2019 Employee Benefits Handbook

Attention! Taking care of yourself – body, mind and spirit – leads to INCREASED AWESOMENESS.

1-877-MyTHRLink (1-877-698-4754) MyTHR.org i About This Employee Benefits Handbook

Texas Health Resources is committed continued employment, or benefits This Handbook is also available to providing employees with a choice of any kind. on the Texas Health employee of comprehensive, affordable, and •• There are no guarantees that the portal MyTHR.org and on competitive benefits. Your benefits right to participate in benefits BeHealthyTHR.org. are an important part of your Total under the plans for employees or If you have questions concerning Rewards from Texas Health. And, other covered persons will exist or your benefits that are not answered as part of your total compensation, remain unchanged. in this Employee Benefits Handbook, Texas Health pays a substantial •• Texas Health intends to continue please contact Human Resources. portion of the benefit costs for the plans indefinitely but reserves eligible employees and their families. the right to change them at any OUR TEXAS HEALTH time. This includes the right to Texas Health is pleased to provide SM change any amounts contributed PROMISE you with this Employee Benefits by Texas Health or employees SM Handbook. It is important for you to Our Texas Health Promise is toward the cost of benefits, the read this Handbook and reference “Individuals Caring for Individuals, level of benefits provided, and the ® it throughout the year. It describes Together. ” It is a recurring theme types of employees eligible for the main features of the benefit throughout this Benefits Handbook. benefits. plans, explains how to use these Whether you are a direct caregiver or benefits, and identifies resources •• Texas Health reserves the sole support those who provide patient for help when you need it. You right to alter, amend, modify, or care, living Our Texas Health Promise should understand your Texas Health terminate the plans, any program enables everyone at Texas Health to benefits and how they work—so described in this Handbook, or any better serve those who entrust their you can select the benefits that best part thereof at its discretion at any medical care to us. protect the needs of you and your time, either in their entirety or with Our Texas Health PromiseSM is valued family. respect to any covered types of employees. From time to time, you throughout our organization—and Throughout this Handbook, the term may receive updated information that includes providing you and your “Texas Health” refers to Texas Health concerning benefit changes. family great benefits. Texas Health Resources and the other employers •• In the event of a conflict between covers over 80% of the costs of that have adopted the benefits being the provisions of this Handbook medical coverage for all employees. described. A list of the employers that and the provisions contained in the have adopted each plan is available legal plan documents, the legal MISSION from the Benefits Department at plan documents will govern. To improve the health of the people Texas Health. •• No employee of Texas Health is in the communities we serve. The following is important responsible for advising you on information about this Handbook: the tax effect of your participation VISION in any plan described in this •• This Employee Benefits Handbook Handbook. Because tax laws Partnering with you for a lifetime of is the Summary Plan Description are complicated and constantly health and well-being. (SPD) for the Texas Health changing, it is recommended Flexible Benefits Plan, the Texas that you consult a tax advisor if VALUES Health Retirement Program, and you have any questions about Respect, Integrity, Compassion, other benefits sponsored by how participation in any of these Excellence (RICE). Texas Health. The provisions of plans will affect your personal tax this Handbook apply to eligible situation. We will provide and maintain a fair employees of Texas Health and •• The plan administrator and in some and equitable environment for all their eligible family members. cases the claims administrator has by valuing and respecting individual •• Nothing in this Handbook says the authority to interpret each plan. differences for our enrichment or implies that coverage under Any interpretation made by the and for the enrichment of the or participation in any plan plan administrator or the claims communities we serve. is a guarantee of continued administrator will be conclusive. employment with Texas Health TEXAS HEALTH POLICIES or other employers who have A glossary of terms begins on page AND PROCEDURES adopted the Texas Health benefits 216. It defines many important terms For more information on program. Neither this Handbook for understanding your benefits Texas Health’s policies, go to nor updated materials are contracts under the plans. MyTexasHealth.texashealth.org. or assurances of compensation,

ii 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Table of Contents Table of Contents

Welcome to Total Health, Where Well-being 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...... 82 Dental and vision care are important to your overall health, and this section explains how your benefits work. Spending Accounts...... 99 The Health Care and Day Care Flexible Spending Accounts can save you money. This section tells you how. Income Protection...... 106 Learn how the disability, life insurance and AD&D coverages help you be financially prepared. Retirement...... 130 Be sure to understand how the Retirement Plan works so you can get the most from it. Time Off...... 147 Everyone needs some time away from work. This section tells you about Texas Health’s time off benefits. Other Benefits...... 158 Tuition reimbursement, adoption assistance, supplemental benefits and employee discounts are available. Leaving Texas Health...... 187 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...... 200 Texas Health has provided important information about claims, your legal rights, Medicare, and your privacy. Resources...... 215 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 iii 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, check your PTO balance, request a leave of absence, and much more. •• www.BeHealthyTHR.org: Accessible anytime, anywhere. Pull up your online benefits guide for information about your benefits at home, at work, or even on your mobile device.

BY PHONE •• 1-877-MyTHRLink (1-877-698-4754): Calling this number gives you direct access to all of our benefits providers, including Texas Health Aetna, UnitedHealthcare, Caremark (prescription), Aetna (dental), EAP, Tuition Reimbursement, and more.

Press To Hear About Then Choose from These Additional Options

THR Benefits Support 9 For assistance with online enrollment, dependent verification, or None general benefit plan information

1 Texas Health Aetna Medical Benefits and Eligibility None

2 UnitedHealthcare (UHC) Medical Benefits and Eligibility None

3 Pharmacy Plan None

Press 1: Real Appeal Press 2: Quit for Life tobacco cessation program Press 3: Be Healthy rewards 4 Wellness Benefits Press 4: Employee Assistance Program (EAP) Press 5: Diabetes Educators Press 6: To repeat these options

5 401(k) Retirement Plan None

Press 1: Leaves of Absence, Workplace Injuries Press 2: Tuition Reimbursement Press 3: Dental Benefits Press 4: Vision Benefits 6 Other Total Health Questions Press 5: Employee Discounts Press 6: Spending Accounts Press 7: Disability Benefits Press 8: Life Insurance Benefits Press 9: To repeat these options

7 To Repeat All Options None

Español 8 None Marque el 8 para ayuda en español.

IN PERSON •• Human Resources: Each entity has a Human Resources office available to assist with your benefit questions. Go to BeHealthyTHR.org for a list of phone numbers for each Human Resources office.

iv 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Welcome to Total Health Welcome to Total Health, Where Well-being is a Way of Life!

Texas Health’s employee benefit GET REWARDED FOR philosophy focuses on helping our GETTING HEALTHY employees and their families optimize For answers to your benefit their health and well-being. We have Be Healthy is a wellness program questions or to access named our benefits program Total designed to inspire and motivate Total Health program information: Health because of our focus on the you to take the best possible care Call 1-877-MyTHRLink total person. Total Health provides of yourself. Be Healthy gives you (1-877-698-4754) prompt 9 one source for all your benefit important tools to help you better or go online to BeHealthyTHR.org. needs—including information about understand your health and make medical, dental, vision, life insurance, well-being a way of life. disability, Paid Time Off (PTO), and If you are a benefits-eligible retirement benefits. Optimizing your employee, you receive a reward each health and well-being by taking time you complete a Be Healthy advantage of all the programs and element with an incentive. After you resources offered through Total have completed the requirements Health supports Texas Health’s for a reward, you will receive an mission to improve the health of our email notifying you that the amount employees and our community. is available in your rewards account. In return for reasonable medical Your reward is redeemable for gift premiums and quality coverage, cards or immediately accessible Texas Health asks that you actively e-gift cards. work at being healthy. This means Why does Texas Health offer these participating in Be Healthy, using generous rewards? Because we want your benefit resources, and making you to participate in Be Healthy! wellness a way of life. As your employer, Texas Health, spends millions of health care dollars each year on illnesses that could have been prevented or managed better if each of us had taken a more active role in managing our health. Our choice is clear—we can improve our health or end up paying more for medical insurance and medical care.

For more information about Be Healthy wellness programs, check online at BeHealthyTHR.org or see page 72 of this handbook.

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

Texas Health offers eligible employees a comprehensive Flexible Benefits Plan that includes Medical, Dental, Vision, Overview Life, Disability, and Flexible Spending Accounts. These benefits help protect you and your family from the financial hardships of illness, injury, disability, and death. Read “Eligibility Requirements” 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 dependents in certain benefits, as described below. Flexible Benefits

Plan Who Can Be Covered Choices Medical You and your eligible ••Texas Health Aetna Select 3000 High Rx family members (as ••Texas Health Aetna Select 3000 Low Rx defined on pages 5 – 7) ••Texas Health Aetna Select 1000 High Rx ••Texas Health Aetna Select 1000 Low Rx ••UHC Choice 500 High Rx ••UHC Choice 500 Low Rx ••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 – 7) ••Participating Dental Network (PDN; 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 – 7) Short Term Disability1 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 of members (as defined on your Basic and Additional Life coverage, but not more than $50,000 pages 5 – 7) ••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 Benefits-eligible physicians employed by Texas Health Physician's Group (THPG) and Texas Health Back Care (THBC) are covered through separate policies and are not eligible for the Texas Health Long Term Disability Plan. Resident interns are not eligible for the Short Term Disability Plan or the 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) MyTHR.org Overview

Flexible Benefits (continued)

Plan Who Can Be Covered Choices Additional AD&D Insurance You and your eligible Employee coverage of one to 10 times your annual base family members (as defined on pay, up to $750,000 Overview pages 5 – 7) 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 family members ••You may contribute up to $2,650 per year before-tax. (as defined on pages 5 – 7) Day Care Spending Account Your eligible family members (as ••You may contribute up to $5,000 per year before-tax. defined on pages 5 – 7)

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

Plan Description 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 on the first pay period after you are hired by Texas Health. ••For 2019, the Texas Health 401(k) Retirement Plan allows you to save up to $19,000 per year ($25,000 if you are age 50 or older) of your pay.

Paid Time Off (PTO)1, 2 ••Full-time and part-time benefits-eligible employees receive PTO per pay period, depending on years of service and your PTO-eligible hours worked. ••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 2019 (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 2019 program year.

Additional Benefits ••Business Travel Accident Insurance ••Tuition reimbursement ••Adoption assistance ••EAP ••Tobacco cessation program ••Employee Discount Program ••Supplemental benefits (hospital indemnity, accident insurance and critical illness insurance)

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 advance practice professionals of THPG and resident interns are not eligible for PTO. Time away from work for physicians and advance practice professionals is based on their contract. THPG Clinic Practice Staff have a different program as explained on page 153.

1-877-MyTHRLink (1-877-698-4754) MyTHR.org 3 Participation Participation Eligibility for Benefits...... 5 Employees 5 Family Members 5 Appealing Eligibility Determination 8 Discrimination Prohibited 9 Misstatements of Facts 9 Documentation 9 Enrolling in Benefits...... 10 New Employee Enrollment 10 Newly Eligible Employee Enrollment 10 Open Enrollment 10 Missed Enrollment Deadline 10 Bridging of Service 11 Changing Your Coverage 11 Summary of Allowable Changes in Coverage 14 Paying for Your 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 Payroll Deductions 16 Medical Subsidy 16 Converting Paid Time Off 16

4 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Eligibility for Benefits Eligibility for Benefits

Your eligibility for benefits is EMPLOYEES FAMILY MEMBERS determined by your job status (full- Eligibility Requirements If you are an eligible employee and time or part-time benefits eligible) in you elect coverage, you also can the HR/payroll system. Unless otherwise noted in this Handbook, eligibility for benefits is elect the following coverage for your Employees of Texas Health wholly determined by your job status in Texas eligible family members: owned or controlled affiliates are Health’s HR/Payroll system, according •• Medical eligible for benefits. Physicians to these categories: employed by Texas Health Physician •• Dental Group (THPG) or Texas Health Back •• Full-time employee—an employee •• Vision Care (THBC) are not eligible to of Texas Health who is classified to •• Dependent Life participate in the following Texas work at least 30 hours per week •• Additional Accidental Death and Health plans: •• Part-time benefits-eligible Dismemberment (AD&D) Participation employee—an employee of Texas •• Supplemental Benefits. •• Long Term Disability Health who is classified to work 24- •• Paid Time Off (PTO) 29 hours per week You may enroll your eligible family •• Separation Pay. •• Part-time benefits-ineligible members for Dependent Life employee—an employee of Texas insurance coverage even if you do The following exclusions also apply: Health who is classified to work less not elect any Additional Life insurance •• Advance Practice professionals than 24 hours per week coverage for yourself. For all other benefits, you must have coverage for employed by THPG/THBC or •• PRN employee—an employee of yourself to enroll your eligible family anyone under contract are not Texas Health who does not have a members. eligible to participate in the Texas set number of hours per week. Health PTO Plan or the Separation Your eligible family members include For those with more than one job, Pay Plan. (eligibility is determined according benefit eligibility is determined by the •• Research fellows are not eligible for to these categories unless otherwise total combined hours from all active the Separation Pay Plan. noted in this Handbook): jobs. •• Resident interns are not eligible for •• Your legal spouse (as defined on PTO, disability or Separation Pay Part-time benefits-ineligible this page) plans. employees and PRN employees are eligible to participate in the Texas •• Your dependent children—including Health 401(k) Retirement Plan, EAP, biological children, children who and Tobacco Cessation program. have been adopted or placed for They are not eligible to participate in adoption, foster children, 1 the Flexible Benefits Plan or any other stepchildren, grandchildren , and plan or program. other qualified children (as defined on pages 6 – 7). Employment Status Change You may be required to reimburse If your job classification changes so Texas Health for all benefits the plan you are classified as full-time or part- pays for a spouse or child who did not time benefits-eligible, you can begin meet the definition of eligible family participating in benefits on the first member at the time the benefits day of the pay period on the later of: were paid. You may also be subject to •• The date your job classification corrective action up to and including changes or termination. •• The date you have completed one Spouse month of service. For purposes of the Handbook, Your benefits will be effective the coverage for a spouse refers to first of the pay period following the opposite and same-sex legally date you make an online election and married couples and common-law provide required documentation. spouses who legally reside in the United States.

Footnotes are on the next page.

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

In the case of a common law You may also cover a child who meets Incapacitated Child marriage, you must have filed a the above criteria if you can provide a Coverage for an unmarried, declaration of informal (common law) copy of the court order signed by the incapacitated child does not end marriage with the county clerk. judge showing one of the following: just because the child has reached If Family Members Work for Texas •• You have adopted the child a certain age. You may extend the coverage for that child beyond the Health •• The child has been placed in your limiting age if both of the following No person can be covered as both home for foster care are true. an employee and a dependent under •• You have been appointed by the same benefit plan. If you are the court as the child’s legal The child: eligible for Texas Health’s benefit guardian or non-parent managing plans and your spouse, parent, or conservator. •• Is not able to be self-supporting child also works for Texas Health and because of mental or physical is eligible for benefits, you will need A child serving in the military or disability and to determine whether it is better for armed forces of any country is •• Depends mainly on you for support you to each elect coverage as an ineligible for coverage. Coverage will continue as long as the Participation employee or whether it is more cost- The employee’s child may be covered enrolled dependent is incapacitated effective for one of you to cover the under a Qualified Medical Child and meets the definition of other as a dependent (if eligible). Support Order (explained on the next dependent, unless coverage is •• If both spouses work for Texas page) even if you do not claim the otherwise terminated under the terms Health, only one of you may child as a dependent on your federal of the plan. cover your eligible children and income tax return. You must furnish the medical claims grandchildren.1 Newborn Children administrator with proof of the child’s •• If a parent and child work for Texas If you elect coverage under the incapacity and dependency within Health: Medical Plan, your newborn child 31 days of the date coverage would ––The child may be covered as will automatically receive medical otherwise have ended because the the parent’s dependent only if coverage for 31 days following birth. child reached a certain age. This the child meets the eligibility If you wish to extend coverage form is located on BeHealthyTHR. requirements beyond the 31-day period, you org. Before the medical claims ––Only one of you may cover must enroll the newborn online administrator agrees to this 1 the grandchildren (the child’s and provide dependent verification extension of coverage, they may children). within 31 days of the child’s birth. A require that a physician chosen by ––The parent cannot elect Social Security number is required the medical claims administrator Dependent Life Insurance within 6 months of birth date. examine the child. The medical coverage for that child. claims administrator will pay for that Child Placed for Adoption Child examination. A child under age 18 will be To be eligible for coverage under The medical claims administrator considered placed with you for the Total Health Medical Plan, a may continue to ask you for proof adoption if you have assumed a dependent child must meet all the that the child continues to meet legal obligation for total or partial following criteria: these conditions of incapacity and support of the child in anticipation dependency. Such proof might of the adoption. In this situation, •• Be under 26 (or any age if include medical examinations at you should submit documentation physically or mentally incapable of the medical claims administrator’s (such as a signed court order) that self-support and unmarried) expense. However, you will not the adoption agency or other entity •• Live in the United States. generally be asked for this information had legal custody of the child on the more than once a year. To be eligible for dental, vision, or date the child was placed with you for life insurance coverage, a dependent adoption. You may add coverage for an child must meet all the following incapacitated child only if the child criteria: meets the definition of eligible child and the definition of incapacitated •• Be under 25 (or any age if physically child (described above) and either: or mentally incapable of self- support)2

1 To cover your grandchildren, you must provide documentation of court appointed legal guardianship or managing conservatorship to Texas Health Benefits Support before the enrollment deadline. 2 For Life Insurance, the term “child” means a child born or legally adopted by you. It includes a child during any waiting period prior to the finalization of the child’s adoption. It also means stepchild living with you and financially dependent upon you. Coverage is from live birth to age 25.

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

•• Your adult child who was not The following information must be To ensure only eligible dependents covered by the plan becomes included in the QMCSO: are covered under our plans, Texas incapacitated or Health requires you to provide •• The name and the last known •• You have an adult child who is documentation when adding a mailing address of the participant incapacitated and are enrolling dependent to medical, dental or vision and the name and mailing address in the Texas Health Medical Plan coverage (for a new hire, rehire, status of each child covered by the order as a new employee, during open change or during open enrollment). If •• A reasonable description of the type enrollment or due to a qualifying you are an employee who left Texas of coverage to be provided by the life event. Health and you were rehired more plan to each child, or the manner in than one year later, you are required Qualified Medical Child Support which the type of coverage will be to resubmit documentation of your Order (QMCSO) determined dependents’ eligibility. Dependent coverage will be offered to •• The time period during which the the extent it is required by a QMCSO, order applies, and Following are acceptable forms of provided you continue to meet the •• Each plan to which the order documentation: eligibility requirements of the medical applies. •• Legally married opposite sex or Participation plan and you are enrolled in the plan. same sex spouse: Both of the If you are not enrolled in a Total Health A medical child support order is not qualified by the plan administrator if it following need to be provided for Medical Plan at the time the plan your spouse: administrator receives the QMCSO, requires a plan to provide any benefit ––Photocopy of marriage license, you and your child will be enrolled in not otherwise provided under the marriage certificate provided by the UHC Choice 500 High Rx Plan to plan. your religious organization, or comply with the court order and the The plan administrator has the most recent tax return and applicable premium will be deducted responsibility for determining whether ––Photocopy of driver’s license, from your paycheck. The plan a QMCSO exists. When a QMCSO is most recent tax return, bill or administrator will determine whether received, the plan administrator will some other documentation that an order or notice is a QMCSO. notify you that the order has been shows both you and your spouse A QMCSO ordering your spouse to received. The notification describes currently have the same address provide coverage for your stepchildren the procedures that will be used to determine its qualification. •• Common-law opposite sex or same is not binding on Texas Health. sex spouse: Both of the following A QMCSO is any judgment, decree, Any health benefits paid under a need to be provided for your or order (including a settlement QMCSO as reimbursement for expenses common-law spouse: agreement) issued by a court of paid by the child or the child’s custodial ––Photocopy of certification of competent jurisdiction that: parent or legal guardian will be paid to common-law marriage filed with the child or the child’s custodial parent the county clerk •• Provides for child support with or legal guardian. and respect to a child of a participant ––Photocopy of driver’s license, under a group health plan Documentation for Dependents most recent tax return, bill or •• Provides health benefit coverage You must provide the social security some other documentation that to a child pursuant to a state number for all covered dependents shows both you and your spouse domestic relations law (including who are at least six months old. You currently have the same address a community property law), and will enter those online when enrolling. relates to benefits under the plan, or Dependents missing or having invalid •• Children: One of the following •• Enforces a law (including a Social Security numbers may be needs to be provided for each child: community property law) and dropped from coverage if you do not ––Photocopy of birth certificate that relates to benefits under the plan, or provide requested information within shows you and/or your spouse as law relating to medical child support 31 days of enrollment at Texas Health. parents or described in the Social Security Act ––Photocopy of birth record from with respect to a group health plan. hospital that shows you and/or your spouse as parents or ––Photocopy of legal guardianship or adoption papers or ––Photocopy of Qualified Medical Child Support Order (QMCSO).

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

You must send documentation APPEALING ELIGIBILITY •• A specific reason or reasons for to THR Benefits Support by DETERMINATION the denial email to THRBenefitsSupport@ •• The specific plan provision on If you believe you or your dependent texashealth.org. Be sure to include which the denial is based is eligible for coverage, within your employee ID number on all •• A description of any additional 60 days of your eligibility date documents. A cover sheet is available material or information necessary you may submit this claim by on BeHealthyTHR.org and should be for you to validate the eligibility emailing the plan administrator at sent with your documentation within and an explanation of why this THRBenefitsSupport@texashealth. 31 days of your event (new hire, information is necessary family status change, etc.). org or sending a written request to the plan administrator at the address •• Information on the steps you If you do not provide complete on page 206 of this handbook. You must take to appeal the plan and timely documentation, your must list the names of the people you administrator’s decision, including dependents will not be added to believe are eligible to participate and your right to submit written your coverage. If your dependent explain the reasons you believe they comments and have them is dropped because of lack of are eligible. You should include any considered, your right to review

Participation documentation, premiums you documents you would like to have (upon request and at no charge) have paid will not be refunded and considered. relevant information, and your dependents will be dropped from right to file suit under ERISA (where coverage, including Life Insurance If your claim for eligibility is denied applicable) with respect to any and Supplemental Benefits. in whole or in part, the plan adverse determination after appeal administrator will notify you in writing of your claim. within 15 days after the date the plan administrator receives your claim. Appeals If your eligibility claim is denied in This time period may be extended whole or part, you (or your authorized for an additional 15 days for matters representative) may request review by beyond the plan administrator’s writing to the Governance Committee control including cases in which of the Texas Health Board (the a claim is incomplete. The plan committee) who acts on behalf of administrator will provide written the plan administrator with respect to notice of any extension, including appeals. Your appeal must be made the reasons for the extension and the in writing within 180 days after you date by which the plan administrator receive the notice that the eligibility expects to make a decision. If a claim was denied. If you do not claim is incomplete, the extension appeal on time, you will lose the right notice will also describe the required to appeal the denial and the right to information and will allow you 45 file suit in court. Your written appeal days from receipt of the notice to should state the reasons you believe provide the specified information. your eligibility claim should not have The extension suspends the time for been denied. It should include any a decision on your claim until the additional facts and/or documents specified information is provided. you believe support your claim. Notification of a denied eligibility You will have the opportunity to ask claim will include: additional questions and make written comments, and you may review (upon request and at no charge) the information relevant to your appeal.

8 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Eligibility for Benefits

Decision on Review DISCRIMINATION DOCUMENTATION Your appeal will be reviewed and PROHIBITED Texas Health has the right to decided by the committee or other Eligibility under the medical, dental, request complete documentation entity designated by the plan in a and vision plans will not be based of dependent status, eligibility for reasonable time no later than 60 days on a health-related factor, such as coverage or change in coverage, or after the committee receives your genetic information or evidence of of a claim for benefits. Texas Health request for review. The committee insurability. Federal law prohibits any reserves the right to refuse coverage may, in its discretion, hold a hearing discrimination in eligibility or cost of or benefits if it does not believe the on the denied claim. If the decision coverage because of a health status- facts are accurate. on review affirms the initial denial of related factor. your claim, you will be furnished with a notice that explains: MISSTATEMENTS OF FACTS •• The specific reasons for the Texas Health benefits are provided decision on review for the exclusive benefit of Texas •• The specific plan provisions on Health employees and their families. Participation which the decision is based Coverage is limited to eligible •• A statement of your right to review employees and their eligible family (upon request and at no charge) members. If you elect to cover an relevant documents and other ineligible person or do not accurately information provide the correct information about •• If an internal rule, guideline, that person—such as giving a false protocol, or other similar criterion age, gender, marital status or any is relied on in making the decision other condition, you will be subject to on review, a description of that corrective action, up to and including rule, guideline, protocol, or other termination and may result in loss similar criterion or a statement that of coverage as explained on page it was relied on and that a copy will 188 under “When Coverage Ends.” be provided free of charge to you Texas Health also reserves the right to upon request, and recover any overpayments made on •• A statement of your right to bring behalf of a person who is ineligible. suit under ERISA §502(a) (where applicable).

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

You have the opportunity to enroll Flexible Benefits OPEN ENROLLMENT in benefits as a new hire or newly Benefits-eligible employees must Current employees will receive eligible employee and during the enroll within the required time frames enrollment materials prior to the open open enrollment period each year. to receive the following Flexible enrollment period. You also may enroll or change your Benefits: benefit elections during the year if you •• Carefully review these materials and experience a status change or have •• Medical determine which benefits you will special enrollment rights, as explained •• Dental choose for yourself and your eligible on pages 13 – 14. •• Vision dependents. The benefit choices you make during •• Short Term Disability •• Enroll in benefits during the open open enrollment remain in effect for •• Additional Long Term Disability enrollment period typically held in the entire plan year unless you have •• Additional Life Insurance November. Your elections become

Participation effective January 1. a status change or special enrollment •• Dependent Life Insurance •• Documentation will be required rights as described on pages 13 – 14. •• Additional AD&D Insurance for dependents newly added to •• Flexible Spending Accounts medical, dental or vision. The due NEW EMPLOYEE •• Hospital Indemnity ENROLLMENT date for this documentation to be •• Accident Insurance submitted will be included with •• New hires must enroll within 14 •• Critical Illness Insurance. open enrollment materials. calendar days of hire date. If you do not enroll within 14 calendar days, NEWLY ELIGIBLE EMPLOYEE MISSED ENROLLMENT your next opportunity to enroll will ENROLLMENT DEADLINE be the next open enrollment period. In this case, you will not have any A newly eligible employee is a current If you are not enrolled in medical benefits (only Basic Benefits) unless employee in a non-benefits-eligible coverage and you miss the deadline you later enroll because you have a position who is hired into a part-time for enrollment but you still want status change or qualify for special benefits-eligible or full-time position. medical coverage, you must contact enrollment rights as explained on You may enroll online within 31 THR Benefits Support within 60 days pages 13 – 14. calendar days of your status change. of your missed deadline. Within the 60 Your benefits are effective the first •• Your participation in benefits day period, you may choose a medical of the pay period following your begins the first pay period after you plan option and pay the premium status change and online election, complete one month of service. on an after-tax basis. You may not along with dependent verification (if enroll in any other benefits until the •• You will be required to provide applicable), if you have completed next open enrollment period unless documentation (as described on one month of service. you have a qualified status change. page 7) of all dependents you cover Contact THR Benefits Support for under medical, dental or vision You will be required to provide information on how to make this within 31 days of your hire date. documentation (as described on election. If you missed the enrollment page 7) of all dependents you cover Basic Benefits deadline at open enrollment, your under medical, dental or vision within effective date for the after-tax plan Eligible employees are automatically 31 days of your status change date. will be January 1. If you missed the enrolled in the following employer- enrollment deadline for any other paid Basic Benefits on the first day reason, your after-tax plan will be of the pay period after one month of effective the first day of the following service: pay period after complete forms and •• Basic Long Term Disability (LTD) documentation are received, if you •• Basic Life Insurance have completed one month of service. •• Basic AD&D Insurance •• Business Travel Accident Insurance •• Paid Time Off (PTO).

You must provide documentation for your dependents you cover under medical, dental or vision.

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

Missed Dependent Verification Coverage is immediate if you CHANGING YOUR COVERAGE Deadline previously satisfied the waiting You may add or drop certain period, unless you were rehired in If you miss the deadline for dependent coverages when you experience a a different calendar year than the verification and you still want medical status change or if you have special year in which you terminated. In coverage for your dependents, you enrollment rights as described later in that case, you have 14 days to make must contact Texas Health Benefits this section. Support prior to January 1 (if for new benefit elections. Those newly open enrollment) or within 60 days elected benefits will take effect the Status Changes first of the pay period following the of your missed deadline. You may The Texas Health Flexible Benefits date you submit new elections. choose a medical plan option and Plan is regulated by federal laws and pay the premiums on an after-tax If you are rehired more than 13 weeks regulations that restrict when you may basis. You may not enroll dependents after your termination, you will be change your elections. According to in any other benefits until the next subject to a new waiting period and these regulations, you may request open enrollment period unless you may make new benefit elections changes to certain benefits during you have a qualified status change. that are effective for the remainder of the year only if you have a qualified Contact Texas Health Benefits the year. Those newly elected benefits status change that affects eligibility or Participation Support (877-MyTHRLink, prompt 9) will take effect the first of the pay coverage. for information on how to make this period after you have completed one Qualified status changes may include: election. Your after-tax plan will be month of service. effective the first day of the following •• You or your eligible family member pay period after complete forms and Status Change Eligibility becomes covered by one of the documentation are received, if you If you regain eligibility for benefits Total Health Medical Plan options have completed one month of service. within 13 weeks of your loss of because of special enrollment rights benefits due to a status change, as explained beginning on page 13. BRIDGING OF SERVICE you qualify for “bridging of service.” •• Your marital status changes due Rehired Employee Enrollment Bridging service means the time gap to marriage, death of your spouse, is closed and your PTO rate picks up divorce, or annulment. If you are rehired by Texas Health at the rate when you lost benefits. •• The number of your dependents within 13 weeks of your termination, Because your service is bridged, you for federal income tax purposes you qualify for “bridging of service.” must continue the same coverage changes due to birth, adoption, Bridging service means the time in effect before you lost benefit placement for adoption, or death. gap is closed and your PTO picks eligibility. The rule to continue the (If you gain a new dependent and up at the rate when you terminated. same coverage in effect before you already have family coverage, you Because your service is bridged, you left does not apply to medical for must go online within 31 days must continue the same coverage employees who go from full-time to after your change to add the new in effect before you left. You are non-benefits-eligible and then to part- dependent to your coverages. A eligible to make changes to medical time benefits-eligible. The rule also new dependent is not automatically insurance if you experience a status does not apply if you go from part- enrolled, even if you already have change. The rule to continue the time benefits-eligible to non-benefits- coverage for your family.) same medical coverage in effect eligible and then to full-time within •• You or your eligible family member before you left does not apply if: 13 weeks. Employees who change begins or ends employment that status can make a new medical •• you were full-time before your affects eligibility for benefits termination and are rehired in a election. Coverage is immediate if you •• You or your eligible family part-time benefits-eligible position previously satisfied the waiting period, unless your status change occurs in a member experiences a change in •• you were in a part-time benefits- different calendar year than the year employment status that affects eligible position prior to in which you lost benefit eligibility. In eligibility for benefits—for example, termination and are rehired as a that case, you have 14 days to make you switch between part-time and full-time employee new benefit elections. full-time, PRN and full-time, or part- •• you were in a full-time or part-time time and PRN. benefits-eligible position prior to If you regain eligibility for benefits •• You or your eligible family member termination and rehired as PRN more than 13 weeks after your loss of takes or returns from an unpaid •• annual benefits enrollment benefits due to a status change, you leave of absence that affects (normally occurring in November) may make new benefit elections that coverage. occurs during a break in service. are effective for the remainder of the •• Your family member becomes year. Those newly elected benefits eligible or loses eligibility for If you can make changes to medical will take effect the first of the pay coverage as defined above, you have medical, dental or vision coverage period following the date you submit due to age (see page 6). 14 days after your rehire date to elect new elections and provide required different medical coverage. documentation.

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

•• You or your eligible family member •• The cost of dependent care In addition, the plan administrator moves to a new home or work significantly increases or decreases may consider the following a loss of location outside of the service area (you can change or revoke your coverage: of the plan (medical plan options previous election only if the •• A substantial decrease in the and dental DMO only). provider is not your relative, as number of medical care providers •• You or your family member defined in the plan). available under an option becomes entitled to coverage or •• You remove your child from a •• A reduction in benefits for a loses coverage under Medicare, facility specific type of medical condition Medicaid, or state-sponsored child •• You or your spouse quit working or treatment for which you, your health plan. •• You experience a qualified status spouse, or dependent child is •• A QMCSO (explained on page change, as defined on page 11. currently in a course of treatment 7) requires you or your former spouse to provide coverage The plan administrator or its You may also make a new election for a dependent under a Texas authorized agent will determine if the change is because of and Health welfare plan and that whether your requested change is corresponds with a change in another coverage is, in fact, provided. consistent with your status change. employer-sponsored plan (including Participation •• Your spouse’s employer offers If you miss the deadline for your your spouse’s plan), if the period of benefit plans with a different plan status change or dependent coverage is different. year that affects your coverage. verification and you still want medical Requesting a Change in Coverage coverage (cannot be previously If your status change allows you and Your Responsibility for enrolled), you must contact Texas to add one family member, you Notification Health Benefits Support within 60 may enroll all other eligible family To change your coverage, you must days of your missed deadline. Within members at this time, as well. make changes online at MyTHR.org the 60 day period, you may choose within 31 days of your event date. Your new election must be consistent a medical plan option and pay the When you initially notify Human with your status change. Under the premiums on an after-tax basis. You Resources of your event, they will medical, dental, vision, STD, LTD, may not enroll dependents in any explain how to enroll or discontinue life, and AD&D plans and the flexible other benefits until the next open coverage. After you enroll, you must spending accounts, “consistent” enrollment period unless you have submit documentation to Texas means the change must result in the a qualified status change. Contact Health Benefits Support by email to gain or loss of coverage by you, your Texas Health Benefits Support for THRBenefitsSupport@texashealth. spouse, or any of your dependent information on how to make this org within 31 days of the event. Your children, and the new election must election. documentation must show your reflect that gain or loss. You may add If your cost for benefits coverage name, the date of the change and, if or drop family members, which may significantly increases or decreases applicable, any dependents affected change your coverage level; and you during the year, you may be allowed by the change. Insurance cards will may change medical or dental plans to make a change in your elections. not be accepted as documentation. (for example, you can change from However, you may not change your 500 High Rx to 1000 High Rx; and You will be required to provide election for the Health Care Spending you can change from employee only documentation for dependents you Account. coverage to employee + children) cover, as described on page 7. when you experience a family status If you, your spouse, or dependent When you go online and make change. child has a significant reduction in changes based on spouse coverage during the year, you may A court order requiring you to provide eligibility, you also need to provide be allowed to change your election. coverage for your spouse is not documentation to verify the event. If the curtailment results in the loss binding on Texas Health. of coverage, you would be permitted You may change or revoke your to either elect new coverage under previous election for the Day Care another option or drop future Spending Account during the year coverage if no similar coverage is and make a new election (you must offered. make your election and provide A loss of coverage means: documentation within 31 days—if documentation is not provided the •• Your current option is being See page 14 for a table that election will be reversed) under these eliminated. summarizes the changes you circumstances: •• Your network is no longer being may make based on your life event. offered where you live.

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

You are also responsible for notifying Special Enrollment Rights You may add or drop coverage if Human Resources when your divorce Under the Health Insurance Portability your dependent becomes eligible for is final so coverage can be stopped. and Accountability Act of 1996 premium assistance under Medicaid To do so, make online elections and (HIPAA), you and your dependents or a state health plan (CHIP) or loses provide the finalized divorce decree may be entitled to enroll in a Total coverage under one of those plans as within 31 days of the finalized divorce. Health Medical Plan option at times a result of loss of eligibility. If you miss the 31-day deadline, your other than the open enrollment Requesting Special Enrollment ex-spouse will be dropped from period. Special enrollment rights are You must notify Human Resources coverage as he/she is no longer available when you lose coverage by making an election online and eligible. However, because of IRS under another plan or gain a new providing documentation within 31 regulations and plan rules, you will dependent. continue to pay the premium for the days of the event that caused your rest of the plan year. You will not If you lose coverage, special special enrollment rights or you will receive a refund. enrollment rights are available for you lose your special enrollment rights and/or your dependents if: for that event. The plan administrator Effective Date of Changes may require documentation of the You must notify Human Resources •• You or your dependents were event. Participation within 31 days of the event that eligible but not enrolled under the Your documentation must show your resulted in the status change by Total Health Medical Plan, and you name, the date of the change and, making online elections and providing or your dependents were covered if applicable, your new dependent’s documentation. All changes are under another health plan or had name effective the following pay period health insurance coverage at the . time coverage was previously after the date of the status change You will also be required to provide offered to you and after online elections are entered and documentation for the dependents •• You or your dependents who had acceptable documentation is received. you cover as described on page 7. lost coverage under the other If you do not complete all the steps health plan because it was COBRA Effective Date of Changes listed above within 31 days of your coverage that was exhausted, or The effective date for special event, you must wait until the next the coverage was not under COBRA enrollment rights is the earlier of open enrollment period. If you have and either: the first day of the month or the not completed one month of service ––the coverage was terminated as first day of the pay period after you at the time your job classification a result of loss of eligibility for notify Human Resources by making changes, your benefits will be the coverage (including divorce, an online election and providing effective on the first payroll period death, termination of employment the appropriate documentation (all after you make your new election, or reduction in number of hours must be done within 31 days after the provide dependent verification of employment), or event). If you are adding coverage documentation, and complete one ––employer contributions toward because of the birth or adoption of month of service. the coverage were terminated. a dependent, your new coverage is When adding coverage because of The term “loss of eligibility” does not effective as of the date of the birth or the birth or adoption of a dependent, include loss of coverage because of adoption. See pages 223 – 225 for the your new coverage is effective as of failure to pay premiums on a timely 2019 cost of coverage. the date of the birth or adoption. basis or any termination of coverage If you do not request your change for cause. In the event of divorce, the effective and/or provide documentation within date of change in coverage is the If you gain a new dependent, you 31 days after the qualifying event, you date of the divorce. The effective date and your dependents are eligible for may elect to change your benefits of change in deduction is the first special enrollment rights if: only during the next open enrollment of the pay period following receipt period or if you have additional of online elections and acceptable •• You are eligible for the Total Health special enrollment rights, as explained documentation. Medical Plan but are not currently beginning on this page. If you do not enrolled, and provide the required documentation •• You acquire a new dependent after you have made your elections, through marriage, birth, adoption, the election will be reversed or or placement for adoption. cancelled and premiums will not be See page 14 for a table that refunded. You may enroll yourself and all your summarizes the changes you eligible dependents on account may make based on your life of your marriage or a child's birth, event. adoption, or placement for adoption with you.

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

Medical, Dental Additional Spouse & Additional Health & Day STD/LTD & Vision Life Child Life AD&D Care FSA

Add Drop Add Drop Change Add Drop Add Drop Add Drop Add Drop Add Drop Event Plan Plan Dep Dep Option Plan Plan Plan Plan Plan Plan Plan Plan Plan Plan 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 13 weeks or √ √ √ √ 2 √ √ √ more following termination1 Employee changes from part-time √ 3 √ 3 √ 3 to full-time Employee changes from full-time √ 3 √ 3 √ 3 √ to part-time Employee changes from PRN √ √ √ √ √ √ √ √ or 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 √ √ √ √ √ LOA5 Employee marries √ 6 √ √ √ √ 3 √ √ 2 √ √ √ √ √

Employee divorces √ √ √ √ √ 2 √ 7 √ √ √ √

Spouse dies √ √ √ √ √ √ 8 √ √ √ √ √

Employee gains a child due to √ 6 √ √ 3 √ √ 2 √ 9 √ √ 13 √ birth, adoption, etc. Child is no longer eligible due to √ √ 10 √ 10 √ √ other coverage, (CHIP, Medicaid or other insurance) divorce, death Spouse or child terminates √ √ √ 3 √ 7 √ 2 √ 7 √ 7 √ √ 11 employment, 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 and/or dependent √ 12 √ 12 √ 12 moves to location outside the plan’s service area Cost of day care changes (and √ 11 √ 11 care is not provided by relative)

1 An employee who is rehired less than 13 weeks following termination will have 8 Child life only the same coverage as before termination, unless rehired in a new plan year. 9 If this is your first child, you may add Spouse Life, as well. 2 Pre-existing condition limitations apply. 10 You may not drop spouse life or AD&D and can only drop child 3 Medical only life coverage for the affected child. 4 An employee who loses eligibility for benefits and again becomes eligible for 11 Day Care FSA only benefits within 13 weeks will have the same coverage as before the loss of 12 Medical and Dental only; must be 50 miles outside of primary providers eligibility. network 5 You are re-enrolled in your previous coverage if you request re-enrollment. 13 If on leave of absence, you must wait until you return from leave to add 6 Employee can only add plan if adding dependents. a Day Care FSA. 7 Spouse event only

You are required to provide documentation for your dependents within the timelines listed on page 7.

14 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Paying for Your Benefits Paying for Your Benefits

You and Texas Health both pay BEFORE-TAX BENEFITS AFTER-TAX BENEFITS the cost of your benefits. Your You pay your portion of the cost for Your contributions for after-tax cost for benefits is deducted from most benefits with before-tax dollars. benefits are subject to federal income 26 paychecks of each calendar This means your contributions for taxes and Social Security taxes. year. Any missed premiums will be benefits are deducted from your Contributions are deducted from your deducted from the next paycheck or paycheck before federal income and paycheck after taxes have been taken you will be billed. Social Security taxes are taken out. out. Your after-tax benefits include:

BENEFITS PAID IN FULL You pay for the following benefits on •• Additional Life Insurance BY TEXAS HEALTH a before-tax basis: •• Dependent Life Insurance •• Paid Time Off •• Medical •• Short Term Disability •• Basic Life Insurance •• Dental •• Additional Long Term Disability Participation •• Basic AD&D Insurance •• Vision •• Hospital Indemnity Insurance •• Basic Long Term Disability •• Additional AD&D Insurance •• Accident Insurance •• Business Travel Accident Insurance •• Flexible Spending Accounts •• Critical Illness Insurance •• Tuition Reimbursement Because you do not pay taxes on the Per IRS regulations, Texas Health is •• Be Healthy wellness program earnings you use to pay for these required to add the value of certain •• Adoption Assistance benefits, your total tax bill may be benefits provided to you as taxable reduced. income on your W-2. This is called BENEFITS PAID BY imputed income. Examples of benefits YOU AND TEXAS HEALTH paid by Texas Health that you must be taxed on include Be Healthy rewards. •• Medical/Prescription

BENEFITS PAID IN FULL BY YOU •• Dental •• Vision •• Additional AD&D Insurance •• Flexible Spending Accounts •• Additional Life Insurance •• Dependent Life Insurance •• Short Term Disability •• Additional Long Term Disability •• Hospital Indemnity Insurance •• Accident Insurance •• Critical Illness Insurance

If you take a leave of absence, you must pay your portion of the cost for benefits biweekly 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) MyTHR.org 15 Paying for Your Benefits

PAYROLL DEDUCTIONS •• Less than $25,000 CONVERTING PAID TIME •• $25,000 – $49,999 You will pay for the benefits you OFF* •• $50,000 – $74,999 elect through payroll deduction. During open enrollment, you can These deductions are taken from 26 •• $75,000 – $99,999 elect to convert up to 80 hours of paychecks during the year based on •• $100,000 or more. Paid Time Off (PTO) in eight-hour pay date. increments that you will earn the Separate medical rates also apply to following year to pay for your Flexible Premiums are based on your annual part-time employees. Benefits. To be eligible to convert base pay for the following benefits: Payroll deductions for other optional PTO, you must elect at least one •• Medical benefits are based on the level of Flexible Benefit option (other than the •• Basic Life Insurance coverage you select and, in some 401(k) Retirement Plan). cases, your age and earnings. •• Additional Life Insurance You are limited to a combined total •• Basic AD&D Insurance Your 2019 costs are listed on pages of 100 hours per year for conversion, •• Additional AD&D Insurance 223 – 225. selling and donating PTO. For example, if you elect to convert Participation •• Short Term Disability •• Basic Long Term Disability MEDICAL SUBSIDY 40 hours of PTO to pay for 2019 •• Additional Long Term Disability. benefits, you will have 60 hours of Because retirement can have a PTO available to sell or donate during Annual base pay is your hourly rate significant financial effect on you and 2019. See page 150 for details on of pay times the number of hours your family, Texas Health will provide converting PTO. you are classified to work in the a medical subsidy if you are age 55 or older and work part-time. This HR/Payroll system. Base pay does * Physicians, advance practice professionals, not include variable pay, bonuses, subsidy (which is taxable), will make THPG Clinic Practice Staff, and resident interns are not eligible for PTO conversion. overtime earnings, commission or your net cost for medical coverage other additional compensation paid the same as for full-time employees to you. Anytime your annual base earning between $50,000 and pay changes, your premiums will be $74,999 per year—regardless of how recalculated based on the new annual much you actually earn. base pay. Changes to your premiums For example, if you elect medical will be effective in the same pay coverage under the UHC Choice 500 period as your change in pay. Low Rx plan for Employee + Spouse, Annual base pay for THPG physicians, the part-time premium listed on page nurse practitioners and physician 225 is $412.23. This is the amount that assistants on a productivity model are will be shown on your paycheck as based on the prior year’s earnings. a deduction for medical coverage. “Earnings” include regular earnings, The premium for full-time employees quarterly true up, physician bonus earning $50,000 – $74,999 is $195.71. (PBN) and physician quality bonus The difference of $216.52 will be (PQB) amounts. For those not shown on your paycheck as a medical completing a full year of service due subsidy from Texas Health. to hire date or a leave of absence in $412.23 Part-time premium the prior year, annual base pay will be based on their contracted rate. – Premium for full-time employees earning Payroll deductions for medical, $195.71 $50,000 – $74,999 dental, and vision benefits are based on the option you elected and the Subsidy for part-time family members you elect to cover. $216.52 employees over age 55 Your cost for medical coverage also varies by which prescription drug coverage you choose and your current salary, depending on whether you earn:

16 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Medical & Wellness Medical & Wellness Total Health Medical Plan...... 18 Overview 18 Administrators, Networks, and Plans 18 Choose Your Medical Coverage 20 Who Can be Covered 21 2019 Medical Plan Comparison 22 Prescription Drug Comparison 31 Texas Health Aetna Plan Options 32 UHC Choice Plan Options 32 UHC Choice Plus Plan Option 32 How the Texas Health Aetna Plan Options Work 32 How the UHC Plan Options Work 34 Receiving Care 36 Pre-existing Conditions 39 Covered Medical Expenses 40 Excluded Medical Expenses 49 Coordination of Benefits 56 Prescription Drug Benefits 58 Filing and Appealing Claims 61 Subrogation and Reimbursement 69 When Coverage Ends 71 Be Healthy Wellness Program...... 72 Eligibility for Be Healthy 72 Be Healthy Rewards 73 Health Assessment Survey 74 Wellness Credit Screening 74 Preventive/Wellness Exam 75 Member Services with Texas Health Aetna 76 Health Advocacy with UHC 76 Total Health Nurse 76 Healthy Pregnancy Programs 76 Cancer Support Nurse 77 Rally Missions 77 Real Appeal 77 Diabetes Care 78 Medical Nutrition Therapy 78 Tobacco Cessation 79 Fitness Memberships 79 Cancer Screenings 80 Employee Assistance Program (EAP) 81

1-877-MyTHRLink (1-877-698-4754) MyTHR.org 17 Total Health Medical Plan Total Health Medical Plan

OVERVIEW •• The Texas Health Aetna Select 3000 •• Employee Assistance Program option qualifies as a high deductible (EAP)—gives you access to Texas Health offers eligible health plan and works differently counselors and information to employees a medical plan that allows than the other options due to the help you cope with life challenges you to choose the administrator, requirement to meet the deductible like stress, relationship issues, and network, medical coverage level, and for office visits and prescriptions financial concerns. It includes up prescription drug coverage that’s best before the plan begins to share to six free counseling sessions per for you and your family. costs with you. issue per year. The EAP is available You have one source for all employee 24 hours a day, seven days a week. benefits needs—Total Health. ADMINISTRATORS, •• Health Pregnancy (Beginning Right/ NETWORKS & PLANS Maternity Support) Program— The medical plan has five different focuses on prevention and You can choose medical coverage options through two different education to help employees and administered by Texas Health Aetna or administrators. Texas Health Aetna families have healthy, full-term UnitedHealthcare. administers the Texas Health Aetna babies. See page 76 for details. Select 3000 and Select 1000 plan Texas Health Aetna coverage gives you options. UnitedHealthcare administers Features of the Texas Health Aetna access to the Open Access EPO Plus the Choice 500, Choice 1000 and Medical Options Network and the Texas Health Aetna Choice Plus 1500 plan options. plan options include the Select Plan These features apply to the Texas Health Aetna Select Plan 1000 and Treating illness is only part of the 1000 and Select Plan 3000. Select Plan 3000 options: way you protect your health. To truly UnitedHealthcare (UHC) gives you protect yourself, you need good access to the Choice or Choice Plus •• Texas Health Aetna ER Doc—gives medical coverage and good resources network, and you save money on your 24/7 access to ER docs on the so you can take an active role in your health care costs when you use Texas medical staff at a Texas Health health. Medical & Wellness Health Preferred Hospitals. The three hospital who communicate in texting format with you regarding You pay nothing for annual wellness UHC medical options include the non-emergency issues and can exams and only a small in-network Choice Plans 500, 1000 and the prevent long, inconvenient waits in copay for doctor’s office visits with Plus 1500. an ER. all plan options except Texas Health Features of All Medical Options Aetna Select 3000. Here are the •• Holistic Care Team—this approach differences among the five options: No matter which medical option you to integrated care management choose, you have access to many of includes a Medical Director, •• The plan administrator, which the same programs: Care Management Supervisor, is Texas Health Aetna or Pharmacist, RN Care Managers, UnitedHealthcare (UHC) •• Prescription Drug Coverage—you Social Workers, Diabetic Educators •• Network coverage – only one plan have two options that differ in the and Care Manager Associates – all option (the UHC Choice Plus 1500) percentage they pay for covered locally based who, when needed, covers out-of-network medical prescription drugs. will meet you wherever it is most care, and both Texas Health Aetna •• Be Healthy—supports you in convenient or advantageous, plan options have a select, narrow optimizing and maintaining your including your home or a physician’s network with local providers only health and well-being. office – to help you with a complex •• The amount you pay for services, •• Preventive Care—is covered for you diagnosis or treatment. including your annual deductible and each covered member of your •• AbleTo—a Cognitive Behavioral and whether or not you have co- family. The Total Health Medical Therapy offering done in a virtual insurance Plan covers an extensive array of format that gives you weekly •• The premiums you pay, which preventive exams including, but not sessions over an 8-week period depend on the plan you choose and limited to, physicals, mammograms, with a Licensed Therapist and your salary tier (Texas Health pays a pap smears, prostate exams, and Health Coach, as well as in-between large percentage of the premiums colonoscopies. You are encouraged sessions with the Health Coach. for all employees – and pays more to have these yearly check ups. for employees who earn less) Prevention is one of the best ways to make wellness a way of life.

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

•• Compassionate Care program Features of UnitedHealthcare ADMINISTRATORS, – offers case management and Medical Options NETWORKS, AND PLANS services to members and their These features apply to medical Texas Health Aetna families who are managing the options administered by complex and emotional issues UnitedHealthcare: The Texas Health Aetna medical involved with advanced illness. plan options give you access to the The program provides assistance •• Complex and Chronic Patient Open Access EPO Plus Network. It's in a culturally sensitive manner Management (CCPM)—Working on a smaller, local network, like a Health that supports and respects their behalf of Texas Health Resources, Maintenance Organization (HMO), but decisions and choices. Support Total Health Nurses, who are there’s no gatekeeper or approvals to includes: skilled case managers, identify see a specialist. ––Providing clinical resources to patients with complex and chronic Texas Health Aetna's local network assist you, your family and/or conditions and build on in-office consists of more than 12,000 caregiver care to fill potential care gaps with: participating providers, including ––Coordination of multiple ––Providing education, as primary care physicians and physicians appropriate, on your condition(s), specialists. It also includes hospital ––Access to community resources and topics to discuss with your systems such as Texas Health providers and family ––Longer-term condition support Resources, UT Southwestern, ––Assisting in the coordination of ––Complex access Methodist Health System, Scottish care among providers ––Care plan coordination Rite System, and the local children’s ––Assisting you with managing ––Psychosocial and knowledge health systems – Cook Children’s and benefits needs. Children’s Medical Center. ––Assisting with pain and symptom •• Health Advocacy—Whenever you To find a doctor or facility in the management have questions about your health, Texas Health Aetna network, simply ––Promoting continuity of care you can ask Health Advocacy. Texas visit TexasHealthAetna.com and Health gives you free access to ––Facilitating advance care planning click “Find a Doctor." Then, select Health Advocacy for information by ––Providing compassionate support “Employer Plan – Open Access EPO phone at 1-877-MyTHRLink (1-877- to you, your family and/or Plus” as your plan. Medical & Wellness caregiver 698-4754), option 2 or online at ––Helping you access community- MyUHC.com. Health Advocacy offers In the event you are not able to find based resources a team of specially trained individuals your physician, it could be that he/ who help you navigate the health she is affiliated with other health •• The member Navigator website – care system and gives you a trusted systems and is a component of the is a fast, easy way to take care of source for health care information parent organization depending on the benefits business and: and support 24 hours a day. specialty or affiliation. For example, ––See who’s covered under your •• Cancer Support Nurse—is available outpatient specialty care, diagnostic plan to you and your family member centers, rehabilitation centers, and ––Check medical claims (covered by a UHC medical plan mental health facilities including ––Get a cost breakdown — your option) that has been diagnosed the Texas Health Resources’ Breast Explanation of Benefits with cancer. These experienced Centers and Envision are providers ––Find providers in your network cancer nurses can assist you during that may not be listed but are in- ––Get a digital ID card active treatment of all forms of network for Texas Health Aetna members. ––Access your Personal Health cancer. •• Transition Support Program— Record to make informed The National Advantage Program provides support to help improve decisions (NAP) is a program in which providers your health care experience by ––Link to health information can choose to participate. Texas providing support from the time ––Access a Health Decision Support Health Aetna contracts with third- you learn you need to go to the Tool to help you understand your party vendor networks of health hospital until after you return home. condition, learn about options, care professionals and facilities. and make the right decision •• Benefits for Mental Health and When members visit providers in Substance Use Disorder—Mental ––While you’re logged in, you these vendor networks, they can get health and Substance-Related and can email or chat with Member negotiated rates for certain out-of- Addictive Disorders Services must Services network services. be coordinated through United Behavioral Health (UBH) if you are covered by a medical plan option administered by UHC.

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

Not all non-participating providers You are not required to choose a •• $0 copay for well-visits (see have a NAP agreement. Texas Health primary care physician (PCP), but Preventive Care on page 36) Aetna's goal is to help a member the network copays are lower when •• $0 copay for telehealth become whole when possible. There you use a physician who specializes •• $30 copay for a PCP office visit in general practice, family practice, are other ways that Texas Health •• $50 copay for a specialist office visit Aetna attempts to negotiate with internal medicine, or pediatrics. You •• $50 copay for Urgent Care Center out of network providers when a may use a network specialist without contracted rate is not available i.e. a referral from a primary physician, •• $100 copay, then 10% after the Facility Claim Review (FCR). but you pay the higher specialist deductible for an Emergency room copay. visit To get the most up to date information, please contact Texas To find a doctor or facility in the UHC The differences are in the premiums, Health Aetna member services at network or a Preferred Hospital, visit the network composition, and the 1-877-MyTHRLink (1-877-698-4754), http://welcometoUHC.com/THR. amount you pay out of your own prompt 1. pocket for medical care. Depending on the geographic UnitedHealthcare area and the service you receive, For the Texas Health Aetna Select 3000 plan option: UnitedHealthcare (UHC) offers the you may have access through Choice and Choice Plus networks of UnitedHealthcare's Shared Savings •• Other than well-visits and doctors, hospitals, and other health Program to non-network providers telehealth, you pay 100% for all care providers. Both networks include who have agreed to discounts medical and prescription costs until the same in-network providers. The negotiated from their charges on the deductible is met. certain claims for Covered Health difference is that you are covered for •• After the deductible is met, you pay Services. Refer to the definition of out-of-network care only if you select 10% of the cost for doctor’s office Shared Savings Program on page the UHC Choice Plus network. visits and at in-network facilities. 222 for details about how the Shared Your prescription costs will be Regardless of which network you Savings Program applies. determined by whether you chose choose, you have the opportunity to the High or Low option. See page save even more. To keep your out-of- For a complete list of Texas Health Preferred Hospitals, go to 58 for more information on how Medical & Wellness pocket costs as low as possible, Texas prescription costs work. Health encourages you to use Texas BeHealthyTHR.org. You can also get the list of Texas Health Health Preferred Hospitals. Texas When choosing your option, you’ll Preferred Hospitals on http:// Health Preferred Hospitals are not a need to decide which factors are welcometouhc.com/thr. separate network. They are a select most important to you: group of hospitals within the UHC network. When you use Texas Health CHOOSE YOUR MEDICAL •• Paying lower premiums but having Preferred Hospitals, you will receive COVERAGE a higher deductible and/or a smaller the highest level of benefit coverage provider network Regardless of which network or and pay the lowest out-of-pocket •• Having a higher level of coverage medical plan option you choose, all costs. It is your responsibility to verify for medical care at non-Preferred the options cover the same medical whether a hospital is a Texas Health Hospitals services. Under all plan options, Preferred Hospital before you receive •• Paying higher premiums but having regardless of the plan administrator, care. a lower deductible there are some services that pay the •• Having coverage for out-of- When you need medical care, first same. network hospitals and doctors. check to be sure your doctor, hospital For example, under all plan options or health care provider is part of the except Texas Health Aetna Select UHC Choice or Choice Plus network. 3000, you pay: By using network providers, you can save money on the cost of your care. These networks are large and include most medical specialties you will Texas Health Preferred Hospitals for UHC Medical Plan Options need. 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.

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

If you select the Texas Health Aetna WHO CAN BE COVERED network, you have the option of: Benefits-eligible employees (as •• Select Plan 3000 defined on page 5) or a COBRA •• Select Plan 1000. participant (as defined on page 189), may elect one of the following levels If you select the UHC Choice of coverage under one of the medical network, you have the option of: plan options:

•• Choice Plan 500 •• You only •• Choice Plan 1000. •• You and your spouse If you select the UHC Choice Plus •• You and your children network, you have: •• You and your family.

•• Choice Plan 1500 Plus. Your dependents must be covered under the same option as you are For a comparison of these options, covered under. See page 5 for see pages 22 – 30. information on eligibility.

Once you have chosen your medical You will be required to provide plan network and coverage, it is time documentation that confirms the to select a prescription drug coverage eligibility of dependents you cover, as that works best for you and your explained on pages 5 – 7. family. Two options are available: Out-of-Area Family Members •• High Rx If you want to cover a family member •• Low Rx. who does not live in an area that has Both options cover the same network providers, you may want to medicines. All UnitedHealthcare select the UHC Choice Plus network because it covers out-of-network medical plan options and the Texas Medical & Wellness Health Aetna Select 1000 option care. have the same copay for generic To find out whether there are any drugs. With the Texas Health Aetna network providers who practice in the Select 3000 option, you pay the location where your dependent lives, full cost of prescriptions, combined logon to http://welcometouhc.com/ with medical costs, until the thr. After you have logged in, you’ll deductible is met. The difference see the option to “Find Physicians and in the prescription options is in Facilities.” the premium you pay from your paycheck and the percentage If you elect the UHC Choice Plus of coinsurance you will pay for Plan, your dependents may use any preferred and non-preferred drugs. provider, either in- or out-of-network. But remember, you must meet the You must submit claims for services deductible first if you choose the received out-of-network. Texas Health Aetna Select 3000 option. For a comparison of the plans, see page 31.

Before making an election, you should review all the plan options carefully to determine which one is most appropriate for you. Refer to the Medical Plan Comparison table on pages 22 – 30.

Important terms that appear in this section are defined in the Glossary of Terms beginning on page 216.

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

2019 MEDICAL PLAN OPTIONS COMPARISON The following pages compare the key features of the different medical options and the copays or coinsurance you must pay. There are differences among the plan option deductibles. Only the Choice 1500 Plus covers out-of-network care. All the plan provisions are subject to each plan option’s copays, coinsurance and/or deductible amounts, as applicable. Some services require prior authorization. Excluded medical expenses are described on pages 49 – 55. Your Cost for Covered Services – Texas Health Aetna Select 3000

Texas Health Aetna EPO Plus Preferred Network Out of Network Plan Feature Doctors, Hospitals, and Free-standing Facilities Deductible $3,000 individual / $6,000 family Not covered

Annual Out-of-Pocket Maximum2 $6,750 individual / $13,500 family Not covered Outpatient Care Office Visits for Illness or Injury 10% after deductible Not covered

Outpatient Diagnostic Lab & 10% after deductible Not covered X-ray (excluding MRI, CT, PET scans)3

Chemotherapy Treatment 10% after deductible Not covered

Radiation 10% after deductible Not covered MRI, CT & PET Scans3 10% after deductible Not covered Outpatient Surgery 10% after deductible Not covered Emergency Room4 10% after deductible Urgent Care Clinic 10% after deductible Not covered Walk-In Clinic (e.g., CVS Minute Clinic) 10% after deductible Not covered

Medical & Wellness Telehealth $0 Not covered Preventive Care Routine Physicals5 $0 Not covered

Well-Woman/Man Exams $0 Not covered (Including Pap Test or PSA Test)5

Well-Child Care $0 Not covered (Including Immunizations)5

Colonoscopy5 $0 Not covered Mammography6 $0 Not covered Maternity Care Office Visits for Pre- and Post-natal 10% after deductible Not covered Care In-hospital Delivery and Newborn Nursery Care including all physician 10% after deductible Not covered charges Inpatient Hospital Care

Hospital Admission8 10% after deductible Not covered Family Planning

Infertility Services—diagnostic testing9 10% after deductible Not covered

Sterilization (tubal ligation) $0 Not covered

Sterilization (vasectomy) 10% after deductible Not covered

Footnotes are on page 30.

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

Your Cost for Covered Services – Texas Health Aetna Select 3000 (continued)

Texas Health Aetna EPO Plus Preferred Network Out of Plan Feature Doctors, Hospitals, and Free-standing Facilities Network Mental Health Care and Substance-Related and Addictive Disorders Services

Outpatient Mental Health Care and Substance- Related and Addictive Disorders Services, including 10% after deductible Not covered Behavioral Health Televideo

Inpatient Mental Health Care and Substance- 10% after deductible Not covered Related and Addictive Disorders Services

Partial Hospitalization/Intensive Outpatient 10% after deductible Not covered Treatment Hearing Care

Hearing Evaluation 10% after deductible Not covered

Hearing Aids (one new pair every 36 months) 10% after deductible Not covered

Outpatient Therapy Cardiac Rehabilitation Therapy 10% after deductible Not covered (up to 36 visits per year)

Chiropractic, Acupuncture and Spinal Manipulation 10% after deductible Not covered (20 combined visits)

Pulmonary and Rehabilitative Services 10% after deductible Not covered (20 combined visits)

Speech, Occupational, and Physical Therapy 10% after deductible Not covered

(combined 60 visits) Medical & Wellness Care at Alternate Sites Home Health Care (up to 100 visits per year; one visit 10% after deductible Not covered is up to four hours)

Skilled Nursing Care (up to 60 days per year) 10% after deductible Not covered

Hospice Care 10% after deductible Not covered

Other Services

Ambulance 10% after deductible

Allergy Tests and Treatment 10% after deductible Not covered

Cosmetic Surgery10 10% after deductible Not covered

Durable Medical Equipment (diabetic supplies are 10% after deductible Not covered unlimited)11

Glasses or Contacts12 10% after deductible Not covered

Organ and Tissue Transplants13 10% after deductible Not covered

Orthognathic and TMJ14 10% after deductible Not covered

Ostomy Supplies 10% after deductible Not covered

Bariatric Surgery15 (must meet specific guidelines described on page 45 under “obesity” and be at least 10% after deductible Not covered 18 years old)

Medical Nutrition Therapy (one initial assessment 10% after deductible (only at Texas Health or UTSW facilities) Not covered and up to three 30-minute sessions per year)16

Diabetes Education17 10% after deductible Not covered

Footnotes are on page 30.

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

Your Cost for Covered Services – Texas Health Aetna Select 1000

Texas Health Aetna EPO Plus Preferred Network Out of Network Plan Feature Doctors, Hospitals, and Free-standing Facilities Deductible $1,000 individual / $3,000 family Not covered

Annual Out-of-Pocket Maximum2 $6,850 individual / $13,700 family Not covered Outpatient Care Office Visits for Illness or Injury $30 copay for PCP; $50 copay for specialist Not covered

Outpatient Diagnostic Lab & No additional charge if processed in doctor’s office; Not covered X-ray (excluding MRI, CT, PET scans)3 10% after deductible if not in doctor’s office

$50 copay for treatment in specialist's office; 10% after deductible Chemotherapy Treatment Not covered if not in specialist's office

Radiation 10% after deductible Not covered MRI, CT & PET Scans3 10% after deductible Not covered

Office visit copay applies; 10% after deductible if not in doctor’s Outpatient Surgery Not covered office

Emergency Room4 $100 copay, then 10% after deductible Urgent Care Clinic $50 copay Not covered Walk-In Clinic (e.g., CVS Minute Clinic) $30 copay Not covered Telehealth $0 Not covered Preventive Care Routine Physicals5 $0 Not covered

Well-Woman/Man Exams Medical & Wellness $0 Not covered (Including Pap Test or PSA Test)5

Well-Child Care $0 Not covered (Including Immunizations)5

Colonoscopy5 $0 Not covered Mammography6 $0 Not covered Maternity Care Office Visits for Pre- and Post-natal $30 copay for initial office visit; no cost for additional visits Not covered Care In-hospital Delivery and Newborn 10% after deductible and only one deductible applies to the Nursery Care including all physician Not covered mother and newborn child charges Inpatient Hospital Care

Hospital Admission8 10% after deductible Not covered Family Planning Infertility Services—diagnostic testing9 10% after deductible Not covered

Sterilization (tubal ligation) $0 Not covered

Office visit copay applies; 10% after deductible if not in doctor’s Sterilization (vasectomy) Not covered office

Footnotes are on page 30.

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

Your Cost for Covered Services – Texas Health Aetna Select 1000 (continued)

Texas Health Aetna EPO Plus Preferred Network Doctors, Out of Plan Feature Hospitals, and Free-standing Facilities Network Mental Health Care and Substance-Related and Addictive Disorders Services

Outpatient Mental Health Care and Substance- Related and Addictive Disorders Services, including $30 per visit Not covered Behavioral Health Televideo

Inpatient Mental Health Care and Substance- 10% after deductible Not covered Related and Addictive Disorders Services

Partial Hospitalization/Intensive Outpatient 10% after deductible Not covered Treatment Hearing Care

Office visit copay applies; 10% after deductible if not in Hearing Evaluation Not covered doctor’s office

Hearing Aids (one new pair every 36 months) 10% after deductible Not covered

Outpatient Therapy Cardiac Rehabilitation Therapy $30 per visit Not covered (up to 36 visits per year)

Chiropractic, Acupuncture and Spinal Manipulation $50 per visit Not covered (20 combined visits)

Pulmonary and Rehabilitative Services $30 per visit Not covered (20 combined visits)

Speech, Occupational, and Physical Therapy $30 per visit Not covered (combined 60 visits) Medical & Wellness Care at Alternate Sites Home Health Care (up to 100 visits per year; one visit 10% after deductible Not covered is up to four hours)

Skilled Nursing Care (up to 60 days per year) 10% after deductible Not covered

Hospice Care 10% after deductible Not covered

Other Services

Covered in full with no deductible for a medical emergency. Transportation to Ambulance nearest facility that can provide appropriate medical care and treatment.

$30 primary physician Allergy Tests and Treatment Not covered $50 specialist (or cost of serum if less) Cosmetic Surgery10 10% after deductible Not covered

Durable Medical Equipment (diabetic supplies are 10% after deductible Not covered unlimited)11

Glasses or Contacts12 10% after deductible Not covered

Organ and Tissue Transplants13 10% after deductible Not covered

Orthognathic and TMJ14 10% after deductible Not covered

Ostomy Supplies 10% after deductible Not covered

Bariatric Surgery15 (must meet specific guidelines described on page 45 under “obesity” and be at least 10% after deductible Not covered 18 years old)

Medical Nutrition Therapy (one initial assessment $0 copay per session (only at Texas Health or UTSW facilities) Not covered and up to three 30-minute sessions per year)16

Diabetes Education17 $10 copay (only at Texas Health or UTSW facilities) Not covered

Footnotes are on page 30.

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

UnitedHealthcare Deductibles and Out-of-Pocket Maximums

• Preferred Hospitals UHC Choice Network Out-of-Network1 OPTION NAME Individual Family Individual Family Individual Family

Choice 500 Annual Deductible $500 $1,500 $3,000 $9,000 Not covered Not covered Annual Out-of-Pocket Maximum2 $6,850 $13,700 $6,850 $13,700 Not covered Not covered Choice 1000 Annual Deductible $1,000 $3,000 $4,000 $12,000 Not covered Not covered Annual Out-of-Pocket Maximum2 $6,850 $13,700 $6,850 $13,700 Not covered Not covered Choice 1500 Plus Annual Deductible $1,500 $4,500 $4,000 $12,000 $5,000 $15,000 Annual Out-of-Pocket Maximum2 $6,850 $13,700 $6,850 $13,700 $18,000 $36,000

Your Cost for Covered Services – UHC Choice 500 and Choice 1000

UHC Choice Network Doctors, Preferred UHC Choice Network Hospitals Plan Feature Hospitals and Free-standing Facilities

Outpatient Care

Office Visits for Illness or Injury $30 copay for primary physician $50 copay for specialist Outpatient Diagnostic Lab & No additional charge if processed in doctor’s 70% after deductible X-ray3 (excluding MRI, CT, PET scans) office; 10% after deductible if not in doctor’s office Medical & Wellness Chemotherapy Treatment $50 copay for specialist Radiation 10% after deductible 70% after deductible MRI, CT & PET Scans3 10% after deductible 70% after deductible Outpatient Surgery Office visit copay applies; 10% after 70% after deductible if not in doctor’s office deductible if not in doctor’s office Emergency Room4 $100 copay, then 10% after deductible Urgent Care Clinic $50 copay Walk-In Clinic (e.g., CVS Minute Clinic) $30 copay Telehealth $0 Preventive Care Routine Physicals5 $0 Well-woman/man exams5 (including $0 pap test and PSA test) Well-child exams (including $0 immunizations)5 Mammography6 $0 Colonoscopy6 $0 Maternity Care Office Visits for Pre- and $30 for initial office visit; no cost for additional visits Post-natal Care In-hospital Delivery and Newborn 10% after deductible and only one deductible 70% after deductible7 Nursery Care including all physician applies to the mother and newborn child charges

Footnotes are on page 30.

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

Your Cost for Covered Services – UHC Choice 500 and Choice 1000 (Continued)

UHC Choice Network Doctors, UHC Choice Network Hospitals Preferred Hospitals and Free- Plan Feature standing Facilities Inpatient Hospital Care Hospital Admission8 10% after deductible 70% after deductible Family Planning Infertility Services—diagnostic testing9 10% after deductible 70% after deductible Sterilization (tubal ligation) $0 $0 Sterilization (vasectomy) Office visit copay applies; 10% after Office visit copay applies; 70% after deductible if not in doctor’s office deductible if not in doctor’s office Mental Health Care and Substance-Related and Addictive Disorders Services Outpatient Mental Health Care and $30 per visit Substance-Related and Addictive Disorders Services Inpatient Mental Health Care and Substance- 10% after deductible Related and Addictive Disorders Services Partial Hospitalization/Intensive Outpatient 10% after deductible Treatment Hearing Care Hearing Evaluation Office visit copay applies; 10% after Office visit copay applies; 70% after deductible if not in doctor’s office deductible if not in doctor’s office Hearing Aids (one new pair every 36 months) 10% after deductible Outpatient Therapy Cardiac Rehabilitation Therapy $30 per visit $50 per visit (up to 36 visits per year) Medical & Wellness Chiropractic, Acupuncture and Spinal $50 per visit Manipulation (20 combined visits) Pulmonary and Rehabilitative Services $30 per visit $50 per visit (20 combined visits) Speech, Occupational, and Physical Therapy $30 per visit $50 per visit (combined 60 visits) Care at Alternate Sites Home Health Care (up to 100 visits per year; 10% after deductible one visit is up to four hours) Skilled Nursing Care 10% after deductible (up to 60 days per year) Hospice Care 10% after deductible

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 specialist (or cost of serum if less) Cosmetic Surgery10 10% after deductible 70% after deductible

Durable Medical Equipment (diabetic supplies 10% after deductible are unlimited)11 Glasses or Contacts12 10% after deductible

Organ and Tissue Transplants13 10% after deductible

Orthognathic and TMJ14 10% after deductible 70% after deductible

Footnotes are on page 30.

1-877-MyTHRLink (1-877-698-4754) MyTHR.org 27 Total Health Medical Plan

Your Cost for Covered Services – UHC Choice 500 and Choice 1000 (Continued)

UHC Choice Network Doctors, UHC Choice Network Hospitals Preferred Hospitals and Free-standing Plan Feature Facilities Other Services Ostomy Supplies 10% after deductible Bariatric Surgery15 (must meet specific 10% after deductible Not covered guidelines described on page 45 under “obesity” and be at least 18 years old) Medical Nutrition Therapy (one initial $0 copay per session (only at Texas Not covered assessment and up to three 30-minute Health and UTSW facilities) sessions per year)16 Diabetes Education17 $10 copay (only at Texas Health or UTSW facilities)

Out-of-network care is not covered under UHC Choice 500 or 1000, unless it is for an emergency.

Your Cost for Covered Services – UHC Choice Plus 1500

UHC Choice Network UHC Choice Network Out-of-Network1 (Covered Doctors, Preferred Hospitals Hospitals only Under Choice Plan Feature and Free-standing Facilities 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 doctor’s office; 10% after 50% after deductible Medical & Wellness X-ray 3 (excluding MRI, CT, PET deductible if not in doctor’s office scans) Chemotherapy Treatment $50 copay for specialist 50% after deductible Radiation 10% after deductible 50% after deductible 50% after deductible MRI, CT & PET Scans3 10% after deductible 50% after deductible 50% after deductible Outpatient Surgery Office visit copay applies; Office visit copay applies; 50% 50% after deductible with 10% after deductible if not in after deductible if not in doctor’s notification7 doctor’s office office Emergency Room4 $100 copay, then 10% after deductible Urgent Care Clinic $50 copay 50% after deductible Walk-In Clinic $30 copay 50% after deductible (e.g., CVS Minute Clinic) Telehealth $0 Preventive Care Routine Physicals5 $0 Not covered Well-woman/man exams5 $0 Not covered (including pap test and PSA test) Well-child exams (including $0 Not covered immunizations)5 Mammography6 $0 Not covered Colonoscopy6 $0 Not covered Maternity Care Office Visits for Pre- and $30 for initial office visit; no cost for additional visits 50% after deductible Post-natal Care In-hospital Delivery and Newborn 10% after deductible and only 50% after deductible7 Nursery Care including all one deductible applies to the physician charges mother and newborn child

Footnotes are on page 30.

28 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Total Health Medical Plan

Your Cost for Covered Services – UHC Choice Plus 1500 (Continued)

UHC Choice Network UHC Choice Network Out-of-Network1 (Covered Doctors, Preferred Hospitals Hospitals only Under Choice Plan Feature and Free-standing Facilities 1500 Plus) Inpatient Hospital Care Hospital Admission8 10% after deductible 50% after deductible 50% after deductible with notification7 Family Planning Infertility Services—diagnostic 10% after deductible 50% after deductible testing9 Sterilization (tubal ligation) $0 $0 50% after deductible Sterilization (vasectomy) Office visit copay applies; Office visit copay applies; 50% after deductible 10% after deductible if not in 50% after deductible if not in doctor’s office doctor’s office Mental Health Care and Substance-Related and Addictive Disorders Services Outpatient Mental Health Care $30 per visit 50% after deductible and Substance-Related and Addictive Disorders Services Inpatient Mental Health Care and 10% after deductible 50% after deductible7 Substance-Related and Addictive Disorders Services Partial Hospitalization/Intensive 10% after deductible 50% after deductible Outpatient Treatment Hearing Care Hearing Evaluation Office visit copay applies; Office visit copay applies; 50% after deductible 10% after deductible if not in 50% after deductible if not in doctor’s office doctor’s office

Hearing Aids (one new pair every 10% after deductible 50% after deductible Medical & Wellness 36 months) Outpatient Therapy Cardiac Rehabilitation Therapy $30 per visit $50 per visit 50% after deductible (up to 36 visits per year) Chiropractic, Acupuncture and $50 per visit 50% after deductible Spinal Manipulation (20 combined visits) Pulmonary and Rehabilitative $30 per visit $50 per visit 50% after deductible Services (20 combined 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 deductible7 visits per year; one visit is up to four hours) Skilled Nursing Care 10% after deductible 50% after deductible7 (up to 60 days per year) Hospice Care 10% after deductible 50% after deductible7

Footnotes are on page 30.

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Your Cost for Covered Services – Choice Plus 1500 (Continued)

UHC Choice Network Doctors, UHC Choice Network Out-of-Network1 (Covered Preferred Hospitals and Free- Hospitals only Under Choice Plan Feature standing Facilities 1500 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 Surgery10 10% after deductible 50% after deductible 50% after deductible7 Durable Medical Equipment 10% after deductible 50% after deductible7 (diabetic supplies are unlimited)11 Glasses or Contacts12 10% after deductible 50% after deductible Organ and Tissue 10% after deductible Not covered Transplants13 Orthognathic and TMJ14 10% after deductible 50% after deductible

Ostomy Supplies 10% after deductible 50% after deductible Bariatric Surgery15 10% after deductible Not covered (must meet specific guidelines described on page 45 under “obesity” and be at least 18 years old) Medical Nutrition Therapy $0 copay per session (only at Not covered (one initial assessment and up Texas Health facilities) to three 30-minute sessions per year)16

17 Medical & Wellness Diabetes Education $10 copay (only at Texas Health or UTSW facilities) Not covered

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 includes the annual deductible, medical coinsurance, medical copays, prescription coinsurance and prescription copays. It does not include non-compliance penalties, your premiums, or expenses that are not covered by the plan. 3 Whenever you have an X-ray or lab service, you may 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 Texas Health Aetna Select 3000, Texas Health Aetna Select 1000, UHC Choice 500 and UHC Choice 1000. 4 Non-emergency use of the emergency room is not covered 5 Wellness exams are 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. 6 One per year is covered in full; additional screenings are covered, however you pay the coinsurance after your deductible. 7 $1,000 penalty for failure to obtain prior authorization. 8 Includes network providers for all of the following: inpatient doctor’s visits and consultations, surgeon, anesthesiologist, pathologist, and radiologist. 9 Infertility drugs, procedures to correct infertility, artificial insemination, GIFT, ZIFT, and other infertility treatments are not covered. 10Coverage 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). 11You must pre-notify the claims administrator for durable medical equipment that costs more than $1,000. 12Only covered when prescribed within 12 months following cataract surgery. 13Coverage is limited to non-experimental transplants at approved hospitals, as explained on page 48. 14No coverage for appliances and orthodontic treatment. Must meet specific guidelines. 15Bariatric surgery can only be performed at Texas Health and UTSW hospitals that are designated as a Texas Health Aetna Institute of Quality (IOQ) or a Center of Excellence by UHC. 16You must have a physician’s referral. 17You must have a physician’s referral. If you visit a Texas Health or UTSW diabetes educator, you may receive free test strips.

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PRESCRIPTION DRUG COMPARISON

Type of High Rx Low Rx Prescription Retail18 Mail Order19 Retail18 Mail Order19 Generic20 $10 copay $20 copay $10 copay $20 copay Preferred 25% of cost of 30-day 25% of cost of 90-day 40% of cost of 30-day 40% of cost of 90-day supply ($20 minimum and supply ($40 minimum supply ($20 minimum and supply ($40 minimum and $100 maximum copay per and $200 maximum $150 maximum copay per $300 maximum copay per prescription) copay per prescription) prescription) prescription) Non-Preferred Not covered. You pay Not covered. You pay Not covered. You pay 100% Not covered. You pay 100% (Drugs Not 100% of the cost. 100% of the cost. of the cost. of the cost. on the Value If an exception is If an exception is If an exception is approved, If an exception is approved, Formulary) approved, you pay 40% approved, you pay 40% you pay 50% of cost of 30- you pay 50% of cost of 90- of cost of 30-day supply of cost of 90-day supply day supply ($40 minimum day supply ($80 minimum ($40 minimum and $300 ($80 minimum and $400 and $300 maximum copay and $600 maximum copay maximum copay per maximum copay per per prescription) per prescription) prescription) prescription) Annual Out- $6,850 individual, $13,700 family for all plan options $6,850 individual, $13,700 family for all plan options of-Pocket except Texas Health Aetna Select 3000 except Texas Health Aetna Select 3000 21 Maximum $6,750 individual, $13,500 family for Texas Health $6,750 individual, $13,500 family for Texas Health Aetna Select 3000 Aetna Select 3000

18Up to a 30-day supply 19Up 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, Texas Health Plano, Texas Health Infusion Pharmacy, or any CVS pharmacy. Otherwise you pay double the retail charge. 20In order to have coverage for prescription drugs in certain drug classes, you must try a generic drug first (see page 59 for more information). 21Maximum combined for retail and mail-order prescriptions. Prescription drug annual out-of-pocket maximum is combined with medical annual out-of- pocket maximum. Copays for generic drugs, as well as coinsurance for drugs, apply toward the out-of-pocket maximum.

For Texas Health Aetna Select 3000, you pay the full cost of your prescription drugs until you reach your deductible: Medical & Wellness $3,000 individual / $6,000 family. After you pay your deductible, your insurance benefits kick in and you pay the copay or coinsurance amount shown in the chart above.

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TEXAS HEALTH AETNA PLAN UHC CHOICE PLAN OPTIONS HOW THE TEXAS HEALTH OPTIONS The UHC Choice 500 and 1000 pay AETNA PLAN OPTIONS WORK The Texas Health Aetna plan options benefits only when you use providers The Texas Health Aetna Select 1000 include the Select 3000 and the Select who are part of the UHC Choice and 3000 network providers agree 1000. The plan options pay benefits network. Virtual Visits are $0 cost. You to charge contracted rates for their when you use providers who are part pay a copay for doctor office visits and services. You must meet an annual of the Open Access EPO Plus Network. urgent care. For most other services, deductible before the plan pays It's a smaller, local network, like a you must meet an annual deductible benefits for services requiring you to Health Maintenance Organization and pay your coinsurance before the pay coinsurance. All medical treatment (HMO), but there’s no gatekeeper or plan pays benefits. You do not file any must be considered a covered health approvals to see a specialist. claims. This plan generally pays no service (as explained on page 217) to benefits if you use out-of-network be eligible for coverage by the plan. Well-care visits and visits through Texas providers, except in the event of an The plan will not pay more than the Health Aetna ER Doc are $0. These plan emergency (as defined on page 218). allowable expenses. options generally pay no benefits if you use out-of-network providers, Advantages of these plan options See pages 40 – 49 for a list of covered except in the event of an emergency include: medical expenses under the Texas (as defined on page 218). You do not Health Aetna options. •• Lower deductible file any claims. •• Lower out-of-pocket expenses You may use any Texas Health Aetna With the Select 3000, a qualifying high •• No claims to file network provider or facility you deductible health plan, you must meet •• Larger network of providers. wish. However, if your Texas Health an annual deductible before the plan Aetna network doctor refers you to a pays for most sevices including office UHC CHOICE PLUS hospital that is not in-network, there visits, urgent care and prescriptions. is no coverage. Because network After meeting the deductible, all The UHC Choice Plus 1500 offers providers may change, you should medical services require coinsurance you the savings of the UHC Choice always verify that the hospital and/ except telehealth and preventive visits. Plus network—while giving you or provider is in the network before the flexibility to use non-network receiving services. Medical & Wellness Advantages of this plan include: providers when you want. You can receive care through a UHC Choice For a list of in-network providers •• No claims to file Plus network provider or through and hospitals, you can use the •• Lowest premiums. another provider of your choice. Texas Health Aetna Call Center at 1-877-698-4754, option 1 or go to With the Select 1000, you pay a copay Virtual visits are $0 cost. You pay a TexasHealthAetna.com. for doctor office visits and urgent copay for doctor's office visits and care. For most other services, you urgent care. For most other services, If you have a medical condition that must meet an annual deductible and you must meet an annual deductible the claims administrator believes pay your coinsurance before the plan and pay your coinsurance before the needs special services, they may pays benefits. All services require plan pays benefits. If you receive care direct you to a designated facility or coinsurance except office visits, through an out-of-network provider, other provider chosen by them. If routine physicals, urgent care and you pay higher out-of-pocket costs. you require certain complex covered walk-in care, telehealth visits, and You must file claims for out-of- health services for which network preventive visits. network services. The plan controls expertise is limited, the claims administrator may direct you to an Advantages of this plan include: your expenses with an annual out- of-pocket maximum, which limits the out-of-network facility or provider. •• No claims to file amount you must pay for covered If you receive prior approval from •• Low premiums. services in one calendar year. the claims administrator, benefits will Advantages of the UHC Choice Plus be paid as though you had used a 1500 include: network hospital only if the covered services or supplies for that condition •• The choice of using a network or are provided by or arranged by the out-of-network provider each time designated facility or other provider you need medical care chosen by the claims administrator. •• Higher benefit levels when you use network providers •• No claims to file when you use network providers.

