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Benefits and Enrollment Guide

Health | HSA | Dental | Disability | Life | Vision | FSA | Retirement Plans

January 1, 2017 to December 31, 2017

2

2017 Benefits and Enrollment Guide

Benefits Overview

Open Enrollment: Open enrollment is your opportunity to

make changes to your benefit elections. Open enrollment begins on November 1, 2016 and ends on November 15, 2016. Once you have made your elections you may not make changes for most coverages until our next annual Open Enrollment, unless you experience a qualifying change in status. These include marriage, separation or divorce, birth or adoption or change in custody of a child, death of a dependent, change in your employment status or loss of spouse’s work-related coverage. You may make changes to your benefit elections within 30 days of a qualifying change in status.

Healthcare: Our medical plans are administered by UMR. We

offer two medical plans for you to choose from. Please refer to the medical section of this guide for complete details. Johnston Health contributes substantially to the cost of this coverage for you and your dependents. Please note: UMR will issue new ID cards this year. The ID card will have a sticker on it for you to call UMR and register the ID card. Please complete the registration process.

Dental: Our dental plans are with Ameritas. We offer two

dental plans for you to choose from. Please refer to the dental plan page for details. Johnston Health pays contributes toward the cost of this coverage for you and your dependents.

Vision: Our vision plans are with EyeMed. We offer two

vision plans for you to choose from. Further details are provided in this guide.

Life: We provide eligible employees with Base Life insurance

through Sun Life at no cost. You may purchase additional supplemental life insurance on yourself and your dependents.

Disability: We provide eligible employees with Short Term and

Long Term Disability coverage at no cost. These coverages are with Sun Life.

Flexible Spending Accounts: We offer Medical Care and

Dependent Care Flexible Spending Accounts. These accounts are administered by P&A Group.

Retirement Plans: We offer 457(b) and 401(a) Retirement

Plans. Further details are provided in this guide.

Online Enrollment: You will enroll for your benefits at https://

unchealthcare.hrintouch.com. Select “ Create an account” . Enter last name, DOB and last four of social security number and complete security check. Next, register for your account by completing the required fields. Once you complete your registration, you will be able to enroll for your 2017 benefits. Enrollment forms for the retirement plan must be returned to Human Resources.

Johnston Health offers eligible employees a variety of benefits that provide you and your family with health care coverage, financial

protection and more, tailored to best fit your needs. Our benefits program is an important part of your overall compensation and with

the assistance of Hylant, we are regularly assessing the quality and cost of the benefits to ensure we offer the most competitive pack-

age possible. This Benefits Guide provides a comprehensive overview of our benefits package, including eligibility, election periods,

and costs. In addition, the guide offers descriptions and detailed explanations of each plan design. We encourage you to carefully con-

sider all aspects of these plans, including premiums, provider networks (where applicable), flexibility and restrictions, so that you can

choose the benefits that best suit the needs of you and your family.

Contents

2 Overview

3 Health Care Reform Overview

4 Eligibility

5 Medical Plan

9 UNCHCS Pharmacy Services

11 Health Savings Account

12 Urgent Care vs ER

13 UMR Resources

14 UNC Personal Health Advocate

16 Preventive Care

18 Dental Insurance

20 Vision Insurance

22 Short & Long Term Disability

23 Base and Supplemental Life Insurance

24 Sun Life Value Added Benefits

25 Flexible Spending Accounts (FSA)

26 Retirement Plan Highlights

27 Important Disclosures

40 Contact Information

This booklet is intended for illustrative and information purposes

only. The plan documents, insurance certificates and policies will

serve as the governing documents. In the case of conflict between

the information in this booklet and the official plan documents, the

plan documents will always govern. Johnston Health reserves the

right to change or terminate at any time, in whole or in part, the em-

ployee benefit package, with respect to all or any class of employees

or former employees.

3 2017 Benefits and Enrollment Guide

Health Insurance Marketplace Coverage & Mandate Penalties

As a result of the Affordable Care Act (ACA), commonly referred to as “health care reform”, the benefits landscape is changing.

Please carefully read the following as it contains important information regarding your healthcare plan and the Affordable

Care Act.

There is a new way to buy health insurance: the Health Insurance

Marketplace. The Marketplace Open Enrollment begins No-

vember 1, 2016 and ends January 31, 2017. To assist you as

you evaluate options for you and your family, this notice provides

some basic information about the Marketplace.

What is the Health Insurance Marketplace?: The Marketplace

is designed to help you find health insurance that meets your

needs and fits your budget. The Marketplace offers "one-stop shop-

ping" to find and compare private health insurance options.

Does Employer Health Coverage Affect Eligibility for Premium

Savings through the Marketplace?: Yes. If you have an offer of

health coverage from your employer that meets certain standards

(minimum value and affordability), you will not be eligible for a tax

credit through the Marketplace and may wish to enroll in your em-

ployer's health plan.

Do the Plans Offered by Johnston Health Meet the Minimum

Value Standard Set by the Affordable Care Act (ACA)?: Yes,

our plans meet the minimum value requirement.

Do any of the Johnston Health plans meet the cost require-

ments (affordability) of the Affordable Care Act (ACA)?: Yes,

the Johnston Health plans meet the cost requirements for most if

not all employees.

Will any Johnston Health employees be eligible for subsidies

through the Marketplace?: Because at least one of our plans

meets the minimum value and the cost (affordability) standards of

the Affordable Care Act, Johnston Health employees who are eligi-

ble for benefits are not expected to be eligible for Marketplace sub-

sidies.

Note: If you purchase a health plan through the Marketplace

instead of accepting health coverage offered by your employer,

then you may lose the employer contribution to the employer-

offered coverage. Also, this employer contribution (as well as your

employee contribution to employer-offered coverage) is excluded

from income for federal and state income tax purposes. Your pay-

ments for coverage through the Marketplace are made on an after-

tax basis.

What is the penalty for noncompliance of the individual man-

date?: As of January 1, 2014, all American citizens are re-

quired to have health insurance, including their dependents. Adults

who do not have health insurance will be subject to a fine of the

greater of 2% of income or $325 per person. The penalty increases

every year. In 2016 it’s 2.5% of income or $695 per person.

After that it's adjusted for inflation.

If you’re uninsured for just part of the year, 1/12 of the yearly

penalty applies to each month you’re uninsured. If you’re unin-

sured for less than 3 months, you don’t have to make a pay-

ment.

Who will be exempt from the mandate?: Individuals who

have a religious exemption, those not lawfully present in the

United States, and incarcerated individuals are exempt from

some requirements. You are also exempt from the penalty if

you have minimum essential health coverage. You are con-

sidered to have minimum essential coverage if you have Medi-

care, Medicaid, CHIP, any job-based plan (i.e. Johnston Health

medical plan or your Spouse’s medical plan through his/her

place of employment), any medical plan you bought through the

Marketplace, COBRA, retiree medical coverage, Tricare, VA

health coverage. If you are uninsured, you will be subject to the

fee. In order to avoid the fee, you should enroll in the company

medical plan.

If you drop our group medical plan can you get immediate

coverage with a Marketplace plan?: No, dropping/

cancelling employer coverage does not qualify as a special

event for the Marketplace. You would have to wait until Market-

place Open Enrollment.

If you get a Marketplace plan and then drop it, can you get

back on the Johnston Health plan?: Dropping/cancelling a

Marketplace plan is not a qualifying event to elect group cover-

age. You would need to wait until the next Open Enrollment to

elect group coverage.

How Can I Get More Information?: For more information

about your coverage offered by your employer, please review

this benefit guide or contact Human Resources.

The Marketplace can help you evaluate your coverage options,

including your eligibility for coverage through the Marketplace

and its cost. Please visit HealthCare.gov for more information,

as well as an online application for health insurance coverage

and contact information for a Health Insurance Marketplace in

your area.

Health Care Reform information is changing al-

most daily. As a result, this information is sub-

ject to change at any time. For more infor-

mation on Health Care Reform, please visit

www.healthcare.gov or call 1-800-318-2596 for

the most current information.

4


Eligibility

This booklet is intended for illustrative and information purposes only. The plan documents, insurance certificates and policies will serve as the governing documents. In the

case of conflict between the information in this booklet and the official plan documents, the plan documents will always govern. Johnston Health reserves the right to

change or terminate at any time, in whole or in part, the employee benefit package, with respect to all or any class of employees or former employees.

Johnston Health is pleased to offer its employees an

excellent benefit program. These health and welfare benefits

are designed to protect you and your family while you are an

active employee.

Eligibility: Health and welfare plans are available to

employees full time and part time employees.

Dependent Eligibility: If you wish, your dependents may

also be covered. Eligible dependents include:

Legal spouse, as defined by Federal Law; and

MEDICAL - Your children up to the end of the month in

which they reach age 26 regardless of marital status,

financial dependency, residency with the Eligible

Employee, student status, employment status, or eligibil-

ity for other coverage.

DENTAL - Your children up to the end of the month in

which they turn 26.

VISION - Your children up to the end of the month in

which they turn 26.

VOLUNTARY LIFE - Your unmarried children to the end

of the month in which they reach age 19 or to age 26 if

full-time student.

It is your responsibility to provide the Human

Resources Department with proof of your depend-

ents’ eligibility, in the form of: (a) your most recent

Federal Income Tax Return, (b) Court Order specify-

ing your responsibility to provide “group health care

coverage” to your dependent children, or (c) Copy of

birth or marriage certificate. It is also your responsi-

bility to notify the Human Resources Department

when your dependents no longer meet the eligi-

bility criteria.

New Hire Coverage: As a new hire, you are eligible for

medical, dental, vision, life, disability, HSA and Flexible

Spending Accounts on the first of the month following date of

hire. You are eligible for retirement and PDO time on your

date of hire. New employees have up to 30 days after their

eligibility date to enroll. If you do not enroll by that deadline,

you will not be eligible for coverage until the following annual

open enrollment period.

Annual Elections: You have the opportunity to pay for

medical, dental and vision coverage, and make HSA or FSA

contributions on a pre-tax basis. IRS rules stipulate that

once you have made your elections for the plan year, you

may not change them until the next annual enrollment unless

a qualifying event occurs. This restriction does not apply to

HSA contributions. It is important that you make your

choices carefully. Exceptions can be made for changes in

family status during the year. A family status change in-

cludes:

Marriage

Separation or Divorce

Birth or adoption or change in custody of a child

Death of a dependent

Change in your spouse’s employment status

Loss of spouse’s work related coverage

If you have a family status change, you must change your

benefit elections within 30 days of the qualifying event, or you

will need to wait until the next annual open enrollment period.

