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Archdiocese of Kansas City in Kansas

Employee Benefits Guide 2020 Plan Year

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Section

Page

2020 Guide to Benefits 2

What’s Changing for 2020? 4

Enrollment Instructions 5

Archdiocese Online Benefits Resources 12

Cost to Participate 13

Effects of Health Care Reform 14

Health Benefits 15

Telemedicine through Teladoc 18

Prescription Drug Benefits 19

Medication Management – Tria Health 21

Alere Oncology Case Management 23

Naturally Slim 24

Dental Insurance 25

Vision Insurance 26

Short Term Disability Benefits 27

Life and Long Term Disability Insurance 28

Voluntary Supplemental Life Insurance 29

Hartford Life Value Added Services 30

Flexible Spending Accounts 32

Employee Assistance Program 36

Voluntary Critical Illness 37

Voluntary Accident Insurance 38

Voluntary Whole Life Insurance 39

College Tuition Benefit 40

Contact Information 41

Retirement Plan Information and Contacts 42

Legal Notices 43

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Welcome to the Archdiocese of Kansas City in

Kansas’ 2020 guide to employee benefits! 2020 Open Enrollment Information This year OPEN ENROLLMENT begins at 12:01 AM on November 1st and ends at 11:59 PM on November 12th. Elections you make during Open Enrollment will become effective January 1, 2020.

2020 New Hire Enrollment Information Newly hired employees are required to enroll or waive enrollment in the Archdiocese benefits within 30 days of your date of hire. Coverage in all benefits will begin the first of the month following 30 days from your date of hire. The Archdiocese offers you and your eligible family members a comprehensive and valuable benefits program. We encourage you to take the time to educate yourself about your options and choose the best coverage for you and your family. This guide describes your benefit options for 2020. Please read it carefully for important information you will need in order to make decisions about your benefit elections.

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Who is Eligible?

An employee who works at least an average of 30 hours per week for the school or calendar year is eligible to participate in all of the Archdiocese Benefit Plans. You may elect coverage for your eligible dependents which include your legal spouse of the opposite gender, and dependent children (until the end of the calendar year in which they turn 26).

How to Enroll Open Enrollment will be completed via the Paylocity system this year. Instructions can be found beginning on page 5. New hires will also enroll via the Paylocity system within their first 30 days of employment. Your onsite benefits administrator can help if you have questions. For both Open Enrollment and new hire enrollment, please remember, once you have made your elections, you will not be able to change them until the next Open Enrollment period unless you have a qualified change in status.

When to Enroll This year Open Enrollment begins November 1st and ends November 12th, 2019. During this period, you must elect, change or waive all of your benefits for 2020. Open Enrollment is also your opportunity to enroll in the voluntary insurance plans. All employees need to go online, verify their information, including eligible family members and beneficiary designations, review the benefits and ensure you are enrolled in the desired plans and have your eligible family members enrolled if desired. If you have any questions, contact your onsite benefits administrator. Your next opportunity to enroll or make changes in benefits will be the next Open Enrollment period unless you have a qualifying status change.

When You Can Make Changes After your initial enrollment, you cannot make changes to the benefits you elect until the next Open Enrollment period unless you have a qualified change in status. Qualified changes in status include: birth, death, marriage, divorce, adoption of a child, change in child’s dependent status, or a significant change in benefits coverage for you or your spouse because of your spouse’s employment. A request for change in status must be received within 30 days of the event. Written proof of the change is required. If you wish to enroll or make changes to your Life and Disability benefits, you will be required to provide proof of insurability before the enrollment or change is approved. Please choose your benefits carefully.

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Medical and Prescription Plan Changes • The Archdiocese plan will not be a Grandfathered Plan beginning 1/1/2020, as that term is used regarding the

Affordable Care Act (ACA).

What does this mean? Giving up Grandfathered status allows the plan to make more significant changes than were allowed while remaining Grandfathered. It also means there will be a cap on prescription member out-of-pocket levels, and all copays will now apply to the out-of-pocket levels. Currently copays do not apply to your out-of-pocket. Contraceptives will continue to be excluded as they are today.

• The Catholic Hospital tier of coverage will be eliminated. Services at these facilities will be covered as either in-network or out-of-network, based on the hospital’s status with the Blue Cross Blue Shield network.

• The table below illustrates other plan features that will be changing. Copay amounts for medical services are not changing. See page 15 for a more complete medical plan summary.

Medical/RX Plan Changes Current Plan 2020 Plan Deductible

In Network Individual $500 $750

In Network Family $1,000 $1,500

Non-Network Individual $500 $1,500

Non-Network Family $1,000 $3,000

Medical Out of Pocket Max

Includes copays plus coinsurance No, copays don't apply to out of pocket

Yes, copays apply to out of pocket maximum

In Network Individual $2,000 $4,000

In Network Family $4,000 $8,000

Non-Network Individual $2,500 $8,000

Non-Network Family $4,500 $16,000

RX Out of Pocket Max

Individual/Family None $3,000 / $6,000

Med & RX Combined In Network Out of Pocket Maximum

Individual/Family None $7,000 / $14,000

RX Copays/Coinsurance - 30-day

Generic $7 $10

Brand Annual Deductible $60 None

Preferred Brand 25% coins., $25 min. 25% coins., $25 min.

Non-preferred Brand 40% coins., $40 min. 40% coins., $40 min. Specialty Drugs (Generic, Pref Brand, Non-Pref Brand) $14 / $28 / $46 25% coinsurance

RX Copays/Coinsurance - 90-day

Generic $22 $25

Preferred Brand $70 25% coins., $62.50 min

Non-preferred Brand $119 40% coins., $100 min

Other Changes • All eligible full-time employees will be covered for basic Life and AD&D insurance, fully paid for by your employer.

You may elect coverage for your dependents and that coverage will be paid 50% by your employer, 50% by you. LTD will also be available at a 50%/50% premium share. Short Term Disability benefits continue to be funded by your employer and the Archdiocese, and will have a 12-week maximum.

• A Roth option is being added to both the 401(k) and the 403(b) plans.

What’s Changing for 2020?

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Open Enrollment Instructions

IMPORTANT!

All benefit eligible employees must complete Open Enrollment for 2020. Failure to complete enrollment by November 12th will result in NO BENEFITS for 2020.

To begin Open Enrollment:

1. Log into your Paylocity Account

2. Use the Menu to navigate to Enterprise Web Benefits

3. Click “Start Your Enrollment”

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Open Enrollment Instructions (cont’d)

If your employer is not listed below, click “No”. Answering no will allow you to enroll in the Archdiocese 401(k) Plan

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Open Enrollment Instructions (cont’d)

Please view plan options for each benefit.

Make sure to select all applicable dependents for each benefit and click “Continue”.

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Open Enrollment Instructions (cont’d)

“Select” the coverage you want for each benefit plan, or “Waive” if you do not want to have coverage.

When you have selected all of your benefits, click Continue

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Open Enrollment Instructions (cont’d)

Next, please choose your beneficiaries, then click “Continue”.

Review your selections for accuracy.

Finally,

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Open Enrollment Instructions (cont’d)

When you have completed your enrollment, read the agreement and check “I agree…”

Click “Complete Enrollment”. Review then print your confirmation for your records.

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New Hire Enrollment Instructions New employees will enroll online via Paylocity and must complete the online enrollment process within 30 days of your date of hire – or the first day you are actively at work. For teachers or school administration under contract, your hire date is the first day of your contract period. Please see your onsite benefits administrator if you have any questions about the enrollment process.

Colonial Voluntary Benefits

Accident, Critical Illness and Whole Life Insurance plans are available for you to purchase from Colonial Life Insurance Company.

These plans will not be payroll-deducted, but you receive better rates and underwriting considerations through this employer-sponsored program.

As a newly hired employee, you can enroll within 30 days of your date of hire by calling Colonial at 1-844-237-3738.

See pages 37-39 of this guide for details on these plans.

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Your Online Resources for

Benefits Information You have online access to the information you need 24 hours a day, 7 days a week at:

https://www.archkck.org/employee-benefits

You’ll find additional information and links to vendor sites at this location on our website. We also provide you with access to benefit information via a mobile-enabled site at:

https://archkck.mybenefitsapp.com

When you access this site from your smart phone, you can add an icon to your home screen for easy access.

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Your Benefit Choices The Archdiocese provides a wide variety of benefits. Some are provided automatically at no cost to you. Check the list to the right and select the benefits that best meet your personal needs.

Cost to Participate

2020 Monthly Premium Deductions The Health and Dental Plan premiums will increase in 2020. Your employer will pay 60% of your cost to participate in the Health and Dental plans. The chart below shows your share of the 2020 monthly cost compared to the total cost. You are 100% responsible for the cost to participate in the Vision Plan, which is not changing for 2020. Your deductions will come out of the first two pay checks each month.

Monthly Rates 2020 Employee

Contribution 2020 Employer Contribution

Total Cost

Health Plan (Includes RX) Single Family

$319.80 $674.70

$479.70

$1,012.04

$799.50

$1,686.74

Dental Plan Single Family

$18.74 $44.18

$28.12 $66.28

$46.86

$110.46

Voluntary Vision Plan Single Family

$9.26

$25.56

n.a. n.a.

$9.26

$25.56

Benefit Who Pays the Cost?

