2016 2017 BENEFITS GUIDE Plan Year 2016 2017

2016 - 2017 BENEFITS GUIDE

Plan Year 2016 - 2017 Open Enrollment Our employee benefits are scheduled to renew October 1, 2016. With the assistance of our consultants at Willis Towers Watson we evaluated our options and made the decision to renew our coverage with Anthem and United Concordia for the 2016 -2017 plan year. Great news, we will continue to offer the same two medical plans that we offer today and there are no changes in the coverages or benefits that these plans provide. However, the out of pocket maximum on the Anthem Open Access POS 20/20% plan will change from calendar year to plan year effective October 1, 2016. We will also continue to offer dental coverage through United Concordia. There are no benefits for the upcoming plan year. Please review the benefit summaries on the following pages to refresh yourself on the benefits that are available to you and your family. Page 1

Medical Coverage Poquoson City Public Schools offers a care services and coverage for choice of 2 medical plan options for you prescription drugs. to choose the plan that best meets your needs – and those of your family. Your Medical plan is with: Anthem which Each plan includes comprehensive health care benefits, including free Preventive offers both in and out-of-network benefits, along with 100% coverage of all preventive care services. AD = After Deductible This is a summary of coverage; please refer to your summary plan description for the full scope of coverage. Page 2

Employee Monthly Contributions – Medical POS 20/20/ $0 Deductible Monthly Premium Employee Rate Employee Only $631. 33 $4. 52 Employee + 1 Dependent $1, 167. 95 $253. 47 Employee + Children $1, 326. 04 $210. 64 Family $1, 837. 17 $468. 36 HSA $2, 800 Deductible Monthly Premium Employee Rate Employee Only $527. 48 $0 Employee + 1 Dependent $975. 81 $193. 52 Employee + Children Family $1, 107. 70 $1, 534. 96 $160. 82 $357. 43 Poquoson City Public Schools contributes $600 for employee only coverage and $1, 200 for all other tiers of coverage into your Health Savings Account. Page 3

Health Savings Accounts (HSA) Poquoson City Public Schools wants to help employees and their families prepare for healthcare issues both now and in the future. For employees comfortable with the concept of a higher deductible plan in exchange for lower premium costs, the High Deductible Health Plan (HDHP) provides a way to save money that is available in future years for health care expenses because it qualifies you to also set up a Health Savings Account (HSA). Benefit Wallet will administer the HSA accounts. With Benefit Wallet you will have 3 options of where your contributions can go. They are: • • • Cash account Interest bearing account Mutual Funds Important Reminders: • • • With the HSA, you can save money in three ways: 1. Money deposited into your HSA can be done so on a tax-free basis and this money is always your money 2. You pay no tax on the interest you earn; and 3. Withdrawals for eligible expenses are tax free. To open an HSA: you must enroll in one of the HDHP plans, you should not be eligible or enrolled in Medicare, you should not be covered by another health insurance plan, nor should you be enrolled in a health flexible spending account including your spouse’s, be enrolled in Tri. Care, or have had VA benefits in the last 90 days. In 2016, individuals can contribute up to $3, 350 and families can contribute up to $6, 650. In 2017, individuals can contribute up to $3, 400 and families can contribute up to $6, 750. If you are 55 or older, you can put in an additional $1, 000 catch-up contribution each year you are HSA eligible. Money is deposited in the HSA fund on a pre-tax basis via payroll deductions, and funds within the HSA grow without incurring taxes. Funds may be withdrawn tax-free for healthcare related needs. Flexible Spending Accounts (FSA) Employees have the opportunity to enroll in Flexible Spending Accounts administered by First Financial Group. General Purpose Health Flexible Spending Account (for those that do not elect a HDHP/HSA) – You can contribute up to $2, 550 pre -tax dollars to pay for eligible expenses such as medical, dental and vision expenses that are not reimbursed by the insurance plan and are not itemized on your IRS tax return. Dependent Care Account (Maximum $5, 000) – You can contribute tax-free dollars to help pay for eligible dependent care expenses that enable you (and your spouse, if you are married) to work (for example, day care and elder care). The maximum amount you can contribute to the Dependent Care Flexible Spending Account is $5, 000 if you are a single employee or married filing jointly, or $2, 500 if you are married and filing separately. Page 4

