base pay is the employee’s hourly pay rate multiplied by the number of hours per your termination of employment (and not week the employee is classified to work in HR/ Payroll System. Base Pay does not less than seven days) after returning the include differentials, bonuses, overtime, or commissions. completed and signed agreement to Texas Health. Years of service is calculated beginning with the employee’s most recent date of hire, each three hundred and sixty-five (365) day period that elapses or has Leaving Texas Health Texas Leaving elapsed while the employee is employed with THR. For purposes of determining an employee’s years of service, the years of service before the employee’s most recent hire date will not be taken into account unless crediting is required under FOR MORE information, THR’s “Bridging of Service Policy” and the employee has not previously received please see the Texas separation pay from Texas Health for that service. Health Separation Pay Policy that can be found The receipt of separation pay is conditioned upon completion of the Agreement on MyTexasHealth or for Separation Pay and Release of Claims document and any other documents request a copy of the plan requested by Human Resources. The employee must sign and return the from Human Resources. Agreement in the format required by Texas Health within 50 days after receiving the Agreement. In the event the employee does not sign and return the Agreement to Texas Health within 50 days or chooses to revoke the release in the seven-day period allowed by law, the employee is not eligible for separation pay.

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 147 Claims and Administration Claims Information...... 149 Payment of Benefits 149 Right of Recovery 149 Reimbursement 149 Misstatements of Fact 149 Subrogation 149 Denial of Claims 149 Administrative Information...... 152 Your ERISA Rights 152 Plan Amendments 153 Plan Sponsor 153 Plan Administration 153 Important Notice from Texas Health About Your Prescription Drug Coverage and Medicare 156 Texas Health Group Health Plan Notice of Privacy Practices 157 Claims & Admin

148 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Claims Information Claims Information Payment of Benefits •• Assign to the plan any medical Denial of Claims benefits you are eligible to receive Your benefit plans are intended to pay under an automobile policy or other Please refer to each section of this benefits only to you or your beneficiaries. coverage, up to the amount the plan Handbook to determine how to submit Your benefits cannot be used as has paid in benefits a claim for that plan (medical, dental, collateral for loans or be assigned in any vision). •• Agree to sign and deliver any other way. However, benefits under the documents necessary to help the plan Texas Health Retirement Program may NON-DISABILITY CLAIMS protect its rights (refusal to sign these be divided under a Qualified Domestic If you file a claim under any of the documents does not diminish the Relations Order (described on page 7) following plans and any portion of that plan’s reimbursement rights) and medical, dental, and vision claims claim is denied, you will receive a written •• Assist the plan by complying with may be assigned to the health care notice. Plans include: any reasonable request to help the provider. plan recover any benefits it has •• Dependent Care Flexible Spending If you are unable to receive any payment paid, without taking any action that Account due to you under any of the plans, may prejudice the plan’s right to •• Life Insurance payment may be made to any person reimbursement. •• AD&D Insurance providing for your care, your guardian, •• Business Travel Accident Insurance your beneficiaries, or your estate. Such Misstatements of Fact •• Texas Health Retirement Program payments will release Texas Health of its Any material misstatement you make (except for disability benefits) obligation with regard to that claim. regarding the age, sex, marital status, or •• Separation Pay Program. other condition or status of any person The notice will be sent to you within Right of Recovery covered under a Texas Health plan may 90 days from the date the claims be grounds for adjustment of payments If you receive any overpayment of administrator received your claim. If due under any plan. benefits by a Texas Health plan, the more time is needed (up to a total of 180 plan will have the right to recover the days), you will be notified within the first overpayment from you. If you receive Subrogation 90 days (except for disability claims). a benefit greater than allowed by the If you receive benefits under the Texas plan, you will be requested to refund the Any denial notice you receive will Health benefit plans (other than the overpayment. If you do not submit the explain: Texas Health Retirement Program) for refund, the amount of overpayment will an injury or illness resulting from any •• Specific reasons for the denial be deducted from future benefits you negligent or any willful act or omission •• Specific reference to pertinent plan receive from the plan. by any person, company or organization, provisions upon which the denial was the plan will be subrogated to all rights based Reimbursement of recovery that you may have against •• Description of any additional If you recover damages for an injury that third party. This means that when information or material necessary or illness (for example, if you receive a you accept payment of benefits under to complete the claim and an settlement from your insurance company, the Texas Health benefit plan, you explanation of why such information the person who caused the injury or assign your rights of recovery from the or material is necessary illness or that person’s insurance carrier), third party to the plan and agree to do •• The steps to take if you wish to submit the Texas Health plans (other than under whatever may be necessary to secure the claim for further review. the Texas Health Retirement Program recovery, including execution of all or the Texas Health Dental Plan) have a appropriate agreements or other papers. Claims & Admin right to be reimbursed for the amount By accepting benefits under the Texas of benefits it has paid on your behalf for Health plans, you agree to assign to treatment of the injury or illness. Texas Health the right to the first dollars As a condition for receiving benefits, you: you receive—including for general damages—up to the full amount paid •• Grant the plan a first lien against any by the plan. If you fail to comply with settlement, verdict, or other amounts this requirement, your benefits under you receive the Texas Health plan will stop and your coverage will terminate.

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REQUESTING A SECOND REVIEW If your claim is extended because REQUESTING A SECOND REVIEW FOR NON-DISABILITY you have failed to submit information FOR DISABILITY If you wish to request a second review necessary to decide your claim, the time If all or part of your claim for disability of a denied claim (except for disability period for the decision will be counted benefits under the STD, LTD, and Texas benefits under the STD, LTD, and Texas from the date the claims administrator Health Retirement Program is denied, Health Retirement Plan), you have 60 sends you notification of the extension you or your representative may appeal days after receiving the denial to request until the date the claims administrator to the claims administrator for a full and a review by the People and Culture receives your response to its request. fair review. You may: Committee or, in the case of a fully The written decision from the claims •• Make a written application for review insured plan, the appropriate insurance administrator will include: within 180 days of the claim denial carrier. You must make your request in •• Request, free of charge, copies of writing. You also have the right to review •• Specific reasons for the decision all documents, records, and other pertinent documents, submit comments •• Specific references to the plan information relevant to your claim, and and have a representative act on your provisions on which the decision is •• Submit written comments, documents, behalf. based records and other information relating •• A description of any additional to your claim. You will receive a written notice of the material or information necessary Committee’s or insurance company’s for you to perfect the claim and an The claims administrator will make a decision within 60 days after a review is explanation of why such material or decision no more than 45 days after requested. In special cases, the review information is necessary it receives your appeal. The time for can take an additional 60 days, and you •• A description of the review decision may be extended for one will be notified if this additional time is procedures and applicable time limits additional 45-day period provided necessary. The Committee has the sole for those procedures that, before the extension, the claims right to determine whether or not you •• A statement that you have the right administrator notifies you in writing that or your representative will personally to bring a civil action under section an extension is necessary because of appear in any review. 502(a) of ERISA after you have special circumstances, identifies those The decision of the Committee or appealed the decision and received a circumstances, and gives the date by insurance carrier is final. You will written denial on appeal, and which it expects to render its decision. receive a written notice of the decision. •• If the denial was based on: If your claim is extended because If you still feel that your claim has been –– An internal rule, guideline, protocol, you have failed to submit information improperly denied, refer to the section or other similar criterion, either: necessary to decide your claim on of this guide entitled “Your ERISA ŒŒ The specific rule, guideline, appeal, the time for decision will be Rights” (beginning on page 152) for a protocol or other similar counted from the date the notification description of your legal rights. criterion or of the extension is sent to you until the ŒŒ A statement that the rule, DISABILITY CLAIMS date the insurance company receives guideline, protocol or other your response to the request. The written This applies to STD, LTD, and the Texas similar criterion was relied upon decision will include specific references Health Retirement Plan. The claims in making the denial and that to the plan provisions on which the administrator will make a decision no a copy will be provided to you decision is based and any other notice, more than 45 days after receipt of your free of charge upon request. statement, or information required by claim. The claims administrator may –– Medical judgment, either: applicable law. extend the time period for two additional ŒŒ An explanation of the 30-day periods provided they: scientific or clinical judgment You may file a lawsuit for benefits only •• Give you written notification in for the determination, applying after you have exercised all appeals advance that the extension is the terms of the plan to your described in this section and all or part necessary for reasons beyond the medical circumstances or of the benefits you request on appeal

Claims & Admin control of the plan ŒŒ A statement that an explanation have been denied. •• Explain the reason for the extension, will be provided to you free of and charge upon your request. •• Give the date by which they expect to render a decision.