Employee Assistance Program (EAP) Archdiocese

Medical/RX Coverage Employer and Employee

Dental Coverage Employer and Employee

Voluntary Vision Employee

Short Term Disability Archdiocese and Employer

Basic Life and AD&D Coverage Employer

Dependent Life Coverage Employer and Employee

Long Term Disability Employer and Employee

Voluntary Supplemental Life Employee

Voluntary Whole Life Employee

Voluntary Accident Insurance Employee

Voluntary Critical Illness Employee

Flexible Spending Accounts Health Care Reimbursement Dependent Care Reimbursement

Employee Employee

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Effects of Health Care Reform

Summary of Benefits and Coverage Under the Patient Protection and Affordable Care Act (PPACA or ACA), insurance companies and group health plans must provide consumers with a concise document detailing, in plain language, simple and consistent information about health plan benefits and coverage. This Summary of Benefits and Coverage (SBC) document will help consumers better understand the coverage they have and, for the first time, allow them to easily compare different coverage options. It will summarize the key features of the plan or coverage, such as the covered benefits, cost-sharing provisions, and coverage limitations and exceptions. A copy of the SBC can be found on the Archdiocese benefits portal.

Grandfathered Status The Archdiocese Health Plan is no longer a “grandfathered health plan” under the ACA as of 1/1/2020.

Women’s Preventive Care Guidelines In August 2011, the US Department of Health and Human Services (HHS) announced additional preventive care services, developed by the independent Institute of Medicine, to cover women’s preventive services without charging a copayment, coinsurance or a deductible. In addition to requiring 100% coverage for well-women visits and various types of screenings, the HHS has included coverage for FDA-approved contraception methods. The Archdiocese Health Plan is not required to comply with these rules, even as a non-grandfathered plan, therefore coverage for contraception continues to be excluded under our plan.

Preventive Services Our health plan has and continues to cover routine preventive services for all members. The health plan also covers one mammogram and one colonoscopy per calendar year at 100%, regardless if it is a routine or diagnostic service. Covered preventive services may have age and/or gender limitations in line with recommendations of the National Preventive Services Task Force. As these recommendations may change from time to time, please verify with Blue Cross Blue Shield or MedTrak what specific preventive services are covered in full.

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Health Benefits

You have the flexibility to seek care from an in-network or out-of-network provider. It is important to note that you receive the maximum benefits from the plan when you seek services from in-network providers. The Blue Cross and Blue Shield networks offer the best national access to providers through the BlueCard PPO Program in which all Blue Cross Blue Shield Plans participate. To learn more about the BlueCard Program, or to find out if your physician participates in the PPO network, please visit their website at www.MyHealthToolkitKC.com. You may also direct your questions to the Customer Service number located on the back of your identification card.

BENEFIT IN-NETWORK PROVIDERS OUT-OF-NETWORK PROVIDERS

Calendar Year Deductible $750 Individual / $1,500 Family $1,500 Individual / $3,000 Family

Medical Out-of-Pocket Max $4,000 Individual / $8,000 Family $8,000 Individual / $16,000 Family

Wellness Benefits – Routine Care Plan pays 100% 100% up to $500 per person, then

Plan pays 60% after Deductible

Physician Office Visit $30 Copay Plan pays 60% after Deductible

Inpatient Hospital Services $120 Copay, then Plan pays 80%

after Deductible $120 Copay, then Plan pays 60%

after Deductible

Emergency Room Services $90 Copay, then Plan pays 80% after

Deductible $90 Copay, then Plan pays 80% after

Deductible

Inpatient Hospice Care Services $120 Copay, then Plan pays 80%

after Deductible $120 Copay, then Plan pays 60%

after Deductible

Chiropractic Care (Limited to 20 visits per calendar year combined in and out of network)

$25 Copay, then Plan pays 80% after Deductible

Plan pays 60% after Deductible

Lab Services 100%, no Deductible Plan Pays 60% after Deductible

This is a brief summary only. Certain restrictions and exclusions apply. For exact terms and conditions, please refer to your Blue Cross Blue Shield benefit booklet.

Natural Family Planning – For Members Covered by the Health Plan The Archdiocese will continue to provide a benefit for Natural Family Planning (NFP) services. This benefit includes office visits and materials (such as the Clear Blue Easy Fertility Monitor and test strips) and is available through programs approved by the Archdiocese. The following programs are considered to be approved: Billings Method, Creighton Model, Couple to Couple League, and Marquette Method. The Archdiocese will cover 100% of costs up to a maximum of $400 per calendar year for the insured employee or their spouse. The benefit is limited to $400 total per family. Please submit copies of receipts to the Human Resources Office for processing.

Gianna Family Care – For Members Covered by the Health Plan The Archdiocese Health Plan provides coverage at Gianna Family Care, which is a membership and faith-based medical practice located in Shawnee, Kansas. Charges from the Gianna Family Care medical practice will be treated as follows, even though this practice is out of network with Blue Cross Blue Shield:

• Membership and other physician fees, such as for delivery or circumcision, will be reimbursed at 90% of billed amount, not subject to calendar year deductible.

• Any other fees, such as labs or medications, if billed by Gianna, will be covered as out of network. A claim form (available on the Archdiocese website), along with an itemized receipt must be submitted to Blue Cross Blue Shield for reimbursement. For more information on this practice visit, www.giannafamilycare.com.

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Health Benefits (Continued)

BLUE DISTINCTION TOTAL CARE A NEW MODEL OF HEALTHCARE DELIVERY There is a nationwide shift in how healthcare is being delivered and received, connecting members to the right care at the right time and place. Blue Distinction Total Care is a national program driven by Blue Cross and Blue Shield plans across the country. The ultimate goal is to improve health outcomes and lower healthcare costs over time. Blue Distinction Total Care programs also reward doctors for helping their patients manage and improve their health by meeting certain criteria set forth by Blue Cross and Blue Shield. There are over 118,000 providers across 40 states that are considered Blue Distinction Total Care providers through programs such as Patient-Centered Medical Home (Blue KC Medical Home for the KC Metro area) and Accountable Care Organizations.

THE RIGHT CARE AT THE RIGHT TIME AND PLACE Your primary care doctor will work with you to understand your health issues and lifestyle habits to develop and coordinate a plan of care that leads to your best health. Your doctor will advise you and work directly with other healthcare specialists in your network regarding your health needs so they can assist you in managing your health.

• Proactive Approach – Your primary care doctor helps you understand when it’s time for preventive medical tests, appointments, and follow –up exams.

• Convenient Access – Receive healthcare advice and easy access to your provider as well as convenient appointment scheduling.

• Cost-effective Care – Your primary care doctor ensures tests and procedures you receive are necessary and cost-effective.

HEALTHCARE FOCUSED ON YOU If you suffer from one or more chronic conditions, Blue Distinction Total Care is focused on the coordination of your care to help you improve your health. If you are in good health, continue to rely on your primary care doctor as your partner in staying healthy. Share your medical history, health successes and challenges. Don’t be afraid to ask questions. Your doctor can help you create a care plan with steps you need to take to achieve your best health. Share the plan with your other healthcare providers for an optimal experience. Tell your doctor if you have trouble sticking to your plan, regardless of the reason. To find a Blue Distinction Total Care Provider, follow these four easy steps:

1. Go to MyHealthToolkitKC.com and log in to your member account. 2. Select the Resources tab, then click Find a Doctor or Hospital. 3. Enter your location and the doctor’s specialty type. 4. On the right side of your search results, select “Is BDTC Certified” to refine your search

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Telemedicine

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Set up your account 1. Go to https://www.teladoc.com and click “Set up account”.

2. Fill in required fields as indicated by the *, such as name, date of birth, etc.

3. Select “no” for user name.

4. Select “my employer or insurance provider offers me access” in response to how you found out about Teladoc.

5. “Who is your employer or insurance provider?” – begin typing “Archdiocese of Kansas City” and a drop down will appear. Enter your BCBS ID in the drop-down field.

6. Enter your user ID/Password and security question, then click “Finish”.

Telemedicine

Available to all health plan participants

Telehealth is a rapidly growing area of health care. Teladoc allows you to talk to a doctor anytime, anywhere by phone consult. It’s an affordable, convenient option for treating many medical conditions. Once you set up your Teladoc account, you can request a consult; a Teladoc doctor is then just a call or click away and there’s no copay! * With your consent, Teladoc will provide information about your consult to your primary care physician.

WHEN CAN I USE TELADOC? Teladoc does not replace your primary care physician. It is a convenient and affordable option for quality care.

• When you need care now

• If you are considering the ER or urgent care center for a non-emergency issue

• On vacation, on a business trip, or away from home

• For common skin problems

GET THE CARE YOU NEED FOR $0 COPAY Teladoc doctors can treat many medical conditions, including:

• Cold and flu symptoms

• Allergies

• Urinary tract infection

• Respiratory infection

• And more!

For Dermatologist services, you simply take up to 5 photos of the skin issue and send them to the Teladoc doctor. You will get a response within 48 hours.

MEET OUR DOCTORS Teladoc is simply a new way to access qualified doctors. All Teladoc doctors:

• Are practicing PCPs,

pediatricians, family medicine physicians and dermatologists

• Average 15 years’ experience

• Are U.S. board-certified and licensed in your state

• Are credentialed every three years meeting NCQA standards

fits

CAREGIVER BENEFITS – If you’re caring for a parent or other loved one not covered by your health insurance, you can add that person to your Teladoc account as your care recipient. You or your care recipient will be able to request a physician visit for a $45 charge. You can even join a 3-way visit.