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Your Costs Fee Limits For Non-Network Benefits* Individual Deductible The Texas Health Aetna Select 1000 Eligible expenses are based on either A deductible is the amount you must and 3000 plan options pay in-network of the following: pay each year from your pocket benefits based on contracted rates. Out-of-network claims are not •• When covered health services before the plan begins to pay benefits are received from a non-network for certain covered health services. covered under the plan unless it is an emergency. Network doctors and provider, allowable expenses are Copays do not count towards the determined, based on: deductible. After you satisfy the hospitals agree to keep their fees •• Negotiated rates agreed to by the deductible, the plan pays a percentage within the plan’s eligible expenses or non-network provider and either of eligible expenses. For the Texas allowable amount for your area. the claims administrator or one of Health Aetna Select 1000 plan option, Eligible Expenses the claims administrator's vendors, your prescription copays are not Texas Health Resources has delegated affiliates or subcontractors, at the subject to deductibles. For the Texas to the claims administrator the claims administrator's discretion. Health Aetna Select 3000 plan option, discretion and authority to decide •• If rates have not been negotiated, prescription costs will not be paid until whether a treatment or supply is a eligible expenses are determined the deductible is met and then copays covered health service and how the based on reasonable and customary and coinsurance apply. eligible expenses will be determined rates for the same or similar service Family Deductible and otherwise covered under the Plan. within the geographic market.

In a family of two, both family Eligible expenses are the amount members must meet their separate the claims administrator determines individual annual deductible in order that the claims administrator will to satisfy the family deductible. In a pay for benefits. For in-network family of three or more members, benefits, you are not responsible for each family member contributes any difference between the eligible to his or her own individual annual expense and the amount the provider deductible. After two covered family bills. Eligible expenses are determined members meet their individual annual solely in accordance with the claims Medical & Wellness deductible, family members together administrator's reimbursement policy can satisfy the family deductible. guidelines. Coinsurance For In-Network Benefits Coinsurance is the percentage of Eligible expenses are based on the medical expenses you are responsible following: for paying after you meet the annual deductible. You pay your coinsurance •• When covered health services are and the plan pays the remaining received from a network provider, percentage until you reach your out of eligible expenses are the claims pocket maximum. administrator's contracted fee(s) with that provider. Out-of-Pocket Maximum •• When covered health services You will not pay more than the annual are received from a non- out-of-pocket maximum in one network provider as a result of year for covered services when you an emergency or as arranged by use network providers. After your the claims administrator, eligible coinsurance, deductible and medical/ expenses are billed charges unless prescription copay costs reach the a lower amount is negotiated or applicable out-of-pocket maximum, authorized by law. Please contact the plan pays the full cost of covered Texas Health Aetna if you are billed expenses for the rest of the year. for amounts in excess of your applicable coinsurance, copayment Your premiums, non-notification or any deductible. The medical penalties, and non-covered medical plan will not pay excessive charges expenses do not count toward the or amounts you are not legally out-of-pocket maximum. obligated to pay.

* Non-network providers are covered as the result of an emergency or if arranged and approved by the claims administrator.

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HOW THE UHC PLAN If you receive prior approval from visits, routine physicals, urgent care, OPTIONS WORK the claims administrator, benefits will and ambulance service. You pay be paid as though you had used a your coinsurance and the plan pays UHC Choice 500 and 1000, and Preferred Hospital only if the covered the remaining percentage. You must Choice Plus 1500 network providers services or supplies for that condition file claims for benefits that require agree to charge contracted rates are provided by or arranged by the coinsurance when you use out-of- for their services. You must meet an designated facility or other provider network providers under the UHC annual deductible before the plan pays chosen by the claims administrator. Choice Plus 1500 option. benefits for services requiring you to pay coinsurance. You are not required Your Costs Out-of-Pocket Maximum to satisfy a deductible when a copay Individual Deductible You will not pay more than the amount applies. All medical treatment A deductible is the amount you must annual out-of-pocket maximum must be considered a covered health pay each year from your pocket in one year for covered services service (as explained on page 217) to before the plan begins to pay benefits when you use network providers. be eligible for coverage by the plan. for covered health services. Copays In-network services have a separate The plan will not pay more than the do not count towards the deductible. out-of-pocket maximum from out- eligible expenses. After you satisfy the deductible, the of-network services in the UHC See pages 40 – 49 for a list of covered plan pays a percentage of eligible Choice Plus. medical expenses. expenses. Your prescription copays After your coinsurance, deductible are not subject to deductibles. You may use any UHC Choice or and medical/prescription copay costs Choice Plus network provider or Family Deductible reach the applicable out-of-pocket maximum, the plan pays the full cost facility you wish. However, if your In a family of two, both family UHC Choice network doctor refers of covered expenses for the rest of members must meet their separate the year. you to a network hospital that is not individual annual deductible in order a Texas Health Preferred Hospital, to satisfy the family deductible. In a If you are in UHC Choice 500 or 1000, you will pay more (70% of the cost family of three or more members, deductible and coinsurance amounts of covered services with the Choice each family member contributes you pay for services provided by Texas 500 and 1000 plan options) than Medical & Wellness to his or her own individual annual Health Preferred and UHC Choice if you use a Texas Health Preferred deductible. After two covered family Network will cross-apply to the Hospital (10% of the cost of covered members meet their individual annual annual deductibles and out-of-pocket services). If you choose a Texas deductible, family members together maximums for both the Texas Health Health Preferred Hospital, the plan can satisfy the family deductible. Preferred and UHC Choice Networks. pays a higher benefit, which reduces your out-of-pocket costs. Because How Deductibles Cross-apply If you are in UHC Choice 1500 Plus, network providers may change, If you participate in UHC Choice 500 deductible and coinsurance amounts you should always verify that the or 1000, the Preferred Hospital and you pay for services provided by hospital is in the network before UHC Choice Network deductibles Texas Health Preferred and UHC receiving services. count towards each other. Choice Network will cross-apply to the annual deductibles and out-of- For a list of Preferred Hospitals, go If you participate in the UHC Choice pocket maximums to both the Texas to BeHealthyTHR.org. You can also 1500 Plus, the Preferred Hospital and Health Preferred and UHC Choice use the Texas Health WellCall Center UHC Choice Network deductibles Networks. However, Texas Health 1-877-THR-WELL (1-877-847-9355) count towards each other. However, Preferred and UHC Choice Network to find a physician. Texas Health Preferred and UHC expenses do not cross-apply to the If you have a medical condition that Choice Network annual deductibles out-of-network annual deductible the claims administrator believes do not cross-apply to the out-of- or out-of-pocket maximum and needs special services, they may network annual deductible and the out-of-network expenses do not direct you to a designated facility or out-of-network annual deductible cross-apply to either the Texas Health other provider chosen by them. If does not cross-apply to either the Preferred or UHC Choice Network you require certain complex covered Texas Health Preferred or UHC Choice annual deductible or out-of-pocket health services for which network Network annual deductibles. maximum. expertise is limited, the claims Coinsurance Your premiums, non-notification administrator may direct you to an Coinsurance is the percentage penalties, and non-covered medical out-of-network facility or provider. of medical expenses you are expenses do not count toward the responsible for paying after you meet out-of-pocket maximum. the annual deductible. All services require coinsurance except generic prescriptions, office visits, virtual

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

Fee Limits •• As indicated in the most recent UnitedHealthcare if you are billed The UHC Choice and Choice Plus edition of the Current Procedural for amounts in excess of your options pay in-network benefits Terminology (CPT), a publication of applicable coinsurance, copayment based on contracted rates. Out-of- the American Medical Association, or any deductible. The medical network claims for the UHC Choice and/or the Centers for Medicare and plan will not pay excessive charges Plus 1500 option will be paid at 140% Medicaid Services (CMS) or amounts you are not legally of the Medicare allowable amount. •• As reported by generally recognized obligated to pay. professionals or publications This is the maximum amount the For Non-Network Benefits plans will consider as an eligible •• As used for Medicare Eligible expenses are based on either expense for a medical service or •• As determined by medical staff of the following: supply. By using the UHC Choice or and outside medical consultants Choice Plus network, you can keep pursuant to other appropriate •• When covered health services your costs lower. Network doctors sources or determinations that UHC are received from a non-network and hospitals agree to keep their fees accepts provider, eligible expenses are within the plan’s eligible expenses or determined, based on: allowable amount for your area. Following evaluation and validation of certain provider billings (e.g., ––Negotiated rates agreed to by the If you are covered under the UHC error, abuse and fraud reviews), non-network provider and either Choice Plus and use an out-of- UHC reimbursement policies are the claims administrator or one of network provider whose fees are applied to provider billings. UHC the claims administrator's vendors, more than the plan’s eligible expenses shares its reimbursement policies affiliates or subcontractors, at the or allowable amount, you must pay with Physicians and other providers claims administrator's discretion. any amount that exceeds the limit, in UHC’s network through UHC’s ––If rates have not been negotiated, in addition to your deductible and provider website. Network physicians then one of the following coinsurance amounts. and providers may not bill you amounts: for the difference between their ŒŒ Eligible expenses are determined Eligible Expenses contract rate (as may be modified by based on 140% of the published Texas Health Resources has delegated UHC’s reimbursement policies) and rates allowed by the Centers for to the claims administrator the Medicare and Medicaid Services

the billed charge. However, non- Medical & Wellness discretion and authority to decide network providers are not subject (CMS) for Medicare for the same whether a treatment or supply is a to this prohibition, and may bill or similar service within the covered health service and how the you for any amounts the plan does geographic market, with the eligible expenses will be determined not pay, including amounts that exception of the following: and otherwise covered under the Plan. are denied because one of UHC’s -- 50% of CMS for the same or reimbursement policies does not similar laboratory service. Eligible expenses are the amount the reimburse (in whole or in part) for the claims administrator determines that -- 45% of CMS for the same service billed. You may obtain copies the claims administrator will pay for or similar durable medical of UHC’s reimbursement policies for benefits. For in-network benefits, you equipment, or CMS yourself or to share with your non- are not responsible for any difference competitive bid rates. network physician or provider by between eligible expenses and the ŒŒ When a rate is not published by going to myUHC.com or by calling the amount the provider bills. For non- CMS for the service, the claims telephone number on your ID card. network benefits, you are responsible administrator uses an available for paying, directly to the non-network For In-Network Benefits gap methodology to determine provider, any difference between the a rate for the service as follows: Eligible expenses are based on the amount the provider bills you and -- For services other than following: the amount the claims administrator pharmaceutical products, will pay for eligible expenses. •• When covered health services are the claims administrator Eligible expenses are determined received from a network provider, uses a gap methodology solely in accordance with the claims eligible expenses are the claims established by OptumInsight administrator's reimbursement policy administrator's contracted fee(s) and/or a third party vendor guidelines. with that provider. that uses a relative value scale. The relative value •• When covered health services Reimbursement Policies scale is usually based on are received from a non- the difficulty, time, work, UnitedHealthcare develops its network provider as a result of risk and resources of the reimbursement policy guidelines, an emergency or as arranged by service. If the relative value in its sole discretion, in accordance the claims administrator, eligible scale(s) currently in use with one or more of the following expenses are billed charges unless become no longer available, methodologies: a lower amount is negotiated or the claims administrator authorized by law. Please contact

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will use a comparable RECEIVING CARE Download the Doctors on Demand or scale(s). UnitedHealthcare Amwell apps. The first time you visit, Preventive Care and OptumInsight are set up an account. You’ll be asked to related companies through The Texas Health Aetna and UHC provide medical history, insurance common ownership by Choice and Choice Plus plan options information, pharmacy preference, UnitedHealth Group. Refer cover routine physicals when you use etc. to UnitedHealthcare's network providers at 100%.* Routine website at MyUHC.com for physicals include well-woman, well- Each time you visit, you’ll be asked brief medical questions about your information regarding the man and well-child exams. Routine current medical concern. Then, you’ll vendor that provides the physicals and well-child care are enter a virtual waiting room until you applicable gap fill relative not covered out-of-network. See are connected with a board-certified value scale information. page 46 for more information about doctor. The doctor will discuss your -- For pharmaceutical products, preventive care. medical issue and send a prescription the claims administrator to your pharmacy, if appropriate. You uses gap methodologies Telehealth with Texas Health Aetna Plan Options: ER Doc can learn more about Virtual Visits at that are similar to the pricing myUHC.com. methodology used by CMS, At zero cost to you, Texas Health and produce fees based on Aetna ER Doc gives 24/7 access to ER Urgent Care published acquisition costs docs on the medical staff at a Texas If you need urgent care for symptoms or average wholesale price Health hospital who communicate such as high fevers, flu, cuts that for the pharmaceuticals.​ in texting format with you regarding may require stitches, or sprains, call These methodologies are non-emergency situations and can your primary physician or family currently created by RJ prevent long, inconvenient waits in doctor. He or she will direct you to Health Systems, Thomson an ER in most cases and a facilitated, the appropriate place for treatment. Reuters (published in its Red more expedited Texas Health ER visit Urgent care clinics or centers (as Book), or UnitedHealthcare in those cases where it is deemed based on an internally necessary and appropriate. defined on page 222) are listed developed pharmaceutical on TexasHealthAetna.com for To access the Texas Health Aetna Texas Health Aetna medical option Medical & Wellness pricing resource. ER Doc: participants, and in the UHC directory -- When a rate is not published on MyUHC.com for UHC medical by CMS for the service and •• Simply register for your option participants. a gap methodology does Texas Health Aetna ER Doc not apply to the service, the app account by going to Emergency Care eligible expense is based on TexasHealthAetnaERdoc.com. The plan options cover emergency 50% of the provider’s billed •• Complete the short form. care worldwide. When you have a charge. •• You can also access the app by medical emergency (as defined on ŒŒ For mental health services and downloading it to your mobile page 218), your visit to a hospital substance-related and addictive device from the App Store or emergency room is covered as shown disorder services, the eligible Google Play™. in the tables on pages 22 – 30. expense will be reduced by 25% for covered health services Telehealth with UHC Plan Options: For UHC medical plan options, in Virtual Visits provided by a psychologist the event of an emergency, you may and by 35% for covered health Virtual Visits are a convenient way receive benefits at the Preferred services provided by a masters to access care, when covered by a Hospital level when using an out- level counselor. UHC medical plan option. When you of-network provider if you call the have a minor illness (such as cold/flu, The claims administrator updates the toll-free number on the back of your bladder infection, pink eye, stomach CMS published rate data on a regular ID card within two business days after ache, sinus infection, rash, etc.), you basis when updated data from CMS the emergency. can see a board-certified doctor by becomes available. These updates are video chat. Most visits take about 15 typically implemented within 30 to 90 minutes, and the doctor can send a days after CMS updates its data. prescription to your local pharmacy, if needed. The best part is Texas Health pays the entire cost.

* Wellness exams are 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.

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You must obtain prior authorization SITUATIONS REQUIRING AUTHORIZATION from the claims administrator of hospital admissions as follows: You must receive prior authorization from Texas Health Aetna or UHC in the following situations: •• Elective admissions—five business days before admission ••Elective admissions—five business days before admission •• Nonelective admissions—within ••Maternity (inpatient stays greater than 48 hours for regular delivery and 96 hours for Cesarean delivery) one business day ••Skilled nursing/inpatient rehabilitation facilities •• Emergency admissions—within two ••Reconstructive procedures business days. ••Nonelective admissions—within one business day or the same day of In the rare circumstance that admission ••Emergency admissions—within two business days Medicare is primary for you and the ••Durable medical equipment costing $1,000 or more coverage through Texas Health is ••Home health care secondary, the prior authorization ••Hospice care requirements above do not apply ••Inpatient services for mental health or substance use disorder conditions to you. ••Transplants Texas Health Aetna Holistic Care ••Congenital heart disease—as soon as it is suspected or diagnosed Team (in utero detection, at birth, or as determined and before the time an evaluation for CHD is performed) Texas Health Aetna's Holistic Care ••Sleep studies Team approach to integrated care management includes a Medical If you do not follow the plan's requirement for authorization as explained Director, Care Management on this page under “Your Responsibility for Prior Authorization” and/or you Supervisor, Pharmacist, RN Care use non-network providers, you may be subject to a penalty. Managers, Social Workers, Diabetic Prior authorization is not a guarantee or a determination of benefits. Educators and Care Manager Associates – all locally based who, when needed, will meet you

wherever it is most convenient or Medical & Wellness Care While Traveling If you elected the UHC Choice advantageous – including your 1500 Plus and you receive certain If you have an emergency, acute home or a physician’s office. To covered services or supplies from illness, or injury while traveling, get access the Holistic Care Team, call non-network providers, you are medical attention immediately. Then, 1-877-MyTHRLink (1-877-698-4754) responsible for notifying UHC before call your doctor or the number on and select prompt 1. your plan ID card within 48 hours you receive these covered health of receiving care to be eligible for services. You will be subject to a Texas Health Aetna Member network benefits. $1,000 penalty if you do not obtain Services prior authorization. Contact Member Services for help. Your Responsibility for Prior Your plan includes the Concierge Authorization You are required to obtain prior authorization for the services listed in program, which provides access to Prior authorization is required before the box on this page. health care resource consultants you receive certain covered services who have been specifically trained in or supplies. In general, network To notify Texas Health Aetna or UHC, the details of your plan. To contact providers are responsible for receiving call the telephone number on your a Concierge, call the Texas Health prior authorization from Texas Health ID card. Aetna Call Center at 1-877-698-4754, Aetna or UHC before they provide option 1, 8 a.m. to 6 p.m. Monday When you receive services from these services to you. However, you through Friday. are responsible for notifying Texas non-network providers, you should Health Aetna or UHC for certain confirm with Texas Health Aetna or network benefits. UHC that the services you plan to receive are covered. If you are not in For mental health/substance-related the UHC 1500 Plus option, they will and addictive disorder services, you not be covered. are responsible for notifying Texas Health Aetna or UHC.

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Texas Health Aetna Plan Benefits •• Admission Counseling: Nurse •• UHC Complex and Chronic Patient Navigator® Advocates are available to help you Management (CCPM): Employees Register for the Plan Benefits prepare for a successful surgical with complex and chronic Navigator, Texas Health Aetna's secure admission and recovery. conditions have access to Total internet access to reliable health •• Inpatient Care Management: If you Health Nurses who help ensure information, tools and resources. From are hospitalized, a nurse will work they understand their diagnosis the TexasHealthAetna.com home with your physician to make sure and treatment recommendations. page, select Member Log In, then Log you are getting the care you need Total Health Nurses will collaborate In Now. Then click, Register. and that your physician’s treatment with you and your physician/care is being carried out effectively. team telephonically, by visiting your Log on to Plan Benefits Navigator to: •• Transition Support: Your Transition home, or by attending doctor visits with you. They can help you: •• See who’s covered under your plan Support nurse will talk with you or your caregiver, usually within 24 - ––Understand your condition and •• Check medical claims 48 hours of your admission to the treatment plan options •• Get a cost breakdown — your hospital or care facility. ––Make lifestyle changes that will Explanation of Benefits After you’re home, your nurse will improve your health •• Find providers in your network work with you face-to-face or by ––Select the appropriate health care •• Get a digital ID card phone to help you do all you can to resources •• Access your Personal Health Record prevent a return to the hospital. ––Discover the best options for to make informed decisions Your Transition Support nurse will future health care needs •• Link to health information help you: ––Learn about medications, •• Access a Health Decision Support ––Understand your condition and including what they’re supposed Tool to help you understand your follow your discharge plan to do, side effects and tips for condition, learn about options, and ––Avoid infection or other illness making them more affordable make the right decision during your recovery ––Make follow-up appointments •• While you’re logged in, you can ––Make follow-up appointments with your doctor and other email or chat with Member Services. with your doctor and other providers. providers Medical & Wellness UHC Personal Health SupportSM •• UHC HealtheNote: You’ll ––Learn about medications, receive reminder letters about UHC Personal Health Support including what they’re supposed recommended screening exams provides you with support to to do, side effects and tips for like mammograms, adolescent help you improve your health making them more affordable immunizations, cervical cancer care experience. It is designed to ––Discover the best options for screening, diabetes screening, encourage personalized, efficient future health care needs. and if you are over age 65, flu and care for you and your covered pneumonia shots. dependents. Personal Health •• Readmission Management: This •• UHC Dedicated Team of Nurses: A Support Nurses center their efforts program serves as a bridge between dedicated team of nurses is available on prevention, education, and the hospital and your home if you to help you manage your pregnancy, closing any gaps in your care. It are at high risk of being readmitted. as well as chronic and complex can help when you require prior After leaving the hospital, if you conditions. authorization, need to be admitted have a certain chronic or complex to a hospital or have an outpatient condition, you may receive a phone Health Advocacy with UHC procedure. The program is available call from a Personal Health Support at 1-877-MyTHRLink (877-698-4754), Nurse to confirm that medications, Coping with health concerns can be prompt 2. needed equipment, or follow-up time-consuming and complex. And, services are in place. The Personal with so many choices, it can be hard Personal Health Support includes: Health Support Nurse will also to know where to look for trusted share important health information, information and support. That’s •• Prior Authorization: If you have reiterate and reinforce discharge why Health Advocacy services were a situation that requires prior instructions, and support a safe developed—to give you peace of mind authorization (listed in the box transition home. with: on the previous page), UHC makes your experience easier by If you do not receive a call from a •• Immediate answers to your health verifying eligibility, confirming Personal Health Support Nurse but and wellness questions any time, benefits, helping you understand feel you could benefit from any of from any where—24 hours a day these programs, please call UHC at your benefits, and offering •• Access to caring registered nurses 1-877-MyTHRLink (877-698-4754), recommendations for network who have an average of 15 years’ prompt 2 and ask to be connected doctors, hospitals, and other health clinical experience care providers. with Personal Health Support.

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•• Trusted, physician-approved •• Information on family and •• Prostheses and treatment of information to guide your health community education classes physical complications at all stages care decisions •• Hospital bill payment of the mastectomy, including lymphedemas. When you call 1-877-MyTHRLink •• Electronic get-well cards (1-877-698-4754) prompt 2, a caring •• Medical encyclopedias in English Newborn’s and Mother’s Health nurse can help you: and Spanish Protection Act •• Information about prescription Federal law (Newborn’s and Mother’s •• Choose appropriate medical care drugs in English and Spanish Health Protection Act of 1996) ––Understand a wide range of prohibits the plan from limiting a symptoms WellCall Center mother’s or newborn’s length of ––Determine if the emergency You can access free Texas Health hospital stay to less than 48 hours for room, a doctor visit or self-care is System information by calling a normal delivery or 96 hours for a right for your needs 1-877-THR-WELL (1-877-847-9355). Cesarean delivery or from requiring The call center provides: •• Find a doctor or hospital the provider to obtain preauthorization ––Find doctors or hospitals that •• Directory listing of physicians on for a stay of 48 or 96 hours, as meet your needs and preferences the medical staff at Texas Health appropriate. ––Locate an urgent care center and hospitals (Be sure the physician you However, federal law generally does other health resources select is in your Texas Health Aetna not prohibit the attending provider, or UHC network.) •• Understand treatment options after consultation with the mother, •• Physician referrals with information ––Learn more about a diagnosis from discharging the mother or matched to your specific needs ––Explore the risks, benefits and her newborn earlier than 48 hours such as specialty, clinical interest, possible outcomes of your for normal delivery or 96 hours for insurance accepted, and hospital treatment options Cesarean delivery. privileges (Be sure the physician you •• Achieve a healthful lifestyle select is in your Texas Health Aetna PRE-EXISTING CONDITIONS ––Get tips on how nutrition and or UHC network.) exercise can help you maintain a •• Family and community class Texas Health is proud that we do

healthful weight information and registration not have any pre-existing condition Medical & Wellness limitations under any of the medical ––Learn about important health •• Information on Texas Health hospital plan options. This means if you are screenings and immunizations departments and services. newly enrolling in our plan, you do •• Ask medication questions You can call and speak to an operator not need to be concerned that our ––Explore how to save money on between 8 a.m. and 5:30 p.m. Monday medical plan will not cover a condition prescriptions through Friday. that you or your dependent has at ––Learn how to take medication the time you enroll—so long as it is a safely and avoid interactions. Health Care Laws condition that is otherwise covered by Mental Health Parity Act our medical plan. While Health Advocacy is an excellent information resource, it cannot According to the Mental Health Parity diagnose problems or recommend Act of 1996, mental health benefits specific treatment. This service is not a under the Texas Health Medical Plan substitute for your doctor’s care. are equal to medical and surgical benefits under this plan. Texas Health WellCall Center and Consumer Web Services Women’s Health Act Texas Health offers you two resources The Women’s Health and Cancer to make it easier for you to use Rights Act of 1998 requires that all Texas Health hospitals for your own health insurance plans that cover health care—the WellCall Center and mastectomy also cover the following Consumer Web Services. medical care:

Consumer Web Services •• Reconstruction of the breast Log on to www.TexasHealth.org for on which the mastectomy was access to a wealth of online resources, performed including: •• Surgery and reconstruction of the other breast to produce a •• Pre-registration for elective surgery, symmetrical appearance maternity stay, or outpatient surgery at Texas Health hospitals

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COVERED MEDICAL •• Autism—plan will cover •• Cellular and Gene Therapy— EXPENSES occupational, physical, and speech received on an inpatient or therapy for children up to age 18 outpatient basis at a hospital or on Covered medical expenses are with Autistic Spectrum Disorder an outpatient basis at an alternate services and supplies that are eligible (ASD). Subject to maximum limits facility or in a physician's office. under the plan and that you or a per plan year of 60 visits combined. Benefits for CAR-T therapy for covered dependent receives to •• Bereavement counseling—for the malignancies are provided as diagnose or treat an illness or injury. immediate family if the patient was described under Transplantation The claims administrator has the receiving hospice care covered Services. For network benefits, discretion and authority to initially under the medical plan you must provide pre-service determine whether a treatment or •• Birthing center notification as soon as the possibility supply is covered and how the eligible of a cellular or gene therapy •• Blood pressure cuffs—covered at expense will be handled by the plan. arises. If you do not obtain prior 100% with a doctor’s order. Contact See the plan comparison table on authorization and if, as a result, the your claims administrator at pages 22 – 30 for a summary of services are not received from a 1-877-MyTHRLink (1-877-698-4754), copays and coinsurance required for designated provider, network benefit prompt 1 for Texas Health Aetna certain services. will not be paid. and prompt 2 for UHC for more The following items are considered information. •• Chemotherapy—including wigs for alopecia following chemotherapy covered expenses if the claims •• Blood processing and administration •• Chiropractic care/acupuncture/ administrator determines that they are •• Breast implant removal—if due to a spinal manipulation—up to 20 visits an eligible expense for diagnosis or medical condition treatment of the patient’s condition per calendar year combined across •• Breast prostheses and regardless of gender identity. All all benefit levels. Benefits are paid reconstruction—internal or external services are subject to the excluded only for rehabilitation services prostheses needed due to a expenses listed on pages 49 – 55. that are expected to result in a mastectomy significant physical improvement •• Acupuncture—combined with •• Breast Pump—Preventive care in your condition. In addition, the chiropractic care, up to 20 visits benefits defined under the claims administrator has the right per year (see chiropractic care for Health Resources and Services Medical & Wellness to deny benefits for any type of details) Administration (HRSA) requirement therapy, service, or supply for the •• Allergy treatment, testing and serum include the cost of purchasing treatment of a condition that ceases injections one breast pump per pregnancy in to be therapeutic treatment and is •• Ambulance—for medical conjunction with childbirth. Benefits instead administered to maintain a emergencies to the nearest hospital are only available if breast pumps level of functioning or to prevent a where emergency health services are obtained from a DME provider. medical problem from occurring or can be performed. Non-emergency Call your medical plan at reoccurring. coverage is available for non- 1-877-MyTHRLink (1-877-698-4754), Each visit may include one spinal emergency ambulance transport prompt 1 for Texas Health Aetna and manipulation, one extra-spinal when it is medically necessary. prompt 2 for UHC to get a breast manipulation and up to three pump at no cost. •• Anesthesia modalities. Massage therapy is not •• Anorexia and bulimia •• Breast reduction—for certain covered. functional impairments but not to •• Attention Deficit Disorder (ADD) Children under 12 are covered solely improve appearance or to and Attention Deficit Hyperactivity for manipulative therapy only for improve athletic performance Disorder (ADHD)—diagnosis and acute or repetitive musculoskeletal treatment are covered. Other •• Cardiac rehabilitation services— injuries, excluding birth trauma and limitations described on page 44 up to 36 visits per calendar year scoliosis. under “Mental health services” also combined across all benefit levels apply. for services that are expected •• Audiologists—includes charges by to result in significant physical a licensed or certified audiologist improvement in the patient’s for physician-prescribed hearing condition within two months of the evaluations to determine the start of treatment. Services must location of a disease within the be performed by a licensed therapy auditory system; for validation or provider under the direction of a tests to confirm an organic hearing physician. problem

This list is not all-inclusive and should not be used to determine whether you may receive treatment.

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•• Clinical Trials—Covered Expenses ––Federally funded trials. The study ––The subject or purpose of the trial include routine patient care costs or investigation is approved or must be the evaluation of an item incurred during participation in funded (which may include funding or service that meets the definition a qualifying clinical trial for the through in-kind contributions) of a covered health service and is treatment of cancer or other life by one or more of the following: not otherwise excluded under the threatening conditions. Consistent National Institutes of Health (NIH) Plan. with Centers for Medicare & which includes National Cancer •• Cochlear implant—for a person Medicaid Services (CMS) policy and Institute (NCI); Centers for Disease who has been diagnosed with a Patient Protection and Affordable Control and Prevention (CDC); severe to profound sensorineural Care Act (PPACA) requirements, Agency for Healthcare Research hearing loss and severely difficult Texas Health covers medically and Quality (AHRQ); Centers for speech discrimination or post-lingual necessary routine patient care Medicare and Medicaid Services sensorineural deafness in an adult costs in clinical trials (in the same (CMS); a cooperative group or •• Colonoscopy—one per year covered way that it reimburses routine center of any of the entities if preventive* care for members not in clinical described above or the Department •• Congenital heart disease services— trials) according to the limitations of Defense (DOD) or the Veterans Benefits are covered for Congenital outlined below. All of the following Administration (VA); a qualified Heart Disease (CHD) services which limitations apply to such coverage: non-governmental research entity are ordered by a physician. CHD identified in the guidelines issued –– All applicable plan limitations for surgical procedures include surgeries by the National Institutes of Health coverage of out-of-network care to treat conditions such as coarctation for center support grants; or the will apply to routine patient care of the aorta, aortic stenosis, tetralogy Department of Veterans Affairs, costs in clinical trials; and of fallot, transposition of the great the Department of Defense or the –– All utilization management rules vessels and hypoplastic left or Department of Energy, as long as and coverage policies that apply right heart syndrome. The claims the study or investigation has been to routine care for members not administrator has specific guidelines reviewed and approved through in clinical trials will also apply to regarding benefits for CHD services. a system of peer review that is routine patient care for members Contact Personal Health Support at determined by the Secretary of in clinical trials; and the number on your ID card for prior Health and Human Services to –– Members must meet all authorization and information about Medical & Wellness meet both of the following criteria: applicable plan requirements for these guidelines. comparable to the system of peer precertification, registration, and CHD services must be received at review of studies and investigations referrals; and a CHD Resource Services program. used by the National Institutes –– To qualify, a clinical trial must Benefits include the facility charge of Health, and ensures unbiased have a written protocol that and the charge for supplies and review of the highest scientific describes a scientifically sound equipment. standards by qualified individuals study and have been approved who have no interest in the Surgery may be performed as open by all relevant institutional review outcome of the review. or closed surgical procedures or may boards (IRBs) before participants be performed through interventional ––The study or investigation is are enrolled. cardiac catheterization. conducted under an investigational With respect to cancer or other life- new drug application reviewed Benefits are available for the threatening diseases or conditions, by the U.S. Food and Drug following CHD services: a qualifying clinical trial is a Phase Administration; ––Outpatient diagnostic testing I, Phase II, Phase III, or Phase IV ––The study or investigation is a drug ––Evaluation clinical trial that is conducted in trial that is exempt from having ––Surgical interventions relation to the prevention, detection such an investigational new drug ––Interventional cardiac or treatment of cancer or other life- application; catheterizations (insertion of a threatening disease or condition and ––Written protocol that describes tubular device in the heart). which meets any of the following a scientifically sound study and ––Fetal echocardiograms criteria in the bulleted list below. have been approved by all relevant (examination, measurement institutional review boards (IRBs) and diagnosis of the heart using before participants are enrolled ultrasound technology). in the trial. We may, at any time, ––Approved fetal interventions. request documentation about the trial;

* Wellness exams are 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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CHD services other than those Anesthesia and hospitalization •• Diabetes education— For all plan listed above are excluded from services including covered options except the Texas Health coverage, unless determined by health services provided in a Aetna Select 3000, after a $10 the Claims Administrator to be hospital or alternate facility for copay, the individual and group proven procedures for the involved dental conditions likely to result education sessions for both adult diagnoses. Contact CHD Resource in a medical condition if left and pediatric diabetes patients are Services at 1-888-936-7246 before untreated, and performed on a covered 100% at Texas Health and receiving care for information about covered person who is under UTSW hospitals, but only with a CHD services. 8 years of age and determined physician’s referral. You are eligible •• Contact lenses—initial pair by a physician to require dental to earn free test strips for self- prescribed and purchased within 12 treatment in a hospital or alternate monitoring of your blood glucose months after cataract surgery facility, due to a complex dental when you visit with Texas Health or •• Cornea transplant condition or a developmental UTSW diabetes educators at least disability that prevents effective quarterly. •• Dental care/oral surgery—Services treatment in a dental office; or has must be performed by a doctor of For the Texas Health Aetna Select one or more medical conditions dental surgery (DDS) or a Doctor of 3000 option, diabetes education at that would create undue medical Medical Dentistry (DMD). Texas Health and UTSW is covered risk if dental treatment were Covered expenses are limited to: but the full cost must be paid until provided in a dental office. ––Surgical treatment of fractures the deductible is met. Then you pay Benefits do not include expenses 10% coinsurance. and dislocations of the jaw or for for diagnosis or treatment of For children, pre-determination treatment of accidental injury to dental disease. Depending on is required. The plan requires sound, natural teeth, including where the covered health service the physician to submit pre- replacement of such teeth. The is provided, any applicable determination including clinical service must be started within notification or authorization notes for review and approval for three months and completed requirements will be the same as medical appropriateness. If deemed within 12 months after the date of those stated under each covered medically necessary, the plan an accident. health service category. ––Surgery needed to correct will cover diabetic education for

Medical & Wellness ––Treatment of a sound, natural children at a $10 copay then 100%, accidental injuries to the jaws, tooth. The physician or dentist for individual or group education cheeks, lips, tongue, floor, and must certify that the injury to the sessions by an in-network provider roof of the mouth. Accidental tooth was a virgin or unrestored or in-network facility when services injury must be severe enough tooth, has no decay, no filling on cannot be performed at Texas that the initial contact with the more than two surfaces, no gum Health Preferred Hospitals (including physician or dentist occurred disease associated with bone UT Southwestern University Hospital within 72 hours of the accident. loss, no root canal therapy, is not and UT Southwestern University Dental services for final treatment a dental implant, and functions Hospital - Zale Lipshy); but only with to repair the damage caused by normally in chewing and speech. a physician’s referral. accidental injury must be started ––Removal of non-odontogenic within 3 months of the accident, lesions, tumors or cysts by a or if not a covered person at the Doctor of Dental Surgery (DDS) time of the accident, within the or Doctor of Medical Dentistry first three months of coverage (DMD) under the plan, unless extenuating ––Incision and drainage of non- circumstances exist (such as odontogenic cellulitis prolonged hospitalization or the ––Surgical treatment of accessory presence of fixation wires from sinuses, salivary glands, ducts, fracture care) and completed and tongue within 12 months of the accident, ––Treatment to correct a non- or if not a covered person at the odontogenic congenital defect time of the accident, within the that results in a functional defect first 12 months of coverage under of a covered dependent child. the plan.

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•• Diabetes supplies—the Caremark •• Family planning—covered services ––Ancillary charges furnished by the prescription drug plan covers oral include Norplant, IUD, diaphragms, hospice while you are confined, medications, insulin, syringes, Depo Provera and home birth; including rental of durable blood glucose monitors, test strips, marriage counseling is excluded medical equipment that is used lancets, and chem strips. You can (see page 81 for services offered by solely for treating an injury or receive a glucose monitor free the EAP). illness through Caremark. The medical plan •• Foot care—includes foot surgery ––Medical supplies, drugs and covers durable medical equipment, or diabetic care; excludes services medicines prescribed by the including external insulin pumps, for corns, calluses, and ingrown attending physician, but only supplies for your pump (infusion toenails unless considered an to the extent such items are sets, cartridges, batteries, and eligible expense as determined by necessary for pain control and medical tape), and glucagon the claims administrator management of a terminal emergency kits when ordered •• Hearing care—hearing screening condition by the physician. Continuous as part of a routine preventive ––Physician services and nursing Glucose Monitors (CGM), pieces of office visit; purchase of aid (or pair) care by a registered nurse, a equipment that dispense glucose and hearing tests associated with licensed practical nurse, or a along with the observing/monitoring the purchase of an aid, every 36 licensed vocational nurse of how the CGM is working on a months. Bone anchored hearing ––Home health aide services member, are covered by the medical aids are covered only for covered ––Home care charges by a plan based on the place of service. persons: hospital or home health care External pumps that deliver insulin ––Who have craniofacial anomalies agency, under the supervision into the intraperitoneal cavity are ––Whose abnormal or absent of a registered nurse, a licensed not covered. ear canals preclude the use of practical nurse, a licensed •• Diagnostic X-ray and lab wearable hearing aids or vocational nurse, or a home •• Dialysis—when done on an ––Whose hearing loss is of sufficient health aide outpatient basis, notification is not severity that it would not be ––Medical social services by required by the claims administrator adequately remedied by wearable licensed or trained social workers, •• Disposable or consumable medical hearing aids. psychologists, or counselors supplies—covered only when a •• Home health care—up to 100 ––Nutrition services by a licensed Medical & Wellness doctor’s prescription is required. visits per calendar year; prior dietitian. Elastic stockings are limited to two authorization is required; each •• Hospital confinement—prior pairs per calendar year. Supplies visit lasting for four hours or less is notification is required; private room that can be purchased without a considered one visit; each visit must at Texas Health hospitals and UT prescription are not covered, such be ordered by a physician; part-time Southwestern hospitals or semi- as bandages, gauze, and dressings. or intermittent nursing care by a private room at other facilities, •• Drug tests—Presumptive and registered nurse, licensed practical board, and other necessary medical definitive drug tests will be limited nurse or licensed vocational services and supplies, up to the to 18 presumptive drug tests per nurse; services of a certified social usual and customary limit (or, for calendar year and 18 definitive drug worker; medical supplies, drugs and a hospital without semi-private tests per calendar year. medicines prescribed by a physician, rooms, 90% of the most common •• Durable medical equipment—for and laboratory services provided private room rate.) equipment that costs $1,000 by or on behalf of a hospital, but Benefits are not payable for hospital or more, prior authorization is only to the extent that they would admissions on a Friday, Saturday, or required. Benefits are available for have been covered under the plan Sunday unless surgery is performed the replacement of durable medical if you had remained in the hospital; within 24 hours of admission, or equipment once every three services of a licensed physical the admission is an emergency; calendar years. therapist; the care cannot be for the you must prenotify Texas Health •• Emergency care—for medical purpose of assisting with daily living Aetna or UHC before hospitalization emergencies (see page 218 for a activities except in emergencies. definition). The plan administrator •• Hospice care—for people with •• Infant formula and donor breast must be notified within 48 hours. terminal illness (diagnosed with milk—if they are the only source of •• Enteral nutrition—the sole source six months or less to live). Prior nutrition or if they are specifically of nutrition or when a nutritional authorization is required. Covered created to treat inborn errors of formula treats inborn error of expenses are limited to: metabolism such as phenylketonuria metabolism such as PICU ––Room and board for confinement (PKU) •• Eyeglasses—initial pair of lenses and in a hospice frames prescribed and purchased within 12 months following cataract surgery

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•• Infertility treatment—coverage for •• Maternity care—includes prenatal The Mental Health/Substance- diagnosis of underlying cause of care, labor, delivery, hospitalization Related and Addictive Disorders infertility in a physician’s office or or a birthing center, and newborn Administrator determines coverage medical facility; excludes fertility care; maternity charges for for all levels of care. You must drugs, artificial insemination, in-vitro dependent children are covered, but contact the Substance-Related and fertilization, gamete intra fallopian the newborn child of a dependent Addictive Disorders Administrator transfer (GIFT), zygote intra fallopian (grandchild of the employee) before receiving any inpatient or transfer (ZIFT) may be covered beyond 31 days outpatient services or as soon as •• Injections—the lesser of the copay after birth only if the employee’s is reasonably possible for non- or the cost of the injection grandchild meets eligibility scheduled services (includes •• Intensive care requirements described on page emergency admissions). You 6; prior authorization is required may contact the Administrator at •• Intensive outpatient program (IOP) if the stay is longer than 48 hours 1-877-MyTHRLink (1-877-698-4754) ––Designed for plan participants for vaginal delivery and 96 hours prompt 1 for Texas Health Aetna and who are recovering from severe for Cesarean delivery. In the event prompt 2 for UHC. and/or chronic behavioral health the newborn stays longer than the The mental health services benefits conditions including mental mother, the newborn will be treated and financial requirements assigned health conditions and substance as discharged from maternity and to these programs or services are use disorders that occur at the re-admitted as a sick infant. There is based on the designation of the same time no newborn coverage after 31 days. program or service to inpatient, ––May include psychotherapy, •• Medical nutrition therapy—coverage partial hospitalization/day treatment, pharmacotherapy, and supportive/ for participants with body mass intensive outpatient treatment, rehabilitative interventions index (BMI) of 28 or more; requires outpatient or a transitional care ––Provided in a freestanding or physician referral; therapy covered category. If an inpatient stay is hospital-based program only if provided by a clinical required, it is covered on a semi- ––Half-day partial-hospital programs dietitian at a Texas Health or UTSW private room basis. provide services at least three hospital. You may receive one initial •• Midwife—services of a licensed hours per day, two or more days 90-minute assessment and up to state-certified midwife who is a per week Medical & Wellness three 30-minute sessions each year. registered nurse ––Covered as an inpatient benefit •• Mental health services—coverage •• Multiple surgical procedures—when with 5 days IOP = 1 day inpatient includes those services received on performed at the same time as care an inpatient or outpatient basis in the primary surgical procedure, ––May be used as a point of entry a hospital and an alternate facility secondary procedures (excluding into care, a step up from routine or in a provider’s office. All services incidental procedures or separate outpatient services, or a transition must be provided by or under the operative areas) are covered at 50% after acute inpatient, residential direction of a properly qualified of the in-network negotiated rate care or a partial hospital program behavioral health provider. Benefits or 50% of the allowable expense for •• Laboratory charges—includes tests include the following levels of care: each additional procedure. and X-rays inpatient treatment, residential •• Narcolepsy—diagnosis and •• Mastectomy—includes treatment, partial hospitalization/ treatment of sleep apnea and reconstruction of the breast day treatment, intensive outpatient narcolepsy on which the mastectomy treatment, and outpatient treatment. was performed or surgery and Services include the following: reconstruction of the other diagnostic evaluations, assessments breast to produce a symmetrical and treatment planning; treatment appearance and prosthesis and and/or procedures; medication physical complications in all stages management and other associated of the mastectomy, including treatments; individual, family and lymphedemas group therapy; provider-based case management services; and crisis intervention.

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•• Neurobiological disorders/autism •• Nutritional Counseling—for covered •• Occupational therapy—up to 60 spectrum disorder services — persons with a body mass index of outpatient visits per calendar year psychiatric services for autism 28, to be provided by a registered (combined with speech therapy spectrum disorder (otherwise dietitian at Texas Health or UTSW and physical therapy); benefits are known as neurodevelopmental hospitals. Nutritional counseling is paid only for rehabilitation services disorders) that are both of the limited to an initial assessment of 90 that are expected to result in a following: (1) provided by or under minutes and up to three 30 minute significant improvement in your the direction of an experienced sessions. condition within two months of the psychiatrist and/or an experienced •• Newborn care—coverage includes start of treatment. In addition, the licensed psychiatric provider; and routine nursery and pediatric care claims administrator has the right (2) focused on treating maladaptive/ following birth, including room and to deny benefits for any type of stereotypic behaviors that are board, professional services for therapy, service, or supply for the posing danger to self, others and well newborn, and circumcision; treatment of a condition that ceases property and impairment in daily newborn must be enrolled for to be therapeutic treatment and is functioning. These benefits describe coverage within 31 days of birth to instead administered to maintain a only the psychiatric component receive coverage after 31 days level of functioning or to prevent of treatment for autism spectrum •• Obesity— nonsurgical or surgical a medical problem from occurring disorder. Medical treatment of treatment of morbid obesity (as or reoccurring. Therapy must be Autism Spectrum Disorder is a defined by the claims administrator). performed by a licensed therapist covered health service for which Nonsurgical treatment is covered under a physician’s order. benefits are available under the only when provided in a physician’s •• Office visit—for medical diagnosis or applicable medical covered health office. treatment services categories as described in To be eligible for surgical treatment •• Orthognathic surgery—covered only this section. (bariatric surgery), your medical for the following conditions: Benefits include the following records must document a body ––A jaw deformity resulting from a levels of care: inpatient treatment, mass index (BMI) of 40+ without facial trauma or cancer residential treatment, partial co-morbidities or 35-39.9 with ––A skeletal anomaly of the jaw hospitalization/day treatment, and co-morbitities. You must have that demonstrates a functional

outpatient treatment. participated in a physician-directed medical impairment, such as: Medical & Wellness Benefits include the following: diet and exercise program or a ŒŒ Being unable to chew solid food diagnostic evaluations, assessments multi-disciplinary weight-loss ŒŒ Choking on solid food that has and treatment planning; treatment program (such as Real Appeal). not been completely chewed and/or procedures; medication Counseling is required before and ŒŒ Damaging soft tissue while management and other associated after surgery. chewing treatments; individual, family and The surgery is covered only at ŒŒ Having a speech impediment group therapy; provider-based case Texas Health and UTSW hospitals caused by a jaw deformity management services; and crisis that are either a Texas Health Aetna ŒŒ Suffering from malnutrition intervention. Institute of Quality (IOQ) or a UHC or weight loss because of The Mental Health/Substance- Center of Excellence, and only for inadequate intake as a result Related and Addictive Disorders participants who are at least age 18. of a jaw deformity Administrator determines coverage See BeHealthyTHR.org for a current •• Orthoptic therapy—orthoptic for all levels of care. If an inpatient list of covered facilities. (vision) therapy for the treatment stay is required, it is covered on Bariatric surgery may be repeated of convergence insufficiency in a semi-private room basis. You if you experience a significant the absence of accommodative must contact the Mental Health/ complication or technical failure disorder. Orthoptic therapy is not a Substance-Related and Addictive requiring surgical revision of original covered expense for treatment of Disorders Administrator before procedure, provided you have been reading or learning disabilities, or for receiving any inpatient or outpatient compliant with the prescribed vision-related diagnoses other than services or as soon as is reasonably nutrition and exercise program. those listed as covered, because possible for non-scheduled services Gastric bypass sleeve procedure and there is not enough clinical evidence (includes emergency admissions). vertical banded gastrolasty (VBG) that these are safe or effective in The administrator may be contacted are covered, however adjustable published, peer-reviewed medical at 1-877-MyTHRLink (1-877-698- gastric band (AGB or lap band) is not literature. 4754) prompt 1 for Texas Health covered. •• Orthotic Devices—covered when Aetna and prompt 2 for UHC. Panniculectomy may also be linked with a medical diagnosis such covered. (See Panniculectomy for as wrist/hand, elbow, and lower more information.) extremity orthotics (excluding foot)

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•• Ostomy supplies—pouches, Certain pharmaceutical products The plan pays benefits for preventive faceplates, belts, irrigation sleeves/ are subject to step therapy care services provided on an bags, catheters, and skin barriers requirements. This means that in outpatient basis at a physician’s •• Outpatient hospital charges order to receive benefits for such office, an alternate facility or •• Outpatient surgery—contact your pharmaceutical products, you must a hospital. Preventive care claims administrator when using an use a different pharmaceutical encompasses medical services that out-of-network provider or facility product and/or prescription drug have been demonstrated by clinical product first. You may find out evidence to be safe and effective in •• Panniculectomy—Removal of excess whether a particular pharmaceutical either the early detection of disease skin will be covered if deemed product is subject to step therapy or in the prevention of disease, have medically necessary by the claims requirements by contacting the been proven to have a beneficial administrator if you maintain a claims administrator. effect on health outcomes and weight loss of at least 20% for at include the following as required least two years by any means of •• Physical therapy—up to 60 under applicable law: weight loss. outpatient visits per calendar year (combined with speech therapy and •• Pharmaceutical products ––Evidence-based items or services occupational therapy); benefits are (outpatient)— Pharmaceutical that have a rating of “A” or “B” in paid only for rehabilitation services products that are administered on the current recommendations that are expected to result in a an outpatient basis in a hospital, of the United States Preventive significant physical improvement alternate facility, physician’s office, Services Task Force in your condition within two or in your home. Examples of ––Immunizations that have a months of the start of treatment what would be included under this recommendation from the (except autism). In addition, the category are antibiotic injections Advisory Committee on claims administrator has the right in the physician’s office or inhaled Immunization Practices of the to deny benefits for any type of medications in an urgent care center Centers for Disease Control and therapy, service, or supply for the for treatment of an asthma attack. Prevention treatment of a condition that ceases Benefits as described here are ––With respect to infants, children to be therapeutic treatment and is provided only for pharmaceutical and adolescents, evidence- instead administered to maintain a products which, due to their informed preventive care

Medical & Wellness level of functioning or to prevent a characteristics, must typically be and screenings provided medical problem from occurring or administered or directly supervised for in the comprehensive reoccurring. by a qualified provider or licensed/ guidelines supported by the •• Physician services—including care certified health professional. Health Resources and Services in the office and hospital visits by Where the pharmaceutical product Administration primary physicians and specialists is administered will determine ––With respect to women, additional •• Pre-admission testing the cost. This does not include preventive care and screenings medications for the treatment of •• Prenatal care/postnatal care provided for in comprehensive infertility. •• Prescription drugs—covered through guidelines supported by the If you require certain Caremark (see page 58) Health Resources and Services pharmaceutical products, •• Preventive care—wellness exams Administration. including specialty pharmaceutical are covered in full if the claims ––Generic birth control prescriptions products, you may be directed to administrator determines the covered at 100% including pills, a designated dispensing location physical is for preventive care. implants and patches with whom the claims administrator Additional screenings or services will •• Private rooms—covered only at has an arrangement to provide be considered diagnostic services Texas Health and UTSW hospitals those products. Such dispensing and will be covered after you pay •• Prosthetic devices— locations may include an outpatient the applicable copay or deductible ––Initial purchase and fitting of pharmacy, specialty pharmacy, and coinsurance. At the time of external prosthetic which is home health agency provider, your preventive care visit, if other necessary to alleviate or correct hospital-affiliated pharmacy or services are performed that are not sickness, injury, or congenital hemophilia treatment center preventive services, as determined defect, to replace or substitute contracted pharmacy. If you or your by the claims administrator, they for a missing body part, limited provider are directed to a designated will not be paid at 100% even if they to artificial arms and legs and dispensing location and you/your are submitted as part of a claim for terminal devices such as a hand provider choose not to obtain your preventive care. pharmaceutical products from a or hook; designated dispensing location, ––Devices may be evaluated for network benefits are not available replacement after five years due for that pharmaceutical product to normal wear and tear;

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––Devices may be replaced before Services are considered cosmetic •• Speech therapy—up to 60 five years for adults and children procedures when they improve (combined with physical therapy if it is determined by medical appearance without making an and occupational therapy) review as appropriate (for organ or body part work better. outpatient visits per calendar year; example defective or damaged) The fact that a person may suffer covered only when the speech or if needed due to normal body psychological consequences from impediment or speech dysfunction growth in children the impairment does not classify results from injury, sickness, •• Psychological counseling—subject a procedure as a reconstructive cancer, autism spectrum disorder, to mental health treatment plan procedure. (Reshaping a nose stroke or congenital anomaly, or is •• Pulmonary rehabilitation therapy— with a prominent “bump” is an required following the placement up to 20 outpatient visits per example of a cosmetic procedure of a cochlear implant. Learning calendar year combined across because it improves appearance disabilities and developmental all benefit levels; benefits are paid without affecting a function like delays are excluded. only for rehabilitation services breathing.) This plan does not Services must be performed by a that are expected to result in a provide benefits for cosmetic licensed therapy provider under the significant improvement in your procedures. direction of a physician. Benefits are available only for rehabilitation condition within two months of the Some services are considered services that are expected to result start of treatment. Services must cosmetic in some circumstances in significant physical improvement be provided by a licensed therapy and reconstructive in others. (An in the patient’s condition within two provider under the direction of a example is upper eyelid surgery. physician. In addition, the claims months of the start of treatment At times, this procedure will administrator has the right to deny (except autism). In addition, the improve vision, while at other benefits for any type of therapy, claims administrator has the right times, it only improves service, or supply for the treatment to deny benefits for any type of appearance.) of a condition that ceases to be therapy, service, or supply for the therapeutic treatment and is instead •• Respiratory therapy—see Pulmonary treatment of a condition that ceases administered to maintain a level therapy to be therapeutic treatment and is of functioning or to prevent a •• Second surgical opinions instead administered to maintain a

medical problem from occurring or •• Short-term rehabilitation therapy— level of functioning or to prevent a Medical & Wellness reoccurring. Benefits can be denied or shortened medical problem from occurring or •• Radiation therapy for covered persons who are reoccurring. •• Reconstructive procedures— not progressing in goal-directed •• Sterilization—voluntary vasectomy services are considered rehabilitation or if rehabilitation goals or tubal ligation; does not cover reconstructive procedures when have been previously met. sterilization reversal a physical impairment exists •• Skilled nursing and rehabilitation—at •• Substance-Related and Addictive and the primary purpose of the an in-network skilled nursing facility Disorders Services include those procedure is to improve or restore or long-term rehabilitation facility received on an inpatient or physiologic function for an organ up to 60 days per year. Services outpatient basis in a hospital, an or body part to make it work better. are covered only for care related to alternate facility or in a provider’s Prior authorization is required. the injury or illness for which you office. Benefits include the following An example of reconstructive are confined. Prior authorization is levels of care: inpatient treatment, procedure is surgery on the inside required. residential treatment, partial of the nose so that a person’s •• Sleep disorders—therapy to treat hospitalization/day treatment, breathing can be improved or sleep apnea or narcolepsy. For sleep intensive outpatient treatment, and restored. studies, prior authorization to the outpatient treatment. Cosmetic surgery is covered only for claims administrator is required. Services include the following: the following situations: Failure to obtain prior authorization diagnostic evaluations, assessments will result in a $1,000 penalty and treatment planning; treatment ––Repair of injuries caused by an and/or procedures; medication accident •• Specialist office visit management and other associated ––Surgical correction of a congenital treatments; individual, family and birth defect in a child group therapy; provider-based ––Reconstructive breast surgery case management services; crisis following mastectomy intervention; and transitional living ––Removal of breast implants if the services. claims administrator deems it necessary

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The mental health/substance use However, arthroscopy is not If you are the recipient, your disorder administrator determines covered for treatment of TMJ covered health services will include: coverage for all levels of care. If because of inadequate clinical ––The expenses (based on URN an inpatient stay is required, it is evidence of its safety and/or contracted rates) incurred to covered on a semi-private room efficacy in published, peer-reviewed secure the organ or tissue directly basis. You must contact the Mental medical literature. from a cadaver or through an Health/Substance-Related and •• Termination of pregnancy—only if organ bank, and Addictive Disorders Administrator it meets the definition of a covered ––The medical expenses incurred by before receiving any inpatient or health service a living donor, but only if they are outpatient services or as soon as •• Transplants—non-experimental not covered by the donor’s own is reasonably possible for non- human organ and tissue transplants plan of benefits scheduled services (includes are covered only at facilities If you are the donor, your covered emergency admissions). The approved in advance by a Texas health services will include the administrator may be contacted at Health Aetna Institute of Quality or medical expenses that you incur to 1-877-MyTHRLink (1-877-698-4754) a UHC Center of Excellence; prior donate the organ or tissue. prompt 1 for Texas Health Aetna and authorization is required; includes Your plan sponsor may provide you prompt 2 for UHC. donor’s expenses to the extent they with travel and lodging assistance. •• Support garments—covered if the are not covered by donor’s own Travel and lodging assistance claims administrator determines medical benefits. is only available for you or your them to be necessary, subject Transplant services include CAR-T eligible family member if you to limitations (see page 43 for cell therapy. Covered organ meet the qualifications for the disposable or consumable medical transplant services include the benefit, including receiving care supplies) recipient’s medical, surgical, at a designated provider and the •• Surgeon’s services—includes and hospital services; inpatient distance from your home address assistant surgeon charges immunosuppressive medications; to the facility. Eligible expenses are •• Temporomandibular joint syndrome and costs for organ procurement: reimbursed after the expense forms (TMJ) treatment—covered for ––Blood/marrow/stem cell have been completed and submitted diagnostic and surgical treatment ––Cornea with the appropriate receipts. If you Medical & Wellness of conditions affecting the have specific questions regarding ––Heart temporomandibular joint when the Travel and Lodging Assistance ––Heart/lung provided by or under the direction Program, please call the claims of physician. Coverage includes ––Intestine administrator. necessary diagnostic or surgical ––Kidney The Plan covers expenses for treatment required as a result of ––Kidney/pancreas travel and lodging for the patient, accident, trauma, congenital defect, ––Kidney/liver provided he or she is not covered developmental defect, or pathology. ––Liver by Medicare, and a companion as Dental services, including appliances ––Liver/intestine follows: and orthodontic treatment, are ––Lung –– Transportation of the patient and not covered in any situation. The ––Pancreas. one companion who is traveling following charges are covered: on the same day(s) to and/or from Coverage for organ procurement ––Arthrocentesis for the treatment the site of the qualified procedure costs will be limited to costs directly of documented, symptomatic provided by a designated provider related to procurement of an organ degenerative joint disease, for the purposes of an evaluation, from a cadaver or a live donor and osteoarthritis or documented, the procedure or necessary post- will consist of surgery necessary for intracapsular soft tissue discharge follow-up. organ removal, organ abnormalities (such as disc –– The Eligible Expenses for displacement or adhesions). transportation, and the transportation, hospitalization, and lodging for the patient (while ––Arthroplasty for the treatment surgery of a live donor. not a hospital inpatient) and one of documented symptomatic companion osteophytes affecting the Compatibility testing undertaken before procurement is covered if –– If the patient is an enrolled temporomandibular joint or dependent minor child, the documented symptomatic the claims administrator considers it to be an eligible expense; the transportation expenses of two intracapsular soft tissue companions will be covered abnormality (such as disc amount payable for donor’s medical –– Travel and lodging expenses are displacement or adhesions) costs will be reduced by the amount payable for those costs from any only available if the patient resides ––Arthrotomy for the treatment other plan; certain transplants are more than 50 miles from the of intracapsular soft tissue not covered, see Excluded Medical Designated Provider abnormality (such as disc Expenses. replacement or adhesions).

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–– Reimbursement for certain •• Urgent care clinic or center EXCLUDED MEDICAL lodging expenses for the patient •• Vision care—examinations by EXPENSES and his/her companion(s) may be a licensed ophthalmologist or included in the taxable income optometrist and glasses, including To provide adequate medical coverage of the plan participant if the frames and one set of lenses and control costs, the medical plan reimbursement exceeds the per (including contacts) within 12 sets reasonable limits on the benefits diem rate months of cataract surgery; for certain types of services and –– The bariatric, cancer, congenital limited to one diabetic retinal supplies. Benefits are not payable for heart disease and transplant exam annually; does not include services that the claims administrator programs offer a combined routine examinations required by an determines do not meet the definition overall lifetime maximum of employer in connection with your of a covered health service (see page $10,000 per covered person for employment 217). In making a determination, the claims administrator considers the all transportation and lodging •• Well-baby immunizations —covered condition and overall health of the expenses incurred by you and at 100%; no coverage for out-of- patient. The following services are reimbursed under the plan in network providers excluded under the medical plan: connection with all qualified •• Wigs—for hair loss following procedures. chemotherapy Alternative Treatments ––The Claims Administrator must •• X-rays—the use of X-ray, radium, or •• Acupressure receive valid receipts for such radioactive isotopes and laboratory •• Aromatherapy charges before you will be services to diagnose or treat an •• Hypnotism reimbursed. Reimbursement is as injury or illness follows: •• Massage therapy and soft-tissue ŒŒ Lodging–a per diem rate of up therapy, regardless of who performs to $50 per day for the patient the service or the caregiver if the patient •• Rolfing is in the hospital; or up to $100 •• Herbal, holistic, and homeopathic per day, for the patient and one medicine caregiver. If the patient is a child, •• Art therapy, music therapy, dance two caregivers may accompany therapy and other forms of Medical & Wellness the child. Examples of items alternative treatment as defined that are not covered: groceries, by the National Center for alcoholic beverages, personal Complementary and Alternative or cleaning supplies, meals, Medicine (NCCAM) of the National over-the-counter dressings Institutes of Health. This exclusion or medical supplies, deposits, does not apply to Manipulative utilities and furniture rental Treatment and non-manipulative when billed separate from the osteopathic care for which benefits rent payment, phone calls, are provided as described on page newspapers, or movie rentals 55. ŒŒ Transportation–automobile •• Maintenance care mileage (reimbursed at the IRS •• Naturopath medical rate) for the most direct route between the patient's Comfort and Convenience home and the designated Supplies, equipment and similar facility, including: taxi fares (not incidentals for personal comfort. including limos or car services), Examples include: economy or coach airfare, parking, trains, boat, bus, tolls •• Television •• Telephone •• Air conditioners •• Beauty/barber service •• Air purifiers and filters •• Dehumidifiers and humidifiers •• Ergonomically correct chairs

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•• Devices and computers to assist in •• Dental implants and braces Experimental or Investigational or communication and speech except This exclusion does not apply to Unproven Services for speech aid devices and tracheo- accident-related dental services Experimental or investigational esophageal voice devices for which for which benefits are provided as services—medical, surgical, diagnostic, benefits are provided as described described under Dental care/oral psychiatric, mental health, substance under Durable Medical Equipment surgery on page 42. use disorders or other health care on page 43. •• Dental braces (orthodontics) services, technologies, supplies, •• Incontinence briefs, lines, or diapers •• Treatment of missing, treatments, procedures, drug when used for custodial purposes malpositioned, or supernumerary therapies, medications or devices that, •• Therapeutic devices (extra) teeth, even if part of a at the time the claims administrator congenital anomaly and Texas Health Resources makes a Dental •• Fluoride preparations determination regarding coverage in a •• Dental care (which includes dental •• Jawbone surgery – upper or lower particular case, are determined to be X-rays, supplies and appliances and jawbone surgery except as required any of the following: all associated expenses, including for direct treatment of acute hospitalizations and anesthesia •• Not approved by the U.S. Food traumatic injury or cancer and Drug Administration (FDA) This exclusion does not apply to •• Orthognathic surgery – not covered to be lawfully marketed for the accident-related dental services for the following conditions: proposed use and not identified in for which benefits are provided as ––Myofascial, neck, head, and the American Hospital Formulary described under Dental care/oral shoulder pain Service or the United States surgery on page 42. ––Irritation of the head or neck Pharmacopoeia Dispensing This exclusion does not apply to muscles Information as appropriate for the dental care (oral examination, proposed use; X-rays, extractions and non-surgical ––Popping or clicking of the •• Subject to review and approval elimination of oral infection) temporomandibular joints by any institutional review board required for the direct treatment ––Potential for development or for the proposed use (Devices of a medical condition for which exacerbation of TMJ which are FDA approved under benefits are available under the plan, ––Teeth grinding

Medical & Wellness the Humanitarian Use Device limited to: ––Treatment of malocclusion (dental exemption are not considered to be ––Transplant preparation and therefore not a covered Experimental or Investigational); or ––Prior to the initiation of medical service) •• The subject of an ongoing clinical immunosuppressives drugs Drugs trial that meets the definition of a ––The direct treatment of acute •• Prescription drugs – covered phase 1, 2 or 3 clinical trial set forth traumatic Injury, cancer or cleft through a separate prescription drug in the FDA regulations, regardless of palate plan as explained on page 58 whether the trial is actually subject •• Preventive care, diagnosis, treatment •• Over-the-counter drugs, supplies, to FDA oversight. of the teeth or gums. Examples and treatments include: Exceptions: •• Growth hormone therapy which ––Extractions (including wisdom is covered by the prescription plan •• Clinical trials for which benefits are teeth), restoration and described on page 59 available as described under Clinical replacement of teeth •• Select Specialty Medications will be trials on page 41 ––Medical or surgical treatments of covered only under the pharmacy dental conditions benefit and not the medical plan. ––Services to improve dental clinical Additionally, the location of infusion outcomes services may be changed based on This exclusion does not apply variables as determined by the CVS to preventive care for which specialty team. benefits are provided under the United States Preventive Services Task Force requirement or the Health Resources and Services Administration (HRSA) requirement. This exclusion does not apply to accident-related dental services for which benefits are provided as described under Dental care/oral surgery on page 42.

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•• If you are not a participant in a Home Health Care •• Services or supplies for the qualifying clinical trial as described •• Services and supplies not included diagnosis or treatment of mental on page 41 and have a sickness in the home health care plan illness, alcoholism or substance use or condition that is likely to cause recommended by the attending disorders that, in the reasonable death within one year of the physician judgment of the Mental Health/ request for treatment, the claims Substance-Related and Addictive •• Services or supplies not included in administrator and Texas Health Disorder Services Administrator, the hospice care program Resources may, at their discretion, are any of the following: (1) not •• Services of your close relative or a consider an otherwise experimental consistent with generally accepted person who ordinarily lives in your or investigational service to be standards of medical practice for home a covered health service for that the treatment of such conditions; sickness or condition. Prior to •• Services of any social worker unless (2) not consistent with services such consideration, the claims designated C.S.W.A.C.P. backed by credible research administrator and Texas Health •• Transportation soundly demonstrating that the Resources must determine that, •• Custodial care services or supplies will have a although unproven, the service has •• Housekeeping measurable and beneficial health significant potential as an effective outcome, and therefore considered treatment for that sickness or Hospice experimental; (3) not consistent condition. •• Services or supplies not included in with the mental health/substance the hospice care program use disorder administrator’s level Foot Care •• Services of a close relative or a of care guidelines or best practices •• Routine foot care, except when person who ordinarily lives in your as modified from time to time; (4) needed for severe systemic disease home not clinically appropriate for the or preventive foot care for covered •• Curative or life-prolonging patient’s mental illness, substance persons with diabetes for which procedures use disorder or condition based on benefits are provided as described generally accepted standards of •• For any period not under the care of under Foot care on page 43. Routine medical practice and benchmarks a physician foot care services that are not •• Health services or supplies that covered include: Medical Supplies and Appliances do not meet the definition of a Medical & Wellness ––Cutting or removal of corns and •• Devices used specifically as safety covered health service as defined calluses items or to affect performance in on page 217. Covered health ––Nail trimming or cutting sports-related activities services are those health services, ––Debriding (removal of dead skin or •• Tubings, nasal cannulas, connectors including services, supplies, or underlying tissue) and masks that are not used in pharmaceutical products, which the •• Hygienic and preventive connection with DME claims administrator determines to be medically necessary maintenance foot care. Examples •• Orthotic Devices – covered when include: linked with a medical diagnosis such •• Mental Health Services as ––Cleaning and soaking the feet as wrist/hand, elbow, and lower treatments for R and T code conditions as listed within the ––Applying skin creams in order to extremity orthotics (excluding foot) current edition of the Diagnostic maintain skin tone •• Prostheses – replacement for theft and Statistical Manual of the ––Other services that are performed or loss, wear and tear, destruction, American Psychiatric Association when there is not a localized or any biomechanical external •• Mental health services as treatment sickness, injury or symptom prosthetic device for a primary diagnosis of involving the foot Mental Health, Neurobiological insomnia and other sleep-wake This exclusion does not apply to Disorders - Autism Spectrum disorders, feeding disorders, sexual preventive foot care for covered Disorder, and Substance-Related & dysfunctions, binge eating disorders, persons who are at risk of Addictive Disorders neurological disorders and other neurological or vascular disease •• Services performed in connection disorders with a known physical arising from diseases such as with conditions not classified in the basis diabetes. current edition of the International •• Outside of initial assessment, •• Treatment of flat or pronated foot/ Classification of Disorders section services as treatments for the feet on Mental and Behavioral Disorders primary diagnoses of learning •• Shoe inserts or the Diagnostic and Statistical disabilities, conduct and disruptive •• Arch supports Manual of the American Psychiatric impulse control and conduct •• Shoes (standard or custom), lifts and Association disorders, pyromania, kleptomania, wedges gambling disorder and paraphilic •• Shoe orthotics disorder. •• Treatment of subluxation of the foot

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•• Services that are solely educational Nutrition and Health Education •• Replacement of an existing in nature or otherwise paid under •• Nutritional or cosmetic therapy intact breast implant if the earlier state or federal law for purely using high dose or mega quantities breast implant was performed educational purposes of vitamins, minerals or elements, as a cosmetic procedure. Note: •• Tuition for or services that are and other nutrition based therapy. Replacement of an existing school-based for children and Examples include supplements, breast implant is considered adolescents under the Individuals electrolytes and foods of any kind reconstructive if the initial breast with Disabilities Education Act (including high protein foods and implant followed mastectomy. •• Learning, motor disorders and low carbohydrate foods) •• Physical conditioning programs primary communication disorders •• Food of any kind. Foods that are such as athletic training, body- as defined in the current edition not covered include: building, exercise, fitness, flexibility and diversion or general motivation, of the Diagnostic and Statistical ––Enteral feedings and other or any therapy to improve general Manual of the American Psychiatric nutritional and electrolyte physical condition Association formulas, including infant •• Intellectual disabilities as a primary formula and donor breast milk, •• Weight loss programs whether diagnosis defined in the current unless they are the only source or not they are under medical edition of the Diagnostic and of nutrition or unless they are supervision or for medical reasons, Statistical Manual of the American specifically created to treat even if for morbid obesity Psychiatric Association inborn errors of metabolism •• Well-being items – items that •• Outside of an initial assessment, such as phenylketonuria (PKU). promote well-being and are not services as treatments for a Infant formula available over the medical in nature, such as bicycles, primary diagnosis of conditions counter is always excluded. exercise equipment, and whirlpool and problems that may be a ––Foods to control weight, treat spas focus of clinical attention, but are obesity (including liquid diets), •• Wigs and other scalp hair prosthesis specifically noted not to be mental lower cholesterol or control unless following chemotherapy disorders within the current edition diabetes •• Treatments for hair loss of the Diagnostic and Statistical ––Oral vitamins and minerals •• A procedure or surgery to remove Manual of the American Psychiatric fatty tissue such as panniculectomy

Medical & Wellness ––Meals you can order from a Association. menu, for an additional charge, (except as defined on page 46) •• Outside of initial assessment, during an inpatient stay abdominoplasty, thighplasty, unspecified disorders for which the ––Other dietary and electrolyte brachioplasty, or mastopexy provider is not obligated to provide supplements. •• Varicose vein treatment of the lower clinical rationale as defined in the •• Health club memberships and extremities, when it is considered current edition of the Diagnostic programs, and spa treatments cosmetic (sclerotherapy) and Statistical Manual of the •• Treatment of benign gynecomastia American Psychiatric Association. •• Nutritional counseling for individuals or groups (abnormal breast enlargement in •• Intensive behavioral therapies such males) as applied behavioral analysis for Physical Appearance autism spectrum disorders Pregnancy and Infertility •• Cosmetic procedures. See the •• Any treatments or other specialized definition on page 217. Examples •• Health services and associated services designed for autism include: expenses for infertility treatments, spectrum disorder that are not including assisted reproductive ––Liposuction or removal of fat backed by credible research technology, regardless of the deposits considered undesirable, demonstrating that the services or reason for the treatment. including fat accumulation under supplies have a measurable and the male breast and nipple This exclusion does not apply to beneficial health outcome and services required to treat or correct ––Pharmacological regimens, therefore considered experimental underlying causes of infertility. or investigational or unproven nutritional procedures or treatments •• Storage and retrieval of all services reproductive materials (examples ––Scar or tattoo removal or revision •• Marriage counseling except as include eggs, sperm, testicular procedures (such as salabrasion, covered by the EAP as described on tissue and ovarian tissue) page 81 chemosurgery and other such skin abrasion procedures). •• In vitro fertilization regardless of the reason for treatment ––Skin abrasion or other procedures performed as a treatment for •• Artificial insemination, gamete acne or acne scars intra-fallopian transfer (GIFT), zygote intra-fallopian transfer (ZIFT) •• Surrogate parenting, donor eggs, donor sperm, and host uterus

52 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Total Health Medical Plan

•• Feed or direct payments to a donor ––Prior to ordering the service ––Cross-species organ transplants or doctor for sperm or ovum ––After the service is received •• Health services for transplants donations involving permanent mechanical This exclusion does not apply to •• The reversal of voluntary or animal organs, except services mammography. sterilization or any form of related to the implant or removal of contraception not specifically Services Provided Under a circulatory assist device (a device covered Another Plan that supports the heart while the •• Artificial reproductive treatments Services for which coverage is patient waits for a suitable donor done for genetic or eugenic available: heart to become available) (selective breeding) purposes •• Health services connected with the •• Services provided by a doula (labor •• Under another plan, except for removal of an organ or tissue from aide) eligible expenses payable as you for purposes of a transplant to described on page 56, Coordination •• Parenting, pre-natal or birthing another person. (Donor costs for of Benefits (COB) classes removal are payable for a transplant •• Under workers' compensation •• Fetal reduction surgery through the organ recipient's (treatment or drug for any illness benefits under the plan.) •• Health services and associated or injury that occurs during or as a expenses for elective abortion, •• Organ donor costs not directly result of work for pay or profit), no- termination of pregnancy, related to organ procurement fault automobile coverage or similar contraceptive supplies and services •• Transplants performed at a facility legislation if you could elect it, or not approved by the claims •• Sex-determination testing – could have it elected for you amniocentesis, ultrasound, or any administrator •• By a mandatory auto insurance other procedures requested solely policy written to comply with a Travel for sex determination of a fetus, “no-fault” or uninsured-motorist •• Health services provided in a unless it meets medical criteria to insurance law foreign country, unless required as determine the existence of a sex- •• While on active military duty emergency health services linked genetic disorder •• For treatment of military service- •• Travel or transportation expenses, Providers related disabilities when you are even if ordered by a physician, Medical & Wellness •• Services performed by a provider legally entitled to other coverage, except as identified Additional travel who is a family member by birth or and facilities are reasonably expenses related to covered health marriage, including your spouse, available to you services received from a designated brother, sister, parent, child or •• For injury or sickness for which facility or designated physician grandparent. This includes any there is non-group coverage may be reimbursed at the plan's service the provider may perform (except individual health insurance discretion. This exclusion does not on himself or herself. plans) providing medical payments apply to ambulance transportation •• Services performed by a provider or medical expense coverage. If for which benefits are provided as with your same legal residence benefits subject to this provision described under Ambulance on are paid or provided, the claims page 40. •• Services performed by an administrator reserves the right unlicensed provider or a provider Vision and Hearing to cover the reasonable value of who is operating outside of the such benefits as provided in the •• Routine vision examinations, scope of his/her license Subrogation and Reimbursement including refractive examinations •• Physician fees for any treatment not section found on page 69. to determine the need for vision rendered by or provided under the correction supervision of a physician Transplants •• Implantable lenses used only to •• Services provided at a diagnostic •• Health services for organ and tissue correct a refractive error (such as facility (hospital-based or free- transplants: Intacs corneal implants) standing) without a written order ––Except as identified under •• Purchase cost and associated from a physician or other provider. Transplants in covered medical fitting charges for eyeglasses or •• Services which are self-directed to expenses found on page 48 contact lenses except the first pair a free-standing or hospital-based ––Determined by Personal Health prescribed and purchased within 12 diagnostic facility Support not to be proven months following cataract surgery •• Services ordered by a physician or procedures for the involved •• Bone anchored hearing aids except other provider who is an employee diagnoses when either of the following or representative of a diagnostic ––Not consistent with the diagnosis applies: facility (hospital-based or free- of the condition standing), when that provider is not ––Experimental transplants actively involved in your medical care: ––Artificial organ transplants

1-877-MyTHRLink (1-877-698-4754) MyTHR.org 53 Total Health Medical Plan

––For covered persons with •• Charges prohibited by federal anti- ––That are received as a result of craniofacial anomalies whose kickback or self-referral statutes war or any act of war, whether abnormal or absent ear canals •• Charges resulting from or occurring declared or undeclared, while preclude the use of a wearable during the commission of a crime part of any armed service force of hearing aid or while engaging in an illegal act, any country. This exclusion does ––For covered persons with hearing illegal occupation or aggravated not apply to covered persons loss of sufficient severity that assault unless injuries result from who are civilians injured or it would not be adequately a medical condition or domestic otherwise affected by war, any remedied by a wearable hearing violence act of war or terrorism in a non- aid •• Chelation therapy, except to treat war zone. •• Eye exercise or vision therapy other heavy metal poisoning ––That are received after the date than as a treatment for strabismus •• Custodial care or services provided your coverage under this plan (misalignment of the eyes) by a personal care assistant ends, including health services for medical conditions which •• Surgery and other related treatment •• Diagnostic tests that are: began before the date your that is intended to correct ––Delivered in other than a coverage under the plan ends nearsightedness, farsightedness, physician's office or health care ––For which you have no legal presbyopia and astigmatism facility responsibility to pay, or for which including, but not limited to, ––Self-administered home a charge would not ordinarily be procedures such as laser and other diagnostic tests, including but made in the absence of coverage refractive eye surgery and radial not limited to HIV and pregnancy under this benefit plan keratotomy tests •• That exceed eligible expenses •• Domiciliary Care All Other Exclusions or any specified limitation in this •• Autopsies and other coroner •• Duplicate coverage – dependent’s Handbook expenses if he or she is receiving services and transportation services •• For which a non-network provider benefits for the same expense as a for a corpse waives the annual deductible or covered employee •• Biofeedback therapy coinsurance amounts •• Ecological and environmental •• Charges for: •• Hospitalization primarily for x-rays,

Medical & Wellness medicine ––Missed appointments laboratory, diagnostic study, •• Educational testing or training ––Room or facility reservations physiotherapy, hydrotherapy, – testing or training that does ––Completion of claim forms medical observation, convalescent not diagnose or treat a medical or rest care, or any medical ––Record processing condition. Includes learning examination or test not connected ––Care, treatment, services, disabilities and treatment for with an illness or injury; admissions supplies or equipment that are hyperkinetic syndrome, except ADD on a Friday, Saturday, or Sunday advertised by the provider as free, or ADHD unless surgery is performed within not legally required or which the •• Government-paid care – care, 24 hours provider offers to waive treatment, services, or supplies •• Immunizations agents – ––Services incurred before the provided or paid for by any prescriptions for immunizations effective date of coverage government plan or law when the agents, biological products for ––Emergency room visits for non- coverage is not restricted to the allergy immunization, biological emergencies government’s civilian employees sera, blood, blood plasma and ––Education, training, or bed and and their dependents (this exclusion other blood products or fractions board while confined in an does not apply to Medicare or and medications used for travel institution that is mainly a school Medicaid) prophylaxis or other institution for training •• Grandchildren – medical expenses •• IQ Testing or a place of rest, a place for the of an employee’s grandchild •• Foreign language and sign aged, or a nursing home (the child of an employee’s language services ––Routine exams and unmarried dependent child) after •• Long term (more than 30 days) immunizations, except those 31 days following birth, unless storage of blood, umbilical cord or listed as covered expenses the grandchild meets eligibility other material ––That others are responsible for requirements described on page 6 paying •• Expenses for health services and •• Charges by a provider sanctioned supplies: under a federal program for reason of fraud, abuse or medical competency

54 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Total Health Medical Plan

•• Health services and supplies that do •• Nursing care, as it relates to: •• The following treatments for not meet the definition of a covered ––Care, treatment, services, or obesity: health service on page 217. Covered supplies that do not require the ––Non-surgical treatment, even if health services are those health skills and training of a nurse for morbid obesity services including services, supplies ––A nurse who is a close relative ––Surgical treatment of obesity even or pharmaceutical products, which (spouse, child, parent, brother, if there is a diagnosis of morbid the claims administrator determines sister, in-law), or lives in the same obesity to be all of the following: household •• Treatment of hyperhidrosis ––Medically necessary •• Penile prostheses (excessive sweating) ––Described as a covered health •• Physical examinations not •• Multi-disciplinary pain management service in this Handbook on required for health reasons – programs provided on an inpatient page 217 including employment, insurance, basis for acute pain or for ––Not otherwise excluded in this government license, court-ordered, exacerbation of chronic pain section, Exclusions forensic, or custodial evaluations This exclusion does not apply •• Private duty nursing to breast pumps for which •• Respite care. This exclusion does benefits are provided under the not apply to respite care that is Health Resources and Services part of an integrated hospice care Administration (HRSA) requirement. program of services provided to a •• Health services related to a non- terminally ill person by a licensed covered health service: When a hospice care agency for which service is not a covered health benefits are described under service, all services related to that Hospice care on page 43 non-covered health service are also •• Sex transformation operations and excluded. This exclusion does not related services apply to services the plan would •• Sexual dysfunctions, deviations or otherwise determine to be covered disorders – all drugs and treatment health services if they are to treat

are excluded (except limited drugs Medical & Wellness complications that arise from the for erectile dysfunction) non-covered health service. •• Smoking cessation aids – except For the purpose of this exclusion, for those covered by the wellness a "complication" is an unexpected program as described on page 79 or unanticipated condition that •• Speech therapy, except when is superimposed on an existing required for treatment of a speech disease and that affects or impediment or speech dysfunction modifies the prognosis of the that results from injury, sickness, original disease or condition. stroke, cancer, autism spectrum Examples of a "complication" are disorder or a congenital anomaly, or bleeding or infections, following a is needed following the placement cosmetic procedure, that require of a cochlear implant as identified hospitalization. under speech therapy on page 47. •• Manipulative treatment to treat a Not covered if: condition unrelated to alignment ––Considered custodial and of the vertebral column, such as educational asthma or allergies ––Therapy to improve speech •• Medical and surgical treatment of skills not fully developed (non- snoring, except when provided as a restorative) part of treatment for documented ––To maintain speech obstructive sleep apnea (a sleep communication disorder in which a person regularly stops breathing for 10 seconds or ––To treat stuttering, stammering, or longer). Appliances for snoring are other articulation disorders always excluded. •• Storage of blood, umbilical cord or other material for use in a covered health service, except if needed for an imminent surgery

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COORDINATION OF •• If you are receiving COBRA If payments should have been made BENEFITS (COB) continuation coverage under under this plan but have been made another employer plan, your Texas under any other plan, the claims Your medical plan is designed to Health plan will pay benefits first. administrator has the right, in its sole integrate benefits with other group •• Your dependent children will discretion, to pay to any insurance or individual plans or policies or receive primary coverage from the company or other organization or government programs, including any parent whose birth date occurs first person making such other payments of the following: in a calendar year. If both parents any amounts it determines and to •• Another employer sponsored health have the same birth date, the plan the extent of such payments, Texas benefits plan that pays benefits first is the one Health and the plan will be fully discharged from liability. The benefits •• A medical component of a group that has been in effect the longest. that are payable will be charged long-term care plan, such as skilled This birthday rule applies only if: against any applicable maximum nursing care ––The parents are married or living payment or benefit of this plan rather •• No-fault or traditional "fault" type together whether or not they than the amount payable in the medical payment benefits or have ever been married and not absence of this provision. personal injury protection benefits legally separated under an auto insurance policy ––A court decree awards joint If you are enrolled in both the medical •• Medical payment benefits under custody without specifying that and dental plans and need treatment any premises liability or other types one party has the responsibility that both plans will cover, the medical of liability coverage to provide health care coverage plan pays first. The dental plan pays •• Medicare or other governmental •• If two or more plans cover a second, but only if it covers the same health benefit. dependent child of divorced or service. separated parents and if there is If you are eligible, either as the no court decree stating that one If you or a dependent has active insured or a dependent, to receive parent is responsible for health medical coverage through Texas medical benefits from another plan, care, the child will be covered Health and is covered under the total benefits you are eligible under the plan of: Medicare, your Texas Health coverage is primary and your Medicare is to receive from all plans will not be ––The parent with custody of the Medical & Wellness secondary. more than the benefits that would be child; then payable from the Total Health Medical ––The spouse of the parent with When Your Texas Health Medical Plan if you had no other coverage. custody of the child; then Plan is Secondary This applies whether or not you file a ––The parent not having custody of claim under the other plan. If needed, If your Texas Health Medical plan is the child; then you must authorize the claims secondary, it determines the amount ––The spouse of the parent not administrator to get information from it will pay for a covered health service having custody of the child. the other plans. How much your by following the steps below. •• Plans for active employees pay Texas Health plan will reimburse you, •• The plan determines the amount if anything, will also depend in part on before plans covering laid-off or retired employees. it would have paid based on the the allowable expense. allowable expense. •• The plan that has covered the Order of Benefit Determination individual claimant the longest will •• If this plan would have paid the Rules pay first. same amount or less than the primary plan paid, this plan pays no If you are covered by two or more •• Finally, if none of the above rules benefits. plans, the benefit payment follows the determines which plan is primary or rules below in this order: secondary, the allowable expenses •• If this plan would have paid more shall be shared equally between the than the primary plan paid, the plan •• Your Total Health Medical Plan will plans. In addition, the Texas Health will pay the difference. always be secondary to medical plan will not pay more than it would payment coverage or personal You will be responsible for any copay, have paid had it been the primary injury protection coverage under coinsurance or deductible payments plan. any auto liability or no-fault as part of the coordination of benefits insurance policy. (COB) payment. The maximum combined payment you can receive •• A plan without a coordinating from all plans may be less than 100% provision is always the primary plan. of the allowable expense. •• If all plans have a coordinating provision, the plan covering you directly (rather than as a spouse or dependent) is primary.

