SHBP: MEDICARE PENSIONERS Coverage Period: 01/01/2015 12/31/2015

SHBP: MEDICARE PENSIONERS Coverage Period: 01/01/2015 – 12/31/2015 Summary of Benefits and Coverage:What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: Secondary This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.seafarers.org or by calling 1-800-252-4674.

Important Questions Answers Why this Matters: You must pay all the costs up to the deductible amount before this Plan begins to pay $125 person/$250 family What is the overall for covered services you use. Check your policy or Plan document to see when the deductible? Doesn’t apply to Inpatient deductible starts over. See the chart starting on page 2 for how much you pay for facility/Vision. covered services after you meet the deductible. You must pay all of the costs for prescription drugs up to the deductible amount before Are there other Yes. $100 person for prescription drug coverage. this Plan begins to pay. Prescription coverage provided through OptumRx. deductibles for specific There are no other specific services? deductibles. Pensioner only. Is there an out–of– There’s no limit on how much you could pay during a coverage period for your share of pocket limit on my No. the cost of covered services. expenses? What is not included in This Plan has no out-of-pocket There’s no limit on how much you could pay during a coverage period for your share of the out–of–pocket limit. the cost of covered services. limit? Is there an overall The chart starting on page 2 describes any limits on what the Plan will pay for specific annual limit on what No. covered services, such as office visits. the plan pays? Does this plan use a No. network of providers? Do I need a referral to No. You don’t need a referral You can see the specialist you choose without permission from this Plan. see a specialist? to see a specialist. Are there services this Some of the services this Plan doesn’t cover are listed on page 5. See your Summary Yes. plan doesn’t cover? Plan Description for additional information about excluded services.

Questions: Call 1-800-252-4674 or visit us at www.seafarers.org If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 1 of 10 at www.seafarers.org or call 1-800-252-4674 to request a copy. SHBP: MEDICARE PENSIONERS Coverage Period: 01/01/2015 – 12/31/2015 Summary of Benefits and Coverage:What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: Secondary  Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.  Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if you haven’t met your deductible.  Your cost sharing depends upon whether the provider accepts Medicare assignment.

Your cost if you use Common Services You May Need Medicare Non Medicare Limitations & Exceptions Medical Event Providers Providers Primary care visit to treat an injury or 50% of Medicare 65% of Medicare Pensioner only. illness co-insurance co-insurance 50% of Medicare 65% of Medicare Pensioner only. If you visit a health Specialist visit co-insurance co-insurance care provider’s 50% of Medicare 65% of Medicare Pensioner only. office or clinic Other practitioner office visit co-insurance co-insurance 50% of Medicare 65% of Medicare Pensioner only. Preventive care/screening/immunization co-insurance co-insurance 50% of Medicare 65% of Medicare Pensioner only. Diagnostic test (x-ray, blood work) co-insurance co-insurance If you have a test 50% of Medicare 65% of Medicare Pensioner only. Outpatient imaging (CT/PET scans, MRIs) co-insurance co-insurance Maintenance drugs cost more when Generic drugs $10 co-pay retail If you need drugs to 100% purchased at retail. 30 day retail; 90 day mail order $20 co-pay mail treat your illness or Pensioner only. condition Maintenance drugs cost more when Preferred brand drugs $25 co-pay retail 100% purchased at retail. 30 day retail; 90 day mail order $50 co-pay mail More information Pensioner only. about prescription Maintenance drugs cost more when Non-preferred brand drugs $50 co-pay retail drug coverage is 100% purchased at retail. 30 day retail; 90 day mail order $100 co-pay mail available at Pensioner only. www.seafarers.org. Through CIGNA Home Delivery Specialty drugs 0% 100% only.