150 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Claims Information

WAIVER OF PREMIUM FOR LIFE INSURANCE If you feel you are entitled to a waiver of premium for disability under Basic or Additional Life Insurance, you must file a claim with the life insurance claims administrator. The claims administrator will advise you of its decision within 45 days. The claims administrator may extend this time period for two additional 30-day periods while gathering information needed to make a decision, but only if the reason for delay is beyond its control.

You have up to 180 days to appeal an adverse benefit determination. You must make your appeal in writing and address it to the appeals unit of the claims administrator. The claims administrator will decide your appeal within 45 days. Under special circumstances, the claims administrator may extend the period for an additional 45 days. Claims & Admin

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Following are some important •• Receive a summary of each benefit In carrying out their respective administrative details concerning the plan’s annual report. The plan responsibilities under the plan, the plan benefit plans offered by Texas Health administrator is required by law to administrator and other plan fiduciaries that are subject to the Employee furnish each participant with a copy shall have discretionary authority to Retirement Income Security Act of 1974 of this summary annual report. interpret the terms of the plan and to (ERISA), as amended from time to time. •• Continue health coverage for determine eligibility for and entitlement These plans are listed on pages 154 – yourself, your spouse, and/or your to plan benefits in accordance with the 155. eligible dependents if any of you lose terms of the plan. Any interpretation coverage because of a qualifying or determination made pursuant to Your ERISA Rights event. You must pay for this continued such discretionary authority shall be coverage. given full force and effect under the This section contains statements of •• Reduce or eliminate any pre-existing plan, unless it can be shown that the your rights under ERISA. This notice condition limitations of this plan if interpretation or determination was follows the format provided by federal you have a certificate of creditable arbitrary and capricious. regulations and summarizes your rights coverage from another plan. Your under the law. As a participant in a No one may discharge you, or otherwise former plan should provide this plan governed by ERISA, you have been discriminate against you, to prevent certificate at no cost when you lose given information about such plan you from receiving a benefit or from coverage under that plan, become coverages and benefits. exercising rights under ERISA. eligible for COBRA coverage, or when To help plan participants reduce COBRA coverage ends. If you do not If your claim for benefits is denied or disputes and to avoid inconvenience or provide a certificate of creditable ignored, in whole or in part, you have delay of payment for eligible expenses, coverage, you may be subject to a a right to know the reason, to obtain this Handbook provides descriptions of pre-existing condition limitations copies of documents (free of charge) claim and appeal procedures on pages for 12 months after you enroll (or 18 relating to the decision, and to appeal 41 - 49, 71 - 73, 76 - 77 and 149 - 150, as months if you do not enroll when first any denial—all within certain time well as addresses, telephone numbers, eligible). schedules. and other references where you may The plan administrator makes obtain additional information and Under ERISA, there are steps you can available all documents required by assistance. take to enforce your rights. For example, law, including a summary of the plan’s if you request a copy of the plan This Handbook summarizes the benefits Annual Financial Report. Additional documents or the latest annual report offered by Texas Health. The Handbook information is also provided that may from the plan and you do not receive does not attempt to cover all details. be helpful to you in making the best use them within 30 days, you may file suit of your benefits. in a federal court. In this case, the court All participants in ERISA plans may: may require the plan administrator PLAN FIDUCIARIES •• Examine all plan documents and to provide the materials and pay up copies of all documents, such as the ERISA imposes obligations upon those to $110 a day until you receive the annual report (Form 5500) and plan persons responsible for the operation materials (unless the materials were not description. These documents can be of the plans. Such persons are called sent for reasons beyond the control of examined without charge in the plan “fiduciaries.” Fiduciaries must act solely the administrator). administrator’s office. in the interest of the plan participants, If your claim for benefit was denied •• Receive, upon written request, plan and they must act prudently in the performance of their duties. Fiduciaries or ignored, in whole or in part, you

Claims & Admin documents, contracts, and other may file suit in a state or federal court. plan information from the plan may be removed for violating these In addition, if you disagree with the administrator. The plan administrator rules and are required to make good plan’s decision (or lack of decision) may make a reasonable charge for any losses they have caused the plans. concerning the qualified status of a the copies. Any materials requested domestic relations order or medical should be received within 30 days child support order, you may file suit in of receipt of your request unless the a federal court. materials are not sent because of circumstances beyond the control of the plan administrator.

152 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Administrative Information

If the fiduciaries misuse the plan’s Plan Amendments •• Rev. Jay L. Beavers, DMin—Texas money, or if you are discriminated Health Board Member against for asserting your rights, you The People and Culture Committee, may seek assistance from the U.S. under the authority granted to it by the 517 Castlebrook Court Department of Labor or you may file Board of Trustees, has the sole authority Saginaw, TX 76179-0994 suit in a federal court. The court will to adopt and/or amend benefit plans. decide who should pay the court costs The People and Culture Committee, in •• Feliz Jarvis—Texas Health Board and legal fees. If you are successful, the consultation with actuaries, consultants, Member court may order the person you have Human Resources, and the Legal sued to pay theses costs and fees. If you Department, has the discretion to 1235 N. Winnetka Ave. lose, the court may order you to pay adopt such rules, forms, procedures, Dallas, TX 75208 these costs and fees—for example if it and amendments it determines are finds your claim is frivolous. necessary for the administration of •• Jimmy C. Payton, Jr.—Texas Health employee benefit plans according to Harris Methodist Hospital HEB Board If you have any questions about their terms, applicable law, regulation, Member this statement or about your rights or to further the objectives of the under ERISA or the Health Insurance employee benefit plans. P.O. Box 1662 Portability and Accountability Act Euless, TX 76039 of 1996 (HIPAA), contact the plan Plan Sponsor administrator or: Texas Health is the plan sponsor for all •• Michael P. West, Ed.D., FACHE— •• The nearest area office of the Pension plans described in this Handbook. External Community Member and Welfare Benefits Administration, Attn: Plan Administrator U.S. Department of Labor, listed in U.T. Arlington/Fort Worth Center Texas Health your telephone directory 1401 Jones Street 612 E. Lamar Blvd., Suite 900 •• The Division of Technical Assistance Fort Worth, TX 76102 Arlington, Texas 76011 and Inquiries, Pension and Welfare Benefits Administration, U.S. The People and Culture Committee has Department of Labor, 200 Constitution Plan Administration the authority, as outlined in each plan, to employ personnel and professionals Avenue, N.W., Washington, D.C. 20210. Texas Health is the plan administrator as it deems advisable to assist in for all the benefit plans listed in You may also request certain administration. It is the People and this Handbook. The People and publications about your rights Culture Committee’s duty to interpret Culture Committee acts on behalf of and responsibilities by calling the each plan’s provisions and make final Texas Health in its capacity as plan publications hotline at the Employee decisions on matters such as eligibility administrator. The People and Culture Benefits Security Administration and payment of benefits. Committee can be reached at: (formerly called the Pension and EMPLOYER IDENTIFICATION Welfare Benefits Administration) People and Culture Committee NUMBER at 1-866-444-3272. Attn: Executive Vice President, People & Culture Texas Health’s employer identification Texas Health number is 75-2702388. 612 E. Lamar Blvd., Suite 900 PLAN TRUSTEES Arlington, Texas 76011 682-236-7900 The current trustees of the Texas Health Retirement Program are: Members of the People and Culture Committee are appointed by the Board •• Richard M. Vigness, M.D.—Chair and of Trustees of Texas Health. The current Texas Health Board Member

members of the People and Culture Claims & Admin Committee are: 1307 8th Avenue, #601 Fort Worth, TX 76104 •• Richard M. Vigness, M.D.—Chair and Texas Health Board Member •• Rev. Jay L. Beavers, DMin—Texas Health Board Member 1307 8th Avenue, #601 Fort Worth, TX 76104 517 Castlebrook Court Saginaw, TX 76179-0994

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•• Feliz Jarvis—Texas Health Board •• Michael P. West, Ed.D., FACHE— AGENT FOR SERVICE OF LEGAL Member External Community Member PROCESS Texas Health Resources 1235 N. Winnetka Ave. U.T. Arlington/Fort Worth Center Charles Boes, General Counsel Dallas, TX 75208 1401 Jones Street 612 E. Lamar Blvd., Suite 900 Fort Worth, TX 76102 Arlington, TX 76011 •• Jimmy C. Payton, Jr.—Texas Health Harris Methodist Hospital HEB Board Service of process may also be Member made upon a plan trustee or plan administrator. P.O. Box 1662 Euless, TX 76039 PLAN YEAR The plan year is January 1 through December 31 for all plans listed in this Handbook.