Important Note: Neither your care recipient nor this $45 charge is covered by the Archdiocese health plan.

Request a consult Once your account is set up, a doctor is always just a call or click away.

1. Visit the Teladoc website and click “Request a consult”.

2. Select the type of consult you want.

3. Talk to a doctor within an hour *

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Prescription Drug Benefits

MedTrakRX is the Pharmacy Benefit Manager for our prescription drug benefits. Your plan includes a list of prescription drugs that are preferred by the plan because they help control rising prescription drug costs. This list, sometimes called a formulary, has a wide selection of generic and brand-name medications. A copy of this list may be obtained on MedTrak’s website at www.medtrakrx.com/Members.

You will want to use a participating retail pharmacy for short-term prescriptions (such as antibiotics to treat infections). Be sure to show your MedTrak prescription benefit card to the pharmacist and pay your retail copayment for each prescription. Long-term medications (those taken for three (3) months or more) may be filled through the Performance 90 retail network. You may fill your long-term medications at a local retail pharmacy like Walgreens, Target, Wal-Mart and many Kansas City grocery stores. MedTrak also offers a mail order pharmacy option through Walgreens Mail. Specialty medications are filled through MedTrak’s “best in class” network of specialty pharmacies.

In order to manage prescription drug costs, we are continuing to offer cost-saving programs in our Plan. “Step Therapy”, one of these programs, helps members as well as the Plan save money when lower cost drug alternatives may be available. MedTrak offers a program for diabetic members which will help them better manage this condition. There’s also a program to cover over-the-counter medications that may save money over prescription medications that treat the same conditions. MedTrak will continue to notify eligible members directly about these programs. We encourage you to discuss the proposed options with your physician and consider taking advantage of these programs if you receive information from MedTrak.

To find a participating retail pharmacy near you, contact MedTrak’s Customer Service department at 800-771-4648 or log on to www.medtrakrx.com/Members

Hours of Operation: Monday through Friday – 8:00 a.m. to 9:00 p.m. Saturday – 9:00 a.m. to 6:00 p.m.

Prescription Drugs Benefit

Retail (30-day Supply) Generic Brand

Formulary Non-Formulary

Lesser of $10 or actual cost

25% of discounted cost or $25 min 40% of discounted cost or $40 min

Mail Order (90-day supply) Generic Brand Formulary Brand Non-Formulary

$25 Copay

25% of discounted cost or $62.50 min 40% of discounted cost or $100 min

Specialty (30-day Supply) Generic Brand Formulary Brand Non-Formulary

25% of discounted cost 25% of discounted cost 25% of discounted cost

Out-of-Pocket Maximum (per calendar year)

$3,000 Individual; $6,000 Family

This is a brief summary only. Certain restrictions and exclusions apply. For exact terms and conditions, please refer to the MedTrak Summary Plan Discription.

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Prescription Drug Benefits (continued)

Coverage for preventive medications was enhanced effective 1/1/2017. Many of these medications are available without a prescription, but for the plan to cover these at no copay, you’ll need to present a physician’s prescription to the MedTrak pharmacy, along with your MedTrak card. For the vaccines shown below to be covered by MedTrak, you’ll need to present your MedTrak card at the pharmacy. Age and gender limitations are based on the recommendations of the National Preventive Services Task Force and are subject to change based on those recommendations. A summary of the 2020 preventive medication coverage is shown below:

Preventive Care Medications

Medication Copay Limits

Aspirin 81 mg $0 Ages 45 through 78 for Males; Ages 11 through 78 for Females; OTC Generics and Legend Generics

Fluoride Supplements (Oral) $0 Ages 6 Months through Age 6; Allow OTC

Folic Acid (400 mcg and 800 mcg only)

$0 Ages 11 through 48 for Females; OTC Generics and Legend Generics

Iron Supplements $0 Ages 6 Months through 12 Months; OTC Generics and Legend Generics

Smoking Deterrents (Oral, gum, lozenges, patches, oral inhaler, and nasal inhaler)

$0 OTC and Legend medications per FDA guidelines; Limit two treatment cycles per calendar year

Vitamin D2, D3 Products, and calcium Vitamin D < 1,000 IU

$0 Age 65 and older; OTC Generics and Legend Generics

Bowel Preps (Bisacodyl, Mag Citrate, Milk of Magnesia, PEG 3350-Electrolyte)

$0 Age 50 through 75; OTC Generics and Legend Generics; Limit 2 prescriptions per year

Breast Cancer Prevention $0 Age 35 and older for Females; OTC Generics and Legend Generics

Cardiovascular Disease Prevention (statin medications)

$0 Age 40 through 75; Single-entity generics only

Vaccines

Medication Copay Limits CDC-Scheduled Vaccinations (includes Hep A & B, Haemophilus influenzae type b, HPV, Herpes Zoster [Shingles], Influenza, Meningitis, MMR, Pneumococcal, Poliovirus, Rotavirus, DPT, Varicella)

$0 Allow up to a $25 administration fee; age limitations apply per CDC schedule; Travel vaccines excluded.

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Medication Management Program Available to all health plan participants

Helping You Manage Your Medications and Reduce Your Health Care Costs! The Tria Health Program is provided at no additional cost to you through your insurance plan with Archdiocese of Kansas City in Kansas. This confidential program is designed to improve your health, reduce your healthcare costs and ensure you’re receiving the best care from your medications. Tria Health’s programs offer you clinical guidance through the complexities of health care. Tria pharmacists act as your personal medication experts and work with you and your physician to achieve 3 primary goals:

1. Your medications are safe 2. You can afford the medications you’re prescribed 3. Your medications effectively treat your conditions

Pharmacy Advocate (PA) Program:

What is it? The PA program offers one-on-one confidential counseling with a Tria Health Pharmacist to discuss how effective your medications are in treating your conditions. Your Tria Pharmacist will work with you and your physicians to reduce the risk of medication-related problems.

Examples of medication-related problems include: - Nausea or other uncomfortable side effects

- Your prescription is too expensive to fill every month

- The medication dosage is too low or too high and isn’t

effectively treating your condition

Who participates? Individuals who have one or more chronic conditions and take multiple medications. Active participants in the PA Program will be eligible to receive 50% off brand copays and free generic copays on medications that are used primarily to treat chronic conditions.

Participants say… “I would recommend Tria’s PA program for the cost-saving benefit alone, but I really like the idea that one central place is coordinating with all my doctors to make sure my prescriptions play well together.” “We are very happy with this program – it only takes 10 minutes or so every 6 months.”

Programs for All Plan Members: The programs below are designed to help all plan members receive the best results from their medications and reduce the risk of medication-related problems.

Program: Details:

Affordable Med

Saves you time and money by identifying less expensive, effective alternatives for your brand medications.

Med Safety Alerts

Prevents the risks associated with taking medications that cause an adverse reaction together.

Tria Clinical Alerts

Identifies when taking an additional medication in conjunction with your current treatment can improve your condition.

Compliance Alerts

Forget to take your medications? Do side effects cause you to skip your meds? Compliance Alerts help find solutions to help you take your medications as prescribed.

Tria Help Desk

Your complete and confidential resource anytime you have a medication-related question. Call us toll-free at 1.888.799.TRIA (8742).

You can enroll by…

Mail Eligible individuals will receive an enrollment packet in the mail. This will include an enrollment form and envelope for you to send back to Tria Health.

Online You may enroll online by visiting the website: www.triahealth.com/patients.aspx

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Medication Management Program (cont’d) Tria Health FAQs: What services does Tria Health provide? Pharmacy Advocate Program This program is designed specifically for individuals who have chronic conditions and are taking multiple medications to control their conditions. Tria offers participating members the opportunity to speak one-on-one with a Clinical Pharmacist to review their current medications. During this personalized counseling session, the Clinical Pharmacist will answer any questions or concerns the member may have regarding their medications and work to ensure that all of their health goals are achieved. Tria Help Desk The Tria Help Desk is a toll-free resource where all members can speak directly with a Tria Health Clinical Pharmacist to receive information ranging from less expensive drug therapies to learning more about potential drug to drug interactions. Members can access the Tria Help Desk at 1.888.799.TRIA Monday - Friday from 8am to 9pm and Saturday from 9am to 8pm. On-going Ancillary Programs (See previous page for program descriptions)

Program Name: Frequency: Recipient: Communication Form:

Compliance Alerts Twice a Year Plan Members Letter Campaign

Med Safety Alerts Weekly Plan Members & Prescribing Physicians Letter & Call Campaign

Tria Clinical Alerts Quarterly Plan Members & Prescribing Physicians Letter Campaign

Affordable Med Twice a Year Plan Members & Prescribing Physicians Letter & Call Campaign