56 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Total Health Medical Plan

Here’s an example: Determining the Allowable Expense Medicare Crossover Program

Let’s say your spouse has coverage If the Texas Health plan is secondary The plan offers a Medicare Crossover at work offering a 70% coinsurance to Medicare, the Medicare- Program for Medicare Part A and Part and coverage as a dependent on your approved amount is the allowable B and Durable Medical Equipment plan with Texas Health, which covers expense, as long as the provider (DME) claims. Under this program, 90% of the bill after a deductible. Your accepts reimbursement directly you no longer have to file a separate spouse’s coverage at his/her work from Medicare. If the provider claim with the plan to receive is primary, with the coverage from accepts reimbursement directly secondary benefits for these expenses. Texas Health paying as secondary. from Medicare, the Medicare- Your dependent will also have this The claims administrator calculates approved amount is the charge that automated crossover, as long as he the benefit as if the spouse only Medicare has determined that it or she is eligible for Medicare and this had coverage at Texas Health and will recognize and which it reports plan is your only secondary medical then subtracts the amount paid by on an "explanation of Medicare coverage. benefits" issued by Medicare (the the primary coverage. Assuming Once the Medicare Part A and Part "EOMB") for a given service. Medicare the deductible has been met and B and DME carriers have reimbursed typically reimburses such providers a services were performed at a Preferred your health care provider, the percentage of its approved charge – Hospital, the plan would pay an Medicare carrier will electronically often 80%. additional 20% of the bill. submit the necessary information to Determining the Allowable Expense If the provider does not accept the Claims Administrator to process assignment of your Medicare benefits, the balance of your claim under the For purposes of COB, an allowable the Medicare limiting charge (the most provisions of this plan. expense is a health care expense that a provider can charge you if they don't You can verify that the automated is covered at least in part by one of the accept Medicare – typically 115% of crossover is in place when your health benefit plans covering you. the Medicare approved amount) will copy of the explanation of Medicare be the allowable expense. Medicare When the provider is a network benefits (EOMB) states your claim has payments, combined with plan provider for both the primary plan and been forwarded to your secondary benefits, will not exceed 100% of the your Texas Health plan, the allowable carrier. allowable expense. expense is the primary plan's network Medical & Wellness This crossover process does not apply rate. When the provider is a network If you are eligible for, but not enrolled to expenses that Medicare does not provider for the primary plan and a in, Medicare, and your Texas Health cover. You must go on to file claims non-network provider for this plan, plan is secondary to Medicare, or if for these expenses. the allowable expense is the primary you have enrolled in Medicare but plan's network rate. When the provider choose to obtain services from a For information about enrollment, is a non-network provider for the provider that does not participate in or if you have questions about the primary plan and a network provider the Medicare program (as opposed program, call 1-877-MyTHRLink, for this Plan, the allowable expense is to a provider who does not accept prompt 1 for Texas Health Aetna and the reasonable and customary charges assignment of Medicare benefits), prompt 2 for UHC. allowed by the primary plan. When the Benefits will be paid on a secondary provider is a non-Network provider for basis under the Texas Health plan and Payment of Claims both the primary plan and your Texas will be determined as if you timely Plan benefits are payable to you unless Health plan, the allowable expense enrolled in Medicare and obtained you give written direction, at the time is the greater of the two plans' services from a Medicare participating you file your claim, to directly pay reasonable and customary charges. provider. the health care provider or unless a Qualified Medical Child Support Order When a covered person Qualifies When calculating the plan's benefits directs the payment to someone for Medicare in these situations, for administrative else. If any benefit remains unpaid at There are Medicare-eligible individuals convenience the claims administrator your death, if the covered person is for whom the plan pays benefits first will treat the provider's billed charges a minor or legally incapable (in the and Medicare pays benefits second: for covered services as the allowable opinion of the claims administrator) expense for both the plan and •• Employees with active current of giving a valid receipt and discharge Medicare, rather than the Medicare- employment status age 65 or older for payment, the claims administrator approved amount or Medicare limiting and their spouses age 65 or older may, at its option, pay benefits to the charge. •• Individuals with end-stage renal spouse, parent or child of the covered disease, for a limited period of time person. •• Disabled individuals under age 65 with current employment status and their dependents under age 65.

1-877-MyTHRLink (1-877-698-4754) MyTHR.org 57 Total Health Medical Plan

Payment to the covered person’s The amount that must be refunded PRESCRIPTION DRUG relative constitutes a complete equals the amount the plan paid in BENEFITS discharge of the claims administrator’s excess of the amount that should obligation to the extent of the have been paid under the plan. If the The Total Health Medical Plan offers payment. The claims administrator is refund is due from another person two prescription drug options—a High not required to see the application of or organization, the covered person Rx and a Low Rx program (see page the money. agrees to help the plan get the refund 31 for details). Both are administered when requested. by Caremark and have the same Overpayment and Underpayment formulary. The difference is in the of Benefits If the covered person, or any other premium and coinsurance you pay. If the plan pays you more than it owes person or organization that was paid, Texas Health’s prescription drug under the coordination of benefits does not promptly refund the full options offer benefits for generic provision, you should pay the excess amount owed, the plan may recover drugs and Preferred drugs, which are back promptly. Otherwise, Texas the overpayment by reallocating the drugs listed on the Value Formulary. Health may recover the amount overpaid amount to pay, in whole Each calendar quarter, Caremark in the form of salary, wages, or or in part, (i) future benefits for the updates the formulary. Before you benefits payable under any company- covered person that are payable fill a prescription, check Caremark. sponsored benefit plans, including under the plan; (ii) future benefits com to be sure the medication is on this plan. Texas Health also reserves that are payable to other covered the Value Formulary list. The Value the right to recover any overpayment persons under the plan; or (iii) Formulary excludes drugs with generic by legal action or offset payments on future benefits that are payable for alternatives. future eligible expenses. If the plan services provided to persons under overpays a health care provider, the other plans for which the claims The plan’s minimum and maximum claims administrator reserves the right administrator makes payments, with copays for preferred prescriptions to recover the excess amount from the the understanding that the claims keep your costs down by limiting provider. administrator will then reimburse the the amount you must pay from your plan the amount of the reallocated own pocket each time you fill a Refund of Overpayments payment. The reallocated payment prescription. Generic copays apply If the plan pays for eligible expenses amount will equal the amount of the toward the out-of-pocket maximum. Medical & Wellness incurred on account of a covered required refund or, if less than the full person, that covered person, or any amount of the required refund, will be After the second time you fill a other person or organization that deducted from the amount of refund maintenance medication, you are was paid, must make a refund to the owed to the plan. The plan may have required to have your maintenance plan if: other rights in addition to the right to medications filled with a 90-day reallocate overpaid amounts and other prescription or you will be penalized •• The plan’s obligation to pay benefits enumerated rights, including the right by paying double the retail charge. was contingent on the expenses to commence a legal action. You can get a 90-day supply at retail incurred being legally owed and pharmacies located at Texas Health paid by the covered person, but all Dallas, Texas Health Plano, Texas or some of the expenses were not Health Infusion Pharmacy, Caremark paid by the covered person or did mail order, or any CVS or Target not legally have to be paid by the pharmacy. covered person. Maintenance medications are those •• All or some of the payment the plan medications that your physician made exceeded the benefits under prescribes for chronic or long-term the plan. conditions (such as diabetes, high •• All of some of the payment was blood pressure, heart conditions, made in error. allergies, thyroid conditions, etc.). If you are not sure if the prescription is for a chronic condition, please check with your pharmacist. Preventive Drugs If you have diabetes, you are The Total Health Medical Plan eligible for free test strips when covers preventive care medications you receive regular follow-up at no cost to you. Preventive care with a diabetes educator at a medications are medications for which Texas Health or UTSW facility a prescription from a physician is required under any of the following:

58 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Total Health Medical Plan

•• Evidence-based items or services Step Therapy with Post-Step Prior •• Drugs that may only be dispensed that have in effect a rating of ‘A’ or Authorization upon the written prescription of a ‘B’ in the current recommendations You must try a lower-cost alternative physician or other lawful qualified of the United States Preventive before a higher-cost medication will prescriber under the applicable state Services Task Force; be covered. If you have a unique law •• With respect to infants, children and medical situation where the lower- •• Glucose test strips and lancets adolescents, evidence-informed cost alternative doesn’t work well for •• Growth hormones and releasing preventive care and screenings you, your doctor must contact CVS/ agents, subject to Caremark’s provided for in the comprehensive Caremark and confirm that a specific guidelines guidelines supported by the medication is clinically necessary for •• Insulin by prescription Health Resources and Services your condition. •• Prenatal vitamins prescribed by a Administration; or Quantity Limit physician •• With respect to women, such •• Prescription drugs and generic The plan limits the amount of a additional preventive care and drugs, except those drugs listed in specific medication that you can fill screenings as provided for the exclusions in comprehensive guidelines in a 30-day or 90-day period. If you •• Smoking cessation drugs covered by supported by the Health Resources have a unique medical situation that the wellness program and Services Administration. requires you to exceed the limit, your doctor can contact CVS/Caremark •• Tretinoin, all dosage forms (for To find out whether a medication is and confirm that a higher quantity is example, Retin-A), for individuals considered to be a preventive care clinically necessary for your condition. age 29 and under medication, sign in or register at Caremark.com and use the Check You can find a comprehensive list of Drugs Not Covered Drug Coverage and Cost tool or call covered drugs along with any specific Drugs that are not covered are: 1-877-797-9847. criteria at Caremark.com. •• Charges for the administration or Drugs With Generic Equivalents Caremark Resources injection of any drug are not paid as The Total Health Medical Plan It is important to understand your part of the drug benefits excludes drugs with generic pharmacy benefit options so you can •• Charges incurred before a person Medical & Wellness alternatives. If a generic drug is make informed and cost-effective was covered available and you elect or your doctor decisions about your care. To give •• Dental drugs prescribes a preferred or non- you access to the most up-to-date •• DESI drugs (drugs determined by the preferred drug, it will be denied. If you information, Caremark provides a FDA as lacking substantial efficacy) have a unique medical situation where tool called “Check Drug Costs” on •• Drugs labeled “Caution-limited by the generic equivalent doesn’t work Caremark.com. “Check Drug Costs” federal law to investigational use,” well for you, your doctor must contact is a tool that you can use to learn or experimental drugs, even though CVS/Caremark and confirm that a about your options for prescription a charge is made to the covered specific brand-name medication is medications. person (unless related to a covered clinically necessary for your condition. clinical trial) Before you fill a prescription, check Medication with Clinical to be sure the medication is on the •• Drugs newly approved by the FDA, Requirements formulary list. Caremark updates prior to review by the applicable the formulary list each quarter. You Pharmacy and Therapeutics Certain medications have Committee requirements that must be met before can view the formulary list online at •• Hair replacement drugs for the plan provides coverage. Caremark.com. treatment of alopecia (hair loss) Prior Authorization Covered Drugs including Minoxidil (Rogaine) and Propecia are not covered unless the This means that your doctor must Drugs that are covered include: hair loss is a result of chemotherapy. contact CVS/Caremark and confirm •• Birth control, oral contraceptives, that a specific medication meets plan •• Hematinics, except Epogen or and contraceptive devices (IUD or Procrit guidelines for covering your condition. diaphragm) and implants (Norplant) •• Immunization agents, biological •• Compounded medication of products for allergy immunization, which at least one ingredient is biological sera, blood, blood a prescription legend drug (pre- plasma and other blood products or authorization may be required and fractions and medications used for limits may apply) travel prophylaxis •• Disposable insulin needles/ •• Infertility drugs syringes by prescription

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•• Medication to be taken or •• Smoking-deterrent medications Grace Fill administered, in whole or in part, containing nicotine or any other If the medical plan denies coverage while a patient is in a licensed smoking-cessation aids, all dosage for a physician-administered drug that hospital, rest home, sanitarium, forms (such as Nicorette, Nicoderm, was formerly covered by the medical extended care facility, convalescent etc.) except as covered under plan, the medical plan may allow a hospital, skilled nursing facility, the Tobacco Cessation program one-time exception (grace fill) via or similar institution that operates described beginning on page 79 the appeals process. If you wish to on its premises, or allows to be •• Therapeutic devices or appliances, obtain this medication in the future, operated on its premises, a facility including needles, syringes, support contact CVS Specialty Customer Care for dispensing pharmaceuticals garments (unless they are a covered at 1-888-265-7790 or Texas Health •• Medications to enhance athletic health service, as defined on Specialty Pharmacy at 682-236-5200. performance page 217), and other nonmedical •• Mineral supplements, except folic acid substances, regardless of intended Mail Order •• Obesity drugs use, are not covered unless Caremark has its own mail order specifically listed as covered items. •• Off-label drugs (pharmaceutical service. Please refer to your Caremark packet for your mail order prescription drugs unapproved by the FDA for Specialty Medications indication or in an unapproved form, mailing address and phone If you take a specialty medication age group, unapproved dosage, or number. You may also get information for a chronic condition such as unapproved form of administration) and forms online at Caremark.com. rheumatoid arthritis or hemophilia, •• Over-the-counter medicines and Mail order prescriptions are normally you may be directed to a designated supplies—that do not require a filled and mailed within two weeks pharmacy* to obtain those physician’s prescription and may following receipt of the prescription. medications. If you choose not to be obtained over-the-counter, obtain your specialty medications New Prescriptions regardless of whether a physician has from a designated pharmacy, no written a prescription for the item If your physician gives you a new benefits will be paid and you will be are not covered except for diabetic prescription for a maintenance responsible for paying the full cost of supplies and prenatal vitamins medication, you should ask him or your specialty medication. her for a 30-day prescription that •• Prescription and nonprescription Medical & Wellness you can fill immediately and a 90- supplies, devices, and appliances Select Specialty Medications will be day prescription that you can fill for other than syringes used in covered only under the pharmacy ongoing use. conjunction with injectable benefit. As part of this policy, these medications Specialty Medications will be excluded Take the 30-day prescription to •• Prescription drugs or medications from coverage under the medical plan. your local pharmacy* to be filled. used for treatment of sexual Additionally, the location of infusion Then order a 90-day supply of your dysfunction, including but not services may be changed based on prescription at the retail pharmacy at limited to erectile dysfunction, variables as determined by the CVS Texas Health Presbyterian Hospitals delayed ejaculation, anorgasmia and specialty team. at Dallas, Plano, Texas Health Infusion decreased libido; however, up to six If you would like to utilize the Texas Pharmacy, through Caremark pills a month are covered for drugs Health Specialty Pharmacy, you may mail order or at any CVS or Target to treat erectile dysfunction call 682-236-2500. The THR Specialty pharmacy. •• Prescription drugs provided free of Pharmacy team helps provide ongoing If you are currently taking charge from local, state, or federal support throughout your treatment maintenance medications, contact programs plan, including: your physician and ask for a 90-day •• Prescription drugs used for cosmetic •• Access to counseling by a team prescription. purposes such as: drugs used to of pharmacists trained in your reduce wrinkles, drugs to promote condition hair growth, drugs used to control •• Pharmaceutical counseling and perspiration and fade cream medication reconciliation before products every refill •• Prescriptions provided without •• Collaborative coordination of care charge under a worker’s with your health care provider compensation program •• Coordination of home infusion •• Prescription vitamins (other services or injection/infusion than prenatal vitamins), dietary training, as needed supplements and fluoride products •• Assistance with insurance and •• Replacement of lost or stolen financial coordination. prescriptions

*Includes retail pharmacies located at Texas Health Dallas, Texas Health Plano, and Texas Health Infusion Pharmacy.

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FILING AND APPEALING You must submit the original itemized difference between the amount the CLAIMS bill or receipt provided by your provider bills you and the amount physician, hospital, or other medical UHC considers as the eligible expense. Benefits under the medical plan are service provider, so you should When you assign your benefits to a self-funded, which means all claims make copies for your own records. non-network provider with the claims are paid from employee payroll Photocopies of receipts are not administrator’s consent, and the non- deductions and Texas Health’s general accepted for claims. assets. Texas Health Aetna, UHC and network provider submits a claim for Caremark provide claims services, but If you do not have a claim form, simply payment, you and the non-network do not insure the plan. attach a brief letter of explanation to provider represent and warrant that the bill, and verify that the bill contains the covered health services were Claims the information listed below. If any of actually provided and were medically Texas Health Aetna and UHC are the these items are missing from the bill, appropriate. claims processors for the medical plan you can include them in your letter: To be recognized as a valid assignment options. The following summarizes •• Your name and address; of benefits, the assignment must how to file claims under the Texas reflect your agreement that the non- Health Aetna and the UHC Choice and •• The patient’s name, age, and network provider will be entitled to Choice Plus plan options. relationship to the employee; •• The number of as shown on your ID all of your rights under the plan and Whenever you file a claim, be sure to card; applicable state and federal laws, including legally required notices keep a copy of the claim and any other •• The name, address, and tax and procedural reviews concerning information (such as itemized bills) identification number of the your benefits, and that you will no that you include with the claim. provider of the service(s); longer be entitled to those rights. If •• A diagnosis from the physician; Network Providers an assignment form does not comply When you use network providers, •• The date of service; with this requirement, but directs that you do not need to file claims. The •• An itemized bill from the provider your benefit payment should be made provider will file the claim with the that includes: directly to the provider, the claims claims administrator. For network ––The current procedural administrator may in its discretion

benefits, if there is any difference terminology (CPT) codes. make payment of the benefits directly Medical & Wellness between the eligible expenses and the ––A description of, and the charge to the provider for your convenience, amount the provider bills, you are not for, each service. but will treat you, rather than the responsible for paying the difference ––The date the sickness or injury provider, as the beneficiary of your unless you agreed to reimburse the began. claim. If benefits are assigned or provider for such services. ––A statement indicating either payment to a non-network provider is made, Texas Health Resources Out-of-network Providers that you are, or you are not, enrolled for coverage under any reserves the right to offset benefits Out-of-network care is generally not other health insurance plan or to be paid to the provider by any covered under the Texas Health Aetna program. If you are enrolled in amounts that the provider owes Texas or UHC Choice plan options. When other coverage, you must include Health Resources (including amounts you use out-of-network providers the name and address of the other owed as a result of the assignment of under the Choice Plus 1500 plan carrier(s). other plans’ overpayment recovery option, you must file a claim for rights to the plan). reimbursement as follows: Failure to provide all the information listed above may delay any The claims administrator will pay •• Complete a medical claim form reimbursement that may be due you. benefits to you unless: (available on the Internet at MyUHC.com) each time you receive Most medical claims payments are •• The provider submits a claim form medical services. Be sure to follow sent to you along with an explanation to the claims administrator that you the instructions on the form. of benefits (EOB) explaining the have provided signed authorization amount paid. In some cases, payments to assign benefits directly to that •• Submit all itemized receipts from may be sent directly to your physician, provider. your physician or other health care hospital, or other medical provider if provider. A canceled check is not •• You make a written request for the your provider accepts assignment of acceptable documentation. non-network provider to be paid benefits (as defined on page 216). In directly at the time you submit your •• Mail the completed claim form this case, the EOB will be mailed to claim. with the original itemized bills and you and the payment mailed to your receipts to UHC at the address on provider. For out-of-network benefits, the claim form. you are responsible for directly paying to the out-of-network provider any

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The claims administrator will only Each claim will be adjudicated Post-service Claims pay benefits to you or, with written (processed) in a way that ensures A post-service claim is any claim for authorization by you, your provider, that the people involved in making a benefit that is not a pre-service and not to a third party, even if your the decisions act independently and claim or an urgent care claim. provider purports to have assigned impartially. For this reason, decisions benefits to that third party. regarding hiring, compensation, Concurrent Care Claims termination, promotion, or other Prescription Drugs A concurrent care claim is one in similar matters related to the which the claims administrator You do not need to file claims for individual who is designated as the approves a course of treatment prescriptions purchased through fiduciary for an internal appeal, or over a period of time or for a network providers. You pay a copay any health care professional or other specified number of treatments. or coinsurance when you present medical or vocational expert involved However, a concurrent care claim your Caremark member ID card at a in the claim or internal appeal, will may be reconsidered by the claims network pharmacy or when you use not be based on the likelihood that administrator and the initially the mail-order prescription program. the individual will support a denial of approved period of time or number You may also use your Caremark benefits. of treatments may be either reduced, member ID card at out-of-network terminated, or extended. pharmacies. Types of Claims There are four different types of If an ongoing course of treatment Notice and Proof of Claim claims. The claim type is determined was previously approved for a You or your primary physician should initially when the claim is filed. If the specific period of time or number file notice and proof of a claim on nature of the claim changes as it of treatments, and your request to the proper claim form with the claims proceeds through claims processing, extend the treatment is an urgent administrator as soon as possible after the claim may be re-characterized. care claim as defined on this page, the claim is incurred and within the For example, a claim may initially be your request will be decided within time frames described in this section. an urgent care claim. If the urgency 24 hours, provided your request is The claim must be filed as soon as subsides, it may be re-characterized made at least 24 hours prior to the possible and in no event (except in as a pre-service claim. end of the approved treatment. The the case of your legal incapacity) claims administrator will make a Medical & Wellness later than 12 months after the date of Pre-service Claims determination on your request for the service. On receipt of a pre-service claim, the extended treatment within 24 hours claims administrator will determine from receipt of your request. If there is a change in claims whether or not it involves urgent care. If an ongoing course of treatment administrator, all claims incurred If a physician with knowledge of your was previously approved for a before the change in vendor must medical condition determines that a specific period of time or number be received by the old claims claim involves urgent care, the claim of treatments, and you request to administrator by December 31 will be treated as an urgent care claim. following the end of the year. extend treatment in a non-urgent A claim is a pre-service claim if all circumstance, your request will If the plan is terminated, all claims or part of your right to the benefit is be considered a new request and incurred before the plan termination conditioned on receiving approval decided according to post-service or must be received within 30 days after before obtaining the medical care pre-service time frames, whichever the plan’s termination or the claims will (such as preauthorization). This does applies. not be paid. Any claims incurred after not apply to a claim involving urgent If your request for extended termination of plan coverage for any care, as defined below. reason are not covered under the plan. treatment is not made at least Urgent Care Claims 24 hours before the end of the An urgent care claim is any pre- approved treatment, the request will service claim for medical care or be treated as an urgent care claim treatment when time periods that and decided according to the time otherwise apply to pre-service claims frames described on the next page. could seriously jeopardize your life, If an ongoing course of treatment health, or ability to regain maximum was previously approved for a function or would, in the opinion specific period of time or number of a physician with knowledge of of treatments, and you request to your medical condition, subject extend treatment in a non-urgent you to severe pain that cannot be circumstance, your request will be adequately managed without the care considered a new claim and decided or treatment that is the subject of the according to post-service or pre- claim. service time frames, whichever applies.

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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 Claims administrator must 5 days Claims administrator must 30 days notify you within: notify you within: Claims administrator must 24 hours notify you within: If your claim is incomplete You must then provide 45 days completed claim after You must then provide 48 hours Claims administrator must 15 days information to claims receiving completed claim after notify you within: administrator within: an information to claims receiving You must then provide 45 days extension administrator within: notice completed claim after notice 2 Notification of Determination information to claims receiving If claims administrator denies your administrator within: an initial claim Claims administrator must extension notify you of the benefit notice 1 Claims administrator must determination: notify you of the denial: If claims administrator denies your ••If the initial claim is 72 hours initial claim ••If the initial claim is complete, within: complete, within: 30 days Claims administrator must ••After receiving the notify you of the denial: ••After receiving the completed claim (if 48 hours completed claim (if 30 days the initial claim is ••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 Claims administrator must 72 hours You must appeal the claim 180 days Claims administrator must 30 days notify you of the appeal after denial no later than: after notify you of the first level after decision within: receiving receiving appeal decision within: receiving the appeal the denial the first Claims administrator must 15 days level 1 You do not need to submit urgent care appeal notify you of the first level after Medical & Wellness claims in writing. You should call the claims appeal decision within: receiving You must appeal the first 60 days administrator as soon as possible to appeal the first an urgent care claim. level appeal (file a second after level level appeal) within: receiving appeal the first You must appeal the first 60 days level level appeal (file a second after appeal level appeal) within: receiving decision the first Claims administrator must 30 days level notify you of the second after appeal level appeal decision receiving decision within: the Claims administrator must 15 days second notify you of the second after level level appeal decision receiving appeal 3 within: the second level 3 The claims administrator may require a one- appeal 2 time extension of no more than 15 days only if more time is needed due to circumstances beyond their control. 2 The claims administrator may require a one- time extension of no more 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 Benefits •• In the case of an incorrectly filed If the claims administrator notifies Except for urgent care claims, a pre-service claim, you should be you that an initially approved claim for benefits is made when you notified as soon as possible but course of treatment will be reduced (or your authorized representative) no later than five days after the or terminated, the notice will be submit a written claim form as claims administrator receives the provided sufficiently in advance of follows. incorrectly filed claim and the reduction or termination to allow •• In the case of an incorrectly filed you to appeal the adverse decision Medical claims administrators: urgent care claim, you should be and receive a decision on review Texas Health Aetna notified as soon as possible, but under these procedures before the PO Box 981106 no later than 24 hours after the reduction or termination. In the El Paso, TX 79998-110 claims administrator receives the meantime, to the extent required www.TexasHealthAetna.com incorrectly filed claim. The notice by applicable law, the plan will will explain that the request is not continue to provide coverage to you UnitedHealthcare a claim and describe the proper with respect to ongoing course of P.O. Box 30555 procedures for filing a claim. The treatment pending the outcome of Salt Lake City, UT 84130-0555 notice may be oral unless you the internal appeal. www.UHC.com specifically request written notice. The claims administrator will decide Prescription claims administrator: Time Frame for Deciding Initial and notify you of an initial post- Caremark Claims Department Benefit Claims service claim within a reasonable P.O. Box 686005 time but no later than 30 days after The claims administrator will San Antonio, TX 78268-6005 receiving the claim. decide an initial pre-service claim www.caremark.com and notify you within a reasonable You may agree to voluntarily extend You can request a claim form from time appropriate to the medical the above time frames. If the claims the claims administrator for your plan circumstances, but no later than 15 administrator is not able to decide option. A claim form is considered to days after receipt of the claim. a pre-service or post-service claim be received by the plan on the date it within the above time frames for The plan will decide an initial urgent is delivered to the applicable address reasons beyond its control, one care claim as soon as possible, taking Medical & Wellness shown above or the date that it is 15-day extension of the applicable into account the medical urgency deposited in the U.S. Mail for first- time frame is permitted, provided and notify you of the determination, class delivery in a properly stamped that you are notified in writing before whether or not adverse, but no envelope containing the above name the end of the initial time frame for later than 72 hours after the claim is and address. The postmark will be the claim. The extension notice will received. proof of the date of mailing. include a description of the reasons If a claim is a request to extend a beyond the plan’s control that justify Because of the expedited time frames concurrent care decision involving the extension and the date by which a for a decision regarding urgent care urgent care and it is made at least 24 decision is expected. No extension is claims, an urgent care claim may be hours before the end of the initially permitted for urgent care claims. submitted to the claims administrator approved time period or number of at the telephone number on your If any information needed to process treatments, the claim will be decided ID card. The claim should include at a claim is missing, the claim will be within no more than 24 hours after least the following information: treated as incomplete. the claim is received. Any other •• Your name request to extend a concurrent care If an urgent care claim is incomplete, •• A specific medical condition or decision will be decided within the the claims administrator will notify symptom applicable time frames for pre- you as soon as possible, but no later service, urgent care, or post-service •• A specific treatment, service, or than 24 hours following receipt of the claims. product for which approval or incomplete claim. The notification payment is requested. may be made orally to you, unless you request written notice. It will These claims procedures do not apply describe the information necessary to to any request for benefits that is complete the claim and will specify not made according to these claims a reasonable time, no less than 48 procedures, except that: hours, within which the claim must be completed.

The claims administrator will decide the claim as soon as possible, but not later than 48 hours after the earlier of:

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•• Receipt of the specified Any new or additional evidence •• If the decision involves scientific information or that was considered, relied upon, or clinical judgment, it will •• The end of the period of time or generated in connection with disclose either an explanation of provided to submit the specified the claim will be provided to you at the scientific or clinical judgment information. no cost and in advance of the date applying the terms of the plan of the notice of adverse benefit to the covered person’s medical If a pre-service or post-service determination. circumstances or a statement that claim is incomplete, the claims such explanation will be provided at administrator may deny the claim You will receive written or electronic no charge upon request. notification of the adverse decision. or may take an extension of time, as •• In the case of an adverse decision The notice will be written so you described above. concerning an urgent care claim, a can understand it, will be made description of the expedited review If the claims administrator takes an in a culturally and linguistically process. Notification of the plan’s extension of time, the extension appropriate manner, and will include adverse decision on an urgent care notice will include a description of the following: the missing information and specify claim may be provided orally, but a time frame, no less than 45 days, •• Information sufficient to identify written or electronic notification in which the necessary information the claim involved, including the will be furnished not later than must be provided. date of service, the health care three days after the oral notice. provider, the claim amount (if •• The availability of, and contact The time frame for deciding the claim applicable) and either the diagnosis information for, any applicable will be suspended from the date you code and its corresponding office of health insurance consumer receive the extension notice until meaning and the treatment code assistance or ombudsman the date the missing information is and its corresponding meaning established under Section 2793 of provided to the claims administrator. or a statement describing your the Public Health Service Act to If the requested information is opportunity to receive as soon assist individuals with the claims and provided, the plan will decide the as practical upon request the the plan’s internal appeal processes claim within the period specified in diagnosis and treatment codes (and and external review processes. the extension notice. If the requested their meanings) The Right to Internal Appeal information is not provided within •• The specific reasons for the Medical & Wellness the time specified, the claim may be decision, the denial code and its You have the right to appeal an decided without that information. corresponding meaning, as well as adverse decision under these claims procedures. Except for urgent care Notification of Initial Benefit a description of the plan’s standard, Decision By the Plan if any, that was used in denying the claims, discussed below, an appeal claim of an adverse benefit decision is Written or electronic notification of •• References to the specific plan filed when you (or your authorized the claims administrator’s decision provisions on which the decision is representative) submit a written on a pre-service or urgent care claim based request for review to your claims will be provided to you, whether or administrator: not the decision is adverse. A decision •• A description of any additional is adverse if it is a denial, reduction, material or information necessary Texas Health Aetna Appeals or termination of a benefit, a failure to perfect the claim and why such THA Appeals-CRT to provide or make payment in information is necessary P. O. Box 14463 whole or in part, or a rescission of •• A description of the plan Lexington, KY 40512 coverage. A rescission of coverage procedures and time limits for www.TexasHealthAetna.com is any retroactive termination of appeal of the decision, the right to obtain information about those your coverage, except where you UHC Appeals procedures, the right to sue in perform an act of fraud or make an P. O. Box 30432 federal court and a description intentional misrepresentation of a Salt Lake City, UT 84130-0432 material fact. Retroactive termination of the procedures to obtain an of your coverage for failure to make external review of the claim (Go to MyUHC.com to print the timely payment of your premiums •• A statement disclosing any internal member service request form for or contributions toward the cost of rule, guidelines, protocol or medical appeal.) coverage is not a rescission. similar criterion that was used in making the adverse decision (or a Caremark Appeals statement that such information will Caremark, Inc. be provided free of charge upon Appeals Department request) and MC 109 P.O. Box 52084 Phoenix, AZ 85072-2084 Fax: (866) 689-3092

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You should request a review in However, an appeal of the plan’s In the case of a claim that was writing. A request for review will be decision to reduce or terminate an denied on the grounds of a medical treated as received by the plan on the initially approved course of treatment judgment, the claims administrator date it is delivered to the applicable (see definition of concurrent care will consult with a health professional address listed above or on the date decision) must be filed within 30 days with appropriate training and that it is deposited in the U.S. Mail of your receipt of the notification experience. The health care for first-class delivery in a properly of the plan’s decision to reduce or professional who is consulted on stamped envelope containing the terminate. Failure to comply with this appeal will not be the same individual, above name and address. The important deadline may cause you to if any, who was consulted regarding postmark on any such envelope will forfeit any right to any further review the initial benefit decision or a be proof of the date of mailing. of an adverse decision under these subordinate of that individual. procedures or in a court of law. You have the right to submit Upon your request and free of charge, documents, written comments, or To initiate a pre-service urgent care you will have reasonable access to, other information in support of an appeal, call 1-877-MyTHRLink and copies of, all documents, records, appeal. The claims administrator (1-877-698-4754) select prompt 1 for and other information relevant to must provide you with any new or Texas Health Aetna and prompt 2 for your claim for benefits. If the advice additional evidence considered, UHC, asking for Care Coordination. of a medical or vocational expert relied upon, or generated by the The claim should include at least the was obtained in connection with the plan (or at the direction of the claims following information: initial benefit decision, the names of administrator or plan administrator) each expert will be provided on your •• Your name in connection with the claim and, if request, regardless of whether the applicable, the rationale for the final •• A specific medical condition or advice was relied on by the plan. internal adverse benefit determination symptom based on such new or additional •• A specific treatment, service, or All necessary information in evidence. product for which approval or connection with an urgent care payment is requested and appeal will be transmitted between The claims administrator or •• Any reasons why the appeal should the plan and you by telephone, fax, or its delegate must provide this be processed on a more expedited email. Medical & Wellness information as soon as possible and basis. sufficiently in advance of the date Time frames for Deciding Benefits Appeals on which the notice of final adverse How the Appeal Will Be Decided The claims administrator will decide benefit determination is required The appeal of an adverse benefit the appeal of a pre-service claim so you will have an opportunity to decision will be reviewed and decided within a reasonable time appropriate respond by, for example, presenting by the claims administrator because to the medical circumstances, but no evidence and testimony, prior to that they are the named fiduciary under later than 30 days after receiving the date. the plan. The person who reviews and request for review. Pre-Service Request for Benefits* decides an appeal will be a different individual than the person who made The claims administrator will decide The appeal of a denied pre-service the initial benefit decision and will the appeal of an urgent care claim as request for benefits, post-service not be a subordinate of the person soon as possible, taking into account claim or a rescission of coverage must who made the initial benefit decision. the urgent medical situation, but no be filed with the claims administrator The claims administrator will follow later than 72 hours after the plan within 180 days after you receive these procedures when deciding any receives the request for review. the notification of adverse benefit appeal. decision. The claims administrator will decide The review by the claims the appeal of a post-service claim This communication should include: administrator will take into account all within a reasonable period, but no •• The patient’s name and ID number information you submitted, whether later than 60 days after receipt of the as shown on the ID Card; or not it was presented or available at request for review. the initial benefit decision. The claims •• The provider’s name; administrator will give no deference The claims administrator will decide •• The date of medical service; to the initial benefit decision. the appeal of a decision to reduce or •• The reason you disagree with the terminate an initially approved course denial; and of treatment (under a concurrent care •• Any documentation or other claim) before the proposed reduction written information to support your or termination takes place. request.

*The claims administrator may require a one-time extension for the initial claim determination, of no more than 15 days, only if more time is needed due to circumstances beyond control of the Plan.

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The claims administrator will decide •• A statement indicating you are The VRP Board will notify you of its the appeal of a denied request to entitled to receive reasonable decision in writing. Such notification extend a concurrent care claim in the access to or copies of all will be written in a manner that you appeal time frame for pre-service, documents, records or other can understand and will contain urgent care, or post-service claims information relevant to the specific reasons for the decision, described above, as appropriate to the determination (on request and as well as specific references to request. without change) and pertinent plan provisions. The •• If the decision involves scientific decision on review will be made Notification of Decision or clinical judgment, either an within 60 days after the VRP Board on Appeal explanation of the scientific or receives your request for review. Written notification of the decision clinical judgment applying the If you do not request a voluntary regarding an appeal will be provided terms of the plan to your medical appeal, the plan cannot say that you to you whether or not the decision circumstance or a statement that failed to exhaust your administrative is adverse. A decision regarding an such explanation will be provided at remedies. The time you spend appeal is adverse if it is either: no charge on request. pursuing your voluntary appeal does •• The availability of, and contact •• A denial, reduction, or termination not shorten the period within which information for, any applicable of benefits or you must file a lawsuit. office of health insurance consumer •• A failure to provide or make all or assistance or ombudsman You may submit a voluntary appeal part of a payment for a benefit. established under Section 2793 of only after exhausting the appeal to You will receive written notification the Public Health Service Act to the claims administrator. of an adverse decision regarding assist individuals with the claims Upon your request, the claims an appeal. It will include the and plan’s external review process. administrator will provide you following information, written in a Notification of an adverse decision sufficient information relating to the manner that you can understand, regarding an appeal of an urgent care voluntary appeal to enable you to and in a culturally and linguistically claim may be provided verbally, but make an informed judgment about appropriate manner according to written notification will be furnished whether to submit a benefit dispute to applicable law: not later than three days after the oral the voluntary appeal. This information Medical & Wellness •• Information sufficient to identify notice. will include a statement that your the claim involved, including the decision to submit a benefit dispute You must exhaust the internal claims date of service, the health care to the voluntary appeal will have no appeals process before you pursue provider, the claim amount (if effect on your rights to any other any other legal or equitable remedy. applicable), the diagnosis code benefits under the plan. A decision of your entitlement to and its corresponding meaning, benefits upon exhaustion of this It will also include information about and the treatment code and its process will constitute a final internal the applicable rules, your right to corresponding meaning adverse benefit determination. representation, the process for •• The specific reasons for the appeal selecting the decision maker, and the decision, the denial code and its You will be deemed to have circumstances, if any, that may affect corresponding meaning, as well as exhausted the internal claims the impartiality of the decision maker, a description of the plan’s standard, appeals process if the plan or claims such as any financial or personal if any, that was used in denying administrator fails to adhere to the interests in the result or any past or the claim and a discussion of the requirements described above and present relationship with any party to decision under applicable law. the review process. No fees or costs •• A reference to the specific plan Voluntary Appeal are imposed on you as part of the provisions on which the decision is voluntary appeal. based Within 180 days after the date •• A statement disclosing any internal you receive written notice of the You may file a lawsuit for benefits only rule, guidelines, protocol or similar decision by the claims administrator after you have exercised all appeals criterion relied on in making the regarding an appeal, you (or your described in this section (except the adverse decision (or a statement authorized representative) may voluntary appeal) and all or part of the that such information will be file a written request for a review benefits you request on appeal have provided free of charge on request) of your denied claim. You (or your been denied. •• A statement of the right to sue in authorized representative) may federal court and a description submit written issues and comments of the procedures to obtain an to the Voluntary Review Process external review of the claim (VRP) Board.

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External Review There are two types of external The claims administrator will provide If, after exhausting your internal reviews available: to the assigned IRO the documents and information considered in appeals, you are not satisfied with •• a standard external review; and the determination, or if a timely making the claims administrator's •• an expedited external review. response is not made to your appeal determination. The documents include: in accordance with applicable Standard External Review regulations regarding timing, you A standard external review is •• all relevant medical records; may be entitled to request an external comprised of all of the following: •• all other documents relied upon by review of the determination. The the claims administrator; and process is available at no charge to •• a preliminary review by the claims •• all other information or evidence you. administrator of the request; that you or your physician •• a referral of the request by the If one of the above conditions is met, submitted. If there is any claims administrator to the IRO; and you may request an external review of information or evidence you or •• a decision by the IRO. adverse benefit determinations based your physician wish to submit that upon any of the following: Within the applicable time frame was not previously provided, you after receipt of the request, the may include this information with •• clinical reasons; claims administrator will complete your external review request and •• the exclusions for experimental or a preliminary review to determine the claims administrator will include investigational services or unproven whether the individual for whom the it with the documents forwarded to services; request was submitted meets all of the IRO. •• rescission of coverage (coverage the following: that was cancelled or discontinued In reaching a decision, the IRO retroactively); or •• is or was covered under the plan will review the claim anew and not be bound by any decisions or •• as otherwise required by applicable at the time the health care service conclusions reached by the claims law. or procedure that is at issue in the request was provided; administrator. The IRO will provide written notice of its determination You or your representative may •• has exhausted the applicable request a standard external review (the "Final External Review Decision")

Medical & Wellness internal appeals process; and by sending a written request to the within 45 days after it receives the •• has provided all the information and address set out in the determination request for the external review (unless forms required so that the claims letter. You or your representative may they request additional time and you administrator may process the request an expedited external review, agree). The IRO will deliver the notice request. in urgent situations as detailed below, of Final External Review Decision to by calling the toll-free number on After the claims administrator you and the claims administrator, and your ID card or by sending a written completes the preliminary review, it will include the clinical basis for the request to the address set out in the the claims administrator will issue a determination. determination letter. A request must notification in writing to you. If the Upon receipt of a Final External be made within four months after the request is eligible for external review, Review Decision reversing the claims date you received a decision. the claims administrator will assign administrator determination, the plan an IRO to conduct such review. An external review request should will immediately provide coverage The claims administrator will assign include all of the following: or payment for the benefit claim at requests by either rotating claims issue in accordance with the terms assignments among the IROs or by •• a specific request for an external and conditions of the plan, and using a random selection process. review; any applicable law regarding plan •• the covered person's name, The IRO will notify you in writing remedies. If the Final External Review address, and insurance ID number; of the request's eligibility and Decision is that payment or referral •• your designated representative's acceptance for external review. You will not be made, the plan will not be name and address, when may submit in writing to the IRO obligated to provide benefits for the applicable; within ten business days following the health care service or procedure. •• the service that was denied; and date of receipt of the notice additional •• any new, relevant information information that the IRO will consider that was not provided during the when conducting the external review. internal appeal. The IRO is not required to, but may, accept and consider additional An external review will be performed information submitted by you after by an Independent Review ten business days. Organization (IRO).

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Expedited External Review After the claims administrator SUBROGATION AND An expedited external review is similar completes the review, the claims REIMBURSEMENT to a standard external review. The administrator will immediately send a notice in writing to you. Upon The plan may be entitled to recover, most significant difference between through either or both of its rights to the two is that the time periods for a determination that a request is eligible for expedited external reimbursement or subrogation, the completing certain portions of the cost of certain benefits previously review process are much shorter, review, the claims administrator will assign an IRO in the same manner provided to you as a result of an and in some instances you may file illness, injury, or condition for which an expedited external review before the claims administrator utilizes to assign standard external reviews to a responsible third party is or may be completing the internal appeals held legally responsible. The right to process. IROs. The claims administrator will provide all necessary documents and subrogation means that the plan is You may make a written or verbal information considered in making substituted to and shall succeed to request for an expedited external the adverse benefit determination or any and all legal claims that you may review if you receive either of the final adverse benefit determination to be entitled to pursue against any third following: the assigned IRO electronically or by party for the benefits that the plan has telephone or facsimile or any other paid that are related to the sickness •• an adverse benefit determination available expeditious method. The or injury for which a third party is of a claim or appeal if the adverse IRO, to the extent the information or alleged to be responsible. The right to benefit determination involves a documents are available and the IRO reimbursement means that if a third medical condition for which the considers them appropriate, must party causes or is alleged to have time frame for completion of an consider the same type of information caused a sickness or injury for which expedited internal appeal would and documents considered in a you receive a settlement, judgment, seriously jeopardize the life or standard external review. or other recovery from any third health of the individual or would party, you must use those proceeds jeopardize the individual's ability In reaching a decision, the IRO to fully return to the plan 100% of any to regain maximum function and will review the claim anew and benefits you received for that sickness you have filed a request for an not be bound by any decisions or or injury. expedited internal appeal; or conclusions reached by the claims Medical & Wellness •• a final appeal decision, if the administrator. The IRO will provide Subrogation – Example determination involves a medical notice of the final external review Suppose you are injured in a car condition where the time frame for decision for an expedited external accident that is not your fault, and completion of a standard external review as expeditiously as the you receive benefits under the plan to review would seriously jeopardize claimant's medical condition or treat your injuries. Under subrogation, the life or health of the individual circumstances require, but in no the plan has the right to take legal or would jeopardize the individual's event more than 72 hours after the action in your name against the driver ability to regain maximum function, IRO receives the request. If the initial who caused the accident and that or if the final appeal decision notice is not in writing, within 48 driver’s insurance carrier to recover concerns an admission, availability hours after the date of providing the the cost of those benefits. of care, continued stay, or health initial notice, the assigned IRO will Reimbursement – Example care service, procedure or product provide written confirmation of the for which the individual received decision to you and to the claims Suppose you are injured in a boating emergency services, but has not administrator. accident that is not your fault, and been discharged from a facility. you receive benefits under the plan You may contact the claims as a result of your injuries. In addition, Immediately upon receipt of the administrator at the toll-free number you receive a settlement in a court request, the claims administrator will on your ID card for more information proceeding from the individual who determine whether the individual regarding external review rights, caused the accident. You must use meets both of the following: or if making a verbal request for an the settlement funds to return to expedited external review. •• is or was covered under the plan the plan 100% of any benefits you at the time the health care service received to treat your injuries. or procedure that is at issue in the The following persons and entities are request was provided. considered third parties: •• has provided all the information and forms required so that the claims •• A person or entity alleged to have administrator may process the caused you to suffer a sickness, request. injury or damages, or who is legally responsible for the sickness, injury or damages

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•• Any insurer or other indemnifier of The plan has the right to terminate •• Regardless of whether you have any person or entity alleged to have your benefits, deny future benefits, been fully compensated or made caused or who caused the sickness, take legal action against you, and/ whole, the plan may collect from injury or damages. or set off from any future benefits you the proceeds of any full or •• The plan sponsor (for example the value of benefits the plan has partial recovery that you or your workers' compensation cases). paid relating to any sickness or legal representative obtain, whether •• Any person or entity who is or may injury alleged to have been caused in the form of a settlement (either be obligated to provide benefits or or caused by any third party to the before or after any determination payments to you, including benefits extent not recovered by the plan of liability) or judgment, no matter or payments for under-insured or due to you or your representative how those proceeds are captioned uninsured motorist protection, no- not cooperating with the plan. If or characterized. Proceeds from fault or traditional auto insurance, the plan incurs attorneys' fees and which the plan may collect include, medical payment coverage (auto, costs in order to collect third party but are not limited to, economic, homeowners or otherwise), settlement funds held by you or non-economic, and punitive workers' compensation coverage, your representative, the plan has damages. No "collateral source" other insurance carriers or third- the right to recover those fees rule, any "Made-Whole Doctrine" party administrators. and costs from you. You will also or "Make-Whole Doctrine," claim be required to pay interest on any of unjust enrichment, nor any •• Any person or entity that is liable for amounts you hold which should other equitable limitation shall payment to you on any equitable or have been returned to the plan. limit the plan's subrogation and legal liability theory. •• The plan has a first priority right reimbursement rights. You agree as follows: to receive payment on any claim •• Benefits paid by the plan may against a third party before you also be considered to be benefits •• You will cooperate with the receive payment from that third advanced. plan in protecting its legal and party. Further, the plan's first •• If you receive any payment from equitable rights to subrogation and priority right to payment is superior any party as a result of sickness or reimbursement in a timely manner, to any and all claims, debts or liens injury, and the plan alleges some or including, but not limited to: asserted by any medical providers, all of those funds are due and owed ––Notifying the plan, in writing, of Medical & Wellness including but not limited to to the plan, you shall hold those any potential legal claim(s) you hospitals or emergency treatment funds in trust, either in a separate may have against any third party facilities, that assert a right to bank account in your name or for acts which caused benefits to payment from funds payable from in your attorney's trust account. be paid or become payable or recovered from an allegedly You agree that you will serve as ––Providing any relevant responsible third party and/or a trustee over those funds to the information requested by the insurance carrier. extent of the benefits the plan has plan •• The plan's subrogation and paid. ––Signing and/or delivering such reimbursement rights apply to full •• The plan's rights to recovery will documents as the plan or its and partial settlements, judgments, not be reduced due to your own agents reasonably request to or other recoveries paid or payable negligence. secure the subrogation and to you or your representative, •• Upon the plan's request, you will reimbursement claim no matter how those proceeds assign to the plan all rights of ––Responding to requests for are captioned or characterized. recovery against third parties, to the information about any accident Payments include, but are not extent of the benefits the plan has or injuries limited to, economic, non- paid for the sickness or injury. ––Making court appearances economic, and punitive damages. •• The plan may, at its option, take ––Obtaining the plan's consent The plan is not required to help you necessary and appropriate action or its agents' consent before to pursue your claim for damages to preserve its rights under these releasing any party from liability or personal injuries and no amount subrogation provisions, including or payment of medical expenses of associated costs, including but not limited to, providing or ––Complying with the terms of this attorneys' fees, shall be deducted exchanging medical payment section. from the plan's recovery without information with an insurer, the the plan's express written consent. insurer's legal representative or No so-called "Fund Doctrine" other third party and filing suit in or "Common Fund Doctrine" or your name, which does not obligate "Attorney's Fund Doctrine" shall the plan in any way to pay you part defeat this right. of any recovery the plan might obtain.

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•• You may not accept any settlement Right of Recovery WHEN COVERAGE ENDS that does not fully reimburse the The plan also has the right to recover Generally, coverage for you and your plan, without its written approval benefits it has paid on you or your covered dependents under the Total •• The plan has the authority and dependent's behalf that were: Health Medical Plan ends on the last discretion to resolve all disputes day of the pay period in which you regarding the interpretation of the •• Made in error terminate employment. language stated herein. •• Due to a mistake in fact •• In the case of your wrongful death •• Advanced during the time period However, there are certain situations or survival claim, the provisions of of meeting the calendar year when it would end on a different date. this section apply to your estate, deductible For example, it would end on the the personal representative of •• Advanced during the time period date: your estate, and your heirs or of meeting the out-of-pocket •• The employee dies beneficiaries. maximum for the calendar year •• You divorce •• No allocation of damages, •• Benefits paid because you or your •• At the end of the month your settlement funds or any other dependent misrepresented facts are dependent reaches the plan's recovery, by you, your estate, the also subject to recovery. personal representative of your maximum age. estate, your heirs, your beneficiaries If the plan provides a benefit for you •• When your termination date falls on or any other person or party, shall or your dependent that exceeds the the first day of a pay period, your be valid if it does not reimburse the amount that should have been paid, benefits will end on the last day of plan for 100% of its interest unless the plan will: the previous pay period. the plan provides written consent •• Require that the overpayment be See page 188 for more information. to the allocation. returned when requested. Other Events Ending Your •• The provisions of this section apply •• Reduce a future benefit payment Coverage to the parents, guardian, or other for you or your dependent by the representative of a dependent child amount of the overpayment. The Plan will provide at least thirty who incurs a sickness or injury days' prior written notice to you caused by a third party. If a parent If the plan provides an advancement that your coverage will end on Medical & Wellness or guardian may bring a claim for of benefits to you or your dependent the date identified in the notice if damages arising out of a minor's during the time period of meeting the you commit an act, practice, or sickness or injury, the terms of this deductible and/or meeting the out- omission that constituted fraud, or subrogation and reimbursement of-pocket maximum for the calendar an intentional misrepresentation clause shall apply to that claim. year, the plan will send you or your of a material fact including, but •• If a third party causes or is alleged dependent a monthly statement not limited to, knowingly providing to have caused you to suffer a identifying the amount you owe with incorrect information relating to sickness or injury while you are payment instructions. The plan has another person's eligibility or status covered under this plan, the the right to recover benefits it has as a dependent. You may appeal this provisions of this section continue advanced by: decision during the 30-day notice to apply, even after you are no period. The notice will contain •• Submitting a reminder letter to you longer covered. information on how to pursue your or a covered dependent that details appeal. •• The plan and all administrators any outstanding balance owed to administering the terms and the plan. Continuation of Medical Coverage conditions of the plan's subrogation •• Conducting courtesy calls to you and reimbursement rights have In some cases, you and your covered or a covered dependent to discuss such powers and duties as dependents may be eligible for any outstanding balance owed to are necessary to discharge its COBRA continued health coverage, the plan. duties and functions, including as explained in “Coverage After the exercise of its discretionary Termination” on page 189. authority to (1) construe and enforce the terms of the plan's subrogation and reimbursement rights and (2) make determinations with respect to the subrogation amounts and reimbursements owed to the plan.

1-877-MyTHRLink (1-877-698-4754) MyTHR.org 71 Wellness Program Be Healthy Wellness Program

Texas Health offers the Be Healthy Eligibility •• Employees and their eligible family wellness program to give you the The table below describes eligibility members can access the Rally tools to improve your well-being and for each program. Keep the following website if they have active Texas help make healthy choices easier. in mind as you review the table: Health medical coverage. Research has shown that people who •• Spouses are eligible to earn rewards have support in managing their health •• Benefits-eligible employees are all for getting an annual physical exam are more successful than people who full-time and part-time employees with their doctor and for completing try to manage their health alone. To who are classified to work 24 hours an annual health assessment survey provide the support you need, Texas or more per week. through Rally if they have active Health offers a variety of programs to •• Your status as full-time or part-time Texas Health medical coverage. help you personalize your well-being is based on your status in Texas •• COBRA participants and retirees are journey. Health’s HR/payroll system and not not eligible for Be Healthy rewards. based on the number of hours you Be Healthy provides many work. opportunities to improve your health—and your life. Several of the program elements also allow you to earn rewards for completing them.

ELIGIBILITY FOR BE HEALTHY WELLNESS PROGRAMS

Not Benefits-eligible but Enrolled in the Total benefits-eligible not enrolled in the Total Health Medical Plan (including PRN Medical & Wellness Health Medical Plan employees)

Program Name Employees Spouses Children Employees Spouses Children Employees Spouses Children Health Assessment Survey √ √ √1 Wellness Credit Screening √2 Preventive/Wellness Exam √ √ √1 Age Appropriate Cancer Screenings ••Colorectal Cancer (Colonoscopy) √ √1 √1 ••Mammogram √ √1 √1 Healthy Pregnancy √ √ Online Rally Missions √ √1 √1 Diabetes Care √ √ √ Cancer Support Nurse √4 √4 √4 Tobacco Cessation √ √ √ √ √ √ √ √ √ Employee Assistance Program √ √ √ √ √ √ √ √ √ Health Advocacy √4 √4 √4 Medical Nutrition Therapy √ √ √ Employee Discounts3 √ √ √ √ √ √ Fitness Center Memberships3 √ √ √ √ √ √ Real Appeal √4 √4 √4

1 Dependents can participate in the program but do not receive an incentive. 2 Employees getting their labs completed at their physician's office or Quest must register at My.QuestForHealth.com (Reg Key: THR2019). If going to your doctor, the form must be taken to your appointment to be completed in order to receive an incentive. 3 Not part of the medical plan 4 Must be at least 18 to participate. Only for participants in the UHC medical plan options.

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BE HEALTHY REWARDS After you have completed the Be sure to redeem rewards before requirements for a reward, you will they expire and while you have active If you have active Texas Health receive an email notifying you that the medical coverage. Rewards expire 150 medical coverage, you can earn the amount is available in your rewards days after the end of each year and rewards listed in the chart below. account. Your reward is redeemable when a member leaves Texas Health Be Healthy rewards and the Rally for gift cards you select, download, or medical coverage ends. website are administered by Optum. and print or use online as e-gift cards, based on merchant selected. The IRS considers incentive rewards Your privacy is protected in all parts of a part of your pay. That means the Be Healthy program. The reward notification will be sent to you will have to pay taxes on the the email address you provide in your rewards you receive and your 401(k) The first time you access the Rally profile on the Rally website. contributions will be deducted. The website, you will be required to tax for your reward (and your spouse's, register and provide your email if applicable) will be shown on your address so you can be notified paycheck as additional pay. On whenever you have earned a reward. average, the tax on a $25 reward will be around $5. You will be taxed upon redeeming rewards. How to Participate in the Be Healthy Rewards Program

Program When and How to Complete It Reward How to Get the Reward

Health Texas Health employees with active Texas Health medical coverage: $75 No additional action necessary. Assessment Log on to MyTHR.org to enroll. Complete the Health Assessment Your completion of the Health Survey Survey during open enrollment each fall to receive your reward. Assessment Survey during open enrollment is reported automatically. Spouses with active Texas Health medical coverage: $25 No additional action necessary. Log on to thr.werally.com to register, then complete the Health Your spouse's completion of the Health Assessment Survey Assessment Survey during open enrollment. Medical & Wellness is reported automatically. Spouses already enrolled in our medical plan may participate during open enrollment in November 2019. Note: Spouses not enrolled in our medical plan during open enrollment in 2019 may participate during open enrollment in November 2020.

Wellness To offset cost of medical premiums, employees with active medical Up to All screening results from Credit coverage can get screened Jan. 1 through Sept. 30, 2019 to earn $520 in Quest labs are reported to our Screening wellness credits on 2020 paychecks. 2020 wellness vendor automatically, except the Health Care Deadline: You have two screening options: Provider option. The completed Sept. 30, ••Quest Labs MD form used for this option 2019 ••Health Care Provider Form (copay may apply; use in-network lab must be faxed to Quest at provider to avoid additional charges). 1-844-560-5221. See page 74 for more details.

Preventive/ Employees with active Texas Health medical coverage may complete $75 No additional action necessary. Wellness this exam anytime during 2019 to earn this reward. When your network doctor Exam files your claim as preventive, Spouses with active Texas Health medical coverage may complete this $25 the claims administrator will exam anytime during 2019 to earn this reward. automatically report your participation.

Cancer Employees with active Texas Health medical coverage and meeting the $25 No additional action necessary. Screenings screening criteria for a mammogram or colonoscopy may complete When your network doctor this screening anytime during 2019 to earn the reward. files your claim as preventive, the claims administrator will automatically report your participation. Healthy Employees and eligible family members with active Texas Health $100 No additional action necessary. Pregnancy medical coverage may complete this program by enrolling in the Successfully completing the Healthy Pregnancy Program by the 16th week of pregnancy and program will trigger the reward. actively participating through the 6th week of the program after the baby is born. To enroll, call Texas Health Aetna or UHC.

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HEALTH ASSESSMENT SURVEY Spouses covered by the Total Health Numbers Wellness Medical Plan in 2018 were eligible Met Credits For employees with active Texas for the Health Assessment during Health medical coverage: When 3-4 $20 per paycheck open enrollment in November 2018. ($520 per year) you log on to MyTHR.org, you can Spouses added to coverage under complete an online health assessment 2 $10 per paycheck the Total Health Medical Plan in 2019 ($260 per year) survey on Rally. Most of the questions may take the Health Assessment on the survey are about things you 1 $5 per paycheck Survey during open enrollment in ($130 per year) know right away—like how much you November 2019. weigh and how many times a week If you get screened and your targets you exercise. It will also ask you to Eligible child dependents are not are outside of the healthy range, you enter recent biometric screening eligible to earn a reward but can can still earn credits by participating in results such as your cholesterol, blood complete the health assessment. a reasonable alternative. Reasonable sugar (glucose) and blood pressure. Spouses and eligible dependents alternatives to obtain this credit (after Even if you don’t have these results, must use their social security number getting screened) are completing you can still complete the survey. when they register. The first time three online Rally missions (can be To complete the Health Assessment spouses take the Health Assessment taken concurrently) or submitting a Survey, go to MyTHR.org and click the Survey, they should: doctor's exception form by September Benefits tile. Then click Be Healthy •• Go to thr.werally.com. 30, 2019. Give yourself at least Rewards. You may also use your Rally five weeks to complete three Rally mobile app or log on directly to thr. •• Click “Sign Up.” missions by September 30, 2019. werally.com. •• Complete the required fields, then click “Continue.” Please note that a Screening results obtained between The Health Assessment Survey asks Social Security Number should be Jan. 1, 2019 and Sept. 30, 2019 will questions and then gives you results used for the “Unique ID.” count toward 2020 wellness credits. in a confidential, personal report that •• After completing the registration, helps you understand more about click on the health assessment You have two screening options: your health and your health risks. survey link. The more complete and accurate •• Quest Labs

Medical & Wellness information you provide, the more WELLNESS CREDIT •• Health Care Provider (copay may valuable the results will be to you. apply; use in-network lab provider Your personal report will explain how SCREENING to avoid additional charges). to improve your health and maintain a Wellness Credit Screenings are Any screening received before your healthy lifestyle. biometric screenings that can medical coverage is active in 2019 provide important information about Based on your Health Assessment through Texas Health will not count your health. By checking four basic Survey results, you can opt to join toward the wellness credits in 2020. metrics, you and your doctor can 4-week Rally missions to improve your learn about your current wellbeing If it is medically inadvisable for you to health immediately after you complete and can identify risks that can be satisfy the Wellness Credit Screening your Health Assessment Survey. managed sooner rather than later. requirements, you can still receive If you completed the Health your rewards. Simply work with your For Wellness Credit Screening Assessment during the 2019 open personal physician to complete measures met in 2019, you can earn enrollment period (Nov. 1 – Nov. 15, the Reasonable Alternative Process up to $520 in wellness credits as 2018), you received an email about Form, which can be found on the income on your 2020 paychecks by redeeming your $75 reward. Wellness Credit Screening page of achieving at least three of the below: BeHealthyTHR.org. Spouse Health Assessment •• LDL cholesterol is less than 130 Spouses with active Total Health mg/dl medical coverage are eligible to earn •• Blood pressure is less than 141/90 a $25 reward for completing the (both diastolic and systolic must Health Assessment Survey during open meet criteria) enrollment in the fall. •• Your abdominal circumference is under 35 in. for women and under 40 in. for men •• Your fasting blood sugar is under 100

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Wellness Credit Screening Options Make sure to review your wellness If you have active Total Health medical To receive credit for getting your credit screening Doctor Form coverage during the time of service, Wellness Credit Screening, you have to ensure all required data are you will receive a $75 reward for two convenient options detailed completed. Doctor Forms can take getting an annual preventive/wellness below. For either, you will need to go up to 21 business days to process. If a exam in 2019. Spouses with active Total to My.QuestForHealth.com before form does not have all required data Health medical coverage at the time of your appointment. Also remember filled in, it will be rejected and not service are eligible to earn a $25 reward to fast for your appointment. Fasting processed. Forms can be resubmitted; for getting their annual preventive/ means do not eat or drink anything however, all forms including wellness exam in 2019. resubmitted forms need to be received except water for 9-12 hours prior to Be sure to complete Rally registration the blood test. by 9/30/2019. It is your responsibility to ensure the form is complete and at thr.werally.com or through MyTHR. Visit a Quest Lab submitted by the due date. org (select the Benefits tile, then Be Healthy Rewards). Email notifications •• Go to My.QuestForHealth.com. Number of Screenings Allowed will be sent to the email listed on your •• First time users will enter THR2019 Eligible employees may re-screen Rally account profile. when prompted for a registration once a quarter through Sept. 30, 2019. key. Your completion of the wellness exam will be automatically reported through •• Complete registration/login and PREVENTIVE/WELLNESS click Schedule a Screening. claims processing by your medical EXAM •• Select a location near you, then plan provider. It takes an average of choose a date/time. Click Confirm. Getting regular check-ups is important six weeks to receive your reward email notification. If you have not received •• After your appointment, Quest will for everyone — even if you are in your award notification within 12 send your results to Rally. good health. By getting a preventive/ weeks please contact BeHealthyTHR@ •• Check Rally to make sure your wellness exam, your doctor may be texashealth.org. results are showing. Only results able to identify your risk for future showing completed in Rally count medical problems, screen for diseases, Only those enrolled in the Total Health toward wellness credits. encourage a healthy lifestyle, and Medical Plan are eligible to earn a update your vaccinations. Plus, it is reward for a preventive/wellness Medical & Wellness See Your Doctor important to have a relationship with a exam. At this time, the administrator •• Schedule an appointment with your doctor in the event of an illness in the of the Be Healthy incentive program doctor. future. is not able to receive information •• Go to My.QuestforHealth.com. To get the most from your exam, write about physical exams from any other •• First time users will enter THR2019 down important information to tell medical plan. when prompted for a registration your doctor—like your personal and If you had lab tests done at the same key. family medical history, symptoms you time as your preventive/wellness •• Complete registration/login. have now and medicines you take. exam, they are billed separately and •• Click Order Form under Provider/ Even non-prescription and herbal your reward notifications may arrive at Physician Form. remedies are important for your separate times. You may earn only one •• Click Download Form. doctor to know about. Bring a pen and $75 reward per year for the preventive/ paper to make notes while you talk to •• Print the form and take it to your wellness exam. your doctor. appointment for your physician to Be sure: complete. It is important that your doctor’s office •• The form needs to be faxed to codes your visit as a wellness exam •• You select a doctor who is part of 844-560-5221. and not a routine office visit so you your medical plan option's network will be able to receive this reward. •• That they send bloodwork to an If your doctor is referring you to a lab in-network lab, and to complete your screening for the This exam may be performed by your •• That they code your visit as a wellness credits, make sure you go primary care physician or women wellness exam to avoid additional to a lab that is in-network to avoid can get a well-woman exam by their charges. additional charges. Additional lab gynecologist. Be sure to tell your codes not associated with the four doctor about the Be Healthy wellness Wellness Credit Screening numbers programs available to you. may incur additional costs. Based on the results of your preventive/wellness exam, your doctor may recommend that you participate in one of them.

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MEMBER SERVICES WITH Your nurse is here to help you: •• Tools and resources to help you have a healthy pregnancy TEXAS HEALTH AETNA •• Follow your doctor’s treatment plan •• Information about prenatal care, Contact Member Services for help. •• Manage medications labor and delivery, newborn and Your plan includes the Concierge •• Get answers to your questions baby care and more program, which provides immediate •• Coordinate your health care •• Follow-up calls after your delivery access to health care resource appointments consultants who have been •• Screenings for depression •• Learn tips for self-care specifically trained in the details of •• Extra support for lactation and •• Access resources or programs that your plan. To contact a Concierge, call breastfeeding, if you need it you need the Texas Health Aetna Call Center at •• Mayo Clinic Guide to Healthy 1-877-698-4754, option 1, 8 a.m. to 6 •• Navigate the health care system Pregnancy, if you complete the p.m. Monday through Friday. The Total Health Nurses are program dedicated to making sure you have If you have risk factors that need HEALTH ADVOCACY WITH the support you need so you can special attention, our nurses can help UHC focus on your health. To learn more, you find ways to manage your risks call 1-877-My-THRLink (1-877-698- A Health Advocate can help you such as stopping smoking or getting 4754), select prompt 2 and ask to be decide whether a health concern special support if you are at risk for an connected to a Total Health Nurse. requires a trip to the emergency early birth. room, urgent care or doctor; better HEALTHY PREGNANCY You can participate by: understand diagnosis and treatment PROGRAMS options; and get answers to questions •• Calling a Beginning Right nurse about prescriptions. Health Advocates If you are pregnant or thinking about anytime during your pregnancy are registered nurses with at least 15 becoming pregnant and you or your or after your delivery us at years of experience and backed by a spouse is enrolled in the Total Health 1-800-CRADLE-1 (1-800-272-3531), team of doctors. Medical Plan, you can get valuable weekdays from 7 a.m. to 6 p.m. C.T. educational information, rewards, Eligibility •• Logging in to your Texas Health advice, and comprehensive case Aetna member website at Medical & Wellness Employees and their eligible family management by enrolling in a Healthy TexasHealthAetna.com. Look under members enrolled in a UHC medical Pregnancy Program. Texas Health Stay Healthy and choose Maternity plan option are eligible to use the Aetna offers the Beginning Right Program. Complete a short survey Health Advocacy Services. Program and UHC offers the Maternity so we can get to know about you How to Participate Support Program. and your pregnancy. If we see we can provide additional help, we will The programs are designed to To speak to a Health Advocate, call call you. We will also call you 3-4 enhance your pregnancy experience 1-877-MyTHRLink (1-877-698-4754) weeks after you deliver to check on by assigning a dedicated OB nurse and select prompt 2. you and your newborn. to help you better understand your TOTAL HEALTH NURSE pregnancy. Your OB nurse will provide If you are an employee or spouse, be clinical and practical advice and sure to complete: If you’re living with a complex or answer your questions throughout chronic health condition and you have your pregnancy. •• The survey prior to 16 weeks and active Texas Health medical coverage •• The post-partum call by the 4th through UHC, you can have support To take full advantage of the program, week after the baby is born to earn from a Total Health Nurse. With you you are encouraged to enroll within a $100 incentive through your every step of the way, your nurse will the first trimester of pregnancy. If you wellness program. get to know you and be a familiar face enroll in a Healthy Pregnancy Program as part of your care. You can meet by your 16th week and complete the If you have any questions or with your nurse in person or by phone, post-partum call after your baby is problems with the processing of and he or she can even attend doctor born, you will receive a $100 reward. your $100 reward, please contact appointments with you to make sure 1-877-MyTHR Link (1-877-698-4754) There is no cost to enroll in a program. all your questions are answered. prompt 4 then 3. Texas Health Aetna's Beginning Right Program The Beginning Right maternity program focuses on prevention and To enroll or find out about any of education to help employees and these programs, visit MyTHR.org or BeHealthyTHR.org. families have healthy, full-term babies. You’ll get:

76 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Wellness Program

UHC's Maternity Support Program CANCER SUPPORT NURSE After you’ve completed the Health Assessment Survey, you will get your Pregnancy is an exciting time in your If you have been diagnosed with Rally age and personalized mission life whether it's your first baby or cancer and you are enrolled in recommendations. you're adding another little one to a UHC medical plan option, you your family. If you're expecting, our can be assisted by an experienced Rally missions provide tools, Maternity Support nurses are available cancer nurse who is dedicated to educational materials, and activities to personally support your journey. Texas Health employees. The nurse to help you change your behavior, The nurse will check in with you is available to help you and/or your change your habits, and improve regularly to answer questions and help dependents during active treatment your well-being. You can tailor calm any worries. for all forms of cancer. your missions to meet goals about what you eat, how much you move, Some of the UHC services include: The cancer nurse focuses on patients improving your mood, and even at high risk of complications and side •• Pre-conception health coaching connecting with others. effects. The nurse will collaborate •• Toll-free information lines staffed by with your treating physicians to This program is administered by experienced OB nurses fill gaps in your knowledge of the Optum Health. •• Your choice of a book: What to cancer you have. He or she works Expect When You’re Expecting, to prevent avoidable complications Rally Missions: An Alternative to What to Expect the First Year, or and side effects to keep you out of Earning Wellness Credits Baby Play and Learn the hospital and emergency room. You may complete three Rally •• Printed and online educational The nurse will also educate and missions as a reasonable alternative resources covering a wide range of empower you to actively participate after getting the Wellness Credit topics in your own treatment and recovery. Screenings and not meeting the •• First and second trimester risk And in the case of terminal cancer, reward criteria. Your participation will screenings the nurse increases your awareness be automatically reported to earn the •• Identification and management of and choice of palliative care and maximum wellness credit on your at-risk or high-risk conditions that hospice services, when appropriate. 2020 paychecks. may affect pregnancy To reach the cancer nurse, call These missions can be completed at the •• Mobile application personalized 1-877-MyTHRLink (1-877-698-4754) Medical & Wellness same time, but all must be completed by to your delivery date (download and select prompt 2. Sep. 30, 2019 to count as an alternative the UnitedHealthcare Healthy to earning wellness credits. Most Pregnancy app) RALLY MISSIONS missions take at least four weeks to •• Pre-delivery consultation You can personalize your well-being complete, so get an early start. •• Coordination with and referrals journey using the Rally website or to other benefits and programs mobile application. Start making For questions or help with Rally available under the medical plan wellness part of your everyday Missions, call 877-MyTHRLink (877- •• Support after your baby is born, life. Start by taking a good look 698-4754) prompt 4, then 3. including a phone call from a nurse at your health record in Rally and approximately two weeks after decide where you want to make REAL APPEAL your baby is born to answer your improvements. Rally helps you set Real Appeal is a clinical weight questions and give you information goals that make sense for your management program that helps UHC about newborn care, feeding, personal well-being needs. medical plan option members lose immunizations and more Eligibility weight by focusing on lasting lifestyle •• Screening for postpartum changes with small, steady sustainable Employees and their spouses with depression. steps. Real Appeal consists of up to active medical coverage through Texas 52 weeks of online support from a For more information or to enroll, call Health are eligible to participate in Real Appeal transformation coach 1-877-MyTHRLink (1-877-698-4754), Rally missions. and a success kit, both provided at no prompt 2. Participation additional cost to eligible participants. You can find Rally through Eligibility MyTHR.org by clicking on the Be If you, your covered spouse, or your Healthy Rewards quick link under covered dependent(s) have active Total Health, or by logging on to UHC medical coverage, are at least thr.werally.com with a computer or 18 years old, and have a BMI of 23 or mobile device. Spouses go to thr. higher, you can enroll in Real Appeal. werally.com to enroll.

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Some exclusions apply: DIABETES CARE MEDICAL NUTRITION •• Pregnant Texas Health offers a program that THERAPY •• Nursing an infant (may enroll when includes diabetes education and Employees and eligible family baby is eating) support. Diabetes Care sessions for members with active medical •• Anorexia or Bulimia Nervosa adults or children (not available at coverage with a BMI greater than (present or recent history) all locations) are covered under all 28 can participate in the Medical Texas Health medical plan options •• Severe liver, heart, kidney, Nutrition Therapy program which except the Texas Health Aetna Select neurologic, psychiatric or any provides one initial 90-minute 3000 after a $10 copay at a Texas severe chronic or acute illness. assessment and up to three Health or UTSW facility. If you are 30-minute therapy sessions per year Participation enrolled in the Texas Health Aetna at no cost to you. To be covered, Select 3000 plan option, Diabetes To enroll in the program, visit THR. you need a physician referral and the Care sessions at Texas Health and realappeal.com. After enrolling, therapy must be provided by a Texas UTSW must be paid at 100% until participants receive: Health or UTSW clinical dietitian. your deductible is met. Then you will •• 52 weeks of access to a pay a 10% co-insurance. Coverage A registered dietitian will customize Transformation Coach—Your online includes either individual or group a healthy eating plan that meets your coach guides you through the sessions with a certified diabetes specific health and wellness needs. program and develops a simple, educator. A physician’s referral is You can make an appointment for: required. customized plan that fits your •• A personal lifestyle assessment needs, preferences and goals. Eligibility •• Personalized meal planning •• Digital tools—24/7 access to tools •• Behavior modification counseling and dashboards that help you track Employees and eligible family to work on your personal your food, activity and weight. members with active Texas Health challenges such as emotional •• Success kit—full of healthy weight medical coverage are eligible for Diabetes Care. eating, skipping meals, portion management tools, including management, and listening to fitness guides, a recipe book (with Participation hunger/fullness cues. quick family meal ideas and fast- Medical & Wellness You can earn free test strips for self- food eating tips), digital weight To participate, contact one of the monitoring of your blood glucose scale and more. Texas Health registered dietitians when you visit with a Texas Health •• Support from weekly online group listed at BeHealthyTHR.org/be- or UTSW diabetes educator at least glasses—to learn healthy ideas from healthy/medical-nutrition-therapy. quarterly. The prescription drug plan your coach and other members covers oral medications, insulin, who share what’s helped them syringes, blood glucose monitors, test achieve success. strips, lancets, and chemical strips. If you experience issues with You can receive a free glucose One enrollment or the products in the Touch monitor through Caremark Success Kit, please contact the Real with a prescription from your doctor. Appeal technical team by emailing The medical plan covers durable [email protected] or calling medical equipment including insulin 1-844-344-REAL (7325). pumps, supplies for your pump (infusion sets, cartridges, batteries, and medical tape), and glucagon emergency kits, when ordered by your physician. Pediatric (under age 16) members obtain test strips through Optum Nurses by contacting Caremark for an override.

For assistance with the program and referrals, employees can call Texas Health Diabetes Education Center at 1-800-804-3399 or UTSW at 214- 645-5305.

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TOBACCO CESSATION ––Chantix is available with a FITNESS MEMBERSHIPS prescription at any Caremark Texas Health has retained Consumer Discounted fitness memberships pharmacy (at no cost for those Wellness Solutions Inc. through are available for benefits-eligible enrolled in the Total Health OptumHealth, a company specializing employees and their dependents. Medical Plan) or through Texas in tobacco cessation, to provide you Health Dallas Apothecary, Texas with resources to help you stop using •• Convenient on-site fitness centers: Health Dallas Prescription Shop tobacco. This program is available See BeHealthythr.org/be-healthy/ and Texas Health Plano Medicine at no charge to help all employees fitness-memberships for a full list Chest (for those not enrolled in (including PRNs) and their eligible of on-site fitness centers. the Total Health Medical Plan, family members. •• Find a fitness center near you there is a 40% copay for these at rates lower than retail. Visit The Quit for Life™ program provides: pharmacies only). Beneplace.com/texashealth and Now is the best time to take the look for corporate fitness discounts. •• An in-depth assessment with a first step toward quitting. This free personal Quit Coach™ including program is available to all employees five outbound calls. Coaches can and their eligible family members. be called for extra support as Your chances of quitting are six times many times as needed, any day of better with the Quit For Life Program the week. Your Quit Coach helps than trying to quit on your own. you create a personal quitting plan that may include treatments to To participate in the Quit for Life help you with withdrawal. Program, call 1-877-MyTHRLink •• Personalized Quit Guides with (1-877-698-4754) and choose helpful tips and information option 4, then press 2 or go online to •• Nicotine Replacement Therapy BeHealthyTHR.org/be-healthy/quit- (NRT) for-life for more information. •• Participants can access one eight- week shipment of one type of NRT

(patch, gum or lozenges) through Medical & Wellness enrollment in Quit for Life. •• Prescription medication bupropion is available at any Caremark pharmacy (at no cost for those enrolled in the Total Health Medical Plan) or through Texas Health Dallas Apothecary, Texas Health Dallas Prescription Shop and Texas Health Plano Medicine Chest (regardless of whether you are enrolled in the Total Health Medical Plan). For those not enrolled in the Total Health Medical Plan, there is a 40% copay at these pharmacies only. •• Prescription medication Chantix™ is covered for participants enrolled in the Quit for Life program if recommended by the Quit Coach. Chantix is a prescription medicine used to help adults quit smoking. Chantix contains no nicotine and helps reduce the urge to smoke.

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

Age Appropriate Cancer Screenings

Medical & Wellness 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 Men and women Every 10 years Covered at 100% cancer— when detected early. It involves cancer cells that starting at age 50 one time per colonoscopy grow in the colon, rectum, or both. According to year2 the American Cancer Society, 90% of cases are in people over age 50. Breast This type of cancer is the second leading cause of Women starting at Every year Covered at 100% cancer— death among American women. But most women age 401 one time per mammogram who are diagnosed at an early stage survive and year2 continue to live normal lives.

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

2 Well exams are 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, THR EAP, Caremark Pharmacy, Quit for Life™ tobacco cessation program, Real Appeal, Texas Health Aetna 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 PROGRAM (EAP) Between a busy home life and a and support are available at no charge, 24 hours a day, seven days a week. Overview busy career, things can get a little overwhelming sometimes. At times, To find out more, contact the EAP by The Texas Health Resources Employee personal challenges can even dialing 1-877-MyTHRLink (1-877-698- Assistance Program provides start to impact our emotional and 4754) prompt 4, then 4 again. professional support and resources physical health, as well as our overall Work and Life Services to help you manage life's challenges, productivity. But as a Texas Health THR EAP Work-Life services save you maximize your potential, and enhance Resources employee, you’ve got help at time by assisting with personal life your emotional and physical well-being. your fingertips. THR EAP can assist with: Self-care isn’t selfish, and a big part of issues that can otherwise cause stress taking care of yourself is getting the right •• Marriage, relationship and family and distract you from work, such as help when facing life’s challenges. The issues concerns related to child and elder Employee Assistance Program is here for •• Problems in the workplace care, financial/legal issues, identity theft you and your family 24/7/365. Whether •• Domestic violence and everyday responsibilities. Let our you’re facing emotional, physical, legal •• Alcohol and drug misuse/ team do the work for you by finding or financial hurdles, we’ve got resources dependency local resources and support services. just for you. •• Stress, anxiety and sadness THR EAP's Website •• Changes in mood You can receive up to six in-person, THR's website has tools to help you telephonic or web-video EAP •• Grief and loss take charge of your wellbeing. You counseling sessions per issue per year, •• Response to traumatic events. can explore the free and confidential at no cost to you. THR EAP counselors Clinical support comes in three ways: resources available to you for a variety are available to assess your concerns, face-to-face, telephonic and web- of work-life related needs, review provide guidance and develop an action video counseling. our extensive library of articles and plan to help resolve personal issues. resources on a variety of health, All THR EAP clinicians are licensed wellness and self-help topics and learn This program is available to all by the State of Texas as either social about upcoming health and wellness employees (including non-benefits- workers, professional counselors or events taking place at your entity and eligible) and their eligible family Medical & Wellness psychologists. system-wide. Visit BeHealthyTHR.org/ members. Availability lasts during an EAP to access the site. employee's tenure with Texas Health and for 12 weeks after employment with Texas Health ends.

Examples of Available Work-Life Services:

Legal Assistance: THR EAP offers employees a 30-minute in-person or telephonic consultation with a lawyer or mediator per separate matter, and also includes a 25% discount on rates if the legal consultant is hired for additional services. Services are for issues related to civil, consumer, personal and family law, financial matters, business law, real estate planning and more. This plan excludes issues related to labor and employment law, medical malpractice or disputes between employees and Texas Health Resources. Identity Theft Services: If you would like more information about identity theft or if you have been a victim of identity theft, THR EAP Identity Theft Services are for you. You can speak with a fraud specialist who will help determine if you are a victim of identity theft and recommend options on how to place fraud alerts, freeze credit, file police reports, and contact other resources as necessary to resolve fraud concerns. THR EAP will also give you information on identity theft prevention and provide you with an identity theft emergency response kit. Child and Eldercare Resource and Referral: Let THR EAP do the work of locating available childcare and eldercare providers. We'll find out what kind of help you need caring for the child/children and elders in your life. Then, we'll give you the names and numbers of at least five local providers with confirmed openings and/or community resources, all within 1-2 business days. Financial Services: Do you have questions about or need assistance with credit counseling, debt and budgeting assistance, tax planning, financial planning for college and retirement planning? Take the time to speak with a financial counselor, who will offer telephonic consultation to help with an array of financial concerns. This service includes one 60-minute telephonic consultation per separate matter and also includes a 25% discount on rates if the financial consultant is hired for additional services. This is not a tax representation/preparation service. Investment advice and loan/bill payments are not included. Concierge Services: Our personalized concierge service will assist in tracking down businesses and consultants to help you plan an event, vacation or set dinner reservations. We can also find local contractors to help you manage home repairs. However, THR EAP does not cover the cost, nor guarantee delivery of the vendors' services.