CLAIMS ADMINISTRATORS Texas Health administers the plans listed below. The hospitals, physicians, dentists, and other service providers that participate in the Medical, Dental, and Vision Plan networks are completely independent of the company. Neither Texas Health, your employer nor the network administrators are responsible for the services provided.

Plan Plan Name Number Plan Type Plan Funding Administrator Total Health Medical Plan ••UHC Choice and Choice Plus 501 Self-funded medical plans 1 Self-funded UnitedHealthcare 2 ••Caremark 501 Self-funded 1 Self-funded Caremark 2 Be Healthy 501 Wellness Funded by company UnitedHealthcare MHN Employee Assistance 501 Employee Assistance Funded by company MHN Program (EAP) Program Texas Health Dental Plan 502 Fully insured dental plans Premiums are ••Aetna Managed Dental Plan paid by employee (DMO)®3 ••Aetna® Managed Dental Plan contributions (DMO®) ••Aetna PPO (Low Option) 3 ••Aetna PPO (Low Option) ••Aetna PDN (High Option) 3 ••Aetna PDN (High Option) Superior Vision Plan 514 Fully insured vision plan Premiums are Superior Vision Plan 3 through National Guardian paid by employee Life Insurance Company contributions Texas Health Short Term 503 Fully insured disability Premiums are CIGNA Group Insurance 3 Disability Plan plan paid by employee contributions Texas Health Long Term 504 Fully insured disability Basic LTD premiums CIGNA Group Insurance 3 Disability Plan plan are paid by the company and Additional LTD premiums are paid by employee

Claims & Admin contributions

1 Self-funded benefits are paid with company assets and employee contributions. 2 Contract claims administrators are independent companies that provide claim payment services. They do not insure self-funded benefits. 3 Insured claims administrators insure the benefits and provide claim payment services.

(Claims Administrators continue on next page)

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CLAIMS ADMINISTRATORS (CONTINUED)

Plan Plan Name Number Plan Type Plan Funding Administrator Texas Health Life and Accident 505 Fully insured life, AD&D Basic Life, Basic CIGNA Group Insurance 3 Insurance Plan and business travel AD&D, and Business Life Insurance Company of North accident plans Travel Accident 3 premiums are paid America (BTA) by the company. Additional Life, Dependent Life, and Additional AD&D premiums are paid by employee contributions Long Term Care Insurance Plan 516 Fully insured long term Premiums are Genworth Life Insurance Company 3 care plan paid by employee contributions Texas Health Flexible 506 Self-funded cafeteria plan, Funded by company PayFlex 2 Benefits Plan Health Care Spending and employee Account, and Day Care contributions Spending Account Texas Health Separation Pay 507 Self-funded severance Funded by company Texas Health Plan pay plan Texas Health Tuition 508 Tuition Reimbursement Funded by company Texas Health Reimbursement Plan Plan

Texas Health Adoption 512 Adoption Assistance Plan Funded by company Texas Health Assistance Plan

1 Self-funded benefits are paid with company assets and employee contributions. 2 Contract claims administrators are independent companies that provide claim payment services. They do not insure self-funded benefits. 3 Insured claims administrators insure the benefits and provide claim payment services.

TEXAS HEALTH RETIREMENT PROGRAM PLAN ADMINISTRATION The plans listed below have been adopted by specific affiliates of Texas Health. A complete list of employers who have adopted the plan is available from Human Resources at no cost to you. JPMorgan is the recordkeeper and contract administrator for the Texas Health Retirement Program. Plan expenses are paid by Texas Health, participating companies, or the plan. Plans are funded by contributions from employees, Texas Health, and other participating employers. Funds are invested by participant direction and held by JPMorgan. Employer and employee contributions are held in a trust/custodial account (403(b) only).

Plan Name Plan Number Plan Type Texas Health 401(k) Retirement Plan 008 Salary deferral defined contribution plan Frozen PHS and HMHS 403(b) 006 Salary deferral defined contribution plan Annuity Plan Frozen PHS and HMHS 401(k) Plan 005 Salary deferral defined contribution plan Frozen PHS 401(a) Plan 001 Money purchase plan Frozen Prior Employer 401(k) Plan 009 Salary deferral defined contribution plan Claims & Admin

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Important Notice from Because your existing coverage is on You should also know that if you Texas Health About Your average at least as good as standard drop or lose your coverage with Texas Medicare prescription drug coverage, Health and don’t enroll in Medicare Prescription Drug Coverage you can keep this coverage and not prescription drug coverage after your and Medicare pay extra if you later decide to enroll in current coverage ends, you may pay Please read this notice carefully and Medicare prescription drug coverage. more (a penalty) to enroll in Medicare keep it where you can find it. This notice prescription drug coverage later. Individuals can enroll in a Medicare has information about your current prescription drug plan when they first If you go 63 days or longer without prescription drug coverage with Texas become eligible for Medicare and prescription drug coverage that’s at Health and prescription drug coverage each year from November 15 through least as good as Medicare’s prescription available for people with Medicare. It December 31. Beneficiaries leaving drug coverage, your monthly premium also explains the options you have under employer/union coverage may be will go up at least 1% per month for Medicare prescription drug coverage eligible for a Special Enrollment Period every month that you did not have that and can help you decide whether or to sign up for a Medicare prescription coverage. For example, if you go 19 not you want to enroll. At the end of this drug plan. months without coverage, your premium notice is information about where you will always be at least 19% higher than can get help to make decisions about You should compare your current what many other people pay. You’ll pay your prescription drug coverage. coverage, including which drugs are this higher premium as long as you have covered, with the coverage and cost of 1. Medicare prescription drug Medicare prescription drug coverage. In the plans offering Medicare prescription coverage became available in 2006 addition, you may have to wait until the drug coverage in your area. to everyone with Medicare through following November to enroll. Medicare prescription drug plans If you do decide to enroll in a Medicare For more information about this notice and Medicare Advantage Plans that prescription drug plan and drop your or your current prescription drug offer prescription drug coverage. All Texas Health prescription drug coverage, coverage contact Human Resources or Medicare prescription drug plans be aware that you and your dependents call 1-877-MyTHRLink (1-877-698-4754) provide at least a standard level of may not be able to get this coverage back. prompt 3. coverage set by Medicare. Some plans may also offer more coverage for a Please contact us for more information You will receive this notice annually higher monthly premium. about what happens to your coverage and at other times in the future such as if you enroll in a Medicare prescription before the next period you can enroll 2. Texas Health has determined that the drug plan. in Medicare prescription drug coverage prescription drug coverage offered and if this coverage through Texas Health by the Total Health Medical Plan is, See the 2013 Employee Benefits Guide changes. You also may request a copy. on average for all plan participants, or beginning on pages 23 and 39 – 41 of expected to pay out as much as the this Benefits Handbook for a description standard Medicare prescription drug of the prescription drug coverage coverage will pay and is considered available under the Total Health Medical Creditable Coverage. Plan.