By participating in Tria Health, do members need to change where they get their prescriptions filled? Does this change the relationship with their physicians? No, participation in Tria Health will not require members to change where their prescriptions are filled. After a member has enrolled in the Pharmacy Advocate Program, the Tria Clinical Pharmacist will notify the member’s physician to inform them about the program. After a member has an appointment with their Tria Pharmacist, their physician will receive a summary of the discussion. Tria Health Clinical Pharmacists work with the members’ physicians in order to ensure all members are receiving the best medical and prescription care possible! How often do members speak with a Tria Health Clinical Pharmacist? Pharmacists will keep in touch with each member approximately 2 or 3 times throughout the year, depending on each member’s personal care plan which is discussed during their initial consultation. All members, however, have unlimited access to the Tria Help Desk where they can speak with a Tria Health Clinical Pharmacist regarding any medication issue. How long does an initial consultation take? The initial consultation can last anywhere from 20 to 45 minutes depending upon the complexity of your medical care. Is this like insurance? Tria Health is an enhancement to your benefit insurance that is designed to reduce your medical costs and keep you healthy. How do I check eligibility for myself and my dependents? Any plan member can check eligibility for themselves and/or dependents by calling 1.888.799.TRIA. Or take Tria Health’s online Medication Risk Quiz. Eligible members have one or more chronic conditions and take multiple medications.

www.triahealth.com | 1.888.799.8742

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Alere Oncology Case Management Support for cancer patients and their caregivers

Available to all health plan participants

Did you know that in the United States a cancer diagnosis is made every 23 seconds? A diagnosis of cancer often brings feelings of fear and uncertainty. Many difficult decisions need to be made and it can be overwhelming. Knowing what to expect physically and emotionally during the course of treatment helps cancer patients and their caregivers cope during a difficult time. For those enrolled in the Archdiocese Health Plan, the Alere Oncology Case Management program gives you access to specially trained nurses in the specific area of cancer care you need. Alere is an independent company that provides cancer advocacy services on behalf of your health plan. The program’s expert nursing staff will provide support and assistance that can help you:

• Learn about your specific diagnosis

• Learn more about the treatment plan your doctor has prescribed

• Learn to control or minimize the side effects of treatments

• Prepare for visits to the doctor

• Receive help in identifying and connecting to support services

• Get help with navigating the health care system. If you or a family member have been diagnosed with cancer, get connected to the resources of the oncology case management program.

Alere Oncology Case Management 1.855.814.5077

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Lose Weight the Right Way

with Naturally Slim®

Available to all health plan participants

There are many possible paths to weight loss, but they don’t all lead to a healthier life. There’s the crash diet before swimsuit season. There’s the starvation diet before your high school reunion. There are complicated regimens of weigh-ins and calorie-counting. Naturally Slim is a different kind of program. Naturally Slim Inc. is an independent company that provides a wellness program on behalf of your health plan. It involves mindful eating — which lets you enjoy foods, think about why you’re hungry, and focus more on how you eat than what you eat. Most importantly, it has helped many people reduce their risk for an increasingly common condition called metabolic syndrome.

Do you already have metabolic syndrome? You might, if you have at least three of these risk factors:

• High blood pressure

• Low HDL (good cholesterol)

• High triglycerides

• High blood sugar

• Large waist circumference With metabolic syndrome, you are:

• 700 percent more likely to get diabetes

• 300 percent more likely to get heart disease

• 200 percent more likely to have a stroke

With 10 one-hour-long, self-paced videos, Naturally Slim is an online program that helps people lose weight for the right reasons: to avoid the costs of these serious diseases and live healthier, happier lives. Some 87 percent of participants lose weight, with an average 10-week loss of 10.1 pounds. The program teaches mindful eating and behavior modification techniques that can reduce health risks, take pounds off and keep them off. Do you think you might qualify for the Naturally Slim program? Contact the Archdiocese Human Resources department to learn more.

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Dental Benefits

Maintaining good dental health by getting regular checkups may prevent you from having major expenses later. Archdiocese of Kansas City in Kansas’ Dental plan covers routine checkups and comprehensive coverage for other types of dental work you might need. Our plan also offers you the flexibility to seek treatment from any Provider. As with our Health Plan, you will maximize your dental benefits if you use a Delta Dental provider due to the agreements Delta has in place with their contracted dentists. Should you decide to use a non-participating dentist, please be advised that your provider may balance bill you for any amount over the Delta Dental Maximum Plan Allowance.

Even though you are not required to use a Delta Dental provider, you have access to the largest dental network in the state of Kansas. To learn more about the Delta Dental network, if your dentist participates in the network, or for more information regarding our Dental plan provider please visit their website at www.deltadentalks.com. Please click on the “Dentist Search” link located halfway down the home page under the section titled “Searching for a Dentist.” In the “Dentist Search” section, you may choose either the “Delta Dental Premier” or “Delta Dental PPO” providers. You can search for providers by name, city and state or zip code. Inquiries may also be made by calling Customer Service at (800) 234-3375 (this number can also be found on your identification card).

Services Description Benefit Amount

Type I Procedures Exams, cleanings, fluoride treatments (2 per year)

Plan pays 100% of the Maximum Plan Allowance. This benefit does not apply towards the Annual Maximum

Type II Procedures Regular fillings (amalgam or composite), extractions, non-surgical root canals

After deductible, plan pays 80% of the Maximum Plan Allowance

Type III Procedures Inlays, crowns, dentures, implants After deductible, plan pays 60% of the Maximum Plan Allowance

Type IV Procedures Orthodontia services For each eligible dependent, treatment must begin prior to age 19

After deductible, plan pays 50% of the Maximum Plan Allowance up to a Lifetime Maximum Benefit of $2,500

Annual Deductible Applies to Type II, Type III and Type IV Procedures

$25 per person

Annual Maximum Per covered person $2,500

This is a brief summary only. Certain restrictions and exclusions apply. For exact terms and conditions, please refer to your summary plan description.

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Vision Benefits

The Archdiocese partners with VSP for your vision benefits. Our Voluntary Vision program provides comprehensive coverage for all of your routine vision needs. You pay the full cost of coverage through pre-tax payroll deductions.

Using your VSP benefit is easy. Create an account at vsp.com. Find an eye care provider who’s right for you. To find a VSP provider, visit vsp.com or call 800-877-7192. At your appointment, tell them you have VSP – no ID card is necessary. That’s it! VSP handles the rest. Average annual savings with VSP coverage is over $400 vs. what you might pay for an exam and glasses without coverage.

Benefit Description Network Copay

Frequency

Well Vision Exam Focuses on your eyes and overall wellness $15 Every 12 months

Frame

• $160 allowance on a wide selection

• $180 allowance for featured brands

• 20% savings on overage

$35 Every 24 months

Lenses • Single vision, lined bifocal, lined trifocal

lenses

• Polycarbonate lenses for children

Included with Frame copay

Every 12 months

Lens Enhancements

• Tints/Photochromic adaptive lenses

• Scratch-resistant coating

• UV protection

• Standard Progressive lenses

• Premium Progressive lenses

• Custom Progressive lenses

• $0

• $0

• $0

• $0

• $80-$90

• $120-$160

Every 12 months

Contacts (instead of glasses)

• $160 allowance, no copay

• Fitting and evaluation exam Up to $60 Every 12 months

Diabetic Eyecare Plus Services related to diabetic eye disease, glaucoma and age-related macular degeneration, retinal screening for eligible diabetic members – coordinated with medical coverage.

$20 As needed

Extra Savings Glasses and Sunglasses

• Extra $20 to spend on featured frame brands

• 30% savings on additional glasses and sunglasses from the same VSP provider on the same day as your Well Vision Exam, or get

• 20% savings from any VSP provider within 12 months of your last Well Vision Exam

Retinal Screening

• No more than a $39 copay on routine retinal screening Laser Vision Correction

• Average 15% off regular price or 5% off promotional price from contracted facilities

• After surgery, use your frame allowance (if eligible) for sunglasses from any VSP provider.

With Out-of-Network Providers you pay the provider and submit a claim to VSP for reimbursement up to the allowances shown below:

Exam $50 Lined Bifocals $75 Contacts $105

Frame $70 Lined Trifocals $100 Tints $5

Standard Lenses $50 Progressives $75

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Short Term Disability Insurance

A disability can occur at any time. If the disability is severe enough, it will prevent the person from being able to work and provide for their family. Food, mortgage payments, and other monthly bills cannot be paid without a steady income. Disability insurance provides some income replacement should you become disabled and unable to work due to a non-work related injury or illness. The Archdiocese and your employer provide short term disability insurance at no cost to you, and eligible employees are automatically enrolled. Maternity leave (though not a sickness) does qualify for short term disability benefits. Please contact your onsite benefit administrator for more information on filing a claim.

Company Paid Short Term Disability

Premiums are paid by The Archdiocese and your employer

Elimination Period

Accidents: You must be unable to work for 7 days due to a qualified disability in order to be eligible for benefits. Benefits may begin on the eighth day of disability Sickness: You must be unable to work for 7 days due to a qualified disability in order to be eligible for benefits. Benefits may begin on the eighth day of disability

Benefit Amount Payout The benefit amount is 67% of your pre-disability earnings up to a maximum of $500 per week.

Taxable Benefit Yes

Benefit Duration Benefits may be payable for up to 12 weeks.

This is a brief summary only. Certain restrictions and Exclusions apply. For exact terms and conditions please refer to your summary plan description.

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Life and Long Term Disability Insurance

The Archdiocese provides Basic Life and Accidental Death and Dismemberment (AD&D) benefits to all full-time employees. You may elect to cover your eligible dependents for Life Insurance at a 50% cost share. You also may elect to cover yourself for Long Term Disability (LTD) at a 50% cost share. The monthly cost for LTD is based on your salary as of January each year. You and your Employer share equally in the cost of the coverage.

