Prepared By:

MEDICAL

PRESCRIPTIONS

LIFE/AD&D

Employee Information Packet

Teachers

(Plan Year 2009)

DENTAL

VISION

DISABILITY

FLEXIBLE SPENDING

TABLE OF CONTENTS

Eligibility 4 Open Enrollment 5 BCBS Medical Plan 6 BCBS Prescription Plan 7

ADN Vision Plan 10 NGS Flexible Spending Account 12 UNUM Life Insurance and AD&D Plan 15 UNUM Voluntary Life Insurance Plan 16 National Insurance Services Long Term Disability Plan 17 Important Notices 18

Appendix 21 Blue Cross Blue Shield Medical & Rx Benefit Summary 22 Blue Cross Blue Shield Value Added Programs 26

Contacts 43

ADN Dental Savings Illustration 29

ADN Dental Plan 8

Flexible Spending Account Worksheet 33 Flexible Spending Account Eligible & Ineligible Expenses 30

Privacy Notice 36

This booklet is intended as an easy-to-read benefits summary. It is not a contract. Additional limitations and exclusions may apply to certain covered services. For an official description of your benefits, please see the appropriate certificate on the benefits website. If needed, contact your benefits office to obtain a copy.

IF YOU HAVE MEDICARE OR WILL BECOME ELIGIBLE FOR MEDICARE IN THE NEXT 12 MONTHS, A NEW FEDERAL LAW GIVES YOU MORE CHOICES ABOUT YOUR PRESCRIPTION DRUG COVERAGE, STARTING IN 2006. FOR FUTHER DETAILS PLEASE LOG ONTO WWW.MEDICARE.GOV OR CALL 1-800-633-42273.

You are eligible for Medical, Flexible Spending, Dental, Vision Life/AD&D & Voluntary Life coverage if you are a teacher working at least 50% of full time (15.5 hours per week). If you are a teacher working less than 50% of full time, you are eligible for dental and vision only. If elected, Medical, Flexible Spending, Dental, Vision, Life/AD&D & Voluntary Life coverage (guarantee issue amount) will go into effect on your date of hire. Any voluntary life amount above the guarantee issue will go into effect on the date that it is approved by UNUM underwriting. You are eligible for LTD coverage if you are a teacher working at least a minimum of 600 hours per year. LTD coverage will go into effect on the first day following 24 months of active employment. Teachers working less than 50% of full time are required to contribute to the cost of their dental & vision coverage based on their assignment percentage. As a participant in the Grosse Pointe Public Schools group benefits program, you may choose coverage for: • Yourself only • Yourself and one dependent • Yourself and two or more dependents Eligible dependents are defined as your: • Legal spouse (see below for guidelines on spousal coverage) • Unmarried dependent child(ren) under age 19 (covered to age 25 if full time student), including:

° Natural child(ren) ° Legally adopted child(ren) ° Child(ren) placed in your home for legal adoption ° Stepchild(ren) ° Child(ren) over whom you have legal guardianship ° A child for whom an employee is required to provide coverage pursuant to a qualified medical

child support order If your spouse has medical insurance available through his or her employer, they must elect that coverage. This provision requires that if your spouse has access through another employer to a “comparable health insurance plan”, they elect it. A comparable health insurance plan is understood to be one for which your spouse’s monthly premium for single coverage is not greater than $175 ($2,100 per year). A spouse who is eligible for employer sponsored coverage that provides benefits under a HMO (Health Maintenance Organization) or a PPO (Preferred Provider Organization) must comply with the rules of that Plan in order to receive coordinated benefits under the GPPSS Plan. If your spouse is enrolled on both their employer’s plan and the GPPSS plan standard coordination of benefit rules will apply. Therefore GPPSS plan will pay spousal claims on a secondary basis. Coordination of Benefits applies on In-network deductibles or co-pays, including both percentage co-pays (coinsurance) and fixed dollar co-pays (deductibles and office visits). The plan will also coordinate on benefits not covered by the primary plan but covered under the GPPSS plan. Coordination of benefits does not apply to out-of-network claims or prescription drugs. Your spouse is required to enroll in his or her employer’s health plan as soon as possible following the September 1, 2007 effective date of this provision, and no later than the spouse’s next open enrollment date. If it is determined that your spouse did not elect available coverage on a timely basis, now or in the future, any and all claims will be denied as of the date when enrollment should have occurred.

ELIGIBILITY

If at any time a spouse’s coverage changes due to a change under their employer’s plan, notice of the change must be communicated to the GPPSS benefits office within 30 days of the date that coverage changes. These changes would include events such as additions or terminations of coverage, a change of the insurance company who is

providing the spouse’s coverage, or a change in the level of benefits offered.