Your Total Health Medical Plan coverage pays for other medical expenses, in addition to prescription drugs, and you will still be eligible to receive all of your current medical and prescription drug benefits if you choose to enroll in a Medicare prescription drug plan. Claims & Admin

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FOR MORE INFORMATION ABOUT For people with limited income and YOUR OPTIONS UNDER MEDICARE resources, extra help paying for Medicare PRESCRIPTION DRUG COVERAGE prescription drug coverage is available. More detailed information about Information about this extra help is Medicare plans that offer prescription available from the Social Security drug coverage is in the “Medicare & Administration (SSA) online at You” handbook. You’ll get a copy of the www.socialsecurity.gov, or call them at handbook in the mail every year from 1-800-772-1213 (TTY 1-800-325-0778). Medicare. You may also be contacted Remember: Keep this notice. If you enroll directly by Medicare prescription drug in one of the new plans approved by plans. For more information about Medicare which offers prescription drug Medicare prescription drug plans: coverage, you may be required to provide Visit www.medicare.gov. a copy of this notice when you join to show that you are not required to pay a • • Call your State Health Insurance higher premium amount. Assistance Program (see your copy of the Medicare and You handbook Date: 10/20/12 for their telephone number) for Name of Sender: Texas Health personalized help. Contact/Office: Benefits Department •• Call 1-800-MEDICARE Address: 612 E. Lamar Blvd., (1-800-633-4227). Suite 400 TTY users should call Arlington, TX 76011 1-877-486-2048. Phone number: 682-236-7236

Texas Health Group Health Plan Notice of Privacy Practices

This notice describes how medical Demographic information about you UNDERSTANDING YOUR HEALTH information about you may be used and and your family members (such as INFORMATION disclosed, and how you can get access name, address, dependent names, This Notice of Privacy Practices describes to this information. Please review it date of birth and coverage levels) is the privacy practices of Texas Health’s carefully. provided to the appropriate TPA each Group Health Plan (GHP) for employees pay period so their files contain the providing for medical, dental, vision, Texas Health contracts with third party most current information. To protect and health care spending account administrators (TPAs) to manage the your privacy even more, Texas Health reimbursement. Federal law requires administration of its medical, dental, may now require you to complete an that any health information the GHP vision, and health care spending Authorization form when you need maintains that identifies participants account plans. In 2013, the medical TPA assistance with a specific claim; to help remain private. Specifically, this notice is UnitedHealthcare. The dental TPA is you with an issue or in order to better describes your rights concerning your Aetna, the vision TPA is Superior Vision administer other Texas Health benefit health information, the responsibilities and the health care spending account plans as described below. The following of the GHP regarding your health TPA is PayFlex. information describes how medical information, how the GHP may use or information about participants may be

disclose your health information, and Claims & Admin used and disclosed and how you can whom you may contact regarding the access this information. GHP’s privacy policies.

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YOUR HEALTH INFORMATION TEXAS HEALTH’S •• Payment—your health information RIGHTS RESPONSIBILITIES may be used or disclosed to If you are a participant in Texas Health’s The GHP has certain responsibilities determine premiums under the medical, dental, vision, or health care regarding your health information, GHP, establish whether the GHP is spending account plan, you have the including the requirement to: responsible for payment of your right to: health care, and make payments •• Maintain the privacy of your health for your health care. For example, •• Request, in writing, a restriction information before paying a doctor’s bill, your on certain uses and disclosures of •• Provide you with this notice that medical information may be used your health information. However, describes the GHP’s legal duties to determine whether the terms of agreement with the request is not and privacy practices regarding the the GHP cover the medical care you required by law when compliance information it maintains about you received. Your medical information with the restriction cannot be •• Abide by the terms of the notice may also be disclosed to a health guaranteed currently in effect. care provider or other person as •• Inspect or obtain a copy of your needed for that person’s payment health information The GHP reserves the right to change activities. its information privacy policies and •• Request, in writing, that your health •• Health Care Operations—health care practices and to make the changes information be amended if you feel operations are activities that federal applicable to any health information the health information about you law considers important to the GHP’s that it maintains. If changes are made, is incorrect or incomplete. You will successful operation. Here are some the revised Notice of Privacy Practices be notified if the request cannot be examples. The GHP may: will be made available on the Benefits granted. –– Use your medical information website (MyTexasHealth) and •• Request that your health information to evaluate the performance of will be supplied when requested by be communicated with you in participating doctors under the participants. a specific way or at a specific GHP location. Reasonable requests will be Use and Disclosure of Health –– Disclose your medical information accommodated. Information Without Authorization to an auditor who will make •• Obtain an accounting of disclosures sure that the GHP is following Certain use and disclosure of your of your health information applicable laws health information is necessary and •• Obtain a paper copy of this Notice of permitted by law to treat you, process –– Contact you to give you Privacy Practices on request. payments for your treatment, and information about treatment alternatives or other health-related You may exercise these rights as follows: support the operations of the GHP and other involved entities. The following benefits and services that may •• The majority of information categories describe ways that the GHP interest you regarding the processing of health may use or disclose your information. It –– Disclose your medical information claims is maintained by third party provides some representative examples. to a health care provider or health administrators, contracted by the GHP All of the ways your health information plan that is involved with your to perform claims administration, is used or disclosed should fall within health care, as needed for that payment, and coverage verification. one of these categories: person’s quality-related health care As a result, you should direct your operations •• Treatment—your health information requests regarding this information to –– Provide some services through may be disclosed to a health care the third party administrators listed contracts with third party provider for your medical treatment. in the Important Contacts (inside business associates. An example back cover) of this Employee Benefits is a TPA who performs claims Handbook. administration, payment, and •• All other requests may be directed coverage verification. To protect to the Privacy Contact listed on this your health information, the GHP Claims & Admin notice. requires these business associates to appropriately protect your information.

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Disclosures Requiring Verbal •• To military command authorities as Uses and Disclosures Requiring Agreement required for members of the armed Written Authorization Your health information may be used or forces With your authorization, your personal disclosed to tell someone responsible •• To authorized federal officials for health information may be disclosed for your care about your location or national security and intelligence to Texas Health, the Group Health Plan condition. Your health information activities, as authorized by law Sponsor, and used by Texas Health in may be disclosed to your relative, •• To correctional institutions or law connection with other benefit plans friend, or other person you identify, if enforcement officials concerning in the Texas Health system for the the information relates to that person’s the health information of inmates, as purpose of managing those plans and involvement with your health care or authorized by law. determining their effectiveness. For payment for your health care. In certain example, to evaluate the design and circumstances, you may need to provide Disclosures to the Plan Sponsor operation of the medical plan and other authorization. The TPA, on behalf of the GHP, may benefit plans/programs; to determine disclose your health information to whether the disability program is Disclosures Required by Law Texas Health as the Plan Sponsor if being administered correctly; to The following disclosures of health the disclosure is permitted by the plan determine whether the leave programs information may be made without document or by law. Also, the TPA may are being used appropriately; to your written authorization or verbal disclose summary medical information, review and evaluate the quality of the agreement: from which information that identifies service provided by vendors for the you has been removed, so Texas Health various programs; and to determine •• When a disclosure is required by may change or terminate the GHP or the effectiveness of the disease federal, state or local law, judicial or obtain new premium bids. The TPA may management program and the wellness administrative proceedings, or for disclose to Texas Health whether you programs. law enforcement (for example when are participating or enrolled in a benefit responding to court orders) option offered by the GHP. Any other uses or disclosures of your •• To persons authorized by law to health information not addressed in receive public health information, Required Uses and Disclosures this notice or otherwise required by including reports of disease, injury, law will be made only with your written Under the law, the GHP must make birth, death, child abuse or neglect, authorization. You may revoke such disclosures when required by the food problems, or product defects authorization at any time. Secretary of the Department of Health •• To health oversight agencies, if and Human Services to investigate or authorized by law, to monitor the Privacy Complaints determine Texas Health’s compliance health care system, government with federal privacy law. You have the right to file a complaint benefit programs, or compliance with if you believe your privacy rights have civil rights laws been violated. This complaint may be •• To organ procurement organizations addressed to the Privacy Contact listed for tissue donation and transplant in this notice, or to the Secretary of •• For research purposes, when the the Department of Health and Human research has been approved by an Services. There will be no retaliation for institutional review board that has registering a complaint. reviewed the research proposal and established guidelines to provide for Privacy Contact the privacy of your health information Address any questions about this notice or the disclosure is of a limited data or how to exercise your privacy rights to set, where personal identifiers have the Texas Health Benefits office at been removed (866) 35-HIPAA (866-354-4722). •• To coroners and funeral directors for identification, determining the cause Effective Date Claims & Admin of death, or performing their duties as April 14, 2003 authorized by law Updated January 2007 •• To avoid a serious threat to the health Updated January 2008 or safety of a person or the public Updated January 2009 •• For specific government functions, Updated January 2010 such as protection of the President of Updated January 2011 the United States Updated January 2012 •• For workers’ compensation purposes Updated January 2013

