University of California Berkeley Visiting Scholar Benefit Plan

University of California Berkeley Visiting Scholar Benefit Plan (UCBVSBP) Effective December 1, 2010

UCBVSBP § The University of California, Berkeley (UCB) has partnered with Garnett-Powers & Associates to administer the Visiting Scholar Benefit Plan (UCBVSBP) § December 1, 2010 is the effective date whereby all domestic and international Visiting Scholars and Visiting Student Researchers must be provide proof of adequate health insurance coverage § The UCBVSP is available to both domestic and international Visiting Scholars and Visiting Student Researchers at UCB who are affiliates of the Visiting Scholar and Postdoc Affairs (VSPA) Program § The UCBVSBP fully meets the U. S. State Department Exchange Scholar requirements for J-1 scholars and their J-2 dependents

UCBVSBP Healthcare Options PPO Plan A Plan B Plan C United. Healthcare In-Network United. Health. Care Out-of-Network IMG Standard Plan IMG Platinum Plan PPO PPO Overall Plan Maximum There is no overall maximum dollar limit on the policy Visiting Scholar - $500, 000 period of coverage Dependent - $100, 000 period of coverage Visiting Scholar - $1, 000 period of coverage Dependent - $100, 000 period of coverage Plan Deductible $250 per Insured Person, Per Policy Year $500 per Illness/Injury PPO Provider: $25 per Illness/ Injury Non-PPO Provider: $50 per Illness/ Injury $4, 500 per Insured Person and $9, 000 for all Insured Families Per Policy Year $9, 000 per Insured Person and $18, 000 for all Insured Families Per Policy Year No Out-of-Pocket Maximum Coinsurance Visiting Scholar pays 20% of Preferred Allowance Visiting Scholar pays 40% of Usual and Customary Charges PPO Provider: Visiting Scholar pays 0% of eligible expenses Non-PPO Provider: Visiting Scholar pays 20% of eligible expenses up to $1, 000, then the plan pays 100% thereafter Prescription Drugs $20 Copay for Tier 1 $40 Copay for Tier 2 $80 Copay for Tier 3 No Benefits Visiting Scholar Pays 50% of actual charges Up to annual maximum of $1, 500 $20 Copay for Generic $40 Copay for Brand $80 Copay for Non-Brand Up to the annual maximum of $3, 000 Benefits Plan Type Out-of-Pocket Maximum

UCBVSBP Healthcare Options PPO Plan A Plan B Plan C United. Healthcare In-Network United. Healthcare Out-of-Network IMG Standard Plan IMG Platinum Plan Maternity Paid as any other illness No Coverage Conception must occur during period of coverage Paid as any other illness Routine Newborn Care Paid as any other illness No Coverage $750 maximum period of coverage Emergency Medical Evacuation No Limit $50, 000 lifetime maximum $500, 000 lifetime maximum Repatriation of Remains No Limit $25, 000 maximum $50, 000 maximum Pre-Existing Conditions Pre-existing conditions are covered with no waiting period Pre-existing conditions are covered after 12 months of continuous coverage Pre-existing conditions are covered after 6 months of continuous coverage Emergency Room $100 Copay per visit (waived if admitted) + Visiting Scholar pays 20% of preferred allowance $100 Deductible per visit + Visiting Scholar pays 20% Usual and Customary Charges $250 Deductible Benefits

UCBVSBP Healthcare Options PPO Plan A Benefits Plan B Plan C United. Healthcare In-Network United. Healthcare Out-of-Network IMG Standard Plan IMG Platinum Plan Hospitalization Visiting Scholar pays 20% of Preferred Allowance Visiting Scholar pays 40% of Usual and Customary Charges $500 per Illness/Injury Usual and Customary Charges PPO Provider: $25 per Illness/ Injury Usual and Customary Charges Mental & Nervous Disorders Visiting Scholar pays 20% of Preferred Allowance Visiting Scholar pays 40% of Usual and Customary Charges $50 Copay with $500 lifetime maximum U. S. Citizens, Non-U. S. Citizens & Dual Citizens Non-U. S. Citizens only Provided at No Cost No Benefits Well Exams covered at 100% (annual max of $500) Immunizations covered at 100% (annual max of $250) Eligibility Preventive Care Services including Immunizations

UCBVSBP Rates* Plan Options Plan A Insurance Plan United. Healthcare Visiting Scholar Additional Premium for Spouse or Domestic Partner Additional Premium for One Child Additional Premium for Two or more Children Additional Premium for Spouse & Two or more Children $322 $644 $966 • $69 • $77 • $122 • $187 • $242 • $238 • $260 • $345 • $356 • $345 • $151 • $172 • $294 • $480 • $641 • $575 • $635 • $845 • $873 • $845 IMG Standard Plan Age Rated: Plan B • 19 -23 years old • 24 -30 years old • 31 -40 years old • 41 -50 years old • 51 -64 years old $66 For every child dependent, the premium is an extra $66 N/A For every child dependent, the premium is an extra $134 N/A IMG Platinum Plan Age Rated: Plan C • 19 -23 years old • 24 -30 years old • 31 -40 years old • 41 -50 years old • 51 -64 years old $134 * Rates are effective September 1, 2016 through August 31, 2017