Dental Coverage Regular dental exams can help Keeping your teeth and gums you and your dentist detect clean and healthy will help problems in the early stages prevent most tooth decay and when treatment is simpler and periodontal disease, and is an costs are lower. important part of maintaining your medical health. Your dental plan is with: United Concordia Dental, which offers in and out-of-network benefits. This is a summary of coverage; please refer to your summary plan description for the full scope of coverage. To find a provider participating in your dental plan network, visit www. UCCI. com Click “Find a Dentist”, Enter your search criteria and click “Show Dentists in My Area”. Employee Monthly Contributions – Dental United Concordia Monthly Premium Employee Only $42. 10 Employee + 1 Dependent $70. 70 Family $112. 47 If you do not elect medical insurance coverage, you can receive dental coverage at no cost. Page 5

Open Enrollment Instructions Open Enrollment is the period when you may enroll in coverage for the first time, change plans and or add/change dependents. During this enrollment period, benefit selection is done of two ways, either: • Agent Assisted or • Self Directed using the First Financial Enrollment System Qualified Life Events Generally, you may change your benefit elections only during the annual enrollment period. However, you may change your benefit elections during the year if you experience a qualified life event, including: n Marriage, divorce or legal separation n Birth of your child n Death of your spouse or dependent child n Adoption of or placement for adoption of your child n Change in employment status of employee, spouse or dependent child n Qualification by the Plan Administrator of a child support order for medical coverage n Entitlement to Medicare or Medicaid You must notify Human Resources within 30 days of the qualified life event. Depending on the type of event, you may be asked to provide proof of the event. If you do not contact Human Resources within 30 days of the qualified event, you will have to wait until the next annual enrollment period to make changes. Open enrollment is currently closed. Contact Information Plan Name Medical: Anthem Dental: United Concordia Web Address Phone Number www. anthem. com HSA: 800. 582. 6941 POS : 800. 421. 1880 www. ucci. com Claims: 800. 247. 4695 Page 6

Important Benefits through Anthem Live. Health Online If you are enrolled in the Anthem medical plan, you and you covered family members have access to 24/7/365 medical care. Live. Health Online U. S. board-certified doctors are available through live video conferencing to resolve many of your medical issues from wherever you happen to be. They can diagnose, recommend treatment and prescribe medication, if necessary, for many of your medical issues including: • Cold and flu symptoms • Bronchitis • Respiratory infection • Sinus problems • Allergies • Urinary tract infection • Ear infection • Pink eye Set up your Live. Health Online account so that when you need care immediately, they're just a click away. The cost for a consultation, which you can pay by debit or credit card is: • $20. 00 – Open Access POS 20/20 • $49. 00 - $2, 800 High Deductible Health Plan/HSA Visit: www. livehealthonline. com or on the free, mobile app. Ready to Quit Smoking? Under health care reform, you can get certain FDA-approved prescription drugs and many over-the-counter (OTC) products to help you quit smoking and it won’t cost you anything extra! Here’s all you have to do: 1. Ask your doctor if one or more of the covered prescription drugs and/or OTC products would be good for you. If so, you will need to get a prescription for each one. (Yes, even OTC products will need a prescription) 2. Go to the pharmacy that’s in your health plan’s network to fill your prescription. 3. Show the pharmacist proof that you’re at least 18 years of age. Covered prescriptions and OTC products: • Chantix • buproban • bupropion SR (generic Zyban) • Nicotine Gum (see covered list) • Nicotine lozenge (see covered list) • Nicotine transdermal patch (see covered list) Get even more support at www. anthem. com! Log on and click on our Health and Wellness section for resources, videos and even an online community for information and inspiration to help you quit! Special. Offers on anthem. com Save money with discounts at anthem. com. With Special. Offers, you can access over 50 discount products and services that help promote better health and well-being. Just a few examples are: • • Vision & Hearing ü 1 -800 CONTACTS ü Glasses. com ü Amplifon ü Beltone Fitness & Health ü Jenny Craig ü Golbal. Fit ü Fit. Orbit • Family & Home ü Safe Beginnings ü VIP Pet Insurance ü Link. Well • Medicine & Treatment ü Puritan’s Pride ü Allergy Control Products ü National Allergy Supply To find the discounts that are available to you, log into www. anthem. com and select Discounts. Page 7