1-877-MyTHRLink (1-877-698-4754) MyTHR.org 81 Dental & Vision Dental & Vision Dental Plan...... 83 Overview 83 Who Can Be Covered 83 Aetna DMO® 83 Aetna PDN (Low Option) 83 What the PDN (Low Option) Covers 85 Participating Dental Network (PDN) (High Option) 87 What the PDN (High Option) Covers 89 Excluded Expenses 91 Filing and Appealing Dental Claims 92 When Coverage Ends 94 Vision Plan...... 95 Overview 95 Who Can Be Covered 95 Summary of Benefits 95 Network Providers 96 Covered In-Network Expenses 96 Exclusions 97 Coordination of Benefits 97 Filing Claims 97 When Coverage Ends 98

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

negotiated fees and the out-of-network Dental & Vision of-network providers whenever you (877-698-4754), prompt 9. dentist's actual charge. need dental care. They are described in more detail in this section. When you enroll in the managed Advantages of the PDN Low include: dental plan, you (and each enrolled Aetna is the brand name used for family member) select a network •• Choice of using network or out-of- products and services provided by dentist located in the state of Texas network providers one or more of the Aetna group of from the provider directory. Except •• Discounted services when you use companies. In case of a discrepancy for emergency treatment outside the network providers between this summary plan service area, you must use the dentist •• 80% coverage for preventive description and the group insurance you have selected to receive dental services whether you use network contracts issued by Aetna Dental benefits. or out-of-network providers. Inc., or in case of any legal action, the terms of the group insurance Advantages of the managed dental contracts will prevail. plan include:

For more detailed information •• No claims to file on the Aetna plans, refer to the •• No annual deductible to meet schedule of benefits available on •• Orthodontia coverage for children BeHealthyTHR.org. and adults •• Ability to change dentists during the year

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

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

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Endodontics Major Services •• Dentures and partials—fees for •• Pulp capping Major services are covered at 40% dentures, partial dentures and relining include adjustments •• Therapeutic pulpotomy (in addition after you meet the deductible and within six months after installation; to restoration) include the following: specialized techniques and •• Vital pulpotomy Restorative characterizations are not eligible •• Remineralization (calcium ––Complete upper denture hydroxide, temporary restoration) •• Gold restorations and crowns— ––Complete lower denture as a separate procedure only covered only as treatment for decay or traumatic injury and only when ––Partial acrylic upper or lower with •• Root canals (devitalized teeth teeth cannot be restored with a chrome cobalt alloy clasps, base, only, other than molar root canal filling material or when the tooth is all teeth and two clasps therapy), including necessary X-rays an abutment to a fixed bridge and cultures but excluding final ––Additional clasps restoration •• Inlays and onlays (one or more ––Partial lower or upper with surfaces) •• Canal therapy (traditional or chrome cobalt alloy lingual or sargenti method), includes single •• Crowns palatal bar and acrylic saddles, rooted or bi-rooted ––Acrylic base, all teeth and two clasps plus additional clasps •• Local anesthetics when necessary ––Acrylic with gold ––Acrylic with non-precious metal ––Simple stress breakers, extra Restorative Dentistry ––Porcelain ––Stayplate, base and additional •• Excludes inlays, crowns (other than ––Porcelain with gold clasps stainless steel) and bridges ––Porcelain with non-precious ––Office reline, cold cure, acrylic •• Multiple restorations in one surface metal ––Laboratory reline will be considered as a single ––Non-precious metal (full cast) ––Special tissue conditioning, per restoration ––Gold (full cast) denture •• Restorations (involving one, two or ––Gold (3⁄4 cast) ––Denture duplication (jump case), three or more surfaces), includes per denture ––Gold dowel pin amalgam, silicate cement, plastic, ––Adjustment to denture more than •• Adding teeth to partial denture to and composite fillings six months after installation replace extracted natural teeth— •• Pins (retention) when part of the teeth and clasps Oral Surgery restoration used instead of gold or crown restoration •• Repairs to crowns and bridges •• General anesthesia, only when •• Stainless steel crowns (when tooth •• Full and partial denture repairs provided in conjunction with a cannot be restored with a filling ––Broken dentures, no teeth surgical procedure material) involved •• Crown exposure to aid eruption ––Partial denture repairs (metal) •• Recementation of inlay, crown, or Periodontics bridge ––Replacing missing or broken teeth. •• Osseous surgery (including flap Dental & Vision entry and closure)—modifies the Prosthodontics bony support of teeth by reshaping •• Bridge Abutments (See Inlays and the alveolar process to achieve a Crowns above) more physiologic form. May include •• Pontics removal of supporting bone or ––Cast Gold (sanitary) non-supporting bone and limited to ––Cast non-precious metal one per quadrant every three years. ––Slotted facing Endodontics ––Slotted pontic •• Molar root canal therapy. ––Porcelain fused to gold ––Porcelain fused to non-precious metal ––Plastic processed to gold ––Plastic processed to non- precious metal •• 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 PDN (Low Option) covers 50% The PDN (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 •• Services or supplies furnished in out-of-network providers. However, described below. The lifetime connection with an orthodontic you receive greater benefits when you maximum orthodontia benefit is procedure and before the end of use network providers. $1,000. the estimated duration shown in If you choose the PDN (High Option) The PDN (Low Option) will not cover the orthodontic treatment plan (which uses the Aetna network) you expenses for orthodontia treatment •• Active appliances inserted while don’t have to satisfy a deductible begun or appliances installed before you or your dependent is covered for preventive care, but you must you or your eligible dependent by the PDN (Low Option) satisfy the deductible before the plan became covered by the Total Health •• Orthodontic procedures needed to pays for other kinds of care. Dental Dental Plan. correct one of these conditions: network providers agree to charge Orthodontic Treatment Plan ––Vertical or horizontal overlap discounted rates for their services. of upper teeth over lower teeth The plan defines orthodontic (overbite or overjet) Although coverage is the same for treatment as the use of active ––Faulty alignment (either network and out-of-network care, appliances to move teeth to correct frontwards or backwards) of the out-of-network providers may charge faulty position of teeth (malposition) upper and lower arches with each higher fees than network providers, or abnormal bite (malocclusion). other resulting in higher out-of-pocket expenses for you. When you use an Before beginning treatment, the ––Cross-bite out-of-network provider, you must dentist must submit a treatment plan •• Services or supplies as part of an file claims to receive benefits under to the claims administrator that: orthodontic treatment plan that, the PDN. before the procedure is performed, •• States the class of malocclusion or have been: Out-of-network payments are based malposition ––Sent to the claims administrator on Reasonable & Customary charges •• Recommends and describes the for review using the 80th percentile of the FAIR required orthodontic treatment ––Returned by the claims Health Benchmark database profile. •• Estimates the duration of the administrator to the dentist The database consists of provider treatment showing estimated benefits. charge data collected from more than •• Estimates the total cost for the 150 major contributors, including treatment commercial insurance companies and •• Includes cephalometric X-rays, third-party administrators. Members study models, and any other may be responsible for the difference supporting evidence that the claims between the R&C amount and the Dental & Vision administrator may reasonably out-of-network dentist’s actual require. charge.

The plan will return an estimate of Advantages of the PDN (High Option) your orthodontic benefits to the include: dentist. After your treatment plan is approved, you begin paying your •• Choice of using network or out-of- portion of orthodontia expenses in network providers equal installments over the duration •• Discounted services when you use of treatment. The PDN (Low Option) network providers pays expenses in equal quarterly •• 100% coverage for preventive installments, beginning with the end services whether you use network of the three-month period following or out-of-network providers. the date the appliances are first inserted.

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PDN (High Option) Plan Features The fact that your network dentist Summary of Benefits Dental coverage under the PDN (High prescribes services or supplies does The table below briefly summarizes Option) is subject to the following not automatically mean they are how the PDN (High Option) covers features: necessary and covered by the plan. dental expenses and shows what the •• Out-of-network—You receive the plan pays for your care. •• Alternative treatment—If you lower level of benefits if you use a undergo a more expensive provider who is not a member of PDN (High treatment or procedure when a less the PDN. Option) expensive alternative was available, •• Predetermination of benefits—You Network the plan may pay benefits based on should request a predetermination or Out-of- the less expensive procedure that is of benefits if your dentist Plan Feature network* consistent with good dental care. recommends a treatment expected Deductible $50 per person •• Annual benefit maximum—The plan to cost $350 or more to find $150 per family pays a maximum benefit of $1,500 out how the plan may cover Preventive care No cost to the per covered person per year. the procedure before receiving (Two visits per employee. Plan •• Bitewing X-rays (limited to once per treatment. Your dentist completes year) pays 100% with no year) a form listing the recommended ••Routine deductible. •• Coordination of benefits—If you or dental services and showing the checkups a covered dependent has coverage charge for each service. The claims ••X-rays under any other group dental plan, administrator reviews the form ••Cleaning and this plan will coordinate benefits and informs the dentist of your polishing with the other plan. estimated benefits. The dentist may ••Space maintainers •• Deductible—You must meet the be asked to provide supporting individual or family deductible X-rays or other diagnostic records Basic care 80% after deductible before the plan pays benefits for before predetermination is made. ••Fillings non-preventive care. The annual •• Reimbursement—The plan will ••Extractions deductible for Basic and Major deduct your coinsurance amount ••Anterior/ Care is $50 per person or $150 per from the total amount of your bicuspid root canal therapy family. Only covered expenses for reimbursement. which no benefits are payable can •• Usual and customary fee limit— ••Oral surgery be counted toward the deductible. The amount of benefits paid for Major care 50% after deductible •• In-network—A group of dental eligible expenses is based on the ••Bridges providers in the PDN has agreed to usual and customary fee limit for a ••Dentures charge negotiated rates for services service or item in the geographic ••Crowns and items. area where you reside. The usual ••Molar root canal •• Necessary services and supplies— fee is the fee most frequently therapy Only dental services that are charged or accepted for covered ••Inlays and necessary are covered by the plan. expenses for dental care or supplies onlays Dental & Vision Dental & Vision Cosmetic services are not covered, by a physician or hospital. The Maximum annual $1,500 per person except to repair accidental injuries customary fee is the fee charged or benefit not covered by the Total Health accepted for covered dental care Orthodontic care 50% with no Medical Plan. The service must be: or supplies by those of a similar (For eligible adults deductible $1,250 professional standing in the same and dependent lifetime maximum ––For the diagnosis or direct children) treatment of a dental injury or geographic area, as determined by illness Aetna. * You will have higher out-of-pocket expenses when you use out-of-network providers. ––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 ––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 (HIGH OPTION) COVERS Basic services are covered at 80% temporomandibular joint •• Meniscectomy of To be covered by a dental plan, a after you meet the deductible and temporomandibular joint dental expense must be necessary include the following: •• Radical resection of mandible with and provided by a duly qualified and Visits and Exams bone graft licensed dentist. Charges for covered items must be within the usual and •• Professional visit after hours •• Removal of foreign body from soft customary fee limits. (payment will be made on the tissue basis of services rendered or visit, •• Frenectomy Preventive Services whichever is greater) •• Suture of soft tissue injury Preventive Services are covered at •• Emergency palliative treatment •• Injection of sclerosing agent into 100% and include the following: X-ray and Pathology temporomandibular joint •• Treatment of trigeminal neuralgia •• Office visits during regular office •• Single films (up to 13) hours, for oral examination (limited by injection into second and third •• Intra-oral, occlusal view, maxillary divisions to two visits per year) or mandibular •• Prophylaxis (cleaning) limited to •• Upper or lower jaw, extra-oral Periodontics two treatments per year •• Biopsy and examination of oral •• Emergency treatment (periodontal •• Topical application of fluoride, tissue abscess, acute periodontitis, etc.) including prophylaxis (limited to •• Root planing and scaling, per one course of treatment per year Oral Surgery quadrant (not prophylaxis), limited for children under age 16) •• Local anesthetics and routine to four separate quadrants every •• Bitewing X-rays (limited to once per postoperative care two years year) •• Uncomplicated extractions •• Correction of occlusion related •• Complete X-ray series or panoramic •• Uncomplicated surgical removal of to periodontal surgery—occlusal film including bitewings, if an erupted tooth guards, one every three years necessary (limited to once every •• Postoperative visit (sutures and •• Gingivectomy (including post- three years) complications) after multiple surgical visits)— one per quadrant •• Vertical bitewing X-rays (limited to extractions and impaction per site every three years one set every three years) •• Surgical removal of impacted tooth •• Gingivectomy, treatment per tooth (soft tissue) Space Maintainers (less than four teeth per quad) •• Alveolectomy (edentulous) •• Post-surgical visits •• No age limit (covered only for •• Alveolectomy (in addition to premature loss of primary teeth) Endodontics removal of teeth) •• Includes all adjustments within six •• Alveoplasty with ridge extension •• Pulp capping months after installation •• Removal of exostosis •• Therapeutic pulpotomy (in addition •• Fixed space maintainer (band type) •• Excision of hyperplastic tissue to restoration) •• Removable acrylic with round wire •• Vital pulpotomy Dental & Vision rest only •• Excision of pericoronal gingiva •• Incision and drainage of abscess •• Remineralization (calcium •• Removable inhibiting appliance to hydroxide, temporary restoration) •• Removal of odontogenic cyst or correct thumb sucking as a separate procedure only tumor •• Fixed or cemented inhibiting •• Root canals (devitalized teeth •• Sialolithotomy (removal of salivary appliance to correct thumb sucking. only, other than molar root canal calculus) therapy), including necessary X-rays •• Closure of salivary fistula and cultures but excluding final •• Dilation of salivary duct restoration •• Transplantation of tooth or tooth •• Canal therapy (traditional or bud sargenti method), includes single •• Removal of foreign body from bone rooted or bi-rooted (independent procedure) •• Local anesthetics where necessary •• Maxillary sinusotomy for removal of tooth fragment or foreign body •• 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 •• Restorations (involving one, two or ––Slotted facing non-supporting bone and limited to three or more surfaces), includes ––Slotted pontic amalgam, silicate cement, plastic, one per quadrant every three years. ––Porcelain fused to gold and composite fillings ––Porcelain fused to non-precious Endodontics •• Pins (retention) when part of the metal •• Molar root canal therapy. restoration used instead of gold or ––Plastic processed to gold crown restoration Orthodontia Expenses •• Stainless steel crowns (when tooth ––Plastic processed to non- The PDN (High Option) covers 50% cannot be restored with a filling precious metal of eligible orthodontia expenses material) •• Removable Bridge (unilateral)— one piece casting, chrome cobalt for eligible adults and dependent •• Recementation of inlay, crown, or children. The plan covers only the bridge alloy clasp attachment (all types) including pontics orthodontic services and treatments described below. The lifetime Major Services •• Dentures and partials—fees for maximum orthodontia benefit is dentures, partial dentures and Major services are covered at 50% $1,250. after you meet the deductible and relining include adjustments include the following: within six months after installation; The PDN (High Option) will not cover specialized techniques and expenses for orthodontia treatment Restorative characterizations are not eligible begun or appliances installed before •• Gold restorations and crowns— ––Complete upper denture you or your eligible dependent covered only as treatment for decay ––Complete lower denture became covered by the Texas Health or traumatic injury and only when ––Partial acrylic upper or lower with Dental Plan. teeth cannot be restored with a chrome cobalt alloy clasps, base, Orthodontic Treatment Plan filling material or when the tooth is all teeth and two clasps The plan defines orthodontic an abutment to a fixed bridge ––Additional clasps treatment as the use of active •• Inlays and onlays (one or more ––Partial lower or upper with appliances to move teeth to correct surfaces) chrome cobalt alloy lingual or faulty position of teeth (malposition) •• Crowns palatal bar and acrylic saddles, or abnormal bite (malocclusion). ––Acrylic base, all teeth and two clasps ––Acrylic with gold plus additional clasps Before beginning treatment, the ––Acrylic with non-precious metal ––Simple stress breakers, extra dentist must submit a treatment plan Dental & Vision ––Porcelain ––Stayplate, base and additional to the claims administrator that: clasps ––Porcelain with gold •• States the class of malocclusion or ––Porcelain with non-precious ––Office reline, cold cure, acrylic malposition metal ––Laboratory reline •• Recommends and describes the ––Non-precious metal (full cast) ––Special tissue conditioning, per required orthodontic treatment ––Gold (full cast) denture •• Estimates the duration of the ––Gold (¾ cast) ––Denture duplication (jump case), treatment ––Gold dowel pin per denture •• Estimates the total cost for the •• Adding teeth to partial denture to ––Adjustment to denture more than treatment replace extracted natural teeth— six months after installation •• Includes cephalometric X-rays, teeth and clasps study models, and any other Oral Surgery •• Repairs to crowns and bridges supporting evidence that the claims •• General anesthesia, only when •• Full and partial denture repairs administrator may reasonably provided in conjunction with a ––Broken dentures, no teeth require. surgical procedure involved •• Crown exposure to aid eruption ––Partial denture repairs (metal) ––Replacing missing or broken teeth.

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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 The following expenses are not dentist. After your treatment plan second bicuspid will always be eligible for benefits under the PDN is approved, you begin paying your considered cosmetic. This does not (Low Option) or PDN (High Option). portion of orthodontia expenses in apply if the treatment is needed equal installments over the duration •• Services not necessary or not as a result of accidental injuries of treatment. The PDN (High Option) customarily performed for the sustained while you are covered pays expenses in equal quarterly dental care of a specific condition under the plan. installments, beginning with the end as determined by Aetna •• Charges in connection with: of the three-month period following •• Services not furnished by a dentist. ––Replacement of lost or stolen the date the appliances are first This does not apply if the service appliances inserted. is performed by a licensed dental ––Appliances, restorations or Covered Orthodontia Expenses hygienist under the direction of a procedures needed to alter dentist or is an X-ray ordered by a vertical dimensions or restore The PDN (High Option) will cover dentist. occlusion, or for the purpose of expenses for orthodontia treatment, •• Charges for a service: splinting or correcting attrition or up to the lifetime maximum, for the ––Furnished by or for the United abrasion following charges: States government or any other •• Charges in connection with injury •• Services or supplies furnished in government, unless payment of arising out of, or in the course connection with an orthodontic the charge is required by law of, any work for wage or profit procedure and before the end of ––To the extent that the service, (whether or not with Texas Health) the estimated duration shown in or any benefit for the charge, •• Charges in connection with a the orthodontic treatment plan is provided by any law or disease covered by any workers’ •• Active appliances inserted while governmental plan under compensation law, occupational you or your dependent is covered which the patient is or could be disease law or similar law by the PDN (High Option) covered. This does not apply to •• Charges for a service to the extent •• Orthodontic procedures needed to a state plan under Medicaid or to it is more than the usual charge correct one of these conditions: any law or plan when, by law, its made by the provider for the ––Vertical or horizontal overlap benefits are in addition to those service when there is no coverage of upper teeth over lower teeth of any private insurance program •• Charges above the prevailing rate (overbite or overjet) or other non-governmental in the area for dental care of a program. ––Faulty alignment (either comparable nature. The area and frontwards or backwards) of the •• Implants the range are determined by the upper and lower arches with each •• Replacement or modification claims administrator other of a partial or full removable •• Charges for a service or supply ––Cross-bite denture, removable bridge or fixed furnished by a network provider in bridgework, or for adding teeth to •• Services or supplies as part of an excess of the provider’s negotiated any of these within five years after orthodontic treatment plan that, charge for that service or supply. A Dental & Vision that denture, bridge, or bridgework before the procedure is performed, negotiated charge is the maximum was installed have been: a network provider has agreed to •• Replacement or modification of a charge for a service or supply under ––Sent to the claims administrator crown or gold restoration within the PDN. for review five years after that crown or gold ––Returned by the claims restoration was installed administrator to the dentist •• Charges for any of the following showing estimated benefits. 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 Benefits under all dental plans provider, you must file a claim (the claims administrator will determine are fully insured by Aetna. Aetna form is available online) for dental whether or not it involves urgent processes all claims under these expense benefits as follows: care. If a dentist with knowledge of plans. Whenever you file a claim, your medical condition determines •• Complete the top portion of the that a claim involves urgent care, the be sure to keep a copy of the claim dental expense claim form by and any other information (such as claim will be treated as an urgent care following the instructions that claim. itemized bills) that you include with accompany the form. Then, present the claim. the form to your dentist, who If the plan requires you to obtain Aetna DMO completes the remaining portion. advance approval for a service, •• Submit all itemized receipts from supply, or procedure, your request The Aetna DMO pays benefits only your dentist. A canceled check is for advance approval is considered when you use network providers, not acceptable documentation. a pre-service claim. The claims so you do not need to file claims for •• Mail the completed claim form administrator will notify you of its benefits. You pay a copay for services, with the original itemized bills and decision no later than 15 days after your provider files claims for you, and receipts to Aetna at the address on receiving your claim. the plan pays the rest of the cost. the claim form. This does not apply to a claim However, in an emergency, you may You must submit the original itemized involving urgent care, as defined use a non-network provider and you bill or receipt provided by your below. or the provider would need to file dentist, so you should make copies a claim. Consult the plan materials Urgent Care Claims for your own records. Photocopies of for more information on claims for receipts are not accepted for claims. If the plan requires advance approval benefits. In addition, each bill or receipt must for a service, supply, or procedure Dental PDN include the following: before a benefit is payable, and the plan or your dentist determines that Under the PDN plans, you may use •• Name of patient your claim is an urgent care claim, the network or out-of-network providers. •• Date the treatment or service was claims administrator will notify you However, you receive greater benefits provided of its decision no later than 72 hours when you use network providers. •• Diagnosis after receiving your claim. Network Providers •• Itemized charges for the treatment Urgent care means services When you use a PDN provider, you or service received for sudden illness, injury, or must first satisfy a deductible and •• Provider’s name, address, and tax ID condition that is not an emergency pay a coinsurance for basic care, number. condition but requires immediate major care, and orthodontia. Network outpatient medical care that cannot All dental claims payments are sent providers will normally file your claims be postponed. An urgent situation is to you along with an explanation of

Dental & Vision for benefits with Aetna PDN. one that is severe enough to require benefits (EOB) explaining the amount prompt medical attention to avoid paid. Payments may, however, be sent If plan benefits differ depending on serious deterioration of your health. directly to your dentist or other dental whether care is given by, or accessed This includes a condition that would provider if your provider accepts through, a network provider, you subject you to severe pain that could assignment of benefits. In this case, may obtain, without charge, a listing not be adequately managed without the EOB will be provided to you and of network providers from your prompt treatment. claims administrator, or by calling the the payment mailed to your provider. toll-free Member Services number Types of Claims on your ID Card. A current list of providers in the Aetna network is There are four different types of available through DocFind® at Aetna. claims. The claim type is determined com. 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.

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If the claims administrator does Extension of Time Periods Payment of Claims not have enough information to For pre-service and post-service Plan benefits are payable to you, decide the claim, they will notify claims, the claims administrator may unless you give written direction you of the information needed extend the time periods for up to an at the time you file your claim, to to complete the claim as soon as additional 15 days for circumstances directly pay the dentist or unless possible after receiving your claim outside the plan’s control. If an a Qualified Medical Child Support but no more than 24 hours later. extension is required, you will be Order directs the payment to The claims administrator will give notified of the extension before someone else. you a reasonable time to provide the end of the initial 15- or 30-day the information but not less than 48 period. For example, if you have not You may request that the claims hours. They will notify you of their submitted sufficient information for processor pay your dentist directly decision no later than 48 hours after the claims administrator to decide by assigning your benefits. You may the end of the additional time period, the claim, they will notify you of assign benefits for eligible expenses or after they receive the information, the specific information needed incurred for dental care only to the if earlier. and provide an additional period person or institution that provides the services or supplies for which these Post-service Claims of at least 45 days to furnish the information. The claims administrator benefits are payable. A post-service claim is any claim for will notify you of their decision no a benefit that is not a pre-service If any benefit remains unpaid at later than 15 days after the end of the claim or an urgent care claim. For your death, if the covered person is extended period, or after receipt of post-service claims, the claims a minor or legally incapable (in the the information, if earlier. administrator will notify you no later opinion of the claims administrator) than 30 days after receiving your If you file a pre-service claim and of giving a valid receipt and discharge claim. include the name of the patient, for payment, the claims administrator dental condition, and service or may, at its option, pay benefits to Ongoing Care supply for which approval is being the spouse, parent or child of the A claim for ongoing care is one requested but you do not follow covered person. Payment to the in which the claims administrator the plan’s procedures for filing covered person’s relative constitutes approves a course of treatment pre-service claims, the claims a complete discharge of the claims over a period of time or for a administrator will notify you of the administrator’s obligation to the specified number of treatments. proper procedures within five days extent of the payment. The claims However, a claim for ongoing (or within 24 hours for an urgent administrator is not required to see care may be reconsidered by the care claim). The notification may the application of the money. claims administrator and the initially be oral unless you request written approved period of time or number notification. of treatments may be either reduced, terminated, or extended. How to File a Claim for Benefits Except for urgent care claims, a The claims administrator will notify

claim for benefits is made when you Dental & Vision you in advance if the plan intends to (or your authorized representative) terminate or reduce benefits for a submit a written claim form to: course of ongoing care so you will have an opportunity to appeal the Aetna decision before the termination or P.O. Box 14066 reduction takes effect. If the ongoing Lexington, KY 40512-4066 care involves urgent care, and you www.aetna.com. request an extension of the ongoing care at least 24 hours before it Coordination of Benefits expires, the claims administrator will If you have dental coverage through notify you of its decision within 24 any other plan, the PDN Plans are hours after receiving your request. coordinated with the other plan so that you do not receive greater benefits than the cost of covered services. Claim Filing Deadline You must submit all dental claims within 90 days after the date the expenses were incurred.

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Filing an Appeal If you have the DMO plan and wish WHEN COVERAGE ENDS to obtain information or make a With the exception of urgent care Generally, coverage for you and your complaint: claims, you have 180 days to file covered dependents under the Total an appeal after you receive an •• You may call Aetna Dental Inc.’s toll- Health Dental Plan ends on the last adverse decision. After the claims free telephone number at day of the pay period in which you administrator receives your appeal, 1-877-238-6200. terminate employment. See page 188 they will notify you of their decision •• You may write to Aetna Dental Inc. for more information. For dependents no more than: at: reaching the maximum age, coverage ends at the end of the month •• 15 days later for a pre-service claim Aetna Dental Inc. containing the dependent's birthdate. •• 30 days later for a post-service One Prudential Circle Sugar Land, TX 77478 claim. In some cases, you and your covered •• You may call the Texas Department dependents may be eligible for You may submit written comments, of Insurance at 1-800-252-3439. COBRA continuation coverage, as documents, records, or other •• You may write the Texas Department explained on page 189. information relating to your claim, of Insurance at: even if you did not submit them P.O. Box 149104 with the initial claim. You may also Austin, TX 78714-9104 request that the plan provide copies Fax: 512-475-1771 of all documents, records, and other information relevant to the claim. Web: www.tdi.state.tx.us Those copies will be provided free of Email: ConsumerProtection@ charge. tdi.state.tx.us.

If your claim involves urgent care, Should you have a dispute concerning you may make an expedited appeal your premium or about a claim by calling Aetna’s Member Services you should contact Aetna first. at the telephone number on your If the dispute is not resolved you ID card. You or your authorized may contact the Texas Department representative may appeal an urgent of Insurance. This notice is for care claim denial either orally or in information only and does not writing. All necessary communication become a part or condition of will be made by telephone, facsimile, the DMO plan as described in the or other similar method, including Handbook. 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 Dental & Vision care, you may file a second-level appeal with Aetna. You will be notified of the decision no later than 36 hours after the 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.

94 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Vision Plan Vision Plan

OVERVIEW SUMMARY OF BENEFITS You may elect coverage for vision The following table summarizes how the plan pays benefits and your cost for care through the Superior Vision Plan. certain services and supplies. The plan pays benefits for annual eye exams and corrective glasses Feature Network Out-of-network or contact lenses. You pay a copay Comprehensive eye Covered in full after $10 copay Up to $42 for for exams and materials (materials exam once every ophthalmologist (M.D.) copayment applies to lenses and 12 consecutive or $37 for optometrist months (O.D.) frames, not contact lenses). The plan pays benefits for frames and lenses Standard lenses Covered in full after $10 copay Single vision—up to $32 once every 12 Bifocal—up to $46 up to certain limits. Under this plan consecutive Trifocal—up to $61 you may use network or out-of- months1 Lenticular—up to $84 network vision care providers, but you Contact lens fitting Covered in full after $35 copay Not covered receive greater benefits when you use (standard) every network providers. 12 consecutive months The Superior Vision Plan allows you Contact lens fitting Up to $50 retail allowance after a Not covered to choose your eye care provider. You (specialty) every $35 copay can choose a network provider or an 12 consecutive months out-of-network provider. Network providers file all claim forms. When Contact lenses Cosmetic elective—up to $140 Cosmetic elective—up (per pair, in lieu allowance ($35 copay for contact to $100 retail allowance you use an out-of-network provider, of eyeglasses) lens fitting exam) you pay the full cost of vision care Medically necessary—up once every 12 Medically necessary—covered to $2102 expenses to the provider and submit consecutive 2 1 in full a claim for reimbursement. Your months reimbursement will be paid under Standard frames Up to $140 retail allowance Up to $53 retail the out-of-network schedule of once every 12 allowance consecutive allowances, less any applicable copay months amounts. Refractive surgery 5%—50% discount No benefit (LASIK, radial WHO CAN BE COVERED keratotomy, or photo-refractive You may elect the following levels of keratotomy) coverage under the Vision Plan: Add-ons to covered lenses (covered in-network only) •• You only You receive 20% off retail, up to the dollar amount listed: Dental & Vision •• You and your spouse ••Factory scratch coat – $133 •• You and your unmarried dependent ••Ultraviolet coat – $153 children up to age 25 who are not ••Standard anti-reflective coat – $503 regularly employed on a full-time ••High index 1.6 – $554 basis ••Polycarbonate – $404 •• You and your family. ••Standard transitions and other photochromic – $804 ••Glass coloring – $355 See pages 5 – 7 for more information ••Plastic tints solid or gradient – $255 on eligibility. ••Retinal imaging – $39 You receive 20% discount off retail for these add-ons to any type of lenses: ••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

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NETWORK PROVIDERS COVERED IN-NETWORK Options at an Additional Cost To find a list of network providers, EXPENSES The Superior Vision Plan is designed visit Superiorvision.com or call You may receive benefits for a to provide your basic eyewear needs. Superior Vision at 1-877-MyTHRLink comprehensive vision examination Many lens upgrades and add-ons are (1-877-698-4754), prompt 6, press 4. by an ophthalmologist or optometrist not covered or have limitations. If When you choose a Superior Vision once every 12 consecutive months, you choose any of the options listed Services network provider, you should which must include: below, you will pay for the options identify yourself as a member of the in addition to the covered benefit. plan when making your appointment. •• Case history You will pay these additional charges Superior Vision Services will give the •• Visual health evaluation, to include: directly to your provider at the time of provider an authorization number to ––Internal and external examinations service; however discounts may apply. verify your benefits before you receive with direct and indirect •• Progressive power lenses—The your services. Although it is not ophthalmoscopy provider’s charge for a standard required, it is recommended that you ––Pupillary reflexes and motility trifocal lens is credited toward the present your ID card to the provider evaluation charge for the style of progressive at the time you receive services. This ––Biomicroscopy lens selected. You pay the provider makes the identification process ––Visual fields testing the difference between the two. easier. You can print additional cards ––Tonometry •• Blended (no-line) bifocal lenses by logging on to Superiorvision.com. •• Refractive state evaluation, to •• Faceted lenses When you receive care, pay only your include: •• Polished bevel lenses copay and any charges not covered ––Visual acuity uncorrected and best •• Polycarbonate lenses by the plan. The network provider will corrected acuity •• Hi-index lenses handle claims for you. ––Subjective refraction with •• Polaroid lenses accommodative function To receive the discount for refractive •• Photochromic lenses ––Objective refraction by surgery, simply present your ID card •• Laminated lenses retinoscopy or autorefractor to a participating refractive surgeon •• Slab-off lenses listed in the Superior Vision provider •• Binocular function. •• Prism lenses directory with the notation “RF” under Your vision benefits also include: •• Coating on lenses (anti-scratch, services provided. anti-reflective, sunglass colors, etc.) •• Standard lenses (plastic or glass) •• Tints (except rose tint #1 and #2) that are clear—once every 12 consecutive months •• Oversized charge for lenses larger than 61 mm ––Single vision •• Ultra-violet tint or coating ––Bifocal •• Retail charges for frames in excess ––Trifocal of the retail frame allowance ––Lenticular •• Additional cost for elective contact Dental & Vision Dental & Vision •• Frames—once every 12 consecutive lenses over the allowance. months •• Contact lenses—once every 12 You may also take advantage of many consecutive months in lieu of discounts through the Superior Vision eyeglass lenses and frames Plan—more information is available at ––Contact lens exam/fitting fee— Superiorvision.com. Most providers charge a fee for fitting contact lenses. This $35 copay is separate from the comprehensive eye examination. Contact lens exam and fitting charges are not covered out-of- network. ––Medically necessary—covered in full in-network, up to $210 allowance out-of-network ––Elective—up to $140 allowance in-network, up to $100 allowance out-of-network ––You may order contact lenses online at contactsdirect.com.

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EXCLUSIONS •• Services rendered after the date a If payments should have been made participant ceases to be covered, under this plan but have been made There is no benefit coverage for the except when vision materials under any other plan, the claims following products and services: ordered before coverage ended are administrator has the right, in its sole •• Replacement frames and/or lenses delivered and the services rendered discretion, to pay to any insurance except at normal intervals when to the participant within 31 days company or other organization or services are otherwise available from the date of such order person making such other payments •• Nonprescription glasses/sunglasses •• Services rendered or materials any amounts it determines and to the or oversized lenses ordered before the date coverage extent of such payments, Texas Health and the plan will be fully discharged •• Orthoptics or vision training and any began. from liability. The benefits that are associated supplemental testing payable will be charged against any •• Frame cases COORDINATION OF BENEFITS applicable maximum payment or •• Low (subnormal) vision aids The Vision Plan is designed to benefit of this plan rather than the •• Eye exams required by your integrate benefits with other group amount payable in the absence of this employer as a condition for or individual plans or policies. If you provision. employment are eligible either as the insured •• Services and materials covered by or a dependent to receive vision FILING CLAIMS another vision plan benefits from another plan (including Written notice of your claim must be •• Conditions covered by workers’ automobile insurance) or government given to Superior Vision within twenty compensation program, the total benefits you are eligible to receive from all plans will (20) days of the date such loss begins. •• Benefits provided under your not be more than the benefits that Notice must be given to Superior medical insurance would be payable from the Total Vision with enough information to •• Medical or surgical treatment of Health Vision Plan if you had no other identify you or your dependents. the eyes coverage. This applies whether or not Failure to file such notice within •• Professional services and/or you file a claim under the other plan. If the time required will not invalidate materials in connection with: needed, you must authorize the claims nor reduce any claim that was not ––Blended bifocals, no line administrator to get information from reasonably possible to file notice ––Compensated or special multi- the other plans. within such time. However, the notice focal lenses must be given as soon as reasonably If you are covered by two vision plans, ––Plain (non-prescription) lenses possible. Superior Vision will provide one of the plans will be primary and ––Anti-reflective, scratch, UV400, or claim forms when you request or the other will be secondary. The any coating or lamination applied when Superior Vision receives notice primary plan pays benefits first. The to lenses of claim. If the forms are not given following criteria determine which within fifteen (15) days, you can submit ––Subnormal visual aids plan is primary: written proof covering the occurrence, ––Tints other than solid character and extent of loss for which ––Orthoptics, vision training and •• If only the other plan is not with Superior Vision, then the Total claim is made. developmental vision procedures Dental & Vision Health Vision Plan is the primary ––Polycarbonate lenses You or your network provider must plan. •• Services rendered or materials provide written proof of your claim to •• If both plans are with Superior purchased outside the U.S. or Superior Vision not later than ninety Vision, then the plan under which Canada (reimbursed at out-of- (90) days after the date of such loss. the insured is the member rather network values) Failure to give such proof within such than a dependent, is primary. time will not invalidate nor reduce •• Charges in excess of the usual, •• If both plans are with Superior Vision any claim if it was not reasonably customary and reasonable charge and the insured is a dependent possible to give proof within such for the professional service or child, the father’s plan is primary. time. However, such proof must materials be furnished as soon as reasonably •• Experimental or non-conventional possible, but in no event, except in treatment or device the absence of legal capacity of the •• Safety eyewear claimant, later than one (1) year from •• Services or materials rendered the date of the claim. by a provider other than an Ophthalmologist, Optometrist, or Superior Vision, at its expense, has the Optician acting within the scope of right to examine you regarding any his or her license claim when and as often as may be •• Any additional service required reasonably required while the claim is other than basic vision analyses for pending. contact lenses, except fitting fees

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If you file a claim, be sure to keep Reimbursements will be mailed For purposes of this grievance a copy of the claim and any other to your home address along with procedure, a grievance is a written information (such as itemized bills) an explanation of benefits (EOB) complaint submitted in accordance that you include with the claim. describing the amounts you have with the above grievance procedure been paid. You must submit all vision by or on behalf of you or a dependent If you cover your dependent under claims within 12 months after the date regarding dissatisfaction with the the Vision Plan and do not have legal the expenses were incurred. administration of claims practices custody of that dependent, Superior or provision of services of this Vision may make benefit payments Grievance Procedure panel provider plan relative to you. directly to the care provider at the If a claim for benefits is wholly or In situations requiring urgent care, request of the custodial parent. partially denied, you will be notified grievances will be resolved within Superior Vision will be released from in writing of such denial and of your four business days of receiving the all further liability to the extent of the right to file a grievance and the grievance. payments made. procedure to follow. The notice of Superior Vision Services has final Superior Vision has the right to denial will state the specific reason for the denial of benefits. discretionary authority to determine contest the validity of your or your all questions of eligibility and status dependent’s coverage under the Within 60 days of receipt of such and to interpret and construe the plan because of inaccurate or false written notice a member may file a terms of the insurance policy. information about eligibility for grievance and make a written request coverage. Superior Vision has two for review to: WHEN COVERAGE ENDS years from the effective date of your coverage to contest eligibility. National Guardian Life Insurance Generally, coverage for you and Only statements that are in writing Company your covered dependents under the and signed by you or your covered c/o Superior Vision Services, Inc. vision plan ends on the last day of the dependent can be used to contest P.O. Box 967 pay period in which you terminate coverage. Rancho Cordova, CA 95741. employment. See page 188 for more information. For dependents reaching If you, your covered dependent, or Superior Vision will resolve the the maximum age, coverage ends at your vision care provider receives an grievance within 30 calendar days the end of the month containing the overpayment of benefits under the of receiving it. If Superior Vision is dependent's birthdate. Vision Plan, you are required to repay unable to resolve the grievance within any excess benefits to the plan. that period, the time period may be In some situations you may continue extended another 30 calendar days vision coverage after you leave Texas Out-of-network Providers if Superior Vision notifies in writing Health. See page 189 for information When you use an out-of-network the person who filed the grievance. on electing COBRA continuation provider, you must file a claim for The notice will include advice as to coverage. vision reimbursement. when resolution of the grievance can be expected and the reason Before you receive services, you why additional time is needed. You Dental & Vision should call Superior Vision Member or someone on his/her behalf also Services at 1-877-MyTHRLink (1- has the right to appear in person 877-698-4754), prompt 6, press 4 to before the Superior Vision grievance verify your eligibility and receive an committee to present written or oral authorization number. After receiving information and to question those services, obtain an itemized invoice people responsible for making the or receipt and mail it to the Superior determination that resulted in the Vision Claims Unit for reimbursement. grievance. You will be informed in Your claim will be paid under the out- writing of the time and place of the of-network schedule of allowances, meeting at least seven calendar days less any applicable copay amounts. before the meeting. The mailing address is:

Superior Vision Services P.O. Box 967 Rancho Cordova, CA 95741

98 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Spending Accounts Spending Accounts Flexible Spending Accounts...... 100 Overview 100 “Use It or Lose It” 100 Health Care Spending Account 100 Day Care Spending Account 103 Filing Claims 104 When Coverage Ends 105

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OVERVIEW If you are married and you file HEALTH CARE a separate income tax return, Most people have medical expenses SPENDING ACCOUNT contributions cannot exceed $2,500 that are not covered by any benefit for each of you, with a $5,000 total The Health Care Spending Account plan—things like deductibles, copays, 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 expenses. And, if you have young by insurance. Eligible expenses children at home or are caring for a The annual amount you contribute include medical, dental, and vision parent, you may have to pay someone is divided into equal amounts and expenses not paid by your medical to care for them while you work. deducted from each paycheck. coverage, such as deductibles, copays, coinsurance, and amounts above the As a full-time or part-time benefits- For example, if you elected to usual and customary fee limits. eligible employee, you may be able to contribute $1,430 during open use the Flexible Spending Accounts enrollment, that amount is divided Who Can Be Covered (FSA) under the Total Health Flexible by 26 pay periods to figure your The Health Care Spending Account Benefits Plan to pay these expenses per-pay-period deduction of $55. If allows you to receive tax-free with tax-free dollars. You pay no you enroll during the calendar year, reimbursement of health care expenses federal income or Social Security the annual contribution you elect is for you and your eligible dependents, taxes on the earnings you deposit in divided by the number of pay periods even if you don’t cover them under the the accounts, meaning you pay lower remaining in the calendar year. Total Health Medical Plan. You may file overall taxes on your income. claims for reimbursement of expenses The Health Care Spending Account “USE IT OR LOSE IT” incurred by: (HCSA) allows you to set aside tax-free The IRS restricts how you may use •• You money through payroll deductions the funds in your Flexible Spending •• Your spouse to pay eligible health care expenses. Accounts. If you decide to contribute Eligible expenses are amounts not to either or both accounts, you •• Your dependent children reimbursed by any health coverage, should carefully estimate your •• Anyone else you can claim as a including a spouse’s plan, for the care expenses for the coming year. The dependent on your federal income of you, your spouse, your children, law requires that the accounts tax return. and other qualified dependents. operate on a “use it or lose it” basis. Changing Your Elections This means you forfeit any money The Day Care Spending Account remaining in your spending accounts If, as a result of a status change, you (DCSA) allows you to set aside tax-free after all eligible expenses have stop your deposits during the year, money through payroll deductions to been reimbursed according to plan you may file claims and be reimbursed pay eligible day care expenses. Eligible guidelines. All Flexible Spending for eligible health care expenses expenses include day care for your Account forfeitures are used to incurred before the change. These children under age 13 or a disabled pay for the plan’s administrative expenses will be reimbursed up to dependent of any age when the care expenses. the original amount you elected to enables you (and your spouse, if you deposit. You will not be reimbursed are married) to work. Your expenses claimed for for expenses incurred after you stop reimbursement must be for health your contributions. Any unused How Much You May Contribute care or day care services incurred amount will be forfeited. If you reduce You may participate in either or both between January 1, 2019, and your deposits as a result of a status accounts. During enrollment, you March 15, 2020, and only during change, you may be reimbursed for decide how much to deposit on a the months that you are eligible to eligible health care expenses up to before-tax basis for the year, up to: participate. If you participate in the the amount of your revised deposit Health Care and Day Care Spending amount. However, you are not allowed •• $2,650 per year into your Health

Spending Accounts Accounts, keep in mind that the to reduce your deposit to less than the Care Spending Account (a minimum accounts are maintained separately. amount you have been reimbursed. of $130 per year) You may not transfer money For example, if your original •• $5,000 per year into your Day between the accounts. All claims contribution was $1,000 and you have Care Spending Account. If you are must be submitted by March 31 of been reimbursed $500, you could only married and your spouse’s employer the following year to be eligible for lower your new contribution to $500. offers a Dependent Care Spending reimbursement. Account, your combined total annual contribution cannot exceed $5,000.

100 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Flexible Spending Accounts

Rehires The debit card can only be used COBRA Participants HCSA Debit If you terminate your employment for expenses you actually incur. Card or lose eligibility and then you are For example, you may be asked to Upon termination, you will no longer rehired within 13 weeks of your pay your provider’s portion of your be able to use your HCSA debit card. termination, you will be reinstated newborn services by a certain month As a COBRA participant, to receive in the plan at the same contribution of your pregnancy. However, this reimbursement for eligible expenses, rate. amount cannot be paid using the you will need to file claims as debit card. When using your debit explained on page 190. HCSA Debit Card card, please remember that your FSA You will receive a Benefits Card funds should be used as the final Eligible Health Care Expenses which is a MasterCard that provides payer. The card cannot be used for In general, your Health Care Spending you immediate access to your FSA pre-treatment or estimated charges. Account can be used to pay any funds upon initial enrollment. You If you go to a retail pharmacy, your unreimbursed health care expenses will not receive a new card each Benefits Card can be used for your that the Internal Revenue Service (IRS) year. Your new annual election will prescription medication at any would normally allow you to deduct be loaded on the card each year. network pharmacy that is set up to when you calculate your taxes. You Until March 15, 2019, when you use take the card. (Please note that not can also find helpful information at your debit card, funds will be drawn all participating pharmacies will be PayFlex.com. The list below gives from your 2018 account balance. able to accept the card.) Mail order examples of the expenses that qualify After you use all the money in your prescriptions can be processed for reimbursement. For a more 2018 account, when you use your without authorization from Caremark comprehensive listing of eligible card it will withdraw from your 2019 and you should be able to use your expenses, refer to IRS Publication account. When you use your card Benefits Card. You may also purchase 502 at IRS.gov/pub/irs-pdf/p502.pdf. after March 15, 2019, it will withdraw a 90-day supply at the retail pharmacy Excluded expenses are listed on the from your 2019 account and you at Texas Health Presbyterian Hospitals next page. will no longer be able to access your of Dallas, Plano, and the Texas Health •• Most medical and dental plan 2018 account. Your Benefits Card Infusion Pharmacy. copays (such as for office visits), can be used for medical, dental and deductibles, and out-of-pocket vision expenses at eligible merchants If your provider does not accept expenses (but not medical or dental with a valid merchant code. MasterCard, or you use a pharmacy that is not set up to process your FSA insurance premiums) When you use your debit card, payment, you will be required to pay •• Hearing expenses including hearing you may be required to provide at the time of service and file a paper aids, special instructions or training documentation such as an claim for reimbursement. for the deaf (such as lip reading), and Explanation of Benefits from your the cost of acquiring and training a medical/dental insurance carrier If you have trouble using your card dog for the deaf or itemized receipts showing the at a physician’s office, pharmacy, •• Vision expenses including charges for the service and the dental or vision provider, you may still eyeglasses, contact lenses, amount of insurance payment (if submit paper reimbursement forms to ophthalmologist fees, the cost of a any). In addition, we may request PayFlex and your eligible claims will be guide dog for the blind, and special additional information such as reimbursed to you. education devices for the blind, a statement of medical purpose Go to PayFlex.com or download the such as an interpreter from your doctor. Your debit card PayFlex app to track your Health Care will be deactivated if you provide Examples of medical expenses that Spending Account expenses, balances, documentation that shows your may be reimbursed if not covered by and statement of claims or to see a transaction is not an eligible FSA a Total Health Medical Plan or other listing of your account activity. expense, or your documentation is medical coverage you may have not received within 60 days of the If you have other questions about your include, but are not limited to, the date of the letter. FSA, call PayFlex at 1-877-MyTHRLink following: (1-877-698-4754), select prompt 6, If you do not provide the required •• Acupuncture that is not paid by the

then press 6. Spending Accounts documentation showing that the medical plan transaction amount is eligible under •• Artificial insemination, including the IRS tax code governing FSA plans, in-vitro fertilization you will need to repay the amount •• Bandages, support hose, or to your account. Any amounts not other pressure garments (when repaid are subject to taxation. recommended by a physician to cure a specific ailment)

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•• Blood, blood plasma, or blood Examples of dental expenses that •• Cosmetic prescriptions and substitutes may be reimbursed if not covered by cosmetic dental procedures such •• Braces, appliances, or equipment, the Total Health Dental Plan or other as cosmetic tooth bonding or including procurement or use dental coverage include, but are not whitening •• Car controls for the handicapped limited to: •• Electrolysis (unless prescribed by a physician to treat a medical •• Charges in excess of usual and •• Anesthesia condition) customary fee limits •• Charges in excess of usual and •• Expenses claimed as a deduction or •• Chromosome or fertility studies customary fee limits •• Confinement to a facility primarily credit on your federal income tax •• Drugs and their administration return for screening tests and physical •• Experimental treatment therapy •• Expenses incurred before you •• Extra sets of dentures or other enrolled or after you terminated •• Copays for covered medical dental appliances expenses from the plan •• Medically necessary orthodontia •• Experimental treatment •• Expenses incurred before or after expenses for adults or dependents the end of the calendar year for •• Foot disorders and treatments •• Myofunctional therapy which the account was established for corns, bunions, calluses, and •• Orthodontia expenses structural disorders •• Expenses for which you do •• Replacement of dentures or not submit the appropriate •• Home health care, hospice care, bridgework less than five years old documentation nursing care, or home health care aides •• Replacement of lost, stolen, or •• Health club fees and exercise missing dentures or orthodontic classes •• Hypnosis for treatment of illness devices •• Marriage and family counseling •• Immunizations •• Tooth cleaning more than twice per •• Massage therapy (unless prescribed •• Learning disability tutoring or year. by a physician to treat a medical therapy condition) •• Nursing home care Please note that effective January 1, 2011, over-the-counter medications •• Medical, dental, or vision insurance •• Physical exams premiums •• Physical therapy sold without a prescription are no longer a reimbursable expense under •• Over the counter medications •• Prescription drug copays the flexible spending account. without prescription •• Prescription eyeglasses and contact •• Personal care items such as lenses Excluded Expenses cosmetics and toiletries •• Prescription vitamins Some health care expenses you •• Transportation expenses for the •• Psychiatric or psychological may incur are not eligible for handicapped to and from work counseling reimbursement. These expenses •• Vacation travel for health purposes •• Radial keratotomies and should not be included in your •• Vitamins and nutritional LASIK procedures to correct budgeting to determine the amount supplements you contribute to either spending nearsightedness •• Weight loss programs—program account. Excluded expenses include: •• Sexual dysfunctions or inadequacy fees are not eligible unless you treatments •• Medical expenses that have been have a letter of medical necessity •• Smoking cessation program costs, reimbursed through any other and diagnosis of obesity or if prescribed, and prescription policy, plan, or program including hypertension. Food and other costs nicotine withdrawal medications if Medicare or any other federal or are not reimbursable. prescribed by a physician state program •• Speech therapy Health Care Spending Account vs. •• Capital expenses Tax Deduction •• Syringes, needles, injections ––Air conditioning units If you pay eligible health care •• Transportation expenses to receive ––Structural additions or changes medical care, including fares for expenses through your Health Care ––Swimming pools public transportation and private Spending Account, you may not also ––Whirlpools take a deduction for these expenses Spending Accounts auto expenses (consult your tax advisor for the current IRS mileage •• Cosmetic medical treatments or on your tax return. However, if you allowance) surgery, other than those that choose to take the tax deduction are medically necessary due to instead of using the account, you may •• Weight loss programs—program accident, trauma, disease or birth deduct only expenses that are greater fees only with a letter of medical defect than 7.5% of your adjusted gross necessity and diagnosis of obesity income, provided that you itemize or hypertension deductions in your income tax return. •• Work-related sickness or injury (not covered by Workers’ Compensation).

102 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Flexible Spending Accounts

Example Changing Your Elections If you go on a leave of absence, payroll For example, if your adjusted gross You may change or revoke your deductions will be stopped. When income is $20,000, only medical previous election for Day Care you return from leave, the annual expenses of more than $1,500 can be Spending Account during the year and per pay period contribution will be deducted on your income tax return: make new election if you experience recalculated based on the number of 7.5% of $20,000 = $1,500 one of the following situations: pay periods left in the year.

If you are in a combined 22.65% tax •• The cost of dependent care You cannot contribute more than bracket (15% income tax + 7.65% FICA significantly increases or decreases your earned income or your spouse’s tax), that means you pay $339.75 more (you can change or revoke your earned income, whichever is less. in taxes by not reimbursing these previous election only if the provider For example, if your spouse works expenses through the Health Care is not your relative, as defined in the part-time and earns $2,000 a year, you Spending Account: 22.65% of $1,500 plan). can deposit no more than $2,000 a year into this account. Please consult = $339.75. •• You remove your child from a facility with a tax advisor to determine the •• You or your spouse quit working limitations that apply in this situation. DAY CARE SPENDING •• You experience a qualified status ACCOUNT change, as defined on pages 11 – 12. Because the IRS specifies that any unused money in your Day Care The Day Care Spending Account You must notify Human Resources, Flexible Spending Account is forfeited can be used to pay eligible child make your election, and provide at the end of the year, consider the or dependent care expenses using documentation of the reason for the following guidelines when enrolling in before-tax dollars while you (and your change within 31 days. If you do not this program: spouse, if you are married) are at work. provide the documentation, your new •• Carefully determine the number of If you are married, your spouse must election will be reversed. weeks of dependent day care you be either: How Much You May Contribute will purchase. Estimate and deduct •• Employed In general, you may contribute up to weeks that might include vacation, •• A full-time student at an $5,000 a year (a minimum of $130 illness, or occasions where your educational institution, or per year) to your Day Care Spending dependents might have free care. •• Unable to care for himself or Account. If you are married and you •• Don’t anticipate expenses you are herself because of a mental or and your spouse are both contributing not sure about, such as day care for physical condition. to a Day Care Spending Account a child not yet born. Birth of a child (regardless of whether your spouse is considered an eligible life event, Who Can Be Covered works for Texas Health or another so you may start participating in a You may claim day care expenses for employer), you and your spouse Day Care Flexible Spending Account your eligible dependents, including: have a combined contribution limit at that time. of $5,000. (The limit is per married •• You must be actively at work to •• Children under age 13 claimed as couple, not per individual.) The annual contribute. dependents on your federal income amount you contribute is divided tax return who spend at least eight equally among your paychecks. Unlike Federal law imposes certain non- hours a day in your home, and your Health Care Spending Account, discrimination tests that can limit the •• A person over age 13 (including your which is credited at the beginning of amount that highly compensated child, spouse or parent) if the person the year with the amount you have employees (as defined by the IRS) can meets all of the following criteria: elected to contribute for the full year, contribute to the Day Care Spending ––Lives with you and depends on your day care account is credited with Account. Generally, employees you for more than half of his or each payroll deduction. earning more than $120,000 in 2019 her financial support are considered highly compensated For example, if you elected to employees. If you are affected by ––Is physically or mentally incapable contribute $2,650 during open of self-care these limits, the plan administrator enrollment, that amount is divided by will notify you if and when the ––Spends at least eight hours a day 26 pay periods to figure your per-

maximum amount has been reached. Spending Accounts in your home, and pay-period deduction of $101.92. If Your contributions into the Day Care ––Is claimed as a dependent on your you enroll during the calendar year, Spending account will be stopped federal income tax return. the annual contribution you elect is for the remainder of the year. You divided by the number of pay periods may be taxed on the amount of your remaining in the calendar year. remaining contributions.

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Eligible Day Care Expenses •• Expenses claimed as a deduction or FILING CLAIMS credit on your federal income tax To qualify for reimbursement, care The Health Care and Day Care Flexible return must be provided by a licensed day Spending Accounts are administered •• Expenses incurred before you care facility or by an individual who is separately. You must submit claims to enrolled or after you terminated not your dependent. PayFlex to receive reimbursement for from the plan eligible health care and dependent day Expenses paid to the following •• Expenses incurred before or after care expenses. providers may be reimbursed through the end of the calendar year for your account if you can provide which the account was established Claims can be submitted multiple their Social Security or taxpayer •• Day care expenses that in any ways. identification number: calendar year are more than your •• Log in to PayFlex.com and select income or your spouse’s income •• A licensed child care center or adult File A Claim (whichever is less), unless you day care center, including a church •• PayFlex Mobile App or non-profit center are married and your spouse is a •• Fax to 402-231-4310 •• A baby sitter inside or outside your full-time student or mentally or •• Mail to: home if the sitter does not care physically disabled PayFlex Systems USA, Inc. for more than six children at a •• Expenses for which you do P.O. Box 981158 time (not including the sitter’s own not submit the appropriate El Paso, TX 79998-1158 dependents) documentation •• A housekeeper whose duties include •• Expenses for child care when your You may file claims for eligible dependent day care spouse is not actively at work expenses at any time during the plan •• A relative who cares for your (unless your spouse is a full-time year. Reimbursements are processed dependents but is neither your student or is mentally or physically Monday through Friday. After your spouse, your child, nor your disabled). claim is approved, either a check will be mailed to your home address or dependent Day Care Spending Account vs. •• Someone who cares for an elderly Federal Tax Credit your reimbursement will be direct or disabled dependent inside or deposited to your account. Federal tax laws allow you to take outside your home a tax credit for eligible dependent Health Care Spending Account •• Au pairs (foreign visitors to the care expenses. You may use both the After you have made your first deposit U.S. who perform day care and dependent day care tax credit and through payroll deduction, the entire domestic services in exchange the Day Care Spending Account, but amount you have agreed to deposit for living expenses), provided the not for the same expenses. Amounts for the calendar year is available for au pair agency is a non-profit reimbursed from your account are to reimbursement. Ongoing deposits organization or the au pair obtains a be deducted from your tax credit. will repay your account for earlier U.S. Social Security number for tax reimbursements you received. If you identification purposes In some cases, using the Day Care enroll in the plan during the year, you Spending Account saves you more. •• Facilities away from home, provided are eligible for reimbursement only of In other cases, you may save more by your dependent spends at least expenses you incur after becoming a taking the credit on your tax return. eight hours per day at home. plan participant. Because tax laws are complex and Excluded Expenses change from time to time, you should Before filing a claim for Some day care expenses you consult a tax advisor or contact the reimbursement from your account: may incur are not eligible for IRS to obtain Publication 503 at: IRS. reimbursement. Therefore, these gov/pub/irs-pdf/p503.pdf •• Pay your health care expense and expenses should not be included submit a claim to the appropriate in your budgeting to determine the Medical, Dental, or Vision Plan. amount you contribute to either If you are not required to submit spending account. Excluded expenses a claim for benefits (for example, include: when you pay a doctor’s office

Spending Accounts copay), keep your receipt from the •• Care provided by anyone you or service provider. your spouse claim as a dependent •• If you have other coverage, such as on your income tax return through your spouse’s employer, •• Care by occasional baby sitters you must first submit your claim to •• A facility or individual for whom that coverage and receive the other you cannot provide a taxpayer plan’s explanation of benefits (EOB) identification or Social Security before filing for reimbursement from number your Health Care Spending Account.

104 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Flexible Spending Accounts

•• If you incur an eligible expense for Pay your day care expenses to You appeal spending account claims which you have no coverage, you your provider and ask for a receipt. in the same way you appeal medical may submit the expense directly for You will only be reimbursed for claims (described beginning on page reimbursement. dependent day care expenses after 65) except you send a spending the actual care has been received. account appeal to PayFlex at the To submit a claim for eligible health above address. care expenses: To file a claim: For information on how to appeal a •• Complete a Flexible Spending •• Complete a Flexible Spending denied claim, see pages 65 – 69. Account Claim Form (available at Account Claim Form and attach BeHealthyTHR.org and PayFlex. original documentation of your WHEN COVERAGE ENDS com). expenses, such as a receipt •• Attach documentation of your from your day care provider. Coverage ends under the Flexible expenses, such as an original receipt Documentation must include Spending Accounts at the end of the from the medical service provider or the dependent care provider’s pay period in which you terminate your explanation of benefits (EOB) name and the dependent's age. A employment with Texas Health or from your plan. A canceled check canceled check is not acceptable stop your contributions. You have is not acceptable documentation. documentation. until March 31 of the following year Each bill or receipt must include: •• Mail or fax the completed claim to submit claims for dependent care ––Name of patient1 form and documentation to and health care expenses incurred before your termination or before you ––Date the treatment or service was PayFlex at the address or fax stopped your contributions. provided number on the claim form. ––Description of the treatment or Claim Filing Deadline You may continue to participate in service given the Health Care Spending Account You have until March 31, 2020 to ––Itemized charges for the by electing COBRA continuation submit claims for health care or day treatment or service coverage (see page 189). By making care expenses incurred: ––Provider’s name. this election, you may extend your •• Mail or fax the completed claim •• Between January 1, 2019 and participation in the Health Care form with the original itemized bills, March 15, 2020 FSA. Although you would now make Explanation of Benefits (EOB) and •• Before you stopped making contributions on an after-tax basis, receipts to PayFlex at the address or contributions because you by electing continuation of coverage fax number on the claim form. experienced a status change for this account you would still have the opportunity to file claims for •• The claims processor will determine during the year. reimbursement based on your account whether the expense is eligible for Filing and Appealing Health Care balance for the year. reimbursement. and Dependent Care Spending Day Care Spending Account Account Claims Unlike the Health Care Flexible Whenever you file a claim, be sure Spending Account, you may be to keep a copy of the claim and any reimbursed from the Day Care other information (such as itemized Account only up to the amount bills) that you include with the claim. you have actually deposited at the A canceled check is not acceptable time you submit the claim (less documentation. You should file your any claims that have already been spending account claims using the paid). If your account balance is less claim form found on BeHealthyTHR. than the amount you request, your org and PayFlex.com and send claims reimbursement will equal only the to: amount in your account. However, PayFlex Systems USA, Inc. unpaid amounts are automatically Flex Dept. paid as additional deposits are made P.O. Box 981158 to cover them. If you enroll in the El Paso, TX 79998-1158 Spending Accounts plan during the year, you are eligible Fax: 402-231-4310 for reimbursement only for expenses www.PayFlex.com you incur after becoming a plan participant.

1 Health care expenses for a domestic partner are not eligible for reimbursement through the Health Care Spending Account.

1-877-MyTHRLink (1-877-698-4754) MyTHR.org 105 Income Protection Income Protection Disability Coverage...... 107 Overview 107 Summary of Disability Benefits 107 Applicable Terms 108 Definition of Disability 109 Deductible Sources of Income 109 Short Term Disability (STD) 111 Long Term Disability (LTD) 112 Exclusions and Limitations 116 Filing STD and LTD Claims 116 When Coverage Ends 117 Converting Coverages 117 Life and Accident Coverage ...... 118 Overview 118 Summary of Benefits 118 Life Insurance 118 Accidental Death & Dismemberment (AD&D) Insurance 121 Business Travel Accident Insurance 125 Beneficiary Designation 126 Filing Claims 127 When Coverage Ends 128 Continuing Coverage 129

106 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Disability Coverage Disability Coverage

OVERVIEW SUMMARY OF Pre-existing Conditions Disability insurance coverage helps DISABILITY BENEFITS The Texas Health disability plan does you meet your financial obligations The table on the next page not require evidence of insurability. if you are unable to work due to your summarizes the disability benefits However, it does have certain own injury or illness. This coverage is available to eligible Texas Health limitations and exclusions for pre- an important element in your financial employees. existing conditions when you enroll planning because it provides a for the plan during open enrollment or continuing source of income if you are To make your disability benefits go add the benefit after a status change. unable to work because of a disability. further, you pay for disability coverage (New hire enrollment isn’t subject to Before choosing disability coverage, on an after-tax basis so that any pre-existing condition limitations for think about how you and your family disability benefits you receive are not Short Term Disability). would manage without your salary. taxable income. A pre-existing condition is any injury Disability coverage is provided by Base pay is your hourly rate times the or sickness for which you incurred Prudential. See pages 5 – 7 for number of hours you are classified in expenses, received medical treatment, information on eligibility. the HR/Payroll system to work and consultation, care or services To protect yourself and your family, that you were receiving on your last including diagnostic measures, or took full-time and part-time benefits- day as an active employee before the prescribed drugs or medicines within eligible employees (as defined on date of disability. Base pay does not 12 months before your most recent page 5) are eligible for the following: include shift differentials, bonuses, effective date of coverage. overtime earnings, commissions, or •• Short Term Disability (STD) with other compensation. Examples of pre-existing conditions a choice of a 14-day or 30-day include, but are not limited to, the elimination period You must have active disability following: •• Basic Long Term Disability (LTD) coverage on the date you become disabled to receive benefits. If you •• Illness •• Additional Long Term Disability. are absent from work due to illness •• Chronic medical conditions If you are a PRN, part-time benefits- or injury on the date your STD or LTD •• Pregnancy ineligible employee (as defined on coverage would otherwise become •• Mental health conditions. page 221), or medical resident/intern, effective, coverage becomes effective This limitation does not apply to a you are not eligible for STD, Basic only after you are actively at work for period of disability that begins after LTD, or Additional LTD. Physicians one full day. you have been covered for at least employed by THPG and THBC are Plan Administration 12 months (counted from your most covered by the STD policy described recent effective date of coverage or in this section, but are covered The Plan Administrator has delegated the effective date of any added or through a separate LTD policy and authority to the Prudential Insurance increased benefits). are not eligible for the Texas Health Company of America to provide claim Long Term Disability Plan. processing, claim investigation, claim If you have a disability that is caused control and the daily administration of by, contributed to, or the result of Coverage is effective on the first day the plan. a pre-existing condition within the of eligibility (see page 5). All decisions concerning the payment first 12 months after your coverage of claims under the plan are at the sole becomes effective under the disability discretion of the insurance company. plan, your STD benefit will be limited to 4 weeks (if you were not covered by STD within 12 months before your disability began). Income Protection

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If you elected the 30-day waiting APPLICABLE TERMS Material and substantial duties means period in 2018 and changed to the 14- duties that: Regular care means you personally day waiting period in 2019, your 2019 visit a doctor as frequently as is benefits for a pre-existing condition •• Are normally required for the medically required, according will be subject to the 30-day waiting performance of your regular to generally accepted medical period. If you become disabled in 2019 occupation; and standards, to effectively manage due to a condition that is not a pre- •• Cannot be reasonably omitted or and treat your disabling condition(s); existing condition, the 14-day waiting modified. and you are receiving the most period will apply. appropriate treatment and care, Illness means any disorder of your Example: If you become pregnant which conforms to generally body or mind, but not an injury; when you have the 30-day waiting accepted medical standards, for your pregnancy including abortion, period and elect the 14-day waiting disabling condition(s) by a doctor miscarriage, or childbirth. Disability period during open enrollment, your whose specialty or experience is the must begin while you are covered STD benefits related to the birth of most appropriate for your disabling under the plan. condition(s), according to generally your baby will be subject to the 30- Injury means a bodily injury that: day waiting period. accepted medical standards. •• Is the direct result of an accident; LTD plan benefits will not be paid for Regular occupation means the •• Is not related to any cause other any period of disability caused by, occupation you are routinely than the accident; and contributed to, or resulting from a performing when your disability pre-existing condition. begins. Prudential will look at your •• Results in immediate disability. occupation as it is normally performed instead of how the work tasks are performed for a specific employer or at a specific location.

Gainful occupation means occupation, including self-employment, that is or can be expected to provide you with an income within 12 months of your return to work, that exceeds:

•• 80% of your indexed monthly earnings, if you are working; or •• 50% (60% if you enrolled in additional LTD) of your monthly earnings, if you are not working.

Comparison of Disability Plans

Coverage When Benefits Begin When Benefits End Amount of Gross Benefit Short Term Disability After 14 continuous calendar See page 112 for a complete 60% of your base pay, up to 14-day elimination period days of disability explanation $1,700 per week and reduced for certain earnings Short Term Disability After 30 continuous calendar See page 112 for a complete 60% of your base pay, up to 30-day elimination period days of disability explanation $1,700 per week and reduced for certain earnings Basic Long Term Disability After 180 continuous days of See page 115 for a complete 50% of your base pay, up to disability or after STD benefits explanation $15,000 per month end Spending Accounts Additional Long Term The same date Basic LTD The same date Basic LTD 10% of your base pay, Disability benefits begin benefits end combined with Basic LTD for a total of 60% of your base pay, up to $15,000 per month Income Protection

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DEFINITION OF DISABILITY •• You are unable to perform the DEDUCTIBLE SOURCES OF duties of any gainful occupation STD INCOME for which you are reasonably The STD plan considers you to be fitted by education, training or Prudential will deduct from your disabled if you are not able to perform experience; and gross disability payment the following deductible sources of income: the material and substantial duties •• You are under the regular care of a of your regular occupation only doctor. 1. The amount that you receive or are because of disease or injury and •• You must be under the appropriate, entitled to receive as loss of time you are not working at any job. After regular care for your condition from benefits under: the elimination period, you could a licensed physician who is not you a. A workers’ compensation law; still meet this definition if you are or a member of your family. performing some of those duties, b. An occupational disease law; or provided you are earning less than If your occupation requires a c. Any other act or law with similar 80% of your pre-disability base pay professional or occupational license or intent. only because of your disease or injury. certification of any kind, the LTD plan 2. The amount that you receive or are does not consider you to be disabled entitled to receive as loss of time You must be under the appropriate, solely because you lose your license disability income payments under regular care for your condition from or certification. any: a licensed physician who is not a. State compulsory benefit act you or a member of your family. The insurance carrier has the right to or law Prudential can request examinations ask you to undergo an examination b. Insurance or a health or welfare as often as it is reasonable to do by the physician of its choice to plan or other group insurance so. You may also be required to confirm your disability. Prudential can plan where Texas Health be interviewed by an authorized request examinations as often as it Resources, directly or indirectly, Prudential representative. Refusal is reasonable to do so. You may also has paid all or part of the cost to be examined or interviewed may be required to be interviewed by an or made payroll deductions result in denial or termination of your authorized Prudential representative. claim. Refusal to be examined or interviewed 3. The gross amount that you, your may result in denial or termination spouse, and children receive or are If your occupation requires a of your claim. You are responsible entitled to receive as loss of time professional or occupational license for providing documentation of your disability payments because of or certification of any kind, the STD disability to the insurance carrier. your disability under: plan does not consider you to be a. The United States Social disabled solely because you lose your You may be considered disabled Security Act license or certification. during and after the elimination period b. Governmental Retirement Plan during any week in which you are c. The Railroad Retirement Act LTD employed if an injury or sickness is d. The Canada Pension Plan From the date that you first become causing physical or mental impairment disabled and until monthly benefits that is severe enough that you are e. The Quebec Pension Plan or are payable for 24 months, the LTD unable to earn at least 80% of your f. Any similar plan or act. plan considers you to be disabled on base pay in any occupation for which Amounts paid to your former any day if: you are qualified by education, spouse or to your children living training, or experience. with such spouse will not be •• You are not able to perform the included. material and substantial duties of You are not considered disabled if 4. The gross amount that you receive your regular occupation due to you are able to earn more than 80% as retirement payments or the sickness or injury and of your base pay. Base pay is your gross amount your spouse and •• Your work earnings are 80% or less hourly rate times the number of children receive as retirement of your adjusted pre-disability base hours you are classified to work in the payments because you are pay, and HR/Payroll system. Base pay does not receiving payments under: •• You are under the regular care of a include shift differentials, bonuses, a. The United States Social doctor. overtime earning, commissions, or Security Act any other compensation. It does not After 24 months of payments, you are include PTO pay. If you receive a b. Governmental Retirement Plan disabled when Prudential determines lump sum payment, it will be prorated c. The Railroad Retirement Act that due to the same sickness or over the time it accrued or the period d. The Canada Pension Plan injury: for which it was paid. e. The Quebec Pension Plan or f. Any similar plan or act. Income Protection

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Benefits paid to your former We will not reduce your payment If your payment has been reduced spouse or to your children living by your Social Security retirement by an estimated amount, your with such spouse will not be payments if your disability begins payment will be adjusted when we included. after age 65 and you were receive proof: Disability payments under a already receiving Social Security ŒŒ Of the amount received or retirement plan will be those retirement payments. ŒŒ That benefits have been denied. benefits which are paid due to If Prudential determines that you In this case, a lump sum refund disability and do not reduce the may qualify for benefits under 1, of the estimated amount will be retirement benefits which would 2 or 3 in the deductible sources made to you. have been paid if the disability had of income section, Prudential will Prudential will not deduct from not occurred. estimate your entitlement to these your gross disability payment Amounts received do not include benefits. Prudential can reduce income you receive from, but not amounts rolled over or transferred your payment by the estimated limited to, the following sources: to any eligible retirement plan. amount if such benefits have not ŒŒ 401(k) plans been awarded. Prudential will use the definition of ŒŒ Profit sharing plans eligible retirement plan as defined However, Prudential will NOT ŒŒ Thrift plans in Section 402 of the Internal reduce your payment by the ŒŒ Tax sheltered annuities Revenue Code including any estimated amount under item 1 future amendments which affect or 2 in the deductible sources of ŒŒ Stock ownership plans the definition. income section if you: ŒŒ Non-qualified plans of deferred 5. The amount you receive under the ŒŒ Apply for the benefits compensation maritime doctrine of maintenance, ŒŒ Appeal any denial to all ŒŒ Pension plans for partners wages and cure. This includes only administrative levels Prudential ŒŒ Military pension and disability the “wages” part of such benefits. feels are necessary and income plans 6. The amount that you receive, ŒŒ Sign Prudential’s ŒŒ Credit disability insurance due to your disability, from a third Reimbursement Agreement ŒŒ Franchise disability income party (after subtracting attorney’s form. This form states that plans fees) by judgment, settlement or you promise to pay us any ŒŒ No-fault motor vehicle otherwise overpayment caused by an insurance award. 7. The amount of loss of time ŒŒ A retirement plan from another benefits that you receive or are If your payment has been reduced employer by an estimated amount, your entitled to receive under any salary ŒŒ Individual retirement accounts payment will be adjusted when continuation or accumulated (IRA). sick leave to the extent that your Prudential receives proof: weekly payment and deductible ŒŒ Of the amount awarded or sources of income, including any ŒŒ That benefits have been denied other group disability benefits, and all appeals Prudential exceed or would exceed 100% of feels are necessary have been your weekly earnings completed. In this case, a lump 8. The amount that you receive from sum refund of the estimated a partnership, proprietorship or amount will be made to you. any similar draws If Prudential determines that you 9. The amount that you receive or may qualify for benefits under item are entitled to receive under any 6 or 8 in the deductible sources unemployment income act or law of income section, Prudential will due to the end of employment estimate your entitlement to these with Texas Health Resources. benefits. Prudential can reduce With the exception of retirement your payment by the estimated payments, or amounts that amount if such benefits have not

Spending Accounts you receive from a partnership, been received. proprietorship or any similar draws, Prudential will only subtract deductible sources of income which are payable as a result of the same disability. Income Protection

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SHORT TERM DISABILITY Benefits You may receive Paid Time Off (PTO) (STD) Your STD benefits begin after the or benefits from the Sick Leave Bank/ EIB while receiving STD benefits, up Short Term Disability coverage is an elimination period and continue for up to 24 weeks following the to a combined total of 100% of your insurance benefit that replaces 60% base pay. of your base pay, up to $1,700 per 14 calendar day elimination period week if you elect coverage under this or for up to 22 weeks following the During your 30-day or 14-day plan and you become disabled while 30 calendar day elimination period, elimination period, you must use Paid covered. You may choose: provided you remain disabled for Time Off (PTO) benefits if you have that period. You will be required over 80 hours in your PTO bank. After Waiting Period 14 days 30 days to provide proof of your disability meeting the waiting period, you may from time to time. STD benefits are Maximum 24 22 only receive a PTO amount (40%) that, not guaranteed. Contributions are number of weeks weeks weeks when combined with STD benefit, required for your coverage while you that benefits will does not exceed 100% of your pre- are receiving payments under this disability earnings. be paid plan. Prudential has the right to recover Premium Costs More Less STD benefits are based on your base any overpaid benefits. To collect an than than pay for which you paid premiums, as overpayment, Prudential may request the the reported to the insurance company. a lump sum payment, reduce any 30-day 14-day If you are disabled, you may receive a option option amounts payable under this plan, and/ weekly benefit. STD benefits are paid or take appropriate collection activity. You pay for STD coverage with after- by the insurance company, not Texas tax payroll deductions. Your cost is Health. The weekly benefit is equal If you are disabled for part of a week, based on your current annual base to 60% of your current base pay for your STD benefit will be prorated. pay. If you receive an increase or one week, up to a maximum benefit The minimum weekly payment is $25. decrease in pay during the year, your of $1,700 per week, less other income Prudential may apply this amount STD payroll deduction will change at benefits you receive (as explained on toward an outstanding payment. page 109 under “Deductible Sources the same time. Return to Work Incentive of Income”). Base pay is determined When Benefits Begin on your last day as an active employee You may receive STD benefits if you You must meet all of the following before the date of disability. Base pay are disabled after the STD plan’s requirements to receive STD benefits: does not include shift differentials, elimination period and continue bonuses, overtime earnings, working, or return to work on a •• You have STD coverage in force on commissions, or other compensation limited basis. The weekly benefit is the date you become disabled and paid to you. Benefits are paid for each reduced only if the total of your pay on the date the elimination period week for which you are qualified. from working plus your STD benefit begins payable exceeds 100% of your pre- •• You are receiving appropriate and Your STD benefits will begin only disability base pay. Periodically, the regular care for your condition from after you have completed the 14 or insurance company will review your a doctor who is someone other 30 calendar day elimination period status and will require satisfactory than you or your immediate family and your health care provider has proof of earnings and continued and whose specialty or expertise submitted necessary proof of medical disability. is the most appropriate for your care to support the claim. disabling condition(s) according No disability benefit will be paid Weekly income benefits are paid for to generally accepted medical and benefits will end if Prudential the period for which you qualified. practice. determines you are able to work Your weekly benefit is reduced by any under a modified work arrangement The elimination period is the length disability retirement, unemployment and you refuse to do so without good of time you must be continuously benefit paid by law or Social Security cause. disabled before you qualify to disability or retirement benefits you receive benefits (either 14 or 30 or your dependents receive on your days). The elimination period begins own behalf or for your dependents on the first day you are determined because of your disability. The weekly to be disabled. Your disability benefit will also be reduced by any must continue through the entire disability or unemployment benefits elimination period. paid as a result of employment with Texas Health or as a result of membership with any group or organization or any retirement benefits paid after age 65. Income Protection

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Successive Disabilities LONG TERM DISABILITY When Benefits Begin A successive disability is a second (LTD) LTD benefits begin after you have disability due to the same cause as Texas Health automatically provides been continuously disabled for 180 the first disability, you return to active you with Basic LTD coverage on your consecutive days or reached the end employment at Texas Health for 30 first day of eligibility. Basic LTD begins of your STD benefits (whichever is consecutive days or less, and/or if paying benefits if you remain disabled later). This is called your elimination during that 30-day period you earn after you have completed the 180-day period. less than 80% of your pre-disability elimination period. LTD replaces 50% pay during at least one week. A You must meet all of the following of your base pay, up to $15,000 per requirements: successive disability has: month. •• No additional elimination period •• Your disability starts while you are You can increase your LTD coverage covered under the LTD plan. •• The same maximum benefit period to a total of 60% of your base pay •• Your disability continues during and as the previous disability. by purchasing Additional LTD. This past the elimination period. plan pays an additional 10% of your For any separate period of disability •• You meet the LTD plan’s eligibility base pay in addition to Basic LTD, up that is not considered continuous, requirements described on page to a combined total of $15,000 per you will be required to complete a 112. month. new elimination period. •• You are under the appropriate care LTD does not cover pre-existing When STD Benefits End of a physician. conditions. A condition is considered Your disability benefits will end on the pre-existing if you incurred expenses, You must provide satisfactory proof of earliest of the following events: received medical treatment, care, disability before benefits will be paid. •• You earn more than 80% of your consultation or services including Benefits diagnostic measures, or took pre-disability base pay from any The basic monthly LTD benefit is occupation prescribed drugs or medicines within 12 months before the effective date of equal to 50% of your current base pay, •• Prudential determines you are not your LTD coverage. A condition is not up to a maximum benefit of $15,000 disabled considered pre-existing if it causes per month, less other income •• You reach the end of the maximum a disability that begins after the LTD benefits you are eligible to receive as benefit period coverage has been in force for at least described earlier in this section. If you •• Your death 12 months or at least 12 months after purchase Additional LTD coverage, •• You refuse, without good cause, the effective date of any added or your benefit will be equal to 60% to fully cooperate in all required increased benefits. of your base pay, up to a combined phases of the rehabilitation plan maximum benefit of $15,000 per and assessment Texas Health pays the full cost of month. Base pay does not include •• You are no longer receiving Basic LTD coverage. You pay for shift differentials, bonuses, overtime appropriate care Additional LTD with after-tax payroll earnings, commissions, or other deductions. Your cost is based on compensation paid to you. Base pay •• You fail to cooperate with your current annual base pay. If you is determined on your last day as an Prudential in the administration receive an increase or decrease in active employee before the date of of the disability claim, including, pay during the year, your LTD payroll disability. but not limited to, providing any deduction will change at the same information or documents needed time. The minimum monthly benefit to determine whether benefits payable is the greater of $100 or are payable or the actual benefit Physicians employed by THPG are 10% of your gross monthly benefit. amount due. covered by the STD policy described Benefits are paid at the end of each •• During a period of incarceration as in this section, but are covered month for the period for which you a result of a conviction. through a separate LTD policy and are qualified. not eligible for the Texas Health Long Benefits may be resumed if you begin Term Disability Plan. Contact Human As described previously, your LTD

Spending Accounts to fully cooperate in the rehabilitation Resources for more information on benefit is reduced by other income plan within 30 days of the date the Physician LTD policy. benefits such as disability, retirement, benefits terminated. or unemployment benefits for which you may be eligible due to your If your STD coverage terminates disability. This does not include during a period of disability that any Social Security benefits you began while you were eligible for were receiving before your date of coverage, STD benefits will continue disability. as long as you remain disabled up to the 180-day maximum. The LTD benefit will be prorated for any period less than one month. Income Protection

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Duration of Benefits 1. Subtract your disability earnings When this occurs, Prudential will Prudential will send you a payment from your indexed monthly reimburse Texas Health Resources for each month up to the maximum earnings. the cost of the modification up to the period of payment. Your maximum 2. Divide the answer in item 1 by your greater of: indexed monthly earnings. This is period of payment is: •• $1000 or your percentage of lost earnings. •• The equivalent of two months of Your Age on Date Your Maximum 3. Multiply your monthly payment by your gross disability payment. Disability Begins Period of Benefits the answer in item 2. Under age 61 To your normal This benefit is available to you on a This is the amount Prudential will pay retirement age*, one-time-only basis. but not less than you each month. 60 months Rehabilitation During Disability Age 61 To your normal If your monthly disability earnings retirement age*, exceed 80% of your indexed monthly Prudential will review your file, but not less than earnings, Prudential will stop sending medical and vocational information 48 months you payments and your claim will to determine if rehabilitation services Age 62 To your normal end. might help you return to work. retirement age*, but not less than Prudential may require you to send Once the initial review is completed 42 months proof of your monthly disability by our rehabilitation program Age 63 To your normal earnings on a monthly basis. We will specialists working along with retirement age*, adjust your payment based on your your doctor and other appropriate but not less than 36 months monthly disability earnings. As part specialists, Prudential may elect to of your proof of disability earnings, offer you and pay for a rehabilitation Age 64 To your normal retirement age*, Prudential can require that you program. If the rehabilitation program but not less than send appropriate financial records, is not developed by Prudential’s 30 months including copies of your IRS federal rehabilitation program specialists, you Age 65 24 months income tax return, W-2’s and 1099’s, must receive written approval from Age 66 21 months which we believe are necessary to Prudential for the program before it substantiate your income. Salary begins. Age 67 18 months continuance paid to supplement Age 68 15 months The rehabilitation program may your disability earnings will not include, but is not limited to, the Age 69 and over 12 months be considered payment for work following services: performed. *Your normal retirement age is your retirement •• Coordination with Texas Health to age under the Social Security Act where Periodically, Prudential will review retirement age depends on your year of birth. assist you to return to work your status and will require •• Evaluation of adaptive equipment to Return to Work Incentive satisfactory proof of earnings and allow you to work continued disability. If you are disabled after the LTD plan’s •• Vocational evaluation to determine elimination period, you may continue If Prudential determines you are how your disability may impact working or return to work on a limited able to work under a modified work your employment options basis and also receive LTD benefits. arrangement and you refuse to do •• Job-placement services so without good cause, no disability During the first 24 months in which •• Resume preparation benefit will be paid and coverage will disability benefits are payable, the •• Job seeking skills training end. disability benefit is reduced only if the •• Retraining for a new occupation or total of your pay from working plus Worksite Modification Benefit •• Assistance with relocation that your LTD benefit payable exceeds A worksite modification might be may be part of an approved 100% of your pre-disability base pay. what is needed to allow you to rehabilitation program. After 24 months of payments, while perform the material and substantial If at any time, you decline to take part working, you will receive payments duties of your regular occupation in or cooperate in a rehabilitation based on the percentage of income with Texas Health Resources. One of evaluation/assessment or program you are losing due to your disability. Prudential’s designated professionals that Prudential feels is appropriate will assist you and Texas Health to for your disability and that has been identify an agreeable modification approved by your doctor, Prudential that is likely to help you remain will cease paying your monthly at work or return to work. This benefit. agreement will be in writing and must be signed by you, Texas Health Resources, and Prudential. Income Protection