Questions: Call 1-800-252-4674 or visit us at www.seafarers.org If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 2 of 10 at www.seafarers.org or call 1-800-252-4674 to request a copy. SHBP: MEDICARE PENSIONERS Coverage Period: 01/01/2015 – 12/31/2015 Summary of Benefits and Coverage:What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: Secondary Your cost if you use Common Services You May Need Medicare Non Medicare Limitations & Exceptions Medical Event Providers Providers Facility fee (e.g., ambulatory surgery 50% of Medicare 65% of Medicare ______none______If you have center) co-insurance co-insurance outpatient surgery 50% of Medicare 65% of Medicare Physician/surgeon fees ______none______co-insurance co-insurance 50% of Medicare 65% of Medicare $300 co-payment if non-injury related Emergency room services co-insurance co-insurance or not admitted. If you need 50% of Medicare 65% of Medicare immediate medical Emergency medical transportation ______none______co-insurance co-insurance attention 50% of Medicare 65% of Medicare Urgent care Pensioner only. co-insurance co-insurance 180 continuous days or $1,000,000 50% of Medicare 65% of Medicare maximum per illness. Inpatient Facility fee (e.g., hospital room) co-insurance co-insurance benefits will resume after 60 days out If you have a $300 co-payment $300 co-payment of hospital. Payment at semi-private hospital stay room rate. 50% of Medicare 65% of Medicare Physician/surgeon fee ______none______co-insurance co-insurance Mental/Behavioral health outpatient 100% 100% Not covered. If you have mental services health, behavioral Mental/Behavioral health inpatient services 100% 100% Not covered. health, or substance Substance use disorder outpatient services 100% 100% Not covered. abuse needs Substance use disorder inpatient services 100% 100% Not covered. 50% of Medicare 65% of Medicare Prenatal and postnatal care Pensioner only. coinsurance coinsurance If you are pregnant 50% of Medicare 65% of Medicare Payment at semi-private room rate. Delivery and all inpatient services co-insurance co-insurance Benefit for pensioner and spouse $300 co-payment $300 co-payment only.

Questions: Call 1-800-252-4674 or visit us at www.seafarers.org If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 3 of 10 at www.seafarers.org or call 1-800-252-4674 to request a copy. SHBP: MEDICARE PENSIONERS Coverage Period: 01/01/2015 – 12/31/2015 Summary of Benefits and Coverage:What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: Secondary Your cost if you use Common Services You May Need Medicare Non Medicare Limitations & Exceptions Medical Event Providers Providers Combined with skilled nursing care; 50% of Medicare 65% of Medicare 60 visits per year. Visit equals two Home health care co-insurance co-insurance hours. Maximum allowed $75 per hour. Pensioner only – after non- catastrophic illness/injury; 20 visits per year for physical therapy. 50% of Medicare 65% of Medicare Pensioner, spouse, or child – after Rehabilitation services co-insurance co-insurance catastrophic illness/injury; 40 visits per year, includes physical, If you need help occupational, speech, pulmonary, and recovering or have cognitive therapies.. other special health Habilitation services 100% 100% Not covered. needs Combined with home health care; 60 50% of Medicare 65% of Medicare visits per year. Visit equals two Skilled nursing care co-insurance co-insurance hours. Maximum allowed $75 per hour. After non-catastrophic illness/injury 30% of Medicare 30% of Medicare for Pensioner only. After Durable medical equipment co-insurance co-insurance catastrophic illness/injury for Pensioner, spouse, or child. 50% of Medicare 65% of Medicare Hospice service For six months. co-insurance co-insurance Eye exam 100% 100% Not covered. If your child needs Glasses 100% 100% Not covered. dental or eye care Dental check-up 100% 100% Not covered.