Important Notices Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you are eligible for health coverage from your employer, your State may have a premium assistance program that can help pay for coverage. These States use funds from their Medicaid or CHIP programs to help people who are eligible for these programs, but also have access to health insurance through their employer. If you or your children are not eligible for Medicaid or CHIP, you will not be eligible for these premium assistance programs. If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, you can contact your State Medicaid or CHIP office to find out if premium assistance is available. If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, you can contact your State Medicaid or CHIP office or dial 1 -877 -KIDS NOW or www. insurekidsnow. gov to find out how to apply. If you qualify, you can ask the State if it has a program that might help you pay the premiums for an employer-sponsored plan. Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must permit you to enroll in your employer plan if you are not already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, you can contact the Department of Labor electronically at www. askebsa. dol. gov or by calling toll-free 1 -866 -444 EBSA (3272). If you live in one of the following States, you may be eligible for assistance paying your employer health plan premiums. The following list of States is current as of July 31, 2013. You should contact your State for further information on eligibility – ALABAMA – Medicaid Website: http: //www. medicaid. alabama. gov Phone: 1 -855 -692 -5447 ALASKA – Medicaid COLORADO – Medicaid Website: http: //www. colorado. gov/ Medicaid Phone (In state): 1 -800 -866 -3513 Medicaid Phone (Out of state): 1 -800 -221 -3943 Website: http: //health. hss. state. ak. us/dpa/programs/medicaid/ Phone (Outside of Anchorage): 1 -888 -318 -8890 Phone (Anchorage): 907 -269 -6529 ARIZONA – CHIP FLORIDA – Medicaid Website: http: //www. azahcccs. gov/applicants Website: https: //www. flmedicaidtplrecovery. com/ Phone (Outside of Maricopa County): 1 -877 -764 -5437 Phone (Maricopa County): 602 -417 -5437 Phone: 1 -877 -357 -3268 GEORGIA – Medicaid Website: http: //dch. georgia. gov/ Click on Programs, then Medicaid, then Health Insurance Premium Payment (HIPP) Phone: 1 -800 -869 -1150 Page 8

Important Notices Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) - continued IDAHO – Medicaid and CHIP MONTANA – Medicaid Website: www. accesstohealthinsurance. idaho. gov Website: http: //medicaidprovider. hhs. mt. gov/clientpages/ clientindex. shtml Medicaid Phone: 1 -800 -926 -2588 CHIP Website: www. medicaid. idaho. gov Phone: 1 -800 -694 -3084 CHIP Phone: 1 -800 -926 -2588 INDIANA – Medicaid NEBRASKA – Medicaid Website: http: //www. in. gov/fssa Website: www. ACCESSNebraska. ne. gov Phone: 1 -800 -889 -9949 Phone: 1 -800 -383 -4278 IOWA – Medicaid NEVADA – Medicaid Website: www. dhs. state. ia. us/hipp/ Medicaid Website: http: //dwss. nv. gov/ Phone: 1 -888 -346 -9562 Medicaid Phone: 1 -800 -992 -0900 KANSAS – Medicaid Website: http: //www. kdheks. gov/hcf/ Phone: 1 -800 -792 -4884 KENTUCKY – Medicaid NEW HAMPSHIRE – Medicaid Website: http: //chfs. ky. gov/dms/default. htm Website: http: //www. dhhs. nh. gov/oii/documents/hippapp. pdf Phone: 1 -800 -635 -2570 Phone: 603 -271 -5218 LOUISIANA – Medicaid NEW JERSEY – Medicaid and CHIP Website: http: //www. lahipp. dhh. louisiana. gov Medicaid Website: http: //www. state. nj. us/humanservices/ dmahs/clients/medicaid/ Phone: 1 -888 -695 -2447 Medicaid Phone: 609 -631 -2392 MAINE – Medicaid Website: http: //www. maine. gov/dhhs/ofi/public-assistance/index. html Phone: 1 -800 -977 -6740 TTY 1 -800 -977 -6741 CHIP Website: http: //www. njfamilycare. org/index. html CHIP Phone: 1 -800 -701 -0710 MASSACHUSETTS – Medicaid and CHIP NEW YORK – Medicaid Website: http: //www. mass. gov/Mass. Health Website: http: //www. nyhealth. gov/health_care/medicaid/ Phone: 1 -800 -462 -1120 Phone: 1 -800 -541 -2831 MINNESOTA – Medicaid NORTH CAROLINA – Medicaid Website: http: //www. dhs. state. mn. us/ Website: http: //www. ncdhhs. gov/dma Click on Health Care, then Medical Assistance Phone: 919 -855 -4100 Phone: 1 -800 -657 -3629 MISSOURI – Medicaid NORTH DAKOTA – Medicaid Website: http: //www. dss. mo. gov/mhd/participants/pages/hipp. htm Website: http: //www. nd. gov/dhs/services/medicalserv/medicaid/ Phone: 573 -751 -2005 Phone: 1 -800 -755 -2604 OKLAHOMA – Medicaid and CHIP Website: http: //www. insureoklahoma. org Phone: 1 -888 -365 -3742 UTAH – Medicaid and CHIP Website: http: //health. utah. gov/upp Phone: 1 -866 -435 -7414 Page 9