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Rehabilitation, Spouse/Elder Care •• No additional elimination period treated by a mental health provider and Day Care Payment •• The same maximum benefit period or other qualified provider using Prudential will send you a as the previous disability. psychotherapy, psychotropic rehabilitation payment, day care drugs, or other similar methods of For any separate period of disability payment, or Spouse/Elder Care treatment as standardly accepted in that is not considered continuous, payment each month up to the the practice of medicine. you will be required to complete a maximum period of eligible payment Prudential will not apply the mental new elimination period. while you are: illness limitation to dementia if it Limited Benefits is a result of: stroke; trauma; viral •• Receiving long term disability infection; Alzheimer’s disease; or •• Mental or Nervous Disorders: benefits under the plan; and other conditions not listed which Disabilities which, as determined •• Participating in a rehabilitation are not usually treated by a mental by Prudential, are due in whole or program that has been approved by health provider or other qualified part to mental illness have a limited Prudential. provider using psychotherapy, pay period during your lifetime. The psychotropic drugs, or other Your maximum period of limited pay period for mental illness similar methods of treatment as rehabilitation payment, day care is 24 months during your lifetime. standardly accepted in the practice payment, or spouse/elder care Prudential will continue to send of medicine. payment is 6 months. you payments for disabilities due in whole or in part to mental illness Catastrophic Disability Benefit •• The monthly rehabilitation beyond the 24-month period if you payment is equal to 5% of your Prudential will pay an additional meet one or both of the following monthly payment. But the monthly 10% of your monthly earnings, but conditions: rehabilitation payment, together not more than $5,000 if you suffer ––If you are confined to a hospital with your monthly payment, will from a Catastrophic Disability due or institution at the end of the not exceed the maximum monthly to the same sickness or injury that 24-month period, Prudential will benefit. caused your disability. You are continue to send you payments •• The monthly day care payment catastrophically disabled when you: during your confinement. If you is equal to the amount of your are still disabled when you are •• Are unable to perform, without eligible day care expenses up to discharged, Prudential will send substantial assistance, at least two the maximum monthly day care you payments for a recovery activities of daily living or amount which is $500 times the period of up to 90 days. If you •• Have a severe cognitive impairment, number of eligible children. Eligible become reconfined at any time which requires substantial children means your children age during the recovery period and supervision to protect you from 12 and under who live with you. remain confined for at least 14 threats to health and safety. •• The monthly spouse and elder care days in a row, Prudential will send payment is equal to the amount payments during that additional You will begin to receive catastrophic of your eligible spouse and elder confinement and for one disability payments when Prudential care expenses up to the maximum additional recovery period up to approves your claim, providing: monthly spouse/elder care amount 90 more days. •• You are receiving long term which is $500 times the number ––If, after the 24-month period disability benefits under the plan of eligible family members. Eligible for which you have received and family member means each of the payments, you continue to following family members who •• You have had your catastrophic be disabled and subsequently have a chronic illness or disability: disability for a period of at least 30 become confined to a hospital spouse, parents/grandparents who consecutive days. or institution for at least 14 days live with you; and spouse’s parents/ in a row, Prudential will send Substantial assistance means: grandparents who live with you. payments during the length of •• The physical assistance of another the confinement. Successive Disabilities person without which you would A successive disability is a second Mental illness means a psychiatric not be able to perform an activity of Spending Accounts disability due to the same cause as or psychological condition daily living or the first disability that occurs less than regardless of cause. Mental illness •• The constant presence of another six consecutive months after you have includes but it is not limited to person within arm’s reach which is returned to your regular job from schizophrenia, depression, manic necessary to prevent, by physical the first disability, and/or during that depressive or bipolar illness, intervention, injury to you while you six month period you earn less than anxiety, somatization, substance are performing an activity of daily 80% of your pre-disability pay during related disorders and/or adjustment living. at least one month. A successive disorders or other conditions. disability has: These conditions are usually Income Protection

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Activities of daily living means: Social Security Claimant If your monthly benefit payments are Assistance Program more than you are entitled to receive, •• Bathing – washing oneself by Prudential can arrange for expert the plan has the right to apply the sponge bath, or in either a tub advice regarding your Social Security overpayment towards the survivor or shower, including the task of disability benefits claim and assist you benefit. getting in or out of the tub or with your application or appeal, if you shower When LTD Benefits End are disabled under the plan. •• Continence – the ability to Your LTD benefits automatically end maintain control of bowel and Receiving Social Security disability on the earliest of the following dates: bladder function; or when unable benefits may enable: to maintain control of bowel or •• You earn more than 80% of your bladder function, the ability to •• You to receive Medicare after 24 pre-disability base pay from any perform associated personal months of disability payments occupation hygiene (including caring for •• You to protect your retirement •• The insurance company determines catheter or colostomy bag) benefits and you are not disabled •• Dressing – putting on and taking •• Your family to be eligible for Social •• The end of the maximum benefit off all items of clothing and any Security benefits. period necessary braces, fasteners, or We can assist you in obtaining Social •• You die artificial limbs Security disability benefits by: •• You refuse, without good cause, •• Eating – feeding oneself by to fully cooperate in all required getting food into the body from a •• Helping you find appropriate legal phases of the rehabilitation plan receptacle (such as a plate, cup, representation and assessment or table) or by feeding tube or •• Obtaining medical and vocational •• You are no longer receiving intravenously evidence and appropriate care •• Toileting – getting to and from the •• Reimbursing pre-approved case •• You fail to cooperate with toilet, getting on and off the toilet, management expenses. Prudential in the administration and performing associated personal of the disability claim, including, hygiene Survivor Income Benefit but not limited to, providing any •• Transferring – sufficient mobility to If you die while disabled, a single, information or documents needed move into or out of bed, chair, or lump sum benefit will be paid under to determine whether benefits wheelchair or to move from place this provision if your disability are payable or the actual benefit to place, either by walking, using a had continued for 180 or more amount due. wheelchair or by other means. consecutive days and you were •• During incarceration as a result of a receiving, or were entitled to receive, conviction Cognitive impairment means a loss or payments under the plan. The deterioration in intellectual capacity •• During the first 24 months of survivor income benefit will equal that is: payments, when you are able to 100% of the sum of the last full work in your regular occupation on •• Comparable to and includes disability benefit payable to you plus a part-time basis but you choose Alzheimer’s disease and similar the amount of any earnings from not to work by which the benefit had been forms or irreversible dementia and •• After 24 months of payments, when reduced for that month. A single lump •• Measured by clinical evidence and you are able to work in any gainful sum payment equal to three monthly standardized tests that reliably occupation on a part-time basis but survivor income benefits will be measure impairment in the you choose not to. individual’s short-term or long-term payable. Benefits may be resumed if you begin memory, orientation as to person, The survivor income benefit will be to cooperate fully in the rehabilitation place or time; and deductive or paid to your spouse. If you do not plan within 30 days of the date abstract reasoning. have a spouse, the benefit will be paid benefits are terminated. Substantial supervision means to your surviving children (including continual oversight that may include step-children) under age 25. If you do cueing by verbal prompting, gestures, not have a spouse or eligible children, or other demonstrations by another the benefit will be paid to your estate. person, and which is necessary to The benefit will be paid as soon as protect you from threats to your Prudential receives the necessary health and safety. written proof of your death and disability status. Income Protection

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EXCLUSIONS AND Important Information for Claim Filing Deadline LIMITATIONS Residents of Certain States You must call Prudential within 30 There are state-specific requirements Disability benefits will not be paid days of the date of disability for STD that may change the provisions for a disability resulting directly or and within 30 days after you become under the coverage(s) described indirectly from: disabled for LTD. in this handbook. If you live in a •• Suicide, attempted suicide, or self- state that has such requirements, Proof of Disability inflicted injury while sane or insane those requirements will apply to For STD, you must provide written •• War or any act of war, whether or your coverage(s) and are made proof of your disability before not declared a part of your group insurance payment of benefits can be approved. •• Active participation in a riot certificate. Prudential has a website Your claim will be denied if you do that describes these state-specific not provide written proof in a timely •• Commission of a crime for which requirements. You may access the manner. Prudential may request that you have been convicted under website at www.prudential.com/ you must provide the information state or federal law etonline. When you access the listed below, at your expense, as part The following exclusions apply only website, you will be asked to enter of your proof of disability. Failure to to STD: your state of residence and your provide all of this information may Access Code. Your Access Code is delay, suspend, or terminate your •• Work-related injury or sickness 52002. benefits. and/or one in which you are For LTD, you must provide the claims entitled to benefit from workers FILING STD AND LTD CLAIMS compensation. administrator with written proof of To initiate your claim for STD or your disability within 90 days after the In addition, STD or LTD benefits will LTD benefits, you are responsible end of your elimination period. If it is not be paid for any period of disability for contacting the insurance carrier not possible to provide proof within during which you are incarcerated in within 31 days of the start of your 90 days, the claim is not affected if a penal or corrections institution. leave of absence. Contact Prudential. you give proof as soon as possible. However, unless you are legally The following exclusions and You, your medical provider, and incapacitated, you must provide proof limitations apply only to the LTD plan: Texas Health will need to provide the no later than one year after it is due. insurance carrier or its authorized •• Disability beyond 24 months Otherwise late claims will not be agent with required information on (after the elimination period) if it is covered. because of certain mental disorders your claim as soon as possible. If listed on page 114. Confinement you are not able to meet the filing See page 202 for information on what in a hospital or institution licensed deadline, through no fault of your to do if your claim is denied. own, your claim will be accepted if to provide care and treatment for Your written description may include: mental illness will not be counted you file as soon as possible. as part of the 24-month limit. Unless you are legally incapacitated, •• The prognosis of your disability •• Substance use disorder related late claims will not be covered if they •• Proof that you are receiving regular disability (drug or alcohol). In no are filed more than one year after the and appropriate care for your event will LTD monthly benefits filing deadline. Contact Prudential at condition from a doctor whose be paid for substance use disorder 1-877-MyTHRLink, prompt 6, then 7 specialty is most appropriate for beyond the earliest of the date you: for additional information on filing a your disabling condition according ––Have received 24 LTD monthly disability claim. to generally accepted medical benefit payments practice (The doctor may not be a The STD, Basic LTD, and Additional ––Have reached the maximum member of your immediate family.) LTD plans are fully insured plans and period payable •• Objective medical findings that benefits are paid by Prudential. ––Refuse to participate in an support your disability, such as appropriate, available treatment You may be asked for additional tests, procedures, or clinical program or you leave the information about your disability. examinations that are accepted as Spending Accounts treatment program before You will be notified of the decision standard medical practice for your completing it regarding your claim. Notification disabling condition ––Are no longer following the and/or payment are made directly •• A description of the extent of your requirements of your treatment to you. You must notify Prudential disability, including restrictions plan under the program immediately when you return to work and limitations that are preventing you from performing your regular ––Complete the initial treatment in any capacity. occupation plan, not including any aftercare or follow-up services. Income Protection

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•• Appropriate documentation of your Timing of Claim Payments If you apply more than 31 days after base pay and, if applicable, regular The claims administrator will begin coverage ends under this plan, you monthly documentation of your paying benefits after your elimination will be required to submit satisfactory disability earnings period after receiving and approving evidence of good health at your own •• The name and address of any your claim. Benefits will continue as expense. Conversion coverage will doctor, hospital or health care long as you continue to qualify up to be effective on the date Prudential facility where you have been the maximum period. agrees in writing to insure you. treated for your disability. Prudential will send a payment to you Prudential will determine the Authorization and Documentation every two weeks for any period for coverage you will have under the conversion policy. The conversion You may be required to supply the which Prudential is liable. policy may not be the same coverage following: Your benefits are not assignable, we offered you under your Employer’s •• Signed authorization for the claims which means you may not transfer group plan. Premiums will be based administrator to obtain and release your benefits to anyone else. on the rates in effect for conversion all reasonably necessary medical, plans at that time. financial, or other non-medical WHEN COVERAGE ENDS You may not convert your Additional information that supports your Generally, coverage for you under LTD coverage if: disability claim. Failure to submit the STD Plan and the LTD Plan ends this information may deny, suspend, when you are no longer eligible for •• You are age 70 or older; or terminate your benefits. coverage, you do not elect coverage, •• You are disabled under the terms of •• Proof that you have applied for you do not pay your premiums, or the plan all other applicable deductible you terminate employment with Texas •• The policy is cancelled for any income benefits such as Workers’ Health. reason Compensation or Social Security •• You are no longer in an eligible disability benefits CONVERTING COVERAGES class of employees, even though •• Objective medical findings that you work for Texas Health. support your disability, such as Short Term Disability Coverage •• You are or become insured tests, procedures, or clinical You may not convert STD coverage under another group long term examinations that are accepted as to an individual policy when your disability plan within 60 days after standard medical practice for your coverage under the Texas Health STD employment ends. disabling condition Plan ends. •• A description of the extent of your Long Term Disability Coverage disability, including restrictions and limitations that are preventing If your coverage under the plan ends you from performing your regular because your employment ends or occupation you have been laid off, you may be •• Appropriate documentation of your eligible to convert your Additional base pay and, if applicable, regular LTD coverage without any evidence of monthly documentation of your insurability. disability earnings To be eligible to convert, you must: •• The name and address of any hospital or health care facility •• Have been covered by the LTD plan where you have been treated for and actively at work for at least 12 your disability consecutive months •• Notification to the claims •• Make application for conversion administrator when you are insurance within 60 days after awarded other income benefits, coverage under the Texas Health including the nature of that group LTD plan ends. benefit, the amount, the period for •• Pay the first premium to Prudential which the benefit applies, and the within 31 days after the date of the duration of the benefit if it is being first billing statement. paid in installments. Conversion coverage will be effective as of the date coverage ends under this plan. Income Protection

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OVERVIEW SUMMARY OF BENEFITS You rely on your paycheck to meet When you make your benefit decisions, you should consider those who daily living expenses. A severe might be affected by your disability or death. accidental injury or your death could jeopardize your family’s financial Pays this security. If death or injury occurs, If you: This policy: benefit: To: your family needs protection. Die Life Insurance Full benefit amount Your beneficiary Texas Health pays the full cost of Die in an accident Life Insurance and Full benefit amount Your beneficiary the following benefits for full-time AD&D Insurance and part-time benefits-eligible Suffer a covered AD&D Percentage of total You employees: dismemberment benefit amount

•• Basic Life Insurance •• Basic Accidental Death and If you are absent from work because LIFE INSURANCE Dismemberment (AD&D) Insurance of sickness or injury on the date Your financial plan should include your Life and/or AD&D coverage or •• Business Travel Accident Insurance. tools to help your family deal not only increase in coverage would otherwise with your own death, but also with Coverage is effective on your first day become effective, your effective date the death of a spouse or child. Texas of eligibility (see page 5). will be deferred until you return to Health provides Basic Life coverage for active service. Full-time and part-time benefits- you, and you can purchase coverage eligible employees may purchase the All Life and AD&D claims are for your spouse and children. You may following benefits: calculated using your annual base also increase your own coverage by pay at the time of your loss. Annual purchasing Additional Life Insurance. •• Additional Life Insurance base pay is your hourly rate of pay •• Dependent Life Insurance Life Insurance cost each year is based times the number of hours you are on your age as of January 1 and your •• Additional AD&D Insurance. classified in the HR/Payroll system annual base pay.1 If you receive an to work. Base pay does not include If you and your spouse both work increase or decrease in your base pay shift differentials, bonuses, overtime for Texas Health and are eligible during the year, your Life Insurance earnings, commissions, or other for Flexible Benefits, you cannot be coverage will change at the same compensation paid to you. Benefit covered both as an employee and a time. Your new rate for coverage will amounts are rounded to the next dependent on the same plan. Also, become effective the same pay period highest $1,000. only one of you may cover your as your change in pay. children. Plan Administration Basic Life Insurance If you and your benefits-eligible child The Plan Administrator has delegated Texas Health pays the full cost of work for Texas Health, your child authority to the Prudential Insurance Basic Life Insurance coverage for full- cannot be covered as an employee Company of America to provide claim time and part-time benefits-eligible and a dependent on the same plan. processing, claim investigation, claim employees. If you die, your beneficiary Therefore, you cannot cover this control and the daily administration of will receive a benefit equal to one child for child life insurance or family the plan. times your annual base pay, up to AD&D. All decisions concerning the payment $50,000. If you have been diagnosed If your spouse is a former Texas of claims under the plan are at the sole as terminally ill, you may also qualify Health employee approved for discretion of the insurance company. for an Accelerated Payment of Death premium waiver life insurance Benefits, as explained later in this through Texas Health, you can not section. Spending Accounts cover your spouse as a dependent.

1 Base pay for physicians employed by THPG is based on the previous year's earnings. THPG physician's life insurance premium will not change during the year unless there is a loss of benefits eligibility or the physician is within the first year of employment. Income Protection

118 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Life and Accident Coverage

Additional Life Insurance If your application is automatically Child life coverage for your fully If you are a full-time or part-time approved after completing the handicapped dependent child may benefits-eligible employee, you may initial questions on the Evidence of be continued past maximum age for elect Additional Life Insurance for Insurability Short Form, you will receive a dependent child. Your child is fully yourself in addition to the Basic Life online confirmation of your approval handicapped if he or she is incapable Insurance provided by Texas Health. immediately. You will have the option of self-sustaining employment Your cost for Additional Life Insurance of printing or emailing that approval because of a mental or physical is based on your annual base pay, confirmation. The new coverage handicap. your age, and the amount of coverage amount goes into effect as of the approval date. You must submit proof of the child’s you select. You pay for Additional Life condition and dependence to coverage on an after-tax basis. If based on your answers to the Prudential within 31 days after your When you first become eligible, you Evidence of Insurability Short Form child reaches the maximum age. may choose coverage of one, two, you are not automatically approved, you will be required to complete You may cover your dependents for three, four, five or six times your the following amounts: annual base pay, up to a combined additional questions, referred to maximum of $2,000,0001 for Basic as the Evidence of Insurability •• Spouse—You may elect coverage and Additional Life coverage. Each Long Form. You will receive an for your spouse in $10,000 open enrollment period (including approval or denial letter in the mail increments, up to the total qualifying life events) after your initial once Prudential has reviewed your amount of your Basic and enrollment, you may increase your information. During this waiting Additional Life coverage, but no coverage by only one level, but you period your coverage amount will be more than $50,000. Each open may decrease your coverage to any $950,000. enrollment period after your initial level. If the application is approved, enrollment you may increase coverage for the total amount goes your spouse’s coverage by one Newly-eligible employees are level, up to $50,000. The cost of guaranteed issue of coverage up to into effect as of the approval date. If you do not meet the medical spouse coverage is based on the $1,000,000 (Basic and Additional employee’s age as of January 1. combined). Coverage amounts over evidence requirements and the •• Each child—You may elect coverage the $1,000,000 guaranteed issue additional coverage is not approved, of $10,000 for your eligible amount require employees complete your benefit amount for additional life children. Newborns may be covered an Evidence of Insurability insurance insurance will remain at $950,000. from the date of live birth. You pay application, which contains health If you have been diagnosed as the same premium amount for related questions. Note that Texas terminally ill, you may also qualify Child Life regardless of the number Health will not have access to any of for an Accelerated Payment of Death of children covered. the health-related information you Benefits, as explained later in this provide. section. Your cost for Dependent Life is based on which family members you choose If you chose a coverage level that Dependent Life Insurance to cover. The options for dependent exceeds the guaranteed issue amount If you are a full-time or part- coverage are spouse only, children during your initial enrollment or time benefits-eligible employee, only, or spouse and children. You during open enrollment, you will be you may elect Dependent Life purchase Dependent Life through directed to the Prudential website Insurance coverage for your eligible payroll deductions on an after-tax to complete an online Evidence of dependents, as defined on pages 5 basis. Insurability Short Form insurance – 7. To be eligible for Dependent Life application. Once you complete the Dependent life coverage will be Insurance coverage, your dependents application, you can return to the delayed if, on the date the insurance do not have to reside with you, be a enrollment website. would otherwise be effective, the U.S. citizen, be unmarried or live in dependent is confined for medical the U.S. Dependent Life coverage care or treatment at home or pays a benefit to you if your covered elsewhere. Coverage will be effective dependent dies. on the final medical release from You may cover your dependent all such confinement. This does not children from live birth or older but apply to an infant that is six months under age 25, regardless of student or old or less. marital status.

1 Coverage over $1,000,000 (including basic) is subject to evidence of insurability. Income Protection

1-877-MyTHRLink (1-877-698-4754) MyTHR.org 119 Life and Accident Coverage

Your request to change the amount Amount of Insurance Accelerated Payment of Death of coverage may be delayed if the If you die while disabled and while Benefits dependent was in the hospital or coverage is continued under this If you or a covered spouse has a disabled due to illness or injury on the provision, Prudential will pay a terminal illness, you may be eligible effective date of the initial enrollment death benefit equal to the amount to receive up to 90% of your Basic or increase. of coverage in effect on the date Life and Additional Life or Spouse Life In the event of a child's death within you became disabled. However, Insurance benefit (to a maximum of the first 31 days, contact Prudential to the life insurance benefit will be $500,000) during your lifetime under inquire about coverage. subject to a reduction of coverage the Accelerated Payment of Death amount because of age, retirement, Benefits. If your covered spouse has been or payment of an accelerated You must be terminally ill (for diagnosed as terminally ill, he or she benefit. Automatic increases in life example, have a prognosis of six may also qualify for an Accelerated insurance benefits will not apply while months or less to live), as diagnosed Payment of Death Benefits, as premiums are waived. Prudential by a physician. This money can be explained later in this section. will pay benefits only if proof of your used to defray medical expenses or continuous disability is received Exclusions replace lost income during the last within one year of the date of the loss. There are no exclusions for Basic Life months of an illness. Termination of Waiver coverage. You must furnish a certification by a If premiums are waived, your If an insured commits suicide, while doctor that your life expectancy is six insurance will end on the earliest of sane or insane, within two years months or less. You should furnish the following dates: from the date his or her insurance the Attending Physician Certification under the policy becomes effective, •• The date you are no longer disabled part of your claim to your doctor and have your doctor complete the form. additional life and dependent life •• The date you refuse to submit to insurance will be limited to a refund any physical examination required Prudential may require, at its of the premiums paid on the insured’s by Prudential expense, an examination of you or behalf. If a dependent child commits •• The last day of the 12-month period your dependent and a review of the suicide and is survived by other of disability during which you fail documented evidence by a physician dependent children covered under to submit satisfactory proof of of its choice. the same certificate, no refund of continued disability premiums will be paid. The suicide Any Accelerated Payment of Death •• The date following your 65th exclusion applies from the effective Benefits paid will be deducted from birthday. date of any additional benefits or the amount of life insurance payable increases in life insurance benefits. “Disability” or “disabled” means upon your death or your spouse's because of injury or sickness, you death. Waiver of Premium for Disability are unable to perform all the material If you submit satisfactory proof that duties of any occupation which you you are totally disabled, coverage will may reasonably become qualified be extended until you reach age 65. based on education, training or Dependent coverage is not eligible for experience. waiver of premium.

Premiums will be waived from the date Prudential agrees in writing to waive your premiums. After premiums have been waived for 12 months, they will be waived for future 12-month periods if you remain disabled and submit satisfactory proof that disability continues. Spending Accounts Income Protection

120 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Life and Accident Coverage

ACCIDENTAL DEATH & Basic AD&D Insurance Loss Benefit1 DISMEMBERMENT (AD&D) Texas Health pays the full cost of INSURANCE Life 100% Basic AD&D Insurance coverage for Two hands, two feet, or 100% full-time and part-time benefits- In addition to Life coverage, you one hand and one foot eligible employees. can protect yourself and your family Sight of both eyes 100% members from the financial hardship If you are injured or killed as a of certain accidental injuries or death One hand or foot 100% result of an accident, you or your and sight in one eye with AD&D coverage. AD&D provides beneficiary will receive a benefit broad 24-hour protection year round, Hearing in both ears and 100% based on the extent of the injury speech (cont. 12 months) including coverage during travel. as shown in the table on this page. The plan pays benefits to you if you Quadriplegia 100% The maximum benefit is one times have a serious accidental injury, and One burn2 covering 75% 100% your annual base pay, up to $50,000. it pays your beneficiary if you die as or more of person’s body Benefit amounts are rounded to the the result of an accident. Death or Paraplegia 75% next highest $1,000. dismemberment must occur as result Triplegia 75% of, and within 365 days following, the Base pay is your hourly rate times the 2 Burn covering 50 – 74% 75% number of hours you are classified accident. of person’s body in the HR/Payroll system to work. If a death benefit is payable, it will be One arm or one leg 75% Base pay does not include shift reduced by any other paid or unpaid Hemiplegia 50% differentials, bonuses, overtime accidental dismemberment loss. To earnings, commissions, or other One hand or one foot 50% pay the death benefit, the insurance compensation. company must receive written notice Sight in one eye 50% of your death within 12 months of your Speech 50% Basic AD&D Insurance pays benefits in addition to any other benefits you death. Hearing in both ears 50% may receive under your Life Insurance You may be required to undergo a Burn2 covering 25 – 49% 50% coverage if you die as a result of an of person’s body physical examination to provide proof accident. Benefits are paid in a single of your loss before AD&D benefits will Thumb and index 25% lump sum payment. be paid. finger of the same hand All four fingers of 25% Additional AD&D Insurance If you experience more than one the same hand If you are a full-time or part-time loss as a result of the same accident, Hearing in one ear 25% benefits-eligible employee, you the plan pays benefits for the largest Uniplegia 25% may purchase Additional AD&D loss amount, up to 100% of the total Insurance to cover only yourself, coverage amount. All the toes of 25% the same foot or you can elect Additional Family Big toe 13% AD&D coverage to cover eligible family members. Additional AD&D 1 Benefit as a percentage of total coverage coverages pay benefits in addition to amount any other benefits you may receive 2 Burns classified by a doctor as being second under your Life or Dependent Life degree or higher coverage if death occurs as a result of an accident.

You may elect Additional AD&D coverages for one to 10 times your annual base pay, up to $750,000.

If your covered spouse or child is injured or dies as a result of an accident, you will receive a benefit based on the extent of the injury as shown in the table for Basic AD&D on this page and then applying the percentages in the table on the next page. Income Protection

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•• Dependent Education Benefit—If If you additional benefit will be payable. The plans pay an additional $10,000 you die as the result of an accident, have these for use of seat belt and an additional the plan pays 5% of your total family Family coverage $5,000 if an airbag is activated under coverage amount (up to $5,000 members: will be: the Plan. per year) to each dependent child Spouse only 50% of your Additional for education. Your child(ren) must AD&D coverage If the police report is not available be enrolled as a full-time student Spouse and ••Your spouse’s or it is unclear whether the covered on your date of death or is at the children coverage is 40% of person was wearing a seatbelt or 12th grade level on the date of your Additional AD&D positioned in a seat protected by an coverage, up to your death and becomes a full- $300,000. airbag, Prudential will pay a default time student in a school within 365 ••Each child’s coverage benefit of $1,000. days after that date. This benefit is is 10% of your payable to your surviving spouse Additional AD&D No benefit will be paid if the loss coverage. results from driving or riding in any for up to four consecutive years, as long as the child: Children Each child’s coverage is automobile used in a race or a speed only 15% of your Additional or endurance test, or for acrobatic ––Enrolls as a full-time student at AD&D, up to $112,500. or stunt driving, or for any illegal an accredited school of higher purpose. learning before reaching age 25; Here is an example: ––Continues his or her education as Other Special Features a full-time student; and Your base pay = $30,000. Basic and Additional AD&D coverage ––Incurs expenses for tuition, fees, You elect coverage of 2 times base also provides the following special books, transportation and any pay for family = $60,000. benefits for you and your covered other costs payable directly to Your family includes you and dependents: or approved and certified by the children. school. •• Coma Benefit—If you or a covered Your child loses sight of one eye. dependent becomes comatose This benefit is payable for your surviving spouse for up to four Benefit payable on basic table on as the result of an accident, you consecutive years, as long as your page 121 = 50% of $60,000 = receive 1% per month of the spouse: $30,000. principal sum less any benefits already paid out or payable for up The percentage of child coverage ––Enrolls in any accredited school to 11 months. After 12 months of in the above table = 15% of to retrain or refresh skills needed continuous coma, the full principal $30,000. for employment within one year sum is payable less any benefit of the date of the employee’s $4,500 is the amount payable in amount paid or payable because of accident; this example. the same accident. ––Remains enrolled in an accredited You purchase Additional AD&D Monthly benefit payments will school; and through payroll deduction on a cease on the earliest of the date ––Incurs expenses payable directly before-tax basis, so the premium all monthly payments have been to, or approved by the school. reduces your taxable income. Your made; the full principal sum is paid; If the dependent child(ren) or cost for Additional AD&D is based on the coma ceases; failure to have surviving spouse does not qualify the amount of coverage and coverage any required exam or to give proof for the special education benefits level you select. of continuous coma; or the policy within 365 days of the employee’s terminates. death, Prudential will pay the AD&D Special Features •• Day Care Benefit—If you or your default benefit of $1,000 to your Seat Belt Benefit spouse dies as the result of an beneficiary. Basic AD&D coverage provides a seat accident and your child under 13 is Additional AD&D Features belt benefit for you and your covered covered by AD&D and was enrolled family members. or does enroll in a child care center •• Bereavement and Trauma within 90 days from the date of the Counseling Benefit—Prudential

Spending Accounts If you or your covered family member accident, the plan pays an annual will pay up to $50 per session for dies in an accident as the driver or benefit of 5% of your total coverage up to five counseling sessions, up passenger of a private automobile, amount (up to $5,000 per child, per to $250 and subject to conditions and the covered person was properly year) for the cost of the surviving and exclusions, when the covered wearing a seat belt at the time of child’s care in a licensed child care person or immediate family the accident (as verified in a police center. This benefit is payable for up member requires bereavement and accident report), a benefit will be to four years from the date of death trauma counseling because the payable. If an airbag is activated as or until the child turns 13. covered person suffered a loss that a result of the same accident, an resulted from an accident. Income Protection

122 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Life and Accident Coverage

•• HIV Occupational Accident •• Home Alteration and Vehicle •• Motorcycle while Wearing Safety Benefit—Prudential will pay an Modification Benefit—Prudential Equipment Benefit—Prudential will additional monthly amount equal will pay the Home Alteration and pay a benefit, subject to conditions to the lesser of 10% of your amount Vehicle Modification Benefit of and exclusions, of an amount equal of insurance and $25,000, subject an amount equal to the least of: to the lesser of 10% of the amount to the conditions and exclusions, the actual cost charged for the of insurance on the person or when the employee suffers an alteration or modification; 10% of $10,000. This benefit is applicable injury resulting from an accident. your amount of insurance; and if the person sustains an accidental The accident must occur during the $10,000, subject to conditions bodily injury while the person is performance of occupational duties and exclusions, when as a direct wearing all of the following as and result in the covered employee result of the loss, the covered verified in an official police accident acquiring and testing positive for person requires adaptive devices report or medical examiner’s Human Immunodeficiency Virus or adaptation of residence and/or report: a helmet, protective (HIV) antibodies within one year vehicle to maintain an independent clothing, long pants and boots. The of the covered injury. Within 48 lifestyle. driver of the motorcycle must have hours following the Occupational •• Monthly Mortgage Payment a current and valid driver’s license Accident you must: Benefit—Prudential will pay a which includes motorcycles. This ––Report the Occupational benefit, subject to conditions and does not include a loss from driving Accident to Prudential and to exclusions, of an amount equal to or riding on any motorcycle used in Texas Health in writing; and the lesser of the amount of your a race or a speed or endurance test, ––Undergo a Food and Drug monthly mortgage payment or or for acrobatic or stunt driving, or Administration (FDA) approved $1,000. This benefit will be paid for any illegal purposes. preliminary screening test for monthly until the first of these •• Rehabilitation Benefit—Prudential HIV which confirms that you do occurs: your spouse dies; your will pay a Rehabilitation Benefit not have a positive test for HIV mortgage is paid in full; your house of 5% of the principal sum (up to at the time of the Occupational is sold or the benefit has been paid $10,000), subject to conditions Accident. for 12 consecutive months. This and exclusions, when the covered •• Hepatitis Occupational Duties benefit applies only if all of the person requires rehabilitation after Accident Benefit—Prudential following are true: you suffer an sustaining a loss resulting from an will pay an additional monthly accidental bodily injury that results accident. The covered person must amount equal to the lesser of 10% in loss of life within 365 days of require rehabilitation within two of your amount of insurance and an accident; you have a surviving years after the date of the loss. spouse at the time of your death; $25,000, subject to conditions Contact Prudential for more your surviving spouse is a co- and exclusions, when the covered information on these special AD&D borrower on your mortgage; and person suffers an injury resulting features. from an accident. The accident you have an outstanding balance must have occurred during the on your mortgage at the time of performance of occupational duties your death. and resulted in the covered person acquiring and testing positive for Hepatitis within one year of the injury. Within 48 hours following the Occupational Accident you must: ––Report the Occupational Accident to Prudential and to Texas Health in writing; and ––Undergo a Food and Drug Administration (FDA) approved preliminary screening test for Hepatitis which confirms that you do not have a positive test for Hepatitis at the time of the Occupational Accident. Income Protection

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Covered Losses Exclusions for AD&D Coverage •• While operating a land, water, or air The AD&D plan pays a benefit if you AD&D benefits do not cover injury or vehicle, being legally intoxicated or or a covered dependent has a loss death caused or contributed to by the under the influence of alcohol or within 365 days of an accidental following: alcohol intoxication, including but injury. The following table explains not limited to having a blood alcohol when an injury is covered as a loss. •• Intentionally self-inflicted injury, level above the limit for permissible suicide or attempted suicide or self- operation of a motor vehicle in the If injury is injury while sane or insane; jurisdiction where the loss occurred, to: It must be: •• Commission or attempt to commit regardless of whether the person a felony or an assault; was convicted of an alcohol related Hand or foot Severed through or above the wrist or •• Participation in a riot, insurrection offense. ankle joint or terrorist act; •• Being under the influence of or Thumb and Severed through •• Bungee jumping, parachuting, taking any non-prescription drug, index finger or above the point base jumping, scuba diving, zip- medication, narcotic, stimulant, or four at which they are hallucinogen, barbiturate, fingers of attached to the hand lining, paramotoring, parascending same hand ballooning, skydiving, paragliding, amphetamine, gas, fumes or or hang-gliding; inhalants, poison or any other Sight Entire and Total and •• Declared or undeclared war or act controlled substance as defined permanent loss of in Title II of the Comprehensive sight. Corrected visual of war; Drug Abuse Prevention and Control acuity must be 20/200 •• Travel or flight in any vehicle used or worse or the field Act of 1970, as now or hereafter for aerial navigation, if any of these of vision must be amended, unless prescribed by and apply: less than 20 degrees. administered in accordance with the irrecoverable loss ––You are riding as a passenger advice of the insured’s doctor. Speech Total and permanent in any aircraft not intended or loss of speech that licensed for the transportation of continues for at least 12 consecutive months passengers following the covered ––You are performing as a pilot or a accident crew member of any aircraft Hearing Hearing loss of greater ––You are riding as a passenger than 70 decibels at in an aircraft owned, operated, all frequencies or there is less than 50% controlled or leased by or on speech discrimination behalf of Texas Health or any of at 70 decibels on an its subsidiaries or affiliates audiogram ––This includes getting in, out, on Movement Complete and or off of any such vehicle. of limbs irreversible paralysis of limbs •• Sickness, disease, bodily or mental Toes Severed at or above infirmity, bacterial or viral infection or the point at which they medical or surgical treatment, except attach to the foot for any bacterial infection resulting Paralysis Total loss of use of from an accidental external cut or limbs with physician wound or accidental ingestion of determination that the contaminated food; loss is complete and irreversible •• An accident that occurs while engaged in the activities of full-time active duty service in the armed forces for more than 31 days. Reserve or National Guard training are not excluded. Spending Accounts Income Protection

124 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Life and Accident Coverage

BUSINESS TRAVEL ACCIDENT To be eligible for benefits, the loss If you experience more than one INSURANCE must meet the plan’s definition loss as a result of the same accident, according to the table at the top of the plan pays benefits for the largest Texas Health pays the full cost of the next column. loss amount, up to 100% of the total Business Travel Accident (BTA) coverage amount. Insurance coverage for all eligible If injury is to: It must be: employees (as defined on page 5). Coverage is effective when you leave Hand or foot Severed through or BTA provides coverage if you die or above the wrist or your home or regular work location lose a body part as the result of an ankle joint (whichever occurs later) to begin a accident while traveling on Texas Thumb and Severed through business trip. It ends when you return Health business. index finger or above the home or to your regular work location metacarpophalangeal (whichever occurs first). Everyday BTA pays a benefit if you lose part of joint travel to and from work is not your body as the result of an accident Sight, speech Entire and covered. Death or dismemberment while traveling on business for Texas or hearing irrecoverable loss must occur as result of, and within Health according to the following Movement Complete and 365 days following, the accident. table. of limbs irreversible paralysis of limbs BTA coverage has aggregate maximums. The maximum total 1 Loss Benefit If you die as the result of an accident benefit payable for the same Life 100% while traveling on business for Texas accident, regardless of the number Health, your beneficiary will receive a Two hands, two feet, 100% of employees injured or killed, is or one hand and one benefit of one times your base pay, up $3,250,000 per accident (except foot to $800,000. accidents on company owned or Sight of both eyes 100% leased aircraft). BTA coverage pays You may be eligible for a benefit if benefits in addition to any other One hand or foot 100% you become comatose within 30 days and sight in one eye benefits you may receive under your of a covered accident while traveling Life and/or AD&D coverage. Benefit Hearing in both 100% on business for Texas Health and ears and speech amounts are rounded to the next remain in a coma for 60 consecutive highest $10,000. Quadriplegia 100% days. The monthly coma benefit is Paraplegia 75% 1% of annual base pay, payable for Benefits are paid in a single lump-sum Hemiplegia 50% 11 months at the end of each month payment, with the exception of the that you are in a coma. A lump sum One hand or one foot 50% coma benefit. benefit of 100% of your annual base Sight in one eye 50% pay will be paid at the beginning If you have a covered injury resulting Speech 50% of the 12th month. You must be from an accident while on a business Hearing in both ears 50% diagnosed and regularly treated by trip that is approved in advance, you will be entitled to an additional Thumb and index 25% a physician. A benefit is not payable finger of the same for any state of unconsciousness benefit if either: hand intentionally induced during the •• The loss is the result of unavoidable course of treatment, unless the state All four fingers of 25% exposure to the elements because the same hand of unconsciousness results from of a forced landing, stranding, the administration of anesthesia in Uniplegia 25% sinking, or wrecking of the form of preparation for surgical treatment All the toes of 20% transportation in which you were of injuries sustained in a covered the same foot traveling at the time of the accident accident. 1 Benefit as a percentage of annual base pay or Benefits are reduced if you are over •• Your body has not been found Base pay is your hourly rate times 70 when the accident occurs, as within one year of the date that the the number of hours you are shown in this table. form of transportation in which classified in the HR/Payroll system you were traveling disappeared, to work. Base pay does not include Benefits will made a forced landing, sank, or was shift differentials, bonuses, overtime If your age is: be reduced to: wrecked. earnings, commissions, or other 70 but less than 75 65% compensation. If your base pay changes, the amount of your 75 but less than 80 45% coverage will change on the date 80 but less than 85 30% your pay changes. 85 or over 15% Income Protection

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BTA Special Features •• Operating any type of vehicle while BENEFICIARY DESIGNATION under the influence of alcohol BTA pays additional benefits if the In the event of your death, benefits or any drug, narcotic or other loss occurs in an automobile while for Basic and Additional Life, Basic intoxicant including any prescribed properly using a seat belt. Seat belt and Additional AD&D, and Business drug for which you have been use must be verified in the police Travel Accident coverage are paid to provided a written warning against accident report or, if not mentioned your named beneficiaries. To ensure operating a vehicle while taking it in the police accident report, by a that benefits are paid according to •• Travel to a location where you are signed statement from a doctor, your wishes in the event of your expected to be assigned for more paramedic, police officer, coroner, or death, you should go online to than 60 days other person of competent authority designate a beneficiary which can be who was at the scene of the accident. •• Any activity not authorized or done at any time. organized, or not reimbursable, by The seat belt benefit equals 10% Texas Health You may name a different beneficiary of your annual base pay up to a •• Any activity not related to the for each plan or combination of plans maximum of $10,000. If you were in purpose of the business trip that if you wish. You may name more than a seat that has a working airbag that you do while traveling for business one beneficiary for each plan, such inflates upon impact, a benefit of 5% •• Driving any vehicle or automobile as your spouse and adult children. of annual base pay will be paid, to a for pay or hire. Beneficiary information cannot be maximum of $5,000. given or changed over the phone. BTA does not provide any benefits Exclusions for BTA Coverage while you are performing job duties To name a beneficiary, log on to BTA benefits do not cover injury or during work hours in a residence work MyTHR.org and select Benefits. death resulting from the following: area, as specified in the Texas Health From your Benefits Summary, select written telecommuting policy. the benefit that you want to add/ •• Commuting to and from work change beneficiary information for •• Suicide or intentionally self-inflicted In addition, benefits will not be paid (Basic Life, Additional Life, Basic injury, whether sane or insane for services or treatment rendered by AD&D, Additional AD&D). Make sure •• Commission of or attempt to you or any person who is either: you name a beneficiary for each life commit an assault or felony benefit you are enrolled in, including •• Employed by Texas Health •• Commission of or active basic life and basic AD&D. Detailed •• Living your household or participation in a riot or insurrection step-by-step instructions are available •• The parent, sibling, spouse, or child •• Sickness, disease, bodily or mental on BeHealthyTHR.org in the Life of you or your spouse. infirmity, bacterial or viral infection section. or medical or surgical treatment The beneficiary you name for Basic of these; exposure (whether or Life Insurance will also be your not accidental) to viral, bacterial beneficiary for the Business Travel or chemical agents; unless the Accident plan. If you do not name bacterial infection results from a beneficiary designation for each an accidental external cut or benefit, the beneficiary designation wound or accidental ingestion of you entered for Basic Life will apply contaminated food to the other benefits. For example, if •• Voluntary ingestion of a narcotic, you designate a beneficiary in Basic drug, poison, gas or fumes, unless Life but not Additional Life, then the prescribed or taken under the Basic Life beneficiary will be applied direction of a physician and in the to Additional Life. If both Basic AD&D prescribed dosage and Additional AD&D are missing •• Injury sustained while in the beneficiary designations, the Basic armed forces of any country or Life beneficiary will apply to those international authority benefits as well. •• Any act of war, declared or

Spending Accounts You may name anyone as your undeclared beneficiary. However, Life, AD&D, and •• Travel or flight as a pilot or crew BTA insurance proceeds cannot be member in any kind of aircraft paid to a minor child until the earlier •• Flight in, boarding or alighting from of the date: an aircraft or any craft designed to fly above the Earth’s surface, except •• The child reaches the age of as a fare-paying passenger on a majority (age 18 in Texas) or regularly scheduled commercial or charter airline Income Protection

126 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Life and Accident Coverage

•• A court has appointed a legal FILING CLAIMS Claim Filing Deadline guardian of the minors’ estate. This Texas Health’s Life Insurance The deadline for filing a claim is one appointment process can be costly, program is fully insured by year from the date of death. If more and state law may limit who may be Prudential. Business Travel Accident than one year after the death has named a guardian of an estate. is fully insured by Life Insurance passed, and you have not reported As an alternative to naming a minor Company of North America. They the death to Texas Health and child as your beneficiary, you can also process all claims. The following returned your claim form and death establish a trust for your child summarizes the procedure for filing certificate to Prudential, the claim will and designate the trust as your a claim for life insurance benefits. not be considered for payment. beneficiary. The trust would receive For information on what to do if your Dependent Life Insurance and manage your life insurance claim is denied, refer to page 202. proceeds on your child’s behalf. If your covered dependent dies, you Send your life insurance or AD&D You should obtain legal advice to should contact the THR Benefits appeal to: determine the best way to set up the Support Center at 1-877-698-4754, prompt 9 as soon as possible to trust under Texas laws. Prudential Insurance Company of report the death. You are the sole America Unless prohibited by law, your life beneficiary for your spouse’s or 80 Livingston Avenue insurance benefits are distributed child’s life insurance. Texas Health Roseland, NJ 07068 as indicated by your beneficiary will submit the claim to Prudential on designation. For this reason, you Send your BTA appeal to: your behalf. Once Prudential receives should periodically review your CIGNA Group Insurance the claim information, they will send beneficiary designation, especially if Life Insurance Company of North a claim form to you. Your claim will you get married or divorced or have America be processed once you mail the or adopt a child. If there is no living Claims Administration completed claim form, along with a designated beneficiary at the time of P.O. Box 22328 legible copy of the death certificate, your death, benefits will be paid in Pittsburgh, PA 15222-0328 to the address on the form. The Texas accordance with the applicable policy Health Benefits Department will make provision. Employee Life Insurance the appropriate changes to your Benefit coverages due to the death. If you elect life insurance coverage Texas Health should be notified as for your spouse or children, you are soon as possible in the event of an If the payment to one individual is automatically the beneficiary for their employee death by calling the THR less than $5,000, benefits are paid insurance benefits. Benefits Support Center at 1-877- in a single lump-sum payment. If 698-4754, prompt 9. Texas Health the payment is $5,000 or more, If more than one person is named will submit the claim to Prudential on beneficiaries will receive a checkbook as beneficiary, the interests of your behalf. Once Prudential receives that can be used to withdraw the each will be equal unless you the claim information, they will send proceeds. You should consult a tax specify otherwise. The share of any a claim form to your beneficiary. The advisor to be sure you understand the beneficiary who does not survive claim will be processed once your tax consequences of life insurance you will pass equally to any surviving beneficiary mails the claim form, proceeds. In either case, payment will beneficiaries unless otherwise along with a legible copy of the death be made as soon as possible after all specified. certificate, to the address on the information is received. form. If there is no named beneficiary or Accelerated Payment of Death surviving beneficiary, or if you die If the payment to one individual is Benefits for Basic and Additional Life while benefits are payable to you, the less than $5,000, benefits are paid To file a claim for an Accelerated remaining benefits will be paid to the in a single lump-sum payment. If Payment of Death Benefits, you first surviving class: the payment is $5,000 or more, or your covered spouse must be beneficiaries will receive a checkbook •• Spouse totally disabled and terminally ill that can be used to withdraw the •• Child or children in equal shares (not expected to live more than six proceeds. You should consult a tax months). Contact the THR Benefits •• Parents in equal shares advisor to be sure you understand the Support Center at 1-877-698- •• Siblings in equal shares tax consequences of life insurance 4754, prompt 9 to file a claim for •• Your estate. proceeds. In either case, payment will an Accelerated Payment of Death be made as soon as possible after all In the event of a covered accidental Benefits. information is received. injury, AD&D coverage pays benefits to:

•• You in the case of certain accidental injuries •• Your named beneficiary in the event of your death. Income Protection

1-877-MyTHRLink (1-877-698-4754) MyTHR.org 127 Life and Accident Coverage

Claim Filing Deadline Business Travel Accident WHEN COVERAGE ENDS The deadline for filing a claim is one Insurance Your Life, AD&D, and Business year from the date of death. If more If you die or are injured in an accident Travel Accident coverage, including than one year after the death has while traveling on Texas Health dependent coverage, will end on the passed, and you have not reported business, you or your dependents earlier of the date: the death to Texas Health and should contact the THR Benefits returned your claim form and death Support Center at 1-877-698-4754, •• Your employment ends certificate to Prudential, the claim will prompt 9 as soon as possible. If you •• You are no longer an eligible not be considered for payment. die, your beneficiary must provide a employee legible copy of your death certificate •• You fail to make any required Accidental Death and before benefits can be paid. Benefits Dismemberment Insurance premium payments are usually paid in a single lump-sum •• The plan terminates If you or your covered dependent payment as soon as possible after all •• Your dependents are no longer is injured or dies as a result of an information is received. accident, contact the THR Benefits eligible Claim Filing Deadline Support Center at 1-877-698- See page 188 for additional 4754, prompt 9. Texas Health will For a covered injury, you must file the information. submit the claim to Prudential, and claim and provide proof of your loss Prudential will send claim forms to within 30 days. If it is not reasonably Death Benefit During Conversion the beneficiary. The claim will be possible to provide proof within 30 Period processed once the beneficiary mails days, you must provide it as soon as A death benefit is payable if you die: the claim form, along with a legible possible, but no later than one year copy of the death certificate, to the after the loss. If more than one year •• Within 31 days after you cease to be address on the form. after the loss or death has passed, a covered person; and and you have not reported the claim •• While entitled to convert your If the payment to one individual is to Texas Health and returned your coverage under this coverage to an less than $5,000, benefits are paid claim form and death certificate (if individual contract. in a single lump sum payment. If applicable) to Prudential, the claim the payment is $5,000 or more, The amount of the benefit is equal will not be considered for payment. beneficiaries will receive a checkbook to the amount of coverage you were that can be used to withdraw the Important Information for entitled to convert (excludes AD&D). processed. You should consult a tax Residents of Certain States It is payable even if you did not apply advisor to be sure you understand the There are state-specific requirements for conversion. It is payable when tax consequences of life insurance that may change the provisions Prudential receives written proof of proceeds. In either case, payment will under the coverage(s) described death. be made as soon as possible after all in this handbook. If you live in a information is received. state that has such requirements, Claim Filing Deadline those requirements will apply to your coverage(s) and are made Claims for a covered dismemberment a part of your group insurance or death should be reported to the certificate. Prudential has a website THR Benefits Support Center at that describes these state-specific 1-877-698-4754, prompt 9 within 90 requirements. You may access the days of the loss or death. If it is not website at www.prudential.com/ reasonably possible to provide proof etonline. When you access the within 90 days, you must provide it website, you will be asked to enter as soon as possible, but no later than your state of residence and your one year after the loss. If more than Access Code. Your Access Code is one year after the loss or death has 52002. passed, and you have not reported

Spending Accounts the claim to Texas Health and returned your claim form and death certificate (if applicable) to Prudential, the claim will not be considered for payment. Income Protection

128 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Life and Accident Coverage

CONTINUING COVERAGE The terms and conditions of the Conversion Options Portability Plan will not be the Portability Options You can choose to convert any of same as those under the Texas the following elected benefits to an You can choose to continue any of Health Group Contract. You and/ or individual policy after your benefits the following elected benefits after your dependent may continue life end with Texas Health: your benefits end with Texas Health: insurance coverage by submitting your application and payment to •• Additional life insurance •• Additional life insurance (does not Prudential within 31 days of the include basic life) •• Elected spouse life date coverage ends with Texas •• elected spouse life (less than age •• Elected child life Health. Proof of insurability is not 80) required to become insured under The conversion option does not •• elected child life (if less than age 25) the Portability Plan but if you submit have age limits nor requirements to •• Additional AD&D (does not include evidence and Prudential decides the be actively at work. It is limited to basic AD&D) evidence is satisfactory, you will pay the amount of coverage you had in •• Additional AD&D Family lower premium rates. The portability effect at the time of your benefits application may be requested from ends including basic life coverage. You must apply and become covered Prudential by calling 877-MyTHRLink Evidence of insurability is not under the Portability Plan to continue (877-698-4754) and selecting prompt required. benefits for dependents. Dependents 6 then 8. must not be confined for medical You or a covered dependent may care or treatment on the day your The coverage amount will be: convert all or any portion of your coverage ends. In no event can your life insurance that would end due amount of accidental death and •• Less than or equal to your amount to termination of employment or dismemberment insurance under the of insurance when your insurance loss of eligibility. You may apply for Portability Plan exceed your amount ends, but not less than $20,000. any type of life insurance Prudential of term life insurance under the •• Maximum is the lesser of five offers (except term life) to persons of Portability Plan. times your annual earnings and the same age in the amount applied $1,000,000. for, except you may not apply for an You will have the right to apply amount of insurance greater than Benefits for Your Dependents for term life coverage under the the coverage amount at the time of Portability Plan if you meet all of A spouse under age 80 who is legally termination. (Also, the conversion these tests: separated, divorced, or widowed from policy will not provide accident, an insured employee may choose to •• Your coverage ends because for disability, or other benefits.) continue their life or AD&D coverage. any reason other than: If your spouse continues coverage, To apply for conversion, you or your ––Your failure to pay, when due, any coverage may also be continued covered dependent must, within 31 contribution required for it; or for dependent children. Dependent days after coverage ends, submit an ––The end of your employment on child coverage ends when he or she application to Prudential and pay the account of your retirement; or no longer qualifies as a dependent required premium. The conversion ––The end of coverage for all child. Spouse and child(ren) cannot application may be requested from employees when coverage is be confined for medical care or Prudential by calling 877-MyTHRLink replaced by group life insurance treatment, at home or elsewhere (877-698-4754) and selecting prompt from any carrier for which you on the day coverage ends. AD&D 6 then 8. are or become eligible within the coverage can be continued if and up next 31 days. to the amount of coverage under the •• You meet the active work term life Portability Plan. requirement on the day your insurance ends. •• You are less than age 80. Income Protection

1-877-MyTHRLink (1-877-698-4754) MyTHR.org 129 Retirement Retirement Texas Health 401(k) Retirement Plan...... 131 Overview 131 Texas Health 401(k) Retirement Plan 131 Contributions 132 Matching Contributions 134 Changing Your Contributions 135 Investing Your Retirement Accounts 136 Plan Loans 138 Plan Withdrawals 139 Plan Distributions 140 Other Provisions 142 Other Texas Health Retirement Plans...... 144 Frozen PHS and HMHS 403(b) Annuity Plan 144 Frozen PHS and HMHS 401(k) Plan 144 Frozen PHS 401(a) Plan 145 Frozen Prior Employer 401(k) Plan 146

130 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Texas Health 401(k) Retirement Plan Texas Health 401(k) Retirement Plan

OVERVIEW Governance Committee How Much You May Contribute

Attn: Executive Vice President, Retirement The Texas Health 401(k) Retirement You may contribute from 2% to 100% Chief People Officer Plan is designed to help you save for of your pay, in whole percentages, Texas Health your future. Through contributions to to your Texas Health 401(k) account, 612 E. Lamar Blvd., Suite 900 your account, you build income for subject to limits explained later in this Arlington, Texas 76011 retirement. You can choose from a section. For example, if your eligible 682-236-7900 variety of investment options offered pay is $50,000 during 2019, you by the plan to help meet your goals The members of the Governance can contribute the full $19,000 (see and personal investment style. Committee are listed on page 206. "Defining Your Pay" and “Legal Limits” on the next page) to the plan by When it was formed in 1997, Texas The Governance Committee has electing a 37% contribution rate. Your Health assumed responsibility contracted with Fidelity Investments contributions are automatically taken for the retirement plans that had to provide many of the day-to-day out of each paycheck and added to previously been sponsored by Harris administrative functions for the Texas your account in the Texas Health Methodist Health System (HMHS) and Health Retirement Program, including 401(k) Retirement Trust. Presbyterian Healthcare System (PHS) recordkeeping. and established the Texas Health If you work for more than one 401(k) Retirement Plan effective TEXAS HEALTH 401(K) employer that has adopted the Texas Health 401(k) Retirement Plan, your January 1, 1998. The plans previously RETIREMENT PLAN sponsored by HMHS and PHS are contribution election will apply to now frozen, meaning that you can Who Is Eligible your pay from all employers. Certain no longer make contributions to All employees of Texas Health are limits may apply to your contributions, them, but they do continue to have eligible to participate in the plan. as described under “Legal Limits.” investment gains or losses with the A person who is treated by Texas Catch-up Contributions market. However, if you had funds in Health as an independent contractor one or more of these plans, you may but who is later determined to be If you are age 50 or older during the be able to take loans or withdrawals an employee, will not be an eligible plan year, you may contribute an under certain circumstances. employee for any part of any plan additional “catch-up” contribution to year in which the person was treated the plan. The “catch-up contribution” Together, the Texas Health 401(k) as an independent contractor despite for 2019 is $6,000, giving you a Retirement Plan and the frozen plans any retroactive recharacterization. contribution maximum of $25,000 for make up the Texas Health Retirement 2019 (annual maximum contribution Program. Refer to the section “Other Contract medical directors are not of $19,000 plus catch-up contribution Texas Health Retirement Plans” eligible to participate in the plan. of $6,000). beginning on page 144 for more information on the frozen plans. When Participation Begins The following sections describe You are eligible to participate in the the current Texas Health 401(k) plan as a new hire. There is no waiting Retirement Plan. period.

Texas Health is the plan administrator An enrollment letter will be sent to for the Texas Health Retirement your home address inviting you to Plan. The Governance Committee participate in the plan. It will contain acts on behalf of Texas Health in details about the plan and instructions its capacity as plan administrator. on how to enroll. The Governance Committee can be contacted at:

The 401(k) Retirement Plan can help provide the financial security you will need when you retire.

1-877-MyTHRLink (1-877-698-4754) MyTHR.org 131 Texas Health 401(k) Retirement Plan

Defining Your Pay If you exceed these limits, the plan You can make one or both types For purposes of making contributions will return the excess (plus any of contributions. However, your to the Texas Health 401(k) Retirement earnings and minus any losses) to combined before-tax and Roth 401(k) Plan, your pay is your W-2 Social you the following year. In addition, to contributions cannot exceed the IRS comply with IRS rules, Texas Health contribution limit for the year. (The Retirement Security earnings plus your before- tax contributions under the Flexible may change the amount of your limit for 2019 is $19,000 or $25,000 if Benefits Plan and the Texas Health contributions and may be required you’re age 50 or older.) to return some of your contributions 401(k) Retirement Plan and certain Because you save a percentage executive tax-deferred plans. W-2 to you. You may forfeit employer matching contributions, if any, on of your pay, your contributions Social Security earnings include, but automatically adjust when your pay are not limited to, your base pay, your refunded contributions. You will be notified if the plan administrator changes. For example, if you receive overtime, shift differentials, Paid a pay raise, the amount you save Time Off (PTO), and PTO cash-out. makes any adjustments to your account. will automatically increase while the Federal law limits eligible wages for percentage of pay saved remains the 401(k) contributions and the employer In addition to the limits noted same. Or, if you work fewer hours match to $280,000 for 2019. This limit previously, federal law imposes than anticipated and earn less than may be adjusted annually. certain discrimination tests that expected, you will save a smaller All bonuses, imputed income, can limit the amount that highly amount while the percentage of pay Applause gifts, incentives related to compensated employees (as saved remains the same. the Total Health Medical Plan or the defined by the IRS) can contribute and receive. Generally, employees Your individual circumstances will Texas Health Resources Incentive help you decide whether before-tax Plan, and similar compensation are earning more than $125,000 in 2019 are considered highly compensated or Roth 401(k) or a combination of excluded from the definition of pay the two are best for you. in determining eligible before-tax employees. The amount of pay and Roth contributions and matching that determines whether you are Before-tax Contributions considered highly compensated is contributions. Payments from the Your 401(k) contributions are not indexed for inflation. Separation Pay Plan are not part of subject to federal income tax at the eligible pay under this plan. If you are affected by these limits, the time they are made, but are subject Legal Limits plan will return the excess (plus any to Social Security and Medicare taxes. earnings and minus any losses) to you You generally pay income taxes Federal law limits the amount you the following year. If you are likely to when you receive money from the may contribute to the Texas Health be affected, you will be notified by the plan if you are not rolling over your 401(k) Retirement Plan each year. For plan administrator. account to another qualified plan 2019, your total annual contributions or IRA. However, before making any (both before-tax and Roth) are CONTRIBUTIONS withdrawal or taking a payment from limited to $19,000 of your W-2 pay. the plan, you should seek the advice You may contribute to the plan in The $19,000 limit also includes of a professional tax advisor. contributions you may have made before-tax dollars and/or make Roth to a similar plan through another 401(k) after-tax contributions to the Roth 401(k) Contributions employer during the same year. plan. The Roth 401(k) allows you to save on an after-tax basis, accumulate tax-free Rollover contributions from a Before-tax contributions help you investment returns, and receive tax- previous employer’s qualified plan do reduce your federal income tax free qualified distributions. not count toward these limits. liability immediately. At retirement your contributions, the matching You must meet two conditions to The 2019 catch up amount for contributions and any earnings are have a “qualified distribution” that employees age 50 or older is $6,000. taxable. allows you to receive your Roth 401(k) In addition to these limits on your investment returns tax-free. (Your contributions, all contributions, Roth 401(k) contributions are made Roth 401(k) contributions are always including your total annual after tax. If they meet certain criteria distributed tax-free.): Spending Accounts contributions (both before-tax and when you withdraw them, your Roth) and the employer matching contributions and their earnings •• You must have had your Roth 401(k) contributions made on your behalf, could be tax free (company match is account for five years. taxable). are limited to 100% of your annual •• Your distribution must be made gross pay or $56,000, whichever is due to termination, death, disability, less. You may designate your catch- hardship, or termination of the plan. up contributions as before-tax, Roth 401(k) contributions, or a combination of both.

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Roth 401(k) contributions are added •• If your tax rate in retirement will be will be lower with Roth 401(k) to the before-tax contributions, and lower than in your working years, contributions than before-tax the IRS limit applies ($19,000 or you may come out ahead with contributions. $25,000 if you are age 50 or older). before-tax contributions. So you may need to reduce your Roth

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

Tax Information on Contributions and Distributions Before-tax Roth 401(k) Contributions taxed when made No Yes

Contributions taxed when distributed Yes No Investment returns taxed when Yes No, if you take a qualified distribution distributed 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 Roth employer’s plan 401(k), if available ••Roll over your money to an ••Roll over your money to a Roth IRA Individual Retirement Account ••Take your money as cash (if money does not (IRA) remain in Roth 401(k) for at least 5 years, your ••Take your money as cash returns will not be tax-free)

*Company match is before-tax. **If your balance is over $5,000. If you are age 65 or older and no longer working, your full vested account balance will be distributed to you.

Rollovers From Other Plans A conduit IRA is one that contains only To make a rollover from your prior You may be eligible to roll over money rolled over from an employer employer’s qualified plan into the before-tax balances from a previous sponsored retirement plan that has Texas Health 401(k) Retirement Plan, employer’s 401(k) plan, 403(b) not been mixed with regular IRA you must complete an application. contributions. plan, or other qualified defined Call the Fidelity Retirement Service contribution plan or conduit IRA into To avoid tax consequences, you Center at 800-343-0860 to request the Texas Health 401(k) Retirement must make a rollover contribution the application or log on to Fidelity Plan. The rollover must be a lump- within 60 days of the time you receive NetBenefits® at Netbenefits.com/thr sum distribution of your before-tax the distribution from your previous for details. balances from a previous employer’s employer’s plan. plan or conduit IRA. You may also roll over Roth 401(k) balances into the Texas Health 401(k) Retirement Plan.

1-877-MyTHRLink (1-877-698-4754) MyTHR.org 133 Texas Health 401(k) Retirement Plan

MATCHING CONTRIBUTIONS Federal law limits eligible wages for A year of service is explained below the 401(k) employer match which may under “Length of Service.” You Texas Health will match a portion of be adjusted annually. For 2019 it is become fully vested in your account each dollar you save, up to the first 6% $280,000. The table below shows the (regardless of your years of service) in of pay. The match is made each pay maximum employer match that may the event of your normal retirement Retirement period and depends on your length be received in 2019. (at age 65), disability, or death. of service. To receive the match, you must contribute at least 2% of your If you reach the employee IRS How Termination Affects Vesting pay each pay period. To receive the contribution limit before the end of If you terminate employment when maximum match, you must contribute the year, you may not receive the you are 0% vested in the Texas Health 6% of your pay each pay period. highest possible match from Texas match, you will forfeit the entire Health because you receive the match You are eligible to immediately begin employer match. Forfeited amounts only when you make a contribution. receiving the employer match if you are generally used to reduce Texas were hired before January 1, 2010, or Health matching contributions and to 2019 Employer Match Limits* if you were hired on or after January pay expenses of the plan. 1, 2010, and you have completed one Less than 5 Years $12,600.00 of Service If you terminate employment when year of service. The match begins in you are partially vested in your the pay period containing your one- 5 Years of Service, $16,800.00 but less than 10 matching contributions, you will year anniversary. Texas Health does Years of Service forfeit the non-vested portion of your not match rollover distributions from 10 or more Years $21,000 employer match on the earlier of the a previous employer’s plan. of Service date you: The following table shows the *The employer match limit is calculated •• Have a five-year break in service, or amount of employer matching using the current IRS maximum eligible compensation limit of $280,000, then •• Receive your vested amounts. contributions you receive based applying the match formula based on on your years of service with Texas years of service. The maximum eligible A five-year break in service occurs if compensation limit is subject to change due Health. The table assumes that you to IRS regulations. you are not employed by Texas Health contribute at least 2% of your pay for 60 consecutive months. each payroll period. Vesting If you return to work for Texas Health Vesting refers to your ownership before you incur five consecutive If your years For each $1 of the money in your account. You one-year breaks in service, you may of service with you contribute, are always 100% vested in your own have your forfeited amounts restored. Texas Health Texas Health contributions (both before-tax and 1 2 Restoration will occur only if you equal : adds : Roth), rollovers from other employer repay the matching contributions that 1 but less than 5 $0.75 plans or conduit IRA, and investment were distributed to you by the plan returns on these amounts. 5 but less than 10 $1.00 before the earlier of: 10 or more $1.25 You become vested in Texas •• Your fifth anniversary of Health’s matching contributions, any 1 You are eligible for company matching re-employment, or contributions if have completed one year of forfeitures allocated to your account, service. and the investment returns on those •• The date you incur five consecutive one-year breaks in service. 2 Up to 6% of your eligible pay. contributions based on your years of service as follows: Length of Service In general, your match will begin within the pay period that your If your years Your vesting Your length of service with Texas retirement vesting date (hire date) of service with in the Texas Health determines: falls within, once you have completed Texas Health Health match •• Your eligibility to receive the match one year of service. For example, if equal: is: made by your employer your retirement vesting date is Jan. 6, Less than 2 None •• The amount of the matching 2018, your match would begin within contribution the pay period that contains Jan. 2 but less than 3 25% Spending Accounts 6, 2019. To access the 2019 Payroll 3 but less than 4 50% •• Your vesting. Schedule, visit MyTexasHealth and 4 but less than 5 75% select Employee Resources. Then, 5 or more 100% select Working at Texas Health from the drop-down box. The 2019 Pay Period schedule is on the left-hand side.

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You generally will receive credit for A break in service is generally a Your election to change or stop one year of service for each 365-day period of greater than 12 months in contributions will be effective as soon period (whether or not consecutive) which you were not employed by an as administratively practical after that you are employed by Texas employer who has adopted the Texas Fidelity receives your change. Health or another employer that Health 401(k) Retirement Plan. Retirement participates in the Texas Health Auto-Increase Feature 401(k) Retirement Plan. This period is Rehired Employees A smart way to make investing for measured from either your first day If you terminate employment with your retirement easier and more of employment or your anniversary Texas Health and are later rehired, efficient is to take advantage of the date of employment during 1997, you are immediately eligible to begin Texas Health 401(k) Retirement Plan’s whichever is later. making contributions to the Texas automatic contribution increase Health 401(k) Retirement Plan. If your feature. This online tool allows Service Credit From Other Plans break in service is less than one year, you to automatically increase your Your service that was credited to you you retain the vesting date you had. contribution percentage each year. under the HMHS Plans and the PHS If you are not vested in the matching You decide what percentage and Plans may also be counted under the contribution when you terminate which month you wish the increase Texas Health 401(k) Retirement Plan and are rehired after you have five to happen on an annual basis. Your for purposes of determining the rate consecutive breaks in service, you automatic increase will occur each of matching contribution and vesting will not be credited with your prior year until you choose to stop the service. You will be credited with vesting service. If you were employed increase or you reach the annual plan your years of service under the HMHS by Harris Methodist Health System or or IRS limit (whichever is lower). You Plans and the PHS Plans unless as of Presbyterian Healthcare Resources can stop the automatic increases at the later of January 1, 1998, or your before August 1, 1997, but were not any time. most recent date of employment, credited with any years of service You might consider having your your breaks in service equal or exceed under any of the HMHS or PHS Plans, automatic increase occur when you the greater of five years or your years your service for purposes of the Texas receive pay increases. It’s a great way of service under these plans. Health 401(k) Retirement Plan will begin on your 1997 anniversary date. to contribute an extra percentage Years of service under the HMHS You will not be credited with any automatically, and you won’t notice and PHS Plans will be based on service before your 1997 anniversary the difference in your paycheck. Take the definitions of years of service date. a look at the graph below to see how contained in those plans. a 1% increase each year can make a huge difference down the road. Your service credited to you under CHANGING YOUR the pension plan sponsored by CONTRIBUTIONS To sign up for this service or make any Arlington Memorial Hospital may also changes to your account, log on to You may change or stop your be counted under the Texas Health Netbenefits.com/thr. Click on Quick contributions to the Texas Health 401(k) Retirement Plan for purposes Links in your plan name, then click 401(k) Retirement Plan at any time of determining the rate of matching on “Contribution Amount”. Select the and as often as you would like during contributions and vesting service. Annual Increase Program hotlink to the plan year. To change or stop your make your selections. You also may contributions, simply contact Fidelity If you were employed by Presbyterian call Fidelity at 1-800-343-0860. Hospital of Denton on May 30, 2009, Investments at 1-800-343-0860 or you will receive credit for your years online at Netbenefits.com/thr. of service with them under the Texas Health 401(k) Retirement Plan. If you were employed by Texas Health TAKE A LOOK AT WHAT A DIFFERENCE Assumes starting salary of $30,000 with a 3% annual wage inflation. Partners on January 1, 2009, or by 1 PERCENTAGE POINT COULD MAKE: Contributions are made at the end Medical Edge/PhyServe on December of each month starting at age 22 and 3% continuing until age 65. Annual rate CONTRIBUTION 31, 2010, you will receive credit for all of return is 8% compounded annually. your years of service. 3% CONTRIBUTION This material has been prepared INCREASING AT 1% for informational and educational UNTIL REACHING 6% If you were employed by Texas purposes only. It is not intended to 3% CONTRIBUTION provide, and should not be relied upon Health Medsynergies on December $443,900 INCREASING AT 1% for, investment, accounting, legal or UNTIL REACHING 10% 30, 2016, you will receive credit for tax advice. all your years of service with them. $842,000 The assumptions are for illustrative Certain acquisitions of the Texas purposes only and are not representative of the performance of Health Physician Group also receive $1,278,500 any security. There is no assurance credit for all years of service. Contact similar results can be achieved, and this the plan administrator for more information should not be relied upon 300,000 600,000 900,000 1,200,000 1,500,000 as a specific recommendation or an information. offer to buy or sell securities.

1-877-MyTHRLink (1-877-698-4754) MyTHR.org 135 Texas Health 401(k) Retirement Plan

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

Spending Accounts market conditions. funds invested in stocks or bonds will decrease/increase with the market.

* The Commingled Pension Trust Fund (JPMCB SmartRetirement funds) of J.P. Morgan Chase Bank N.A. is a collective trust fund established and maintained by J.P. Morgan Chase Bank N.A. under a declaration of trust. The fund is not required to file a prospectus or registration statement with the SEC, and accordingly, neither is available. The fund is available only to certain qualified retirement and government plans and is not offered to the general public. Units of the fund are not bank deposits and are not insured or guaranteed by any bank, government entity, the FDIC or any other type of deposit insurance. You should carefully consider the investment objectives, risk, charges, and expenses of the fund before investing.

136 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Texas Health 401(k) Retirement Plan

––Growth Funds—Attempt to Professional Management Program1 Please note that performance of invest in companies with above The Plan also offers Fidelity® the model portfolios depends on average growth prospects. Personalized Planning & Advice, the performance of the underlying Typically, investments are made a managed account service that investment options. These in companies that have exhibited investments are subject to the lets you delegate the day-to-day Retirement consistent above average management of your workplace volatility of the financial markets growth, and/or companies which savings plan account to professional in the U.S. and abroad and may are expected to exhibit above investment managers. Fidelity’s be subject to additional risks with average growth in the near experienced professionals evaluate investing in high yield, small-cap, and future. the investment options available foreign securities. ––Value Funds—Attempt to invest in your plan and identify a model Changing Your Investment in companies with a stock price portfolio of investments appropriate Options that is considered undervalued for an investor like you. The service You may change your investment relative to the market. then invests your account to align fund elections for existing balances ––Index Funds—Seek to match, with this model portfolio and and future contributions (both as closely as possible, the provides ongoing management of employee and employer) at any time investment results of the S&P 500 your account to address changes in by contacting Fidelity at the phone Composite Stock Price Index, the markets, your plan’s investment number or website listed on the inside which emphasizes stocks of lineup, and changes in your personal back cover. Changes made by 3:00 large U.S. companies by using or financial situation. a passive investment approach. p.m. Central time take effect the same Typically, investments replicate With a managed account, you can day. Changes made after 3:00 p.m. the companies and weightings of take advantage of Fidelity’s resources Central time will take effect the next a style specific index. and experience to help ensure that: business day. Transaction requests received after the close of the market, ––Global Funds—Invest in common •• Your investments are managed normally 3 p.m. CT, or on weekends stocks and other types of through the ups and downs of the or holidays will receive the next securities of U.S. and/or foreign market. business day's (or next calculated) based companies, typically with •• You’re keeping your accounts closing price. a higher degree of risk and price aligned with your goals through fluctuation than domestic, U.S. annual reviews and check-ins. A confirmation email will be sent equity funds. •• Your account is actively managed to you after Fidelity processes the ––International Funds—Invest to create an opportunity for long- change. You do not need to complete exclusively in common stocks term gains while managing the risk any paperwork. Before making and other securities of foreign- associated with investing. any change, you should review the based companies, typically with prospectus of the funds that you wish a higher degree of risk and price To see if Fidelity® Personalized to select. Contact Fidelity to request fluctuation than domestic, U.S. Planning & Advice is right for you, log the prospectus. equity funds. onto NetBenefits® at Netbenefits. If you were employed before 1997 or •• Brokerage Account—Allows you to fidelity.com/pas where you can were part of an acquisition, you may invest a portion of your account easily enroll in the Service and learn have other accounts in addition to the in an unlimited number of mutual more. Fidelity® Personalized Planning Texas Health 401(k) Retirement Plan. funds, stocks, and bonds. All fees & Advice is a service of Strategic When making investment changes, associated with brokerage accounts Advisers, Inc., a registered investment you are able to designate changes for will be paid by participating adviser and a Fidelity Investments each individual plan. employees. For more information, company. you can speak with a Retirement This service provides discretionary In adherence with securities laws that Consultant by calling 1-800-776- money management for a fee. are applicable to mutual funds, Texas 6061. 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 Fidelity Portfolio Advisory Service at Work is a service of Strategic Advisers, Inc., a registered investment adviser and a Fidelity Investments company. This service provides discretionary money management for a fee.

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Fidelity Investments monitors Account Statements PLAN LOANS potential short-term abusive trading The notice of availability of your The Texas Health 401(k) Retirement activity for our funds. You will be quarterly statement will be sent to Plan allows you to borrow money notified if your account is identified you through email after the end of from your participant contributions as having short-term abusive trading Retirement each quarter. Statements are available and rollovers in your account. The activity. Contact Fidelity for specific online after the end of the quarter. amount you may borrow includes trading activity rules allowed for each To view your statement online, log 50% of your contributions and fund. on to Netbenefits.com/thr, select the the investment returns on those Rebalance Notification account from which you want to print contributions, plus any rollovers from a statement, then click on Statements other plans. You are charged interest If you're managing your retirement under the Quick Links drop down. for your 401(k) loan and must repay plan assets on your own, remember You can update your delivery your own account. that a consistent, long-term savings preferences at any time under the strategy can help you reach your Mail Preferences hotlink under Your The amount you may borrow is retirement goals once you stop Profile. subject to certain limits. You must working. As the market changes, borrow a minimum of $1,000. The you'll want to review your portfolio If you were employed before 1997 or maximum you can borrow is the to make sure your current asset were part of an acquisition, you may lesser of: allocation is still in line with your have other accounts in addition to the goals, adjusting your investment Texas Health 401(k) Retirement Plan. •• 50% of your contributions and mix and rebalancing your assets as When making investment changes, rollovers (including investment necessary. you are able to designate changes for returns) or each individual plan. •• $50,000—less your outstanding Consider the free Rebalance loan balance during the previous Notification service, which alerts Your quarterly statement will show 12- month period. you by email when your account’s your activity for the previous three investment mix deviates from your months with account balances in The maximum applies to all current original specification. the retirement plan based on the and outstanding loans from all last business day of the quarter. plans, including frozen plans listed If you were employed before 1997 or Your account balance is the sum on pages 144 – 146. You may take were part of an acquisition, you may of contributions (employee and only one loan per plan per calendar have other accounts in addition to employer match) if any, allocated year, and may have only one loan the Texas Health 401(k) Retirement to your account, plus your per plan outstanding at a time. The Plan. When making investment investment gains or losses on those interest you pay on your loan is fixed changes, you are able to designate contributions. Your accounts will for the period of the loan at a rate changes for each individual plan. reflect gains and losses as of the end established by the plan administrator. For more detailed information on of the previous business day. Currently, the loan interest rate is the rebalancing, contact Fidelity. prime interest rate plus 1% as of the If you want more detailed information first of the month when your request about your account statement or the is received. The loan is secured by balances of your accounts between the remaining 50% of your account quarterly statements, contact Fidelity balance. or view your information online at Netbenefits.com/thr. Most employees repay loans through Choosing Pre-tax after-tax payroll deductions. When or Roth 401(k) you take a loan, you choose the Contributions repayment period. Your choice will affect the amount of your loan Visit Netbenefits.com/ payment. The repayment period thr for help in making the available for your loan depends on decision between your reason for taking the loan: Spending Accounts pre-tax and Roth 401(k) •• For a general purpose loan, you can contributions using the elect a repayment period of up to Roth Education Calculator five years located under Tools & •• For a loan to purchase your primary Calculators on the Tools & home, you can elect a repayment Resources tab. of up to 20 years. You must provide documentation of your home purchase.

138 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Texas Health 401(k) Retirement Plan

Generally, you do not pay taxes on Loans While On LOA PLAN WITHDRAWALS a loan unless you do not repay the Employees on a leave of absence Under certain circumstances, federal loan in a timely manner. In these (LOA) in the HR/Payroll system may law allows you to make a withdrawal cases, the loan may be treated as a make loan payments directly to of your vested contributions from the taxable distribution, and if you are Fidelity while on leave. If employees Texas Health 401(k) Retirement Plan Retirement under age 59½, a 10% premature on a leave of absence do not send while you are an active Texas Health distribution penalty may apply. If you their missed payments directly to employee. You may make withdrawals terminate employment while the loan Fidelity, their loan will automatically when you reach age 59½ or later, is outstanding, your loan will be due be re-amortized when they return to or during a time of serious financial in full on the earlier of the date you work to bring the loan current. hardship. Each option is explained take a distribution or 30 days after below. you terminate. If you do not repay If your loan reaches maturity while on your loan in full by this date, your loan leave, the entire balance will be due In-service Withdrawals After is in default. in full based on the default period, Age 591⁄2 which is the end of the quarter You may withdraw all or a part of A loan is considered in default if following the quarter the last payment your vested account from the Texas the full amount of any payment is was made. If this occurs, you will Health 401(k) Retirement Plan without not paid by the end of the quarter need to contact Fidelity to get the penalty while you are an active immediately following the quarter in exact balance due and send a manual employee after you reach age 59½. If which it was due. In case of default, payment to Fidelity to pay off the loan you do not roll the account over, the your account balance will be reduced in full before the default period is distributions will be subject to federal by the amount of the outstanding reached. loan balance that was defaulted. income tax, but no tax penalties. You If you are active and your loan is If the loan is not paid off in full by may continue contributing to the plan defaulted, and you are over the age the end of default period, it will be after you take a withdrawal. of 59 1/2, the defaulted loan will be defaulted and the balance left on the To request an in-service withdrawal, treated as an in service distribution. loan will be considered income for go online to Netbenefits.com/thr or Please consult your tax advisor on the the current year. Fidelity will issue a contact Fidelity by phone. consequences of taking a loan from 1099-R form that you will use when your account. filing your taxes. Hardship Withdrawals

Other limitations or rules may restrict While you are an active Texas Health your ability to borrow from the Texas employee (regardless of your age), Health 401(k) Retirement Plan. For you may withdraw some or all of your additional information or to apply contributions, but not the investment for a loan, call Fidelity at 1-800-343- returns on them if you have an 0860. A $50 loan processing fee will immediate and heavy financial need be deducted from your account for as defined by the IRS. each new loan you take. The distribution cannot be more than the amount of your immediate financial need (including applicable taxes). The minimum hardship withdrawal allowed is $200. Once you have taken a hardship, you are not eligible to take another one until 30 days have passed.

The following reasons are defined as hardships:

•• Cost related to the purchase of a primary residence (not including mortgage payments) •• Payment of medical expenses incurred by you, your spouse, or your dependents that would be deductible on your federal income tax return

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•• Payment of tuition and board If you request a distribution, your Termination for the next 12 months of post- account will be valued on the day Generally, within two weeks of your secondary education for you, your your distribution is processed by termination from Texas Health, spouse, or your dependents Fidelity. If you are concerned that your Fidelity Investments will be notified account balance will fluctuate during Retirement •• Prevention of your eviction from of the event. At that time, you may or foreclosure on your primary the distribution processing period, request a distribution from your residence you may want to consider changing account by logging on to Netbenefits. •• Funeral expenses for your your investment choices to a more com/thr or by contacting Fidelity parent, spouse, children or other conservative investment option. Investments. dependents If you are an active employee, you Following are restrictions on how •• Expenses for the repair of damage are not required to take a minimum your account can be distributed. to your principal residence that required distribution beginning the would qualify for a casualty loss year you reach age 70 1/2. If you If Your Balance Is $5,000 or More deduction. choose to take one at that time, you You may leave your money in the You will be required to submit proof should contact Fidelity. Texas Health 401(k) Retirement Plan of your hardship. You must meet two conditions to until you reach age 65 while your have a “qualified distribution” that vested balance remains $5,000 or The amount of hardship withdrawal more. When you turn age 65, Fidelity you receive will be subject to federal allows you to receive your Roth 401(k) investment returns tax-free. (Your will send notification that you are now income tax. In addition, if you are required to take a distribution. younger than 59½, you must also pay Roth 401(k) contributions are always a 10% tax penalty on the amount of distributed tax-free.): If you request a distribution of the hardship withdrawal. You do not •• You must have had your Roth 401(k) your account after you terminate have to pay the penalty if the hardship account for five years. employment, you immediately forfeit the non-vested portion of withdrawal is being made to pay •• Your distribution must be made your account. If you do not elect deductible medical expenses or if you due to termination, death, disability, a direct rollover of your vested meet the IRS definition of disability. hardship, or termination of the plan. account balance, the law requires If you want to take a hardship A Roth account is separate from the plan to withhold 20% of your withdrawal, contact Fidelity at the employer match and employee distribution for income taxes. If you 1-800-343-0860. before-tax contribution accounts. are younger than 59½, a 10% penalty for early withdrawal may apply. You PLAN DISTRIBUTIONS When you take a distribution from a should consult with your tax advisor Roth account, you will receive two The Texas Health 401(k) Retirement regarding the tax consequences. checks. One check will be for your Plan generally distributes your full Roth contributions and the other If Your Balance is More Than $1,000, vested account balance to you when will be for the earnings on your Roth But Less Than $5,000 your participation in the plan ends account, your employer match, and If you do not initiate a distribution of because you experience one of the employee before-tax contributions, if your account after termination and following events. Either you: applicable. your vested account balance is more •• Retire at age 65 or later than $1,000, but less than $5,000, Retirement •• Terminate employment with Texas your vested account balance (and Health Your normal retirement date under the any rollover account balances) will be Texas Health 401(k) Retirement Plan is •• Become disabled (as determined by directly rolled over to an individual your 65th birthday. You may continue the plan administrator) retirement account (IRA) designated to participate in the plan after age 65 if by the plan administrator. You will •• Die. you are still employed by Texas Health. forfeit the non-vested portion of You can request a distribution by If you terminate employment due to your account. You will be informed of calling Fidelity at 1-800-343-0860. retirement after age 65, a distribution the automatic rollover by Fidelity in or by going online to Netbenefits. of your total account balance (less March, June or September depending Spending Accounts com/thr. The table on the next page any outstanding loan balance) will on your date of termination. You will indicates the ways you can request a automatically be paid the quarter be notified of the financial institution distribution, depending on the reason following the quarter you retire from that holds your IRA after the rollover for the distribution. Texas Health. is complete. You will be notified by Fidelity before this distribution and given the opportunity to rollover your account as you wish.

140 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Texas Health 401(k) Retirement Plan

Distribution Options Type of distribution Online at By phone with Request paper form Netbenefits.com/thr Fidelity from Fidelity and (800) 343-0860 return to Fidelity Retirement Distribution due to termination X X PHS 401(a) distribution X Hardships X In-service – active employee over age 59½ X X Qualified Domestic Relations Orders X X Beneficiary distribution (upon employee's death) X

If you elect to have your vested If you have an account balance You can also rollover your Roth 401(k) account balance paid in the form of a of $1,000 or less, you have not contributions as long as your new lump sum, the law requires the plan elected a direct rollover, and you employer’s plan accepts rollovers of to withhold 20% of your distribution have not settled payment within 180 Roth amounts. If not, you may roll for income taxes. If you are younger days of distribution or cannot be your Roth 401(k) into a Roth IRA or than 59½, a 10% penalty for early located within 180 days after your leave the money in the Texas Health withdrawal may apply. After you account becomes payable, the plan Retirement Program if it meets the return your distribution form and administrator will treat your account minimum balance requirements. elect to roll over your account, you as a forfeiture. Your account will be will have 60 days from the time you restored if you make a claim after the Rehired Employees receive the check to roll over your account is forfeited. If you receive your vested account distribution to another employer’s balance when you terminate and You should consult with your plan or individual retirement then are rehired by Texas Health tax advisor regarding the tax account. You should consult with before you have a five-year break in consequences of any distributions. your tax advisor regarding the tax service (as described under “Rehired consequences of any distributions. If you worked for the company before Employees” on page 135), the amount 1998, the above information also of your account that was forfeited will If Your Balance is $1,000 or Less applies to the Frozen PHS and HMHS be reinstated if you repay the amount If you do not initiate a distribution 401(k), the Frozen PHS and HMHS of your distribution before either your of your account by the end of the 403(b), and the Frozen PHS 401(a). fifth anniversary of reemployment or quarter following the quarter in However, you may leave money in the date you incur a five-year break which you terminated, and your those plans until April 1 following the in service, whichever occurs first. If vested account balance is $1,000 or year in which you reach age 70½. The you do not repay the amount of the less (including any rollover account above information also applies to the distribution, your forfeited account balances), your vested account will be Frozen Prior Employer 401(k) Plan. balance will not be reinstated. automatically distributed to you and you will forfeit the non-vested portion Direct Rollovers of your account. You may elect to take all or part of your vested account balance as a The law requires the plan to withhold direct rollover. A direct rollover is 20% of your distribution for income the payment by the Trustee of your taxes. If you are younger than 59½, a vested account balance to another 10% penalty for early withdrawal may employer’s qualified retirement plan apply. or an IRA. You can make a direct If you terminate employment and rollover of part of your balance take a distribution in or after the year and receive the rest of it as a direct in which you reach age 55, the 10% lump-sum distribution. By making penalty does not apply. It also does a direct rollover to an Individual not apply for distributions that are Retirement Account (IRA) or to an paid due to disability, beneficiary employer’s qualified plan, you avoid claims or Qualified Domestic tax withholding and penalties that Relations Orders. you would pay if you received a distribution payable to you.