COBRA Continuation Coverage: When you or any of your

dependents no longer meet the eligibility requirements for

health and welfare plans, you may be eligible for continued

coverage as required by the Consolidated Omnibus Budget

Reconciliation Act (COBRA) of 1986. Please refer to the

COBRA explanation in this guide.


Healthcare is one of the most important and necessary parts of your benefit package. The following is a summary of our benefit plan. For

a more detailed explanation of benefits, please refer to your Summary Plan Description and Summary of Benefits and Coverage (SBC).

Copay Plan Summary

This booklet is intended for illustrative and information purposes only. The plan documents, insurance certificates and policies will serve as the governing

documents. In the case of conflict between the information in this booklet and the official plan documents, the plan documents will always govern.

PPO COPAY PLAN

SUMMARY OF BENEFITS

DOMESTIC NETWORK

UNC Providers

IN-NETWORK SERVICES

UHC Choice Plus Pro-viders

NON-NETWORK SERVICES

Out-of-Network Providers

DEDUCTIBLES & MAXIMUMS

Lifetime Benefit Maximum Unlimited Unlimited Unlimited

Annual Deductible $750 Single

$1,500 Family $2,000 Single $4,000 Family

$2,500 Single $5,000 Family

Member Coinsurance 15% 25% 40%

Out-of-Pocket Maximum – Includes Calendar Year Deductible, Medical Co-pays, Member Coinsurance & Rx Copays.




HRA Contribution Amount – Only when services are obtained at Johnston Health. HRA Dollars are applied to the

claim before the Annual Deductible.


n/a n/a

THE DEDUCTIBLE AND OUT-OF-POCKET MAX AMOUNTS FOR THE DOMESTIC NETWORK (UNC PROVIDERS) AND UHC CHOICE PLUS PROVIDERS CROSS-FEED.

PREVENTIVE & OFFICE VISITS

Physician Office Visit Primary Care providers

$15 Copay then 100% $40 Copay then 100% Covered at 60% after

deductible

Specialist Office Visit $25 Copay then 100% $60 Copay then 100% Covered at 60% after

deductible

Preventive Office Visit Primary Care or Specialist

Covered at 100% Covered at 100% Covered at 60% after

deductible

Well Baby Office Visit Covered at 100% Covered at 100% Covered at 60% after

deductible

Routine Lab & X-rays Primary Care or Specialist


deductible

Vision Care Diagnostic visits only

Covered at 100% Covered at 100% Covered at 100%

Prenatal Care Does not include Sonograms


deductible

Postnatal Care Covered at 85% after

deductible Covered at 75% after


deductible

INPATIENT & OUTPATIENT SERVICES

Inpatient Facility & Physician Services Covered at 85% after



deductible

Outpatient Hospital & Surgery Ser-vices including Physician & Surgeon

Charges

Covered at 85% after deductible


Covered at 60% after deductible.

Note: Surgery is excluded

DIAGNOSTIC SERVICES

Outpatient Hospital Lab and

X-rays Charges $15 copay then 100%



Independent Clinical Lab Facilities $15 copay then 100% Covered at 75% after


deductible

Outpatient Advanced Imaging (MRI,

MRA, CT, CAT Scan) $15 copay then 100%



PET Scans $15 copay then 100% Covered at 75% after


deductible

6


Copay Plan Summary



SUMMARY OF BENEFITS DOMESTIC NETWORK

UNC Providers

IN-NETWORK SERVICES UHC Choice Plus

Providers

NON-NETWORK SERVICES Out-of-Network Providers

URGENT CARE & EMERGENCY SERVICES

Urgent Care Includes Lab & X-ray &

Physician Charges $30 Copay then 100% $50 Copay then 100% $50 Copay then 100%

Emergency Room Facility Services

& Physician Charges $175 Copay and then 100% $175 Copay and then 100% $175 Copay and then 100%

MENTAL HEALTH/SUBSTANCE DEPENDENCY

Inpatient Facility Services Covered at 85% after

deductible

Covered at 75% after

deductible


deductible

Inpatient Physician Charges Covered at 85% after

deductible


deductible


deductible

Outpatient Hospital Services Covered at 85% after

deductible


deductible


deductible

Outpatient Hospital Physician

Charges


deductible


deductible


deductible

Physician Office Visit Primary Care

providers $15 Copay then 100% $40 Copay then 100%


deductible

Specialist Office Visit $25 Copay then 100% $60 Copay then 100% Covered at 60% after

deductible

OTHER SERVICES

Chiropractic Care 30 Visits per Cal-

endar Year combined for all tier levels $25 Copay then 100% $60 Copay then 100%


deductible

Durable Medical Equipment Covered at 85% after

deductible


deductible


deductible

Occupational and Physical Therapy

30 Visits per Calendar Year for Occu-

pational Therapy combined for all

tier levels

30 Visits per Calendar Year for Physi-

cal Therapy combined for all tier

levels

$25 Copay then 100%

Outpatient Hospital Setting

Covered at 75%

after deductible

Office Setting

$60 Copay then 100%


deductible

Speech Therapy

30 Visits per Plan Year combined for

all tier levels

$25 Copay then 100%

Outpatient Hospital Setting

Covered at 80%

after deductible

Office Setting

$60 Copay then 100%


deductible

Infertility Treatment

Benefit varies based on the

facility in which it is per-

formed. Lifetime benefit

maximum of $7,500.




maximum of $7,500.




maximum of $7,500.

PHARMACY INFORMATION

Prescription Drugs

Member Cost Share

UNC In-house

Pharmacies

30-day Supply

UNC In-house

Pharmacies

60-day Supply

UNC In-house

Pharmacies Mail Order

90-day Supply

Retail Pharmacies

30-day Supply

Generic $5 Copay $7.50 Copay $10 Copay $15 Copay

Preferred Brand $20 Copay $30 Copay $40 Copay $55 Copay

Non-Preferred Brand $35 Copay $52.50 Copay $70 Copay $80 Copay

Specialty $100 Copay No coverage No Coverage No Coverage


Healthcare is one of the most important and necessary parts of your benefit package. The following is a summary of our benefit plan. For

a more detailed explanation of benefits, please refer to your Summary Plan Description and Summary of Benefits and Coverage (SBC).

HSA Plan Summary



HIGH DEDUCTIBLE HEALTH PLAN (HDHP)

SUMMARY OF BENEFITS DOMESTIC NETWORK

UNC Providers

IN-NETWORK SERVICES

UHC Choice Plus Providers



DEDUCTIBLES & MAXIMUMS

Lifetime Benefit Maximum Unlimited Unlimited Unlimited

Annual Deductible $1,500 Single

$3,000 Family

$2,750 Single

$5,500 Family

$3,000 Single

$6,000 Family

Member Coinsurance 15% 25% 35%

Out-of-Pocket Maximum –

Includes Calendar Year Deductible

& Member Coinsurance

$3,000 Single

$6,000 Family

$5,000 Single

$10,000 Family

$5,000 Single

$10,000 Family

THE DEDUCTIBLE AND OUT-OF-POCKET MAX AMOUNTS FOR THE DOMESTIC NETWORK (UNC PROVIDERS) AND UHC CHOICE PLUS PROVID-

ERS CROSS-FEED.

PREVENTIVE CARE & OFFICE VISITS

Physician Office Visit

Primary Care & Specialist


deductible


deductible


deductible

Preventive Office Visit

Primary Care or Specialist Covered at 100% Covered at 100%


deductible

Well Baby Office Visit Covered at 100% Covered at 100% Covered at 65% after

deductible

Routine Lab & X-rays

Primary Care or Specialist Covered at 100% Covered at 100%


deductible

Vision Care Diagnostic visits only Covered at 100% Covered at 100% Covered at 100%

Prenatal Care

Does not include Sonograms Covered at 100% Covered at 100%


deductible

Postnatal Care Covered at 85% after

deductible


deductible


deductible

INPATIENT & OUTPATIENT SERVICES


deductible


deductible


deductible


deductible


deductible


deductible

Outpatient Hospital & Surgery

Services


deductible


deductible


deductible.


Outpatient Hospital Physician &

Surgeon Charges


deductible


deductible


deductible.


DIAGNOSTIC SERVICES

Outpatient Hospital Lab and

X-rays Charges


deductible


deductible


deductible

Independent Clinical Lab

Facilities


deductible


deductible


deductible

Outpatient Advanced Imaging

(MRI, MRA, CT, CAT Scan)


deductible


deductible


deductible

PET Scans Covered at 85% after

deductible


deductible


deductible

8


HSA Plan Summary

This booklet is intended for illustrative and information purposes only. The plan documents, insurance certificates and policies will serve as the governing documents. In the case

of conflict between the information in this booklet and the official plan documents, the plan documents will always govern.

SUMMARY OF BENEFITS

DOMESTIC NETWORK

UNC Providers

IN-NETWORK SERVICES

UHC Choice Plus Providers



URGENT CARE & EMERGENCY SERVICES

Urgent Care Includes Lab & X-ray & Physician Charges




Emergency Room Facility Ser-

vices & Physician Charges




MENTAL HEALTH/SUBSTANCE DEPENDENCY




deductible




deductible

Outpatient Hospital Services Covered at 85% after



deductible

Outpatient Hospital Physician

Charges




Physician Office Visit Primary Care providers




Specialist Office Visit Covered at 85% after



deductible

OTHER SERVICES

Chiropractic Care 30 Visits per Calendar Year combined for all tier levels




Durable Medical Equipment Covered at 85% after



deductible

Occupational & Physical Therapy

30 Visits per Calendar Year for Oc-cupational Therapy combined for all tier levels

30 Visits per Calendar Year for Physical Therapy combined for all tier levels




Speech Therapy 30 Visits/Plan Year combined for all tier levels




Infertility Treatment

Benefit varies based on the facility in which it is per-formed. Lifetime benefit

maximum of $7,500.

Benefit varies based on the facility in which it is per-formed. Lifetime benefit

maximum of $7,500.

Benefit varies based on the facility in which it is performed. Lifetime benefit maximum of

$7,500.

PHARMACY INFORMATION

Prescription Drugs

Member Cost Share

UNC In-house Pharmacies

30-day Supply

UNC In-house Pharmacies

60-day Supply

UNC In-house Pharmacies Mail Order

90-day Supply

Retail Pharmacies

30-day Supply

Generic Covered at 90% after




deductible

Preferred Brand Covered at 90% after




deductible

Non-Preferred Brand Covered at 80% after




deductible

Specialty Covered at 80% after

deductible No coverage No Coverage No Coverage

Preventive Medications Covered at 100%, Deductible Waived

Covered at 100%, Deductible Waived

Covered at 100%, Deductible Waived

Covered at 80% or 70% (dependent on

medication) after deductible


UNCHCS Pharmacy Services



UNC Health Care System Affiliate Health Plan

Pharmacy Benefits

Get the most out of your pharmacy benefit!