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160 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Glossary Glossary The following terms are important for COBRA: Consolidated Omnibus Concurrent Care Claims: If an understanding your benefits. Budget Reconciliation Act (COBRA) on-going course of treatment was gives workers and their families who previously approved for a specific Active employee: An employee that is lose their health benefits the right period of time or number of treatments, not in an unpaid or terminated status in to choose to continue group health and your request to extend the PeopleSoft. benefits provided by their group health treatment is an Urgent Care request plan for a limited period of time under for Benefits as defined above, your Assignment of benefits: You may certain circumstances. Examples request will be decided within 24 authorize the claims processor to include voluntary or involuntary job hours, provided your request is made directly reimburse your medical service loss, reduction in the hours worked, at least 24 hours prior to the end of the provider for your eligible expenses transition between jobs, death, divorce, approved treatment. UnitedHealthcare by requesting that the provider and other life events. will make a determination on your accept assignment of benefits. When request for the extended treatment you request assignment of benefits, Coinsurance: The portion of an eligible within 24 hours from receipt of your you avoid paying the full cost of the expense you are required to pay. The request. medical service up front, filing a claim, medical plan pays the remaining and waiting for reimbursement. Your percentage. For example, after you If your request for extended treatment medical service provider generally files satisfy your deductible under the Texas is not made at least 24 hours prior to your medical claim for you if he or she Health Choice 500 plan, you pay 10% the end of the approved treatment, accepts assignment. coinsurance for network hospitalization the request will be treated as an in a Texas Health Preferred Hospital and Urgent Care request for Benefits and Base pay: Your current hourly rate the plan pays 90%. Your coinsurance decided according to the time frames times the number of hours you are is applied toward your out-of-pocket described above. If an on-going course classified in the HR/Payroll system maximum for the medical plan. of treatment was previously approved to work. Base pay does not include for a specific period of time or number shift differentials, bonuses, overtime Complications of pregnancy: For of treatments, and you request to extend earnings, commissions, or any other any covered person, the word “illness” treatment in a non-urgent circumstance, compensation. includes “complications of pregnancy.” your request will be considered a new request and decided according to Benefits base rate (also called Included are conditions distinct from, post-service or pre-service time frames, ABBR): Your annual base pay on the but caused or affected by pregnancy: latest of: your hire date, your rehire date whichever applies. • if rehired within 180 days of termination, • Acute nephritis or nephrosis Convalescent or skilled nursing October 1 of the previous year, or the •• Cardiac decompensation or missed facility: An institution operated and date of your last change in job status. abortion •• Similar conditions as severe as these. licensed by the state as a skilled Birthing center: A facility staffed nursing facility, extended care facility or Also included are complications of the by physicians which is licensed as a convalescent nursing home that meets pregnancy itself: birthing center in its jurisdiction to all of the following conditions: provide prenatal, birth, postpartum, •• A non-elective Cesarean delivery •• Licensed to provide and is providing newborn, and gynecologic services to •• An ectopic pregnancy inpatient care for patients recovering pregnant women. •• Spontaneous termination when a live from an injury or illness, professional birth is not possible. nursing services rendered by a Claims administrator: The third party registered graduate nurse (R.N.), or parties with whom Texas Health has licensed practical nurse (L.P.N.), or contracted to process the claims for licensed vocational nurse (L.V.N.) medical, dental, and prescription drug under the direction of a registered benefits under this plan. graduate nurse Close relative: Your spouse, mother, •• Licensed to provide and is providing father, sister, brother, child, grandparent, physical restoration services to help or in-laws. patients reach a degree of body functioning to permit self-care in essential daily living activities Resources

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•• Provides services for compensation •• Appropriate and consistent with the “Prevailing medical standards and from its patients and under the full- symptoms and findings or diagnosis clinical guidelines” means nationally time supervision of a physician or and treatment of the injury or illness recognized professional standards registered graduate nurse •• The most appropriate supply or level of care including, but not limited •• Provides 24-hour nursing services by of service that can be provided on to, national consensus statements, licensed nurses, under the direction a cost-effective basis (including, but nationally recognized clinical of a full-time registered graduate not limited to, inpatient vs. outpatient guidelines, and national specialty nurse care, electric vs. manual wheelchair, society guidelines. •• Maintains a complete medical record surgical vs. medical or other types of The claims administrator maintains on each patient care) clinical protocols that describe the •• Is approved and licensed by •• Performed in the least costly setting scientific evidence, prevailing medical Medicare where the services can be solely and standards and clinical guidelines appropriately provided •• Is not a place (other than supporting its determinations regarding •• Not provided for the convenience of incidentally) for the elderly, a place specific services. You can access these the covered person, physician, facility for rest, drug addicts, alcoholics, clinical protocols (as revised from time to or any other person custodial or educational care, care of time) on www.myuhc.com or by calling mental disorders or of the mentally •• Under generally accepted medical the number on the back of your ID card. retarded. standards, the service or treatment This information is available to physicians This term also applies to expenses cannot be omitted without adversely and other health care professionals on incurred in an institution referring affecting the patient’s condition or UnitedHealthcareOnline. In determining to itself as a skilled nursing facility, the quality of medical care rendered. whether new technologies, procedures, and treatments are covered, the plan extended care facility, convalescent The fact that the patient’s physician will make decisions that are consistent nursing home, or any similar name. prescribes services or supplies does not with prevailing medical research, based automatically mean they are covered Copay: This is the specific dollar on well-conducted randomized trials or health services. amount you pay for many covered cohort studies. service providers. For example, you pay For the health service to be covered, it Covered person: A covered employee, $25 for an office visit to your primary must be provided: physician or family doctor. Copays do a covered dependent, an alternate not apply toward your deductible or •• While the plan is in effect recipient receiving benefits under a out-of-pocket maximum. This is the •• Before any individual termination Qualified Medical Child Support Order portion of the charge collected when conditions take effect, as explained in (QMCSO), or a participating COBRA the service or supply is provided and this Handbook beneficiary meeting the eligibility before the plan pays benefits. •• To a person who is covered by this requirements for coverage as specified plan and meets all of the plan’s in this plan, and who is properly Cosmetic procedure: A procedure eligibility requirements. enrolled in the plan. performed solely for the improvement of your appearance rather than for the In addition, to be a covered health Custodial care: Care designed improvement or restoration of bodily service, it must be consistent with primarily to assist in the activities of function. A cosmetic procedure includes nationally recognized scientific daily living, such as bathing, dressing, any expense that does not qualify as a evidence, and prevailing medical feeding, preparation of special diets, medical expense that is deductible under standards and clinical guidelines as assistance in walking or in getting in Section 213(d) of the Code. described below. and out of bed, and supervision over medication which can normally be self- Covered health services: Covered “Scientific evidence” means the results administered. health services must be ordered by of controlled clinical trials or other a physician and determined by the studies published in peer-reviewed Deductible: The amount of eligible claims administrator to meet all of the medical literature generally recognized expenses a person or family must incur following conditions: by the relevant medical specialty and pay during the plan year before community. a plan will begin reimbursing eligible •• Provided to prevent, diagnose, or expenses. The plan administrator has treat a sickness, injury, mental illness, the right to allocate the deductible or substance abuse, or any of their and benefits among covered family symptoms members. •• Not excluded by the plan and is not considered experimental, investigational, or unproven Resources