Questions: Call 1-800-252-4674 or visit us at www.seafarers.org If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 4 of 10 at www.seafarers.org or call 1-800-252-4674 to request a copy. SHBP: MEDICARE PENSIONERS Coverage Period: 01/01/2015 – 12/31/2015 Summary of Benefits and Coverage:What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: Secondary Excluded Services & Other Covered Services:

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

 Acupuncture  Infertility treatment  Prenatal and postnatal care for your spouse, and all services related to your child’s  Bariatric surgery  Long-term care pregnancy  Chiropractic care  Mental health  Prescriptions for spouse or child  Cosmetic surgery  Occupational and speech therapy for non-  Private duty nursing (inpatient)  Dental care catastrophic illness/injury  Routine foot care  Durable medical equipment for spouse or  Outpatient services for spouse or child  Services outside the U.S. and its territories child after non-catastrophic illness/injury  Outpatient and inpatient substance use  Treatment not medically necessary  Habilitation services, except following disorder catastrophic illness/injury  Physical therapy for spouse or child for  Weight loss programs  Hearing aids for spouse or child non-catastrophic illness/injury

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

 Private duty nursing (for home health care  Hearing aids for pensioner only  Routine eye care only)

Your Rights to Continue Coverage: Federal laws may provide protections that allow you to keep health coverage as long as you pay your premium. There are exceptions however, such as if you commit fraud. For more information on your rights to continue coverage, contact the Plan at 1-800-252-4674. You may also contact the U.S. Department of Labor, Employee Benefits Security Administration at 1-866-444-3272 or www.dol.gov/ebsa, or the U.S. Department of Health and Human services at 1-877-267-2323 x61565 or www.cciio.cms.gov

Questions: Call 1-800-252-4674 or visit us at www.seafarers.org If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 5 of 10 at www.seafarers.org or call 1-800-252-4674 to request a copy. SHBP: MEDICARE PENSIONERS Coverage Period: 01/01/2015 – 12/31/2015 Summary of Benefits and Coverage:What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: Secondary

Your Appeal Rights:

If you have a complaint or are dissatisfied with a denial of coverage for claims under your Plan, you may be able to appeal. For questions about your rights, this notice, or assistance, you can contact the Plan at 1-800-252-4674. Your appeal must be in writing and sent within 180 days of the date your claim was denied. You should include any supporting documentation you have when making your request. Your written appeal should be sent to: Board of Trustees, Seafarers Health and Benefits Plan, P.O. Box 380, Piney Point, Maryland 20674. You may also contact the U.S. Department of Labor, EBSA at 1-866-444-3272, or at www.dol.gov/ebsa.

Does this Coverage Provide Minimum Essential Coverage?

The Affordable Care Act requires most people to have health coverage that qualifies as “minimum essential coverage.” This Plan is secondary to Medicare, so this coverage alone does not provide minimum essential coverage; however Medicare qualifies as minimum essential coverage.

Does this Coverage Meet the Minimum Value Standard?

The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). Because this Plan is secondary to Medicare, it does not on its own meet the minimum value standard; however the Plan believes that when combined with Medicare it meets minimum value.

Language Access Services:

Spanish (Español): Para obtener asistencia en Español, llame al 1-800-252-4674.

The Seafarers Health and Benefits Plan is a “grandfathered health plan” under the Patient Protection and Affordable Care Act.

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

Questions: Call 1-800-252-4674 or visit us at www.seafarers.org If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 6 of 10 at www.seafarers.org or call 1-800-252-4674 to request a copy. SHBP: MEDICARE PENSIONERS Coverage Period: 01/01/2015 – 12/31/2015 Summary of Benefits and Coverage:What this Plan Covers & What it Costs Coverage for: Individual + Family | Plan Type: Secondary

Questions: Call 1-800-252-4674 or visit us at www.seafarers.org If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 7 of 10 at www.seafarers.org or call 1-800-252-4674 to request a copy. SHBP: MEDICARE PENSIONERS Coverage Period: 01/01/2015 – 12/31/2015 Coverage Examples Coverage for: Individual + Family| Plan Type: Secondary

Having a baby Managing type 2 diabetes About these Coverage (normal delivery) (routine maintenance of Examples: a well-controlled condition)