Save Money

Did you know you could save money on your prescriptions by using

one of the UNCHCS In-house Pharmacies?

All you have to do is transfer your prescriptions to one of the

UNCHCS In-house Pharmacies to begin saving TODAY!

Save Time

Enroll into home delivery and enjoy prescriptions delivered directly

to your home for up to a 90 day supply!

Currently, your pharmacy benefit includes two home delivery op-

tions: UNC Shared Services Center Pharmacy (for all members)

& Rex Pharmacy of Raleigh (for Rex Members)

Do You Need Specialty Pharmacy Services?

All Specialty Prescriptions are provided through the

UNCHCS In-house Pharmacy Network.

Please note Specialty prescriptions are limited to a 30 day supply.

For more details about the UNCHCS In-house Pharmacy Network and the Incentive

Program, please refer to the following page.

10


UNCHCS Pharmacy Services

This booklet is intended for illustrative and information purposes only. The plan documents, insurance certificates and policies will serve as the governing documents. In the case

of conflict between the information in this booklet and the official plan documents, the plan documents will always govern.

UNC Health Care System Affiliate Health Plan Pharmacy

Benefits

UNCHCS In-House Pharmacy Network UNCHCS Affiliation Pharmacy Phone

Caldwell Community Pharmacy 828-757-5162

Chatham Siler City Pharmacy 919-663-5541

High Point Regional High Point Regional Retail Pharmacy 336-878-6599

Hillsborough Hillsborough Outpatient Pharmacy 984-215-2060

Johnston Johnston Health Outpatient Pharmacy 919-938-7386

Nash Nash Employee Pharmacy 252-962-3880

Pardee Pardee Outpatient Pharmacy 828-696-1078

Rex Rex Pharmacy of Raleigh

Provides Home Delivery for Rex Members 919-784-3242

UNC Medical Center

Ambulatory Care Center Pharmacy 984-974-5705

Central Outpatient Pharmacy 984-974-2374

Employee Pharmacy - Preferred Employee Pharmacy for UNC Medical Center Campus 984-974-5415

Shared Services Pharmacy - Provides Home Delivery and Specialty Pharmacy Services 919-957-6900

UNCHCS In-house Pharmacy Network Incentive Program

Prescription Drug Type UNCHCS In-house Pharmacy Network

Day supply=30

UNCHCS In-house Pharmacy Network

Day supply=90

Retail (OptumRx Network)

Day supply=30

Co-pay Plan

Generic $5 $10 $15

Preferred Brand $20 $40 $55

Non-Preferred Brand $35 $70 $80

Specialty $100 $100 (30 day supply) No Coverage

Health Savings Account Health Plan

Generic 10% after Deductible 10% after Deductible 20% after Deductible

Preferred Brand 10% after Deductible 10% after Deductible 20% after Deductible

Non-Preferred Brand 20% after Deductible 20% after Deductible 30% after Deductible

Specialty 20% after Deductible 20% after Deductible

(30 day supply) No Coverage

Preventative Medication List

100% Covered;

no Deductible

100% Covered;

no Deductible

Deductible &

Co-insurance


Health Savings Account



We are pleased to be able to offer a HSA as part of the HDHP Medical Plan. The Health Savings Accounts are adminis-

tered by Optum Bank. Below are highlights of a Health Savings Account.

For calendar year 2017, you may deposit up to $3,400 if you have

single health coverage, and up to $6,750 if you cover dependents.

Contributions made to your HSA by Johnston Health ($500 for single

and $1,000 if dependents are covered) must be included in those

limits. If you are age 55 or older you may also make “catch up”

contributions of up to an additional $1,000 per calendar year.

You may deposit funds to your HSA on a pre-tax basis through payroll

deductions. Johnston Health will participate with you in funding your

HSA by making a contribution of $500 for single coverage and $1,000

if you cover dependents. We fund 50% of our contribution in January,

and the other 50% in July.

You may change, discontinue and resume HSA payroll deduction deposits at any time.

You are not required to spend the funds in your account each year as you are when enrolled in an FSA. Unspent

funds at the end of the year remain in your account to be spent as needed in the future.

Your funds will earn interest while in your HSA. After a minimum balance is reached, you may invest your funds in a

variety of mutual funds. Interest and investment earnings accrue in your account tax-free.

If you open an HSA you may not participate in our regular Medical Flexible Spending Account. You may participate

in a Limited Purpose FSA covering dental and vision costs.

You may spend funds in your account tax-free for all eligible medical, dental and vision expenses for you and your

family members, regardless of whether family members are covered by our health plan. If you spend the funds for

expenses that are not eligible, you will pay income tax on these expenditures plus a 20% penalty tax if you have not

yet reached Social Security retirement age. After you reach retirement age, expenditures that are not eligible will be

taxed as ordinary income, the same as withdrawals from qualified retirement plans.

You may also pay certain insurance premiums tax-free from your HSA:

COBRA premiums

Qualified long term care insurance premiums

Medicare premiums

You will not be required to provide documentation or receipts to Optum Bank. However, it is important to keep

receipts in case the IRS audits your expenditures.

You can reach Optum Bank at 1-866-234-8913 or online at www.optumbank.com.

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiK3uyv2uLOAhWDYiYKHYPeAc0QjRwIBw&url=http%3A%2F%2Fwww.americanhealthvalue.com%2Fhealth_savings_accounts%2Fwhat_is_an_hsa_%2F&psig=AFQjCNFYuEwynAt2NUrtqcRP3GtV19rse

12


Emergency Care/Urgent Care



Emergency Room (ER) vs. Urgent Care It’s second nature for many of us to visit the emergency room (ER) if we’re suddenly sick or injured – a sound idea, in

many cases. But what if you have an urgent, but non-life-threatening medical issue like a sinus infection or ankle

sprain?

A hefty ER wait time, and an even heftier hospital bill might not be your best option. Quicker, more affordable and

more convenient treatment is closer than you think: your local urgent care center. Many of these facilities are open

seven days a week, nights, weekends and even holidays with no appointments necessary.

Patients should be aware that their out of pocket cost is based on the facility they visit. It is usually much cheaper to go

to urgent care centers than ERs. The average urgent care visit costs patients $71-125 for basic care, with additional

costs added for shots, x-rays, and labs. The average emergency room visit costs $1,318.

Being informed about the differences and similarities between these kinds of facilities is important. Whether you choose

to receive care from an urgent care center or an emergency room, it is important to follow-up with additional treatments

as necessary.

Please be aware that some emergency room doctors are out of network for many insurance plans, even though the

facility is in network. These doctors may balance bill you for their charges. If this occurs, please provide a copy of the

bill to our representatives at Hylant to have the claim reviewed.

Comparisons for treatment for some of the most common

ailments at an emergency room vs. an urgent care center

Ailments Emergency

Room

Urgent Care

Center

Potential

Savings

Acute Bronchitis $814 $122 85%

Sore Throat $620 $93 85%

Low Back Pain $751 $113 85%

Attention to Dressing/

Removal of Sutures

$343 $76 78%

EXAMPLES OF TIMES YOU

SHOULD GO TO THE ER

Poisoning

Sudden, severe abdominal pain

Coughing up or vomiting blood

Cut or wound that will not stop bleeding

Major trauma or accident

Heart attack or chest pain

Loss of consciousness


UMR Resources



By registering online at www.umr.com, you have access to helpful information, including the ability to:

View your claims and download copies of your Explanation of Benefits (EOB’s)

View your health plan benefit information such as copays and deductible amounts

Find out how much you have paid towards your deductible and out-of-pocket maximum

Order duplicate or replacement ID cards

Search for network providers and medical facilities in your area

Find a glossary of common health care terms

We strongly encourage you to use this resource. The key to controlling health care costs is your informed engagement

in spending and treatment decisions. The information you need is at your fingertips.

Compare provider costs and become a more educated consumer at umr.com!

Health Education Library – offers health education content including Care Guides, DrugNotes, Drug Interaction

checker and Symptom Navigator.

myHealthcare Cost Estimator – provides fee schedule estimates of care costs and integrates health plan coverage

to estimate patient responsibility. Includes UHC Choice Plus network data grading physician quality and efficiency. The

tool allows you to comparison shop based on cost and quality before services are received.

Health Center – here you can search your health symptoms and find first aid information, utilize health education tools

including healthy body apps and calculators, watch step-by-step recipe videos, read health articles and much more!

Plan Cost Estimator – this tool helps you compare estimated healthcare expenses between our health plans so you

can decide which health plan is most appropriate for you and your family.

UMR Mobile

You can access your health plan benefit and

claim information on the go from a mobile de-

vice. Just go to www.umr.com on a mobile de-

vice and log in using the same username and

password that you use on the full site. It’s quick

and easy! There's no app to download, nothing

to install and no waiting. Go mobile today!

http://www.umr.com

http://www.umr.com

14


UNC Personal Health Advocate




UNC Personal Health Advocate



What is UNC Health Care Network Health Plan?

This is the health plan offered to UNC Health Care (UNCHC) em-ployees and their dependents across the system except for those employees who are NC state employees and their dependents who are offered the State Health Plan. Most employees will rec-ognize the UNC Health Care Network Health Plan as the health plan of their direct employer (e.g., “Pardee Health Plan” or “Caldwell Health Plan”).

Who will be invited to join the program?

Enrollment in 2017 is by invitation only to members with specific conditions or need for extra support such as members taking many medications or members with multiple disease states, can-cer, autoimmune disease, recent hospital discharges or multiple ED visits.

Are all employee covered by the UNCHC Network Health Plan

eligible to enroll?

Only employees who have primary health care coverage through the UNCHC Network Health Plan administered by UMR are eligi-ble and during 2017, employees and dependents must be invited to enroll.

If I get sick, can I request access to the program?

No, but if you are suffering from an illness that causes you to ac-cess multiple physicians, be admitted to the hospital or take more than ten prescription medications or certain medications, you may be eligible for the program.

I don’t want my employer to know my health information.

Who sees my health information?

Under federal HIPAA requirements, your private health information is private. Personal Health Advocate is part of UNCHC’s clinical operations, separate from UNCHC Human Resources or Employ-ee Health. All personal health information used as part of this pro-gram is protected with the same precautions as our patients’ health information.

I received a call or letter encouraging me to join. Why was I

contacted?

We are here to support you to achieve optimum health, based on your individual needs. A review of your claims history and health information suggests you could benefit from additional resources to help you manage your medical condition.