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Disability If you list more than one beneficiary, OTHER PROVISIONS the people you name will share your If the plan administrator determines Qualified Domestic Relations account equally unless you specify that you meet the plan’s definition Orders of disability, you can receive a different percentages. You may name both primary and contingent Generally, you cannot pledge or assign Retirement distribution of your full account your account balance in the Texas balance (less any outstanding loan beneficiaries. A contingent beneficiary Health 401(k) Retirement Plan or any balance) as soon as administratively will receive proceeds only if all of other plan that is part of the Texas practical. The distribution will be the primary beneficiaries die before Health Retirement Program. The plan made according to the procedure payment is made. may be required by law to recognize described above for termination of If you have named your spouse as obligations you incur as a result of employment. your beneficiary and later you divorce, court-ordered child support, agreed If the plan administrator receives the designation of your spouse will alimony, or as a result of the division satisfactory evidence that you be deemed to be revoked if written of your community property interest are physically unable or mentally notice of the divorce is received in your account balance in connection incompetent to receive the by the plan administrator before with your divorce. To bind the plan distribution, the plan administrator payment has been made. administrator, the court order must be a Qualified Domestic Relations Order may make payments on your behalf Unless otherwise designated in (QDRO). If you are in the process of to your spouse, a relative, or your writing, the beneficiary you name a divorce, the plan administrator can custodian. to receive your accounts under the provide you with acceptable language Texas Health 401(k) Retirement Plan Death for your court order. will also be the beneficiary designated In the event of your death, your for any other retirement plan included By law the plan must recognize a full account balance (less any in the Texas Health Retirement QDRO, which is a decree or order outstanding loan balance) will be Program. issued by a court that obligates paid as a lump sum to your spouse if you to pay child support or agreed you are married, or to any beneficiary If you completed a beneficiary alimony, or otherwise allocates a you have designated on a properly designation under the Harris portion of your account balance to completed Designation of Beneficiary Methodist Health System Retirement an alternate payee, who may be your Form. Payment will be made as soon Plan or the Presbyterian Healthcare spouse, former spouse, child, or as possible following your death, but System Employees’ Retirement Plan other dependent. If such an order is no later than the end of the plan year before 1998 and did not complete a received by the plan, all or a portion following the plan year of your death. new form after January 1, 1998, the of your account will be used to satisfy people named in the designation will the obligation. Naming a Beneficiary be the beneficiaries only for those Fidelity’s Online Beneficiaries plans and not for the Texas Health The Fidelity QDRO Center is a website Service, available through Fidelity 401(k) Retirement Plan. that was created to assist individuals NetBenefits®, offers a straightforward, in the preparation of domestic convenient process that takes relations orders. The Fidelity QDRO just minutes. Simply log on to Center website provides immediate NetBenefits® at Netbenefits.com/ access to a Glossary of Terms, thr and click on “Beneficiaries” in the Frequently Asked Questions, and each About You section of Your Profile. If Plan’s QDRO Approval Guidelines and you do not have access to the Internet Procedures (“QDRO Guidelines”). or prefer to complete your beneficiary information by paper form, please The Fidelity QDRO Center may be contact 800-343-0860. accessed by going to https://qdro. fidelity.com (then registering as a user According to federal law, if you are and logging in). Specific step-by-step married you must have your spouse’s questions will guide you through the written consent to designate a Order creation process. Spending Accounts beneficiary other than your spouse. Your spouse’s signature on the Designation of Beneficiary Form must be witnessed by a notary public. If you name a beneficiary other than your spouse but the waiver form has not been signed by your spouse and notarized, your designation is invalid.

142 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Texas Health 401(k) Retirement Plan

Note: The Fidelity QDRO Center No PBGC Coverage Plan Termination website is designed to assist in the While a government agency known Texas Health has the right to creation of an Order. Use of the as the Pension Benefit Guaranty terminate the Texas Health 401(k) Fidelity QDRO Center website does Corporation (PBGC) insures benefits Retirement Plan at any time and for not result in an automatic electronic payable under certain types of any reason. Upon termination of the Retirement submission of an Order to Fidelity. retirement plans, it does not insure plan, you will become 100% vested in Orders created using the Fidelity any of the benefits provided under all amounts credited to your account QDRO Center website must be the Texas Health Retirement Program under the plan. Texas Health has printed out and executed by a court because each participant’s benefits certain options upon termination of competent jurisdiction prior to depend upon his or her account of the plan concerning when your submission to Fidelity for review. balance under the particular plan benefits will be distributed, and the Claims Procedures at the time of payment. The PBGC fact that the plan has been terminated insures only benefits payable under does not necessarily entitle you to For information on how to file a those plans that provide for fixed immediate payment of your benefits. claim or appeal a claim that has been and determinable (defined benefit) Termination procedures adopted by denied, see “Claims Information” retirement plans. Texas Health will be explained to you beginning on page 201. upon termination of a plan. No Fixed Benefit Amount Unclaimed Benefits ERISA classifies the Texas Health Withdrawal by Participating When you or your beneficiary 401(k) Retirement Plan as a “defined Employer become entitled to payment of a contribution plan.” This means A participating employer may benefit, the plan administrator will the plan does not provide a fixed withdraw from the Texas Health send you or your beneficiary a notice dollar amount of benefit. Your 401(k) Retirement Plan at any time. of the right to receive the benefit. The actual benefit will depend on the Texas Health, as the sponsor, may also notice will be sent to the last known fair market value of your account terminate the employer’s participation address of the person as shown on balances under a particular plan at in the plan at any time. Either way, the the plan’s records. the time of distribution. Your account participating employer may continue If the benefit is not claimed within balances will reflect contributions the plan on its own. and investment earnings on those six months after the date the notice Texas Health Contributions contributions. is mailed (or if the plan is being Conditioned terminated before the effective date Limitations on Employment Contributions to the Texas of the plan’s termination), the benefit Health 401(k) Retirement Plan by may be segregated in an interest- The plan does not give you the right Texas Health or your employer bearing account in your name while to continue to be employed by any are conditioned upon the initial the plan administrator attempts to of the participating employers or qualification of the plan for federal locate you or your beneficiary. diminish your employer’s right to terminate you at any time. income tax purposes and the The segregated account will not deductibility of the contribution for receive allocations of investment Amendment of the Plan federal income tax purposes (for for- returns. It will, however, be entitled Texas Health has the right to amend profit companies). Such conditional to all investment returns it earns as a the Texas Health 401(k) Retirement contributions can be returned to separate account and will separately Plan at any time and for any reason. Texas Health or your employer if bear all expenses or losses related to However, no amendment to the plan these conditions are not satisfied. its operation. may: Your Rights Under the Plan If the benefit is not claimed within five •• Authorize or permit any part of Except for Texas Health’s years, it will be forfeited. Your benefit the plan’s assets to be used for contributions being conditioned upon will be restored after you or your purposes other than the payment the initial qualification of the plan, beneficiary is located. You should of benefits and the payment of there are no specific plan provisions make sure Texas Health always has reasonable plan expenses that provide for a disqualification of your current address and the current •• Reduce the amount of your your status as a participant under the address of your beneficiary. account balance or the vested plan or for denial or loss of vested portion thereof If you terminate when your vested plan benefits. •• Cause any plan assets to revert to account balance is $1,000 or less Your ERISA Rights (including any rollover account any employer. balances), you must take a distribution See “Your ERISA Rights” on page 205 of your account. See page 140 for for more information. more information.

1-877-MyTHRLink (1-877-698-4754) MyTHR.org 143 Other Texas Health Retirement Plans Other Texas Health Retirement Plans

When Harris Methodist Health FROZEN PHS AND HMHS You may receive a distribution of your Retirement System (HMHS) and Presbyterian 403(B) ANNUITY PLAN full account from the Frozen PHS and Healthcare System (PHS) formed HMHS 403(b) for the same reasons Texas Health in 1997, Texas Health On October 1, 2001, the following (retirement, termination, disability, and assumed responsibility for the HMHS plans were merged to form the Frozen death) at the same time, and in the and PHS Retirement Programs. The PHS/HMHS 403(b) Plan: same way as described for the Texas former HMHS and PHS retirement •• Harris Methodist Health Retirement Health 401(k) Retirement Plan on plans were frozen on December 31, Plan—HMHS 403(b) Plan pages 140 – 142 except that you may 1997, which means that no one is delay the distribution of your account •• Presbyterian Healthcare System eligible to become a participant, no until April 1 following the year in which Section 403(b) Annuity Plan—PHS additional contributions may be made, you reach age 70½ if your account 403(b) Plan. and all participants are 100% vested. balance is $5,000 or greater. At that Many of the provisions previously Vesting time, your account will be distributed described under the Texas Health in the form of a lump sum to you. You are 100% vested in all 401(k) Retirement Plan also apply to contributions made on your behalf. the frozen PHS and HMHS retirement FROZEN PHS AND HMHS plans. These provisions are: Insurance Investments 401(K) PLAN You may have part of your •• Investing Your Retirement On October 1, 2001, the following contributions invested in an insurance Accounts—see page 136 plans were merged to form the Frozen company contract or an annuity •• Choosing Your Investment PHS/HMHS 401(k) Plan: contract. You may direct the plan Options—see page 136 administrator to transfer all or a •• Harris Methodist Health System •• Changing Your Investment portion of these contributions to 401(k) Retirement Plan—HMHS Options—see page 137 one or more of the investment 401(k) Plan •• Rebalancing Notification—see page funds available in the Texas Health •• Harris Methodist Health System 138 Retirement Program. If you would like Productivity Sharing Plan and Trust— •• Account Statements—see page 138 to transfer your contributions, please HMHS 401(a) Plan •• Plan Loans—see page 138 (not contact Human Resources. You are •• Harris Methodist Health System applicable to the Frozen PHS 100% vested in all contributions made Thrift Savings Plan—HMHS 401(m) 401(a) Plan) on your behalf. Plan •• Plan Withdrawals—see page 139 Pre-1989 Contributions •• Presbyterian Healthcare System (not applicable to the Frozen PHS Section 401(k) Retirement Plan— If you were a participant in the HMHS 401(a) Plan) PHS 401(k) Plan. •• Naming a Beneficiary—see 403(b) Plan before January 1, 1989, page 142 you may withdraw any of the savings Vesting •• Qualified Domestic Relations and earnings credited to your account You are 100% vested in all Orders—see page 142 before January 1, 1989. You may make contributions made on your behalf. a withdrawal for any reason regardless •• Claims Procedures—page 143 of your age or financial need if the You may receive a distribution of your •• Unclaimed Benefits—see page 143 savings were always held in an annuity full account from the Frozen PHS and •• No PBGC Coverage—see page 143 contract maintained by an insurance HMHS 401(k) for the same reasons •• Limitations on Employment—see carrier. You cannot withdraw (retirement, termination, disability, and page 143 matching funds, however. Amounts death) at the same time, and in the •• Amendment of the Plan—see held by Fidelity are not eligible for same way as described for the Texas page 143 withdrawal. You must withdraw Health 401(k) Retirement Plan on •• Plan Termination—see page 143 eligible contributions (those made pages 140 – 142, except that you may before January 1, 1989) and earnings delay the distribution of your account

Spending Accounts •• Your Rights Under the Plan—see page 143 before making any financial hardship until April 1 following the year in which •• Your ERISA Rights—see page 205. withdrawal. you reach age 70½ if your account balance is $5,000 or greater. At that time your account will be distributed in the form of a lump sum to you.

144 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Other Texas Health Retirement Plans

FROZEN PHS 401(A) PLAN If you are not married on the date If your spouse has validly waived the your benefits are to begin, you will right to the death benefit or you are On October 1, 2001, the PHS 401(a) receive a life annuity unless you elect not married at the time of your death Plan was renamed the Frozen PHS to waive this form of distribution. and have not begun receiving benefits 401(a) Plan. Under a life annuity, you will receive under the plan, then your death Retirement Vesting equal monthly payments for as long benefit will be paid to the beneficiary as you live. of your choice in a single lump sum. You are 100% vested in all You may designate a beneficiary using contributions made on your behalf. You may elect not to receive the a form available from Netbenefits. automatic form of distribution and Plan Withdrawals While Employed com/thr (see page 142 for more by Texas Health to receive a lump sum distribution information). by contacting Fidelity 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 greater than $5,000, your account hardship withdrawals, while you are on a notarized waiver if the value of balance will be distributed to your working for Texas Health. your account is more than $5,000. spouse if you are married, unless Plan Loans You may revoke your waiver election, you have elected otherwise with but your spouse may revoke his or her your spouse’s consent in writing on The PHS 401(a) Plan does not permit waiver only if you revoke yours. a form furnished to you by the plan loans. administrator. Your account balance Disability Plan Distributions will be paid to your spouse in the If the plan administrator determines form of a survivor annuity—that is, You may receive a distribution of that you meet the plan’s definition periodic payments for the life of your full account from the Frozen of disability, you can receive a your spouse. The size of the monthly PHS 401(a) Plan for the same reasons distribution of your full account payments will depend upon the value (retirement, termination, disability, balance (less any outstanding loan of your account balance at the time and death), at the same time as balance) as soon as administratively of your death. The plan administrator described for the Texas Health practicable. The distribution will be may, however, distribute the benefit 401(k) Retirement Plan on pages made according to the procedure in a single lump sum, provided your 140 – 142 by contacting Fidelity to described above for termination of spouse consents in writing on a request a distribution form, except as employment. To request a disability notarized form. described below. You may delay your distribution, contact Fidelity. distribution until April 1 following the If your spouse consents, you may 1 year you turn 70 ⁄2. If the plan administrator receives waive the survivor annuity at any time satisfactory evidence that you after the first day of the plan year Distributions Other Than are physically unable or mentally in which you reach age 35. If your On Death incompetent to receive the spouse has validly waived the right If you are married on the date distribution, the plan administrator to the death benefit, or you are not your benefits are to begin, you will may make payments on your behalf married at the time of your death and automatically receive a joint and to your spouse, a relative, or your have not begun receiving your plan survivor annuity unless you elect to custodian. benefits, then your death benefit will waive this form of distribution. Under be paid to the beneficiary of your a joint and survivor annuity when Death choice in a single lump sum. you die, your spouse will receive a If you die and your account balance is monthly benefit for the remainder of $5,000 or less, it will be automatically If you are not married, your account his or her life equal to 50% or 75% of distributed to your spouse (if you are will be paid to the beneficiary the benefit you were receiving while married) in a lump sum balance as you designate in one of the forms both of you were alive. If your spouse soon as administratively practicable, described above. You may designate dies before you do, your benefit will unless you have elected otherwise a beneficiary on a form available from not be reduced and you will continue with your spouse’s consent in writing Netbenefits.com/thr (see page 142 to receive the same monthly benefit on a form furnished to you by the for more information). you were receiving while both you plan administrator. and your 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.

1-877-MyTHRLink (1-877-698-4754) MyTHR.org 145 Other Texas Health Retirement Plans

Termination FROZEN PRIOR EMPLOYER •• Amendment of the Plan—see page When you leave Texas Health before 401(K) PLAN 143 •• Plan Termination—see page 143 age 65, you will receive a description The plans sponsored by the •• Your Rights Under the Plan—see of the annuity distribution and the companies listed below were

Retirement page 143 lump sum option available to you. transferred to the Frozen Prior This information is included with Employer 401(k) Plan on the date •• Your ERISA Rights—see page 205. the distribution paperwork. You will indicated. If you were working for Vesting indicate your choice of the method one of these companies on the date of distribution on the form. The tax indicated, your retirement account You are 100% vested in all consequences of the distribution may have been transferred to the contributions made on your behalf. option may vary, and you should Frozen Prior Employer 401(k) Plan: consult with a tax advisor before Plan Withdrawals While Employed by Texas Health making any elections. •• Texas Health Partners, transferred on October 19, 2009 You may receive a distribution of your •• Presbyterian Plan Center for full account from the Frozen Prior Radiation Services, PPCRS, Employer 401(k) Plan for the same transferred February 1, 2010 reasons (retirement, termination, disability, or death) at the same time, •• AMH Cath Lab, transferred on April and in the same way as described for 1, 2010 the Texas Health 401(k) Retirement •• Health First, transferred on May 1, Plan on page 140. You may also 2010. withdraw all or any portion of your •• MedicalEdge Healthcare Group PA, rollover contributions and any transferred on December 31, 2014. earnings allocated on them at any •• Texas Health Medsynergies time, regardless of whether you have transferred on December 30, 2016. reached age 59½. Many of the provisions described under the Texas Health 401(k) Retirement Plan also apply to the Frozen Prior Employer 401(k) Plan. These provisions are:

•• Investing Your Retirement Accounts—see page 136 •• Choosing Your Investment Options—see page 136 •• Changing Your Investment Options—see page 137 •• Rebalance Notification—see page 138 •• Account Statements—see page 138 •• Plan Loans—see page 138 •• Plan Withdrawals—see page 139 •• Naming a Beneficiary—see page 142 •• Qualified Domestic Relations Orders—see page 142 •• Claims Procedures—see page 143 •• Unclaimed Benefits—see page 143 Spending Accounts •• No PBGC Coverage—see page 143 •• Limitations on Employment—see page 143

146 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Time Off Time Off Time Away From Work (THR Employees except THPG Clinic Practice Staff)...... 148 Paid Time Off 148 Who Is Eligible 148 PTO Rate 148 Using PTO 149 Converting PTO 150 Selling PTO 150 Terminating Employment 150 Donating PTO to Charity 151 Receiving PTO as an Incentive 151 Extended Illness Bank/Sick Bank 151 Community Time Off 151 Time Away From Work (THPG Clinic Practice Staff)...... 153 Who Is Eligible 153 PTO Rate 153 Using PTO 153 Maximum PTO 153 Terminating Employment 153 Earning Schedule 153 Time Away From Work (THR and THPG Clinic Practice Staff)...... 154 Changing Employers 154 Donating PTO to the Helping Hands Fund 154 Receiving PTO from the Helping Hands Fund 154 Bereavement Pay 155 Jury Duty 155 Leaves of Absence 155 Employee Rights & Responsibilities Under the Family and Medical Leave Act 156

1-877-MyTHRLink (1-877-698-4754) MyTHR.org 147 Time Away From Work (THR Employees) Time Away From Work (THR Employees except THPG Clinic Practice Staff)

PAID TIME OFF (PTO) WHO IS ELIGIBLE PTO Max Rate for Full-time Employees Texas Health recognizes that time Both full-time and part-time benefits- away from work is important and eligible employees (as defined on If your standard hours as classified necessary for you to balance work page 5) are eligible to receive PTO. in the HR/Payroll system equals 80 with the rest of your life. Texas Health hours a pay period, your PTO Max offers a Paid Time Off program to PRNs, part-time benefits-ineligible Rate can be found in the table below help you continue receiving pay employees (as defined on page under Per Pay Period. when you take time off. The primary 221), and medical residents/interns If you are a full-time employee purpose of the PTO program is to are not eligible for PTO. Based on classified in the HR/Payroll system Time Off provide you pay while you are away line of business, the PTO programs Time Off to work 60-79 hours per pay period, from work due to: described on pages 148 – 152 are not applicable to THPG Clinic Practice your rate (called your PTO Max Rate) •• Vacation Staff (formerly THM employees). is a percentage of the 80-hour PTO •• Holidays Time away from work for physicians schedule. For example, if you are classified to work 64 hours per pay •• Illness or injury and advance practice professionals period, you will receive 80% of the •• Leave of absence employed by THPG is based on their contract. The PTO program for THPG 80-hour PTO schedule (64 hours is •• Family and Medical Leave. Clinic Practice Staff is described on 80% of 80 hours). Paid time off (PTO) is a combination page 153. PTO Max Rate for Part-time of vacation, holiday, and sick time. Employees You receive PTO based on your PTO RATE If you are a part-time benefits-eligible employment status, position, hours You receive PTO each pay period employee (as defined on page 5), worked, and length of service, as beginning the first pay period after your rate (called your PTO Max Rate) described below. If you miss work you complete one month of service. is a percentage of the 80-hour PTO for more than three consecutive schedule. For example, if you are calendar days due to a medical The table below shows the PTO rate classified to work 48 hours per pay condition (your own or an immediate schedule for a full-time employee period, you will receive 60% of the family member’s), you must contact working 80 hours a pay period. Your 80-hour PTO schedule. Integrated Disability Management at PTO rate may be less if affected by 1-877-MyTHRLink (1-877-698-4754), one of two things: 1) your standard prompt 6, press 1 to discuss eligibility hours as classified in the HR/Payroll for leave of absence. Although PTO system are less than 80 hours a pay provides pay for a brief illness, to be period or 2) your PTO Eligible Hours sure you have protected your income within a pay period are less than your in case of a longer illness or injury, it standard hours as classified in the HR/ is important to consider Short Term Payroll system. To determine your Disability coverage as explained on PTO rate, you’ll need to know your pages 111 – 112. PTO Max Rate and understand PTO Eligible Hours. It is important to manage your PTO bank like a savings account. You want to make sure there is enough PTO for Years of THR PTO Rate Schedule vacations and holidays; but also have Service Positions Below Director Director & Above some set aside in case you have to Annual Per Pay Period Annual Per Pay Period miss work due to illness or disability. Spending Accounts Less than 1 176 hours 6.77 216 hours 8.31 1 192 hours 7.38 232 hours 8.92 2 - 4 208 hours 8.00 248 hours 9.54 5 - 9 232 hours 8.92 272 hours 10.46 10 - 14 256 hours 9.85 296 hours 11.38 15 - 19 280 hours 10.77 312 hours 12.00 20 or more 296 hours 11.38 328 hours 12.62

148 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Time Away From Work (THR Employees)

PTO Eligible Hours USING PTO Exempt Employees Your PTO Rate in a pay period could PTO provides you with pay while you If you are an exempt employee, you be less than your PTO Max Rate. take time off from work for vacation, must use PTO in full-day increments This happens when your actual holiday, illness, or disability. Your based on your schedule for the day, hours worked (based on PTO Eligible PTO rate is based on your standard unless you are on an intermittent hours) in a pay period are less than hours in the HR/Payroll System and FMLA leave. If you are on an approved your standard hours as classified in your years of service. Subject to your intermittent FMLA leave and you the HR/Payroll system. PTO Eligible supervisor’s approval, you can use choose to use your PTO for the Hours are earnings codes entered by your PTO when received, up to the portion of the day not worked, you timekeepers in the HR/Payroll system amount that matches your scheduled must use PTO in hourly increments. that count as hours worked when hours in the HR/Payroll system. If If you are an exempt employee who calculating your actual PTO rate. A you are a full-time employee, you are is not on intermittent FMLA and you full list of the earnings codes can be encouraged to take at least 10 days miss a portion of a scheduled day, found on BeHealthyTHR.org. If you (80 hours) of PTO each year. you are paid for the full day without are benefit eligible and you have a the addition of PTO. Time Off second job as PRN, the hours you Generally, you must use PTO when work as PRN do count toward your you are away from work on a regularly Non-exempt Employees hours worked/PTO Eligible Hours. scheduled day, unless it would cause If you are a non-exempt employee you to exceed the number of hours and you are away from work on a For example, your standard hours you are classified in the HR/Payroll regularly scheduled day, you are are 80 hours a pay period week with system to work. However, there are required to use PTO to bring you up PTO Max Rate of 8.0 hours. You work some exceptions. to the hours for the week according 60 hours that pay period and do not to your Full-time Equivalent (FTE) have PTO to use. For that pay period, You cannot use PTO if: defined in the HR/Payroll system. you will receive 75% of your PTO Max •• Your absence is due to jury duty. Rate making your actual PTO rate Employees on a schedule with •• You are receiving bereavement pay. 6.0 hours. Your actual rate cannot be different hours each week during a higher than your PTO Max Rate. •• You are on an unpaid administrative pay period must receive an exception leave or suspension. from Human Resources. Employees on Leave of Absence You may use PTO, but are not For example, if your FTE is 100% You do not receive PTO while on paid required to use it if: or unpaid leave of absence. (40 hours per week) and you work •• You are on military reserve training 32 hours during the week, you are Maximum PTO or duty. required to use eight hours of PTO unless you qualify for one of the You may have up to 350 hours of •• You are not at work or are sent exceptions described in this section. PTO. You will forfeit hours in excess home because of low census or of the maximum. You may carry over other business reason. A non-exempt employee with up to 350 PTO hours at any time. •• You are on a leave of absence and intermittent FMLA absences and a Your PTO balance is shown on each have less than 80 hours of PTO PTO balance that falls below 80 hours paycheck. available. is not required to use PTO.

PTO is paid at your current regular You may not use PTO during any pay hourly pay rate (excludes shift week if using it would cause you to differential). exceed the number of hours you are classified in the HR/Payroll system to If you are receiving STD or workers’ work. 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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CONVERTING PTO SELLING PTO TERMINATING EMPLOYMENT By converting PTO, you can use The primary purpose of the PTO If you leave Texas Health, you will be some of the PTO pay you earn in program is to provide you with paid for 100% of your unused PTO the current year to instead pay for pay while you are away from work hours (up to 350 hours), provided Flexible Benefits during this year. for vacation, illness, or disability. you continue to work for at least two During annual benefit enrollment, However, there may be times when weeks (four weeks for management most employees can elect to convert you need additional income for an employees and supervisors) after up to 80 hours of PTO (in eight-hour unexpected expense. giving written notice of your intent increments) that you will earn next to resign. If you do not give proper year to pay for next year's Flexible You may sell PTO two times a year, written notice, your PTO will be Benefits. The value of PTO hours you up to an annual total of 80 hours reduced to offset the amount of elect to convert will be deducted anytime during each calendar year notice not given. PTO hours may be from your paycheck over 26 pay except the last paycheck of the year, used only during the notice period for periods based on your hourly rate of based on pay-period ending dates. PTO scheduled and approved by your You must maintain at least 80 hours

Time Off pay at the time the PTO is converted. supervisor before you give notice. You of PTO after the sale. Each hour of may not use PTO to extend pay or To be eligible to convert PTO, you PTO is valued at your regular hourly benefits after your last day of work. must elect at least one Flexible pay rate. You may sell a maximum of Benefit option (Medical, Dental, 80 hours per year. PTO is paid at your current regular Vision, Additional Life, Additional hourly pay rate at the time of AD&D, Short Term Disability, The hours you sell are included in temination (excludes shift differential). Additional Long Term Disability, the 100-hour annual maximum for Dependent Life Insurance, or a selling, converting, and donating If you switch to a status that is not Flexible Spending Account) during PTO. For example, if you converted eligible for benefits (such as full-time the open enrollment period. The 40 hours during open enrollment and to PRN), you will be paid for 100% of hours you convert are included in the have not sold any PTO this year, you your unused PTO, up to 350 hours, 100-hour annual maximum for the have 60 hours that can be sold or within two or three pay periods after selling, converting, and donating of donated during 2019. However, if you your change. Your PTO cash-out PTO. You may convert a maximum of have donated 40 hours and converted will be subject to applicable payroll 80 hours per year. PTO conversion is 40 hours this year, you only have 20 taxes and 401(k) deductions if you are suspended while you are on a leave of hours available to sell during 2019. enrolled in the 401(k) Plan. absence. When you sell PTO, you will receive THPG providers and THPG Clinic 80% of the value of your sold PTO Practice Staff are not eligible to hours as a cash payment, less the convert PTO. applicable payroll taxes. The 20% penalty is imposed for tax-related reasons. If you participate in the Texas Health 401(k) Retirement Plan, your contribution to the 401(k) Plan will also be deducted from the PTO payment.

If you are interested in selling PTO, log on to MyTHR.org. Click My PTO Balance, then click the PTO Sell link at the bottom of the page. You cannot be suspended at the time you choose to sell PTO or when the payment is made.

Due to IRS regulations, the combined Spending Accounts amount of PTO you convert, sell, and donate must be less than 100 hours per year. Each plan has an individual maximum, as well. This maximum does not apply to Helping Hands donations.

THPG providers and THPG Clinic Practice Staff are not eligible to use the PTO Sell program.

150 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Time Away From Work (THR Employees)

DONATING PTO TO CHARITY RECEIVING PTO AS AN COMMUNITY TIME OFF You may sell your PTO hours to INCENTIVE (CTO) Texas Health and direct that the net You cannot receive extra PTO Each full-time and benefits-eligible after-tax proceeds from the sale be as an incentive to participate in part-time employee is eligible for up donated to one or a combination of philanthropic events or activities. to one regularly scheduled workday the following charities: PTO can only be earned through the of paid time off per year to volunteer normal process. at a hospital/entity/system sponsored •• Community Giving community benefit event and/or ––United Way EXTENDED ILLNESS BANK/ for a non-profit organization in the ––American Cancer Society SICK BANK community. Hours may be taken ––American Heart Association incrementally, as approved by your ––March of Dimes Before the formation of Texas Health, manager. CTO hours are non- some employers had an Extended ––Susan G. Komen for the Cure productive paid time that counts Illness Bank (EIB) or Sick Bank Foundation toward hours worked, however is program to provide paid time off for •• Texas Health Associates not meant to place an employee into Time Off illness or injury. These programs are overtime. ––Arlington Memorial Hospital, Inc. now frozen and no longer receive ––Harris Methodist Health hours, but employees may use their Guidelines for the program are: Foundation previously received hours under •• Full-time and benefits-eligible ––Presbyterian Healthcare certain circumstances until their part-time employees receive one Foundation. accounts are depleted. full, scheduled workday per year You may sell up to 80 hours of PTO Employees with hours credited to for CTO for charity any time during the year, the former Presbyterian EIB or the •• The activity must be within the as long as you maintain at least 80 Harris Methodist Sick Bank before Texas Health service area. hours of PTO after the sale. The January 1, 1998, or the Arlington •• It must benefit a charitable 501(c)3 hours you donate are included in the Memorial Hospital Sick Bank before or 170c-1 (school) organization. 100-hour annual maximum for the January 1, 2000, or Presbyterian •• The activity utilizes Texas Health selling, converting, and donating of Hospital of Denton EIB before May paid time. PTO. 1, 2009, can access them after three •• Your manager’s approval is consecutive days of absence due to When you sell your PTO for donation required prior to using CTO and illness or injury. If your schedule is 12 to a charity, the proceeds are is contingent on business and hours a day, you will have to take 36 reported as taxable income to you. operational needs. hours of PTO before you are eligible Your PTO donation will be subject to •• Hours may be taken incrementally to use EIB. You must use PTO time, applicable payroll taxes and 401(k) as approved by a manager. if available, during the three-day deductions (if you are enrolled in the waiting period. You cannot substitute •• CTO hours do count toward the 401(k) Plan). EIB or Sick Bank to replace the three pay week hours and contribute to the calculation of overtime; You may be able to claim the net days of PTO. however, it is not advised to place after-tax proceeds of the sale as a You may use EIB/Sick Bank hours for an employee into overtime by using tax-deductible charitable contribution an approved FMLA leave of absence. CTO. if you itemize tax deductions when You cannot transfer EIB or Sick Bank you file your income tax return. •• Both exempt and non-exempt time between accounts or exchange employees should report CTO time THPG providers and THPG Clinic them for PTO. Unused time will not to their department time keeper for Practice Staff are not eligible to be paid out upon your termination of tracking on Texas Health's annual use the donation of PTO to charity employment or change in status to Community Benefit report. Texas program. benefits-ineligible regardless of your Health does many activities in and years of service. for the community and we want to make sure that the hours you work If you terminate or have a change in in this capacity are tracked in this status to benefits-ineligible (such as report each year. PRN or part-time benefits-ineligible as defined on page 221) you will •• Exempt employees do not receive forfeit your EIB or Sick Bank time additional compensation for even if you are later rehired or move participating in CTO projects. back into a benefits-eligible status. •• Non-exempt employees must be paid for all CTO hours worked.

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•• Managers may flex a non-exempt •• Schools—all public and private employee’s hours to compensate schools are qualifying organizations for CTO to avoid placing the as long as CTO is used to further employee in overtime. education through the support •• CTO cannot be donated. of academic programs. Examples •• CTO cannot be used to solicit funds would include mentoring, tutoring or donations from employees and and science fairs. Examples of is to be used strictly for community ineligible activities would be volunteerism. watching a school performance, parent-teacher conferences, field Your responsibilities: trip, or driving a child to a school event. •• Log on to Employee Volunteer Tool located at TexasHealth.org/ Non-qualifying organizations TexasHealthGives. include political organizations and

Time Off •• Complete your employee profile. organizations that may compete with •• Read the CTO policy. Texas Health. •• Join an existing project or propose For more information, contact a new project and submit your CTO Texas Health Community Affairs request two weeks prior to the Department at 682-236-7619 or email volunteer project. thrcommunityaffairs@texashealth. •• Your supervisor will receive an email org. requesting approval of your CTO project. •• If your project is approved by your supervisor, report CTO hours to department personnel responsible for payroll entry (CTO payroll code) before payroll Monday.

Qualifying charitable organization is one that is tax-exempt under section 501(c)3 or 170c1:

•• Healthcare organization/ social services—all health care organizations qualify, including community health activities that Texas Health may organize that benefit the community at large. CTO is not for personal benefit such as visiting a sick relative or friend. •• Faith organizations—all faith organizations qualify for CTO as long as it is used to promote the health and well being of the faith organization members or the community at large. An example includes participating in faith community activities that feed the homeless. Spending Accounts

152 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Time Away From Work (Clinic Practice Staff)

Time Away From Work (THPG Clinic Practice Staff)

WHO IS ELIGIBLE Employees are required to use PTO •• You are not scheduled to work or are for pre-approved vacation, holidays, sent home because of low census or The PTO program described on this and time-off. Pre-approved PTO may other business reason. page is applicable to both full-time and be rescinded if the employee does not part-time benefits-eligible employees (as have enough hours to cover it when Exempt Employees defined on page 5) that are THPG Clinic the time comes for the employee to Practice Staff (formerly THM). The PTO If you are an exempt employee, you must be out. Program for other employees can be use PTO in full-day increments based on found on pages 148 – 152. If an employee knows that he/she will your schedule for the day, unless you are be late or absent from work, he/she on an intermittent FMLA leave. If you are Texas Health Resources is committed to must verbally inform their supervisor on an approved intermittent FMLA leave providing THPG Clinic Practice Staff the (or preauthorized designee) as far in and you choose to use your PTO for the flexibility to balance work and personal portion of the day not worked, you must advance of the start of the workday as Time Off goals. Paid time off (PTO) combines sick, possible. If there is an urgent need that use PTO in hourly increments. If you vacation, personal days and holidays requires an employee to leave work are an exempt employee who is not on into one integrated program from which early, the employee must get prior intermittent FMLA and you miss a portion employees can schedule paid time off permission from their supervisor. of a scheduled day, you are paid for the with agreement with his/her supervisor. full day without the addition of PTO. If you Employees are expected to manage are an exempt employee and you miss a PTO responsibly. PTO RATE full scheduled day, you must record PTO. You receive PTO each pay period Employees will be required to use PTO beginning the first pay period after you for any unscheduled absences, instances MAXIMUM PTO complete one month of service. of tardiness, pre-approved vacation, holidays, and personal time off. Employees are encouraged to use PTO Employees will receive PTO in to maintain a good work life balance and accordance with the schedule below. Employees may not use PTO during any may carry over up to eighty (80) hours of Employees working less than 35 hours week if using it would cause them to unused PTO at the end of the year. exceed the number of hours they are per week will receive prorated PTO In order to be paid for PTO, it must be classified to work in the HR/Payroll system. time, depending on hours worked. The correctly entered into the system prior to amount of PTO an employee receives is If PTO hours are exhausted and the the payroll cut-off for that pay cycle. determined by his/her years of service employee needs to take a day off due to with the company. The higher rate is illness, it will be unpaid. TERMINATING EMPLOYMENT received effective on the employee’s Employees are required to use PTO for anniversary date. Upon separation of employment, approved leaves of absence and have employees will be paid at straight time more than 80 hours of PTO balance. USING PTO rate of pay for any unused PTO up to a Employees may use PTO, but are not maximum of eighty (80) hours, providing PTO is available to use once it has required to use it if they are on leave of a two (2) week notice is given in writing. been received and is approved at the absence and have less than 80 hours. Employees must work the entire manager’s discretion based on the You cannot use PTO if: notice period in order to be paid out needs of the business. •• Your absence is due to jury duty. for PTO. Employees may not use PTO All PTO must be requested through the •• You are receiving bereavement pay. during the notice period unless it was timekeeping system, at least (2) two •• You are on an unpaid administrative previously scheduled and approved by weeks in advance (except for sick days) leave or suspension. the manager. and have supervisor approval prior to Employees who fail to work through the the start of PTO. You may use PTO, but are not required to use it if: notice period or who are terminated for cause will not be eligible for unused PTO •• You are on military reserve training or pay out. duty.

EARNING SCHEDULE: 35.00 – 40.00 HRS/WEEK PRO-RATED EARNING: LESS THAN 35 HOURS After Hours Hours Per Maximum Hours Worked Maximum Allotted Level Months Per Year Pay Period Balance Per Week PTO Time 0-3 years 0 192.00 7.3846 80 30-34 hours 75% of earning schedule 4-8 years 48 232.00 8.9231 80 25-29 hours 60% of earning schedule 9+ year 108 272.00 10.4615 80 Less than 24 hours No PTO time allotted

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CHANGING EMPLOYERS Because the PTO that you donate to RECEIVING PTO FROM THE the Helping Hands Fund is actually If you work in a department, division, HELPING HANDS FUND used by other employees to take time or operating unit or an affiliate or off, there is no maximum donation To be eligible to receive PTO benefits subsidiary that Texas Health sells or and it does not count toward the 100 from the Helping Hands Fund, you otherwise transfers to a third party hour annual maximum that includes must: and you are employed by the new PTO you sell, donate, or convert. owner, your PTO will be transferred •• Be missing time from work Because no taxes have been withheld to your new employer if Texas Health •• Be an active, benefits-eligible from the PTO you donate, the and the new owner agree to the employee with at least 90 days of donation itself is not tax deductible. transfer before the date you are service To donate PTO, log on to MyTHR.org, employed by the new owner. If the •• Demonstrate that an unpaid leave select My PTO Balance and click the Time Off new owner does not agree to the will create a financial hardship Helping Hands link at the bottom of transfer, you will be paid your PTO as the page. •• Not have received more than 80 if you had terminated employment, as hours of PTO from the Texas Health explained above. When transferring to THPG providers are not eligible to Helping Hands Fund in the same a THPG Clinic Practice Staff position, donate to the Helping Hands fund. calendar year employee will be paid out any excess •• Be in good standing at your entity PTO balance over 80 hours. and are not under any type of disciplinary action program. DONATING PTO TO THE HELPING HANDS FUND The PTO you receive is considered taxable income and will have other The Helping Hands Fund is a program deductions taken from it, such as your that gives Texas Health employees a 401(k) contribution. You can receive way to help other employees. a maximum of 80 hours of donated PTO in a calendar year. You may donate PTO to the Helping Hands Fund. Then, an employee who The Helping Hands Fund is not must miss work due to a personal/ intended to act as an income family illness or a catastrophic event replacement fund or to help people and has used all of his or her PTO can who don’t have catastrophic apply and, if approved, receive PTO situations. THPG providers are not hours from the fund. eligible to receive PTO benefits from the Helping Hands fund. A central system-wide Helping Hands Committee administers distributions When you apply for the Helping from the fund. They will consider Hands Fund, you will also be referred the nature of the catastrophic event, to the Texas Health EAP (see page employee’s economic circumstances, 81) to identify other community the estimated length of absence resources and services that may be from work, and the amount of PTO of additional help to you. Contact requested. Human Resources to request a donation from the Helping Hands To be an employee donor, you: Fund. •• Must be an active, benefits-eligible employee with at least one year of service

Spending Accounts •• May make a single donation of PTO (in one hour increments), or you can sign up to make regular donations of PTO each pay period. •• Have enough PTO in your bank that you will have at least 80 hours left after making the donation.1

1 The 80-hour minimum does not apply to chaplain residents.

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BEREAVEMENT PAY If you are receiving Short Term If you have a 401(k) loan, during Disability (STD) or workers' an approved leave of absence, you Time Away From Work If you are a full-time or part-time compensation temporary income may request that loan payments be benefits-eligible employee (based on benefits, the combined amounts suspended during your leave. If you the employee’s eligibility requirements cannot be more than 100% of your suspend payments during a leave of as defined on page 5) in an active normal base pay. absence, the loan will be reamortized status, when a family member dies upon returning to work. you can take days off with pay to JURY DUTY grieve, attend the funeral, make You may continue the following Texas funeral arrangements, or settle the If you are a full-time or part-time Health benefits during an unpaid leave estate. The time off does not need to benefits-eligible employee, you will be of absence: be consecutive, and you are eligible paid for each hour you are away from immediately upon hire. scheduled work to perform jury duty •• Medical or serve as a subpoenaed witness on •• Dental You are paid at your base pay for each behalf of Texas Health. Jury Duty pay is •• Vision hour you are away from work for equal to your hourly base pay rate. The •• Short Term Disability (STD) Time Off bereavement, to the amount based on maximum pay per day is based on the •• Long Term Disability (LTD) the number of hours you are classified number of hours you are classified to to work in the HR/Payroll system. You •• Life Insurance work in the HR/Payroll system. may be eligible for bereavement pay for •• Voluntary AD&D the following: You may not use jury duty leave during •• Accident Insurance any pay week if using it would cause •• Hospital Indemnity Amount Relationship to you to exceed the number of hours •• Critical Illness Insurance of Days Employee* you are classified to work in the HR/ •• Health Care Flexible Spending Payroll system. Account. Up to ••Spouse three ••Child days LEAVES OF ABSENCE You may not participate in the Day ••Grandchild Care Flexible Spending Account during All employees may be eligible to take ••Sibling, or spouse’s a leave of absence. sibling the following types of leave: If you continue coverage during your ••Parent, or spouse’s •• Family and Medical Leave parent leave, you will pay the same cost of •• Military Leave ••Grandparent coverage as active employees pay. If •• ADA ••Great-grandparent you do not pay your premiums, your •• Personal Leave. ••Son- or daughter-in- benefits will be canceled. law Employees on leave of absence are For more information, contact the ••Brother or sister-in- not eligible for any type of pay except Integrated Disability Management law for any eligible Extended Illness Bank Department at 1-877-MyTHRLink ••Niece or nephew (EIB), paid time off (PTO), workers' (1-877-698-4754), prompt 6, press 1. Up to ••Aunt or uncle of compensation benefits, provider You may view the Texas Health Leave one day employee draw, success sharing and/or disability of Absence policy on MyTexasHealth. ••Spouse of grandchild benefits. texashealth.org or email at THRIDM@ ••Brother- or sister- TexasHealth.org. in-law of employee’s You do not accrue PTO while on a spouse paid or unpaid leave of absence. ••Niece or nephew of employee’s spouse During your leave, you may keep your ••Great-grandchild benefits coverage effective under the Texas Health benefits plans by paying ••Spouse's grandparent your share of the premiums. Your cost

* Includes current step relationships as well. will be the same as active employees pay. If you are receiving PTO and/or You may not receive bereavement pay EIB, your premiums will be deducted during any pay week if using it would from your check. If you are not cause you to exceed the number of receiving PTO and/or EIB during your hours you are classified to work in the leave, you must pay your share of the HR/Payroll system. premiums each pay period. If you do not pay your premiums, your benefits An employee on any approved leave of will be canceled. absence (paid or unpaid) may receive bereavement pay.

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EMPLOYEE RIGHTS & Use of FMLA leave cannot result in When returning from FMLA, you RESPONSIBILITIES UNDER the loss of any employment benefit may resume participation in your THE FAMILY & MEDICAL that accrued prior to the start of an Dependent Care Flexible Spending employee’s leave. Account at your original annual LEAVE ACT (FMLA) election prior to beginning leave (and Basic Leave Entitlement During your leave, you are entitled to thus pay via the "catch up" option) keep in effect your coverage under FMLA is a federal law that gives you or resume participation at a reduced the Texas Health benefit plans. You level under the proration rule. the opportunity to take up to 12 work must pay your share of the premiums. weeks of unpaid, job -protected leave If you are receiving PTO, your Qualifying for FMLA during any 12-month period for the premiums will be deducted from your following reasons: To qualify for FMLA, you must have check. If you are not receiving PTO been employed by Texas Health for •• The birth and care of your newborn for all of your leave, you must pay by 12 months and worked at least 1,250 child check your share of the premiums. If hours in the 12-month period before you do not pay your premiums, your •• The placement of a child with you the leave.

Time Off benefits will be canceled. for adoption or foster care Definition of Serious Health •• The care of your spouse, child You may also revoke your election Condition (under age 18 or incapable of of coverage under any of the above A serious health condition is an illness, caring for him- or herself because plans before your leave or during injury, impairment, or physical or of physical or mental disability) or your leave, as long as it’s within 31 mental condition that involves either parent who has a serious health days of beginning of unpaid leave. an overnight stay in a medical care condition You also have the right to revoke or facility, or continuing treatment by a •• Your own serious health condition change elections under the same health care provider for a condition that makes you unable to perform terms and conditions as are available that either prevents the employee your job to employees participating in the plan from performing the functions of •• Any qualifying exigency, i.e., the who are not on leave (see “Status the employee’s job, or prevents employee’s spouse, son, daughter, Changes” on pages 11 – 12). the qualified family member from or parent is a military member If your coverage under one of the participating in school or other daily on covered active duty or call to plans has been terminated, you may activities. covered active duty status. choose to be reinstated on your Subject to certain conditions, the In addition, eligible employees may return to work after your leave on continuing treatment requirement take up to 26 workweeks of leave in a the same terms as before the leave may be met by a period of incapacity single 12-month period to care for a (including family and dependent of more than 3 consecutive calendar covered servicemember with a serious coverage). days combined with at least two injury or illness if the employee is the If your coverage under a plan visits to a health care provider or one spouse, son, daughter, parent, or next terminates while you are on FMLA visit and a regimen of continuing of kin of the servicemember (referred leave, you are not entitled to receive treatment, or incapacity due to to as military caregiver leave). An reimbursements for claims incurred pregnancy, or incapacity due to a eligible employee is limited to a during the period when the coverage chronic condition. Other conditions combined total of 26 workweeks of was terminated. If you later elect to be may meet the definition of continuing leave for any FMLA-qualifying reasons reinstated in a plan upon return from treatment. during the single 12-month period. FMLA leave for the reminder of the Texas Health calculates FMLA wage Use of Leave plan year, you may not retroactively and eligibility using a rolling 12-month elect coverage for claims incurred Leave can be taken intermittently or period. during the period when the coverage on a reduced leave schedule when Benefits and Protections was terminated. medically necessary. You must make reasonable efforts to schedule leave During FMLA leave, Texas Health must If you have a qualifying change in for planned medical treatment so as maintain your health coverage under family status (such as the birth of a not to unduly disrupt Texas Health

Spending Accounts any “group health plan” on the same child, marriage, etc.) during your leave, operations. Leave due to qualifying terms as if you had continued to work. you must contact Human Resources exigencies may also be taken on an Upon return from FMLA leave, most and make the change within 31 days intermittent basis. employees must be restored to their of your status change (see “Status original or equivalent positions with Changes” on pages 11 – 12). equivalent pay, benefits, and other employment terms.

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Substitution of Paid Leave for Unpaid Your Responsibilities Employer Responsibilities Leave You must provide 30 days advance Texas Health must inform you when You must use PTO while taking FMLA notice of the need to take FMLA requesting leave whether you are leave unless you have a PTO balance leave when the need is foreseeable. eligible under FMLA. If you are, the of 80 hours or less. In order to use When 30 day’s notice is not possible, notice must specify any additional PTO for FMLA leave, you must submit you must provide notice as soon information required as well as your the PTO Supplement form to your as practicable and generally must rights and responsibilities. If you are timekeeper. comply with Texas Health’s normal not eligible, Texas Health must provide call-in procedures. a reason for the ineligibility.

You must provide sufficient Texas Health must inform you if leave information for the employer to will be designated as FMLA-protected determine if the leave may qualify and the amount of leave counted for FMLA protection and the against your leave entitlement. If Texas anticipated timing and duration of Health determines that the leave is not

the leave. Sufficient information FMLA-protected, Texas Health must Time Off may include that you are unable notify you. to perform job functions, your family member is unable to Unlawful Acts by Employers perform daily activities, the need FMLA makes it unlawful for any for hospitalization or continuing employer to: treatment by a health care provider, •• Interfere with, restrain, or deny the or circumstances supporting the exercise of any right provided under need for military family leave. FMLA; and You also must inform the employer •• Discharge or discriminate against if the requested leave is for a reason any person for opposing any for which FMLA leave was previously practice made unlawful by FMLA or taken or certified. for involvement in any proceeding under or relating to FMLA. You also may be required to provide a certification and periodic You should refer to the Texas Health recertification supporting the need Leave of Absence Policy to get more for leave. information about your rights under FMLA. You may also contact the Integrated Disability Management department at 682-236-7278. An employee may file a complaint with the U.S. Department of Labor, Wage and Hour Division or may bring a private lawsuit against an employer.

FMLA does not affect any Federal or State law prohibiting discrimination, or supersede any State or local law or collective bargaining agreement which provides greater family or medical leave rights.

1-877-MyTHRLink (1-877-698-4754) MyTHR.org 157 Other Benefits Other Benefits Tuition Reimbursement ...... 159 Adoption Assistance Program ...... 163 Supplemental Benefits through MetLife...... 164 Other Benefits Spending Accounts

158 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Other Benefits Other Benefits TUITION REIMBURSEMENT Key Actions to Take The following are not eligible: Program Overview •• Verify that you are eligible •• Medical directors employed under to participate in the Tuition contract Attending school can open many Reimbursement Program. •• Medical residents or interns doors for your career, but paying for school can be a big challenge. •• Determine if your coursework •• Administrative residents or interns Texas Health offers the Tuition or field of study is eligible for •• Fellows or interns Reimbursement Program to help you reimbursement through the •• Dependents of employees. further your education. Through the program. To be eligible for the Tuition Tuition Reimbursement Program, Texas •• Complete a Career Development Reimbursement Program, you must have Health will reimburse tuition and some Inventory (CDI) if required six or more months of service before recurring fees for approved degrees •• Submit your request for the start of the courses, semester, or that benefit Texas Health or your reimbursement with all required term. (This six-month rule is waived for position at Texas Health (certificate documents no later than 60 employees pursuing clinical degrees.) programs are not eligible for tuition calendar days after completing the You may be on a leave of absence while reimbursement). courses, semester, or term. taking the courses, but you must be a Courses must be taken at universities, Eligibility benefits-eligible employee and actively at work when any of the following occur: colleges and vocational tech schools Full-time and part-time benefits- in the U.S. that have been accredited eligible employees (as defined on •• You submit your reimbursement by specific nationally recognized page 5) may participate. You must request accrediting agencies as defined in the earn a C or better (or pass in a pass/ •• Your payment is processed table below. The Texas Health Benefits fail class) to receive reimbursement. •• Course, semester, or term start date. Department administers the Tuition Reimbursement Program. Exceptions are made for employees on

military leave. Other Benefits Approved Accrediting Agencies All Degrees 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) ••Distance Education Accrediting Commission ••Accrediting Bureau of Health Education Schools ••Accrediting Commission of Career Schools ••Transnational Association of Christian Colleges and Schools 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 Nursing In addition to one of the above accreditations for all degrees, nursing pre-licensing undergraduate (ADN, BSN) courses must be taken at colleges or universities that are accredited by one of the following nursing accrediting agencies: ••Accreditation Commission for Education in Nursing (ACEN), formerly National League for Nursing Accreditation Commission (NLNAC) ••American Association of Colleges of Nursing — BSN or higher degree programs ••Commission of Collegiate Nursing Education (CCNE) If your college or university is not accredited by one of these associations, contact Tuition Reimbursement. Required Clinical Rotations/Practicum Texas Health has affiliations with certain schools for students to be able to complete clinical rotations or practicum at Texas Health Resources facilities. While your university or college may be eligible for our tuition reimbursement program, this does not mean that Texas Health also has or will have an affiliation for clinical rotations or practicum. To determine whether your school has an established affiliation with Texas Health, go to https://mytexashealth.texashealth.org/LearningTraining/THRU/Academic/Documents/ THR%20Clinical%20Affiliations.pdf.

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Eligible Degrees and Coursework

Topic Description Clinical degrees Benefits-eligible 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 degrees up to: ••$5,250 per calendar year for full-time employees ••$5,250 per calendar year for 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 calendar year for part-time employees/part-time students. In addition to tuition, you may submit receipts for reimbursement of textbooks (books purchased from individuals are not covered). Books for clinical nurse leader programs are not eligible for reimbursement.

Non-clinical Benefits-eligible employees who have completed six months of service prior to the semester/course start date degrees are eligible for tuition, up to the following maximums: •• $4,000 per calendar year for full-time employees •• $2,000 per calendar 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)

How you are You must be actively at work in a benefits-eligible position before the start of the course, at the time you submit reimbursed your reimbursement request, and at the time your reimbursement is processed. All employees using the Tuition Reimbursement program are required to complete a Career Development Inventory (CDI). You may complete this inventory at any time. To complete, log on to MyTHR.org. Click the Benefits tile, click Tuition Reimbursement, then click Career Development Inventory. At the top of the page on the right-hand side, you will see a yellow circle that says “New to Our site? Click here to complete the Career Other Benefits Development Inventory." There are seven sections on the inventory and a total of 36 questions to complete. Please allot adequate time to complete all sections. Once the inventory is completed, you will notice upon logging back in that your overall rating is reflected in the green circle on the top of the first page of the portal. If you would like to go more in-depth with your career preparedness, you can complete sections under the My Career Development Resources section. If you have technical questions regarding the CDI, please contact [email protected]. If you have questions regarding Tuition Reimbursement, contact us at 682-236-6238 or email THRTuitionReimbursement@ texashealth.org. Within 60 days after completing the courses, semester, or term, you must submit your request for reimbursement by following the steps below: ••Download your documents to a drive on a computer or electronic device. ••Log on to MyTHR.org. ••Click the Benefits tile. ••Click Access Tuition Reimbursement. ••Click the Submit Request for Reimbursement box on the Tuition Reimbursement Program screen. ••Select the College or University. ••Select the number of course you completed. ••Click Continue. ••Enter all requested information. 1. Estimated graduation date 2. Major and degree 3. Course start and end dates 4. Email address (enter the one you use most often) Spending Accounts 5. Course information ••Enter any comments. ••Click Submit Application Request. ••Enter book information, if applicable (clinical degrees only). ••Click Continue.

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How the Program Works

Topic Description

How you are ••Read the instructions and the participant certification. You may also view a copy of the program guide by reimbursed, clicking the link at the bottom of the page. continued ••Type your full name and click the Acknowledge box. ••Check the boxes verifying that your documents contain all the required information needed to process your request: ––Itemized statement from the college or university with your name pre-printed on it that reflects the actual cost of the courses, not a payment receipt ––Final grade report or unofficial/official transcript that has your name pre-printed on it ––Copy of the course schedule, student schedule, or enrollment verification with your name pre-printed on it that lists the actual course start and end dates of the classes you just completed. (Please note general college calendars or college academic schedules are not accepted.) ––Itemized book receipts (if applicable) ––Financial aid award letter (if applicable) ••Upload your documents (if one document contains all of the information needed, only attach it once). ••Click the Submit Request box. ••Read the message regarding your submission. ••Click OK. After you click OK, you will receive a confirmation email. Make sure the email address you provided is correct. ••Your request will be received in our office and processed in 1-2 payroll periods from receipt of complete information. This time frame may vary. If you receive a request for missing documentation, you will need to resend all documents together by clicking the Reimbursement edit button in the actions tab on the side of your application. This way you do not have to re-enter all of the previously entered information. ••Reimbursement amounts are determined by your employment status as classified in the HR/payroll system at the time your request is paid. ••Please make sure your email address is correct because you will receive a confirmation email once you click OK Other Benefits ••Tuition reimbursement payments are deducted from your annual benefit maximum of the calendar year that your classes began. Scholarship, grant money, or waived or exempted tuition received by the student may reduce benefits payable through the Tuition Reimbursement Program. Please submit a copy of your financial aid award letter. Requesting advance You may request advance tuition assistance if you are a full-time employee or part-time benefits-eligible funds employee with a current annual base pay rate of less than $40,000.00. All eligibility, maximums, and other policy requirements apply to advances. More information about advance funds is provided later in this section.

Expenses that are not The Tuition Reimbursement Program does not reimburse charges for waived or exempted tuition, covered professional meetings, workshops, conventions, drop fees, exam fees, late fees, supply kits, licensures, room and board, parking fees, uniforms, drug screens, background checks, certificate courses, CEUs, 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, shipping and handling, supplies, lab packs, laptops, software, calculators, nurse skills pack, college repeat fees, association fees, administrative costs for research projects or studies, continuing education classes, membership fees, or 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 reimbursement you receive that reimbursement exceeds $5,250 in a calendar year will be taxed, even if the payment was for the prior benefit year.

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Changes in Employment

Topic Description If your If you terminate employment or change to a non-benefits-eligible status (such as PRN or part-time benefits- employment ineligible, as defined on page 221) within 12 months of receiving payment for the courses, you will be required to status repay the reimbursed funds paid on your behalf to Texas Health. The 12 months is from the paycheck date. changes If your position is eliminated and you are eligible for separation pay, or you did not voluntarily change to the 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. You are also eligible to receive tuition reimbursement for your current semester as long as you meet all other requirements for the program. 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 tuition reimbursement for your courses. All funds paid to you or the college/university could be deducted from your final regular paycheck as a full-time or part-time employee (this includes any PTO payout you might receive). Uncollected amounts owed to Texas Health may be sent to an outside agency to assist with collection efforts. Any funds that are recovered are not refundable, even if you return to a benefits-eligible position within the rehire period. Participation in the tuition reimbursement program does not guarantee job placement.

Advance Fund Eligibility •• Take your voucher to the college or If you are in a clinical degree plan If you are a full-time or part-time university as payment for tuition. See and eligible for advance funds, benefits-eligible employee with an the employee handbook for a list of you may also request advance annual base rate of less than $40,000, fees not covered. reimbursement for your textbooks. you qualify for advance funds. Texas Advance Book Reimbursement (for Grade Submission Health will pay for your coursework voucher-eligible employees only) Once your courses end, save your grade in advance once your application is Once your application is approved report to a drive on your computer. approved. All employees who are and you purchase your books (clinical Your name must be pre-printed on eligible to receive advance funds must degrees only) or if you did not use the document you submit. Log on to input an application prior to their Other Benefits your voucher and are requesting MyTHR.org and follow these steps: course start date. You will have to print reimbursement paid directly to you, a voucher and give it to the college or you can submit your request for •• Click on the Benefits tile and then university as your source of payment. reimbursement in advance by following Tuition Reimbursement. If you have already paid for your classes the steps below: •• Click Submit Grade Report under (and meet the above requirements) Actions on the right side of your •• Purchase your books. and want to request advance application. funds, you may ask for immediate •• Download a copy of your book •• Read the Participant Certification reimbursement of the payment by receipt to a computer. statement. submitting your class schedule and •• Log on to MyTHR.org. •• Type your full name. paid invoice itemizing the cost of •• Click on the Benefits tile and then •• Click the Acknowledge button. tuition and recurring mandatory fees. Tuition Reimbursement. Then click •• Click the Grades box. Apply for Advance Funds. Recurring fees do not include fees for •• Upload the grade report. parking, insurance, or transportation •• Click on Reimbursement Request •• Click the Submit Request button. fees. Follow these steps to submit the under Actions on the right side of documents: your application. You have 60 days after the course/ •• Input the book information and the semester end date to submit your final •• Log on to MyTHR.org. cost of the books (include taxes but grade report. •• Click on the Benefits tile and then not shipping). Tuition Reimbursement. Grades •• Click Continue. •• Click the Apply for Advance Funds link. •• Read the participant certification. If your final grade is not a C or •• Click Create New Application. above (or passing in a pass/fail class) •• Type your name and click •• Select college or university. or you do not submit your grades Acknowledge. Spending Accounts •• Select the number of courses you within 60 days after completing the •• Attach the book receipts are taking. course, the advance funds and book •• Click Submit Request. •• Click Continue and follow directions reimbursement that Texas Health has on the form. Your book reimbursement will be paid in advance will be deducted from your pay over a number of pay periods, •• Click Submit. processed in one to two payroll periods listed in the table on the next page. •• Once your application is reviewed from receipt of the documents. and approved, print your voucher. Additional advance funds will not be available until all funds due back to Texas Health have been repaid.

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Repayment of Funds ADOPTION ASSISTANCE If you receive advance funds and/ PROGRAM or you are required to repay Texas You may receive reimbursement of Health, your payments will be costs for legally adopting a child deducted from your pay over a under age 18, unless mentally number of pay periods based on the impaired, while you are employed amount you owe Texas Health. at Texas Health. The Adoption Assistance Program will reimburse If you owe Your you up to $2,000 per child after you this amount: repayments will submit the necessary documentation be over: to THR Benefits Support and the $2,000 or more 15 pay periods adoption is final. You must submit $1,000 – $1,999 10 pay periods your request within 90 days of the date of adoption. $500 – $999 8 pay periods $300 – $499 6 pay periods You must include the final Decree of $200 – $299 4 pay periods Adoption, a Letter of Possession (if applicable) and a copy of itemized $199 or less $50 a pay period bills along with the adoption Payroll deductions will be at least assistance application found online at $50. However, the final deduction BeHealthyTHR.org. The amount you may be lower if you owe less are reimbursed will not exceed the than $50. You are not eligible for actual expenses you have incurred. further advance funds until you Who Is Eligible have completely repaid the amount you owe. If you terminate your Full-time and part-time benefits- employment with Texas Health, eligible employees (as defined on page the amount you still owe to Texas 5) are eligible for this benefit. You Other Benefits Health will be deducted from all must have at least one year of service remaining paychecks (this includes and be in a benefits-eligible position any PTO payout you might receive). at the time you make the application If your final paycheck is less than the and the child is placed in your home. amount you owe, you must repay You must be in benefits-eligible active Texas Health for any remaining status in the HR/Payroll System at the balance. Uncollected amounts time payment is made. owed to Texas Health may be sent You may not be reimbursed for to an outside agency to assist with adoption expenses for one spouse collection efforts. to adopt the other spouse's children Contact Information (for example, children from a previous marriage). If you have questions, you may contact the Tuition Reimbursement program using the contact information below.

Phone: 682-236-6238 or 1-877-698-4754 press 6, then 2

Fax: 682-236-7291

Email: THRTuitionReimbursement@ TexasHealth.org

Address: 612 E. Lamar Blvd., Suite 400, Arlington, TX 76011

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To help lessen the burden of out Insurance for a dependent child Benefit Increases of-pocket medical costs and other may be continued past the age limit If you are enrolled in MetLife coverage expenses associated with unexpected if that child is incapable of self- and your enrollment election results health emergencies, Texas Health sustaining employment because in a benefit increase, your increase offers three types of supplemental of a mental or physical handicap (provided you are actively at work and benefits: Accident Insurance, Critical as defined by applicable law. Proof that you have not already attained the Illness Insurance, and Hospital of such handicap must be sent to maximum benefit amount) will take Indemnity Insurance. These products MetLife within 31 days after the date effect on the later of: are available for you to purchase the dependent child attains the max through MetLife. age and at reasonable intervals after •• The date the benefit increase is such date, but not more often than scheduled to go into effect; and You can purchase this coverage for annually after the two-year period •• The date your online election is yourself and your eligible dependents following such dependent child’s effective. through payroll deductions, just attainment of the limiting age. like your other benefits. The cost of Definitions coverage is affordable, but depends Effective Date When the terms below are used in the on things like your age and who you Your effective date is as follows: Accident, Critical Illness, and Hospital cover. Indemnity sections of this Handbook, 1. Your coverage will be effective the following definitions will apply. Who Can Be Covered (provided you are actively at work): You are eligible if you are actively at a. January 1 if enrolling during •• Actively at work means that you work in a benefits-eligible position at open enrollment or are performing all of the usual and Texas Health Resources as described b. The first of the pay period customary duties of your job on a on page 5. following completion of one full-time or part-time basis. You will be deemed actively at work during Other Benefits Dependents are eligible for coverage month of service if enrolling as weekends, approved vacations, under this policy. A Dependent is: a new hire c. The first of the pay period holidays, and temporary business •• The legal spouse (as defined on following online elections closures if you were actively at work page 5) of an employee or and submitting required on the last scheduled work day •• Your biological, adopted, or step documentation if enrolling preceding such time off. child who is under age 26 (as as a newly benefits eligible •• Accident means an act or event defined on page 6) employee or due to qualifying which: life event. ––is unforeseen, unexpected and You cannot be covered both as an 2. If you are not actively at work unanticipated; employee and a spouse. The term on the date coverage would ––is definite as to time and place; child does not include an unborn or otherwise become effective, the ––is not a sickness; and stillborn child. You cannot be covered effective date of coverage will both as an employee and a child. A ––occurs while insurance is in be the date on which you first dependent child cannot be insured as effect. return actively to work. Except as a dependent child of more than one The term accident includes provided for newborn coverage, employee. unavoidable exposure to the if a dependent is under medical elements if such exposure was a A dependent child born to you restriction on the date insurance direct result of an accident. for such dependent would while insurance is in effect will •• Benefit Increases means a otherwise take effect, insurance be eligible for newborn coverage simultaneous increase in both for the dependent will take effect which is coverage for 31 days from the benefit amount and the total on the date the dependent is no the moment of the child’s birth. To benefit amount. continue coverage beyond the first 31 longer under a medical restriction. Spending Accounts days, you must complete enrollment Please see page 180 for further online at MyTHR.org to add the child details on the date dependent to your policies. Enrollment must insurance takes effect regarding occur within 31 days of the child’s the critical illness insurance. birth.

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•• Confined or confinement means •• Injury means any bodily harm: ACCIDENT INSURANCE the assignment to a bed as a –– That results directly from an Overview resident inpatient in a hospital accident; and Just like the Accidental Death and (including an intensive care unit –– Is not specifically excluded. Dismemberment (AD&D) Insurance (ICU) of a hospital) on the advice •• Medical Restriction means a person also offered by Texas Health, the of a physician or confinement in an is: observation area within a hospital accident insurance policy through –– restricted to the person’s home for a period of no less than 20 MetLife covers accidental death and under a physician’s care; continuous hours on the advice of a loss of limb. However, unlike AD&D, physician. –– receiving or applying to receive accident insurance: disability benefits from any •• Covered person means you and source; •• Covers many other types of if insured under the group policy –– an inpatient in a hospital; accidental injuries, from a cut for the insurance described in the requiring stitches to second-degree –– receiving care in a hospice Handbook, your dependents. burns; and facility, an intermediate care •• Hospital means a short-term, acute •• Pays flat dollar amounts directly to care, general facility which: facility or a long-term care facility; or you not only for covered injuries, –– Is primarily engaged in providing, but for other expenses you incur as –– receiving chemotherapy, by or under the continuous a result. supervision of physicians, to radiation therapy or dialysis. inpatients, diagnostic services •• Proof means written evidence The policy also pays benefits for some and therapeutic services for satisfactory to MetLife that medical fees, follow-up treatments, diagnosis, treatment and care of a claimant has satisfied the physical therapy, appliances such as injured or sick persons; conditions and requirements crutches, and blood plasma. Under –– Has organized departments of for any benefit described. When some circumstances, you receive medicine; a claim is made for any benefit a benefit for travel and lodging if a described, proof must establish: required service is far from home. ––has facilities for major surgery –– The nature and extent of the loss either on its premises or through If you are injured as a result of a or condition; Other Benefits contractual arrangement with covered accident, submit a claim –– MetLife’s obligation to pay the another hospital; online at mybenefits.metlife.com. –– Has a requirement that every claim; and patient must be under the care of –– The claimant’s right to receive Insureds are defined as those who physician or dentist; payment. might be eligible for coverage in the following categories under this policy: –– Provides 24-hour nursing service Except as provided in the examinations and autopsy by or under the supervision of •• Employee Coverage provisions within the supplemental a registered professional nurse •• Employee and Spouse Coverage (R.N.); benefits section of this Handbook, •• Employee and Child(ren) Coverage –– Is duly licensed by the agency proof must be provided at the •• Employee and Family Coverage responsible for licensing such claimant’s expense. hospitals; and •• Schedule means the schedule of Accidental Death Benefits –– Is not, other than incidentally, a insurance that appears on page 175 of this Handbook. Payment of the Accidental Death place of rest, a place primarily Benefits described in this section are •• Sickness means: for the treatment of tuberculosis, subject to all conditions, maximums, –– A physical illness, physical a place for the aged, a place for limitations, exclusions, and proof infirmity, or physical disease; drug addicts, alcoholics, or a requirements. The accidental place for convalescent, custodial, ––Pregnancy; or death benefits described in the educational or rehabilitative care. –– Infection, but not infection supplemental benefits sections •• Hospitalized means: received through an accidental of this Handbook are in addition –– Admission for inpatient care in a cut or wound. to the benefits paid through the hospital; •• Total Benefit Amount means the the Prudential Life Insurance and –– Receipt of care in a hospice maximum aggregate amount that Prudential Accidental Death and facility, an intermediate care MetLife will pay for any and all Dismemberment (AD&D) policies. facility or a long-term care covered conditions combined, per facility; or covered person, per lifetime. –– Receipt of the following treatment, wherever performed: ŒŒ Chemotherapy; ŒŒ Radiation therapy; or ŒŒ Dialysis.

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Basic Accidental Death Benefit The term common carrier does not •• If a covered person sustains an MetLife will pay the applicable basic include taxis, limousines, or privately injury that is a dismemberment accidental death benefit for a covered chartered vehicles. or functional loss that falls under person’s death if: more than one classification on Reduction of the Accidental Death – the schedule, MetLife will only Common Carrier Benefit •• The death results directly from an pay the benefit that applies to the accident; and The accidental death – common classification that pays the highest •• The death occurs within 180 days carrier benefit will be reduced by the benefit. following the accident. following if paid for injuries sustained by the covered person in the same Dismemberment means any of the Reduction of the Basic Accidental accident that resulted in the covered following: Death Benefit person’s death: •• Loss of an arm: the arm is The basic accidental death benefit •• The amount of any benefits permanently severed at or above will be reduced by the following if paid under the accidental the elbow. paid for injuries sustained by the dismemberment/functional loss/ •• Loss of a hand: the hand is covered person in the same accident paralysis benefits; and permanently severed at or above that resulted in the covered person’s the wrist joint. death: •• The modification benefit under the accident – medical treatment & •• Loss of a finger: the finger is •• The amount of any benefits services benefits. permanently severed at the paid under the accidental joint proximate to the first dismemberment/functional loss/ Accidental Dismemberment/ interphalangeal joint where it is paralysis benefits; and Functional Loss/Paralysis Benefits attached to the hand. •• The modification benefit under the Payment of the accidental •• Loss of a foot: the foot is accident – medical treatment & dismemberment/functional loss/ permanently severed at or above services benefits. paralysis benefits are subject to the ankle joint. all of the conditions, maximums, •• Loss of a leg: the leg is permanently Accidental Death – Common Carrier limitations, exclusions, and proof severed at or above the knee. Other Benefits Benefit requirements. The accidental •• Loss of a toe: the toe is MetLife will pay the applicable death benefits described in the permanently severed at the accidental death – common supplemental benefits are in addition joint proximate to the first carrier benefit, instead of the basic to the benefits paid through the interphalangeal joint where it is accidental death benefit for a covered Prudential Accidental Death and attached to the foot. person’s death if: Dismemberment (AD&D) policies. Functional Loss means any of the •• The death results directly from an Basic Dismemberment/Functional following: accident sustained by the covered Loss Benefit OR Catastrophic person while: Dismemberment/Functional Loss •• Loss of hearing: permanent Benefit –– A fare paying passenger on a deafness in at least one ear, such common carrier; or If a covered person sustains an that it cannot be corrected to any –– A passenger on public injury that is a dismemberment or functional degree of any procedure, transportation that is a common functional loss, MetLife will pay the aid, or device. Loss of hearing must carrier, for which there is no fare; basic dismemberment/functional last for a continuous period of not and loss benefit or the catastrophic less than 90 days as confirmed by a dismemberment/functional loss •• The death occurs within 180 days physician. benefit that applies to the type of following the accident. •• Loss of sight: permanent loss of dismemberment or functional loss sight in an eye. With correction, MetLife will not pay both the the covered person sustained, subject visual acuity must be 20/200 accidental death – common carrier to all of the following: or worse in the eye or the field and the basic accidental death benefit of vision must be less than 20 •• The dismemberment or functional for the same covered person. degrees. Loss of sight must last loss must be documented by a Spending Accounts for a continuous period of not less Common carrier means airplanes, physician within 180 days after the than 90 days as confirmed by a trains, buses, trolleys, subways, and accident occurs. physician. boats that: •• In order for the catastrophic dismemberment/functional loss •• Run on a regularly scheduled basis benefit to be payable, the injuries between predetermined points or that qualify for such benefit must cities; and have been sustained by the covered •• Are operated by a government person in a single accident. regulated entity.

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Paralysis Benefit •• If more than one bone is fractured •• If a partial dislocation was paid, or If a covered person sustains an injury in a single accident, the amount becomes payable, and the covered that is a paralysis, MetLife will pay MetLife will pay for all fractures person subsequently sustains an the paralysis benefit that applies to combined will be no more than 2 injury that is a full dislocation, the type of paralysis the covered times the highest fracture benefit MetLife will reduce what is paid for person sustained, subject to all of the that would otherwise be payable for the full dislocation by the amount following: any one of the bones involved. that was paid or is payable for the •• The chip fracture benefit will be partial dislocation. •• Paralysis must be documented by a 25% of the fracture benefit for the •• For each joint, MetLife will pay physician within 180 days after the bone involved. no more than one full dislocation accident occurs. •• If the same fracture is treated with benefit amount for all injuries •• If a covered person sustains an both open reduction and closed combined that are dislocations injury that is a paralysis that falls reduction, MetLife will pay no more of the same joint, regardless of under more than one classification, than the fracture benefit payable for whether the injuries are sustained MetLife will only pay the benefit the open reduction. in the same accident. Once the that applies to the classification that covered person has received pays the highest benefit. Fracture means a break in bone an amount equal to one full of a body part that is listed on the dislocation benefit for a joint, Paralysis means the permanent total schedule under fracture benefit, no further dislocation benefits and irrecoverable loss of movement which can be detected by an x-ray or will be paid for that same joint, of two or more limbs: a similar diagnostic exam. even if the same covered person subsequently sustains an injury that •• That has lasted for a continuous Chip fracture means a fracture in is a dislocation of the same joint in period of not less than 90 days as which a small fragment of the bone is a new accident. confirmed by a physician; or broken off. •• As a result of transected spinal •• MetLife will only pay benefits for cord with supporting clinical and Dislocation Benefit those dislocations specifically listed radiological evidence and no If a covered person sustains an injury on page 176. expectation of return to function. that is a dislocation, MetLife will Other Benefits Dislocation means a separated joint pay the dislocation benefit that is The term paralysis does not include a of a body part listed under dislocation applicable to the type of dislocation dismemberment or coma. benefit. The term dislocation does not the covered person sustained, subject include vertebral subluxation complex to all of the following: Accidental Injury Benefits (misaligned vertebrae). Payment of the accidental injury •• The injury must be diagnosed Full dislocation means a dislocation benefits are subject to all conditions, and treated as a dislocation by a in which the joint is completely maximums, limitations, exclusions, physician within 180 days after the separated. and proof requirements. accident occurs. •• The dislocation must require, and Partial dislocation means a dislocation Fracture Benefit be corrected by, open (surgical) or in which the joint is not completely If a covered person sustains an injury closed (non-surgical) reduction by separated. that is a fracture, MetLife will pay the a physician. Burn Benefit fracture benefit that is applicable to •• If more than one joint is dislocated the type of fracture sustained by the in a single accident, the amount If a covered person sustains an injury covered person, subject to all of the MetLife will pay for all dislocations that is a second or third-degree burn, following: combined will be no more than MetLife will pay the burn benefit that is applicable to the size and severity •• The injury must be diagnosed and 2 times the highest dislocation of the burn, subject to all of the treated as a fracture by a physician benefit that would otherwise be following: within 180 days after the accident payable for any one of the joints occurs. involved. •• The burn must be treated by a •• The fracture must require and be •• The partial dislocation benefit will physician within 96 hours after the corrected by open (surgical) or be 25% of the dislocation benefit accident occurs. closed (non-surgical) reduction for a full dislocation of the joint •• If a burn meets more than one of by a physician. Closed reduction involved. the burn classifications, the amount includes immobilization. MetLife pays will be based on the •• MetLife will pay no more than classification of the burn that pays one fracture benefit per bone, per the highest benefit. accident.

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•• MetLife will pay the burn benefit no •• The covered person must be •• If the laceration is repaired with more than one time per covered treated by a physician for the stitches, MetLife will pay the person, per accident. ruptured disc within 180 days after laceration benefit repaired with •• No benefit is payable for a first- the accident occurs. stitches; or degree burn. •• The surgery to repair the ruptured •• If the laceration is not repaired disc must be performed by a with stitches, MetLife will pay the Skin Graft Benefit physician within 365 days after the laceration benefit repaired without MetLife will pay the applicable skin accident occurs. stitches. graft benefit if a covered person •• MetLife will pay the ruptured disc Payment of the laceration benefit is receives a skin graft for a burn for with surgical repair benefit no more subject to all of the following: which MetLife paid a burn benefit. than 1 time per covered person, per MetLife will pay a skin graft benefit accident. •• The laceration must be treated by a no more than one time per covered physician within 96 hours after the Ruptured disc means a tear in the person, per accident. accident occurs. spinal disc capsule. It does not •• A laceration repaired with sutures Concussion Benefit include a bulging disc. or staples will be deemed to be a If a covered person sustains an injury Torn Cartilage in Knee Benefit laceration repaired with stitches for that is a concussion, MetLife will pay purposes of this laceration benefit. the concussion benefit, subject to all If a covered person sustains an injury •• If the covered person has more of the following: that is torn cartilage in the knee (meniscus) and undergoes surgery to than one laceration, the amount •• The injury must be diagnosed as a repair or explore it, MetLife will pay MetLife will pay will be based on concussion by a physician within 96 the torn cartilage in knee benefit that the total length of all lacerations hours after the accident occurs. is applicable to the type of surgery received in any one accident that •• MetLife will pay the concussion performed as follows: are repaired with stitches. If some, benefit no more than one time per but not all, of the lacerations covered person, per calendar year. •• If the surgery performed is to require repair with stitches, MetLife repair the knee, MetLife will pay the will not pay any benefit for the Other Benefits Coma Benefit torn cartilage in knee benefit with laceration or lacerations that are If a covered person sustains an injury surgical repair; and repaired without stitches. that is a coma, MetLife will pay the •• If the surgery performed is •• MetLife will pay the laceration coma benefit, subject to both of the exploratory surgery and either no benefit no more than one time per following: repair is done or the cartilage is covered person, per accident and shaved or trimmed, MetLife will pay no more than 3 times per covered •• The coma must begin within 180 the torn cartilage in knee benefit for person, per calendar year. days after the accident occurs. exploratory surgery without repair. •• MetLife will pay the coma benefit Laceration mean a cut. no more than one time per covered Payment of the torn cartilage in knee benefit is subject to all the following: Torn, Ruptured, or Severed Tendon/ person, per accident. Ligament/Rotator Cuff Benefit Coma means a continuous state of •• The covered person must be If a covered person sustains an injury profound unconsciousness lasting for treated by a physician for the torn that is a torn, ruptured, or severed a period of 14 or more consecutive cartilage in the knee within 180 tendon, ligament, or rotator cuff days, characterized by the absence of days after the accident occurs. and undergoes surgery to explore purposeful response to commands, •• Surgery must be performed by a or repair it, MetLife will pay the torn, including: physician on the knee within 365 ruptured or severed tendon/ligament/ days after the accident occurs. rotator cuff benefit, that is applicable •• Eye opening; •• MetLife will pay the torn cartilage in to the type of surgery performed as •• Verbal response; and knee benefit no more than 1 time follows: •• Motor response. per covered person, per accident. •• If the surgery is performed to repair Ruptured Disc with Surgical Repair Laceration Benefit Spending Accounts the tendon, ligament, or rotator Benefit If a covered person sustains an injury cuff, MetLife will pay the benefit for If a covered person sustains an injury that is a laceration and receives torn, ruptured, or severed tendon, that is ruptured and undergoes treatment from a physician to repair it, ligament, or rotator cuff with surgery to repair it, MetLife will pay MetLife will pay the laceration benefit surgical repair; or the ruptured disc with surgical repair that is applicable to the length of the benefit subject to all of the following: laceration and the treatment received as follows:

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•• If the surgery performed is •• The injury to the eye must require Emergency Care Benefit or Non- exploratory surgery and no repair surgery or the removal of a foreign Emergency Initial Care Benefit is done, the benefit MetLife will object by a physician within 180 If a covered person sustains an pay will be for exploratory surgery days after the accident occurs. injury and receives initial care from without repair. •• MetLife will pay the eye injury a physician for the injury in an benefit no more than 1 time per emergency room, a physician’s office, Payment of the torn, ruptured, or covered person, per accident and or an urgent care facility, within 96 severed tendon/ligament/rotator no more than 3 times per covered hours after the accident occurs, cuff benefit is subject to all of the person, per calendar year. MetLife will pay the emergency care following: benefit that is applicable to the place Accident - Medical Treatment & •• The covered person must be where care is received. Services Benefits treated by a physician for torn, If a covered person sustains an ruptured, or severed tendon, Payment of the accident- medical injury and receives initial care from ligament, or rotator cuff within 180 treatment and services benefits are a physician for the injury in an days after the accident occurs. subject to all conditions, maximums, emergency room, a physician’s office, •• Surgery must be performed by a limitations, exclusions, and proof or an urgent care facility, more than physician on the tendon, ligament requirements. 96 hours but less than 180 days after or rotator cuff within 365 days after Air Ambulance Benefit the accident occurs, MetLife will pay the accident. MetLife will pay the air ambulance the non-emergency care initial care •• MetLife will pay the torn, ruptured, benefit if a licensed professional air benefit. or severed tendon/ligament/rotator ambulance service is required to cuff benefit no more than one time Payment of the emergency care transport a covered person by air per covered person, per accident. benefit and the non-emergency initial to or from a hospital or between care benefit is subject to both of the medical facilities, where treatment for Broken Tooth Benefit following: an injury is received, subject to both If a covered person sustains an injury of the following: •• MetLife will never pay both the that is a broken tooth and the tooth is

emergency care benefit and the Other Benefits repaired by a dental crown or filling, •• The air ambulance transportation non-emergency initial care benefit or is extracted, MetLife will pay the must be within 90 days after the for the same covered person, for broken tooth benefit that is applicable accident occurs. the same accident. to the dental crown, filling, and/ •• MetLife will pay the air ambulance •• If MetLife pays either the or extraction, subject to all of the benefit no more than 1 time per emergency care benefit or the following: covered person, per accident. non-emergency initial care benefit, •• No benefit will be payable for an Ground Ambulance Benefit MetLife will pay the benefit no more injury that is not a sound, natural than one time per covered person, MetLife will pay the ground tooth. per accident. ambulance benefit if a licensed •• No benefit will be payable for an professional ambulance service Medical Testing Benefit injury caused by biting or chewing. is required to transport a covered If a covered person sustains an injury •• The dental services must begin person by ground to or from a and receives any of the following within 180 days after the accident hospital or between medical facilities, medical tests to evaluate the injury, occurs. where treatment for an injury is MetLife will pay the medical testing •• Regardless of the number of teeth received, subject to both of the benefit: involved, MetLife will pay the following: broken tooth benefit for no more •• X-rays; than 1 dental crown, no more than •• The ambulance transportation must •• Magnetic resonance imaging (MRI) 1 dental filling, and no more than be within 90 days after the accident or magnetic resonance (MR); 1 dental extraction per covered occurs. •• Ultrasound; person, per accident. •• MetLife will pay the ground ambulance benefit no more than •• Nerve conduction velocity test Eye Injury Benefit 1 time per covered person, per (NCV); If a covered person sustains an injury accident. •• Computed tomography scan (CT) to an eye, MetLife will pay the eye or computed axial tomography injury benefit subject to both of the (CAT); or following: •• Electroencephalogram (EEG).