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The Open Enrollment Period is the time of year when you can make any necessary changes to your current benefit elections. Open enrollment for medical, dental & vision takes place during the month of May, with any changes being effective on July 1st. The elections that you choose may be changed only at the next Open Enrollment Period, unless you have a Qualified Change of Status which would allow for a Special Open Enrollment. In accordance with federal regulations, the benefits you choose in your benefit package will remain in effect through the next plan year. However, you may be allowed to make changes in certain benefits if you have a Qualified Change of Status Event. Examples of Qualified Change of Status Events are listed below: • Change in Status

• Change in Employee’s Legal Marital Status • Change in Number of Dependents • Change in Employment Status • Dependent Satisfied (or ceases to satisfy) Eligibility Requirements • Commencement or Termination of Adoption Proceedings

• Significant Cost Increase • Significant Curtailment of Coverage • Addition or Elimination of Benefit Package Option • Change in Coverage of Spouse or Dependent Under Other Employer’s Plan • FMLA Leave • COBRA Event • Judgement, Decree or Court Order • Medicare or Medicaid Entitlement • Employee/dependent loss of Medicaid or Children’s Health Insurance Program (CHIP) or

employee/dependent entitlement for a premium assistance program through Medicaid or CHIP. Please note that these qualifying events have a special 60 day enrollment period rather than the typical 30 day enrollment period.

Note that there are certain limitations and/or exclusions within each qualifying event. For more information please see the Fringe Benefits Coordinator. The Internal Revenue Service requires that the change in benefits must be consistent with the change of status. If you have a qualified change of status, you must complete a new Enrollment Form within 30 days of the date of the qualifying event. These forms are available from the Fringe Benefits Coordinator. Changes made after 30 days from the date of the qualifying event will not be accepted. Notice of HIPAA Special Open Enrollment Rights – If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance coverage, you may in the future be able to enroll yourself or your dependents in this plan provided that you request enrollment within 30 days after your other coverage ends. In addition, if you acquire a new dependent, as a result of marriage, birth, adoption or placement for adoption, you may be able to enroll yourself, your spouse and your newly acquired dependents provided that you request enrollment within 30 days after the marriage, birth, adoption and placement for adoption.

OPEN ENROLLMENT

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SUMMARY OF MEDICAL PLAN Medical coverage is certainly one of the most important and necessary parts of our benefit package. The Grosse Pointe Public School System (GPPSS) strives to provide its employees with comprehensive and affordable medical coverage. The plan that will be offered is a PPO plan through Blue Cross Blue Shield of Michigan. You are eligible for medical coverage if you are a teacher working at least 50% of full time (15.5 hours per week). To locate a participating provider, you can visit www.bcbsm.com. Below is a brief outline of the benefits that will be provided to you. For a more detailed description of the plan, please refer to the benefit summaries located in the appendix portion of this package.

Blue Cross Blue Shield of Michigan PPO Option

This is a Preferred Provider Organization (PPO) that utilizes the Blue Preferred PPO Network. Although you have the freedom to use doctors and hospitals both in and out of network, the highest level of coverage is received when using in network doctors.

Plan Year—January—December

In-Network Out-of-Network

Preventive Care Covered at 100%, No Annual Maximum

Not Covered

Office Visit $10 Copay Subject to Deductible & Coinsurance

Chiropractic Office Visit $10 Copay Subject to Deductible & Coinsurance

Urgent Care $10 Copay Subject to Deductible & Coinsurance

Emergency Room $50 Copay, Waived If Admitted or For Accidental Injury $50 Copay, Waived If Admitted or For

Accidental Injury

Hospitalization Subject to Deductible & Coinsurance Subject to Deductible & Coinsurance

Your Deductible $100 Single/$200 Family (Per Calendar Year) $250 Single/$500 Family

(Per Calendar Year)

Your Coinsurance 10% For General Services & 50% For

Substance Abuse & Private Duty Nursing

30% For General Services & 50% For

Substance Abuse & Private Duty Nursing

Your Maximum Coinsurance

$500 Single/$1,000 Family (Per Calendar Year, Excludes Mental

Health Care, Substance Abuse, & Private Duty Nursing)

$1,500 Single/$3,000 Family (Per Calendar Year, Excludes Mental

Health Care, Substance Abuse, & Private Duty Nursing)

Your Maximum Out-of-Pocket Cost (Including Deductible)

$600 Single/$1,200 Family (Per Calendar Year, Maximum Excludes Mental Health Care,

Substance Abuse & Private Duty Nursing Percent Copays )

$1,750 Single/$3,500 Family (Per Calendar Year, Maximum Excludes Mental Health Care, Substance Abuse & Private Duty Nursing Percent Copays)

Note: The Human Papillomavirus Vaccine (HPV) is covered through age 26.