Can dependents enroll in the program?

Yes, if invited.

What is the cost?

This benefit is part of your health insurance plan and there is no additional cost to you.

To use this benefit, am I limited to UNCHC physicians and

facilities for care?

No, you may see any health care providers you choose and your Personal Health Advocate will work directly with your providers whether or not they are part of UNCHC. If you do not have a primary care physician, or would like to switch to a new one, we will help you with that.

What’s the benefit to UNCHC? Why are they offering this

program?

The good health of our employees and their dependents is very important to us. Our ultimate goal is to provide better care for members that have more complex care needs so that our employees and their dependents can be healthier and happier.

Do I have to join if asked?

No, the program is optional. However, there is a financial ben-efit and other valuable care coordination benefits associated with participation.

How is this different from other programs offered by

health insurance plans?

Unlike other programs, we will support your current treatment plan by coordinating directly with your physicians, the hospital or other health care providers that you may benefit from see-ing through comprehensive care management tailored to meet your needs. If you don’t currently have a treatment plan or access to appropriate providers, we can help you with these.

How is this different from the UNCHC health benefit,

Nurseline?

The UNC HealthLink Nurseline is another benefit of the UNC Health Care Network Health Plan for all plan members and their enrolled dependents. You can call the toll free number 24/7 and an experienced registered nurse will review symp-toms and determine if and when you should go to your primary care provider, urgent care or emergency room. They will sug-gest home care advice for urgent issues, discuss medications and can recommend a primary care physician within UNCHC. Members of the Personal Health Advocate program can use the UNC HealthLink Nurseline for urgent issues. The nurse assisting you will communicate with your Personal Health Ad-vocate to ensure we provide you with continuity of care.

16


Preventive Care



UMR is dedicated to helping people live healthier lives. We encourage you to obtain preventive care services and health

screenings, as appropriate for your age, to help maintain or improve your health and achieve your health and wellness

goals. Regular preventive care visits and health screenings may help to identify potential health risks for early diagnosis

and treatment. Consult your doctor for your specific preventive care recommendations, as he or she is your most im-

portant source of information about your health. Below and on the next page you will find a summary of preventive care

services covered under your health plan with UMR.

All Members

Preventive medicine for adults, all stand-

ard immunizations recommended by the Advisory

Committee on Immunization Practices of the Centers

for Disease Control and Prevention (CDC)

All Members at an Appropriate Age

and/or Risk Status

Screening for:

Obesity

Cholesterol level and lipids

Colorectal cancer for ages 50-plus

Certain sexually transmitted diseases, including HIV

Lung cancer with low-dose computer tomography

Men’s Health Services

Screening for:

Abdominal aortic aneurysm for men who are 65-75 years old who have ever smoked

Cardiovascular disease aspirin use counseling for ages 45+

High blood pressure

Diabetes for certain populations

Tobacco use

Diet and nutrition

Alcohol abuse

Depression

Well-man exam

Hepatitis C screening


Preventive Care



Women’s Health Services

Screening mammography (film and digital) for all adult women

Cervical cancer screening, including Pap smears

Breast cancer genetic test evaluation and counseling (BRCA)

Counseling for certain sexually transmitted diseases

Osteoporosis for certain populations

Pregnant women screenings for:

Iron-deficiency anemia

Bacteria in urine

Hepatitis B virus

Rh incompatibility

Rubella

Yearly well-women visits

Sexually transmitted infections counseling

Contraception methods and counseling

Domestic violence screening

Gestational diabetes screening

HIV screening and counseling

HPV testing (beginning at age 30)

Breastfeeding support and supplies, including renting or purchase of specified breast-feeding equipment from an approved vendor and counseling

Children’s Health Services

Services at each of these preventive visits will vary based on age, but will include some of the following:

Measurement of child’s head size

Measurement of length/height and weight

Screening blood tests, if appropriate

Providing age appropriate immunizations

Vision screening

Hearing screening

Counseling on oral health

Psychological and behavioral development assess-ment

Counseling on the harmful effects of smoking and illicit use of drugs (for older children and adoles-cents)

Counseling for children and their parents on nutri-tion and exercise

Screening certain children at high risk for choles-terol, sexually transmitted diseases, lead poison-ing, tuberculosis and more

Fluoride application in primary care

18


For 2017, Johnston Health will offer two dental insurance options from Ameritas: a Freedom of Choice Plan and a Network Plan.

The Freedom of Choice plan will cost more and provide benefit levels similar to our current Premium Plan with Ameri-tas. With this plan you may go to any dental provider. Payments from Ameritas to out of network providers will be at the 90th percentile of reasonable and customary charges.

The Network plan will cost less and is intended to reward you for going to Ameritas network dental providers. Benefit levels are the same in this plan as the Freedom of Choice Plan. Network providers will accept Ameritas’ payment as payment in full, and cannot balance bill you. Non-network providers will be paid by Ameritas at the 50th percentile of reasonable and customary charges and may balance bill you for the difference.

To see a list of participating providers go to: www.ameritas.com. Click on Find a Provider. We use the Classic (PPO) network.

Dental



Summary of Dental Plan Benefits

Network Plan Freedom of Choice Plan

In Network Out of Network In Network Out of Network

Preventive Services 100% 100% 100% 100%

Basic Services 80% 80% 80% 80%

Major Services 50% 50% 50% 50%

Deductible (Waived for

Preventive) Calendar Year Deductible

Individual

Family

$50

$150

$50

$150

Reimbursement Level Network Fee Network Fee 50th % Reasonable &

Customary

90th % of Reasonable

& Customary

Maximum Annual

Benefit (per person) $1,500 $1,500

Orthodontics (Children

and adults)* 50% up to $1,500 Lifetime Max (no deductible) 50% up to $1,500 Lifetime Max (no deductible)

Ameritas Resources

Create an online secure member account at www.ameritas.com to view your dental benefit information, view or

print your ID card, find a provider or use the Dental Cost Estimator tool to estimate of out of pocket costs based

on zip code and procedure.

Download the Ameritas Provider Locator app for your mobile phone to access a map of provider locations and

call a provider’s office to schedule an appointment.

Utilize the customized Ameritas website for UNCHCS co-workers at www.Ameritas.com/group/olbc/UNCHCS.

*You may go to any orthodontist in either plan and your orthodontist will be paid at the 90th percentile of reasonable and customary charges.


Dental Rewards Benefit

Both dental plans include a valuable feature that allows qualifying plan members to carryover part of their unused

annual maximum.

To qualify, a member must visit the dentist and not exceed the paid claims threshold during the benefit year.

Employees and covered dependents may accumulate rewards up to the stated maximum carryover amount

shown in the box below, and then use those rewards for any covered dental procedures subject to applicable

coinsurance and plan provisions. In this way, prudent users of this benefit can accumulate additional coverage

that will be available in future years.

If you or your covered dependent do not submit a dental claim during the benefit year, all accumulated rewards are

lost. But he or she can begin earning rewards again the very next year.



Paid Claims Threshold: $500

Annual Carryover Amount: $250

Annual In-Network provider bonus: $100

Maximum Carryover: $1,000

https://www.google.com/imgres?imgurl=http%3A%2F%2Fwww.dentalinsurance.org%2Fblog%2Fwp-content%2Fuploads%2FDental-Insurance-Cost.jpg&imgrefurl=https%3A%2F%2Fwww.dentalinsurance.org%2Fblog%2Findex.php%2F2014%2F05%2Fhow-much-does-dental-insurance-cost%2F&do

20


We offer two vision plans through EyeMed, the Standard Plan and the Premium Plan.

Both plans are designed to provide routine preventive care such as eye exams,

eyewear and other vision services along with discounts on a second pair of glasses

and balances over your allowances.

EyeMed has a large network of providers that offers a wide selection of eyewear for

you to choose from. You’ll receive the most out of your benefit when you visit an

EyeMed network doctor.

The EyeMed network is comprised of both independent and optical retail locations. To locate a participating provider,

visit the EyeMed website at www.eyemed.com and choose the INSIGHT network.

To access laser vision discount, call the US Laser network at 1-877-5laser6 to find the laser correction provider closest

to you. Tell the provider that you are an EyeMed member.

Vision

Standard Plan Benefit Summary

In-Network Benefits Out-of-Network Benefits

Annual Eye Exam

(every 12 months) $10 Copay Up to $30 reimbursement

Lenses (every 12 months)

Single Vision

Bifocal

Trifocal

Lenticular

$25 Copay

100% after Copay

100% after Copay

100% after Copay

100% after Copay

Up to $25 reimbursement




Frames

(every 24 months)

$0 copay, up to $150 retail allowance, then

20% discount off balance Up to $75 reimbursement

Contact Lenses in lieu of

glasses (every 12 months)

Elective

Medically Necessary

Up to $150 allowance

Covered in full






Vision



Premium Plan Benefit Summary

In-Network Benefits Out-of-Network Benefits

Annual Eye Exam

(every 12 months) $0 Copay Up to $32 reimbursement

Lenses (every 12 months)

Single Vision

Bifocal

Trifocal

Lenticular

$20 Copay

100% after Copay

100% after Copay

100% after Copay

100% after Copay





Frames

(every 12 months) $0 copay, up to $200 retail allowance, then

20% discount off balance Up to $100 reimbursement

Contact Lenses in lieu of

glasses (every 12 months)

Elective

Medically Necessary

Up to $200 allowance

Covered in full



22


Short Term Disability (STD) insurance is designed to provide you with a periodic income in the event you cannot work for

a short period of time due to a disabling illness or accident.

We offer Short Term Disability insurance through Sun Life to full time employees - the cost of this benefit is paid in full

by Johnston Health. The plan provides financial protection by paying a portion of your income while you are disabled.

The benefit you receive is based on your pre-disability earnings - the amount you earned before your disability began. The

benefit starts after it has been medically determined that you meet the plan's definition of disability.

Short Term Disability

Short Term Disability Benefit Summary

Benefit Amount 60% of Weekly Income

Benefit Maximum $2,500 per week

Benefit Begins On 31st day of disability for injury or illness

Pre-existing Condition

Limitation None

Maximum Benefit Period Benefits may be payable up to 90 days



Long Term Disability Long Term Disability (LTD) insurance is designed to provide you with a periodic income in the event you cannot work for

an extended period of time due to a disabling illness or accident. We offer Long Term Disability insurance to full time

employees through Sun Life - the cost of this benefit is paid in full by Johnston Health.