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Dispense as written (DAW): This is •• Reliable evidence (see below) shows Explanation of benefits (EOB): when your doctor prescribes a preferred it is the subject of an ongoing Phase I, A statement provided by the claims or non-preferred drug and specifies II or III clinical trial or is under study administrator that shows how a service that the pharmacy may not substitute a to determine its maximum tolerated was covered by the plan, how much is generic drug of the same formula if one dose, toxicity, safety, efficacy, or being reimbursed, and what portion (if is available. efficacy as compared with a standard any) is not covered. means of treatment or diagnosis or Dispense as written penalty: A •• Prevailing opinion among experts, as Foster child: A child who is placed charge you pay for a prescription, shown by reliable evidence, is that with you by an authorized placement in addition to the preferred or non- further studies or clinical trials are agency or by a judgment, decree or preferred copay. The amount of necessary to determine its maximum other order of any court of competent this penalty is the difference in cost tolerated dose, toxicity, safety, efficacy, jurisdiction. between the preferred or non-preferred or efficacy as compared with a Generic drug: Drugs or substances and generic drug. standard means of treatment or that are not trademarked, are legally diagnosis or Durable medical equipment (DME): substituted for trademark drugs or Equipment that is ordered or provided •• It is less effective than conventional substances, and must be prescribed by a physician for outpatient use, for treatment methods or by and can only be obtained with a medical purposes, is not consumable or •• A review shows that patients have prescription from a qualified prescriber disposable, and not of use to a person in received the treatment or procedure as a legal substitute for trademarked the absence of an illness or injury. during Phase I, II or III of the clinical drugs. trial of the development of the Emergency: A serious medical treatment or procedure or Home health care agency: A public condition or symptom resulting from •• It is currently undergoing review by or private agency or organization that injury, sickness or mental illness which the Institutional Review Board (or specializes in providing medical care arises suddenly, and in the judgment similar body) for the treating health and treatment in the patient’s home and of a reasonable person, requires care facility or meets all of the following conditions: immediate care and treatment, generally •• The language appearing in the •• It is primarily engaged in and received within 24 hours of onset, to consent form or in the treating licensed, if such licensing is required, avoid jeopardy to life or health. hospital’s protocol for treatment by the appropriate licensing authority indicates that the hospital or to provide skilled nursing services EOB: See Explanation of benefits. physician regards the treatment or and other therapeutic services. Experimental service or treatment: procedure as experimental. •• It has policies established by a A drug, device, treatment, or procedure professional group associated with “Reliable evidence” means only: that meets one or more of the following the agency or organization. This conditions: •• Published reports and articles in the professional group must include authoritative medical and scientific at least one registered graduate •• It cannot be lawfully marketed literature or nurse (R.N.) to govern the services without the approval of the U.S. Food provided and it must provide for and Drug Administration and has not •• The written protocol or protocols full-time supervision of such services been so approved for marketing at used by the treating facility or the by a physician or registered graduate the time it is furnished or protocol or protocols of another facility studying substantially the nurse. •• It was reviewed and approved (or same drug, device, treatment or •• It maintains a complete medical is required by federal law to be procedure or record on each individual. reviewed and approved) by the treating facility’s Institutional Review •• The written informed consent form •• It has a full-time administrator. Board or other body serving a similar used by the treating facility or by function or another facility studying substantially the same drug, device, treatment •• It was used with a patient informed or procedure with respect to the consent document that was reviewed condition of the covered person in and approved (or is required by question. federal law to be reviewed and approved) by the treating facility’s All determinations of experimental Institutional Review Board or other service or treatment for all medical body serving a similar function or plans will be made by the claims administrator. Resources

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Home health care does not include: Hospital: An institution primarily Maintenance medications: •• Home health care visits in excess engaged in inpatient medical care or Medications that your physician of any applicable home health care treatment at the patient’s expense and prescribes for chronic or long-term agency limit listed in the Medical Plan that is: conditions (such as diabetes, high Comparison table on pages 20 – 22. •• Licensed by the applicable state blood pressure, heart conditions, Each visit by an employee of a home authority allergies, thyroid conditions, etc.). If you are not sure if the prescription is for a health care agency will be considered •• Accredited as a hospital by The chronic condition, please check with one home health care visit, and Joint Commission, Medicare or its your pharmacist. each four hours of home health aide designated reviewing agency and the services will be considered one home applicable state authority Medical necessity or medically health care visit. •• Supervised by a staff of physicians, necessary: Dental or vision care •• Care or treatment not stated in the has 24-hour nursing services by services, supplies or treatment home health care plan registered professional nurses, ordered by a physician or dentist and •• Services provided by a person who provides diagnostic and therapeutic determined by the claims administrator is a member of your family or your facilities for surgical and medical to meet all of the following conditions: dependent’s family or who normally diagnosis and treatment, and •• Provided for the diagnosis or direct lives in your home or your covered operates continuously; or, if primarily treatment of an injury, illness or dependent’s home a facility for treatment of mental or dental or vision condition •• A period when you are not under the nervous conditions, drug addiction •• Appropriate and consistent with the continuing care of a physician. or alcoholism, it has a contract with a hospital to perform surgical symptoms and findings or diagnosis Hospice care: A health care program procedures when necessary and treatment of the injury, illness or condition that provides coordinated services •• Not, other than incidentally, a place • at home, in outpatient facilities or for rest or the aged, a nursing home, • Provided in accordance with national institutional settings for terminally ill or a hotel. generally accepted medical or dental patients. A hospice must: practice • •• Have an interdisciplinary group Hospitalization or hospital stay: See • Not for the convenience of the of providers including at least one inpatient. patient, treating physician, or facility physician and one R.N. •• Under generally accepted medical Illness: A bodily disorder, disease, or or dental standards, the service or •• Maintain central clinical records on physical illness of a covered person. all patients treatment cannot be omitted without adversely affecting the patient’s •• Meet the standards of the National Injury: A condition caused by condition or the quality of care. Hospice Organization (NHO) accidental means which results in •• Meet applicable state licensing damage to the covered person’s body The fact that the patient’s physician or requirements. from an external force or self-inflicted. dentist prescribes services or supplies does not automatically mean they are Hospice care does not include: In-network: A provider who has medically necessary or covered by the contracted to be part of the UHC •• Services provided by a person who medical plan. Choice network. is a member of your family or your Mental health disorder/condition/ dependent’s family or who normally Inpatient: Medical treatment or Treatment for mental health lives in your home or your covered services provided at a hospital when illness: disorder/condition/illness evidenced dependent’s home a patient is admitted and confined for by symptoms of abnormal behavior, •• Any period when you are not under treatment, for which a room and board behavioral disturbances, nervous the continuing care of a physician charge is incurred. conditions, mood swings, anorexia •• Any curative or life-prolonging nervosa or bulimia nervosa or other procedures Institute of higher education: An institution accredited in the current aberrant behavior regardless of •• Any other benefits that are payable publication of Accredited Institutions of whether the origin of the symptoms is for hospice care expenses under the Higher Education. traceable to an organic abnormality, policy cause or origin, or is traceable to an •• Services or supplies that are primarily environmental cause or experience, to aid you or your covered dependent excluding treatment for alcoholism, in daily living drug and/or substance abuse •• More than three bereavement dependency or addiction. counseling sessions. Resources