Payment of the medical testing benefit is subject to both of the following:

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•• The test must be ordered by a •• MetLife will not pay the Pain Management Benefit (for physician and be performed within transportation benefit if the epidural anesthesia) 180 days after the accident occurs. ground ambulance benefit or air If a covered person sustains an injury •• MetLife will pay the medical testing ambulance benefit is payable for and receives epidural anesthesia to benefit no more than 1 time per the trip. manage the pain from the injury, covered person, per accident. •• MetLife will pay the transportation MetLife will pay the pain management benefit no more than: benefit, subject to all of the following: Physician Follow-Up Visit Benefit –– 1 time per covered person, per •• MetLife will not pay a benefit for If a covered person sustains an injury accident; and epidural anesthesia administered and receives follow-up care for the –– 3 times per covered person, per more than 180 days after the injury that is recommended by a calendar year. physician or is a second opinion, accident occurs. MetLife will pay the physician follow- Therapy Service Benefit •• MetLife will pay the pain up visit benefit, subject to all of the If a covered person sustains an injury management benefit no more than following: and receives therapy services, MetLife 1 time per covered person, per will pay the therapy services benefit accident. •• Treatment must: that applies to the type of therapy Prosthetic Device Benefit –– Begin within 180 days after the service received, subject to all of the accident occurs and be provided following: If a covered person sustains an injury within 365 days after the accident that is a loss of a limb, hand, foot, occurs; •• Therapy services must: or sight in an eye and receives a –– Be specific to the injury; –– Begin within 180 days and be prosthetic device as a result of the –– Occur on an outpatient basis in provided within 365 days after loss, MetLife will pay the prosthetic a physician’s office, urgent care the accident occurs; device benefit, that is applicable to facility or hospital; and –– Be provided on an outpatient the number of prosthetic devices the –– Not be for routine examinations, basis; covered person receives, subject to all preventive testing, or any –– Be prescribed by a physician; and of the following: Other Benefits treatment for which a benefit –– Be provided by a practitioner •• The prosthetic device must be is payable under the therapy licensed to provide the type of received within 365 days after the services benefit. therapy services provided and accident occurs. operating within the scope of •• MetLife will pay the physician •• No benefit will be payable for such license. follow-up visit benefit no more replacement of a prosthetic device. than: •• MetLife will pay the therapy •• MetLife will not pay the prosthetic services benefit for therapy services device benefit for a joint –– 2 times per covered person, per received no more than 10 times per replacement such as an artificial hip accident; and covered person, per accident. or knee. –– 6 times per covered person, per •• MetLife will not pay a therapy •• MetLife will pay the prosthetic calendar year. services benefit for therapy services device benefit no more than 1 time Transportation Benefit received by the covered person per covered person, per accident. MetLife will pay the transportation on the same day for which the Prosthetic device means an artificial benefit when a covered person inpatient rehabilitation benefit is device that replaces a missing body travels more than 50 miles one way payable under accident – hospital part. The term prosthetic device does for follow-up treatment of an injury benefits. not include hearing aids, dental aids which MetLife pays a benefit for under Therapy services means any of the (including false teeth), eyeglasses, or the accident insurance at a hospital or following: cosmetic prostheses such as wigs. other treatment facility, subject to all of the following: •• Cognitive behavioral therapy; Medical Appliance Benefit •• Occupational therapy; •• Mileage is measured from the If a covered person sustains an injury •• Physical therapy; covered person’s primary residence for which a physician prescribes Spending Accounts to the facility where the follow-up •• Respiratory therapy; the use of a medical appliance as treatment is provided. •• Speech therapy; and an aid in personal locomotion or •• The follow-up treatment must be •• Vocational therapy. mobility, MetLife will pay the medical prescribed by a physician and not appliance benefit, for the type of available within 50 miles of the medical appliance that the physician covered person’s primary residence. prescribes, subject to all of the following: •• You must submit proof that the follow-up treatment was provided.

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•• The use of such medical appliance •• The blood, plasma, or platelets •• Thoracic cavity and abdominal must begin within 180 days after must be prescribed by a physician pelvic cavity surgery. the accident occurs. on an emergency basis or provided Outpatient Ambulatory Surgery •• The amount MetLife will pay for while the covered person is Benefit all medical appliances combined, undergoing surgery and must be per covered person, per accident, administered within 180 days after If a covered person sustains an injury will be no more than the medical the accident. and undergoes surgery required appliance benefit limit. •• MetLife will pay the blood/plasma/ to treat the injury in an outpatient ambulatory surgery facility, MetLife •• MetLife will not pay the platelet benefit no more than 1 time will pay the outpatient ambulatory medical appliance benefit for per covered person, per accident. surgery benefit, subject to all of the the replacement of a medical Inpatient Surgery Benefit following: appliance. If a covered person undergoes •• The covered person must seek Medical appliance means any of the covered surgery to treat an injury treatment for the injury within 180 following: while the covered person is confined days after the accident occurs. as an inpatient in a hospital, MetLife •• Brace for the neck, back or leg; •• The surgery must be performed in will pay the inpatient surgery benefit, •• Cane; an outpatient surgery facility within for the type of covered surgery the 365 days after the accident occurs. •• Crutches; covered person undergoes, subject to •• MetLife will pay the outpatient •• Walker; all of the following: •• Walking boot that extends above ambulatory surgery benefit no the ankle; •• The covered person must seek more than one time, per covered treatment for the injury within 180 person, per accident. •• Wheelchair or motorized scooter days after the accident occurs. for medical purposes; and Accident – Hospital Benefits •• The surgery must be performed •• Any other medical device used for within 365 days after the accident Payment of the Accident- Hospital mobility. occurs. Benefits are subject to all of the conditions, maximums, limitations, Modification Benefit •• If a covered person has open Other Benefits exclusions, and proof requirements. If a covered person sustains an injury abdominal and hernia surgery, or which is a dismemberment, functional open thoracic and hernia surgery Accident – Hospital Admission loss, or paralysis for which MetLife as a result of the same accident, Benefit the benefit MetLife will pay will be paid a benefit under the Accident If a covered person is admitted to a based on the abdominal or thoracic Insurance policy, MetLife will pay the hospital for treatment of an injury, surgery and MetLife will not pay a modification benefit for modifications MetLife will pay the accident – benefit for the hernia surgery. made to the covered person’s primary hospital admission benefit that applies •• If a covered person has exploratory residence or vehicle, subject to all of to the type of hospital admission, surgery at the same time as any the following: subject to all of the following: other type of covered surgery, •• A physician must certify that MetLife will not pay a benefit for the •• In order for the accident – hospital because of the injury, the exploratory surgery. admission benefit to be payable, modification is necessary to help •• MetLife will not pay the inpatient the admission must occur within enable the covered person to live surgery benefit if any of the 180 days after the accident occurs. in his or her primary residence or following benefits are payable for •• This benefit does not apply to travel in his or her personal vehicle the same surgery: emergency room treatment, •• The modification must be made –– Broken tooth benefit; outpatient treatment, or a stay of within 365 days after the accident –– Eye injury benefit; less than 20 hours in an observation occurs. –– Ruptured disc with surgical repair area. •• MetLife will pay the modification benefit; •• MetLife will only pay one Accident- benefit no more than 1 time per –– Skin graft benefit; hospital admission benefit per covered person, per accident. covered person, per accident. If –– Torn cartilage in knee benefit; or the covered person moves from Blood/Plasma/Platelets Benefit –– Torn, ruptured, or severed or to an ICU after initial admission tendon/ligament/rotator cuff If a covered person sustains an injury to a hospital, MetLife will not pay benefit. for which the covered person receives an additional accident- hospital a transfusion of blood, plasma or Covered surgery means: admission benefit. platelets, MetLife will pay the blood/ plasma/platelets benefit, subject to all •• Cranial surgery; of the following: •• Exploratory surgery; •• Hernia repair; or

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Accident – Hospital Confinement Inpatient Rehabilitation Benefit •• MetLife will pay the lodging benefit Benefit If a covered person is transferred to a for each day the companion stays If a covered person is confined rehabilitation facility immediately after in a lodging while the covered in a hospital for treatment of an a period of confinement for treatment person is confined in a hospital for injury, MetLife will pay the accident of an injury for which MetLife paid treatment of an injury, and for the – hospital confinement benefit an accident- hospital confinement 24 hours following the hospital that applies to the type of hospital benefit, MetLife will pay the inpatient confinement. confinement for each day the covered rehabilitation benefit, subject to all of •• MetLife will pay the lodging benefit person is confined to the hospital, the following: for up to 31 days per calendar year. subject to all of the following: •• The lodging benefit is only •• MetLife will pay the inpatient payable on account of a hospital •• In order for the accident – hospital rehabilitation benefit for each day confinement for which MetLife confinement benefit to be payable, of the covered person’s continuous is paying an accident – hospital the initial confinement must occur stay as a resident inpatient in confinement benefit. within 180 days after the accident a rehabilitation facility, up to a •• You must submit proof that the occurs. maximum stay of 30 days per companion incurred an expense for •• For a non-ICU hospital covered person, per accident but staying at a lodging. confinement, the Accident- hospital not to exceed 60 days per calendar confinement benefit is payable for year. Lodging means an establishment up to 365 days per covered person, •• The covered person’s inpatient licensed under the laws where it per accident, and may be used over stay in the rehabilitation facility is located, such as motel, hotel, or a two-year period following the must start within 365 days after the other facility that provides sleeping date of accident. accident. accommodations to the general •• For an ICU confinement, the •• After the covered person is public in exchange for a fee and is Accident- hospital confinement discharged from the rehabilitation located at least 50 miles from the benefit is payable for up to 30 days facility, MetLife will not pay the covered person’s primary residence. per covered person, per accident, inpatient rehabilitation benefit Accident Exclusions Other Benefits and may be used over a two- for a subsequent admission to a year period following the date of rehabilitation facility for treatment The exclusions apply to the benefits accident. of the same injury for which described in the following sections: •• MetLife will pay the accident- MetLife already paid the inpatient •• Accidental death benefits hospital confinement benefit for rehabilitation benefit. •• Accidental dismemberment/ only one hospital confinement at •• MetLife will not pay the inpatient functional loss/paralysis benefits a time, even if the confinement is rehabilitation benefit for any day for •• Accidental injury benefits caused by more than one accident. which MetLife paid an accident - •• MetLife will only pay one accident- hospital confinement benefit. •• Accident – medical treatments & hospital confinement benefit per services benefits day. If the covered person has a Accident – Other Benefits •• Accident – hospital benefits non-ICU hospital confinement Payment of the Other Benefits are MetLife will not pay benefits for any and an ICU confinement on the subject to all of the conditions, loss for a covered person caused by same day, MetLife will only pay the maximums, limitations, exclusions, the covered person’s sickness, or accident – hospital confinement and proof requirements. the diagnosis or treatment of such benefit that applies to the ICU Lodging Benefit sickness, except for the covered confinement. person’s use of: •• If a covered person exhausts the If a covered person is confined in a accident – hospital confinement hospital for treatment of an injury, •• any drug, medication or sedative benefit that applies to confinement and a companion who accompanies that is taken or used as prescribed in an ICU and remains confined in the covered person while the covered by a physician; or an ICU, the covered person may person is so confined stays in a •• an “over the counter” drug, still be eligible for the accident lodging for which a charge is made, medication or sedative taken as Spending Accounts – hospital confinement benefit MetLife will pay the lodging benefit, directed. that applies to a non-ICU hospital subject to all of the following: confinement. MetLife will not pay benefits for any loss for a covered person caused or contributed to by:

•• the covered person’s voluntary use, by any means, of:

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––any drug, medication or sedative, ––reconstruct a part of the body •• any of the following outside of the unless it is: which was disfigured or removed United States, Canada or Mexico: ŒŒ taken or used as prescribed by a as a result of an injury for which ––medical treatment; physician; or coverage is not otherwise ––hospital admission or ŒŒ an “over the counter” drug, excluded under the Accident confinement; or medication or sedative taken as Insurance; ––inpatient stay in a rehabilitation directed; •• the covered person’s mental illness, facility. ––alcohol in combination with any or the diagnosis or treatment of drug, medication, or sedative; or such mental illness, except for the Claim Provisions covered person’s use of: ––poison, gas, or fumes; Filing a Claim •• the covered person’s suicide or ––any drug, medication or The insured must begin the claim attempted suicide (while sane or sedative that is taken or used as process: insane); prescribed by a physician; or •• the covered person’s intentionally ––an “over the counter” drug, •• within 60 days after a covered self-inflicted injury; medication or sedative taken as accident or •• war, whether declared or directed; •• as soon as reasonably possible by undeclared; or act of war; •• activities required by the covered visiting mybenefits.metlife.com •• the covered person’s active person’s service in the armed or calling 1-866-626-3705 and participation in an insurrection, forces or any auxiliary unit of the requesting a claim form. rebellion, riot, or terrorist act; armed forces of any country or international authority; Claim Forms •• the covered person’s engagement in any activity that constitutes •• the covered person’s travel or flight When MetLife receives notice of a a felony under the laws of the in any aircraft except as a fare- claim, MetLife will send you a claims jurisdiction in which the activity paying passenger on a regularly packet with forms to be completed occurred; scheduled charter or commercial and signed by you and your physician. flight; You may return all necessary •• the covered person’s infection, •• the covered person parachuting or information to MetLife via fax (1-855- other than infection occurring in an Other Benefits 306-7350) or mail to: external wound resulting from an otherwise exiting from a motorized or non-motorized aircraft while injury; Metropolitan Life Insurance Company such aircraft is in flight, except for •• food poisoning; Attn: Accident Insurance Product self-preservation; •• the covered person’s operation, P.O. Box 80826 •• the covered person riding in or while intoxicated, of a motor Lincoln, NE 68501-0826 driving any motor-driven vehicle in vehicle involved in the incident. For a race, stunt show or speed test; Claim Review, Processing and purposes of this exclusion: •• the covered person participating Decision ––intoxicated means that the in any semi-professional or Once a claim is set up, the claims insured’s blood alcohol level met professional competitive athletic examiner: or exceeded .08%; and activity for which any type of ––motor vehicle means any vehicle compensation or remuneration is 1. Validates eligibility and premium that is powered by a motor, received; payments are current. including, but not limited to: an •• the covered person bungee 2. Reviews information to ensure automobile; a boat; a motorcycle; jumping, base jumping, hang no additional information is a truck; an all-terrain vehicle; or a gliding, para-kiting, sail-gliding, necessary. snow mobile; scuba diving deeper than 130 feet; a. If additional information is •• dental or plastic surgery for spelunking; or mountaineering needed, the claimant will cosmetic purposes, except when including rock climbing using ropes be mailed a letter and/or such surgery is performed to: and any other climbing equipment. the examiner will call them ––treat an injury; For the purposes of this exclusion directly. They will ask for the ––correct a disorder of normal the term mountaineering does not details required to continue the bodily function or structure include backpacking, mountain review. that was caused by an injury for biking, hiking or trail running. b. MetLife will then request the which coverage is not otherwise necessary medical information excluded under the Accident In addition, MetLife will not pay from your doctor to make a Insurance; or benefits for: claim determination. •• a covered person while 3. The examiner will make a claim incarcerated in any type of penal or decision. detention facility; or 4. They will notify you of decision in writing.

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a. You may also check on Instead of making payment in the status via MyBenefits (https:// order above, MetLife may pay your mybenefits.metlife.com) or call estate. Any payment made in good customer service (1-866-626- faith will discharge MetLife’s liability 3705). to the extent of such payment. If a 5. MetLife will issue benefits if claim beneficiary or a payee is a minor or approved. incompetent to receive payment, a. You can receive the claim MetLife will pay that person’s amount from: guardian. i. MyBenefits (https:// You may name a beneficiary to mybenefits.metlife.com, receive a benefit payable due to claims section, under the death of your spouse under specific product) or the accidental death benefit. If no customer service (1-866- beneficiary is named, or if there is no 626-3705). surviving named beneficiary at the ii. Direct Deposit (if you filled time of your spouse’s death, MetLife out your bank information will pay the benefit to you. on the claim form you received in your packet). Examinations 6. If claim is denied, you will be sent At MetLife’s expense, as often as is a letter. MetLife will include the reasonably necessary, MetLife may denial and appeals process within require a covered person to have the letter for next steps. an independent examination by a physician of its choice. Your Beneficiary You can change your beneficiary At MetLife’s expense, as often as at any time by visiting mybenefits. is reasonably necessary, MetLife Other Benefits metlife.com. The change will not may have representatives conduct have any bearing on payments made telephone or in-person interviews before MetLife approved the request. with you regarding your claim. Once the request is recorded, the Time Limit on Legal Actions change will take effect as of the date you sign the request, whether or not A legal action on a claim may only you are living when we receive the be brought against MetLife during a request. The change will be subject certain period. This period begins 60 to any legal restrictions. It will also be days after the date proof is filed and subject to any payment MetLife made ends three years after the date such or action MetLife took before MetLife proof is required to be filed. recorded the change. If you designate two or more beneficiaries and their shares are not specified, they will share the benefit payable equally.

If there is no beneficiary designated or no surviving beneficiary at your death, MetLife will determine the beneficiary according to the following order:

1. Your Spouse, if alive;

Spending Accounts 2. Your child(ren) if there is no surviving spouse; 3. Your parent(s), if there is no surviving child; 4. Your sibling(s), if there is no surviving parent; or 5. Your estate, if there is no surviving sibling.

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BENEFITS SCHEDULE (DIFFERENT COVERAGE FOR DEPENDENTS/SPOUSES)

Employee Low Employee High Spouse Dependent Accidental Death $12,500 Low $5,000 Low Basic Accidental Death $25,000 $40,000 $20,000 High $5,000 High $37,500 Low $15,000 Low Accidental Death – Common Carrier $75,000 $100,000 $50,000 High $20,000 High Basic Dismemberment/Functional Loss Loss of one finger or one toe $625 $625 $250 $200 Loss of one arm or one leg $6,250 $6,250 $2,500 $1,250 Loss of one hand or one foot $6,250 $6,250 $2,500 $1,250 Loss of two or more fingers or toes in any combination $625 $625 $250 $200 Loss of sight in one eye $6,250 $6,250 $2,500 $1,250 Loss of hearing in one ear $6,250 $6,250 $2,500 $1,250

BENEFITS SCHEDULE (SAME FOR ALL COVERED FAMILY MEMBERS)

Employee Low Employee High Catastrophic Dismemberment/Functional Loss Loss of both arms or both legs or one arm and one leg $15,000 $25,000 Loss of both hands or both feet or one hand and one foot $15,000 $25,000 Loss of sight in both eyes $15,000 $25,000 Other Benefits Loss of hearing in both ears $15,000 $25,000 Loss of ability to speak $15,000 $25,000 Paralysis Two limbs (paraplegia or hemiplegia) $5,000 $20,000 Four limbs (quadriplegia) $10,000 $40,000 Closed Open Closed Open Fracture Reduction Reduction Reduction Reduction Face or Nose (except mandible or maxilla) $600 $1,200 $900 $1,800 Skull fracture – depressed (except bones of face or nose) $1,500 $3,000 $2,250 $4,500 Skull fracture – non-depressed (except bones of face or nose) $1,000 $2,000 $1,600 $3,200 Lower Jaw, Mandible (except alveolar process) $800 $1,600 $1,200 $2,400 Upper Jaw, Maxilla (except alveolar process) $700 $1,400 $1,050 $2,100 Upper Arm between Elbow and Shoulder (humerus) $700 $1,400 $1,050 $2,100 Shoulder Blade (scapula), Collarbone (clavicle, sternum) $800 $1,600 $1,200 $2,400 Forearm (radius and/or ulna), Hand, Wrist (except fingers) $1,000 $2,000 $1,500 $3,000 Rib $250 $500 $400 $800 Finger, Toe $160 $320 $240 $480 Vertebrae, Body of (excluding vertebral processes) $1,800 $3,600 $2,700 $5,400 Vertebral Processes $400 $800 $600 $1200 Pelvis (includes ilium, ischium, pubis, acetabulum except coccyx) $1,600 $3,200 $2,400 $4,800 Hip, Thigh (femur) $2,000 $4,000 $3,000 $6,000 Coccyx $250 $500 $400 $800 Leg (tibia and/or fibula) $1,200 $2,400 $1,800 $3,600 Kneecap (patella) $1,000 $2,000 $1,500 $3,000 Ankle $1,000 $2,000 $1,500 $3,000 Foot (except toes) $1,000 $2,000 $1,500 $3,000 Chip Fracture 25% of the applicable benefit for the bone involved

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BENEFITS SCHEDULE (SAME FOR ALL COVERED FAMILY MEMBERS)

Employee Low Employee High Closed Open Closed Open Full Dislocation Reduction Reduction Reduction Reduction Lower jaw $450 $900 $750 $1,500 Collarbone (sternoclavicular) $500 $1,000 $800 $1,600 Collarbone (acromioclavicular and separation) $250 $500 $400 $800 Shoulder (glenohumeral) $750 $1,500 $1,250 $2,500 Rib $250 $500 $400 $800 Elbow $300 $600 $500 $1,000 Wrist $375 $750 $625 $1,250 Bone or Bones of the Hand (other than fingers) $525 $1,050 $875 $1,750 Hip $1,500 $3,000 $2,500 $5,000 Knee (except patella) $1,000 $2,000 $1,625 $3,250 Ankle - Bone or Bones of the Foot (other than toes) $600 $1,200 $1,000 $2,000 One Toe or Finger $120 $240 $200 $400 Partial Dislocation 25% of the applicable benefit for the joint involved Burns (Percentage of total surface skin area that is burnt) 2nd Degree 3rd Degree 2nd Degree 3rd Degree Less than 10% $50 $500 $100 $1,000 At least 10% but less than 25% $100 $2,500 $200 $5,000 At least 25% but less than 35% $250 $5,000 $500 $10,000 35% or more $500 $10,000 $1,000 $20,000 Other Benefits Skin Grafts for 2nd or 3rd Degree Burn 50% of the applicable Burn Benefit Concussion $200 $300 Coma $5,000 $7,500 Ruptured Disc with Surgical Repair $500 $800 Torn Cartilage in Knee With surgical repair $500 $600 Exploratory surgery without repair $100 $120 Laceration Repaired without stitches $25 $40 Repaired with stitches: Total of all lacerations is less than two inches (5.08 cm) long $50 $80 Total of all lacerations is two to six inches (5.08 to 15.24 cm) long $100 $160 Total of all lacerations is over six inches (over 15.24 cm) long $200 $320 Torn, Ruptured or Severed Tendon / Ligament / Rotator Cuff Surgical repair: one tendon/ligament/rotator cuff $500 $600 Surgical repair: two or more tendons/ligaments/rotator cuffs $750 $800 Exploratory surgery without repair $100 $120 Broken Tooth Crown $100 $160

Spending Accounts Extraction $50 $80 Filling $25 $40 Eye Injury $200 $240 Air Ambulance $750 $800 Ground Ambulance $200 $240 Emergency Care Emergency Room $100 $125 Physician’s Office $25 $40

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BENEFITS SCHEDULE (SAME FOR ALL COVERED FAMILY MEMBERS)

Employee Low Employee High Urgent Care $25 $40 Non-Emergency Initial Care $25 $40 Medical Testing $100 $180 Physician Follow-Up Visit $25 $35 Transportation $200 $320 Therapy Services Cognitive behavioral therapy $15 $20 Occupational therapy $15 $20 Physical therapy $15 $20 Respiratory therapy $15 $20 Speech therapy $15 $20 Vocational therapy $15 $20 Pain Management Benefit (for Epidural Anesthesia) $50 $20 Prosthetic Devices One device only $500 $600 More than one device $1,000 $1,200 Medical Appliances Brace $50 $75 Cane $50 $75

Crutches $50 $75 Other Benefits Walker (expected use less than 1 year) $100 $160 Walker (expected use 1 year or longer) $250 $400 Walking boot $50 $75 Wheel chair or motorized scooter (expected use less than 1 year) $100 $160 Wheel chair or motorized scooter (expected use 1 year or longer) $500 $800 Other medical device used for mobility $50 $75 Limit for all Medical Appliances combined, per Covered Person, $500 $800 per Accident Modification Benefit $500 $800 Blood/Plasma/Platelets $300 $320 Inpatient Surgery Cranial surgery $1,000 $1,600 Exploratory surgery $125 $175 Hernia repair $100 $160 Thoracic cavity or abdominal pelvic cavity surgery $1,000 $1,600 Outpatient Ambulatory Surgery $150 $240 Accident - Hospital Admission Non-ICU Hospital Admission $500 $800 Intensive Care Unit Admission $500 $800 Accident - Hospital Confinement Non-ICU Hospital Admission $100 $150 Intensive Care Unit Admission $200 $300 Inpatient Rehabilitation $100 $160 Lodging $100 $160

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CRITICAL ILLNESS ––laser relief; •• Full Benefit Cancer means the presence of one or more malignant Overview ––stent insertion; ––coronary angiography; or tumors characterized by the To help provide extra financial uncontrollable and abnormal ––any other intra-catheter protection, an individual critical illness growth and spread of malignant technique. insurance policy is available for you cells with invasion of normal tissue •• Covered condition means the to purchase through MetLife. With provided that a physician has following as they are defined in this this coverage, you receive a lumpsum determined that: Handbook: benefit if you or a covered family ––surgery, radiotherapy, or –– Coronary Artery Bypass Graft; member is diagnosed with a covered chemotherapy is medically illness. –– Full Benefit Cancer; necessary; –– Partial Benefit Cancer; Definitions ––there is metastasis; or ––Heart Attack; ––the patient has terminal cancer, is When the terms below are used in ––Kidney Failure; expected to die within 24 months the Critical Illness section of this –– Major Organ Transplant; or less from the date of diagnosis Handbook, the following definitions ––Occupational HIV; and will not benefit from, or has will apply: ––Stroke. exhausted, curative therapy. •• Benefit Amount is the amount used •• Diagnosis means the establishment •• Heart Attack (myocardial to determine the benefit payable for of a covered condition by a infarction) means the death of a a covered condition. physician through the use of clinical portion of the heart muscle as •• Benefit Suspension Period means and/or laboratory findings. a result of obstruction of one or the 365 day period following the •• Diagnose means the act of making more coronary arteries due to date a covered condition, for which a diagnosis. atherosclerosis, spasm, thrombus or emboli. MetLife pays a benefit, occurs with •• First Occurs or First Occurrence respect to a covered person. means, with respect to: •• Initial Benefit means the benefit that MetLife will pay for a covered •• Clinical Diagnosis means a ––Full Benefit Cancer, the first time diagnosis of partial benefit cancer condition that first occurs while

Other Benefits after a covered person initially coverage is in effect. or full benefit cancer based on the becomes insured under the study of symptoms and diagnostic group policy that such covered •• Kidney Failure means the total, end tests. MetLife will accept a clinical condition occurs; stage, irreversible failure of both diagnosis of partial benefit cancer kidneys to function, provided that a ––Full Benefit Cancer, after an or full benefit cancer only if the physician has determined that such occurrence of Full Benefit Cancer following conditions are met: failure requires either: while the covered person is –– Under generally accepted insured under the group policy, ––immediate and regular kidney medical standards, a pathological an occurrence of a separate and dialysis (no less often than diagnosis cannot be made unrelated Full Benefit Cancer; weekly) that is expected by such because it would be medically physician to continue for at least ––Partial Benefit Cancer, the first inappropriate or life-threatening; 6 months; or time after a covered person –– Medical diagnostic testing initially becomes insured under ––a kidney transplant. supports the diagnosis; and the group policy that such •• Major Organ Transplant means: –– A physician is treating the covered condition occurs; ––the irreversible failure of a covered person for partial benefit ––Partial Benefit Cancer, after an covered person’s heart, lung, cancer or full benefit cancer. occurrence of Partial Benefit pancreas, entire kidney or any •• Coronary Artery Bypass Graft Cancer while the covered person combination thereof, for which means the undergoing of open is insured under the group policy, a physician has determined that heart surgery performed by a an occurrence of a separate and the complete replacement of physician to bypass a narrowing or unrelated Partial Benefit Cancer; such organ with an entire organ blockage of one or more coronary or from a human donor is medically arteries using venous or arterial ––all other covered conditions, necessary, and either such Spending Accounts grafts. The procedure must be the first time after a covered covered person has been placed deemed medically necessary by person initially becomes insured on the transplant list or such a physician and be supported under the group policy that such transplant procedure has been by preoperative angiographic covered condition occurs. performed; evidence. Coronary Artery Bypass Graft does not include: ––angioplasty (percutaneous transluminal coronary angioplasty);

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––the irreversible failure of a ––with respect to Major Organ ŒŒ occurs after an initial benefit covered person’s liver for which Transplant, that the covered was paid for a first occurrence a physician has determined person of that same partial benefit that the complete or partial 1. is placed on the transplant cancer; replacement of the liver with a list; or ––with respect to heart attack: liver or liver tissue from a human 2. undergo[es] such Major Organ ŒŒ an occurrence of heart attack donor is medically necessary by a Transplant. after MetLife has already paid physician and either such covered ––with respect to Occupational HIV, an initial benefit for the first person has been placed on the that the covered person: occurrence of heart attack; transplant list or such procedure ––with respect to stroke: 1. experiences such covered has been performed; or condition; and ŒŒ an occurrence of stroke after ––the replacement of a covered MetLife has already paid an 2. is diagnosed with such person’s bone marrow with initial benefit for the first covered condition. bone marrow from the covered occurrence of stroke. •• Partial Benefit Cancer means one of person or another human donor, •• Separate & Unrelated means a Full the following conditions that meets which replacement is determined Benefit Cancer or a Partial Benefit the TNM staging classification to be medically necessary by Cancer that is: and other qualifications specified a physician in order to treat ––not a metastasis of a previously below: irreversible failure of such Diagnosed Full Benefit Cancer; ––carcinoma in situ classified as covered person’s bone marrow. and TisN0M0, provided that surgery, •• Maximum Benefit Amount means ––distinct from any previously radiotherapy or chemotherapy the maximum amount of benefits Diagnosed Full Benefit Cancer or has been determined to be for which an individual in an eligible Partial Benefit Cancer. medically necessary by a class can apply under the group physician; •• Stroke means a cerebrovascular policy. accident or incident producing ––malignant tumors classified •• Occupational HIV means that a measurable, functional and as T1N0M0 or greater which covered person becomes HIV permanent neurological

are treated by endoscopic Other Benefits positive as a direct result of an impairment (not including transient procedures alone; accidental exposure. ischemic attacks (TIA), or prolonged ––malignant melanomas •• Accidental Exposure means reversible ischemic attacks) caused classified as T1N0M0, for which that while coverage is in effect by any of the following which a pathology report shows and during the normal course results in an infarction of brain maximum thickness less than of the covered person’s regular tissue: or equal to 0.75 millimeters occupational duties for which ––hemorrhage; using the Breslow method of remuneration is earned, that the determining tumor thickness; and ––thrombus; or covered person is accidentally ––embolus from an extracranial exposed to blood or other bodily ––tumors of the prostate classified source. fluids of another person that as T1bN0M0, or T1cN0M0, •• Supplemental Benefit(s) are the are contaminated with Human provided that they are treated following: Immunodeficiency Virus (HIV) with a radical prostatectomy or through: external beam radiotherapy. ––Health Screening Benefit ––cutaneous exposure through •• Recur or recurrence means: •• Surgery means a procedure abraded skin; ––with respect to coronary artery performed by a physician involving the cutting of the covered person’s ––percutaneous exposure; or bypass graft: skin or tissue that in and of itself ––mucocutaneous exposure. ŒŒ an occurrence of coronary artery bypass graft if MetLife is intended to be curative or •• Occurs or Occurrence means: has already paid an initial palliative. Surgery does not include ––with respect to Heart Attack, benefit for the first occurrence endoscopic procedures. Stroke, Kidney Failure, Full Benefit of coronary artery bypass graft; •• Transplant List means the Organ Cancer, or Partial Benefit Cancer: ––with respect to full benefit Procurement and Transportation 1. experiences such covered cancer, an occurrence of full Network (OPTN) list. condition; and benefit cancer that: 2. is diagnosed with such ŒŒ occurs after an initial benefit covered condition. was paid for first occurrence of ––with respect to Coronary Artery that same full benefit cancer; Bypass Graft, that the covered ––with respect to partial benefit person undergoes a Coronary cancer, an occurrence of partial Artery Bypass Graft. benefit cancer that:

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Benefit Provisions Reoccurrence Benefit •• Breast ultrasound; Critical Illness Benefit MetLife will pay the reoccurrence •• Breast sonogram; benefit for a reoccurrence subject to •• CA 15-3 (blood test for breast MetLife will pay this benefit when one the following limitations:* cancer); of the critical illnesses first occurs •• CA 125 (blood test for ovarian while the covered person is insured. •• MetLife will not pay a reoccurrence cancer); Proof of the covered condition must benefit for a covered condition that •• CEA (blood test for colon cancer); be sent to MetLife. recurs during a suspension period; •• Carotid doppler; Benefits will be based on the benefit and •• Chest X-rays; amount in effect on the critical illness •• MetLife will not pay a reoccurrence date of diagnosis. MetLife will deduct benefit for either a full benefit •• Clinical testicular exam; any previously paid partial benefits cancer or a partial benefit cancer •• Colonoscopy; from the appropriate critical illness unless the covered person has •• Digital rectal exam (DRE); benefit. MetLife will never pay more not, for a period of 180 days, had •• Doppler screening for cancer; with respect to any covered persons symptoms of or been treated for •• Doppler screening for peripheral than the total benefit amount. the full benefit cancer or partial vascular disease; benefit cancer for which MetLife •• Echocardiogram; Except as provided in the newborn paid an initial benefit. children provision, dependent •• Electrocardiogram (EKG); insurance for a dependent will take Payment of this benefit will reduce •• Endoscopy; effect on the later of the date you the total benefit amount. •• Fasting blood glucose test; are eligible for coverage and the •• Fasting plasma glucose test; date the dependent becomes your Reduction on Account of Prior Claims Paid •• Flexible sigmoidoscopy; dependent, provided that on the date •• Hemoccult stool specimen; the dependent meets the following MetLife will reduce what they pay for requirements: a claim so that the amount they pay, •• Hemoglobin A1C; when combined with amounts for •• Human papillomavirus (HPV) •• The dependent is not confined at all claims MetLife has previously paid vaccination;

Other Benefits home under a physician’s care; for the same covered person, does •• Lipid panel; •• The dependent is not receiving not exceed the total benefit amount •• Mammogram; or applying to receive disability that was in effect for that covered •• Oral cancer screening; benefits from any source; and person on the date of the most recent •• Pap smear or thin prep pap test; •• The dependent is not hospitalized. covered condition. this provision •• PSA (blood test for prostate cancer); does not apply to claim payments for If a dependent does not meet these Supplemental Benefits. •• Serum cholesterol test to determine requirements, insurance for the LDL or HDL levels; dependent will take effect on the date Health Screening Benefit •• Serum protein electrophoresis the dependent is no longer: MetLife will pay a $50 benefit for (blood test for myeloma); •• Confined at home under a one of the screening/prevention •• Skin cancer biopsy; physician’s care; measures tests performed while an •• Skin cancer screening; •• Receiving or applying to receive insured’s coverage is in force. MetLife •• Skin exam; will pay this benefit once per covered disability benefits from any source; or •• Stress test on a bicycle or treadmill; person per calendar year. Payment of •• Hospitalized. •• Successful completion of smoking this benefit will not reduce the total cessation program; Regarding coronary artery bypass benefit amount. •• Tests for sexually transmitted graft, full benefit cancer, heart attack, Health Screening Tests infections (STIs); kidney failure and stroke, payment of the benefit for these conditions Screening/prevention measures •• Thermography; reduces the total benefit amount. include, but are not limited to, the •• Two hour post-load plasma glucose following: test; MetLife will only pay for one major •• Ultrasounds for cancer detection;

Spending Accounts organ transplant per covered person •• Annual physical exam; •• Ultrasound screening of the while coverage is in effect under the •• Biopsies for cancer; abdominal aorta for abdominal Critical Illness benefit. •• Blood test to determine total aortic aneurysms; or cholesterol; Occupational HIV Injuries are payable •• Virtual colonoscopy. only once. After the benefit is paid, •• Blood test for triglycerides; Occupational HIV injury coverage for •• Bone marrow testing; that insured will terminate. •• Breast MRI;

*Benefits are payable for the reoccurrence of a previously diagnosed cancer and/or carcinoma in situ as long as the covered person: •• Has been free from signs or symptoms of that cancer for a consecutive 12-month period before the date of diagnosis (for the reoccurrence) and •• Has been treatment-free from that cancer for the 12 consecutive months before the date of diagnosis (for the reoccurrence).

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Pre-Existing Condition Exclusion ––any tumor of the prostate ––performed outside the United Preexisting condition means a classified as T1N0M0 under TNM States; sickness or injury for which, in the Staging; ––involving organs received from 3 months before a covered person ––any papillary tumor of the non-human donors; becomes insured, or before any thyroid that is classified as ––involving implantation of benefit increase with respect to such T1N0M0 or less under TNM mechanical devices or covered person medical advice, Staging and is one centimeter or mechanical organs; treatment or care was sought by such less in diameter unless there is ––involving stem cell generated covered person, or recommended metastasis; transplants; or by, prescribed by or received from a ––any cancer in the presence of ––involving islet cell transplants. physician or other practitioner of the human immuno-deficiency •• Occupational HIV if: healing arts. virus (HIV) for which there is a ––the Accidental Exposure takes known increased risk due to the place prior to the effective date MetLife will not pay benefits for a presence of Acquired Immune of coverage; covered condition that is caused by or Deficiency Syndrome (AIDS) or results from a preexisting condition if the presence of HIV; ––the Accidental Exposure takes the covered condition occurs during place after coverage for the ––any non-melanoma skin cancer the first 6 months that a covered covered person ends; unless there is metastasis; or person is insured. ––the covered person tested HIV ––any malignant tumor classified positive prior to the Accidental With respect to a benefit increase, as less than T1N0M0 under TNM Exposure, unless the covered MetLife will not pay benefits for Staging. person tested positive on an HIV such benefit increase for a covered •• Diagnosis of Partial Benefit Cancer screening test and subsequently condition that is caused by or results for: tested negative for HIV before the from a preexisting condition if the ––any benign tumor, dysplasia, date of the Accidental Exposure; covered condition occurs during the intraepithelial neoplasia or or first 6 months after such increase in premalignant growth; ––the covered person becomes HIV the Total Benefit Amount.

––any papillary tumor of the positive as a result of intravenous Other Benefits This provision does not apply to bladder classified as Ta under drug use or sexual transmission. TNM Staging; benefits for the following covered ––No benefits for Occupational ––any tumor of the prostate conditions: Heart Attack, Stroke and HIV will be paid for an Accidental classified as T1aN0M0 under Occupational HIV. Exposure that takes place outside TNM Staging; the United States. Exclusions ––any papillary tumor of the thyroid ––Metlife will not pay for any cost Exclusions Related to Covered that is classified as T1N0M0 or incurred for HIV tests or any Conditions less under TNM Staging and related testing. MetLife will not pay benefits for any of is one centimeter or less in the following: diameter; General Exclusions ––any cancer in the presence of •• Coronary Artery Bypass Graft: MetLife will not pay benefits for human immuno-deficiency covered conditions caused by, ––performed outside the United virus (HIV) for which there is a contributed to by, or resulting from a States; or known increased risk due to the covered person: ––that does not involve median presence of Acquired Immune sternotomy (a surgical incision in Deficiency Syndrome (AIDS) or •• participating in a felony, riot or which the sternum, also known the presence of HIV; insurrection; as the breastbone, is divided ––any non-melanoma skin cancer; •• intentionally causing a self-inflicted down the middle from top to or injury; bottom). ––any melanoma in situ classified as •• committing or attempting to •• Diagnosis of Full Benefit Cancer for: TisN0M0 under TNM Staging. commit suicide while sane or ––any condition that is Partial •• Diagnosis of Stroke for: insane; Benefit Cancer; ––cerebral symptoms due to •• voluntarily taking or using any drug, ––any benign tumor, dysplasia, migraine medication or sedative unless it is: intraepithelial neoplasia or ––cerebral injury resulting from –– taken or used as prescribed by a premalignant growth; trauma or hypoxia; or physician; an “over the counter” ––any papillary tumor of the ––vascular disease affecting the drug, medication or sedative bladder classified as Ta under eye or optic nerve or vestibular taken according to package TNM Staging; functions. directions; •• Major Organ Transplant:

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•• engaging in an illegal occupation; or a. The claimant may also check on status via •• serving in the armed forces or any auxiliary unit of the MyBenefits (https://mybenefits.metlife.com) or call armed forces of any country customer service (1-866-626-3705). •• arising from war or any act of war, even if war is not 5. MetLife will issue benefits if claim approved. delcared. a. Claimant can receive the claim amount from: i. MyBenefits (https:// mybenefits.metlife.com, MetLife will not pay benefits for any covered condition for claims section, under specific product) or which diagnosis is made outside the United States unless customer service (1-866-626-3705). the diagnosis is confirmed in the United States, in which case the covered condition will be deemed to occur on the ii. Direct Deposit (if they filled out their bank date the diagnosis is made outside the United States. information on the claim form they received in their packet). Exclusion for Intoxication 6. If claim is denied, you will be sent a letter. MetLife will •• MetLife will not pay benefits for any covered condition include the denial and appeals process within the letter that is caused by, contributed to by, or results from a for next steps. covered person’s involvement in an incident, where such Physical Examination and Autopsy covered person is intoxicated at the time of the incident and is the operator of a vehicle involved in the incident. MetLife may have an insured examined as often as reasonably necessary while a claim is pending. In the •• Intoxicated means that the covered person’s alcohol case of death, MetLife may also require an autopsy, unless level met or exceeded the level that creates a legal prohibited by law. MetLife will cover all costs for exams or presumption of intoxication under the laws of the autopsy. jurisdiction in which the incident happened. Claim Provisions Legal Action The insured cannot take legal action against MetLife for Filing a Claim benefits under this policy: The insured must begin the claim process: •• Within 60 days after the insured has sent MetLife written

Other Benefits •• within 30 days after a covered accident or proof of loss; or •• as soon as reasonably possible by visiting mybenefits. •• More than 3 years from the time written proof is required metlife.com or calling 1-866-626-3705 and requesting a to be given. claim form. Benefits Schedule Claim Forms The face amount of your benefit election, either $15,000 When MetLife receives notice of a claim, MetLife will or $30,000, is payable for the following employee or send you a claims packet with forms to be completed spouse critical illnesses: and signed by you and your physician. You may return all necessary information to MetLife via fax (1-855- 306-7350) BENEFITS SCHEDULE or mail to: Low Amount High Amount Covered Illness* Metropolitan Life Insurance Company ($15,000) ($30,000) Attn: Critical Illness Insurance Product Cancer (internal or 100% 100% P.O. Box 80826 invasive) Lincoln, NE 68501-0826 Heart Attack 100% 100% Claim Review, Processing and Decision Kidney Failure 100% 100% Once a claim is set up, the claims examiner: Major Organ Transplant 100% 100% 1. Validates eligibility and premium payments are current. Stroke 100% 100% 2. Reviews information to ensure no additional Occupational HIV 100% 100% information is necessary. Coronary Artery Bypass 100% 100% a. If additional information is needed, the claimant will Graft Spending Accounts be mailed a letter and the examiner will call them Carcinoma in Situ** 25% 25% directly. They will ask for the details required to continue the review. * Benefits are paid for covered dependent children at 50% of the b. MetLife will then request the necessary medical employee benefit amount. The benefit is payable for a spouse only if dependent critical illness coverage was elected. information from your doctor to make a claim **When this partial benefit is paid, it will reduce the cancer benefit by 25%. determination. 3. The examiner will make a claim decision. Additional Benefits 4. They will notify claimant of decision in writing. •• Health Screening Benefit Amount: $50 per insured employee or spouse per calendar year.

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HOSPITAL INDEMNITY •• In order for the accident – hospital MetLife will not pay any benefits for confinement benefit to be payable, sickness caused by or resulting from Overview the initial confinement must begin a preexisting condition if the sickness Hospital indemnity insurance through within 180 days after the accident occurs during the first 12 months that MetLife helps you cover your out-of- occurs. the covered person is insured. pocket expenses (like deductibles and •• For a non-ICU hospital Pregnancy is a “pre-existing coinsurance) when you are admitted confinement, the accident – condition” if conception was before to the hospital. hospital confinement benefit is the effective date of coverage. The Hospital Indemnity policy pays payable for up to 180 days per benefits directly to you when you covered person, per accident, Sickness – Hospital Admission have an eligible hospital stay. and may be used over a two-year Benefit period following the date of the If a covered person is admitted Insureds are defined as those who accident. to a hospital for treatment of a might be eligible for coverage in the •• For an ICU confinement, the sickness, MetLife will pay the benefit following categories under this policy: accident – hospital confinement that applies to the type of hospital benefit is payable for up to 30 days •• Employee Coverage admission, subject to all of the per covered person, per accident, •• Employee and Spouse Coverage following: and may be used over a two-year •• Employee and Child(ren) Coverage period following the date of the •• This benefit does not apply to •• Employee and Family Coverage accident. emergency room treatment, outpatient treatment, or a stay of Accident – Hospital Admission •• MetLife will pay the accident – less than 20 hours in an observation Benefit hospital confinement benefit for only one hospital confinement at unit. If a covered person is admitted to a a time, even if the confinement is •• MetLife will only pay one sickness hospital for treatment of an injury, caused by more than one accident. – hospital admission benefit per MetLife will pay the accident-hospital •• MetLife will only pay one accident covered person, per sickness. If admission benefit that applies to the – hospital confinement benefit the covered person moves from type of hospital admission, subject to Other Benefits per day. If the covered person has or to ICU after initial admission all of the following: a non-ICU hospital confinement to a hospital, MetLife will not pay •• In order for the accident – hospital and an ICU confinement on the an additional sickness – hospital admission benefit to be payable, same day, MetLife will only pay the admission benefit. admission must occur within 180 accident – hospital confinement •• MetLife will pay the sickness – days after the accident occurs. benefit that applies to ICU hospital admission benefit no more •• This benefit does not apply to confinement. than 1 time per covered person, per emergency room treatment, •• If a covered person exhausts the calendar year. outpatient treatment, or a stay of accident – hospital confinement Sickness – Hospital Confinement less than 20 hours in an observation benefit that applies to confinement Benefit area. in an ICU and remains confined in If a covered person is confined in a •• MetLife will only pay one accident an ICU, the covered person may hospital for treatment of a sickness, – hospital admission benefit per still be eligible for the accident MetLife will pay the sickness – covered person, per accident. If – hospital confinement benefit hospital confinement benefit that the covered person moves from that applies to a non-ICU hospital applies to the type of hospital or to an ICU after initial admission confinement. confinement for each day the covered to a hospital, MetLife will not pay Sickness – Hospital Benefits person is confined in the hospital for an additional accident – hospital treatment of a sickness, subject to all admission benefit. Pre-Existing Condition Limitation of the following: Preexisting condition means a Accident – Hospital Confinement sickness for which, in the 12 months •• For a non-ICU hospital Benefit before a covered person becomes confinement, the sickness – If a covered person is confined in a insured , medical advice, treatment hospital confinement benefit is hospital for treatment of an injury, or care was sought by the covered payable for up to 180 days per MetLife will pay the accident-hospital person, or, was recommended by, covered person, per sickness. confinement benefit that applies to prescribed by or received from a •• For an ICU confinement, the the type of hospital confinement physician. sickness – hospital confinement for each day the covered person is benefit is payable for up to 30 days confined in the hospital, subject to all per covered person, per sickness. of the following:

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•• MetLife will pay the sickness – ––alcohol in combination with any •• the covered person’s operation, hospital confinement benefit for drug, medication, or sedative; or while intoxicated, of a motor only one hospital confinement at ––poison, gas, or fumes; vehicle involved in the incident. For a time, even if the confinement is •• the covered person’s suicide or purposes of this exclusion: caused by more than one sickness. attempted suicide (while sane or ––intoxicated means that the •• MetLife will only pay one sickness insane); Insured’s blood alcohol level met – hospital confinement benefit •• the covered person’s intentionally or exceeded .08%; and per day. If the covered person has self-inflicted injury; ––motor vehicle means any vehicle a non-ICU hospital confinement •• war, whether declared or that is powered by a motor, and an ICU confinement on the undeclared; or act of war; including, but not limited to: an same day, MetLife will only pay the automobile; a boat; a motorcycle; •• the covered person’s active sickness – hospital confinement a truck; an all terrain vehicle; or a participation in an insurrection, benefit that applies to ICU snow mobile; rebellion, riot, or terrorist act; confinement. •• the covered person’s travel or •• the covered person’s engagement •• If a covered person exhausts the flight in any aircraft except as a in any activity that constitutes sickness – hospital confinement farepaying passenger on a regularly a felony under the laws of the benefit that applies to confinement scheduled charter or commercial jurisdiction in which the activity in an ICU and remains confined in flight; occurred; an ICU, the covered person may •• the covered person parachuting or •• dental or plastic surgery for still be eligible for the sickness otherwise exiting from a motorized cosmetic purposes, except when – hospital confinement benefit or non-motorized aircraft while such surgery is performed to: that applies to a non-ICU hospital such aircraft is in flight, except for ––treat an injury or sickness; confinement. self-preservation; ––correct a disorder of normal •• the covered person riding in or Additional Limitation bodily function or structure driving any motor-driven vehicle in If a covered person is confined that was caused by a injury or a race, stunt show or speed test; for both an injury and sickness at sickness for which coverage is •• the covered person participating Other Benefits the same time, MetLife will only not otherwise excluded; or in any semi-professional or pay benefits for the admission and ––reconstruct a part of the body professional competitive athletic confinement under the accident – which was disfigured or removed activity for which any type of hospital benefits. In this case, if the as a result of an injury for which compensation or remuneration is covered person exhausts the benefits coverage is not otherwise received; or under the accident – hospital benefit excluded; •• the covered person bungee for hospital confinement and remains •• the covered person’s mental illness, jumping, base jumping, hang confined for treatment of a sickness, or the diagnosis or treatment of gliding, para-kiting, sail-gliding, the covered person may still be such mental illness, except for the scuba diving deeper than 130 feet; eligible for the sickness – hospital covered person’s use of: confinement benefit. spelunking; or mountaineering ––any drug, medication or including rock climbing using ropes Exclusions sedative that is taken or used as and any other climbing equipment. prescribed by a physician; or MetLife will not pay benefits for loss For the purposes of this exclusion ––an “over the counter” drug, caused by pre-existing conditions the term mountaineering does not medication or sedative taken as (except as stated in the previous include backpacking, mountain directed; provision). These exclusions apply to biking, hiking or trail running. •• activities required by the covered the employee, spouse and covered person’s service in the armed In addition, MetLife will not pay children. forces or any auxiliary unit of the benefits for: MetLife will not pay benefits for loss armed forces of any country or •• a covered person while contributed to, caused by, or resulting international authority; incarcerated in any type of penal or from: Related to accident exclusions only, detention facility; Spending Accounts •• the covered person’s voluntary use, not sickness: •• any hospital admission or by any means, of: confinement outside the United •• the covered person’s infection, ––any drug, medication or sedative, States, Canada or Mexico; or other than infection occurring in an unless it is: •• routine nursing or well baby care external wound resulting from an for a newborn child. ŒŒ taken or used as prescribed by a Injury; physician; or •• food poisoning; ŒŒ an “over the counter” drug, medication or sedative taken as directed;

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Claim Provisions Benefit Schedule Filing a Claim Benefits Summary The insured must begin the claim process: Maximum Low High Benefit Days per •• within 30 days after a hospital admission or confinement Amount Amount Confinement or •• as soon as reasonably possible Hospital Confinement $150 $250 180 by visiting mybenefits.metlife.com or calling 1-866-626- (Per Day) 3705 and requesting a claim form. Hospital Admission (Per $500 $1000 N/A Claim Forms Confinement) When MetLife receives notice of a claim, MetLife will Hospital send you a claims packet with forms to be completed Intensive Care $150 $250 30 and signed by you and your physician. You may return all (Per Day) necessary information to MetLife via fax (1-855-306-7350) or mail to:

Metropolitan Life Insurance Company Attn: Hospital Indemnity Insurance Product P.O. Box 80826 Lincoln, NE 68501-0826

Claim Review, Processing and Decision Once a claim is set up, the claims examiner:

1. Validates eligibility and premium payments are current. 2. Reviews information to ensure no additional information is necessary. Other Benefits a. If additional information is needed, the claimant will be mailed a letter and the examiner will call them directly. They will ask for the details required to continue the review. b. MetLife will then request the necessary medical information from your doctor to make a claim determination. 3. The examiner will make a claim decision. 4. They will notify claimant of decision in writing. a. The claimant may also check on status via MyBenefits (https://mybenefits.metlife. com) or call customer service (1-866-626-3705). 5. MetLife will issue benefits if claim approved. a. Claimant can receive the claim amount from: i. MyBenefits (https://mybenefits.metlife.com, claims section, under specific product) or customer service (1-866-626-3705). i. Direct Deposit (if they filled out their bank information on the claim form they received in their packet). 6. If claim is denied, you will be sent a letter. MetLife will include the denial and appeals process within the letter for next steps.

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GENERAL PROVISIONS Continuation of Insurance with Premium Payment Misstatement of Age When your employment ends with If an age has been misstated, the Texas Health Resources and your correct age will be used to determine coverage would otherwise terminate, if insurance is in effect and as you may elect to continue your appropriate, MetLife will adjust the coverage under this policy. You may benefits and/or your payments. continue the coverage that you had Assignment on the date your employment ended, including any in-force spouse or The benefits under this policy are dependent child coverage. Evidence not assignable, prior to a claim for of insurability will not be required to benefits, except to a physician or obtain continued insurance. other health care provider who provides health care services to you, To keep your coverage in force, you or except as required by law. must:

Conformity with Law •• Apply to MetLife in writing on a Any policy provision that conflicts form approved by MetLife within 31 with state statutes where this policy days after the date your insurance was issued on its effective date is would otherwise terminate, and hereby amended to conform to the •• Pay the required premium to minimum requirements of those MetLife no later than 31 days after statutes. the date the coverage would otherwise end and on each When Coverage Ends premium due date thereafter. Your insurance will terminate on whichever occurs first: Coverage will end on the earliest of Other Benefits the following dates: •• The date the group policy ends; •• The date you die; •• The date you die; •• 31 days after the date you fail to pay •• The end of the period for which the any required premium; or last full premium has been paid for you; •• The date the group policy is terminated, whichever occurs first. •• The date your employment ends for any reason. If you qualify for this continuation Insurance for a covered spouse or privilege, then MetLife will apply the dependent child will terminate on the same benefits, policy provisions, earliest of the listed above, or: and premium rate as shown in your previously issued coverage. •• The premium due date following the date the covered spouse or dependent child no longer qualifies as a dependent; •• The premium due date following the date the employee’s online request to terminate coverage for a spouse or dependent child(ren).

In certain cases, insurance may be continued as stated in Continuation Spending Accounts of Insurance with Premium Payment.

186 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Leaving Texas Health When Coverage Ends...... 188 Coverage After Termination...... 189 What is COBRA? 189 Who Is Eligible 189 Your Responsibility for Notifying the COBRA Administrator 189 When Continuation Coverage Is Effective 189 How to Elect COBRA Continuation 190 HCSA Continuation 190 Paying for Continuation Coverage 190 How Long Coverage Continues 190 Changing Your Coverage 191 If You Gain a New Dependent 191 If Your Address Changes 192 When Continuation Coverage Ends 192 If You Have Questions 192 Separation Pay Plan (THR Employees excluding THPG)...... 193 Overview 193 Who is Eligible 193 When a Position is Eliminated 193 Transition Plan 193 Notice 193 Resignation During Notice Period 194 Reasonable Offer 194 Leave of Absence 194 Failure to Investigate, Apply or Interview 195 Transfer Pay Guidelines 195 Separation Pay 195 Employment and Consulting 196 Payment 196 Separation Pay Plan (THPG Clinic Practice Staff)...... 197 Overview 197 Who is Eligible 197 When a Position is Eliminated 197 Transition Plan 197 Notice 197 Resignation During Notice Period 198 Reasonable Offer 198 Leave of Absence 198 Failure to Investigate, Apply or Interview 199 Transfer Pay Guidelines 199 Separation Pay 199 Employment and Consulting 199 Payment 199

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Coverage for you and your covered •• Commit an act, practice, or Coverage for your dependents also dependents under the Texas Health omission that constitutes fraud, or ends when: Medical, Dental, Vision, STD, LTD, an intentional misrepresentation of •• The dependent no longer meets Life Insurance, AD&D, and Flexible a material fact including, but not the eligibility requirements or dies Spending Accounts Plans ends when limited to, false information relating you: to another person’s eligibility or •• You have failed to provide timely status as a dependent. Texas Health documentation of your dependent’s •• No longer meet the eligibility has the right to request complete eligibility requirements (See page 5. Texas documentation of dependent •• You terminate employment or Health Medical, Dental, and status, eligibility for coverage or cease to be eligible for coverage Vision, Life, AD&D, and Disability change in coverage or of a claim •• The plan no longer covers coverages, as well as participation for benefits. dependents in FSA, end on the last day of the •• Knowingly provide incorrect •• The dependent knowingly provides pay period in which you were in a information or submit false or incorrect information or submits a benefits-eligible position.)* fraudulent claims information false or fraudulent claim, in which •• Terminate employment (Texas (termination is retroactive to the case coverage ends retroactively Health Medical, Dental, and Vision first day of coverage). Texas Health •• The dependent fails to comply with coverages, as well as participation has the right to request complete the plan’s subrogation provisions. in FSA, end on the last day of documentation of dependent the pay period in which you status, eligibility for coverage or In some cases, you and your covered terminate.)* change in coverage or of a claim dependents may be eligible for •• Die for benefits. Texas Health reserves COBRA continuation coverage, as •• Retire the right to refuse coverage of explained on the next page. •• Cancel or drop coverage (includes benefits if we don’t believe the facts For 12 weeks following your failing to re-enroll) are accurate termination, you and your eligible •• Become a full-time, active-duty •• Fail to make the required covered dependents may continue member of the armed forces of any contributions to use the Employee Assistance country for more than 30 days. The •• Fail to comply with the plan’s Program. The program is explained disability plan extends coverage for subrogation provisions. on page 81. up to two months if you pay the premium. Coverage for you and your dependents will also end on:

•• The date the plan is terminated •• The date the plan is modified, eliminating any benefits for your Leaving Texas Health Texas Leaving employment classification. Spending Accounts

* When your termination date falls on the first day of a pay period, your benefits will end on the last day of the previous pay period.

188 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Coverage After Termination Coverage After Termination

Under certain circumstances, you WHO IS ELIGIBLE? •• You (the parent-employee) die may have the right to request a •• You no longer meet the eligibility If you and/or your covered family temporary extension of coverage requirements for benefits, as members would otherwise lose under Texas Health’s medical, dental, explained on page 5 coverage under the plan after and vision plans and the health care a qualifying event, each person •• Your employment ends for any spending account. This section considered a qualified beneficiary reason other than your gross describes that right to continuation (including you, your spouse, and misconduct coverage. It generally explains when your dependent children) may elect •• You become entitled to Medicare continuation may become available COBRA. benefits (Part A, Part B, or both) to you and your family and what you •• You and your spouse divorce need to do to protect the right to If you are an employee of Texas •• The child stops being eligible for receive it. Health, you will become a qualified coverage as a dependent child beneficiary if you lose your coverage The Consolidated Omnibus Budget under the plan. under the plan because you Reconciliation Act of 1985 (COBRA) experience one of these qualifying is a federal law that requires Texas Sometimes, filing a proceeding events: Health to offer continuation coverage. in bankruptcy under Title 11 of the United States Code can be a •• Your hours are reduced to non- qualifying event. If Texas Health files WHAT IS COBRA? benefits-eligible a bankruptcy proceeding that results COBRA continuation coverage •• Your employment ends for any in the loss of coverage for retired is coverage under Texas Health’s reason other than your gross employees covered under the plan, medical, dental, and vision plans and misconduct the retired employee, employee’s the health care spending account •• Texas Health begins bankruptcy. spouse, and dependent children also that may be available if your coverage become qualified beneficiaries. Your spouse will become a qualified would otherwise end because beneficiary if he or she loses your you experience a qualifying event coverage under the plan because you YOUR RESPONSIBILITY FOR (described under “Who Is Eligible” experience one of these qualifying NOTIFYING THE COBRA on this page). Depending on the events: ADMINISTRATOR event, you and/or your covered dependents may be eligible for •• You die For some qualifying events, you COBRA continuation coverage. After a •• You no longer meet the eligibility must notify Texas Health within 31 qualifying event, COBRA continuation requirements for benefits, as days after the event occurs. You coverage must be offered to each explained on page 5 must provide this notice to the Human Resources Department at person who is a “qualified beneficiary.” •• Your employment ends for any your entity if: You must elect the same coverage reason other than your gross

when you initially elect COBRA. Health Texas Leaving misconduct •• You and your spouse divorce All rules and procedures for filing •• You become entitled to Medicare •• A dependent child loses eligibility claims and determining benefits benefits (under Part A, Part B, for coverage as a dependent child. under the plan for active employees or both) also apply to continuation coverage. •• You and your spouse divorce. WHEN CONTINUATION Qualified beneficiaries who elect You will be notified of your rights to COVERAGE IS EFFECTIVE COBRA continuation coverage must COBRA continuation coverage only If you or your dependents elect to pay for the coverage. after the COBRA administrator has continue coverage, after the COBRA been notified that one of the above administrator receives your premium qualifying events has occurred. payment, the coverage becomes Texas Health must notify the COBRA effective on the date coverage would administrator of these qualifying otherwise end. events.

Your dependent children will become qualified beneficiaries if they lose coverage under the plan because:

1-877-MyTHRLink (1-877-698-4754) MyTHR.org 189 Coverage After Termination

HOW TO ELECT COBRA HCSA CONTINUATION HOW LONG COVERAGE CONTINUATION If you have the Health Care Spending CONTINUES You will automatically receive a Account (HCSA) plan as an active After the COBRA administrator letter and election form from Texas employee, you can elect to continue receives notice of a qualifying event, Health’s COBRA administrator after this plan under COBRA until the they will send information about your employment with Texas Health end of the plan year (which ends electing COBRA to each qualified ends or you lose coverage because December 31). However, you may beneficiary. Each qualified beneficiary of a reduction in scheduled work not elect the HCSA during Open will have an independent right to hours. The letter will explain the Enrollment. If you elect to continue elect COBRA continuation coverage. available COBRA coverage and cost the health care spending account, Covered employees may elect COBRA to continue coverage. you must continue making the full continuation coverage on behalf of contribution to the account. their spouses, and parents may elect If you divorce or your dependent child COBRA continuation coverage on Although your contributions will no longer meets the requirements of behalf of their children. a “dependent” under the plans, you, be on an after-tax basis, you will your spouse, your dependent, or your still have the opportunity to file COBRA continuation coverage is representative will receive a letter and claims for reimbursement based on temporary. election form from PayFlex after you your account balance for the year. go online to drop the dependent from Continued coverage under the health 18 Months coverage. care account will last until March 15 You, your spouse, and dependent following the end of the plan year. children may elect continuation If your entity’s Human Resources The use it or lose it rule will continue coverage for up to 18 months if: Department does not receive to apply, so any unused amounts notice within 60 days of the event, will be forfeited and coverage will •• You end your employment with your dependent will not be offered terminate at the end of the plan year. Texas Health continuation coverage. •• You no longer meet the eligibility requirements for benefits as When Human Resources receives PAYING FOR CONTINUATION explained on page 5. notice that a qualifying event has COVERAGE occurred, it will advise the COBRA To keep your COBRA continuation 36 Months administrator. You and/or your coverage, you must pay the full Your spouse and dependent children dependents will be notified by the cost of continuation coverage may elect continued coverage for up COBRA administrator (at the address on time, including any additional to 36 months if: on record if you have not provided expenses permitted by law. If you an updated address on MyTHR.org) elect continuation coverage, you will •• You die of your right to continue coverage. receive a statement from the COBRA •• You become entitled to Medicare You should receive the paperwork to administrator indicating when each benefits (under Part A, Part B, elect continuation coverage within 44 payment is due. or both) days of your qualifying event. Within •• You and your spouse divorce 60 days of the postmark date on the The cost of continuation coverage is Leaving Texas Health Texas Leaving •• Your dependent child loses notice, you or your dependent must typically 102% of the total premium eligibility as a dependent child. inform the COBRA administrator if (the employee’s and the company’s you want to purchase continuation combined cost, plus a 2% fee for If you become entitled to Medicare coverage. administrative expenses). However, benefits less than 18 months before if continuation coverage is extended the end of employment or before If you do not elect to continue from 18 months to 29 months due to you lose eligibility for benefits (as coverage within the 60-day time disability, the cost increases to 150% explained on page 5), qualified limit, your benefits under the medical, of the total premium. beneficiaries (other than the dental, and vision plans will end on employee) may elect continuation the date of the qualifying event. You coverage for up to 36 months after or your dependent cannot later elect the date of Medicare entitlement. Spending Accounts to continue coverage. For example, if your employment ends eight months after you become entitled to Medicare, your spouse and children can continue coverage for up to 28 months after the date of the qualifying event (36 months minus 8 months).

190 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Coverage After Termination

Extending COBRA for Disability Extending COBRA for a Second CHANGING YOUR COVERAGE Qualifying Event In case of disability, you and your When you elect COBRA continuation entire family may be entitled to If your family experiences another coverage, you must keep the same receive up to 11 additional months of qualifying event while receiving 18 plan you had as an active employee COBRA continuation coverage (for a months of continuation coverage, or dependent of an employee. For maximum of 29 months). your spouse and dependent children example, if you elected the Choice can get up to 18 additional months Plan 500 High as a benefits-eligible The disability must have started of continuation coverage—for a employee with Texas Health, you must before the 60th day of the COBRA maximum of 36 months if the plan continue that plan under COBRA. You continuation coverage and must last receives proper notice of the second have an opportunity to change your at least until the end of the 18-month qualifying event. plan during open enrollment, which is period of continuation coverage. generally in November. You must make sure that the COBRA To qualify for the extension, you administrator is notified in writing of Prior to open enrollment, enrollment must timely notify the COBRA the second qualifying event within 60 materials are mailed to the home of Administrator in writing and provide days of that event. This notice should a COBRA participant explaining the documentation of the disability from include a death certificate or divorce plan changes beginning January 1 the Social Security Administration decree, if applicable. You may mail, of the next year. Also included is an within 60 days of the later of the fax, or hand-deliver the notice. enrollment form. If you want to keep following: the same plan, you do not need to This extension may be available to complete the form. To change your •• The date of the Social Security your spouse and dependent children disability determination, plan, you need to complete the if the event would have caused them form and mail it to the Texas Health •• The date the qualifying event to lose coverage under the plan if Benefits Dept. by the deadline for open occurs, the first qualifying event had not enrollment. Your new election will take •• The date you lose (or would occurred. effect on January 1. You may not re- lose) coverage as a result of the enroll in an HCSA. qualifying event, or Your spouse and any dependent children may receive an extension •• The date you receive the general if you (the employee or former IF YOU GAIN A NEW COBRA notice. employee): DEPENDENT •• Die If you elect continuation coverage •• Become divorced. for yourself and later marry, a child is born to you, or you adopt a child A dependent child may also receive while covered by continuation an extension if he or she stops being coverage, you may elect coverage eligible under the plan as a dependent for your newly acquired dependents child and Texas Health is notified after the qualifying event. To add timely. your dependents, notify the COBRA

administrator within 30 days of the Health Texas Leaving marriage, birth, or adoption. A new dependent may be a participant under this coverage for the remainder of your continuation period (18, 29, or 36 months, depending on the qualifying event). This new dependent will not have the right to continue coverage on his or her own if a divorce or other event causes loss of coverage.

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IF YOUR ADDRESS CHANGES WHEN CONTINUATION IF YOU HAVE QUESTIONS To protect your family’s rights, you COVERAGE ENDS Questions concerning your plan or should keep the plan administrator Coverage automatically ends on the your COBRA continuation coverage informed of any address changes earliest of the following dates: rights should be addressed to the of family members. You should also plan administrator, Texas Health, or keep a copy, for your records, of any •• The maximum continuation period the COBRA administrator (PayFlex). notices you send to Texas Health or (18, 29, or 36 months) expires. Their addresses and phone numbers the COBRA administrator. •• Full premium payment for are listed on the back cover of this continuation coverage is Handbook. You may also contact not received by the COBRA them for information about your administrator within 30 days after rights and obligations under each the payment due date. Partial plan and under federal law. payment or checks returned for non-sufficient funds (“NSF” or For more information about your “bounced”) are considered non- rights under ERISA, including COBRA, payment of premium. the Health Insurance Portability and •• The person who is continuing Accountability Act (HIPAA), and other coverage becomes covered laws affecting group health plans, under any other group medical, contact the nearest Regional or dental, or vision plan, unless District Office of the U.S. Department that plan contains a pre-existing of Labor’s Employee Benefits Security condition limitation that affects Administration (EBSA) or visit the the plan participant. In that event, EBSA website at DOL.gov/ebsa. the participant is entitled to (The address and phone number of continuation coverage up to the Regional and District EBSA Offices are maximum time period. available on the website.) •• The person continuing coverage becomes entitled to Medicare. •• 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 Spending Accounts

192 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Separation Pay Plan (THR Employees)

Separation Pay Plan (THR Employees excluding THPG)

OVERVIEW WHEN A POSITION IS NOTICE The Texas Health Separation Pay ELIMINATED If your position is eliminated, as Plan is designed to provide benefits Under this Plan, you are considered to defined under the Plan, you will to eligible employees who are have your position eliminated if you receive notification and transition involuntarily terminated due to job are involuntarily separated because information when management and elimination as a result of outsourcing all or part of an entity, department, Human Resources have evaluated all or part of a department, division, division, operating unit, or function each employee’s specific information. operating unit, or function; closing is being outsourced, restructured, Options that may be available include all or part of an entity, department, or closed. Employees who are transfer opportunities, career center division operating unit or function; terminated for cause (such as poor services and, in certain situations, restructuring all or part of an entity, performance or violation of policy) separation pay (as defined in the Plan). department or division, operating unit will not be eligible for Separation Pay. Generally, if you are not a director or or function; so other changes as THR Employees who are terminated for officer, you will be given a minimum may designate from time to time. This cause (such as poor performance or of 30 calendar days’ notice before is a summary of the Plan. If there is a policy violation) are not eligible for your position is eliminated. During conflict between this summary and separation pay. the actual Plan document, the Plan this period, you will continue in your document will govern. current position while pursuing other TRANSITION PLAN employment opportunities. You are required to actively search for other WHO IS ELIGIBLE A transition plan is required whenever positions are being eliminated positions within Texas Health during The Separation Pay Plan applies to because of outsourcing, restructuring, the notice period, regardless of work full and part-time benefits-eligible or closing of an entity, department, status. employees (as defined in the division, operating unit or function. If you are a director or officer, you Employee Handbook) of Texas Health The plan helps determine what will are not eligible for the notice period. Resources wholly-owned entities happen to the affected employees. In this case, your separation will be whose positions are eliminated. The When management anticipates the on the date agreed by your manager plan for THPG Clinic Practice Staff need for a transition plan, they will and Human Resources. However, you can be found on pages 197 – 199. consult with Human Resources may be given a notice period in which PRN and part-time benefits-ineligible to develop a plan that includes a case you must actively search for employees, administrative residents/ summary of the need for transition, other positions within Texas Health interns/fellows, medical directors, as well as the names and other during the notice period to be eligible medical residents/interns/fellows, information regarding employees for separation pay. THPG/THBC physicians, employees who are potentially affected. hired as a direct result of a research In certain situations, with the approval or educational grant, and employees

of the EVP, Chief People Officer, Health Texas Leaving under contract are not eligible for management may deem it necessary the Plan. Employee status, base pay, to separate an employee immediately. standard hours and years of service The employee will cease to be an are determined by Texas Health’s HR/ active employee as of the date of Payroll system. separation.

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RESIGNATION DURING •• That contracts with Texas Health Employees are expected to actively NOTICE PERIOD to offer employment to employees pursue reasonable opportunities for whose positions have been which they are qualified. If, during the If you resign during the notice period, eliminated. notice period, an employee fails to, you will not be entitled to separation If you accept a position from Texas does not or refuses to interview for pay or pay for the remainder of the Health that is not a reasonable offer open positions with Texas Health or notice period. as defined in the Plan, you will not be an acquiring employer, he or she will eligible for separation pay but may be not be eligible for separation pay. REASONABLE OFFER eligible for transition pay. Transition Employees who continue working pay is a percentage of the separation If, during the notice period, you through their notice period are pay you would have received if fail to actively apply for full-time or expected to meet and maintain all you had not accepted a position. part-time positions for which you conditions of performance for their The percentage is determined by a are qualified and that could result assigned job. Failure to do so may fraction: in a reasonable offer or refuse or result in immediate separation with decline one reasonable offer from a •• The numerator is the difference no separation pay. The Career Center wholly-owned Texas Health facility between: can assist employees in identifying or an acquiring employer, you will be ––The eliminated position hourly job opportunities for which they may treated as having voluntarily separated be qualified. and will not be eligible for separation rate times the eliminated position pay. standard hours If requested, the EVP, Chief People ––The new position hourly rate Officer may, in her discretion, elect to A reasonable offer means an offer times new position standard pay separation pay in lieu of providing from a Texas Health wholly owned hours. an employee with notice or requiring entity which the employee meets •• The denominator is the eliminated the employee to actively pursue a job. minimum qualifications of the position hourly rate times the position (some additional training may eliminated position standard hours. LEAVE OF ABSENCE be necessary) and the base pay (as defined below) for the new position is Pay for the notice period is not taken If you receive a reasonable offer from 95% or more of the base pay for the into account in determining transition an acquiring employer, your position employee’s current position. An offer pay. An employee receiving transition may be eliminated even if you are of a PRN position is not considered a pay is not entitled to the notice on a protected leave of absence. If reasonable offer. A reasonable offer period. Transition pay will begin with your position is eliminated before may include an offer that involves a the payroll period in which you begin you begin your protected leave of change in the employee’s benefits in the new position. Transition pay is absence, the notice period will be status. A reasonable offer may also paid over a maximum period of six extended by the time period of the include a shift change, schedule months with your regular paycheck. protected leave of absence. change, change in benefits status, If you leave before the end of the If you are on a leave of absence of or reassignment to a different six-month period, you will lose the any kind, including a protected leave department or operating unit if that remainder of the transition pay. If you of absence, your position may be Leaving Texas Health Texas Leaving operating unit is located no more are receiving transition pay and you eliminated or terminated for business than 35 miles from the employee’s change to a position that would have reasons. current work location. An employee’s been a reasonable offer at the time current work location for purposes of your position elimination during A “protected leave of absence” is an of the Plan is defined as the location the six month period, you will stop approved military leave, ADA or Family where 60% of their time is recorded. receiving transition pay effective as of Medical Leave Act (FMLA) leave at the the first day of the payroll period that end of which the employee has the An “acquiring employer” for purposes includes the change in position. right to be reemployed according to of the Plan, is an entity or person: If you accept a PRN position (after federal law. Any other type of leave of •• To whom all or part of an entity, researching and applying for full-time absence is not considered a protected department, division, operating unit or part-time positions), you will not leave of absence. Spending Accounts or function is outsourced; receive transition pay, but may be •• That purchases or acquires all eligible for separation pay. or part of the assets of an entity, department, division, operating unit or function to which the employee’s job relates; •• That performs the functions of the entity, department, division, operating unit or function; or

194 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Separation Pay Plan (THR Employees)

FAILURE TO INVESTIGATE, SEPARATION PAY Years of service is calculated beginning with the employee’s APPLY OR INTERVIEW Employees who have been most recent date of hire, each three unsuccessful in securing a new During the notice period, you are hundred and sixty-five (365) day position may be eligible for separation expected to actively pursue job period that elapses or has elapsed pay (based on the level of the affected opportunities within Texas Health while the employee is employed position and the employee’s years of for which you are qualified and that with Texas Health. For purposes of service) and internal Career Center may result in a reasonable offer from determining an employee’s years of services if he or she does not: a Texas Health wholly owned entity service, the years of service before or an acquiring employer. If you fail •• Have a new position at the end of the employee’s most recent hire date to investigate, apply or interview for the notice period or will not be taken into account unless open positions that could result in •• Receive one reasonable offer from crediting is required under Texas a reasonable offer, you will not be Texas Health or Health’s “Bridging of Service Policy” eligible for separation pay. and the employee has not previously •• Receive a reasonable offer from an received separation pay from Texas acquiring employer. TRANSFER PAY GUIDELINES Health for that service. The EVP, If an employee accepts an offer within If you meet all the requirements of Chief People Officer must approve the Texas Health system, his or her the Separation Pay Plan, you will be all exceptions to the years of service pay will be determined as follows: entitled to separation pay according calculation. This determination will to the table below. be at the discretion of the EVP, Chief •• If an employee accepts a position People Officer. with the same or higher salary Base pay is the employee’s hourly range, Texas Health’s compensation pay rate multiplied by the number The receipt of separation pay is guidelines concerning lateral or of hours per week the employee conditioned upon completion of the promotional transfers will apply. is classified to work in HR/Payroll Agreement for Separation Pay and •• If an employee accepts a position System (standard hours). Base Release of Claims document and that is in a lower salary range, and Pay does not include differentials, any other documents requested by the employee’s current base pay bonuses, overtime, or commissions. Human Resources. The employee falls within the salary range for the Title is based on EEO category in the must sign and return the Agreement position, the employee’s base pay HR/payroll system. in the format required by Texas Health will not change. within 50 days after receiving the Agreement. •• If the employee’s current base pay is above the maximum of the new The employee will have seven (7) days salary grade range, the employee’s to revoke the release once signed. In base pay will be adjusted to equal the event the employee does not sign the maximum of the new salary and return the Agreement to Texas range. Health within 50 days or chooses to revoke the release in the seven-day Benefits base pay will be adjusted period allowed by law, the employee according to the terms of the Health Texas Leaving is not eligible for separation pay. applicable benefits plan. Separation Pay Minimum Maximum Weeks of Base Number of Number of Position Defined Pay Earned Weeks of Base Weeks of Base by Title Per Year of Pay per Year of Pay per Year of Service Service Service Staff 1 2 12 Managers 2 2 26 Directors 6 13 39 Executives 8 26 52

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EMPLOYMENT AND CONSULTING You will be required to repay all or part of your separation pay if you receive separation pay from Texas Health and then are either employed or engaged to do consulting work for Texas Health, the acquiring entity, or any entity that was part of the transaction that resulted in the elimination of your position. The amount you will be required to repay is described in the Separation Pay Plan and is based on the number of weeks of separation pay you received and when you began employment or consulting.

The EVP, Chief People Officer must approve all exceptions to the requirements of this section. You are not required to repay any part of the separation pay if you are employed in a PRN position, provided you are accurately classified as a PRN. This determination will be at the discretion of the EVP, Chief People Officer.

PAYMENT After you satisfy all of the conditions of the Separation Pay Plan, you will receive separation pay in a lump sum, less applicable withholding, within 90 days of your termination of employment (and not less than seven days) after returning the completed and signed agreement to Texas Health. Leaving Texas Health Texas Leaving Spending Accounts

196 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Separation Pay Plan (THPG Clinic Practice Staff)

Separation Pay Plan (THPG Clinic Practice Staff)

OVERVIEW WHEN A POSITION IS NOTICE The Texas Health Separation Pay ELIMINATED If your position is eliminated, as Plan is designed to provide benefits Under this Plan, you are considered to defined under the Plan, you will to eligible employees who are have your position eliminated if you receive notification and transition involuntarily terminated due to job are involuntarily separated because information when management and elimination as a result of outsourcing all or part of an entity, department, Human Resources have evaluated all or part of a department, division, division, operating unit, or function each employee’s specific information. operating unit, or function; closing is being outsourced, restructured, Options that may be available include all or part of an entity, department, or closed. Employees who are transfer opportunities, career center division operating unit or function; terminated for cause (such as poor services and, in certain situations, restructuring all or part of an entity, performance or violation of policy) separation pay (as defined in the Plan). department or division, operating unit will not be eligible for Separation Pay. Generally, if you are not a director or or function; so other changes as THR Employees who are terminated for officer, you will be given a minimum may designate from time to time. This cause (such as poor performance or of 30 calendar days’ notice before is a summary of the Plan. If there is a policy violation) are not eligible for your position is eliminated. During conflict between this summary and separation pay. the actual Plan document, the Plan this period, you will continue in your document will govern. current position while pursuing other TRANSITION PLAN employment opportunities. You are required to actively search for other WHO IS ELIGIBLE A transition plan is required whenever positions are being eliminated positions within Texas Health during The Separation Pay Plan applies because of outsourcing, restructuring, the notice period, regardless of work to full and part-time benefits- or closing of an entity, department, status. eligible employees (as defined division, operating unit or function. If you are a director or officer, you in the Employee Handbook) of The plan helps determine what will are not eligible for the notice period. Texas Health Resources wholly- happen to the affected employees. In this case, your separation will be owned entities whose positions When management anticipates the on the date agreed by your manager are eliminated. This section applies need for a transition plan, they will and Human Resources. However, you to THPG Clinic Practice Staff consult with Human Resources may be given a notice period in which (formerly THM employees). The to develop a plan that includes a case you must actively search for plan for non-THPG employees can summary of the need for transition, other positions within Texas Health be found on pages 193 – 196. PRN as well as the names and other during the notice period to be eligible and part-time benefits-ineligible information regarding employees for separation pay. employees, administrative residents/ who are potentially affected. interns/fellows, medical directors, In certain situations, with the approval medical residents/interns/fellows,

of the EVP, Chief People Officer, Health Texas Leaving THPG physicians, employees hired management may deem it necessary as a direct result of a research or to separate an employee immediately. educational grant, and employees The employee will cease to be an under contract are not eligible for active employee as of the date of the Plan. Employee status, base pay, separation. standard hours and years of service are determined by Texas Health’s HR/ Payroll system.

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RESIGNATION DURING •• That contracts with Texas Health Employees are expected to actively NOTICE PERIOD to offer employment to employees pursue reasonable opportunities for whose positions have been which they are qualified. If, during the If you resign during the notice period, eliminated. notice period, an employee fails to, you will not be entitled to separation does not or refuses to interview for pay or pay for the remainder of the If you accept a position from Texas open positions with Texas Health or notice period. Health that is not a reasonable offer an acquiring employer, he or she will as defined in the Plan, you will not be not be eligible for separation pay. REASONABLE OFFER eligible for separation pay but may be eligible for transition pay. Transition Employees who continue working If, during the notice period, you pay is a percentage of the separation through their notice period are fail to actively apply for full-time or pay you would have received if expected to meet and maintain all part-time positions for which you you had not accepted a position. conditions of performance for their are qualified and that could result The percentage is determined by a assigned job. Failure to do so may in a reasonable offer or refuse or fraction: result in immediate separation with decline one reasonable offer from a no separation pay. The Career Center wholly-owned Texas Health facility •• The numerator is the difference can assist employees in identifying or an acquiring employer, you will be between: job opportunities for which they may treated as having voluntarily separated ––The eliminated position hourly be qualified. and will not be eligible for separation rate times the eliminated position pay. standard hours If requested, the EVP, Chief People ––The new position hourly rate Officer may, in her discretion, elect to A reasonable offer means an offer pay separation pay in lieu of providing from a Texas Health wholly owned times new position standard hours. an employee with notice or requiring entity which the employee meets the employee to actively pursue a job. minimum qualifications of the •• The denominator is the eliminated position (some additional training may position hourly rate times the LEAVE OF ABSENCE be necessary) and the base pay (as eliminated position standard hours. If you receive a reasonable offer from defined below) for the new position is Pay for the notice period is not taken an acquiring employer, your position 95% or more of the base pay for the into account in determining transition may be eliminated even if you are employee’s current position. An offer pay. An employee receiving transition on a protected leave of absence. If of a PRN position is not considered a pay is not entitled to the notice your position is eliminated before reasonable offer. A reasonable offer period. Transition pay will begin with you begin your protected leave of may include an offer that involves a the payroll period in which you begin absence, the notice period will be change in the employee’s benefits in the new position. Transition pay is extended by the time period of the status. A reasonable offer may also paid over a maximum period of six protected leave of absence. include a shift change, schedule months with your regular paycheck. change, change in benefits status, If you leave before the end of the If you are on a leave of absence of or reassignment to a different six-month period, you will lose the any kind, including a protected leave department or operating unit if that remainder of the transition pay. If you of absence, your position may be Leaving Texas Health Texas Leaving operating unit is located no more are receiving transition pay and you eliminated or terminated for business than 35 miles from the employee’s change to a position that would have reasons. current work location. An employee’s been a reasonable offer at the time current work location for purposes of your position elimination during A “protected leave of absence” is an of the Plan is defined as the location the six month period, you will stop approved military leave, ADA or Family where 60% of their time is recorded. receiving transition pay effective as of Medical Leave Act (FMLA) leave at the end of which the employee has the An “acquiring employer” for purposes the first day of the payroll period that right to be reemployed according to of the Plan, is an entity or person: includes the change in position. federal law. Any other type of leave of •• To whom all or part of an entity, If you accept a PRN position (after absence is not considered a protected department, division, operating unit researching and applying for full-time leave of absence.