Long Term Disability Benefit Summary

Benefit Amount 60% of Monthly Income

Benefit Maximum $10,000 Per Month

Benefit Begins On 91st day of disability

Benefit Limitations 24 months for Mental Illness and Substance Abuse

Preexisting Condition

Limitation

3/12 Exclusion (No coverage for disabilities which begin during the first 12 months insured, if

treatment for disabling condition was received within 3 months prior to effective date)

Maximum Benefit

Period

Benefits are payable up to 2 years if unable to perform the duties of your job, or to Social

Security Retirement Age if unable to perform the duties of any job.


Johnston Health pays the cost of this benefit insured by Sun Life. Life insurance provides a monetary benefit to your

beneficiary in the event of your death while you are employed at Johnston Health. It is important to keep your

beneficiary information up-to-date.

Plan Features Benefit Amount

Life Insurance Class 1: 1.5x annual earnings up to $400,000

Class 2: 1.5x annual earnings up to $750,000

Accidental Death and

Dismemberment Benefit up to 100% of the Life amount due to certain injuries or death from an accident

Benefit Reduction

Schedule Coverage reduces to 67% at age 65 and to 50% at age 70

Accelerated Death

Benefit A percentage of this benefit may be withdrawn when diagnosed with a terminal illness

Additional Information Coverage may be converted or ported by contacting Sun Life within 30 days of termination of

employment

Life and Accidental Death & Dismemberment (AD&D)

Supplemental Life Insurance Though our Life/AD&D program provides valuable protection, it may not be enough for you; therefore, we offer a Supplemental Life insurance program through Sun Life that allows you to purchase additional coverage for yourself and your dependents. You pay 100% of the cost of this additional life insurance. During this enrollment, you can purchase supplemental life insurance for yourself, your spouse and your children up to the Guarantee Issue amounts

with no Evidence of Insurability (EOI) required. Existing amounts over GI maximums are grandfathered.

Coverage may be converted or ported by contacting Sun Life within 30 days of termination of employment.

Plan Features Benefit Amount

Employee Life

Insurance $10,000 increments to lesser of 5x pay or $750,000

Spouse Life Insurance $5,000 increments up to $250,000

Dependent Child(ren)

Life Insurance $5,000 or $10,000 for each child

Benefit Reduction

Schedule Coverage reduces to 67% at age 65 and to 50% at age 70

Maximum Benefit $750,000 for Employees, $250,000 for Spouses and $10,000 for Children

Guarantee Issue

$350,000 for Employees, $25,000 for Spouse, $10,000 for Children

For amounts higher than the Guarantee Issue, Evidence of Insurability (EOI) is required. Coverage is subject to carrier’s approval.

You must buy coverage on yourself in order to buy coverage for your dependents.



24


Sun Life Value Added Benefits



Sun Life offers value added benefits to its covered members. These benefits include Identity Theft Protection and

Emergency Travel Assistance through Assist America. Below are additional details about these benefits.

Services Benefit Information

Identity Theft Protection services

from Assist America’s SecurAssist

Identity Protection Program provides:

24/7 telephone support and step by step guidance by anti-fraud experts

Expert case worker assigned to you will help you notify your credit bureaus

and file paperwork to correct your credit reports

Help canceling stolen cards and reissuing new cards

Help notifying police, financial institutions and government agencies

If you or your family member are the victim of financial or medical identity

fraud, call 1-877-409-9597

Emergency Travel Assistance

If you have a medical emergency while you are more than 100 miles away

from home, you can receive assistance from Assist America’s medically

trained staff

Free Assist America Mobile App (download, and log in with your reference

number 01-AA-SUL-100101. You can view a list of services, download a

membership card, call Assist America’s Operations Center for assistance.

Medical consultation, evaluation & referral

Foreign hospital admission assistance

Emergency medical evacuation

Lost prescriptions, luggage or document assistance

If you or a family member has a medical emergency while traveling more

than 100 miles from home, contact Assist America’s Emergency Travel

Assistance at 1-800-872-1414 or 301-656-4152 outside of the U.S. You can

email them at [email protected].


Flexible Spending Account

What Is It Used For?

The IRS permits you to pay certain health and dependent related expenses with earnings that are not taxed. If you are in the 28% tax bracket, for example, your earnings are reduced by nearly 36% in Federal taxes (28% income tax and 7.65% FICA tax).

If you or your family have predictable medical, dental or eye care costs that are not fully reimbursed by insurance, you could benefit from our Medical Care Account. Eligible expenses include your deductibles, copays and coinsur-ance under our health insurance plans, dental expenses, orthodontics, eye exams, glasses and contact lenses, hearing aids, etc.

Under Health Care Reform over-the-counter medica-tions are not considered eligible expenses for the Medical Care Account without a prescription from your

physician.

The Dependent Care Account allows you to pay for daycare expenses for children under age 13, or for a disabled dependent of any age living in your home, if such daycare is necessary to enable you to work.

How Does It Work?

You choose the dollar amount you want to contribute to each account based on your estimated expenses for the upcoming year. For the Medical Care Account the entire contribution you have elected will be available immediate-ly. For the Dependent Care Account only the amounts that have been deposited from your pay will be available. Your contributions will be deducted in equal amounts from each paycheck pre-tax throughout the plan year. The important thing is that the deposits to your account are not taxed and are used by you tax-free. The result is a direct saving to you equal to the taxes you would otherwise pay on this income.

How Much Can I Contribute to the FSA Plan?

Medical Flexible Spending or Limited Purpose FSA:

$2,550 Maximum

Dependent Care Flexible Spending:

$5,000 married couple filing jointly OR

$2,500 per person if filing separate returns

Rules and Contact Information

There are important rules which you must understand before electing to participate. For example, once you have elected to have a specified amount deducted from each paycheck, you cannot change your election until the end of the plan year unless you experience a qualified change in status. There is also a risk of forfeiture. Any balance left in your account at the end of the plan year is forfeited. It cannot be refunded to you. If you currently pay daycare in order to work, you may receive a tax credit on your tax return. In lower tax brackets the tax credit may be more valuable than the benefits of the Dependent Care Account. You should consult your tax advisor.

What is a Limited Purpose Health FSA?

When you enroll in an HSA medical plan and open a Health Savings Account, you can also contribute to a Limited Purpose Flexible Spending Account to pay for eligible dental and vision expenses. You cannot use your Limited Purpose FSA to pay medical expenses. You may contribute up to $2,550 per year in a Limited Purpose FSA.

Our Flexible Spending Accounts are administered by P&A Group. You may call a specialist at 1-800-688-2611. You may track your balance and transactions by logging in at www.padmin.com.



http://www.mywealthcareonline.com/medcom

26


Retirement Plan Highlights

Our 457(b) and 401(a) Retirement Plans provide retirement income and tax benefits for you. These important features

help you save:

Convenient Payroll Deductions - You may contribute up to 100% of your pay, subject to a calendar year maximum

of $17,500.

Age 50 Catch-up Contributions - If you will be at least age 50 by the end of the calendar year, you may contribute

an additional $5,500.

Matching Contributions - For each $1.00 you contribute up to the first 5% of your eligible earnings per pay period,

Johnston Health will add $0.50 to your account.

Discretionary Contributions - Johnston Health may make an additional 2% discretionary contribution as of each

December 31, based on your annual earnings for that calendar year. You must have been employed for 12 months, completed 1,000 or more hours in the calendar year and be employed as of the last day of the plan year (December 31) to be eligible for the Discretionary Contributions.

Lower Income Taxes - Contributing to the plan lowers your present income taxes because your contributions are

tax-deferred.

Tax-Deferred Earnings - As long as the money stays in the plan, your earnings compound tax-deferred.

Choice of Investment Funds - You will have a choice of investing in up to 11 different Mutual funds or 4 “Risk

Based” Asset Models.

On any January 1, April 1, July 1 or October 1, you can increase or decrease the amount you contribute. You may

stop your contributions at any time, however, you may not re-enter the plan until the beginning of the next calendar quarter (January 1, April 1, July 1, October 1).

All employees hired after September 30, 2011 that are classified as either Full-Time or Part-Time with benefits are

eligible to participate in the plan as of the first day of the payroll period following their date of employment. To enroll in the Plan, simply complete an enrollment form. Contact Human Resources for more details.

You will receive a personalized Account statement four times each year (after the end of each calendar quarter) in

order to check your savings progress and have a record for your files.

Employee Contributions are 100% vested at all times. Employer contributions will vest as follows:



Years of Service % Vested

Less than 5 years 0%

5 or more 100%


Important Disclosures

NOTE TO ALL EMPLOYEES: Certain State and Federal Reg-ulations require employers to provide disclosures of these regu-lations to all employees. The remainder of this document pro-vides you with all of the required disclosures related to our em-ployee benefits plan. If you have any questions or need further assistance please contact your Plan Administrator as follows:

Johnston Health Human Resources 509 N Bright Leaf Blvd, PO Box 1376, Smithfield, NC 27577

THIS DOCUMENT IS FOR INFORMATION PURPOSES ONLY This communication is intended for illustrative and information purposes only. The plan documents, insurance certificates, and policies will serve as the governing documents to determine plan eligibility, benefits, and payments.

LIMITATIONS AND EXCLUSIONS Insurance and benefit plans always contain exclusions and limitations. Please see ben-efit booklets and/or contracts for complete details of coverage and eligibility.

ALL RIGHTS RESERVED Johnston Health reserves the right to amend, modify, or terminate its insurance and benefit plans at any time, including during treatment.

NOTICE REGARDING SPECIAL ENROLLMENT RIGHTS If you do not timely or properly complete the enrollment process, you and your Eligible Dependents generally will not be covered under the applicable Plan, except as described below. Also, if you fail to specifically enroll your Eligible Dependents on the enrollment form, your Eligible Dependents will not be covered under the applicable Plan, except as otherwise provided below.

(a.) If you decline enrollment because you or your dependent had other group health plan coverage, either through COBRA or otherwise, you may enroll yourself and Eligible Dependents in the Medical Program within 30 days of the loss of that coverage. Your enrollment will become effective on the date you enroll in the Medical Program. For this purpose, “loss of coverage” will occur if the other group health plan coverage terminates as a result of: (i) termination of employer contributions for the other coverage; (ii) exhaustion of the maximum COBRA period; (iii) legal separation or divorce; (iv) death; (v) termination of employ-ment; (vi) reduction in hours of employment; or (vii) failure to elect COBRA coverage. However, a loss of coverage will not be deemed to occur if the other coverage terminates due to a failure to pay premiums or termination for cause. At the time you enroll in the Employer’s Plan, you must provide a written statement from the administrator of the other medical plan that you no long-er have that coverage.