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SUMMARY OF PRESCRIPTION PLAN

Mail-Order/Maintenance Prescriptions - Certain prescription drugs may be ordered through the mail using Medco. A 90 day supply of medication is available at two times the retail copay. If you would like to utilize this service, please request a mail order packet from the Fringe Benefits Coordinator, or visit www.bcbsm.com

Specialty Prescriptions - Specialty drugs are prescription medications that require special handling, administration, or monitoring. These drugs are used to treat complex, chronic, and often costly conditions. A list of specialty drugs can be obtained at www.bcbsm.com or the benefits website. Please note that the specialty drug list is subject to change, and you should refer to the BCBS website for the most up-to-date listing. You can visit your retail pharmacy to have a specialty drug prescription filled, however, not all pharmacies will dispense these drugs. You can also have them delivered to your home by using Option Care, BCBS’ specialty drug vendor. You can reach Option Care at 888-282-5166. A copy of the appropriate order form can also be found on the benefits website.

Generic Medications - The American Medical Association, the largest organization of medical doctors, endorses generic drugs as acceptable for the American public. And most hospitals routinely use generic drugs for treatment of their patients. Did you also know?

• Generic drugs are held to the same federal Food and Drug Administration standards for safety and performance as the brand names, yet sell for 30 - 75% less.

• To earn FDA approval, a generic must deliver the same amount of active ingredients in the same time as the brand name.

• The FDA requires generics to have the same quality, strength, purity and stability as the brand names.

If you elect medical coverage through GPPSS, prescriptions are also a covered benefit. The plan includes coverage for contraceptives. Below is a brief outline of the benefits offered to you. For a more detailed description of benefits, please refer to the benefit summary in the appendix portion of this package.

Plan Features: Network Pharmacy Non-Network Pharmacy

Pharmacy Prescription Pharmacy Prescription

Supply Up to a 34 Day Supply Up to a 34 Day Supply

Generic Prescription Drugs $5 Copay $5 Copay

Brand Name Prescription Drugs $25 Copay $25 Copay

Out-of-Network Sanction N/A 25% Plus Copay

Mail-Order/Maintenance Prescriptions

Mail-Order/Maintenance Prescriptions

Supply 35-90 Day Supply Not Available

Generic Prescription Drugs $10 Copay N/A

Brand Name Prescription Drugs $50 Copay N/A

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SUMMARY OF DENTAL PLAN

Grosse Pointe Public School System provides all eligible employees with a choice of two dental programs: High Option and Low Option. These plans are administered by ADN Administrators, Inc. As a participant in these plans, you have the ability to choose an in-network dentist from 3 different dental networks: ADN, Michigan Dental Plan, or Dentemax. To locate a participating provider in any one of these networks, you can visit www.adndental.com. If you visit a dentist within these networks, you will receive deeper discounts than if you visit a non-network dentist. Below is a brief outline of the benefits offered to you. For a more detailed description of benefits, as well as an example of network discounts, please refer to the appendix portion of this package.

High Option Plan Features: In Network

Office Visit Copay None None

Coinsurance

• Class I (Preventive Services) 80% 80%

• Class II (Basic Services) 80% 80%

• Class III (Major Services) 80% 80%

• Class IV (Orthodontia For Dependent Children Between Ages 6 & 18)

80% 80%

Annual Deductible $0 Single/$0 Family $0 Single/$0 Family

Annual Maximum $1,000 $1,000

Lifetime Orthodontia Maximum (Orthodontia For Dependent Children Between Ages 6 & 18)

$800 $800

Provider Choice ADN, Michigan Dental Plan or

Dentemax Provider Any Other Dental Provider

Plan Year : December—November Out-Of-Network

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Low Option Plan Features: In Network Out-Of-Network

Office Visit Copay None None

Coinsurance • Class I (Preventive Services) 60% 60%

• Class II (Basic Services) 60% After Deductible 60% After Deductible

• Class III (Major Services) 60% After Deductible 60% After Deductible

• Class IV (Orthodontia For Dependent Children Between Ages 6 & 18)