Spending Accounts or function is outsourced; or part-time positions), you will not •• That purchases or acquires all receive transition pay, but may be or part of the assets of an entity, eligible for separation pay. department, division, operating unit or function to which the employee’s job relates; •• That performs the functions of the entity, department, division, operating unit or function; or

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FAILURE TO INVESTIGATE, THPG Clinic Practice Staff who meet EMPLOYMENT AND APPLY OR INTERVIEW all the requirements of the Separation CONSULTING Pay Plan will be entitled to two (2) During the notice period, you are weeks of separation pay. You will be required to repay all or expected to actively pursue job part of your separation pay if you opportunities within Texas Health Base pay is the employee’s hourly receive separation pay from Texas for which you are qualified and that pay rate multiplied by the number Health and then are either employed may result in a reasonable offer from of hours per week the employee or engaged to do consulting work a Texas Health wholly owned entity is classified to work in HR/Payroll for Texas Health, the acquiring or an acquiring employer. If you fail System (standard hours). Base entity, or any entity that was part of to investigate, apply or interview for Pay does not include differentials, the transaction that resulted in the open positions that could result in bonuses, overtime, or commissions. elimination of your position. The a reasonable offer, you will not be Title is based on EEO category in the amount you will be required to repay eligible for separation pay. HR/payroll system. is described in the Separation Pay Plan and is based on the number of Years of service is calculated weeks of separation pay you received TRANSFER PAY GUIDELINES beginning with the employee’s and when you began employment or If an employee accepts an offer within most recent date of hire, each three consulting. the Texas Health system, his or her hundred and sixty-five (365) day pay will be determined as follows: period that elapses or has elapsed The EVP, Chief People Officer while the employee is employed must approve all exceptions to the •• If an employee accepts a position with Texas Health. For purposes of requirements of this section. You are with the same or higher salary determining an employee’s years of not required to repay any part of the range, Texas Health’s compensation service, the years of service before separation pay if you are employed guidelines concerning lateral or the employee’s most recent hire date in a PRN position, provided you are promotional transfers will apply. will not be taken into account unless accurately classified as a PRN. This •• If an employee accepts a position crediting is required under Texas determination will be at the discretion that is in a lower salary range, and Health’s “Bridging of Service Policy” of the EVP, Chief People Officer. the employee’s current base pay and the employee has not previously falls within the salary range for the received separation pay from Texas PAYMENT position, the employee’s base pay Health for that service. will not change. After you satisfy all of the conditions •• If the employee’s current base pay The receipt of separation pay is of the Separation Pay Plan, you will is above the maximum of the new conditioned upon completion of the receive separation pay in a lump salary grade range, the employee’s Agreement for Separation Pay and sum, less applicable withholding, base pay will be adjusted to equal Release of Claims document and within 90 days of your termination of the maximum of the new salary any other documents requested by employment (and not less than seven range. Human Resources. The employee days) after returning the completed must sign and return the Agreement and signed agreement to Texas Benefits base pay will be adjusted in the format required by Texas Health Health. according to the terms of the within 50 days after receiving the Health Texas Leaving applicable benefits plan. Agreement.

SEPARATION PAY The employee will have seven (7) days to revoke the release once signed. In Employees who have been the event the employee does not sign unsuccessful in securing a new and return the Agreement to Texas position may be eligible for separation Health within 50 days or chooses to pay (based on the level of the affected revoke the release in the seven-day position and the employee’s years of period allowed by law, the employee service) and internal Career Center is not eligible for separation pay. services if he or she does not:

•• Have a new position at the end of the notice period or •• Receive one reasonable offer from Texas Health or •• Receive a reasonable offer from an acquiring employer.

1-877-MyTHRLink (1-877-698-4754) MyTHR.org 199 Claims and Administration Claims Information...... 201 Payment of Benefits 201 Right of Recovery 201 Reimbursement 201 Misstatements of Fact 201 Subrogation 201 Denial of Claims 202 Administrative Information...... 205 Your ERISA Rights 205 Plan Amendments 206 Plan Sponsor 206 Plan Administration 206 Important Notice from Texas Health About Your Prescription Drug Coverage and Medicare 209 Texas Health Group Health Plan Notice of Privacy Practices 210 CHIP Notice 212 Notice Regarding Wellness Program 213 Discrimination is Against the Law 214

200 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Claims Information Claims Information

PAYMENT OF BENEFITS REIMBURSEMENT SUBROGATION Your benefit plans are intended to If you recover damages for an injury If you receive benefits under the pay benefits only to you or your or illness (for example, if you receive Texas Health benefit plans (other than beneficiaries. Your benefits cannot a settlement from your insurance the Texas Health Retirement Program) be used as collateral for loans or be company, the person who caused for an injury or illness resulting from assigned in any other way. However, the injury or illness or that person’s any negligent or any willful act or benefits under the Texas Health insurance carrier), the Texas Health omission by any person, company Retirement Program may be divided plans (other than under the Texas or organization, the plan will be under a Qualified Domestic Relations Health Retirement Program or the subrogated to all rights of recovery Order (described on page 142) and Texas Health Dental Plan) have a right that you may have against that third medical, dental, and vision claims to be reimbursed for the amount of party. This means that when you may be assigned to the health care benefits it has paid on your behalf for accept payment of benefits under provider. treatment of the injury or illness. the Texas Health benefit plan, you assign your rights of recovery from If you are unable to receive any As a condition for receiving benefits, the third party to the plan and agree payment due to you under any of the you: to do whatever may be necessary to plans, payment may be made to any secure recovery, including execution person providing for your care, your •• Grant the plan a first lien against any settlement, verdict, or other of all appropriate agreements or other guardian, your beneficiaries, or your papers. estate. Such payments will release amounts you receive Texas Health of its obligation with •• Assign to the plan any medical By accepting benefits under the regard to that claim. benefits you are eligible to receive Texas Health plans, you agree to under an automobile policy or assign to Texas Health the right to the RIGHT OF RECOVERY other coverage, up to the amount first dollars you receive—including the plan has paid in benefits for general damages—up to the full If you receive any overpayment of •• Agree to sign and deliver any amount paid by the plan. If you fail benefits by a Texas Health plan, the documents necessary to help the to comply with this requirement, plan will have the right to recover plan protect its rights (refusal to your benefits under the Texas Health the overpayment from you. If you sign these documents does not plan will stop and your coverage will receive a benefit greater than allowed diminish the plan’s reimbursement terminate. by the plan, you will be requested to rights) refund the overpayment. If you do •• Assist the plan by complying with not submit the refund, the amount of any reasonable request to help the overpayment will be deducted from plan recover any benefits it has future benefits you receive from the paid, without taking any action that plan. may prejudice the plan’s right to reimbursement.

MISSTATEMENTS OF FACT Any material misstatement you make regarding the age, sex, marital status, or other condition or status of any person covered under a Texas Health plan may be grounds for adjustment of payments due under any plan. Claims & Admin

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DENIAL OF CLAIMS Requesting a Second Review for Disability Claims Non-disability Please refer to each section of this This applies to STD, LTD, and the Handbook to determine how to If you wish to request a second Texas Health Retirement Plan. The submit a claim for that plan (medical, review of a denied claim (except for claims administrator will make a dental, vision). disability benefits under the STD, LTD, decision no more than 45 days after and Texas Health Retirement Plan), receipt of your claim. The claims Non-disability Claims you have 60 days after receiving administrator may extend the time If you file a claim under any of the the denial to request a review by period for two additional 30-day following plans and any portion of the Governance Committee or, periods provided they: that claim is denied, you will receive a in the case of a fully insured plan, •• Give you written notification in written notice. Plans include: the appropriate insurance carrier. You must make your request in advance that the extension is •• Dependent Care Flexible Spending writing. You also have the right to necessary for reasons beyond the Account review pertinent documents, submit control of the plan •• Life Insurance comments and have a representative •• Explain the reason for the •• AD&D Insurance act on your behalf. extension, and •• Business Travel Accident Insurance •• Give the date by which they expect You will receive a written notice of the to render a decision. •• Texas Health Retirement Program Committee’s or insurance company’s (except for disability benefits) decision within 60 days after a review If your claim is extended because •• Separation Pay Program. is requested. In special cases, the you have failed to submit information review can take an additional 60 necessary to decide your claim, the The notice will be sent to you within days, and you will be notified if this time period for the decision will be 90 days from the date the claims additional time is necessary. The counted from the date the claims administrator received your claim. If Committee has the sole right to administrator sends you notification more time is needed (up to a total of determine whether or not you or your of the extension until the date the 180 days), you will be notified within representative will personally appear claims administrator receives your the first 90 days (except for disability in any review. response to its request. claims). The decision of the Committee The written decision from the claims Any denial notice you receive will or insurance carrier is final. You administrator will be written in a way explain: will receive a written notice of that is calculated to be understood •• Specific reasons for the denial the decision. If you still feel that by you and in a culturally and •• Specific reference to pertinent plan your claim has been improperly linguistically appropriate manner. The provisions upon which the denial denied, refer to the section of this decision will include: guide entitled “Your ERISA Rights” was based •• the specific reason or reasons for (beginning on page 205) for a •• Description of any additional the denial of benefits; description of your legal rights. information or material necessary •• a specific reference to the pertinent to complete the claim and provisions of the Plan upon which an explanation of why such the denial is based; information or material is necessary •• a description of any additional •• The steps to take if you wish to material or information that is submit the claim for further review. necessary for you to perfect the claim and an explanation of why such material or information is necessary; •• a discussion of the decision, including an explanation of the basis for disagreeing with or not

Claims & Admin following: Spending Accounts ––the views you presented to the Plan of health care professionals treating you and vocational professionals who evaluated you;

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–– the views of medical or Requesting a Second Review for If the adverse benefit determination is vocational experts whose advice Disability based in whole or in part on a medical was obtained on behalf of the If all or part of your claim for judgment, including determinations Plan in connection with your disability benefits under the STD, with regard to whether a particular adverse benefit determination, LTD, and Texas Health Retirement treatment, drug, or other item is without regard to whether the Program is denied, you or your experimental, investigational, or not advice was relied upon in making representative may appeal to the medically necessary or appropriate, the benefit determination; and claims administrator for a full and fair the appropriate named fiduciary ––a disability determination review. You may: will consult with a health care regarding you presented by you professional who has appropriate to the Plan made by the Social •• Make a written application for training and experience in the Security Administration; review within 180 days of the claim field of medicine involved in the •• if the adverse benefit determination denial medical judgment. The health care is based on a medical necessity •• Request, free of charge, copies of professional will be an individual or experimental treatment or all documents, records, and other who is neither an individual who was similar exclusion or limit, either information relevant to your claim, consulted in connection with the an explanation of the scientific and adverse benefit determination that or clinical judgment for the •• Submit written comments, is the subject of the appeal, nor the determination, applying the documents, records and other subordinate of any such individual. terms of the Plan to your medical information relating to your claim. Any medical or vocational experts circumstances, or a statement that whose advice was obtained on behalf The claims administrator will make a such explanation will be provided of the Plan in connection with your decision no more than 45 days after free of charge upon request; adverse benefit determination will it receives your appeal. The time for be identified upon written request by •• an explanation of the Plan’s review decision may be extended for one you or your authorized representative, procedures and the time limits additional 45-day period provided without regard to whether the advice applicable to such procedures, that, before the extension, the was relied upon in making the benefit as provided below, including a claims administrator notifies you in determination. statement of your right to bring a writing that an extension is necessary civil action under Section 502(a) of because of special circumstances, The decision shall be in writing the Employee Retirement Income identifies those circumstances, and and shall set forth, in a manner Security Act of 1974, as amended, gives the date by which it expects to calculated to be understood by you following an adverse benefit render its decision. and in a culturally and linguistically determination on review; appropriate manner: •• if an internal rule, guideline, If your claim is extended because protocol, or other similar criterion you have failed to submit information •• the specific reason or reasons for was relied upon in making the necessary to decide your claim the denial of benefits; adverse determination, either the on appeal, the time for decision •• a specific reference to the pertinent specific rule, guideline, protocol, will be counted from the date the provisions of the Plan upon which or other similar criterion, or notification of the extension is sent the denial is based; a statement that such a rule, to you until the date the insurance •• a statement that you is entitled to guideline, protocol, or other company receives your response to receive, upon request and free of similar criterion was relied upon in the request. The written decision will charge, reasonable access to, and making the adverse determination include specific references to the copies of, all documents, records, or, alternatively, a statement that plan provisions on which the decision and other information relevant to such rules, guidelines, protocols, is based and any other notice, your claim for benefits; standards or other similar criteria of statement, or information required by •• a statement describing any the plan do not exist; applicable law. voluntary appeal procedures •• a statement that you is entitled to offered by the plan and your right to The review shall not afford deference receive, upon request and free of obtain the information about such

to the initial adverse benefit Claims & Admin charge, reasonable access to, and procedures described in paragraph determination and shall be conducted copies of, all documents, records, (c)(3)(iv) of this section, and a by an appropriate named fiduciary of and other information relevant to statement of your right to bring the Plan who is neither the individual your claim for benefits. an action under section 502(a) of who made the adverse benefit the Act, including any applicable determination that is the subject of contractual limitations period that the appeal, nor the subordinate of applies to your right to bring such that individual. an action and the calendar date on which the contractual limitations period expires for the claim;

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•• a discussion of the decision, Before the Plan can issue an adverse Waiver of Premium for Life including an explanation of the benefit determination on review on Insurance basis for disagreeing with or not a claim based on disability, the Plan If you feel you are entitled to a waiver following: Administrator will: of premium for disability under Basic –– the views presented by you to the 1. provide you, free of charge, with or Additional Life Insurance, you must Plan of health care professionals any new or additional evidence file a claim with the life insurance treating you and vocational considered, relied upon, or claims administrator. The claims professionals who evaluated you; generated by the plan, insurer, or administrator will advise you of its –– the views of medical or other person making the benefit decision within 45 days. The claims vocational experts whose determination (or at the direction administrator may extend this time advice was obtained on behalf of the plan, insurer or such other period for two additional 30-day of the Plan in connection with person) in connection with the periods while gathering information a claimant's adverse benefit claim; such evidence must be needed to make a decision, but only determination, without regard provided as soon as possible and if the reason for delay is beyond its to whether the advice was relied sufficiently in advance of the date control. upon in making the benefit on which the notice of adverse determination; and You have up to 180 days to appeal an benefit determination on review is adverse benefit determination. You –– a disability determination required to be provided hereunder must make your appeal in writing regarding you presented by you to give you a reasonable and address it to the appeals unit to the Plan made by the Social opportunity to respond prior to of the claims administrator. The Security Administration; that date; and claims administrator will decide •• if the adverse benefit determination 2. provide you, free of charge, with your appeal within 45 days. Under is based on a medical necessity the rationale as soon as possible special circumstances, the claims or experimental treatment or and sufficiently in advance of administrator may extend the period similar exclusion or limit, either the date on which the notice of for an additional 45 days. an explanation of the scientific adverse benefit determination or clinical judgment for the on review is required to be determination, applying the provided to give you a reasonable terms of the Plan to your medical opportunity to respond prior to circumstances, or a statement that that date. such explanation will be provided free of charge upon request; You may file a lawsuit for benefits only after you have exercised all appeals •• an explanation of your right to described in this section and all or bring a civil action under Section part of the benefits you request on 502(a) of the Employee Retirement appeal have been denied. Income Security Act of 1974, as amended, following an adverse benefit determination on review. Claims & Admin Spending Accounts

204 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Administrative Information Administrative Information

Following are some important •• Receive, upon written request, In carrying out their respective administrative details concerning the plan documents, contracts, and responsibilities under the plan, the benefit plans offered by Texas Health other plan information from plan administrator and other plan that are subject to the Employee the plan administrator. The fiduciaries shall have discretionary Retirement Income Security Act of plan administrator may make a authority to interpret the terms of 1974 (ERISA), as amended from time reasonable charge for the copies. the plan and to determine eligibility to time. These plans are listed on Any materials requested should for and entitlement to plan benefits pages 207 – 208. be received within 30 days of in accordance with the terms of receipt of your request unless the the plan. Any interpretation or YOUR ERISA RIGHTS materials are not sent because of determination made pursuant to circumstances beyond the control such discretionary authority shall be This section contains statements of of the plan administrator. given full force and effect under the your rights under ERISA. This notice •• Receive a summary of each benefit plan, unless it can be shown that the follows the format provided by federal plan’s annual report. The plan interpretation or determination was regulations and summarizes your administrator is required by law to arbitrary and capricious. rights under the law. As a participant furnish each participant with a copy in a plan governed by ERISA, you have No one may discharge you, or of this summary annual report. been given information about such otherwise discriminate against you, to plan coverages and benefits. •• Continue health coverage for prevent you from receiving a benefit yourself, your spouse, and/or or from exercising rights under ERISA. To help plan participants reduce your eligible dependents if any of disputes and to avoid inconvenience you lose coverage because of a If your claim for benefits is denied or or delay of payment for eligible qualifying event. You must pay for ignored, in whole or in part, you have expenses, this Handbook provides this continued coverage. a right to know the reason, to obtain descriptions of claim and appeal copies of documents (free of charge) procedures on pages 61 – 69, 92 – The plan administrator makes relating to the decision, and to appeal 94, 97 – 98 and 202 – 204, as well available all documents required any denial—all within certain time as addresses, telephone numbers, by law, including a summary of schedules. and other references where you may the plan’s Annual Financial Report. obtain additional information and Additional information is also Under ERISA, there are steps you assistance. provided that may be helpful to can take to enforce your rights. For you in making the best use of your example, if you request a copy of This Handbook summarizes the benefits. the plan documents or the latest benefits offered by Texas Health. The annual report from the plan and you Handbook does not attempt to cover Plan Fiduciaries do not receive them within 30 days, all details. ERISA imposes obligations upon you may file suit in a federal court. those persons responsible for the In this case, the court may require All participants in ERISA plans may: operation of the plans. Such persons the plan administrator to provide •• Examine all plan documents and are called “fiduciaries.” Fiduciaries the materials and pay up to $110 a copies of all documents, such as must act solely in the interest of the day until you receive the materials the annual report (Form 5500) and plan participants, and they must act (unless the materials were not sent plan description. These documents prudently in the performance of their for reasons beyond the control of the can be examined without charge in duties. Fiduciaries may be removed administrator). the plan administrator’s office. for violating these rules and are required to make good any losses If your claim for benefit was denied they have caused the plans. or ignored, in whole or in part, you may file suit in a state or federal court. In addition, if you disagree with the Claims & Admin plan’s decision (or lack of decision) concerning the qualified status of a domestic relations order or medical child support order, you may file suit in a federal court.

1-877-MyTHRLink (1-877-698-4754) MyTHR.org 205 Administrative Information

If the fiduciaries misuse the plan’s PLAN AMENDMENTS PLAN ADMINISTRATION money, or if you are discriminated The Governance Committee, under Texas Health is the plan administrator against for asserting your rights, the authority granted to it by the for all the benefit plans listed in you may seek assistance from the Board of Trustees, has the sole this Handbook. The Governance U.S. Department of Labor or you authority to adopt and/or amend Committee acts on behalf of may file suit in a federal court. The benefit plans. The Governance Texas Health in its capacity as plan court will decide who should pay the Committee, in consultation with administrator. The Governance court costs and legal fees. If you are actuaries, consultants, Human Committee can be reached at: successful, the court may order the Resources, and the Legal Department, person you have sued to pay theses has the discretion to adopt such rules, Governance Committee costs and fees. If you lose, the court forms, procedures, and amendments Attn: Executive Vice President, may order you to pay these costs and it determines are necessary for Chief People Officer fees—for example if it finds your claim the administration of employee Texas Health is frivolous. benefit plans according to their 612 E. Lamar Blvd., Suite 900 Arlington, Texas 76011 If you have any questions about terms, applicable law, regulation, 682-236-7900 this statement or about your rights or to further the objectives of the under ERISA or the Health Insurance employee benefit plans. Members of the Governance Portability and Accountability Act Committee are appointed by the of 1996 (HIPAA), contact the plan PLAN SPONSOR Board of Trustees of Texas Health. administrator or: Texas Health is the plan sponsor for The current members of the Governance Committee are: •• The nearest area office of the all plans described in this Handbook. Employee Benefits Security Attn: Plan Administrator •• W. Dennis Stripling, M.D. Administration, U.S. Department Texas Health 612 E. Lamar Blvd., Suite 400 of Labor, listed in your telephone 612 E. Lamar Blvd., Suite 900 Arlington, TX 76011 directory Arlington, Texas 76011 •• The Division of Technical Assistance and Inquiries, Employee •• Wesley R. Turner Benefits Security Administration, 500 W. 7th St., Suite 1725 U.S. Department of Labor, 200 Fort Worth, TX 76102 Constitution Avenue, N.W., Washington, D.C. 20210. •• Lynn Montgomery You may also request certain 3707 Camp Bowie Blvd. publications about your rights Fort Worth, TX 76107 and responsibilities by calling the publications hotline at the Employee •• Hunter L. Hunt Benefits Security Administration (formerly called the Pension and 1900 North Akard Street Welfare Benefits Administration) Dallas, TX 75201 at 1-866-444-3272. •• Stephen L. Tatum 600 West 6th Street, Suite 300 Fort Worth, TX 76102-3685

•• Richard M. Vigness, M.D. 1307 8th Ave. #601 Fort Worth, TX 76104 Claims & Admin

Spending Accounts •• Charles John Wilder, Jr. 200 Crescent Court, Suite 1900 Dallas, TX 75201

206 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Administrative Information

The Governance Committee has the •• Lynn Montgomery Agent for Service of Legal Process authority, as outlined in each plan, to 3707 Camp Bowie Blvd. Texas Health Resources employ personnel and professionals Fort Worth, TX 76107 Ken Kramer, General Counsel as it deems advisable to assist in 612 E. Lamar Blvd., Suite 900 administration. It is the Governance Arlington, TX 76011 Committee’s duty to interpret each •• Hunter L. Hunt plan’s provisions and make final 1900 North Akard Street Service of process may also be decisions on matters such as eligibility Dallas, TX 75201 made upon a plan trustee or plan and payment of benefits. administrator. Employer Identification Number •• Stephen L. Tatum Plan Year Texas Health’s employer 600 West 6th Street, Suite 300 The plan year is January 1 through identification number is 75-2702388. Fort Worth, TX 76102-3685 December 31 for all plans listed in this Handbook. Plan Trustees •• Richard M. Vigness, M.D. The current trustees of the Texas 1307 8th Ave. #601 Health Retirement Program are: Fort Worth, TX 76104 •• W. Dennis Stripling, M.D. 612 E. Lamar Blvd., Suite 400 •• Charles John Wilder, Jr. Arlington, TX 76011 200 Crescent Court, Suite 1900 Dallas, TX 75201 •• Wesley R. Turner 500 W. 7th St., Suite 1725 Fort Worth, TX 76102

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 Plan Type Plan Funding Administrator Number Total Health Medical Plan ••Texas Health Aetna 501 Self-funded medical plans1 Self-funded Texas Health Aetna2 ••UHC Choice and Choice Plus 501 Self-funded medical plans1 Self-funded UnitedHealthcare2 ••Caremark 501 Self-funded1 Self-funded Caremark2 Be Healthy 501 Wellness Funded by company UnitedHealthcare Employee Assistance Program 501 Employee Assistance Funded by company Texas Health Resources (EAP) Program Texas Health Dental Plan 502 Fully insured dental plans Premiums are paid by ••Aetna Managed Dental employee contributions Plan (DMO)®3 ••Aetna® Managed Dental Plan (DMO®) ••Aetna PPO (Low Option)3 ••Aetna PDN (Low Option) ••Aetna PDN (High ••Aetna PDN (High Option) Option)3

Superior Vision Plan 514 Fully insured vision plan Premiums are paid by Superior Vision Plan3 Claims & Admin through National Guardian employee contributions Life Insurance Company Texas Health Short Term 503 Fully insured disability plan Premiums are paid by Prudential Disability Plan employee 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)

1-877-MyTHRLink (1-877-698-4754) MyTHR.org 207 Administrative Information

Claims Administrators (Continued)

Plan Plan Name Number Plan Type Plan Funding Administrator Texas Health Long Term 504 Fully insured disability plan Basic LTD premiums Prudential Disability Plan are paid by the company and Additional LTD premiums are paid by employee contributions Texas Health Life and Accident 505 Fully insured life, AD&D Basic Life, Basic Prudential3 Insurance Plan and business travel AD&D, and Business Life Insurance Company of accident plans Travel Accident North America (BTA)3 premiums are paid by the company. Additional Life, Dependent Life, and Additional AD&D premiums are paid by employee contributions Texas Health Flexible 506 Self-funded cafeteria plan, Funded by employee PayFlex2 Benefits Plan Health Care Spending contributions Account, and Day Care 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 Texas Health Supplemental 509 Supplemental Plans Funded by employee MetLife Plans 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.

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. Fidelity Investments 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 Fidelity Investments. 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) Annuity Plan 006 Salary deferral defined contribution plan

Claims & Admin Frozen PHS and HMHS 401(k) Plan 005 Salary deferral defined contribution plan Spending Accounts Frozen PHS 401(a) Plan 001 Money purchase plan Frozen Prior Employer 401(k) Plan 009 Salary deferral defined contribution plan

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IMPORTANT NOTICE FROM You should compare your current You will receive this notice annually TEXAS HEALTH ABOUT coverage, including which drugs and at other times in the future such YOUR PRESCRIPTION DRUG are covered, with the coverage and as before the next period you can cost of the plans offering Medicare enroll in Medicare prescription drug COVERAGE AND MEDICARE prescription drug coverage in your coverage and if this coverage through Please read this notice carefully and area. Texas Health changes. You also may keep it where you can find it. This request a copy. notice has information about your If you do decide to enroll in a current prescription drug coverage Medicare prescription drug plan and For more information about your options under Medicare with Texas Health and prescription drop your Texas Health prescription prescription drug coverage drug coverage available for people drug coverage, be aware that you and with Medicare. It also explains the your dependents may not be able to More detailed information about options you have under Medicare get this coverage back. Medicare plans that offer prescription drug coverage is in the “Medicare prescription drug coverage and can Please contact us for more & You” handbook. You’ll get a copy help you decide whether or not you information about what happens of the handbook in the mail every want to enroll. At the end of this to your coverage if you enroll in a year from Medicare. You may also notice is information about where you Medicare prescription drug plan. can get help to make decisions about be contacted directly by Medicare your prescription drug coverage. See pages 58 – 60 of this Benefits prescription drug plans. For more Handbook for a description of the information about Medicare 1. Medicare prescription drug prescription drug coverage available prescription drug plans: coverage became available in 2006 under the Total Health Medical Plan. to everyone with Medicare through Visit www.medicare.gov. Medicare prescription drug plans Your Total Health Medical Plan •• Call your State Health Insurance and Medicare Advantage Plans that coverage pays for other medical Assistance Program (see your copy offer prescription drug coverage. All expenses, in addition to prescription of the Medicare and You handbook Medicare prescription drug plans drugs, and you will still be eligible to for their telephone number) for provide at least a standard level of receive all of your current medical personalized help. coverage set by Medicare. Some and prescription drug benefits if •• Call 1-800-MEDICARE plans may also offer more coverage you choose to enroll in a Medicare (1-800-633-4227). for a higher monthly premium. prescription drug plan. TTY users should call 2. Texas Health has determined that You should also know that if you drop 1-877-486-2048. the prescription drug coverage or lose your coverage with Texas For people with limited income and offered by the Total Health Medical Health and don’t enroll in Medicare resources, extra help paying for Plan is, on average for all plan prescription drug coverage after your Medicare prescription drug coverage participants, expected to pay out current coverage ends, you may pay is available. Information about this as much as the standard Medicare more (a penalty) to enroll in Medicare extra help is available from the Social prescription drug coverage will prescription drug coverage later. Security Administration (SSA) online at pay and is considered Creditable If you go 63 days or longer without www.socialsecurity.gov, or call them Coverage. prescription drug coverage that’s at 1-800-772-1213 (TTY 1-800-325- Because your existing coverage is on at least as good as Medicare’s 0778). average at least as good as standard prescription drug coverage, your Remember: Keep this notice. If Medicare prescription drug coverage, monthly premium will go up at least you enroll in one of the new plans you can keep this coverage and not 1% per month for every month that approved by Medicare which offers pay extra if you later decide to enroll in you did not have that coverage. For prescription drug coverage, you may Medicare prescription drug coverage. example, if you go 19 months without coverage, your premium will always be required to provide a copy of this Individuals can enroll in a Medicare be at least 19% higher than what notice when you join to show that prescription drug plan when they first many other people pay. You’ll pay this you are not required to pay a higher become eligible for Medicare and higher premium as long as you have premium amount. Claims & Admin each year from November 15 through Medicare prescription drug coverage. Date: 10/13/2018 December 31. Beneficiaries leaving In addition, you may have to wait until Name of Sender: Texas Health employer/union coverage may be the following November to enroll. eligible for a Special Enrollment Period Contact/Office: Benefits Department to sign up for a Medicare prescription For more information about this notice Address: 612 E. Lamar Blvd. drug plan. or your current prescription drug Suite 400 coverage contact Human Resources Arlington, TX 76011 or call 1-877-MyTHRLink (1-877-698- Phone number: 682-236-7236 4754) prompt 3.

1-877-MyTHRLink (1-877-698-4754) MyTHR.org 209 Administrative Information

TEXAS HEALTH GROUP Understanding Your Health •• Request, in writing, to obtain an HEALTH PLAN NOTICE OF Information accounting of disclosures or a PRIVACY PRACTICES This Notice of Privacy Practices report of who has accessed of your describes the privacy practices of health information, as provided by This notice describes how medical Texas Health’s Group Health Plan the law information about you may be used (GHP) for employees providing for •• Obtain a paper copy of this Notice and disclosed, and how you can get medical, dental, vision, and health care of Privacy Practices on request. access to this information. Please spending account reimbursement. review it carefully. You may exercise these rights as Federal law requires that any health follows: Texas Health contracts with third party information the GHP maintains that administrators (TPAs) to manage the identifies participants remain private. •• The majority of information administration of its medical, dental, Specifically, this notice describes regarding the processing of health vision, and health care spending your rights concerning your health claims is maintained by third account plans. In 2019, the medical information, the responsibilities party administrators, contracted TPAs are Texas Health Aetna and of the GHP regarding your health by the GHP to perform claims UnitedHealthcare. The dental TPA is information, how the GHP may use administration, payment, and Aetna, the vision TPA is Superior Vision or disclose your health information, coverage verification. As a result, and the health care spending account and whom you may contact regarding you should direct your requests TPA is PayFlex. the GHP’s privacy policies. The regarding this information to the GHP will not use or disclosure your third party administrators listed in Demographic information about you health information without written the Important Contacts (inside back and your family members (such as authorization, except as described in cover) of this Employee Benefits name, address, dependent names, this Notice. Use or disclosure pursuant Handbook. date of birth and coverage levels) is to this Notice may include electronic •• All other requests may be directed provided to the appropriate TPA each transfer of your health information. to the Privacy Contact listed on this pay period so their files contain the notice. most current information. To protect Your Health Information Rights your privacy even more, Texas Health If you are a participant in Texas Texas Health’s Responsibilities may now require you to complete an Health’s medical, dental, vision, or The GHP has certain responsibilities Authorization form when you need health care spending account plan, regarding your health information, assistance with a specific claim; to you have the right to: including the requirement to: help you with an issue or in order to better administer other Texas Health •• Request, in writing, a restriction •• Maintain the privacy of your health benefit plans as described below. The on certain uses and disclosures of information. following information describes how your health information. However, •• Provide you with this notice that medical information about participants agreement with the request is not describes the GHP’s legal duties may be used and disclosed and how required by law, such as when it is and privacy practices regarding the you can access this information. determined that compliance with information it maintains about you. the restriction cannot be guaranteed •• Abide by the terms of the notice •• Request, by written authorization, currently in effect. to inspect or obtain a copy of your health information as provided by The GHP reserves the right to change the law its information privacy policies and •• Request, in writing, that your practices and to make the changes health information be amended, applicable to any health information as provided by the law, if you feel that it maintains. If changes are made, the health information about you the revised Notice of Privacy Practices is incorrect or incomplete. You will will be made available on the Benefits be notified if the request cannot be website (BeHealthyTHR.org) and granted. will be supplied when requested by Claims & Admin

Spending Accounts •• Request that your health participants. information be communicated with you in a specific way or at a specific location. Reasonable requests will be accommodated.

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Use and Disclosure of Health ––Disclose your medical •• To health oversight agencies, if Information Without Authorization information to a health care authorized by law, to monitor the Certain use and disclosure of your provider or health plan that is health care system, government health information is necessary and involved with your health care, as benefit programs, or compliance permitted by law to treat you, process needed for that person’s quality- with civil rights laws payments for your treatment, and related health care operations •• To organ procurement support the operations of the GHP ––Provide some services through organizations for tissue donation and other involved entities. The contracts with third party and transplant following categories describe ways business associates. An example •• For research purposes, when the that the GHP may use or disclose is a TPA who performs claims research has been approved by an your information. It provides some administration, payment, and institutional review board that has representative examples. All of the coverage verification. To protect reviewed the research proposal and ways your health information is used your health information, the established guidelines to provide or disclosed should fall within one of GHP requires these business for the privacy of your health these categories: associates to appropriately information; or the disclosure is of protect your information. a limited data set, where personal •• Treatment—your health information identifiers have been removed may be disclosed to a health Disclosures Requiring Verbal •• To coroners and funeral directors care provider for your medical Agreement for identification, determining the treatment. Unless you give notice of an cause of death, or performing their •• Payment—your health information objection, and in accordance duties as authorized by law may be used or disclosed to with your agreement, your health •• To avoid a serious threat to the determine premiums under the information about your location or health or safety of a person or the GHP, establish whether the GHP condition may be used or disclosed public is responsible for payment of your to a family member or other person health care, and make payments who is responsible for your care or •• For specific government functions, for your health care. For example, who helps you pay for your care. Your such as protection of the President before paying a doctor’s bill, your health information may be disclosed of the United States medical information may be used to your relative, friend, or other •• For workers’ compensation to determine whether the terms of person you identify, if the information purposes the GHP cover the medical care you relates to that person’s involvement •• To military command authorities as received. Your medical information with your health care or payment for required for members of the armed may also be disclosed to a health your health care. You will be given forces care provider or other person as an opportunity to agree or object •• To authorized federal officials for needed for that person’s payment to these disclosures, except as due national security and intelligence activities. to your incapacity or in emergency activities, as authorized by law •• Health Care Operations—health circumstances. •• To correctional institutions or law care operations are activities that enforcement officials concerning Disclosures Required by Law federal law considers important to or Otherwise Allowed Without the health information of inmates, the GHP’s successful operation. Authorization or Notification as authorized by law. Here are some examples. The GHP The following disclosures of health may: Disclosures to the Plan Sponsor information may be made without ––Use your medical information The TPA, on behalf of the GHP, may your written authorization or verbal to evaluate the performance of disclose your health information to agreement: participating doctors under the Texas Health as the Plan Sponsor if GHP •• When a disclosure is required by the disclosure is permitted by the ––Disclose your medical federal, state or local law, judicial plan document or by law. Also, the information to an auditor who or administrative proceedings, or TPA may disclose summary medical will make sure that the GHP is for law enforcement (for example information, from which information

following applicable laws when responding to court orders) that identifies you has been removed, Claims & Admin ––Contact you to give you •• To persons authorized by law to so Texas Health may change or information about treatment receive public health information, terminate the GHP or obtain new alternatives or other health- including reports of disease, injury, premium bids. The TPA may disclose related benefits and services that birth, death, child abuse or neglect, to Texas Health whether you are may interest you food problems, or product defects participating or enrolled in a benefit option offered by the GHP.

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Breach Notification Privacy Complaints If you or your dependents are NOT In certain instances, you have the right You have the right to file a complaint currently enrolled in Medicaid or to be notified in the event that the if you believe your privacy rights have CHIP, and you think you or any of GHP, or one of its business associates, been violated. This complaint may be your dependents might be eligible discloses an inappropriate use or addressed to the Privacy Contact listed for either of these programs, contact disclosure of your health information. in this notice, or to the Secretary of your State Medicaid or CHIP office Notice of any such use or disclosure the Department of Health and Human or dial 1-877-KIDS NOW or www. will be made as required by state and Services. There will be no retaliation insurekidsnow.gov to find out how to federal law. for registering a complaint. apply. If you qualify, ask your state if it has a program that might help you Required Uses and Disclosures Privacy Contact pay the premiums for an employer- Under the law, the GHP must make Address any questions about this sponsored plan. disclosures when required by the notice or how to exercise your If you or your dependents are Secretary of the Department of Health privacy rights to the Texas Health eligible for premium assistance and Human Services to investigate or Benefits office at 1-866-35-HIPAA under Medicaid or CHIP, as well as determine Texas Health’s compliance (1-866-354-4722). eligible under your employer plan, with federal privacy law. Effective Date your employer must allow you to enroll in your employer plan if you Uses and Disclosures Requiring April 14, 2003 Written Authorization aren’t already enrolled. This is called Updated January 2014 a “special enrollment” opportunity, With your authorization, your and you must request coverage personal health information may PREMIUM ASSISTANCE within 60 days of being determined be disclosed to Texas Health, the UNDER MEDICAID AND eligible for premium assistance. If Group Health Plan Sponsor, and you have questions about enrolling used by Texas Health in connection THE CHILDREN’S HEALTH in your employer plan, contact the with other benefit plans in the Texas INSURANCE PROGRAM (CHIP) Department of Labor at www.askebsa. Health system for the purpose If you or your children are eligible dol.gov or call 1-866-444-EBSA of managing those plans and for Medicaid or CHIP and you’re (3272). determining their effectiveness. For eligible for health coverage from your example, to evaluate the design employer, the state of Texas may You may be eligible for assistance and operation of the medical plan have a premium assistance program paying your employer health plan and other benefit plans/programs; that can help pay for coverage using premiums. Contact your State for to determine whether the disability funds from their Medicaid or CHIP more information on eligibility. program is being administered programs. correctly; to determine whether Website: http://chipmedicaid.org If you or your children aren’t eligible the leave programs are being used Phone: 1-877-541-7905 appropriately; to review and evaluate for Medicaid or CHIP, you won’t be the quality of the service provided eligible for these premium assistance For more information on special by vendors for the various programs; programs but you may be able to enrollment rights, contact either: and to determine the effectiveness buy individual insurance coverage U.S. Department of Labor of the disease management program through the Health Insurance Employee Benefits Security and the wellness programs. Marketplace. For more information, visit www.healthcare.gov. Administration Any other uses or disclosures of your www.dol.gov/ebsa health information not addressed If you or your dependents are already 1-866-444-EBSA (3272) in this notice or otherwise required enrolled in Medicaid or CHIP, contact U.S. Department of Health and by law will be made only with your your State Medicaid or CHIP office Human Services written authorization. You may to find out if premium assistance is Centers for Medicare & Medicaid revoke such authorization at any available. Services time. Specific examples of uses or

Claims & Admin www.cms.hhs.gov disclosures requiring authorization Spending Accounts 1-877-267-2323, Menu Option 4, include: use of psychotherapy notes, Ext. 61565 marketing activities, and some types of sale of your health information.

Your genetic information cannot be used or disclosed for underwriting purposes except for the long term care policy.

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NOTICE REGARDING The information from your health In addition, all medical information WELLNESS PROGRAM assessment and the results from your obtained through the wellness biometric screening will be used to program will be maintained separate Be Healthy is a voluntary wellness provide you with information to help from your personnel records, program available to benefits- you understand your current health information stored electronically will eligible employees. The program is and potential risks, and may also be be encrypted, and no information administered according to federal used to offer you services through you provide as part of the wellness rules permitting employer-sponsored the wellness program. You also are program will be used in making any wellness programs that seek to encouraged to share your results or employment decision. Appropriate improve employee health or prevent concerns with your own doctor. precautions will be taken to avoid any disease, including the Americans with data breach, and in the event a data Disabilities Act of 1990, the Genetic Protections from Disclosure of breach occurs involving information Medical Information Information Nondiscrimination Act you provide in connection with the of 2008, and the Health Insurance We are required by law to maintain wellness program, we will notify you Portability and Accountability Act, the privacy and security of your immediately. as applicable, among others. If personally identifiable health you choose to participate in the Be information. Although the wellness You may not be discriminated against Healthy program, you will be asked program and Texas Health may use in employment because of the to complete a voluntary health aggregate information it collects to medical information you provide as survey assessment that asks a series design a program based on identified part of participating in the wellness of questions about your health- health risks in the workplace, Be program, nor may you be subjected related activities and behaviors and Healthy will never disclose any of to retaliation if you choose not to whether you have or had certain your personal information either participate. medical conditions (e.g., cancer, publicly or to the employer, except If you have questions or concerns diabetes, or heart disease). You will as necessary to respond to a regarding this notice, or about also be asked to complete a biometric request from you for a reasonable protections against discrimination screening, which will include a blood accommodation needed to and retaliation, please contact the test in regard to blood glucose participate in the wellness program, Texas Health Benefits department at and LDL cholesterol. You are not or as expressly permitted by law. 1-877-MyTHRLink (877-698-4754), required to complete the health Medical information that personally prompt 9. survey assessment or to participate identifies you that is provided in in the blood test or other medical connection with the wellness examinations. program will not be provided to your supervisors or managers and may However, employees who choose to never be used to make decisions participate in the Be Healthy program regarding your employment. will receive an incentive of $75 for completion of the health assessment Your health information will not survey and up to $520 in premiums be sold, exchanged, transferred, credits for completion of the or otherwise disclosed except to biometric screening (or completion the extent permitted by law to of a reasonable alternative). Although carry out specific activities related you are not required to complete to the wellness program, and you the health assessment or participate will not be asked or required to in the biometric screening, only waive the confidentiality of your employees who do so will receive the health information as a condition of incentive. participating in the wellness program or receiving an incentive. Anyone If you are unable to participate in who receives your information for any of the health-related activities or purposes of providing you services

achieve any of the health outcomes Claims & Admin as part of the wellness program will required to earn an incentive, you abide by the same confidentiality may be entitled to a reasonable requirements. The only individual(s) accommodation or an alternative who will receive your personally standard. You may request a identifiable health information include reasonable accommodation or an doctors, nurses, Employee Health, alternative standard by contacting the applicable and need-to-know third- Texas Health Benefits department at party vendors, and health coaches 1-877-MyTHRLink (877-698-4754), in order to provide you with services prompt 9. under the wellness program.

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DISCRIMINATION IS AGAINST You can also file a civil rights THE LAW complaint with the U.S. Department of Health and Human Services, Office Texas Health Resources complies with for Civil Rights, electronically through applicable Federal civil rights laws and the Office for Civil Rights Complaint does not discriminate on the basis Portal, available at https://ocrportal. of race, color, national origin, age, hhs.gov/ocr/portal/lobby.jsf, or by disability, or sex. Texas Health does mail or phone at: not exclude people or treat them differently because of race, color, U.S. Department of Health and national origin, age, disability, or sex. Human Services 200 Independence Avenue Texas Health: SW Room 509F, HHH Building •• Provides free aids and services Washington, D.C. 20201 to people with disabilities to 1-800-368-1019, 800-537-7697 communicate effectively with us, (TDD) such as: Complaint forms are available at ––Qualified sign language hhs.gov/ocr/office/file/index.html. interpreters ––Written information in other formats (large print, audio, accessible electronic formats, other formats) •• Provides free language services to people whose primary language is not English, such as: ––Qualified interpreters ––Information written in other languages

If you need these services, contact Jeanette Oliveros.

If you believe that Texas Health has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Jeanette Oliveros Civil Rights Coordinator 612 E. Lamar Blvd. Suite 400 Arlington TX 76011 682-236-7555 [email protected]

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Jeanette Oliveros,

Claims & Admin Civil Rights Coordinator, is available to

Spending Accounts help you.

214 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Resources Resources Glossary...... 216 2019 Cost of Coverage...... 223 Important Contacts...... 228

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The following terms are important COBRA: Consolidated Omnibus Concurrent Care Claims: If an for understanding your benefits. Budget Reconciliation Act (COBRA) on-going course of treatment gives workers and their families who was previously approved for a Active employee: An employee that lose their health benefits the right specific period of time or number is not in an unpaid or terminated to choose to continue group health of treatments, and your request to status in PeopleSoft. benefits provided by their group extend the treatment is an Urgent Assignment of benefits: You may health plan for a limited period of Care request for Benefits as defined authorize the claims processor to time under certain circumstances. above, your request will be decided directly reimburse your medical Examples include voluntary or within 24 hours, provided your service provider for your eligible involuntary job loss, reduction in the request is made at least 24 hours prior expenses by requesting that hours worked, transition between to the end of the approved treatment. the provider accept assignment jobs, death, divorce, and other life The claims administrator will make a of benefits. When you request events. determination on your request for the assignment of benefits, you avoid extended treatment within 24 hours Coinsurance: The portion of an from receipt of your request. paying the full cost of the medical eligible expense you are required service up front, filing a claim, and to pay. The medical plan pays the If your request for extended treatment waiting for reimbursement. Your remaining percentage. For example, is not made at least 24 hours prior to medical service provider generally after you satisfy your deductible the end of the approved treatment, files your medical claim for you if he under the Texas Health Choice 500 the request will be treated as an or she accepts assignment. plan, you pay 10% coinsurance for Urgent Care request for Benefits and Autism Spectrum Disorder: A network hospitalization in a Texas decided according to the time frames condition marked by enduring Health Preferred Hospital and the plan described above. If an on-going problems communicating and pays 90%. Your coinsurance is applied course of treatment was previously interacting with others, along with toward your out-of-pocket maximum approved for a specific period of time restricted and repetitive behaviors, for the medical plan. or number of treatments, and you interests or activities. request to extend treatment in a non- Complications of pregnancy: urgent circumstance, your request Base pay: Your current hourly rate For any covered person, the word will be considered a new request and times the number of hours you are “illness” includes “complications of decided according to post-service or classified in the HR/Payroll system pregnancy.” pre-service time frames, whichever to work. Base pay does not include Included are conditions distinct from, applies. shift differentials, bonuses, overtime but caused or affected by pregnancy: earnings, commissions, or any other Convalescent or skilled nursing compensation. •• Acute nephritis or nephrosis facility: An institution operated and •• Cardiac decompensation or missed licensed by the state as a skilled Birthing center: A facility staffed abortion nursing facility, extended care facility by physicians which is licensed as a •• Similar conditions as severe as or convalescent nursing home that birthing center in its jurisdiction to these. meets all of the following conditions: provide prenatal, birth, postpartum, newborn, and gynecologic services to Also included are complications of •• Licensed to provide and is pregnant women. the pregnancy itself: providing inpatient care for patients recovering from an injury Cellular Therapy: Administration of •• A non-elective Cesarean delivery or illness, professional nursing living whole cells into a patient for the •• An ectopic pregnancy services rendered by a registered treatment of disease. •• Spontaneous termination when a graduate nurse (R.N.), licensed practical nurse (L.P.N.), or licensed Claims administrator: The third party live birth is not possible. vocational nurse (L.V.N.) under the or parties with whom Texas Health direction of a registered graduate has contracted to process the claims nurse for medical, dental, and prescription •• Licensed to provide and is providing drug benefits under this plan. physical restoration services to help Close relative: Your spouse, patients reach a degree of body mother, father, sister, brother, child, functioning to permit self-care in grandparent, or in-laws. 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 recognized professional standards registered graduate nurse illness of care including, but not limited •• Provides 24-hour nursing services •• The most appropriate supply or to, national consensus statements, by licensed nurses, under the level of service that can be provided nationally recognized clinical direction of a full-time registered on a cost-effective basis (including, guidelines, and national specialty graduate nurse but not limited to, inpatient vs. society guidelines. outpatient care, electric vs. manual •• Maintains a complete medical The claims administrator wheelchair, surgical vs. medical or record on each patient maintains clinical protocols that other types of care) •• Is approved and licensed by describe the scientific evidence, Medicare •• Performed in the least costly setting prevailing medical standards and •• Is not a place (other than where the services can be solely clinical guidelines supporting its incidentally) for the elderly, a place and appropriately provided determinations regarding specific for rest, drug addicts, alcoholics, •• Not provided for the convenience services. You can access these custodial or educational care, of the covered person, physician, clinical protocols (as revised from care of mental disorders or of the facility or any other person time to time) on TexasHealthAetna. mentally retarded. •• Under generally accepted medical com or MyUHC.com or by calling standards, the service or treatment the number on the back of your ID This term also applies to expenses cannot be omitted without card. This information is available incurred in an institution referring adversely affecting the patient’s to physicians and other health care to itself as a skilled nursing facility, condition or the quality of medical professionals on TexasHealthAetna. extended care facility, convalescent care rendered. com and UnitedHealthcareOnline. nursing home, or any similar name. com. In determining whether new The fact that the patient’s physician technologies, procedures, and Copay: This is the specific dollar prescribes services or supplies does treatments are covered, the plan will amount you pay for many covered not automatically mean they are make decisions that are consistent service providers. For example, you covered health services. with prevailing medical research, pay $30 for an office visit to your based on well-conducted randomized primary physician or family doctor. For the health service to be covered, trials or cohort studies. Medical copays do not apply toward it must be provided: your deductible or out-of-pocket •• While the plan is in effect Covered person: A covered maximum. This is the portion of the •• Before any individual termination employee, a covered dependent, charge collected when the service or conditions take effect, as explained an alternate recipient receiving supply is provided and before the plan in this Handbook benefits under a Qualified Medical pays benefits. Child Support Order (QMCSO), or •• To a person who is covered by this a participating COBRA beneficiary Cosmetic procedure: A procedure plan and meets all of the plan’s meeting the eligibility requirements performed solely for the improvement eligibility requirements. for coverage as specified in this plan, of your appearance rather than for In addition, to be a covered health and who is properly enrolled in the the improvement or restoration of service, it must be consistent with plan. bodily function. A cosmetic procedure nationally recognized scientific includes any expense that does not Custodial care: Care designed evidence, and prevailing medical qualify as a medical expense that is primarily to assist in the activities of standards and clinical guidelines as deductible under Section 213(d) of the daily living, such as bathing, dressing, described below. Code. feeding, preparation of special diets, “Scientific evidence” means the assistance in walking or in getting in Covered health services: Covered results of controlled clinical trials and out of bed, and supervision over health services must be ordered by or other studies published in peer- medication which can normally be a physician and determined by the reviewed medical literature generally self-administered. claims administrator to meet all of the recognized by the relevant medical following conditions: Deductible: The amount of eligible specialty community. expenses a person or family must •• Provided to prevent, diagnose, incur and pay during the plan year or treat a sickness, injury, mental before a plan will begin reimbursing illness, or substance use disorder, eligible expenses. The plan or any of their symptoms administrator has the right to allocate •• Not excluded by the plan and the deductible and benefits among is not considered experimental, covered family members. investigational, or unproven Resources

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Definitive Drug Test: Test to identify Emergency: A medical condition Exceptions: manifesting itself by acute symptoms specific medications, illicit substances •• Clinical trials for which benefits are of sufficient severity (including severe and metabolites and is qualitative or available. quantitative to identify possible use or pain) so that a prudent layperson, •• If you are not a participant in a non-use of a drug. who possesses an average knowledge qualifying clinical trial and have a of health and medicine, could sickness or condition that is likely to Dispense as written (DAW): This reasonably expect the absence of cause death within one year of the is when your doctor prescribes a immediate medical attention to result request for treatment, the claims preferred or non-preferred drug and in any of the following: specifies that the pharmacy may not administrator and Texas Health substitute a generic drug of the same •• Placing the health of the covered Resources may, at their discretion, formula if one is available. person (or, with respect to a consider an otherwise experimental pregnant woman, the health of or investigational service to be Dispense as written penalty: A the woman or her unborn child) in a covered health service for that charge you pay for a prescription, in serious jeopardy. sickness or condition. Prior to addition to the preferred or non- •• Serious impairment to bodily such consideration, the claims preferred copay. The amount of functions. administrator and Texas Health this penalty is the difference in cost •• Serious dysfunction of any bodily Resources must determine that, between the preferred or non- organ or part. although unproven, the service has preferred and generic drug. significant potential as an effective EOB: See Explanation of benefits. treatment for that sickness or Durable medical equipment (DME): condition. Equipment that is ordered or provided Experimental or investigational by a physician for outpatient use, for services: Medical, surgical, diagnostic, Explanation of benefits (EOB): A medical purposes, is not consumable psychiatric, mental health, substance- statement provided by the claims or disposable, and not of use to a related and addictive disorders administrator that shows how a person in the absence of an illness or or other health care services, service was covered by the plan, how injury. technologies, supplies, treatments, much is being reimbursed, and what procedures, drug therapies, portion (if any) is not covered. Eligible Expenses: For covered medications or devices that, at the health services incurred while the time the claims administrator makes a Foster child: A child who is placed plan is in effect. Eligible expenses determination regarding coverage in a with you by an authorized placement are determined in accordance particular case, are determined to be agency or by a judgment, decree or with the claim’s administrator’s any of the following: other order of any court of competent reimbursement policy guidelines. The jurisdiction. claims administrator develops the •• Not approved by the U.S. Food reimbursement policy guidelines, in and Drug Administration (FDA) Gene Therapy: Therapeutic delivery the claims administrator’s discretion, to be lawfully marketed for the of nucleic acid (DNA or RNA) into following evaluation and validation proposed use and not identified in a patient's cells as a drug to treat a of all provider billings in accordance the American Hospital Formulary disease. with one or more of the following Service or the United States Generic drug: Drugs or substances methodologies: Pharmacopoeia Dispensing that are not trademarked, are legally Information as appropriate for the •• As indicated in the most recent substituted for trademark drugs or proposed use. edition of the Current Procedural substances, and must be prescribed Terminology (CPT), a publication of •• Subject to review and approval by and can only be obtained with the American Medical Association, by any institutional review board a prescription from a qualified and/or the Centers for Medicare for the proposed use (Devices prescriber as a legal substitute for and Medicaid Services (CMS); which are FDA approved under trademarked drugs. the Humanitarian Use Device •• As reported by generally recognized exemption are not considered to be Home health care agency: A public professionals or publications; experimental or investigational.) or private agency or organization •• As used for Medicare; or •• The subject of an ongoing clinical that specializes in providing medical •• As determined by medical staff trial that meets the definition of care and treatment in the patient’s and outside medical consultants a Phase I, II, or III Clinical Trial home and meets all of the following pursuant to other appropriate set forth in the FDA regulations, conditions: source or determination that the regardless of whether the trial is claims administrator accepts. actually subject to FDA oversight. Resources

218 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Glossary

•• It is primarily engaged in and Hospice care does not include: Injury: A condition caused by licensed, if such licensing is accidental means which results in required, by the appropriate •• Services provided by a person who damage to the covered person’s licensing authority to provide is a member of your family or your body from an external force or self- skilled nursing services and other dependent’s family or who normally inflicted. therapeutic services. lives in your home or your covered dependent’s home In-network: A provider who has •• It has policies established by a contracted to be part of the network. professional group associated with •• Any period when you are not under the continuing care of a physician the agency or organization. This Inpatient: Medical treatment or professional group must include •• Any curative or life-prolonging services provided at a hospital when at least one registered graduate procedures a patient is admitted and confined nurse (R.N.) to govern the services •• Any other benefits that are payable for treatment, for which a room and provided and it must provide for hospice care expenses under board charge is incurred. for full-time supervision of such the policy services by a physician or registered •• Services or supplies that are Institute of higher education: An graduate nurse. primarily to aid you or your covered institution accredited in the current publication of Accredited Institutions •• It maintains a complete medical dependent in daily living of Higher Education. record on each individual. •• More than three bereavement •• It has a full-time administrator. counseling sessions. Intensive Behavioral Therapy (IBT): Outpatient behavioral/educational Hospital: An institution primarily Home health care does not include: services that aim to reinforce adaptive engaged in inpatient medical care or behaviors, reduce maladaptive •• Home health care visits in excess treatment at the patient’s expense and behaviors, and improve the mastery of any applicable home health care that is: agency limit listed in the Medical of functional age-appropriate skills Plan Comparison tables on pages •• Licensed by the applicable state in people with Autism Spectrum 22 – 30. Each visit by an employee authority Disorders. Examples include Applied of a home health care agency will •• Accredited as a hospital by The Behavior Analysis (ABA), The Denver be considered one home health Joint Commission, Medicare or its Model, and Relationship Development care visit, and each four hours of designated reviewing agency and Intervention (RDI). the applicable state authority home health aide services will be Intensive outpatient treatment: A considered one home health care •• Supervised by a staff of physicians, structured outpatient mental health visit. has 24-hour nursing services by or substance-related and addictive •• Care or treatment not stated in the registered professional nurses, disorders treatment program that may home health care plan provides diagnostic and therapeutic be free-standing or hospital-based •• Services provided by a person who facilities for surgical and medical and provides services for at least is a member of your family or your diagnosis and treatment, and three hours per day, two or more days dependent’s family or who normally operates continuously; or, if per week. lives in your home or your covered primarily a facility for treatment dependent’s home of mental or nervous conditions, Maintenance medications: drug addiction or alcoholism, it Medications that your physician •• A period when you are not under has a contract with a hospital to prescribes for chronic or long-term the continuing care of a physician. perform surgical procedures when conditions (such as diabetes, high Hospice care: A health care program necessary blood pressure, heart conditions, that provides coordinated services •• Not, other than incidentally, a place allergies, thyroid conditions, etc.). If at home, in outpatient facilities or for rest or the aged, a nursing you are not sure if the prescription is institutional settings for terminally ill home, or a hotel. for a chronic condition, please check patients. A hospice must: with your pharmacist. Hospitalization or hospital stay: See •• Have an interdisciplinary group of inpatient. Medically necessary: health care providers including at least one services that are all of the following physician and one R.N. Illness: Physical illness, disease or as determined by the claims pregnancy. Includes mental illness, •• Maintain central clinical records on administrator or its designee, within or substance-related and addictive all patients the claims administrator’s sole disorders, regardless of the cause •• Meet the standards of the National discretion. or origin of the mental illness, or Hospice Organization (NHO) substance-related and addictive •• in accordance with Generally •• Meet applicable state licensing disorder. Accepted Standards of Medical requirements. Practice; Resources

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•• clinically appropriate, in terms of The claims administrator develops National Advantage Program (NAP): type, frequency, extent, service and maintains clinical policies that A program in which providers can site and duration, and considered describe the Generally Accepted choose to participate. Texas Health effective for your sickness, injury, Standards of Medical Practice Aetna contracts with third-party mental illness, substance-related scientific evidence, prevailing medical vendor networks of health care and addictive disorders disease or standards and clinical guidelines professionals and facilities. When its symptoms; supporting its determinations members visit providers in these •• not mainly for your convenience or regarding specific services. These vendor networks, they can get that of your doctor or other health clinical policies (as developed by the negotiated rates for certain out-of- care provider; and claims administrator and revised from network services. time to time), are available to covered •• not more costly than an alternative Not all non-participating providers persons on TexasHealthAetna.com, drug, service(s), service site, have a NAP agreement. Texas Health MyUHC.com or by calling the number or supply that is at least as Aetna's goal is to help a member on your ID card, and to physicians and likely to produce equivalent become whole when possible. There other health care professionals on therapeutic or diagnostic results are other ways that Texas Health Unitedhealthcareonline.com. as to the diagnosis or treatment Aetna attempts to negotiate with of your sickness, injury, disease or Mental health disorder/condition/ out of network providers when a symptoms. illness: Treatment for mental health contracted rate is not available i.e. Generally Accepted Standards of disorder/condition/illness evidenced Facility Claim Review(FCR). by symptoms of abnormal behavior, Medical Practice are standards that Network: A group of physicians, behavioral disturbances, nervous are based on credible scientific hospitals, pharmacies, and other conditions, mood swings, anorexia evidence published in peer- medical service providers who have nervosa or bulimia nervosa or other reviewed medical literature generally agreed to provide discounted fees for aberrant behavior regardless of recognized by the relevant medical their services. community, relying primarily on whether the origin of the symptoms is controlled clinical trials, or, if not traceable to an organic abnormality, Non-preferred drug: Brand name available, observational studies cause or origin, or is traceable to an prescription drugs that are covered from more than one institution that environmental cause or experience, under the Texas Health Medical Plan suggest a causal relationship between excluding treatment for alcoholism, at a higher copay than generic drugs the service or treatment and health drug and/or substance use disorder or preferred drugs. outcomes. dependency or addiction. Nurse: An individual who has received If no credible scientific evidence is Mental health/substance specialized nursing training and is available, then standards that are use disorder administrator: a authorized to use one of the following based on physician specialty society representative from the claims professional designations: recommendations or professional administrator that provides •• Registered nurse (R.N.) standards of care may be considered. coordination of care and referrals to The claims administrator reserves providers for mental health services •• Licensed practical nurse (L.P.N.) the right to consult expert opinion benefits and substance use disorder •• Licensed vocational nurse (L.V.N.). in determining whether health care services. Nursing services are covered only services are medically necessary. The Midwife: A registered nurse (R.N.) decision to apply physician specialty when they meet the definition of a who is certified after receiving covered health service (as defined on society recommendations, the choice specialized training in the field of of expert and the determination page 217) and the nurse is licensed by midwifery who performs services in the Texas State Board of Nursing, and of when to use any such expert the home or birthing center. If the opinion, shall be within the claims if the nurse is not living with you or state in which the midwife performs related to you or your spouse. administrator’s sole discretion. services licenses midwives, the midwife must be licensed by the Out-of-network: A provider who appropriate state licensing agent. has not contracted to be part of the network.

Out-of-pocket maximum: The highest or total amount of costs in a year that you will pay towards covered healthcare services. Resources

220 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Glossary

Outpatient: Medical treatment Prescription drugs: Drugs and Rehabilitation facility: A legally or services provided at a hospital medicines that must be accompanied operating institution or distinct or clinic for a patient who is not by a physician’s written order part of an institution which has a admitted to the hospital for an and dispensed only by a licensed transfer agreement with one or more overnight stay. pharmacist for the treatment of hospitals and which is primarily an illness, injury, or pregnancy. engaged in providing comprehensive Over-the-counter: Drugs, products, Prescription drugs include injectable multi-disciplinary physical restorative and supplies that do not require a insulin, oral contraceptives, and services, post-acute hospital, and prescription by federal law. prenatal vitamins. rehabilitative inpatient care, and is duly licensed by the appropriate Part-time benefits-ineligible Presumptive Drug Test: Test to employee: An employee of Texas governmental agency to provide such determine the presence or absence services. Health who is classified in the HR/ of drugs or a drug class in which the Payroll system as part-time benefits- results are indicated as negative or It does not include institutions ineligible and classified to work less positive result. which provide only minimal care, than 24 hours per week. custodial care, ambulatory or part- Primary physician: A network physician time care services, or an institution Pharmaceutical product: U.S. Food who specializes in general practice, which primarily provides treatment and Drug Administration (FDA)- obstetrics/gynecology, family practice, approved prescription medications or internal medicine, or pediatrics. You of mental disorders, chemical products administered in connection are not required to select a primary dependency, or tuberculosis, except with a Covered Health Service by a physician or to get a referral from if such facility is licensed, certified, Physician. your primary physician before seeing or approved as a rehabilitation facility for the treatment of medical Physician: A legally licensed medical a network specialist. However, the conditions, drug addiction or or dental doctor or surgeon, office visit copay is lower for primary chiropractor, osteopath, podiatrist, physicians under all the Total Health alcoholism in its jurisdiction or is certified consulting psychologist, Medical Plan options. accredited by The Joint Commission, licensed professional counselor or Medicare, or Commission on the Private duty nursing: Continuous Accreditation of Rehabilitation psychiatrist, permitted to perform skilled care or intermittent care Facilities. services within scope of his or her by a Registered Nurse or Licensed license. Practical Nurse while the patient is Room and board: All charges, Pre-admission testing: The actual not confined to an institution. by whatever name called, which are made by a hospital, hospice, charges for covered health services PRN employee: An employee of Texas rehabilitation facility, or convalescent made by a hospital for services Health Resources who is classified in nursing facility or other covered rendered on an outpatient basis the HR/Payroll system as benefits- facilities as a condition of occupancy. before a scheduled inpatient ineligible and does not have a set Such charges do not include the confinement at the same facility. number of hours per week. professional services of physicians, Preferred drug: These are brand Provider: The individual or institution intensive nursing care, or any other name medications that have which provides medical services or rehabilitative therapy, occupational been chosen based on their high supplies. Providers include physicians, therapy, physical therapy, or speech level of clinical efficacy and cost hospitals, pharmacies, surgical or hearing therapy, by whatever name effectiveness. The preferred drug list facilities, dentists, and other covered called. is regularly reviewed and updated by a medical or dental service and supply Routine newborn care: Inpatient committee of physicians, pharmacists providers. and other allied health professionals. charges for a well newborn baby for Registered nurse: An individual who nursery room and board and pediatric Pregnancy: The physical state which has received specialized nursing services including circumcision. results in childbirth, life-threatening training and is authorized to use the Semi-private: A class of abortion, or miscarriage, and any designation “R.N.” and who is duly accommodations in a hospital or medical complications arising out of, licensed by the state or regulatory skilled nursing facility or other facility or resulting from, such state. agency responsible for such licensing providing services on an inpatient in the state in which the individual basis in which at least two patient performs such nursing services. beds are available per room. Regularly scheduled to work: The hours and full-time equivalent (FTE) that are assigned to the employee in Texas Health’s HR/Payroll system. Resources

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Shared Savings Program: a program in Texas Health Preferred Hospitals: A which UnitedHealthcare may obtain a list of Texas Health hospitals and other discount to a non-Network provider’s select hospitals. It is your responsibility billed charges. This discount is usually to verify whether a hospital is a Texas based on a schedule previously agreed Health Preferred Hospital before you to by the non-network provider. When receive care. Your cost for medical care this happens, you may experience is lower when you use a Texas Health lower out-of-pocket amounts. Plan Preferred Hospital. coinsurance and deductibles would Urgent care: Care that requires still apply to the reduced charge. prompt attention to avoid adverse Sometimes plan provisions or consequences, but does not pose administrative practices conflict with an immediate threat to a person’s the scheduled rate, and a different rate life. Urgent care is usually delivered is determined by UnitedHealthcare. In in a walk-in setting and without an this case the non-Network provider appointment. Urgent care facilities may bill you for the difference between are a location, distinct from a hospital the billed amount and the rate emergency department, an office or a determined by UnitedHealthcare. If this clinic. The purpose is to diagnose and happens you should call the number treat illness or injury for unscheduled, on your ID Card. Shared Savings ambulatory patients seeking immediate Program providers are not network medical attention. providers and are not credentialed by UnitedHealthcare. Urgent care clinic or center: A facility that provides covered health services Skilled nursing facility/extended that are required to prevent serious care facility: An institution that deterioration of your health, and primarily provides skilled, as opposed that are required as a result of an to custodial, nursing service to unforeseen sickness, injury, or the patients, and is approved by The Joint onset of acute or severe symptoms. Commission, the applicable state licensing authority and/or Medicare. Well-baby care: Medical treatment, services, or supplies rendered to a Substance use disorder services: child solely for the purpose of health Covered health services for the maintenance and not for the treatment diagnosis and treatment of alcoholism of an illness of injury. and substance-related and addictive disorders that are listed in the current UTSW entity: William P. Clements Jr. Diagnostic and Statistical Manual of University Hospital and Zale Lipshy the American Psychiatric Association, University Hospital unless those services are specifically excluded. The fact that a disorder is listed in the Diagnostic and Statistical Manual of the American Psychiatric Association does not mean that treatment of the disorder is a covered health service.

Temporomandibular joint syndrome: A condition that is also known as myofascial pain-dysfunction syndrome, a disorder that affects the two joints at either side of the jaw (the temporomandibular joints).

Texas Health entity: Any hospital wholly owned or controlled by Texas Health. Resources

222 1-877-MyTHRLink (1-877-698-4754) MyTHR.org 2019 Cost of Coverage 2019 Cost of Coverage

The tables below and on the following page show your benefit costs per pay period. Premiums will be deducted from 26 pay periods. Following is your cost per pay period for medical coverage. Remember to deduct your wellness credits from the medical costs shown below (see page 74 for more information). Medical Coverage with Low Rx and High Rx (Paid Before Tax)1

Employee Employee Employee + Employee Only + Spouse Child(ren) + Family OPTION NAME YOU Texas YOU Texas YOU Texas YOU Texas Health Health Health Health PAY Pays PAY Pays PAY Pays PAY Pays

Full-Time Employees Who Earn Less Than $25,000

Texas Health Aetna Select 3000/Low Rx $11.48 $275.56 $42.20 $560.59 $24.04 $512.73 $55.41 $797.09

Texas Health Aetna Select 3000/High Rx $12.74 $286.20 $52.22 $575.56 $28.45 $530.57 $74.57 $813.28

Texas Health Aetna Select 1000/Low Rx $23.43 $319.31 $71.86 $647.89 $49.06 $591.87 $93.02 $924.91

Texas Health Aetna Select 1000/High Rx $24.69 $329.95 $81.88 $662.86 $53.47 $609.71 $112.18 $941.10

UHC Choice 500/Low Rx $28.69 $323.51 $123.62 $616.00 $76.36 $582.26 $164.19 $881.84

UHC Choice 500/High Rx $29.95 $334.15 $133.64 $630.97 $80.77 $600.10 $183.35 $898.03

UHC Choice 1000/Low Rx $26.03 $309.73 $79.84 $625.25 $54.51 $573.35 $103.36 $893.83

UHC Choice 1000/High Rx $27.29 $320.37 $89.86 $640.22 $58.92 $591.19 $122.52 $910.02

UHC Choice Plus 1500/Low Rx $45.85 $294.66 $249.17 $465.90 $173.12 $463.63 $328.65 $682.68

UHC Choice Plus 1500/High Rx $47.11 $305.30 $259.19 $480.87 $177.53 $481.47 $347.81 $698.87

Full-Time Employees Who Earn $25,000 - $49,999

Texas Health Aetna Select 3000/Low Rx $14.35 $272.69 $45.96 $556.83 $41.13 $495.64 $71.79 $780.71

Texas Health Aetna Select 3000/High Rx $18.15 $280.79 $60.59 $567.19 $47.55 $511.47 $100.18 $787.67

Texas Health Aetna Select 1000/Low Rx $29.10 $313.64 $93.17 $626.58 $83.38 $557.55 $145.54 $872.39

Texas Health Aetna Select 1000/High Rx $32.90 $321.74 $107.80 $636.94 $89.80 $573.38 $173.93 $879.35

UHC Choice 500/Low Rx $45.72 $306.48 $189.11 $550.51 $164.42 $494.20 $307.00 $739.03

UHC Choice 500/High Rx $49.52 $314.58 $203.74 $560.87 $170.84 $510.03 $335.39 $745.99

UHC Choice 1000/Low Rx $32.33 $303.43 $103.52 $601.57 $92.64 $535.22 $161.71 $835.48

UHC Choice 1000/High Rx $36.13 $311.53 $118.15 $611.93 $99.06 $551.05 $190.10 $842.44

UHC Choice Plus 1500/Low Rx $91.07 $249.44 $363.82 $351.25 $300.09 $336.66 $570.93 $440.40

UHC Choice Plus 1500/High Rx $94.87 $257.54 $378.45 $361.61 $306.51 $352.49 $599.32 $447.36

1 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) MyTHR.org 223 2019 Cost of Coverage

Employee Employee Employee + Employee Only + Spouse Child(ren) + Family OPTION NAME YOU Texas YOU Texas YOU Texas YOU Texas Health Health Health Health PAY Pays PAY Pays PAY Pays PAY Pays

Full-Time Employees Who Earn $50,000 - $74,999

Texas Health Aetna Select 3000/Low Rx $15.79 $271.25 $50.36 $552.43 $45.89 $490.88 $78.02 $774.48

Texas Health Aetna Select 3000/High Rx $20.88 $278.06 $67.28 $560.50 $53.65 $505.37 $111.00 $776.85

Texas Health Aetna Select 1000/Low Rx $29.63 $313.11 $94.52 $625.23 $86.13 $554.80 $146.44 $871.49

Texas Health Aetna Select 1000/High Rx $34.72 $319.92 $111.44 $633.30 $93.89 $569.29 $179.42 $873.86

UHC Choice 500/Low Rx $45.97 $306.23 $195.71 $543.91 $174.76 $483.86 $318.91 $727.12

UHC Choice 500/High Rx $51.06 $313.04 $212.63 $551.98 $182.52 $498.35 $351.89 $729.49

UHC Choice 1000/Low Rx $32.92 $302.84 $105.02 $600.07 $95.70 $532.16 $162.71 $834.48

UHC Choice 1000/High Rx $38.01 $309.65 $121.94 $608.14 $103.46 $546.65 $195.69 $836.85

UHC Choice Plus 1500/Low Rx $93.31 $247.20 $378.35 $336.72 $316.81 $319.94 $594.70 $416.63

UHC Choice Plus 1500/High Rx $98.40 $254.01 $395.27 $344.79 $324.57 $334.43 $627.68 $419.00

Full-Time Employees Who Earn $75,000 - $99,999

Texas Health Aetna Select 3000/Low Rx $16.50 $270.54 $72.33 $530.46 $64.41 $472.36 $149.19 $703.31

Texas Health Aetna Select 3000/High Rx $22.84 $276.10 $96.71 $531.07 $75.22 $483.80 $184.54 $703.31

Texas Health Aetna Select 1000/Low Rx $33.31 $309.43 $127.01 $592.74 $115.65 $525.28 $208.33 $809.60

Texas Health Aetna Select 1000/High Rx $39.65 $314.99 $151.39 $593.35 $126.46 $536.72 $243.68 $809.60

UHC Choice 500/Low Rx $58.94 $293.26 $290.41 $449.21 $240.08 $418.54 $462.66 $583.37

UHC Choice 500/High Rx $65.28 $298.82 $314.79 $449.82 $250.89 $429.98 $498.01 $583.37

UHC Choice 1000/Low Rx $37.01 $298.75 $141.12 $563.97 $128.50 $499.36 $231.48 $765.71

UHC Choice 1000/High Rx $43.35 $304.31 $165.50 $564.58 $139.31 $510.80 $266.83 $765.71

UHC Choice Plus 1500/Low Rx $133.97 $206.54 $572.74 $142.33 $475.47 $161.28 $908.45 $102.88

UHC Choice Plus 1500/High Rx $140.31 $212.10 $597.12 $142.94 $486.28 $172.72 $943.80 $102.88

1 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

224 1-877-MyTHRLink (1-877-698-4754) MyTHR.org 2019 Cost of Coverage

Employee Employee Employee + Employee Only + Spouse Child(ren) + Family OPTION NAME YOU Texas YOU Texas YOU Texas YOU Texas Health Health Health Health PAY Pays PAY Pays PAY Pays PAY Pays

Full-Time Employees Who Earn $100,000 and above

Texas Health Aetna Select 3000/Low Rx $23.00 $264.04 $103.50 $499.29 $92.16 $444.61 $170.77 $681.73

Texas Health Aetna Select 3000/High Rx $30.75 $268.19 $128.49 $499.29 $105.02 $454.00 $206.12 $681.73

Texas Health Aetna Select 1000/Low Rx $38.66 $304.08 $153.32 $566.43 $137.94 $502.99 $249.82 $768.11

Texas Health Aetna Select 1000/High Rx $46.41 $308.23 $178.31 $566.43 $150.80 $512.38 $285.17 $768.11

UHC Choice 500/Low Rx $69.36 $282.84 $345.11 $394.51 $286.13 $372.49 $555.49 $490.54

UHC Choice 500/High Rx $77.11 $286.99 $370.10 $394.51 $298.99 $381.88 $590.84 $490.54

UHC Choice 1000/Low Rx $42.96 $292.80 $170.36 $534.73 $153.27 $474.59 $277.58 $719.61

UHC Choice 1000/High Rx $50.71 $296.95 $195.35 $534.73 $166.13 $483.98 $312.93 $719.61

UHC Choice Plus 1500/Low Rx $159.77 $180.74 $686.87 $28.20 $570.03 $66.72 $1,011.33 $0.00

UHC Choice Plus 1500/High Rx $167.52 $184.89 $711.86 $28.20 $582.89 $76.11 $1,046.68 $0.00

Part-Time Employees1

Texas Health Aetna Select 3000/Low Rx $57.41 $229.63 $132.75 $470.04 $120.94 $415.83 $194.53 $657.97

Texas Health Aetna Select 3000/High Rx $69.31 $229.63 $157.74 $470.04 $139.74 $419.28 $229.88 $657.97

Texas Health Aetna Select 1000/Low Rx $74.52 $268.22 $172.31 $547.44 $156.99 $483.94 $252.52 $765.41

Texas Health Aetna Select 1000/High Rx $86.42 $268.22 $197.30 $547.44 $175.79 $487.39 $287.87 $765.41

UHC Choice 500/Low Rx $170.70 $181.50 $412.23 $327.39 $353.90 $304.72 $580.96 $465.07

UHC Choice 500/High Rx $182.60 $181.50 $437.22 $327.39 $372.70 $308.17 $616.31 $465.07

UHC Choice 1000/Low Rx $82.80 $252.96 $191.46 $513.63 $174.43 $453.43 $280.58 $716.61

UHC Choice 1000/High Rx $94.70 $252.96 $216.45 $513.63 $193.23 $456.88 $315.93 $716.61

UHC Choice Plus 1500/Low Rx $247.52 $92.99 $603.82 $111.25 $507.55 $129.20 $967.92 $43.41

UHC Choice Plus 1500/High Rx $259.42 $92.99 $628.81 $111.25 $526.35 $132.65 $1,003.27 $43.41

1 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) MyTHR.org 225 2019 Cost of Coverage

Dental (Paid Before-Tax) Vision (Paid Before-Tax)

Aetna Managed Aetna PPO Max Aetna PDN Superior Coverage Level Coverage Level (DMO) (Low Option) (High Option) Vision

Employee Only $6.54 $8.73 $21.00 Employee Only $3.68

Employee + Spouse $13.08 $17.46 $41.97 Employee + Spouse $7.93

Employee + Child(ren) $17.50 $23.35 $56.16 Employee + Child(ren) $5.97

Employee + Family $22.20 $29.64 $71.28 Employee + Family $10.87

Additional Life* Spouse Life* Child Life (Paid After-Tax) (Paid After-Tax) (Paid After-Tax)-Tax)

Cost per pay period Cost per pay period Cost per Your Coverage per $1,000 of Your Age* per $1,000 of pay period Age* coverage coverage $0.270 for Under 30 $0.016 Under 30 $0.026 All your children $10,000 of coverage 30 - 34 $0.020 30 - 34 $0.035

35 - 39 $0.028 35 - 39 $0.040 Additional AD&D 40 - 44 $0.036 40 - 44 $0.044 (Paid Before-Tax) 45 - 49 $0.056 45 - 49 $0.066 Cost per pay 50 - 54 $0.087 50 - 54 $0.102 period per Coverage 55 - 59 $0.131 55 - 59 $0.190 $1,000 of coverage 60 - 64 $0.171 60 - 64 $0.291

65 - 69 $0.254 65 - 69 $0.560 Employee Only $0.0055

70 - 74 $0.345 70 - 74 $0.908 Employee + $0.0102 Family 75 - 79 $0.496 75 - 79 $0.908

* Additional and Spouse Life rates are based on the employee’s age as of Jan. 1, 2019.

Cost of Disability Coverage To calculate your premiums for disability, multiply your hourly base rate by the cost of coverage listed in the tables below. For example, if you earn $11 per hour and you are electing STD with a 14-day waiting period, multiply $11 x $0.7643 = $8.41 per paycheck.

If you are regularly scheduled to work less than 80 hours per pay period, multiply $11 x $0.7643 x (hours you are regularly scheduled to work ÷ 80).

STD Additional LTD (Paid After-Tax) (Paid After-Tax)

Waiting Period Rate Multiplier Coverage Rate Multiplier

14 days $0.7643 Additional LTD $0.3008 (“Buy-Up” Plan) 30 days $0.5317 Resources

226 1-877-MyTHRLink (1-877-698-4754) MyTHR.org 2019 Cost of Coverage

Hospital Indemnity (Paid After-Tax) Accident Insurance (Paid After-Tax)

Low High Low High Coverage Coverage Option Option Option Option

Employee Only $5.83 $10.54 Employee Only $3.15 $4.74

Employee + Spouse $11.46 $20.74 Employee + Spouse $5.01 $7.54

Employee + Child(ren) $8.30 $15.02 Employee + Child(ren) $6.29 $9.46

Employee + Family $13.92 $25.22 Employee + Family $8.15 $12.25

Critical Illness Insurance (Paid After-Tax)

Employee Employee Employee + Employee + Your Age Only + Spouse Children Family

$15,000 OF COVERAGE

29 and Under $2.35 $4.78 $2.42 $4.85

30-34 $3.18 $6.44 $3.25 $6.51

35-39 $3.60 $7.27 $3.67 $7.34

40-44 $4.36 $8.79 $4.43 $8.86

45-49 $6.23 $12.53 $6.30 $12.60

50-54 $8.72 $17.52 $8.79 $17.58

55-59 $12.88 $25.82 $12.95 $25.89

60-64 $21.67 $43.41 $21.74 $43.48

65 and Over $47.70 $95.47 $47.77 $95.54

$30,000 OF COVERAGE

29 and Under $3.88 $7.89 $4.02 $8.03

30-34 $5.54 $11.22 $5.68 $11.35

35-39 $6.37 $12.88 $6.51 $13.02

40-44 $7.89 $15.92 $8.03 $16.06

45-49 $11.63 $23.40 $11.77 $23.54

50-54 $16.62 $33.37 $16.75 $33.51

55-59 $24.92 $49.98 $25.06 $50.12

60-64 $42.51 $85.15 $42.65 $85.29

65 and Over $94.71 $189.55 $94.85 $189.69

*Employee and spouse rates are based on employee's age as of Jan. 1. Resources

1-877-MyTHRLink (1-877-698-4754) MyTHR.org 227 Important Contacts Important Contacts

For Information About: Contact: At: Flexible Benefits THR Benefits Support 1-877-MyTHRLink, prompt 9 or email General questions and to request [email protected] forms

Medical Plan Texas Health Aetna 1-877-MyTHRLink, prompt 1 P.O. Box 981106 TexasHealthAetna.com El Paso, TX 79998-1106

UnitedHealthcare Services Inc. 1-877-MyTHRLink, prompt 2 185 Asylum St. 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 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 Aetna.com Lexington, KY 40512-4094

Vision Plan Superior Vision Services 1-877-MyTHRLink, prompt 6, press 4 11101 White Rock Road, Suite 150 Superiorvision.com Rancho Cordova, CA 95670

Life and Accident Insurance Prudential Insurance Company of America 1-877-MyTHRLink, prompt 6, press 8 Life Insurance and Accidental Death & 80 Livingston Avenue Dismemberment Roseland, NJ 07068

Business Travel Accident Life Insurance Company of North America 1-877-MyTHRLink, press 9

Disability The Prudential Insurance Company of 1-844-223-4398 Short Term Disability America Long Term Disability 751 Broad Street Newark, New Jersey 07102 Flexible Spending Accounts PayFlex Systems USA, Inc. 1-877-MyTHRLink, prompt 6, press 6 Health Care Spending Account and Flex Dept. Fax: 855-703-5305 Day Care Spending Account P.O. Box 3039 Omaha, NE 68103-3039 Payflex.com to track expenses Paid Time Off THR Benefits Support 1-877-MyTHRLink, prompt 9

Texas Health Retirement Program Fidelity 1-877-MyTHRLink, prompt 5 NetBenefits.com/thr

Tuition Reimbursement Texas Health Tuition Reimbursement 1-877-MyTHRLink, prompt 6, press 2 or e-mail at 612 E. Lamar Blvd., Suite 400 [email protected] Arlington, TX 76011 Resources

228 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Important Contacts

Flexible Benefits (continued)

For Information About: Contact: At: COBRA Continuation of Coverage PayFlex Systems USA, Inc. 1-800-359-3921 COBRA & Direct Billing Department P.O. Box 2239 Omaha, NE 68103-2239

Governance Committee Texas Health 682-236-7900 612 E. Lamar Blvd, Suite 900 Arlington, TX 76011

Employee Assistance Program (EAP) Texas Health Resources Behavioral Health 1-877-MyTHRLink, prompt 4, press 4

Tobacco Cessation Consumer Wellness Solutions Inc. 1-877-MyTHRLink, prompt 4, press 2

Quitnow.net/texashealthresources

Leave of Absence (LOA) Your IDM representative 1-877-MyTHRLink, prompt 6, press 1 or e-mail at [email protected]

Discount Program Beneplace Beneplace.com/texashealth

Real Appeal Real Appeal THR.realappeal.com

Supplemental Benefits (MetLife) Metropolitan Life Insurance Company 1-866-626-3705 Accident Insurance P.O. Box 80826 mybenefits.metlife.com Hospital Indemnity Insurance Lincoln, NE 68501-0826 Critical Illness Insurance Resources

1-877-MyTHRLink (1-877-698-4754) MyTHR.org 229 Notes Notes Spending Accounts

230 1-877-MyTHRLink (1-877-698-4754) MyTHR.org Notes Notes

1-877-MyTHRLink (1-877-698-4754) MyTHR.org 231 Don't forget, www.BeHealthyTHR.org is your one-stop source for additional information about your benefits.

Visit www.BeHealthyTHR.org for:

•• An electronic copy of your benefits handbook

•• Enrollment information and instructions

•• Claim forms

•• Wellness program information

•• Safety information and more!

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.

Information has been provided by Texas Health Resources. Fidelity Investments is not responsible for its content. GC 061 2/2019 12,300