(b.) You are eligible to enroll yourself and your Eligible Depend-ent in the Medical Program within 30 days of the date you ac-quire a new Eligible Dependent through marriage, birth, adoption or placement for adoption. Your enrollment will become effective on the date of marriage, birth, adoption or placement for adop-tion.

(c.) You are eligible to enroll yourself and your Eligible Depend-

ent in the Plan within 60 days after either:

(1.) Your or your Eligible Dependent’s Medicaid coverage under title XIX of the Social Security Act or CHIP coverage through a State child health plan under title XXI of the Social Security Act is terminated as a result of loss of eligibility for such coverage; or

(2.) You or your Eligible Dependent is determined to be eligible for employment assistance under Medicaid or CHIP to help pay for coverage under the Plan.

(d.) You are eligible to enroll yourself and your Eligible Depend-ents in the Plan during an Open Enrollment Period. Your enroll-ment will become effective on the 1st day of the Plan Year follow-ing the Open Enrollment Period.

(e.) You may enroll in the Plan an Eligible Dependent child for whom you are required to provide medical coverage pursuant to a Qualified Medical Child Support Order (as defined under ERISA Section 609). This enrollment of an Eligible Dependent will be-come effective as of the Plan Administrator’s qualification and acceptance of the Qualified Medical Child Support Order.

(f.) You are eligible to enroll yourself and your Eligible Depend-ents in the Plan under any other special circumstances permitted under the applicable Benefits Guide (and subject to the Cafeteria Plan rules outlined in Section 125 of the Internal Revenue Code).

NOTE: You will not be allowed to enroll yourself and/or Eligible Dependents for coverage in the Plan for a Plan Year unless you timely and affirmatively complete the enrollment process by the deadlines set forth above (i.e. within 30 days for loss of coverage or new dependents; within 60 days for Medicaid or CHIP circum-stances; within 30 days of receipt of this notice for a dependent under the age of 26; or within the deadline established by the Plan Administrator for Open Enrollment Period). Should you have any questions regarding this information or require additional de-tails, please contact the Plan Administrator at the address below.

Johnston Health Human Resources 509 N Bright Leaf Blvd, PO Box 1376, Smithfield, NC 27577 HOW TO REQUEST A CERTIFICATION OF CREDITABLE COVERAGE FROM THIS PLAN: HIPAA also requires any medical program offered by the Employer to provide certificates of creditable coverage to you after you lose coverage under such medical program. This certificate allows you to use your cover-age under the medical program to reduce or eliminate any pre-existing condition exclusion period that might otherwise apply to you when you change health care plans. You also may request a certificate of creditable coverage for periods of coverage on and after July 1, 1996, within 24 months of your loss of coverage. To request a HIPAA Certificate of Creditable Coverage, please con-tact the insurance company customer service department by call-ing the phone number on your healthcare identification card. If you are unable to obtain the certificate of coverage through the carrier, or have other questions regarding Pre-existing Conditions, please contact the Plan Administrator for assistance at the ad-dress below.


NOTICE REGARDING WOMEN’S HEALTH AND CANCER RIGHTS ACT (JANET’S LAW) On October 21, 1998, Congress passed a Federal Law known as the Women’s Health and Cancer Rights Act. Under the Women's Health and Cancer Rights Act, group health plans and insurers offering mastectomy coverage must also provide coverage for:

Reconstruction of the breast on which the mastectomy was

28



performed;

Surgery and reconstruction of the other breast to produce a

symmetrical appearance; and

Prostheses and treatment of physical complications at all stages of the mastectomy, including lymph edemas

These services are payable to a patient who is receiving bene-fits in connection with a mastectomy and elects reconstruction. The physician and patient determine the manner in which these services are performed. The plan may apply deductibles and copayments consistent with other coverage within the plan. This notice serves as the official annual notice and disclosure of that the fact that the company’s health and welfare plan has been designed to comply with this law. This notification is a require-ment of the act.

The Women’s Health and Cancer Rights Act (Women’s Health Act) was signed into law on October 21, 1998. The law includes important new protections for breast cancer patients who elect breast reconstruction in connection with a mastectomy. The Women’s Health Act amended the Employee Retirement In-come Security Act of 1974 (ERISA) and the Public Health Ser-vices Act (PHS Act) and is administered by the Departments of Labor and Health and Human Services.

NOTICE REGARDING MICHELLE’S LAW

On Thursday, October 9, 2008, President Bush signed into law H.R. 2851, known as Michelle’s Law. This law requires employer health plans to continue coverage for employees’ dependent children who are college students and need a medically neces-sary leave of absence. This law applies to both fully insured and self-insured medical plans.

The dependent child’s change in college enrollment must meet the following requirements:

The dependent is suffering from a serious illness or injury.

The leave is medically necessary.

The dependent loses student status for purposes of cover-age under the terms of the plan or coverage.

Coverage for the dependent child must remain in force until the earlier of:

One year after the medically necessary leave of absence

began.

The date the coverage would otherwise terminate under the terms of the plan.

A written certification by the treating physician is required. The certification must state that the dependent child is suffering from a serious illness or injury and that the leave is medically neces-sary. Provisions under this law become effective for plan years beginning on or after October 9, 2009.

NOTICE REGARDING NEWBORNS AND MOTHERS HEALTH

PROTECTION ACT

Group health plans and health insurance issuers offering group health insurance may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child for less than 48 hours following normal vaginal delivery, or less than 96 hours following a cesarean sec-tion, or require that a provider obtain authorization from the plan or insurance issuer to prescribe a length of stay not in excess of the above periods.

MEDICARE NOTICE

You must notify Johnston Health when you or your dependents become Medicare eligible. Johnston Health is required to contact the insurer to inform them of your Medicare status. Federal law determines whether Medicare or the group health plan is the pri-mary payer. You must also notify Medicare directly that you have group health insurance coverage. Privacy laws prohibit Medicare from discussing coverage with anyone other then the Medicare beneficiary or their legal guardian. The toll free number to Medi-care Coordination of Benefits is 1-800-999-1118.

If you have Medicare or will become eligible for Medicare in the next 12 months, a Federal law gives you more choices in your prescription drug plan. Please see the complete Medicare Part D Non-Creditable Coverage Notice. Should you have any ques-tions regarding this information or require additional details, please contact the Plan Administrator at the address below.


NOTICE REGARDING PATIENT PROTECTION RIGHTS The Johnston Health group health plan does not require mem-bers to designate a Primary Care Physician. The following para-graphs outline certain protections under the PPACA and only apply when the Plan requires the designation of a Primary Care Physician.

One of the provisions in the PPACA of 2010 is for plans and in-surers that require or allow for the designation of primary care providers by participants to inform the participants of their rights beginning on the first day of the first plan year on or after Sep-tember 23, 2010.

You will have the right to designate any primary care provider who participates in the Plan’s network and who is available to accept you and/or your Eligible Dependents. For children, you may designate a pediatrician as the primary care provider. You also do not need prior authorization from the Plan or from any other person (including your primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in the Plan’s network. The health care profes-sional, however, may be required to comply with certain proce-dures, including obtaining prior authorization for certain services, following a pre-approved treatment plan or procedures for mak-ing referrals or notifying primary care provider or Plan of treat-ment decisions.

If you do not make a provider designation, the Plan may make one for you. For information on how to select or change a prima-ry care provider, and for a list of the participating primary care providers, pediatricians, or obstetrics or gynecology health care professionals, please contact the insurer.

Should you have any questions regarding this information or re-quire additional details, please contact the Plan Administrator at the address below.



IMPORTANT INFORMATION ABOUT YOUR PRESCRIPTION

DRUG COVERAGE AND MEDICARE

Please note that the following notice only applies to individu-

als who are eligible for Medicare. Medicare eligible individu-

als may include employees, spouses or dependent children who

are Medicare eligible for one of the following reasons.

Due to the attainment of age 65

Due to certain disabilities as determined by the Social Securi-

ty Administration

Due to End Stage Renal Disease (ESRD)

If you are covered by Medicare, please read this notice carefully

and keep it where you can find it. This notice has information

about your current prescription drug coverage with Johnston

Healthand 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 consider-

ing joining, you should compare your current coverage, includ-

ing which drugs are covered at what cost, with the coverage

and costs of the plans offering Medicare prescription drug cov-

erage 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. Johnston Health has determined that the prescription drug

coverage offered by their carrier’s Benefits Plan is, on aver-

age for all plan participants, expected to pay out as much as

standard Medicare prescription drug coverage pays and is

therefore considered Creditable Coverage. If 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 15th

through December 7th. 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 Spe-

cial 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 cover-

age will not be affected. Your current coverage pays for other

health expenses in addition to prescription drugs. The pre-

scription drug coverage is part of the Group Health Plan and

cannot be separated from the medical coverage. If you enroll

in a Medicare prescription drug plan, you and your eligible

dependents will still be eligible to receive all of your current

health and prescription drug benefits. You have the option to

waive the coverage provided under the Group Health plan

due to your eligibility for Medicare. If you decide to waive

coverage under the Group Health Plan due to your Medicare

eligibility, you will be entitled to re-enroll in the plan during the

next open enrollment period.

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 and don’t join a Medicare drug plan within 63 con-

tinuous 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 credita-

ble prescription drug coverage, your monthly premium may

go up by at least 1% of the Medicare base beneficiary premi-

um per month for every month that you did not have that cov-

erage. For example, if you go nineteen months without cred-

itable 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.


30


For More Information About This Notice or Your Current

Prescription Drug Coverage…

Contact your HR Representative. 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 your compa-

ny changes. You also may request a copy of this notice at

any time.

For More Information About Your Options Under Medi-

care Prescription Drug Coverage…

More detailed information about Medicare plans that offer

prescription drug coverage is in the “Medicare & You” hand-

book. You’ll get a copy of the handbook in the mail every year

from Medicare. You may also be contacted directly by Medi-

care drug plans. For more information about Medicare pre-

scription drug coverage:

Visit www.medicare.gov

Call your State Health Insurance Assistance Pro-

gram (see the inside back cover of your copy of

the “Medicare & You” handbook for their tele-

phone 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 in-

formation, visit Social Security at www.socialsecurity.gov, or

call 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 coy of this notice when you join

to show whether or not you have maintained creditable

coverage and, therefore, whether or not you are require

to pay a higher premium (penalty).

Johnston Health

Human Resources

509 N Bright Leaf Blvd, PO Box 1376, Smithfield, NC

27577

NOTICE OF RESCISSION OF COVERAGE

Under Health Care Reform, your coverage may be rescinded

(i.e., retroactively revoked) due to fraud or intentional misrep-

resentation regarding health benefits or due to failure to pay

premiums. A 30 day advance notice will be provided before

coverage can be rescinded.