60% After Deductible 60% After Deductible

Annual Deductible $25 Single/$50 Family $25 Single/$50 Family

Annual Maximum $1,000 $1,000

Lifetime Orthodontia Maximum (Orthodontia For Dependent Children Between Ages 6 & 18)

$600 $600

Provider Choice ADN, Michigan Dental Plan or

Dentemax Provider Any Other Dental Provider

Plan Year : December—November

SUMMARY OF DENTAL PLAN-continued

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SUMMARY OF VISION PLAN

Premium Plan Features:

Frequency of Service: • Exam • Materials:

° Lenses ° Frames

Once Every Plan Year

Once Every Plan Year Once Every Plan Year

Copayments: • Exam • Material

None None

Plan Benefits Per Plan Year

Exam Up to $69

Frames Up to $90

Single Lenses Up to $98

Bifocals Up to $126

Trifocals Up to $160

Lenticular Lenses Up to $160

Cosmetic Contacts Up to $119

Medically Necessary Contacts Up to $293

Plan Year : December—November

Grosse Pointe Public School system also offers two different vision coverage options to its employees: Premium Plan & Standard Plan. These plans are also serviced through ADN Administrators, Inc. You are able to obtain services from any vision provider that you wish under this plan. Please note that you may be required to fill out a form to receive reimbursement from ADN if your vision provider will not bill ADN for services. These forms can be obtained on the Fringe Benefits website. Below is a brief outline of the benefits offered to you.

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Standard Plan Features:

Frequency of Service: • Exam • Materials:

° Lenses ° Frames

Once Every Plan Year

Not Covered Not Covered

Copayments: • Exam • Material

None N/A

Exam Up to $69

Plan Benefits Per Plan Year

Single Lenses Not Covered

Bifocals Not Covered

Trifocals Not Covered

Lenticular Lenses Not Covered

Cosmetic Contacts Not Covered

Medically Necessary Contacts Not Covered

Frames Not Covered

SUMMARY OF VISION PLAN-continued

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Section 125 and 129 of the Internal Revenue Code allows deduction of your eligible dependent care and eligible health care expenditures on a pre-tax basis. With an FSA, money is taken out of your paycheck before taxes to pay for these eligible expenses. Since you don’t pay taxes on the money in your FSA, you can reduce your taxable income. Grosse Pointe Public Schools allows you the opportunity to participate in an FSA program through NGS. The plan year for the FSA plan is July 1 through June 30. There are 2 ways to save with a Flexible Spending Account: 1. Health Care Account (HCA)- Expenses not covered by your health plan, such as copays

and deductibles, may be eligible for reimbursement through your Health Care Account. Dental and vision expenses may also qualify for coverage under this account. For a list of eligible & ineligible expenses, please refer to the listing in the appendix portion of this package. If you know how much you’ll spend on health care each year, set that money aside in your FSA. Through the GPPSS FSA plan, you are eligible to set aside up to $3,000 per plan year in your account.

2. Dependent Care Account (DCA)- The Dependent Care Account lets you use pre-tax dollars towards qualified dependent care. You can set aside up to $5,000 a year ($2,500 if married & filing separately). You and your spouse must each earn more than the amount you set aside. Typically, if you make less than $11,000 or more than $24,000, you’ll receive the greatest tax savings from an FSA dependent account. In order for dependent care services to be eligible, they must be for the care of a tax dependent child under age 13 who lives with you, or a tax dependent parent, spouse, or child who lives with you and is incapable of caring for himself or herself. The care must be needed so that you and your spouse (if applicable) can go to work. Care must be given during normal working hours — Saturday night babysitting does not qualify — and cannot be provided by another of your dependents.

IRS rules apply Consider these points before enrolling: 1. Before the beginning of each plan year, you designate the amount you wish to contribute to

your health care and/or dependent care account for the next year. Money set aside for health care expense cannot be used for dependent care, or vice versa. To assist you in determining how much you should set aside, NGS provides an FSA Calculation Worksheet. A copy of this worksheet is located in the appendix portion of this package, as well as on the benefits website.

2. You may only change your annual contributions if there’s a change in your family status, such as marriage, divorce, or the addition or loss of a dependent.

3. You have three (3) months after the end of the plan year to submit your claims (September 30).

SUMMARY OF FLEXIBLE SPENDING ACCOUNT

**To obtain more detailed information on the Health Care & Dependent Care accounts, including a summary of how they work & frequently asked questions, please refer to the materials posted on the benefits website.