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Midwife: A registered nurse (R.N.) who Physician: A legally licensed Provider: The individual or institution is certified after receiving specialized medical or dental doctor or surgeon, which provides medical services or training in the field of midwifery who chiropractor, osteopath, podiatrist, supplies. Providers include physicians, performs services in the home or certified consulting psychologist, hospitals, pharmacies, surgical facilities, birthing center. If the state in which licensed professional counselor or dentists, and other covered medical or the midwife performs services licenses psychiatrist, permitted to perform dental service and supply providers. midwives, the midwife must be licensed services within scope of his or her by the appropriate state licensing agent. license. Registered nurse: An individual who has received specialized nursing Network: A group of physicians, Pre-admission testing: The actual training and is authorized to use the hospitals, pharmacies, and other charges for covered health services designation “R.N.” and who is duly medical service providers who have made by a hospital for services licensed by the state or regulatory agreed to provide discounted fees for rendered on an outpatient basis before agency responsible for such licensing their services. a scheduled inpatient confinement at in the state in which the individual the same facility. performs such nursing services. Non-preferred drug: Brand name prescription drugs that are covered Preferred drug: These are brand Regularly scheduled to work: The under the Texas Health Medical Plan at name medications that have been hours and full-time equivalent (FTE) a higher copay than generic drugs or chosen based on their high level of that are assigned to the employee in preferred drugs. clinical efficacy and cost effectiveness. Texas Health’s HR/Payroll system. The preferred drug list is regularly Nurse: An individual who has received reviewed and updated by a committee Rehabilitation facility: A legally specialized nursing training and is of physicians, pharmacists and other operating institution or distinct part authorized to use one of the following allied health professionals. of an institution which has a transfer professional designations: agreement with one or more hospitals •• Registered nurse (R.N.) Pregnancy: The physical state which and which is primarily engaged in results in childbirth, life-threatening providing comprehensive multi- •• Licensed practical nurse (L.P.N.) abortion, or miscarriage, and any disciplinary physical restorative services, •• Licensed vocational nurse (L.V.N.) medical complications arising out of, or post-acute hospital, and rehabilitative Nursing services are covered only when resulting from, such state. inpatient care, and is duly licensed by they meet the definition of a covered the appropriate governmental agency to Prescription drugs: Drugs and health service (as defined on page 162) provide such services. medicines that must be accompanied and the nurse is licensed by the Texas by a physician’s written order It does not include institutions which State Board of Nursing, and if the nurse and dispensed only by a licensed provide only minimal care, custodial is not living with you or related to you pharmacist for the treatment of an care, ambulatory or part-time care or your spouse. illness, injury, or pregnancy. Prescription services, or an institution which Out-of-network: A provider who has drugs include injectable insulin, oral primarily provides treatment of mental not contracted to be part of the UHC contraceptives, and prenatal vitamins. disorders, chemical dependency, or Choice network. tuberculosis, except if such facility is Primary physician: A network physician licensed, certified, or approved as a Outpatient: Medical treatment or who specializes in general practice, rehabilitation facility for the treatment services provided at a hospital or clinic family practice, internal medicine, or of medical conditions, drug addiction for a patient who is not admitted to the pediatrics. You are not required to select a or alcoholism in its jurisdiction or is hospital for an overnight stay. primary physician or to get a referral from accredited by The Joint Commission, your primary physician before seeing a Medicare, or Commission on the Over-the-counter: Drugs, products, network specialist. However, the office Accreditation of Rehabilitation and supplies that do not require a visit copay is lower for primary physicians Facilities. prescription by federal law. under all the Total Health Medical Plan options. Part-time benefits-ineligible employee: An employee of Texas Health Private duty nursing: Continuous who is classified in the HR/Payroll system skilled care or intermittent care by a as part-time benefits-ineligible and Registered Nurse or Licensed Practical classified to work less than 48 hours per Nurse while the patient is not confined pay period. to an institution. Resources

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 165 Glossary

Room and board: All charges, by Substance abuse/chemical Urgent care clinic or center: A free- whatever name called, which are made dependency/alcoholism conditions: standing facility, other than a hospital, by a hospital, hospice, rehabilitation A condition, illness, or diagnosis of which is engaged primarily in providing facility, or convalescent nursing alcoholism, drug use or abuse, or minor emergency and episodic medical facility or other covered facilities as a chemical dependency or substance care to a person. A board-certified condition of occupancy. Such charges abuse requiring medical or psychiatric physician, a registered nurse, and a do not include the professional services care, including detoxification services. registered X-ray technician must be in of physicians, intensive nursing care, Any treatment for overdose of alcohol attendance at all times that the clinic or any other rehabilitative therapy, or other substances will be treated is open. The clinic’s facilities must occupational therapy, physical therapy, as a medical claim and not a mental include X-ray and laboratory equipment or speech or hearing therapy, by health or substance abuse claim. and a life-support system. For the whatever name called. Any treatments following the initial purposes of this Plan, a clinic meeting treatment of the overdose will be those requirements will be considered Routine newborn care: Inpatient classified by the illness or diagnosis for to be an urgent care medical clinic, charges for a well newborn baby for which the care is provided. by whatever actual name it may be nursery room and board and pediatric called. However, a clinic located on the services including circumcision. Temporomandibular joint premises of or in conjunction with or syndrome: A condition that is also in any way a part of a regular hospital Semi-private: A class of known as myofascial pain-dysfunction will be excluded from terms of this accommodations in a hospital or syndrome, a disorder that affects the definition. skilled nursing facility or other facility two joints at either side of the jaw (the providing services on an inpatient basis temporomandibular joints). Well-baby care: Medical treatment, in which at least two patient beds are services, or supplies rendered to a available per room. Texas Health entity: Any hospital child solely for the purpose of health wholly owned or controlled by Texas maintenance and not for the treatment Skilled nursing facility/extended Health. of an illness of injury. care facility: An institution that primarily provides skilled, as opposed Texas Health Preferred Hospitals: A to custodial, nursing service to list of Texas Health hospitals and other patients, and is approved by The Joint select hospitals. It is your responsibility Commission, the applicable state to verify whether a hospital is a Texas licensing authority and/or Medicare. Health Preferred Hospital before you receive care. Your cost for medical care is lower when you use a Texas Health Preferred Hospital. Resources

166 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 2013 Cost of Coverage 2013 Cost of Coverage

MEDICAL COVERAGE (PAID BEFORE-TAX) Following is you cost per pay period for medical coverage with Low Rx and the additional cost each pay period if you elect the High Rx.

Employee + Employee Only Employee + Spouse Employee + Family Child(ren) Plan Name Texas Texas Texas Texas Employee Employee Employee Employee Health Health Health Health FULL-TIME EMPLOYEES WHO EARN LESS THAN $25,000 Choice Plan 500/Low Rx $2.62 $268.83 $51.52 $483.75 $30.92 $466.09 $74.54 $752.71 Choice Plan 1000/Low Rx $0.96 $232.33 $28.67 $430.86 $17.86 $409.44 $42.05 $668.48 Choice Plan 1500 Plus/Low Rx $12.48 $224.30 $113.92 $355.63 $85.69 $351.15 $157.13 $568.73 Additional cost for High Rx $0.75 $8.00 $5.25 $12.00 $2.75 $10.25 $10.75 $17.50 FULL-TIME EMPLOYEES WHO EARN $25,000 - $49,999 Choice Plan 500/Low Rx $13.30 $258.15 $87.18 $448.09 $85.50 $411.51 $155.20 $672.05 Choice Plan 1000/Low Rx $4.91 $228.38 $41.57 $417.96 $41.59 $385.71 $75.21 $635.32 Choice Plan 1500 Plus/Low Rx $39.98 $196.80 $176.06 $293.49 $163.09 $273.75 $290.89 $434.97 Additional cost for High Rx $2.50 $6.25 $8.00 $9.25 $4.00 $9.00 $16.00 $12.25 FULL-TIME EMPLOYEES WHO EARN $50,000 - $74,999 Choice Plan 500/Low Rx $13.47 $257.98 $90.60 $444.67 $89.95 $407.06 $161.70 $665.55 Choice Plan 1000/Low Rx $4.72 $228.57 $42.33 $417.20 $42.53 $384.77 $75.64 $634.89 Choice Plan 1500 Plus/Low Rx $41.34 $195.44 $183.55 $286.00 $169.88 $266.96 $303.52 $422.34 Additional cost for High Rx $3.25 $5.50 $9.25 $8.00 $4.75 $8.25 $18.50 $9.75 FULL-TIME EMPLOYEES WHO EARN $75,000 - $99,999 Choice Plan 500/Low Rx $21.60 $249.85 $140.83 $394.44 $129.18 $367.83 $239.91 $587. 34 Choice Plan 1000/Low Rx $7.84 $225.45 $61.47 $398.06 $62.17 $365.13 $113.75 $596.78 Choice Plan 1500 Plus/Low Rx $66.05 $170.73 $284.96 $184.59 $262.46 $174.38 $471.09 $254.77 Additional cost for High Rx $4.00 $4.75 $13.25 $4.00 $6.75 $6.25 $21.25 $7.00 FULL-TIME EMPLOYEES WHO EARN $100,000 AND ABOVE Choice Plan 500/Low Rx $22.64 $248.81 $146.74 $388.53 $135.10 $361.91 $252.53 $574.72 Choice Plan 1000/Low Rx $8.17 $225.12 $65.50 $394.03 $65.39 $361.91 $119.67 $590.86 Choice Plan 1500 Plus/Low Rx $69.46 $167.32 $299.21 $170.34 $275.60 $161.24 $494.63 $231.23 Additional cost for High Rx $4.25 $4.50 $14.00 $3.25 $7.00 $6.00 $22.25 $6.00 PART-TIME EMPLOYEES* Choice Plan 500/Low Rx $9 1 .74 $179.71 $216.16 $319.11 $200.52 $296.49 $310.23 $517.02 Choice Plan 1000/Low Rx $36.58 $196.71 $92.55 $366.98 $90.99 $336.31 $142.91 $567.62 Choice Plan 1500 Plus/Low Rx $135.07 $101.71 $317.18 $152.37 $288.23 $148.61 $455.45 $270.41 Additional cost for High Rx $8.50 $0.25 $17.00 $0.25 $12.25 $0.75 $26.75 $1.50