Important Notices Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP) – continued To see if any more States have added a premium assistance program since July 31, 2013, or for more information on special enrollment rights, you can contact either: U. S. Department of Labor U. S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www. dol. gov/ebsa www. cms. hhs. gov 1 -866 -444 -EBSA (3272) 1 -877 -267 -2323, Menu Option 4, Ext. 61565 Page 10

Important Notices HIPAA Special Enrollment Rights If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself or your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing towards your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage). In addition, if you have a new dependent as result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. Special enrollment rights also may exist in the following circumstances: If you or your dependents experience a loss of eligibility for Medicaid or a state Children’s Health Insurance Program (CHIP) coverage and you request enrollment within 60 days after that coverage ends; or If you or your dependents become eligible for a state premium assistance subsidy through Medicaid or a state CHIP with respect to coverage under this plan and you request enrollment within 60 days after the determination of eligibility for such assistance. Note: The 60 -day period for requesting enrollment applies only in these last two listed circumstances relating to Medicaid and state CHIP. As described above, a 30 -day period applies to most special enrollments. To request special enrollment or obtain more information, contact Human Resources. The Women’s Health and Cancer Rights Act of 1998 requires group health plans to make certain benefits available to participants who have undergone a mastectomy. In particular, a plan must offer mastectomy patients benefits for: n All stages of reconstruction of the breast on which the mastectomy was performed n Surgery and reconstruction of the other breast to produce a symmetrical appearance n Prostheses n Treatment of physical complications of the mastectomy, including lymphedema Our plan complies with these requirements. Benefits for these items generally are comparable to those provided under our plan for similar types of medical services and supplies. Of course, the extent to which any of these items is appropriate following mastectomy is a matter to be determined by the patient and her physician. Our plan neither imposes penalties (for example, reducing or limiting reimbursements) nor provides incentives to induce attending providers to provide care inconsistent with these requirements. If you would like more information about WHCRA required coverage, you can contact Human Resources. Page 11

Important Notices Medicare Part D Creditable Coverage Notice for Anthem Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Poquoson City Public Schools and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium. 2. Poquoson City Public Schools has determined that the prescription drug coverage offered by the medical plan is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan. When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15 th to December 7 th. However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan. What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your current Poquoson City Public Schools coverage may be affected. If you do decide to join a Medicare drug plan and drop your current Poquoson City Public Schools coverage, be aware that you and your dependents may not be able to get this coverage back. This determination depends on your specific circumstances and is subject to the terms of the group health insurance policies in effect under the Poquoson City Public Schools medical plan. When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with Poquoson City Public Schools and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join. Page 12

Important Notices For More Information About This Notice Or Your Current Prescription Drug Coverage… Contact Human Resources. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through Poquoson City Public Schools changes. You also may request a copy of this notice at any time. For More Information About Your Options Under Medicare Prescription Drug Coverage… More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage: Visit www. medicare. gov Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help Call 1 -800 -MEDICARE (1 -800 -633 -4227). TTY users should call 1 -877 -486 -2048. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www. socialsecurity. gov, or call them at 1 -800 -772 -1213 (TTY 1 -800 -325 -0778). Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty). This benefit summary provides selected highlights of the Poquoson City Public Schools employee benefits program. It is not a legal document and shall not be construed as a guarantee of benefits nor of continued employment at the Company. All benefit plans are governed by master policies, contracts and plan documents. Any discrepancies between any information provided through this summary and the actual terms of the policies, contracts and plan documents are governed by the terms of these policies, contracts and plan documents. Poquoson City Public Schools reserves the right to amend, suspend or terminate any benefit plan, in whole or in part, at any time. The Plan Administrator has the authority to make these changes. Page 13