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How You Are Reimbursed Once an expense is incurred, you will submit a Health Care or Dependent Care Account Claim Form to NGS to obtain reimbursement. You will also need to provide the following, depending on the expense: 1. For all health account expenses partially covered by you or your spouse’s medical, dental,

vision, or other health care plans, you will need to provide an Explanation of Benefits (EOB).

2. For other health account expenses, a statement or receipt must be attached which shows the following :

• Description of service or supply • Date expense was incurred (not when statement was received or bill paid) • Person or organization providing the service/supply • Name of person who received the service/supply • Amount of expense (cancelled checks, credit card receipts/statements, check copies,

balance due or balance forward statements are not acceptable documentation). 3. For dependent care account expenses, you must include the following information regarding

the daycare provider: • Name and address • Taxpayer ID or Social Security number. If daycare provider is self-employed, enter

Social Security number, if provider is a tax-exempt organization, enter “Tax-Exempt”

• Receipt or statement from daycare provider indicating charged amounts and dates of service (cancelled checks, credit card receipts/statements, check copies, balance due or balance forward statements are not acceptable documentation)

4. Mail your documentation, along with the appropriate claim form to the address displayed on the form.

5. Make sure that you keep a copy of your submission to NGS! For more details on how to submit for reimbursement, please refer to the “How To File A Claim” document on the benefits website. You may also find a copy of the appropriate claim forms on this website.

SUMMARY OF FLEXIBLE SPENDING ACCOUNT—continued

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The following example demonstrates the tax savings that can be realized through the use of a flex plan. Your tax savings may be more or less, depending on your tax bracket and your tax withholding election.

Without FlexPlan With FlexPlan

Annual Salary

$35,000

$35,000

Annual FSA election

$0

$4,000

Taxable Income $35,000 $31,000

Federal Income Tax (Assume 15%) $5,250 $4,650 State Income Tax (Assume 8%)

$2,800

$2,480

Social Security Tax (Assume 7.265%)

$2,669

$2,364

After Tax Income (Take Home Pay) $24,281 $21,506 Medical Expenses

$1,000

Dependent Care Expenses

$3,000

Take Home Pay After Expenses $20,281 $21,506

Tax Savings $1,225

SUMMARY OF FLEXIBLE SPENDING ACCOUNT—continued

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SUMMARY OF LIFE INSURANCE AND AD&D PLAN

Life insurance provides a benefit to your beneficiary in the event of your death while you are employed. The AD&D amount is equal to your life insurance amount and is also payable to your beneficiary if you die as a result of an accident. The AD&D insurance may also pay a benefit to you if you have certain injuries. Grosse Pointe Public School System provides its employees with Life/AD&D Insurance through UNUM. Outlined below is a brief description of the benefits of your plan.

Plan Features: Benefit Amount

Life Insurance Flat $60,000

Accidental Death & Dismemberment Flat $60,000

Guarantee Issue Amount $60,000

Conversion/Portability Option - Any employee who has a change in employment status (Ex: termination, assignment change) with GPPSS may convert or port his or her life insurance through UNUM according to the provisions listed in your Life & Voluntary Life insurance contract. Upon your change of employment status, the applicable forms will be provided to you by the Fringe Benefits Department. Your application must be submitted to UNUM within 31 days of loss of coverage to qualify for the conversion or portability option.

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SUMMARY OF VOLUNTARY LIFE INSURANCE PLAN

Plan Features:

Schedule: Employee The Lesser of 3x Base Annual Earnings or $150,000

(Increments of $5,000) Spouse

$50,000 Maximum (Increments of $5,000)

Not to Exceed 50% of Employee Amount Child

Live Birth to 6 Months: $1,000 6 Months to Age 19 (25 If FT Student): $2,000 or $5,000,

Maximum Benefit: Employee:

Spouse:

Child:

$150,000

$50,000, Not to Exceed 50% of Employee Amount

$5,000, Not to Exceed 50% of Employee Amount

*Guarantee Issue Amount:

Employee:

Spouse:

Child:

$100,000

$20,000

Elected Amount

GPPSS also allows you the opportunity to buy additional life insurance for yourself, your spouse and/or your dependent children. If you elect this benefit, the premiums will be taken from you on a post tax basis, over 21 pays. Below is a brief summary of the benefits offered to you.

*If you are electing an additional Life/AD&D benefit that is greater than the guarantee issue amounts listed above, you will be required to fill out an evidence of insurability form. If you do not fill out this form, you will not receive the full elected benefit amount. These forms can be obtained from the Fringe Benefits Coordinator or on the Fringe Benefits Website. Late entrants (employees who do not elect coverage within 31 days of becoming eligible) who wish to join the plan at a later date will be required to provide evidence of insurability for any employee, spouse or child amount. If you do not fill out this form, you will not receive an additional Life/AD&D benefit. Currently enrolled employees increas-ing their insurance amount, their spouse’s insurance amount, or their child’s insurance amount at a later date will also be required to provide evidence of insurability for any amount of increase.