You are eligible for Life and Disability benefits if you are an active employee working a minimum of 30 hours per week, per school or calendar year (whichever is appropriate). Your spouse and dependent children (from 15 days old to the end of the calendar year they turn 26) are eligible for Dependent Life coverage. If you enroll in Dependent Life and/or LTD coverage within 30 days of your eligibility date, coverage is guarantee issue. Evidence of Insurability will be required if you do not enroll when first eligible. This includes a health statement that must be approved by The Hartford before coverage can become effective.

Employee Basic Life Benefit Employee

Pays Employer

Pays Total Monthly

Cost

Employee Life * AD&D *

$20,000 $20,000

$0.00 $0.00

$1.76 $.20

$1.76 $0.20

*At age 70 *Life and AD&D coverage reduces 50% at age 70, so $10,000 of coverage at ½ the cost shown

above will apply for employees after turning age 70.

Additional Coverage Benefit Employee Pays 50%

Employer Pays 50%

Total Monthly Cost

Dependent Life Spouse Child(ren)

$4,000 $2,000

$0.588 $0.588 $1.176

Long Term Disability

Benefit is 50% of monthly income to a maximum

benefit of $3,000. Benefits begin after 12 weeks.

To calculate your monthly cost: Annual salary divided by 12 = $______________ (monthly income not to exceed $6,000) divided by 100 x $0.241 = $_________ (total cost). Divide in half to determine your cost. One-half is paid by your employer and one-half is paid by you.

This is a brief summary only. Certain restrictions and Exclusions apply. For exact terms and conditions please refer to your summary plan description.

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Voluntary Supplemental Life Insurance

The Archdiocese offers a Voluntary Supplemental Life Insurance benefit that can be purchased at your expense for you and your dependents. You will receive group rates and the premium is conveniently deducted from your payroll. The cost is determined by the age of the employee and spouse as of January of each calendar year or date of hire for a new employee. For benefit and rate information, please see the table below. Full-time employees are eligible to purchase additional life insurance for themselves and their spouses up to the coverage maximums of $150,000 and $75,000 shown in the table below. If you enroll within 30 days of your date of hire no evidence of insurability is required. Coverage for your children is also guarantee issue. During our annual enrollment period you will be able to enroll or increase your coverage by $10,000 and your spouse’s by $5,000 (up to the maximum) without having to provide evidence of insurability. Any amounts over these increments that you elect during annual enrollment will be subject to approval by Hartford Life.

Coverage Employee Paid Benefit

Employee $10,000 increments to $150,000 maximum

Spouse $5,000 increments to $75,000 maximum, cannot exceed 50% of employee’s benefit

Children Option 1 - $5,000 on each child; Option 2 - $10,000 on each child

Monthly Cost for Each $1,000 of Employee and Spouse Life Insurance Coverage

Age <30 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75 +

Life $0.06 $0.08 $0.10 $0.14 $0.23 $0.36 $0.56 $0.71 $1.27 $2.10 $3.70

Children All children are covered for one monthly cost. Option 1: $5,000 - $0.35; Option 2: $10,000 - $0.70

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Hartford Life Value-Added Services Ability Assist Counseling Services – You and your family, including spouse and dependents, can access these services at any time, as long as you are covered under the Short Term Disability program.

Available Services

Emotional or work-life counseling

Helps address stress, relationship or other personal issues you or your family

members may face. It’s staffed by GuidanceExperts℠ – highly trained master’s

and doctoral level clinicians – who listen to concerns and quickly make referrals to in-person counseling or other valuable resources. Situations may include: • Job pressures • Relationship/marital conflicts • Stress, anxiety and depression • Work/school disagreements • Substance abuse • Child and elder care referral services

Financial information and resources

Provides support for the complicated financial decisions you or your family members may face. Speak by phone with a Certified Public Accountant and Certified Financial Planners on a wide range of financial issues. Topics may include: • Managing a budget • Retirement • Saving for college • Getting out of debt • Tax questions

Legal support and resources

Offers assistance if legal uncertainties arise. Talk to an attorney by phone about the issues that are important to you or your family members. If you require representation, you’ll be referred to a qualified attorney in your area with a 25% reduction in customary legal fees thereafter. Topics may include: • Debt and bankruptcy • Guardianship • Divorce

Health Champion health care support service

A service that supports you through all aspects of your health care issues by helping to ensure that you’re fully supported with employee assistance programs and/or work-life services. Situations may include:

• One-on-one review of your health concerns

• Preparation for upcoming doctor’s visits/lab work/tests/surgeries

• Answers regarding diagnosis and treatment options

• Coordination with appropriate health care plan provider(s)

• Cost estimation for covered or non-covered treatment

• Fee/payment plan negotiation

The service includes up to three face-to-face emotional or work-life counseling sessions per occurrence per year. This means you and your family members won’t have to share visits. Each individual can get counseling help for his/her own unique needs. Getting in touch is easy – for phone access simply call toll-free:

1-800-96-HELPS (1-800-964-3577) You’ll also have 24/7 access to GuidanceResources Online which includes chat sessions with professional moderators and access to hundreds of personal health topics and resources for child care, elder care, attorneys or financial planners. Visit www.guidanceresources.com and create your own personal username and password. First time users will provide the following information on the profile page:

1. In the Company/Organization field, use HLF902. 2. Then create your own confidential user name and password. 3. Finally, in the Company Name field at the bottom of the personalization page, use ABILI.

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Hartford Life Value-Added Services (cont’d) Travel Assistance and ID Theft Protection Services The best laid travel plans can go awry, leaving you vulnerable and, possibly, unable to communicate your needs. When the unexpected happens far from home, it’s important to know whom to call for assistance. If you are covered under a Hartford Group Policy, you and your family have access to Travel Assistance Services provided by Europ Assistance USA. With a local presence in 200 countries and territories around the world, and numerous 24/7 assistance centers, they are available to help you anytime, anywhere. Identity theft, America’s fast-growing crime, victimizes almost 10 million American consumers each year. Europ Assistance USA helps protect you and your family from its consequences 24/7, at home and when you travel. In addition to prevention education, this service provides advice and help with administrative tasks resulting from identity theft. Estate Guidance Will Services As a covered employee under a Hartford Group Life insurance policy, you have access to EstateGuidance® Will Services provided by ComPsych®. It helps you create a simple, legally binding will quickly and conveniently online, saving you the time and expense of a private legal consultation. Other advantages include:

• Online assistance from licensed attorneys should you have questions.

• The ability to save drafts for up to six months. During this period, you can revise your will at no cost, as long as you haven’t already printed or downloaded it.

• Additional estate planning services are also available for purchase, including the creation of living wills and trusts, guidance about divorce

Beneficiary Assist Counseling Services For those covered under the Life Insurance, Beneficiary Assist provides you, your eligible beneficiaries and immediate family members with unlimited 24/7 phone access to help related to the death of yourself or a loved one. That includes:

• Legal advice, financial planning and emotional counseling for up to one year from the date the claim is filed.

• Up to five face-to-face sessions or equivalent professional time for one service or a combination.

Funeral Planning and Concierge Services The death of a loved one is one of life’s most stressful situations. Quick, often costly decisions must be made while emotions are at their peak. Yet, how many people know how to plan a funeral? That’s why your employer offers a funeral planning and concierge service through The Hartford’s Group Life insurance program— provided by Everest the first to offer this service nationwide.

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Health Care and Dependent Care

Flexible Spending Accounts

What is a Flexible Spending Account (FSA)? A Flexible Spending Account (FSA) is an account in which you set aside pre-tax dollars to pay for eligible health care or dependent care expenses not covered by insurance. The annual amount you elect to contribute to each account will be divided into equal amounts and deducted from your paycheck pre-tax. You are eligible to participate in both the Health Care Reimbursement account and the Dependent Care Reimbursement Account if you work a minimum of 30 hours per week.

Health Care Account: You may elect an up to $2,700 for the 2020 plan year to be used for medical, prescription drug, dental and vision expenses for you and eligible dependents. Some eligible expenses include (but are not limited to) the following:

• Medical or Dental Deductibles and Coinsurance

• Office Visit and Prescription Drug Copays

• Eyeglasses and Contact Lenses

• Hearing Aides Please note that our plan does not cover the following expenses, which are allowable under IRS rules. Members who incur these expenses will not be allowed to pay them with pre-tax funds:

• Contraceptives, abortion, reversal of sterilization, sex transformations, actual or attempted impregnation or fertilization which involves either a covered person or surrogate as a donor or a recipient, and the diagnosis or treatment of infertility.

More details on expenses that are allowable or not is shown on pages 34 and 35 of this guide.

Dependent Care Account: You may elect an amount up to $5,000 per plan year ($2,500 maximum per year if married and filing a separate tax return) to be used for child day care or elder day care expenses for your eligible dependents. Some eligible expenses include (but are not limited to) the following:

▪ Chi ld Daycare ▪ Before and/or After School Care ▪ Adult Day Care for your Tax-Qualified Dependent

Why Should I Participate? By setting aside pre-tax dollars to pay for out-of-pocket expenses you would normally pay for using after-tax dollars, you are reducing your “taxable income” because it reduces the amount of federal, state and FICA taxes you pay. This means more take-home pay for you!