FORM 1095-C

The Affordable Care Act (ACA) continues to impact the health

insurance industry. At Johnston Health, we value our employees

and are committed to providing you and your family with afforda-

ble, substantial health benefits that meet the requirements of

“minimum essential coverage” under the ACA. You will be re-

ceiving the forms listed below by March 2017, similar to how you

receive your W-2 each year. The purpose of the form is to report

to the IRS that you were offered minimum essential health cov-

erage during 2016.

Form 1095-C is being provided to you by Johnston Health

as proof of the health coverage we offer you and your family. It

contains information about who provides the health insurance,

as well as information about the health coverage that was of-

fered to you. It also lists the lowest monthly premium that you

could have elected for the self-only health benefits we offered to

you.

What Do I Do With This Form?

You can use this form to help you report your insurance cover-

age when filing your tax return. Keep a copy of the form with

your tax records. Only one form is provided for all the individu-

als listed on your policy, you may need to provide copies to your

spouse or dependents, as necessary.

Summary of Benefits & Coverage (SBC)

The Summary of Benefits & Coverage (SBC) is a document in-

tended to help people understand their health coverage and

compare health plans when shopping for coverage.

The federal government requires all healthcare insurers and

group health care sponsors to provide this document to plan

participants. Group health plan sponsors must provide a copy of

the SBC to each employee eligible for coverage under the plan.

The SBC includes:

· A summary of the services covered by the plan

· A summary of the services not covered by the plan

· A glossary of terms commonly used in health insurance

· The copays and/or deductibles required by the plan, but not the premium

· Information about members’ rights to continue coverage

· Information about members’ appeal rights

· Examples of how the plan will pay for certain services

The SBCs are available electronically on your employer intranet

site. A paper copy is also available, free of charge, by calling

Human Resources.

http://www.medicare.gov/

http://www.socialsecurity.gov/


HIPAA Privacy Notice

32



For Law Enforcement Purposes. We may disclose your health information to a law enforcement official for purposes such as providing limited information to locate a missing per-son or report a crime.

To Avoid a Serious Threat to Health or Safety to you, an-other person, or the public, by, for example, disclosing infor-mation to public health agencies or law enforcement authori-ties, or in the event of an emergency or natural disaster.

For Specialized Government Functions such as military and veteran activities, national security and intelligence activi-ties, and the protective services for the President and others.

For Workers’ Compensation as authorized by, or to the extent necessary to comply with, state workers compensation laws that govern job-related injuries or illness.

For Research Purposes such as research related to the evaluation of certain treatments or the prevention of disease or disability, if the research study meets federal privacy law re-quirements.

To Provide Information Regarding Decedents. We may disclose information to a coroner or medical examiner to identi-fy a deceased person, determine a cause of death, or as au-thorized by law. We may also disclose information to funeral directors as necessary to carry out their duties.

For Organ Procurement Purposes. We may use or dis-close information to entities that handle procurement, banking or transplantation of organs, eyes or tissue to facilitate dona-tion and transplantation.

To Correctional Institutions or Law Enforcement Officials if you are an inmate of a correctional institution or under the custody of a law enforcement official, but only if necessary (1)for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

To Business Associates that perform functions on our behalf or provide us with services if the information is neces-sary for such functions or services. Our business associates are required, under contract with us and pursuant to federal law, to protect the privacy of your information and are not al-lowed to use or disclose any information other than as speci-fied in our contract and as permitted by federal law.

Additional Restrictions on Use and Disclosure. Certain federal and state laws may require special privacy protections that restrict the use and disclosure of certain health infor-mation, including highly confidential information about you. “Highly confidential information” may include confidential infor-mation under federal laws governing alcohol and drug abuse information and genetic information as well as state laws that often protect the following types of information:

HIV/AIDS; Mental health; Genetic tests; Alcohol and drug abuse; Sexually transmitted diseases and reproductive health information; and Child or adult abuse or neglect, including sex-ual assault.

If a use or disclosure of health information described above in this

notice is prohibited or materially limited by other laws that apply to

us, it is our intent to meet the requirements of the more stringent

law. Attached to this notice is a “Federal and State Amendments”

document.

Except for uses and disclosures described and limited as set forth

in this notice, we will use and disclose your health information

only with a written authorization from you. This includes, except

for limited circumstances allowed by federal privacy law, not using

or disclosing psychotherapy notes about you, selling your health

information to others, or using or disclosing your health infor-

mation for certain promotional communications that are prohibited

marketing communications under federal law, without your written

authorization. Once you give us authorization to release your

health information, we cannot guarantee that the recipient to

whom the information is provided will not disclose the information.

You may take back or "revoke" your written authorization at any

time in writing, except if we have already acted based on your

authorization. To find out where to mail your written authorization

and how to revoke an authorization, contact the phone number

listed on your ID card.

What Are Your Rights

The following are your rights with respect to your health infor-

mation:

You have the right to ask to restrict uses or disclosures of

your information for treatment, payment, or health care opera-

tions. You also have the right to ask to restrict disclosures to fami-

ly members or to others who are involved in your health care or

payment for your health care. We may also have policies on de-

pendent access that authorize your dependents to request certain

restrictions. Please note that while we will try to honor your re-

quest and will permit requests consistent with our policies,

we are not required to agree to any restriction.

You have the right to ask to receive confidential communica-

tions of information in a different manner or at a different

place (for example, by sending information to a P.O. Box instead

of your home address). We will accommodate reasonable re-

quests where a disclosure of all or part of your health information

otherwise could endanger you. In certain circumstances, we will

accept your verbal request to receive confidential communica-

tions, however, we may also require you confirm your request in

writing. In addition, any requests to modify or cancel a previous

confidential communication request must be made in writing. Mail

your request to the address listed at the end of this notice.



You have the right to see and obtain a copy of certain

health information we maintain about you such as claims and

case or medical management records. If we maintain your

health information electronically, you will have the right to re-

quest that we send a copy of your health information in an

electronic format to you. You can also request that we provide

a copy of your information to a third party that you identify. In

some cases you may receive a summary of this health infor-

mation. You must make a written request to inspect and copy

your health information or have your information sent to a third

party. Mail your request to the address listed below. In certain

limited circumstances, we may deny your request to inspect

and copy your health information. If we deny your request, you

may have the right to have the denial reviewed. We may

charge a reasonable fee for any copies.

You have the right to ask to amend certain health infor-

mation we maintain about you such as claims and case or

medical management records, if you believe the health infor-

mation about you is wrong or incomplete. Your request must

be in writing and provide the reasons for the requested

amendment. Mail your request to the address listed below. If

we deny your request, you may have a statement of your disa-

greement added to your health information.

You have the right to receive an accounting of certain dis-

closures of your information made by us during the six years

prior to your request. This accounting will not include disclo-

sures of information made: (i) for treatment, payment, and

health care operations purposes; (ii) to you or pursuant to

your authorization; and (iii) to correctional institutions or law

enforcement officials; and (iv) other disclosures for which fed-

eral law does not require us to provide an accounting.

You have the right to a paper copy of this notice. You may

ask for a copy of this notice at any time. Even if you have

agreed to receive this notice electronically, you are still entitled

to a paper copy of this notice. You also may also obtain a copy

of this notice on your health plan website, such as

www.myuhc.com or www.uhcwest.com.

Exercising Your Rights

Contacting your Health Plan. If you have any questions

about this notice or want information about exercising your

rights, please call the toll-free member phone number on your

health plan ID card or you may contact a UnitedHealth Group

Customer Call Center Representative at 1-866-633-2446 (TTY

711).

Submitting a Written Request. Mail to us your written re-

quests to exercise any of your rights, including modifying or

cancelling a confidential communication, requesting copies of

your records, or requesting amendments to your record, at the

following address:

UnitedHealthcare

Customer Service - Privacy Unit

PO Box 740815

Atlanta, GA 30374-0815

Filing a Complaint. If you believe your privacy rights have

been violated, you may file a complaint with us at the address

listed above.

You may also notify the Secretary of the U.S. Department of

Health and Human Services of your complaint. We will not take

any action against you for filing a complaint.

FINANCIAL INFORMATION PRIVACY NOTICE. This notice

describes how financial information about you may be used and

disclosed. Please review it carefully.

Effective January 1, 2015

We2 are committed to maintaining the confidentiality of your per-

sonal financial information. For the purposes of this notice,

“personal financial information” means information about an en-

rollee or an applicant for health care coverage that identifies the

individual, is not generally publicly available, and is collected

from the individual or is obtained in connection with providing

health care coverage to the individual.

Information We Collect

Depending upon the product or service you have with us, we

may collect personal financial information about you from the

following sources:

Information we receive from you on applications or other

forms, such as name, address, age, medical information and

Social Security number;

Information about your transactions with us, our affiliates or

others, such as premium payment and claims history; and

Information from a consumer reporting agency.

Disclosure of Information

We do not disclose personal financial information about our en-

rollees or former enrollees to any third party, except as required

or permitted by law. For example, in the course of our general

business practices, we may, as permitted by law, disclose any of

the personal financial information that we collect about you, with-

out your authorization, to the following types of institutions:

To our corporate affiliates, which include financial service

providers, such as other insurers, and non-financial compa-

nies, such as data processors;

To nonaffiliated companies that perform services for us, in-

cluding sending promotional communications on our behalf.

34



To nonaffiliated companies for our everyday business purposes, such as to process your transactions, maintain your account(s),

or respond to court orders and legal investigations; and

Confidentiality and Security We maintain physical, electronic and procedural safeguards, in accordance with applicable state and

federal standards, to protect your personal financial information against risks such as loss, destruction or misuse. These measures

include computer safeguards, secured files and buildings, and restrictions on who may access your personal financial information.

Questions About this Notice If you have any questions about this notice, please call the toll- free member phone number on your

health plan ID card or contact the UnitedHealth Group Customer Call Center at 1-866-633-2446 (TTY 711).

UNITEDHEALTH GROUP HEALTH PLAN NOTICE OF PRIVACY PRACTICES: FEDERAL AND STATE AMENDMENTS

Revised: January 1, 2015. The first part of this Notice, which provides our privacy practices for Medical Information (pages 1-4), de-

scribes how we may use and disclose your health information under federal privacy rules. There are other laws that may limit our

rights to use and disclose your health information beyond what we are allowed to do under the federal privacy rules. The purpose of

the charts below is to: show the categories of health information that are subject to these more restrictive laws; and give you a gen-

eral summary of when we can use and disclose your health information without your consent. If your written consent is required under

the more restrictive laws, the consent must meet the particular rules of the applicable federal or state law.