Conversion/Portability Option - Any employee who has a change in employment status (Ex: termination, assignment change) with GPPSS may convert or port his or her life insurance through UNUM according to the provisions listed in your Life & Voluntary Life insurance contract. Upon your change of employment status, the applicable forms will be provided to you by the Fringe Benefits Department. Your application must be submitted to UNUM within 31 days of loss of coverage to qualify for the conversion or portability option.

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SUMMARY OF LONG TERM DISABILITY PLAN

Plan Features:

Benefit Amount 66 2/3% of Monthly Earnings

Benefit Maximum $3,750

Elimination Period Benefit payments will begin after you have been unable to work for 120 consecutive working days due to your disability.

Benefit Duration Age at Disablement Duration Of Benefit Prior to Age 61 To Age 65

61 or 62 4 Years 63 or 64 3 Years

65 to 68 2 Years, But Not To Exceed Age 70

69+ 1 Year

Pre-Existing Condition Limitation None

Own Occupation Period 2 Years

Long Term Disability Insurance provides an important source of income if you become disabled and unable to work for an extended period of time. This can affect your financial security and that of your family if you are out on disability. GPPSS offers all eligible employees a Long Term Disability program administered by National Insurance Services, underwritten by Lafayette Life. You are eligible for LTD coverage if you are a teacher working at least 600 hours per year. Below is a brief description of the benefit provided to you.

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IMPORTANT NOTICES Women’s Health and Cancer Rights Act of 1998 (Janet’s Law) Your plan, as required by the Women’s Health and Cancer Rights Act of 1998, provides benefits for mastectomy-related services including reconstruction and surgery to achieve symmetry between the breasts, prostheses, and complications resulting from a mastectomy (including lymphedema). These benefits are subject to applicable terms and conditions under your health plan, including copayments, deductible, and coinsurance provisions. They are also subject to medical insurance limitations and exclusions. This notification is a requirement of the act. The Women’s Health and Cancer Rights Act (Women’s Health Act) was signed into law on October 21, 1998. The law includes important new protections for breast cancer patients who elect breast reconstruction in connection with a mastectomy. The Women’s Health Act amended the Employee Retirement Income Security Act of 1974 (ERISA) and the Public Health Service Act (PHS Act) and is administered by the Departments of Labor and Health and Human Services. Newborns’ and Mothers’ Health Protection Act The Newborns’ Act is a federal law that prohibits group health plans and insurance companies (including HMOs) that cover hospitalization in connection with childbirth from restricting a mother’s or newborn’s benefits for such hospital stays to less than 48 hours following a natural delivery or 96 hours following delivery by cesarean section, unless the attending doctor, nurse midwife or other licensed health care provider, in consultation with the mother, discharge earlier. Michelle’s Law Michelle’s Law is an act that requires health plans to allow college students who take a leave of absence or reduce their class load because of illness to retain their dependent status under their parents’ health plan for up to one year. Students’ eligibility for dependent coverage will continue for one year (unless the student would otherwise lose eligibility within the year). To qualify for protection under Michelle’s Law, the following requirements must be met: the student must be enrolled as a full-time student immediately before the leave of absence or scheduled reduction, the student must have written certification from a treating physician that the leave of absence or reduced schedule is necessary due to a severe illness or injury, and the leave or reduced schedule must have triggered the loss of student status under the health plan. If the plan sponsor changes group health plans during a medically necessary leave and the new health plan offers coverage of dependent children, the new plan will be subject to the same rules. National Defense Authorization Act (NDAA) The NDAA expands the federal Family and Medical Leave Act of 1993 (FMLA) to permit a “spouse, son, daughter, parent or next of kin” to take up to 26 work weeks of leave to care for a “member of the Armed Forces, including a member of the National Guard or Reserves, who is undergoing medical treatment, recuperation, or therapy, is otherwise in outpatient status, or is otherwise on the temporary disability retired list, for a serious injury or illness. How to Obtain a Notice of HIPAA Privacy Practices A copy of the Grosse Pointe Public Schools’ HIPAA privacy practices is included in the appendix of this packet on pages 36-42. You may also contact any of the carriers/administrators listed on page 43 to request a copy of each company’s unique privacy practices. Tell us when you’re Medicare Eligible Please notify Human Resources when you or your dependents become eligible for Medicare. We are required to contact the insurer to inform them of your Medicare status. Federal law determines whether Medicare or the health plan pays primary. You must also contact Medicare directly to notify them that you have health care coverage through an employer group. Privacy laws prohibit anyone other than the Medicare beneficiary, or their legal guardian, to update or change Medicare records. The toll free number to contact Medicare Coordination of Benefits Contractor is 1-800-999-1118.