How Does an FSA Work? Your contributions are taken pre-tax and will be taken out of the first two pay checks each month. Health FSA funds can be used for expenses incurred from January 1st through December 31st. Federal laws require FSA plans to operate on a “use it or lose it” basis, however, they allow up to $500 of unused funds in the health care account at the end of the plan year to be rolled over for use in the following plan year. This applies only to the Health FSA funds, not to the Dependent Care Account funds. For additional rules and restrictions, please see Human Resources.

What Happens if I Leave Employment Mid-year? If your employment ends mid calendar year, you have two options for utilizing your Flexible Spending Accounts. Please contact your onsite benefit administrator so that you can understand your benefit options for FSA.

33

Health Care and Dependent Care Flexible Spending

Accounts (cont’d)

Can Orthodontia be reimbursed through your FSA? Orthodontia expenses can be reimbursed through your Flexible Spending Account (FSA), but the reimbursement process governed by the Internal Revenue Service can be challenging to understand. In short, your FSA reimbursement aligns with the payment/treatment schedule set up with your orthodontist/dentist. Reimbursement can span as much as two years if the treatment time is that long. Even if you pay for orthodontia in full prior to treatment, your reimbursement schedule will align with the treatment months. Contact NueSynergy FSA Customer Service at (855) 890-7239 or email at customerservice@NueSynergy.com for details.

REIMBURSEMENTS – 2 OPTIONS • File a claim – complete the Claim for Reimbursement form and submit it with itemized receipts to our FSA

administrator, NueSynergy. Reimbursement for your expenses may be paid to you via check or direct deposit.

• Debit Card –Allows you to pay directly from your Flexible Spending Account at the point of service, eliminating the hassles associated with having to “pay twice.”

• If you would like a debit card, contact NueSynergy – a debit card fee of $12 per year will be deducted from your account at the beginning of the calendar year.

• By electing to use the debit card, you agree to save all invoices and receipts related to any expense paid with the debit card. Upon request you must submit these documents for review by NueSynergy. Failure to submit the requested documents will cause the expense to be treated as a non-qualified expense and you will be required to remit payment to your employer.

• Note debit cards may no longer be used to purchase OTC medicines and drugs. You will need to use another form of payment and file a claim for reimbursement.

Tips and Reminders ✓ Estimate your expenses and plan carefully so that you don’t leave a balance in your account at the end

of the year because the use-it-or-lose-it rule does generally apply to both the Health Care and Dependent Care FSAs.

✓ Keep your receipts! Even if you use the debit card successfully, you may still be asked to submit a receipt in order to comply with IRS regulations.

✓ Most over-the-counter medications are not eligible expenses. You can find a full list of eligible expenses on the NueSynergy website.

✓ Debit card will be mailed to your home in a plain white envelope labeled “Important Benefit Information”. ✓ You can’t use funds in your Health Care FSA to pay for Dependent Care expenses, and vice versa. ✓ You can use your Health Care FSA to purchase over-the-counter (OTC) medications as long as you

have a prescription. ✓ Some OTC items do not require prescriptions like insulin, diabetic supplies, band aids, and contact lens

solution.

PRE-TAX PREMIUM DEDUCTIONS Premium deductions for the Archdiocese Health, Dental, and Voluntary Vision plans will be deducted from your pay checks on a pre-tax basis. By electing to participate in the Pre-Tax Premium plan you may take advantage of tax savings. Please note that your social security benefits may be affected due to the pre-tax reduction in your salary.

NueSynergy gives you access to your account status 24 hours a day, seven days a week, through an interactive voice response system. Call (855) 890-7239, email customerservice@NueSynergy.com or visit the website at www.NueSynergy.com.

Health Care and Dependent Care

Flexible Spending Accounts (cont’d)

34

Health Care Qualified Medical Expenses

The qualified medical expenses that can be reimbursed by an FSA on a tax-free basis are limited to expenses

for medical care (as defined in the federal tax code) for the employee and his or her spouse and dependents,

to the extent those expenses are not reimbursed by any other health coverage. The federal tax code defines

medical care expenses as amounts paid for the diagnosis, cure, mitigation or treatment of a disease, and for

treatments affecting any part or function of the body. The expenses must be primarily to alleviate a physical or

mental defect or illness.

The products and services listed below are examples of medical expenses that may be eligible for payment

under your Flexible Spending Account, when such services are not covered by your health plan. This list is not

exhaustive; additional expenses may qualify as medical expenses, and the items listed below are subject to

change. Our plan has additional restrictions on the types of expenses it will reimburse. Those are

crossed out on the list below.

Over-the-counter medicine or drug expenses (other than insulin) cannot be reimbursed without a prescription.

This rule does not apply to items for medical care that are not medicines or drugs.

• Abortion

• Acupuncture

• Alcoholism treatment

• Ambulance

• Annual physical exam

• Artificial limb

• Artificial teeth

• Bandages

• Birth control pills

• Body scan

• Breast pumps and supplies

• Breast reconstruction surgery following mastectomy for cancer

• Capital expenses (improvements or special equipment installed to a home, if meant to accommodate a disabled condition)

• Car modifications or special equipment installed for a person with a disability

• Chiropractor

• Contact lenses

• Contraceptive Substances and Devices

• Crutches

• Dental treatment (not including teeth whitening)

• Diagnostic devices

• Disabled dependent care expenses (medical care of the disabled dependent)

• Drug addiction treatment

• Eye exam

• Eye glasses

• Eye surgery

• Fertility enhancement (for example, in vitro fertilization or surgery)

• Guide dog or other service animal

• Hearing Aids

• Hospital services

• Infertility Treatment

• Laboratory fees

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Health Care Qualified Medical Expenses (cont.)

The Archdiocese flexible spending account allows the following medical expenses except for those that are crossed out.

• Lactation expenses

• Lodging at a hospital or similar institution

• Medical conference expenses, if the conference concerns a chronic illness of yourself, your spouse or your dependent (excluding meals and lodging)

• Medications, if prescribed

• Nursing services

• Operations

• Optometrist

• Osteopath

• Oxygen

• Physical exam

• Pregnancy test kit

• Prosthesis

• Psychiatric care

• Psychoanalysis

• Psychologist

• Reversal of Sterilization

• Sex Change Surgery

• Stop-smoking programs

• Surgery

• Special telephone for hearing-impaired individual

• Television for hearing-impaired individuals

• Therapy received as medical treatment

• Transplants

• Transportation for medical care

• Vasectomy

• Vision correction surgery

• Weight-loss program if it is a treatment for a specific disease

• Wheelchair

• Wigs when recommended due to hair loss related to an illness

• X-rays

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The New Directions EAP The EAP can give you the support you need. Whether you sense that a life challenge is just ahead, or you’re already knee-deep in it, the EAP is here to help with top-notch providers, experts and offerings in these areas:

• Relationship and family challenges • Excessive worry

• Life-changing events • Feeling sad or blue

• Legal or financial challenges • Substance dependence or addiction

• Stress • Workplace challenges The EAP is available around the clock. Call the Helpline at 800-624-5544 or go online at www.ndbh.com (company code ARCHKCK) for quick and easy access to experts who can immediately point you to the right resources. An EAP professional is always available.

Resources The expansive list of EAP resources includes: Assessment and Referral In-person or telephone assessments are available to help match you with the appropriate EAP service, health plan or community services.

Short-term Counseling Certified, licensed and passionate professionals are available to help you manage almost any part of your life in person, over the phone or via text.

Relationship Support Staff are on hand around the clock to help you find resources to work through parental, personal or work-related relationship challenges.

Mobile App Access all EAP Benefits via smartphone. Search New Directions EAP in App Store, download and enter company code.

Legal and Financial Service Access the network of attorneys and financial counselors who can provide advice on a multitude of challenges. Connect with them in-person or online as well as explore a database of customizable legal documents.

Health Resource Library Search a comprehensive collection of articles, videos, self-assessments, calculators and planners for information on thousands of topics designed to help improve your health.

Subscribe to "A Better You" Need a Monday morning pick-me-up? Relationship advice? Health tip? A reason to be inspired this week? Subscribe to New Directions EAP (ndbh.com) bi-weekly emails and spend 30 seconds improving your mental

health.

The Archdiocese Plan

The EAP through the Archdiocese covers all employees and their immediate family members, whether or not you are covered by the health plan. You and each of your family members has up to 3 counseling sessions available per incident per year.

Employee Assistance Program (EAP)

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Voluntary Critical Illness Insurance

Colonial Life’s Group Critical Care insurance helps employees and their families maintain financial security during the lengthy, expensive recovery period of a serious medical event such as cancer, heart attack or stroke. It provides a lump sum benefit to help with the out-of-pocket medical and/or non-medical expenses of a critical illness or cancer. Benefits are paid directly to the covered person, in addition to other insurance you may have. Rates are based on age, tobacco status and plan benefits selected.

Coverage Type Voluntary Critical Illness is a group policy that includes coverage for heart/stroke, cancer and other critical illnesses

Benefit Amount

Benefit amounts are available at various levels. You can choose:

• $5,000 to $100,000 for employees (amounts above $20,000 require underwriting approval)

You can also add coverage for your dependents:

• Spouse and dependent child benefit amounts are 50% of the employee’s elected amount.