Medical Evacuation & Repatriation Coverage n The UCBVSBP plan includes medical evacuation and repatriation of remains benefits that meet the U. S. State Department requirements ü International J-1 scholars and their J-2 dependents do not need to purchase supplemental coverage to meet their J Visa requirements

UCBVSBP Administrative Process n n n Department staff prepares an affiliate application in the VSPA Gateway VSPA Program confirms approval of affiliate application VSPA sends notification of eligibility to GPA for new and extended appointments Department creates a Human Capital Management (HCM) Contingent Worker Job Organizational Instance. NOTE: Staff can create record up to 3 months in advance of appointment Cal Numerical ID is generated Continued next page…

UCBVSBP Administrative Process n n n Affiliate has 31 days from appointment date to visit the GPA website and enroll in VSBP or opt out of the plan When enrollment form is completed and premiums are paid, GPA will notify the scholar. The insurance company will provide an insurance ID card If waiving or opting out: Affiliate must provide proof of comparable coverage to GPA for verification. Upon approval, GPA will notify the affiliate, department staff and VSPA Program that health insurance requirement has been satisfied

UCBVSBP Administrative Process n VSPA creates a Person of Interest (POI) record in HCM, which activates the HCM Contingent Worker Job Organizational Instance üIf the affiliate’s insurance does not meet the waiver requirements, or if the affiliate drops coverage early, GPA will notify department staff of the deficiency üIf the requirements are not satisfied by the affiliate, GPA will inform the VSPA Program and the POI record will be deactivated, resulting in loss of campus services

VSPA Affiliate Enrollment Process n Affiliate must enroll online through Garnett-Powers & Associates’ UCVSBP website: www. garnett-powers. com/vs/ucb n Affiliates must follow the enrollment process carefully. To get started, the affiliate clicks on the ‘Enrollment’ link and prints (or reads) the ‘Enrollment/Payment Instructions. ’ These instructions are written to guide the affiliate’s completion of the enrollment form. Once the affiliate has filled out the form, the affiliate should print the completed form for record-keeping purposes. n IMPORTANT: Failure to adhere to the recommended enrollment process may result in a long delay in becoming active in the insurance carrier’s system

VSPA Affiliate Enrollment Process n Affiliate must provide a current and correct email address because all correspondence between GPA and the affiliate will transacted by email including confirmation of enrollment and quarterly invoices for subsequent quarterly enrollment. n Enrollment is not complete until GPA receives: 1) confirmation of eligibility from the campus, and 2) initial payment n Health insurance ID cards will be mailed to the affiliate’s U. S. mailing address listed on the enrollment form 7 to 10 business days after the enrollment process is complete n If the affiliate would like to make changes to enrollment in the future, the affiliate must click ‘Making Changes to Your Enrollment’ link and print (or read) the ‘Instructions on Making Changes’ link for detailed instructions.

VSPA Affiliate Payment Process n Upon completion of the enrollment form, the affiliate is directed to ‘Submit and Create Printable Enrollment Form’. A reminder that payment is due immediately is issued. n Payment is due for the current quarter (or portion as determined by the affiliate’s insurance start date) at initial enrollment (whole months only no pro-rated amounts when enrolling after the first of the month) n When the affiliate clicks on the ‘Calculate Premium’ button, the system automatically ‘populates’ both the initial premium owed for the first quarter and premium owed for subsequent quarter(s) on the payment coupon at the bottom of the enrollment form. The affiliate should print this document for record-keeping purposes.

VSPA Affiliate Payment Process n The affiliate can pay by debit or credit card or with a check. If the affiliate is paying by check, the affiliate should return the payment coupon with a check to Garnett-Powers & Associates. n After the initial premium has been paid, the GPA billing department will send the affiliate an electronic invoice for subsequent billing(s) prior to the expiration date of the insurance policy. If affiliate’s appointment ends before the end of any quarter, affiliate will only be billed the premium through the end of the last month of appointment.

Family Member Eligibility* n Family member categories (including J-2 dependents) are the following: ü Spouse ü Domestic partner Ø Same-sex domestic partner Ø Opposite-sex domestic partner only if one partner is over age 62 ü Unmarried natural or adopted children to age 19 or to age 23 if a full-time student who is not self-supporting ü NOTE: Other family members (e. g. , parents, nieces or nephews) are NOT eligible *See Eligibility and Definitions sections in policy brochure

Information Sources n Website: Garnett-Powers’ UCBVSBP website: www. garnett-powers. com/vs/ucb n Toll Free Phone: Garnett-Powers’ UCBVSBP customer service number: 888 -441 -3719 n Email Address: Garnett-Powers’ email address: UCBVSBP@Garnett-Powers. com