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MEDICARE PART-D CREDITABLE COVERAGE NOTICE

Important Notice from Grosse Pointe Public School System About Your Prescription Drug Coverage and Medicare

BCBSM Plan Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Grosse Pointe Public School System 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. Grosse Pointe Public School System has determined that the prescription drug

coverage offered by BCBSM is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is considered Creditable Coverage. Because your existing coverage is Credible 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 November 15th through December 31st. However, if you lose your current credit-able prescription drug coverage, through no fault of your own, you will 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 Grosse Pointe Public School System coverage may be affected. If you do decide to join a Medicare drug plan and drop your Grosse Pointe Public School System coverage, be aware that you and your dependents may not be able to get this coverage back.

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MEDICARE PART-D CREDITABLE COVERAGE NOTICE

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 coverage with Grosse Pointe Public School System 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 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 credible 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. 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 also may request a copy of this notice at any time. You will also receive this notice if the coverage through Grosse Pointe Public School System changes. 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).

Date: May 1, 2009 Name of Entity/Sender: Grosse Pointe Public School System Address: 389 St. Clair, Grosse Pointe, MI 48230 Phone Number: (313) 432-3072

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).

20

Appendix

21

Grosse Pointe Public Schools Health Care Benefits

22

Benefits-at-a-Glance In-network Out-of-network Deductibles, copays and dollar maximums Note: Services from a provider for which there is no PPO network and services from a non-network provider in a geographic area of Michigan deemed a “low access area” by BCBSM for that particular provider specialty are covered at the in-network benefit level. If you receive care from a nonparticipating provider, even when referred, you may be billed for the difference between our approved amount and the provider’s charge. Deductibles (each calendar year)

$100 for one member $200 for the family (when two or more members are covered under your contract) Note: Deductible waived if service is performed in a PPO physician’s office.

$250 for one member $500 for the family (when two or more members are covered under your contract) Note: Out-of-network deductible amounts also apply toward the in-network deductible.

Copays Fixed dollar copays • $10 for office visits • $50 for emergency room visits

$50 for emergency room visits

Percent copays • 50% of approved amount for substance abuse treatment and private duty nursing

• 10% of approved amount for most other covered services, waived if service is performed in a PPO physician’s office

• 50% of approved amount for substance abuse treatment and private duty nursing

• 30% of approved amount for most other covered services

Copay dollar maximums (each calendar year) – excludes fixed dollar copays and mental health care, substance abuse treatment and private duty nursing percent copays

10% copays limited to $500 for one member $1,000 for two or more members

30% copays limited to $1,500 for one member $3,000 for two or more members Note: Out-of-network copays also apply toward the in-network maximum.

Dollar maximums $1 million lifetime per covered specified human organ transplant type and a separate $5 million lifetime per member for all other covered services

and as noted for individual services

Preventive care services

Health maintenance exam (includes chest x-ray, EKG and select lab procedures) – one per calendar year

Covered – 100% Not covered

Gynecological exam – one per calendar year Covered – 100% Not covered Pap smear screening (laboratory and pathology services) – one per calendar year

Covered – 100% Not covered

Well-baby and child care: • 6 visits, birth through 12 months • 6 visits, 13 months through 23 months • 2 visits, 24 months through 35 months • 2 visits, 36 months through 47 months • 1 visit per birth year, 48 months through age 15

Covered – 100% Not covered

Childhood immunizations as recommended by the Advisory Committee on Immunizations Practices and the American Academy of Pediatrics

Covered – 100% Not covered

Fecal occult blood screening – one per calendar year Covered – 100% Not covered Flexible sigmoidoscopy exam – one per calendar year Covered – 100% Not covered Prostate specific antigen (PSA) screening – one per calendar year

Covered – 100% Not covered

Screening mammography

Routine mammogram – one per calendar year Covered – 100% Covered – 70% after deductible

Physician office services

Office visits, includes urgent care visits and office consultations

Covered – $10 copay per visit Covered – 70% after deductible, must be medically necessary

Outpatient and home medical care visits Covered – 90% after deductible Covered – 70% after deductible, must be medically necessary