Summary of Federal Laws



Summary of State Laws

KY

KY, MO, NJ, SD

KS Prescriptions

CA, FL, IN, KS, MI, MT, NJ, NV, PR,

information. WA

recipients. AK, AZ, FL, GA, IA, MD, MA, MO, NJ,

HIV / AIDS

KS, KY, ME, MI, MO, MT, NY, NC, NH,

NM, PR, TN, WA, WI WA

CT ME

AL, CO, IL, LA, MD, NE, NJ, NM, NY,

36



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’re eligible for health coverage from your employer, your state may

have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or

your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to

buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, 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 eli-

gible for either of these programs, 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, ask your state if it has a program that might help you pay the premiums for an employer-

sponsored plan.

If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan,

your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” op-

portunity, 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, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).

ALABAMA – Medicaid GEORGIA – Medicaid Website: www.myalhipp.com

Phone: 1-855-692-5447 Website: http://dch.georgia.gov/

Click on Programs, then Medicaid, then Health Insurance Premium

Payment (HIPP)

Phone: 1-800-869-1150

ALASKA – Medicaid INDIANA – Medicaid Website: http://health.hss.state.ak.us/dpa/programs/medicaid/

Phone (Outside of Anchorage): 1-888-318-8890 Phone (Anchorage): 907-269-6529

Website: http://www.in.gov/fssa Phone: 1-800-889-9949

COLORADO – Medicaid IOWA – Medicaid Medicaid Website: http://www.colorado.gov/hcpf

Medicaid Customer Contact Center: 1-800-221-3943

Website: www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562

FLORIDA – Medicaid KANSAS – Medicaid Website: https://www.flmedicaidtplrecovery.com/

Phone: 1-877-357-3268

Website: http://www.kdheks.gov/hcf/ Phone: 1-800-792-4884

KENTUCKY – Medicaid NEW HAMPSHIRE – Medicaid Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570

Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf Phone: 603-271-5218

LOUISIANA – Medicaid NEW JERSEY – Medicaid and CHIP Website: http://www.lahipp.dhh.louisiana.gov Phone: 1-888-695-2447

Medicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/

medicaid/ Medicaid Phone: 609-631-2392 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710

MAINE – Medicaid NEW YORK – Medicaid

Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html Phone: 1-800-977-6740, TTY 1-800-977-6741

Website: http://www.nyhealth.gov/health_care/medicaid/ Phone: 1-800-541-2831

http://www.healthcare.gov

http://www.askebsa.dol.gov

http://www.myalhipp.com

http://dch.georgia.gov/

http://health.hss.state.ak.us/dpa/programs/medicaid/

http://www.colorado.gov/hcpf

https://www.flmedicaidtplrecovery.com/



MASSACHUSETTS – Medicaid and CHIP NORTH CAROLINA – Medicaid Website: http://www.mass.gov/MassHealth Phone: 1-800-462-1120

Website: http://www.ncdhhs.gov/dma Phone: 919-855-4100

MINNESOTA – Medicaid NORTH DAKOTA – Medicaid Website: http://www.dhs.state.mn.us/id_006254

Click on Health Care, then Medical Assistance

Phone: 1-800-657-3739

Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/

Phone: 1-800-755-2604

MISSOURI – Medicaid OKLAHOMA – Medicaid and CHIP Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm

Phone: 573-751-2005

Website: http://www.insureoklahoma.org Phone: 1-888-365-3742

MONTANA – Medicaid OREGON – Medicaid Website: http://medicaid.mt.gov/member Phone: 1-800-694-3084

Website: http://www.oregonhealthykids.gov http://www.hijossaludablesoregon.gov

Phone: 1-800-699-9075

NEBRASKA – Medicaid PENNSYLVANIA – Medicaid Website: www.ACCESSNebraska.ne.gov

Phone: 1-855-632-7633

Website: http://www.dpw.state.pa.us/hipp Phone: 1-800-692-7462

NEVADA – Medicaid RHODE ISLAND – Medicaid Medicaid Website: http://dwss.nv.gov/ Medicaid Phone: 1-800-992-0900

Website: www.ohhs.ri.gov Phone: 401-462-5300

SOUTH CAROLINA – Medicaid VIRGINIA – Medicaid and CHIP Website: http://www.scdhhs.gov Phone: 1-888-549-0820

Medicaid Website: http://www.coverva.org/

programs_premium_assistance.cfm Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.coverva.org/

programs_premium_assistance.cfm CHIP Phone: 1-855-242-8282

SOUTH DAKOTA - Medicaid WASHINGTON – Medicaid Website: http://dss.sd.gov Phone: 1-888-828-0059

Website: http://www.hca.wa.gov/medicaid/premiumpymt/pages/ in-

dex.aspx

Phone: 1-800-562-3022 ext. 15473

TEXAS – Medicaid WEST VIRGINIA – Medicaid Website: https://www.gethipptexas.com/ Phone: 1-800-440-0493

Website: www.dhhr.wv.gov/bms/ Phone: 1-877-598-5820, HMS Third Party Liability

UTAH – Medicaid and CHIP WISCONSIN – Medicaid and CHIP Website - Medicaid: http://health.utah.gov/medicaid CHIP: http://health.utah.gov/chip Phone: 1-866-435-7414

Website: https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm Phone: 1-800-362-3002

VERMONT– Medicaid WYOMING – Medicaid Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427

Website: http://health.wyo.gov/healthcarefin/equalitycare Phone: 307-777-7531

To see if any other states have added a premium assistance program since January 31, 2015, or for more information on special

enrollment rights, 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

http://www.dhs.state.mn.us/id_006254

http://www.dss.mo.gov/mhd/participants/pages/hipp.htm

http://dhhs.ne.gov/medicaid/Pages/med_kidsconx.aspx

http://dwss.nv.gov

http://www.hca.wa.gov/medicaid/premiumpymt/pages/%20index.aspx

http://www.hca.wa.gov/medicaid/premiumpymt/pages/%20index.aspx

http://www.dol.gov/ebsa

http://www.cms.hhs.gov/

38


General Notice of COBRA Continuation Coverage Rights

Introduction

You’re getting this notice because you recently gained coverage under a group health plan (the Plan). This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect your right to get it. When you become eligible for COBRA, you may also become eligible for other cover-age options that may cost less than COBRA continuation coverage. The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you and other members of your family when group health coverage would otherwise end. For more information about your rights and obligations under the Plan and under federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator.

You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may quali-fy for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special en-rollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees. What is COBRA Continuation Coverage?

COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified benefi-ciaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. If you’re an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following quali-fying events:

Your hours of employment are reduced, or Your employment ends for any reason other than your gross misconduct.

If you’re the spouse of an employee, you’ll become a qualified beneficiary if you lose your coverage under the Plan because of the following qualifying events:

Your spouse dies; Your spouse’s hours of employment are reduced; Your spouse’s employment ends for any reason other than his or her gross misconduct; Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or You become divorced or legally separated from your spouse.

Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of the following qualifying events:

The parent-employee dies; The parent-employee’s hours of employment are reduced; The parent-employee’s employment ends for any reason other than his or her gross misconduct; The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both); The parents become divorced or legally separated; or The child stops being eligible for coverage under the Plan as a “dependent child.”

When is COBRA Coverage Available?

The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. The employer must notify the Plan Administrator of the following qualifying events:

The end of employment or reduction of hours of employment; Death of the employee; Commencement of a proceeding in bankruptcy with respect to the employer; or The employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both).

You Must Give Notice of Some Qualifying Events For all other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Plan Administrator within 30 days after the qualifying event occurs. You must provide this notice to:

Johnston Health Human Resources 509 N Bright Leaf Blvd, PO Box 1376, Smithfield, NC 27577 Notification should be in writing and include official documentation of qualifying event (i.e. divorce decree, marriage certificate, birth

certificate).


How is COBRA Coverage Provided? Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children. COBRA continuation coverage is a temporary continuation of coverage that generally lasts for 18 months due to employment termination or reduction of hours of work. Certain qualifying events, or a second qualifying event during the initial period of coverage, may permit a beneficiary to receive a maximum of 36 months of coverage. There are also ways in which this 18-month period of COBRA continuation coverage can be extended: Disability extension of 18-month period of continuation coverage If you or anyone in your family covered under the Plan is determined by Social Security to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to get up to an additional 11 months of COBRA continuation coverage, for a maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage. Please provide Social Security disability determination confirmation to: Johnston Health Human Resources 509 N Bright Leaf Blvd, PO Box 1376, Smithfield, NC 27577 Second qualifying event extension of 18-month period of continuation coverage If your family experiences another qualifying event during the 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if the Plan is properly notified about the second qualifying event. This extension may be available to the spouse and any dependent children getting COBRA continuation coverage if the employee or former employee dies; becomes entitled to Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated; or if the dependent child stops being eligible under the Plan as a dependent child. This extension is only available if the second qualifying event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. Are there other coverage options besides COBRA Continuation Coverage? Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at www.healthcare.gov. If you have questions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more

information about the Marketplace, visit www.HealthCare.gov. Keep your Plan informed of address changes To protect your family’s rights, let the Plan Administrator know about any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. Plan Contact Information Johnston Health Human Resources 509 N Bright Leaf Blvd, PO Box 1376, Smithfield, NC 27577

General Notice of COBRA Continuation Coverage Rights

http://www.HealthCare.gov

40


Contact Information

Coverage Administrator Phone Number Website

Health Insurance UMR

OptumRx

UNC HealthLink

1-877-265-9194

1-877-559-2955

1-855-848-0424

www.umr.com

www.optumrx.com

Health Savings Account Optum Bank 1-866-234-8913 Option 1

www.optumbank.com

Dental Ameritas

1-800-487-5553 www.ameritas.com

Vision EyeMed 1-866-800-5457 www.eyemed.com

Life and Disability Sun Life 1-800-SUN-LIFE www.SunLife.com

Flexible Spending Account P&A Group 1-800-688-2611 www.padmin.com

Retirement Plans Stanley Benefits 1-866-469-376 www.stanleybenefits.com

Benefits Consultant Hylant 1-888-578-9988 www.hylant.com

If a health care claim you will be incurring or have incurred is denied or if you have a question

regarding the benefits, you may contact your insurance company using the contact information

above or on the back of your ID card or on your Explanation of Benefits.

In the event that this does not resolve the issue, you may contact Hylant at 1-888-578-9988. When

you call please be able to provide the following:

Name of Patient

Date of Service

Name of Provider

Explanation of Benefits (EOB) from the Insurance Company

Invoice from the Provider (if applicable)

You may also be required to provide a signed HIPAA authorization which gives Hylant permission to

speak to your providers about your protected health information, as well as permission for your

provider to speak to Hylant about your protected health information.

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