Coverage for Vascular Conditions

Percent of benefit amount paid at initial diagnosis:

• Heart Attack

• Stroke

• Coronary artery bypass surgery as a result of coronary artery disease

100% 100% 25%

Coverage for Cancer Conditions

Percent of benefit amount paid at initial diagnosis:

• First diagnosis of internal or invasive cancer

• Carcinoma in situ

• Skin Cancer

100% 25% $500 flat amount

Coverage for Other Critical Illnesses

Percent benefit amount paid at initial diagnosis:

• Major organ failure

• End stage renal (kidney) failure

• Coma

• Blindness

• Permanent paralysis due to an accident

• Occupational infectious HIV, Hepatitis B, C or D

100% 100% 100% 100% 100% 100%

Additional Included Benefits

Subsequent Diagnosis: If an insured receives a benefit for a critical illness and is later diagnosed with a different covered illness, the original benefit for that particular illness is payable. Benefit Recurrence: This provides an additional benefit for the same condition if a covered participant is subsequently diagnosed at least 180 days after the initial diagnosis. Health Screening: Benefit pays $50 or $100 once per year for covered health screenings. There are 24 covered tests including mammograms, colonoscopies, and stress tests.

This is a brief summary only and is not intended to provide complete details. Certain restrictions and exclusions apply.

38

Voluntary Accident Insurance

Colonial Life’s voluntary accident insurance is a medical indemnity plan that provides employees and their families with hospital, doctor, accidental death and catastrophic accident benefits in the event of a covered accident. There are six plan choices, from basic to premier with or without health screening benefits. Additional benefit riders may also be available. Base plans are guaranteed issue, so there is no health underwriting. Benefits are paid directly to you in addition to any other insurance you may have.

Base Policy Benefits Basic Preferred Premier

Accident Emergency Treatment

For treatment in a doctor’s office, urgent care facility or emergency room within

the first 72 hours of the accident. If

initially treated after 72 hours, please

see Accident Follow-up Doctor’s Visit

$75 $125 $125

Accident Follow-Up Doctor Visit $50/visit up to 2

visits per accident

$50/visit up to 3

visits per accident

$50/visit up to 4

visits per accident

Accidental Death $20,000 Employee $20,000 Spouse

$4,000 Child(ren)

$25,000 Employee $25,000 Spouse

$5,000 Child(ren)

$50,000 Employee $50,000 Spouse

$10,000 Child(ren)

Ambulance - Air $1,200 $2,000 $2,000

Ambulance - Ground $120 $200 $200

Appliances (such as wheelchair, crutches)

$75 $100 $100

Burns (based on size and degree)

$1,000- $12,000 $1,000- $12,000 $1,000- $12,000

Coma (duration of at least 7 days) $7,500 $10,000 $12,500

Concussion $60 $60 $60

Eye Injury $200 $300 $300

Fractures (Based on bone and if repaired by open or closed reduction)

$90 - $4,500 $110 - $5,500 $120 - $6,000

Hospital Admission* $750/accident $1,250/accident $1,500/accident

Hospital Confinement (Per day up to 365 days)

$175 $250 $275

Hospital ICU Admission* $1,500/accident $2,500/accident $3,000/accident

Hospital ICU Confinement (Up to 15 days per accident)

$350 $500 $550

The table above illustrates some of the benefits only and does not provide full details. There are exclusions and limitations that may apply. Rates are not age banded and vary based on plan design elected, and whether coverage includes spouse and dependents.

39

Voluntary Whole Life Insurance

Colonial Life’s Whole Life 1000 is an individually owned, whole life insurance plan with guaranteed level premiums, guaranteed cash values and a guaranteed death benefit. This is permanent insurance guaranteed for the life of the policy (to age 100) provided premiums are paid when due. Employees may purchase death benefit amounts from $5,000 to $100,000. Coverage is guarantee issue, no health questions up to $75,000. Family coverage is available through a separate spouse policy or term insurance riders for the spouse and/or dependent children. Rates are age specific and will be calculated at time of enrollment.

Important Information about Colonial Life

Critical Illness, Accident and/or Whole Life coverage!

✓ Take advantage of these individual plans being offered with high Guarantee Issue amounts, no health questions.

✓ Premiums for these plans are not paid through payroll deduction; Colonial will provide these benefits through the convenience of Bank Draft.

✓ Provides you with the ability to KEEP these coverages at the same cost, even if you change jobs or retire.

✓ Benefits are paid directly to you regardless of the type of health insurance you have. ✓ You may only receive additional coverage details by meeting with a benefit counselor

during Open Enrollment, or by calling Colonial Life at 1-844-237-3738, then select the “Archdiocese of KCK Employees” prompt.

NOTE: For enrollment in the Colonial Life coverages, you’ll need to have your banking account

(checking or debit) and routing numbers

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College Tuition Benefit

Helping Families Save for College College Tuition Benefit ® (CTB) provides all Archdiocese employees’ children, grandchildren, nieces, and nephews with guaranteed college scholarships. This benefit is being provided due to our offering of Colonial Life voluntary plans. All scholarships come from the SAGE Scholars Network of colleges. Currently almost 40% of the National Association of Independent Colleges and Universities, NAICU, participate in the Network. Included locally are Benedictine, Avila, and William Jewel. How the Program Works

• Register for the program. The Colonial Life representatives can help you with this step. It is important to note that you do not need to enroll in the Colonial Life plans to register for this program.

• You receive 1,000 Tuition Rewards points when you enroll in the program.

• Each student you register receives 500 Tuition Rewards in his or her own name.

• Each employee then receives 1,000 additional points each anniversary year.

• Each Tuition Reward Point is equal to $1.00 guaranteed minimum reduction in full tuition.

What Else You Should Know

• You can learn more at www.CollegeTuitionBenefit.com

• There is no limit to the number of students you can register.

• You do not pick the colleges ahead of time.

• The SAGE Scholars network has over 385 colleges, and the list keeps growing.

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Contact Information

Archdiocese of Kansas City in Kansas, in partnership with the following vendors, strives to meet your benefit needs. If you have any questions regarding your benefits, please visit:

https://www.archkck.org/employee-benefits

or contact the corresponding vendor listed below. If you still have questions, please contact your onsite Benefits Administrator or the Human Resources office of the Archdiocese.

Benefit Vendor Name Customer Service

Health Care Plan Blue Cross Blue Shield of Kansas City

(888) 495-9340 www.MyHealthToolkitKC.com

Prescription Drug Benefits MedTrak (800) 771-4648

www.medtrakrx.com

Medication Management Tria Health (888) 799-8742

www.triahealth.com

Cancer Care Advocacy Alere Oncology Management (855) 814-5077

Telemedicine Teladoc (800) TELADOC (835-2362)

www.teladoc.com

Dental Plan Delta Dental of Kansas (800) 234-3375 / (316) 264-4511

www.deltadentalks.com

Vision Plan VSP (800) 877-7195 www.vsp.com

Hartford Life Value Added Services

Hartford Life (800) 96-HELPS

www.thehartford.com/employeebenefits

Voluntary Whole Life, Accident and Critical Illness Insurance

Colonial Life Ryan Bowling: ryan.bowling@coloniallife.com

844-237-3738

Flexible Spending Accounts NueSynergy (855) 890-7239 or

customerservice@NueSynergy.com www.NueSynergy.com

Archdiocese Human Resources Maura Dodson

mdodson@archkck.org (913) 647-0362

The information in this Enrollment Guide is presented for illustrative purposes and is based on information provided by the employer. The text contained in this Guide was taken from various summary plan descriptions and benefit information. While every effort was taken to accurately report your benefits, discrepancies or errors are always possible. In case of discrepancy between the Guide and the actual plan documents the actual plan documents will prevail. All information is confidential, pursuant to the Health Insurance Portability and Accountability Act of 1996. If you have any questions about your Guide, contact Human Resources.

42

401(k) Plan for Active Employees Investing for Catholics (IFC) and TIAA have joined forces to meet the unique needs of Catholic institutions and their employees. The Archdiocese seeks to provide financially secure investments that are aligned with the teachings of the Church. Investing for Catholics selects funds that are in keeping with the U.S. Bishops’ Guidelines for Socially Responsible Investing. Together they bring a state-of-the-art retirement plan offering that incorporates the highest level of fiduciary protection with IFC, and recordkeeping and administration services from one of the largest and most highly regarded names in the non-profit industry, TIAA. All full-time regular employees (30 hours or more a week) will be auto-enrolled in the 401(k) plan at 1%. Employees are eligible to voluntarily contribute to a self-directed, tax advantage investment account, which includes both pre-tax and Roth source options. Full-time employees are also eligible for employer matching contributions available at 50% of the employee contribution – up to a maximum of 4% (match would be 2%). Additionally, an employer-funded discretionary 2% will also be contributed to the employee’s account. Part-time, regular employees working less than 30 hours a week may also establish an account and make voluntary contributions, but they are not eligible for the employer match or discretionary contributions. Individual administrative fees of $12.00 (TIAA) and .25% (IFC) are deducted on a quarterly basis. 401(k) accounts are qualified retirement accounts subject to early withdrawal penalties before age 59 & 1/2. If you are a new or existing employee and would like to deduct bi-weekly 401k voluntary contributions from your pay, you are required to complete the 401k enrollment online on the Paylocity benefits site. You will receive a welcome packet from TIAA after your first contribution. Contact Information for 401(k) Plan

TIAA Customer Service: 800-842-2252 Lay Plan #406426 www.tiaa.org/archkck

Investing for Catholics: 949-428-0432 Mary Brunson, Vice-president

mary@ifa.org

Contact Information for Previous Archdiocese 403b plans

Lincoln Financial Group: 800-341-0441 Contract #891526+006, Plan ID 2462, ER ID 2593-001

VOYA Investment Services (formerly ING):

913-661-3755 Archdiocese Plan Billing Number VT5564

Frozen Lay Pension Plan If you were employed full time before 01/01/2014 you may have a benefit when you end employment. Please contact CBIZ at 866-715-1354 with any questions.