These examples show how this plan might  Amount owed to providers: $7,540  Amount owed to providers: $5,400 cover medical care in given situations. Use . Medicare allowed $5,000 . Medicare allowed $3,340 these examples to see, in general, how much . Medicare paid $4,000 . Medicare paid $2,672 financial protection a sample patient might get  Plan pays $300  Plan pays $111.25 if they are covered under different plans.  Patient pays $700  Patient pays $556.75

Sample care costs: Sample care costs: Hospital charges $2,700 Prescriptions $2,900 This is Routine obstetric care $2,100 Medical Equipment and $1,300 not a cost Hospital charges (baby) $900 Supplies estimator. Anesthesia $900 Office Visits and Procedures $700 Laboratory tests $500 Education $300 Don’t use these examples to Laboratory tests $100 estimate your actual costs Prescriptions $200 under this plan. The actual Radiology $200 Vaccines, other preventive $100 care you receive will be Vaccines, other preventive $40 Total $5,400 different from these examples, Total $7,540 and the cost of that care will Patient pays: Deductibles also be different. Patient pays: $125/$100 Deductibles Medical/Prescription $125/$100 See the next page for Medical/Prescription Co-pays (RX mail order) $80 important information about Co-pays $300 Co-insurance $251.75 these examples. Co-insurance $175 Limits or exclusions $0 Limits or exclusions $0 Total $556.75 Total $700 Note: Examples assume it is the = beginning of the year and you have not met your deductible. Outpatient or prescription coverage is for pensioner only. Questions: Call 1-800-252-4674 or visit us at www.seafarers.org If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 8 of 10 at www.seafarers.org or call 1-800-252-4674 to request a copy. SHBP: MEDICARE PENSIONERS Coverage Period: 01/01/2015 – 12/31/2015 Coverage Examples Coverage for: Individual + Family| Plan Type: Secondary Questions and answers about the Coverage Examples:

What are some of the What does a Coverage Example No. Coverage Examples are not cost assumptions behind the show? estimators. You can’t use the examples to Coverage Examples? For each treatment situation, the Coverage estimate costs for an actual condition. Example helps you see how deductibles, They are for comparative purposes only.  Costs don’t include premiums. co-payments, and co-insurance can add up. Your own costs will be different  Sample care costs are based on national It also helps you see what expenses might be depending on the care you receive, the averages supplied by the U.S. left up to you to pay because the service or prices your providers charge, and the Department of Health and Human treatment isn’t covered or payment is reimbursement your health plan allows. Services, and aren’t specific to a limited. particular geographic area or health Can I use Coverage Examples plan.  The patient’s condition was not an Does the Coverage Example to compare plans? excluded or preexisting condition. predict my own care needs? Yes. When you look at the Summary of  All services and treatments started and ended in the same coverage period.  No. Treatments shown are just examples. Benefits and Coverage for other plans, you’ll find the same Coverage Examples.  There are no other medical expenses for The care you would receive for this When you compare plans, check the any member covered under this plan. condition could be different based on “Patient Pays” box in each example. The  Out-of-pocket expenses are based only your doctor’s advice, your age, how smaller that number, the more coverage on treating the condition in the serious your condition is, and many other the plan provides. example. factors.  The patient received all care from in- network providers. If the patient had Are there other costs I should Does the Coverage Example received care from out-of-network consider when comparing providers, costs would have been predict my future expenses? plans? higher. Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you’ll pay in out-of- pocket costs, such as co-payments, deductibles, and co-insurance. You

Questions: Call 1-800-252-4674 or visit us at www.seafarers.org If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 9 of 10 at www.seafarers.org or call 1-800-252-4674 to request a copy. SHBP: MEDICARE PENSIONERS Coverage Period: 01/01/2015 – 12/31/2015 Coverage Examples Coverage for: Individual + Family| Plan Type: Secondary should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses.

Note: Medicare primary pensioners do not have a premium.

Questions: Call 1-800-252-4674 or visit us at www.seafarers.org If you aren’t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary 10 of 10 at www.seafarers.org or call 1-800-252-4674 to request a copy.