*If you are a part-time employee over age 55, Texas Health provides you with a subsidy for medical coverage equal to the difference between the cost of coverage for a full-time employee earning between $50,000 and $74,999 a year and a part-time employee’s cost. When you enroll online, the premium amount you see will have the part-time over age 55 subsidy included. However, your paycheck will show the regular part-time premium amount on one line and the over age 55 subsidy on a separate line. Resources

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 167 2013 Cost of Coverage

DENTAL (PAID BEFORE-TAX) VISION (PAID BEFORE-TAX)

Aetna Aetna PPO Aetna PDN Superior Managed (Low Option) (High Option) Vision Coverage Level (DMO) Coverage Level Employee Only $5.75 $7.02 $17.84 Employee Only $3.68

Employee + Spouse $11.49 $14.05 $35.67 Employee + Spouse $7.93

Employee + Child(ren) $15.38 $18.79 $47.72 Employee + Child(ren) $5.97

Employee + Family $19.51 $23.84 $60.57 Employee + Family $10.87

ADDITIONAL LIFE 1 SPOUSE LIFE 1 (PAID AFTER-TAX) (PAID AFTER-TAX) CHILD LIFE (PAID AFTER-TAX)

Cost per pay period Cost per pay period per $1,000 of per $1,000 of Coverage Cost Your Age coverage Your Age coverage $0.2689 for All of your eligible $10,000 Under 30 $0.0176 Under 30 $0.0264 children of coverage 30 - 34 $0.0220 30 - 34 $0.0353

35 - 39 $0.0309 35 - 39 $0.0397 ADDITIONAL AD&D (PAID BEFORE-TAX) 40 - 44 $0.0397 40 - 44 $0.0441 Cost per pay 45 - 49 $0.0617 45 - 49 $0.0661 period per 50 - 54 $0.0970 50 - 54 $0.1014 $1,000 of 55 - 59 $0.1455 55 - 59 $0.1895 Coverage coverage

60 - 64 $0.1895 60 - 64 $0.2909 Employee Only $0.0055 Employee + 65 - 69 $0.2821 65 - 69 $0.5598 $0.0102 Family 70 - 74 $0.3835 70 - 74 $0.9080

75 - 79 $0.5510 75 - 79 $0.9080

1 Additional and Spouse Life rates are based on the employee’s age as of Jan. 1, 2013.

Cost of Disability Coverage (Paid After-Tax) STD (PAID AFTER-TAX) ADDITIONAL LTD (PAID AFTER-TAX) To calculate your premiums for Disability, multiply your hourly base rate Waiting Rate Rate by the cost of your benefit elections Period Multiplier Coverage Multiplier listed in the tables below. For example, 14 days $0.7643 Additional LTD $0.3360 if you earn $8 per hour, multiply $8 x (“Buy-Up” Plan) $0.7643 = $6.11 per paycheck. 2 30 days $0.5317

2 Example for part-time employees: multiply $8 x $0.7643 x [hours you are regularly scheduled to work per pay period ÷ 80].

Cost of Long Term Care Coverage (Paid After-Tax) Contact Genworth Life at 1-800-416-3624 for rate information and to enroll.

The plans, policies, and procedures described in this Handbook are not to be construed as conditions of employment. Texas Health reserves the right to modify, revoke, suspend, terminate, or change any or all such plans, policies, or procedures, in whole or in part, at any time, without notice. The language used in this Handbook is not intended to create, nor is it to be construed to create, a contract between Texas Health and any one of its employees. Nothing herein shall be construed to give any person the right to be retained in the employ of Texas Health or otherwise restrain Texas Health’s right to deal with its employees. Resources

168 1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org Important Contacts Important Contacts For Information About: Contact: At: Flexible Benefits Human Resources Human Resources (see page 35 of your 2013 Benefits Guide for phone numbers to HR) General questions and to request forms Medical Plan UnitedHealthcare Services Inc. 1-877-MyTHRLink, prompt 1 185 Asylum St. www.myuhc.com Hartford, CT 06103-3408 Health Advocacy UnitedHealthcare 1-877-MyTHRLink, prompt 2 P.O. Box 30555 Salt Lake City, UT 84130-0555 Pharmacy Benefits Caremark 1-877-MyTHRLink, prompt 3 P.O. Box 659529 www.caremark.com San Antonio, TX 78265-9529

Be Healthy OptumHealth 1-877-MyTHRLink, prompt 4, press 3 Dental Plan Aetna 1-877-MyTHRLink, prompt 6, press 3 P.O. Box 14094 Participating Dental Network (PDN) www.aetna.com Lexington, KY 40512-4094 Aetna Managed Dental Plan (DMO) Vision Plan Superior Vision Services 1-877-MyTHRLink, prompt 6, press 4 11101 White Rock Road, Suite 150 www.superiorvision.com Rancho Cordova, CA 95670

Life and Accident Insurance CIGNA Group Insurance 1-(800) 238-2125 P.O. Box 22328 Life Insurance and Accidental Death & Pittsburgh, PA 15222-0328 Dismemberment

Business Travel Accident Life Insurance Company of North America 1-877-MyTHRLink, prompt 6, press 5

Disability CIGNA Group Insurance 1-(800) 781-2006 P.O. Box 29063 Short Term Disability 1-(800) 36-CIGNA or 1-(800) 362-4462 to Glendale, CA 91209 report a claim Long Term Disability Long Term Care Insurance Genworth Life Insurance Company 1-877-MyTHRLink, prompt 6, press 7 P.O. Box 64010 www.genworth.com/groupltc St. Paul, MN 58164-0010 Group ID: thr Code: groupltc Flexible Spending Accounts PayFlex Systems USA, Inc. 1-877-MyTHRLink, prompt 6, press 6 Flex Dept. Health Care Spending Account and Fax: (402) 231-4310 P.O. Box 3039 Day Care Spending Account Omaha, NE 68103-3039 www.healthhub.com to track expenses

Paid Time Off Human Resources Human Resources Texas Health Retirement Program JPMorgan Retirement Plan Services 1-877-MyTHRLink, prompt 5 11500 Outlook St. www.retireonline.com Overland Park, KS 66211

Tuition Reimbursement Texas Health Tuition Reimbursement 1-877-MyTHRLink, prompt 6, press 2 or e-mail at [email protected]

COBRA Continuation of Coverage PayFlex Systems USA, Inc. 1-(800) 359-3921 COBRA & Direct Billing Department P.O. Box 2239 Omaha, NE 68103-2239

People and Culture Committee Texas Health (682) 236-7900 612 E. Lamar Blvd, Suite 900 Arlington, TX 76011

Employee Assistance Program (EAP) MHN 1-877-MyTHRLink, prompt 4, press 4 Tobacco Cessation Alere 1-877-MyTHRLink, prompt 4, press 2 Leave of Absence (LOA) Your entity’s IDM representative 1-877-MyTHRLink, prompt 6, press 1 or e-mail at [email protected] Weight Watchers Weight Watchers 1-877-MyTHRLink, prompt 4, press 1

Discount Program Beneplace www.Beneplace.com/texashealth Resources

1-877-MyTHRLink (1-877-698-4754) www.MyTHR.org 169

Lisa Norris, Admissions Specialist, THS Dr. Noushin Firouzbakht, MD, Physician, THPG Clara Mainoo, RN, THHEB Toni Stegemoller Clinical Documentation Specialist, THC

d GC 012 2/2013 19,000