43

Legal Notices

The Archdiocese of Kansas City in Kansas Benefit Program qualifies as a “church plan” as defined under IRS Code 414(e). By meeting this definition, the Archdiocese Benefit Program is permanently exempt from meeting certain requirements including, but not limited to, the Employee Retirement Income Security Act (ERISA) and Consolidated Omnibus Budget Reconciliation Act (COBRA) regulations. The Archdiocese offers continuation of medical and dental benefits for employees who either terminate their employment or otherwise lose eligibility for benefits. All members enrolled in the benefit plan who lose eligibility (employees, spouses and dependent children) are eligible to receive benefits under the continuation provision. Women’s Health and Cancer Rights Act If you had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights of 1998. For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with attending physician and the patient, for:

1. All stages of reconstruction of the breast on which the mastectomy was performed. 2. Surgery and reconstruction of the other breast to produce a symmetrical appearance; 3. Prostheses; and 4. Treatment of physical complications during all stages of the mastectomy, including lymphedemas.

These benefits will be provided subject to the same deductible, copays, and coinsurance applicable to other medical and surgical benefits under the plan. Mothers and Newborn Act Group health plans and health insurance issuers generally may not, under Federal Law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under Federal law require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours or (96 hours). HIPAA Privacy Notice The Archdiocese of Kansas City in Kansas Health Care Plan is required by law to take reasonable steps to ensure the privacy of your personally identifiable health information and to inform you about the uses of protected health information (PHI) and your privacy rights. PHI use and disclosure by the Archdiocese Health Care Plan is regulated by federal law known as HIPAA (the Health Insurance Portability and Accountability Act). A copy of this notice is available on the benefits information portal.

44

Legal Notices

Premium Assistance Under Medicaid

and the Children’s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you’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 eligible 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” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272). ________________________________________________________________________________________ If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2019. Contact your State for more information on eligibility.

ALABAMA – Medicaid INDIANA – Medicaid

Website: www.myalhipp.com Phone: 1-855-692-5447

Healthy Indiana Plan for low-income adults 19-64 Website: http://www.in.gov/fssa/hip/ Phone 1-877-438-4479 All other Medicaid Website: http://www.indianamedicaid.com Phone: 1-800-403-0864

ALASKA – Medicaid IOWA – Medicaid

Website: http:myakhipp.com Phone: 1-866-251-4861 Email: CustomerService@MyAKHIPP.com Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

Website: http://dhs.iowa.gov/hawki Phone: 1-800-257-8563

ARKANSAS – Medicaid KANSAS – Medicaid

Website: http://myarhipp.com/ Phone: 1-855-MyARHIPP (855-692-7447)

Website: http://www.kdheks.gov/hcf/ Phone: 1-785-296-3512

COLORADO – Health First Colorado (Medicaid) & Child Health Plan Plus (CHP+)

KENTUCKY – Medicaid

Health First CO Website: https://www.healthfirstcolorado.com/ Health First Colorado Member Contact Center: 1-800-221-3943/ State Relay 711 CHP+: https://www.colorado.gov/pacific/hcpf/child-health-plan-plus CHP+ Customer Service: 1-800-359-1991/ State Relay 711

Website: https://chfs.ky.gov Phone: 1-800-635-2570

FLORIDA – Medicaid LOUISIANA – Medicaid

Website: https://www.flmedicaidtplrecovery.com/hipp/ Phone: 1-877-357-3268

Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331 Phone: 1-888-695-2447

GEORGIA – Medicaid MAINE – Medicaid

Website: https://medicaid.georgia.gov/health-insurance-premium-payment-program-hipp Phone: 678-564-1162 ext 2131

Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html Phone: 1-800-442-6003 TTY Maine relay 711

45

Premium Assistance Under Medicaid and CHIP (continued)

MASSACHUSETTS – Medicaid and CHIP PENNSYLVANIA – Medicaid

Website: http://www.mass.gov/eohhs/gov/departments/masshealth/ Phone: 1-800-862-4840

Website: http://www.dhs.pa.gov/provider/medicalassistance/healthinsurancepremiumpaymenthippprogram/index.htm Phone: 1-800-692-7462

MINNESOTA – Medicaid RHODE ISLAND – Medicaid and CHIP

Website: http://mn.gov/dhs/people-we-serve/seniors/health-care/health-care-programs/programs-and-services/other-insurance.jsp Phone: 1-800-657-3739

Website: http://www.eohhs.ri.gov Phone: 855-697-4347, or 401-462-0311 (Direct Rite Share Line)

MISSOURI – Medicaid SOUTH CAROLINA – Medicaid

Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: 573-751-2005

Website: http://www.scdhhs.gov Phone: 1-888-549-0820

MONTANA – Medicaid SOUTH DAKOTA – Medicaid

Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP Phone: 1-800-694-3084

Website: http://dss.sd.gov Phone: 1-888-828-0059

NEBRASKA – Medicaid TEXAS – Medicaid

Website: http://www.ACCESSNebraska.ne.gov Phone: 1-855-632-7633; Lincoln 402-473-7000; Omaha 402-595-1178

Website: https://www.gethipptexas.com/ Phone: 1-800-440-0493

NEVADA – Medicaid UTAH – Medicaid and CHIP

Medicaid Website: http://dhcfp.nv.gov Medicaid Phone: 1-800-992-0900

Website: Medicaid: https://medicaid.utah.gov/ CHIP: http://health.utah.gov/chip Phone: 1-877-543-7669

NEW HAMPSHIRE – Medicaid VERMONT– Medicaid

Website: https://www.dhhs.nh.gov/oii/hipp.htm Phone: 603-271-5218; Toll-free number for the HIPP program: 1-800-852-3345 ext 5218

Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427

NEW JERSEY – Medicaid and CHIP VIRGINIA – Medicaid and CHIP

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

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

NEW YORK – Medicaid WASHINGTON – Medicaid

Website: https://www.health.ny.gov/health_care/medicaid/ Phone: 1-800-541-2831

Website: https://www.hca.wa.gov/ Phone: 1-800-562-3022 ext. 15473

NORTH CAROLINA – Medicaid WEST VIRGINIA – Medicaid

Website: https://medicaid.ncdhhs.gov/ Phone: 919-855-4100 Website: http://mywvhipp.com/

Phone: 1-855-MYWVHIPP (1-855-699-8447)

NORTH DAKOTA – Medicaid WISCONSIN – Medicaid and CHIP

Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-844-854-4825

Website: https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf Phone: 1-800-362-3002

OKLAHOMA – Medicaid and CHIP WYOMING – Medicaid

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

Website: https://wyequalitycare.acs-inc.com/ Phone: 307-777-7531

OREGON – Medicaid

Website: http://healthcare.oregon.gov/Pages/index.aspx http://oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075

To see if any other states have added a premium assistance program since July 31, 2019, or for more information on special enrollment rights, contact either: U.S. Dept. of Labor; Employee Benefits Security Administration www.dol.gov/agencies/ebsa; 1-866-EBSA (3272) or U.S. Dept. of Health and Human Services, Centers for Medicaid Services; www.cms.hhs.gov; 1-877-267-2323 Menu Option 4, Ext. 61565

Legal Notices

46

Legal Notices

Important Notice from Archdiocese of Kansas City in Kansas About Your Prescription Drug Coverage and 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 Archdiocese of Kansas City in Kansas and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice. There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this

coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.

2. Archdiocese of Kansas City in Kansas has determined that the prescription drug coverage offered by the

Archdiocese of Kansas City in Kansas Employee Health Care Plan is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.

_______________________________________________________________________________________________ When Can You Join A Medicare Drug Plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 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 Special Enrollment Period (SEP) to join a Medicare drug plan.

What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan? If you decide to join a Medicare drug plan, your current coverage with Archdiocese of Kansas City in Kansas will not be affected. Archdiocese of Kansas City in Kansas Employee Health Care Plan will coordinate benefits with Part D coverage. Please be advised that our group medical plan will be primary and the Medicare Part D plan will be secondary.

If you do decide to join a Medicare drug plan and drop your current Archdiocese of Kansas City in Kansas coverage, be aware that you and your dependents may not be able to get this coverage back. When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan? You should also know that if you drop or lose your current coverage with Archdiocese of Kansas City in Kansas and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following November to join.

47

Legal Notices

For More Information About This Notice or Your Current Prescription Drug Coverage… Contact the person listed below for further information. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through Archdiocese of Kansas City in Kansas changes. You also may request a copy of this notice at any time. For More Information About Your Options Under Medicare Prescription Drug Coverage… More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans. For more information about Medicare prescription drug coverage:

• Visit www.medicare.gov

• Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help

• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).

Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).

Date: October 1, 2019 Name of Entity/Sender: Archdiocese of Kansas City in Kansas Contact--Position/Office: Maura Dodson Address: 12615 Parallel Parkway Kansas City KS 66109 Phone Number: 913.647.0362

Archdiocese of Kansas City in Kansas

12615 Parallel Parkway

Kansas City, KS 66109