Emergency medical care

Hospital emergency room Covered – $50 copay per visit for facility services, waived if admitted or for an accidental injury

Covered – $50 copay per visit for facility services, waived if admitted or for an accidental injury

Ambulance services – medically necessary Covered – 90% after deductible Covered – 90% after deductible

Diagnostic services

Laboratory and pathology services Covered – 90% after deductible Covered – 70% after deductible Diagnostic tests and x-rays Covered – 90% after deductible Covered – 70% after deductible Therapeutic radiology Covered – 90% after deductible Covered – 70% after deductible

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Benefits-at-a-Glance In-network Out-of-network Maternity services provided by a physician or certified nurse midwife

Prenatal and postnatal care Covered – 100% Covered – 70% after deductible Delivery and nursery care Covered – 90% after deductible Covered – 70% after deductible

Hospital care

Semiprivate room, inpatient physician care, general nursing care, hospital services and supplies – unlimited days Note: Nonemergency services must be rendered in a participating hospital.

Covered – 90% after deductible Covered – 70% after deductible

Inpatient consultations Covered – 90% after deductible Covered – 70% after deductible Chemotherapy Covered – 90% after deductible Covered – 70% after deductible

Alternatives to hospital care

Skilled nursing care -- up to a maximum of 120 days per calendar year per member

Covered – 90% after deductible Covered – 90% after deductible

Hospice care – limited to dollar maximum that is reviewed and adjusted periodically

Covered – 100% Covered – 100%

Home health care – medically necessary Covered – 90% after deductible Covered – 90% after deductible Home infusion therapy – medically necessary Covered – 90% after deductible Covered – 90% after deductible

Surgical services

Surgery – includes related surgical services Covered – 90% after deductible Covered – 70% after deductible Presurgical consultations Covered – 100% Covered – 70% after deductible Voluntary sterilization Covered – 90% after deductible Covered – 70% after deductible Voluntary abortions Not covered Not covered

Human organ transplants Covered – 100% Covered – in designated facilities only Specified human organ transplants – in designated facilities

only, when coordinated through the BCBSM Human Organ Transplant Program (800-242-3504)

Limited to $1 million lifetime maximum per member per transplant type for transplant procedure(s) and related professional, hospital and pharmacy services

Bone marrow transplants – when coordinated through the BCBSM Human Organ Transplant Program (800-242-3504)

Covered – 90% after deductible Covered – 70% after deductible

Specified oncology clinical trials Covered – 90% after deductible Covered – 70% after deductible Kidney, cornea and skin transplants Covered – 90% after deductible Covered – 70% after deductible

Mental health care and substance abuse treatment Inpatient mental health care

Covered – 100% after deductible Covered – 100% after deductible Inpatient mental health care and substance abuse treatment – up to a combined maximum of 60 days per calendar year with a lifetime maximum of 120 days per member

Inpatient substance abuse treatment

Covered – 50% after deductible Covered – 50% after deductible

Facility and clinic

Covered – 100% after deductible Covered – 100% after deductible Outpatient mental health care – up to 50 visits per calendar year with a lifetime maximum of 120 visits per member

Physician’s office Covered – 100% Covered – 100% after deductible

Outpatient substance abuse treatment (in approved facilities) – up to the state-dollar amount that is adjusted annually

Covered – 50% after deductible Covered – 50% after deductible

Other covered services

Outpatient diabetes management program (ODMP) Covered – 90% after deductible Covered – 70% after deductible Contraceptive injections Covered – 90% after deductible Covered – 70% after deductible Prescription contraceptive devices Covered – 100% after deductible Covered – 70% after deductible Allergy testing and therapy Covered – 100% Covered – 70% after deductible Chiropractic spinal manipulation – up to 24 visits per calendar year per member

Covered – $10 copay per visit Covered – 70% after deductible

Outpatient physical, speech and occupational therapy – limited to a combined benefit maximum of 60 visits per calendar year per member; all services provided in any outpatient location (hospital, facility, office or home) are combined to meet the 60-visit maximum

Covered – 90% after deductible Covered – 70% after deductible

Durable medical equipment Covered – 90% after deductible Covered – 70% after deductible Prosthetic and orthotic appliances Covered – 90% after deductible Covered – 70% after deductible Private duty nursing Covered – 50% after deductible Covered – 50% after deductible

24

Blue Preferred® Rx Prescription Drug Coverage Note: Effective October 1, 2006, the mail order pharmacy for specialty drugs changed to Option Care, an independent company. Specialty prescription drugs (such as Enbrel® and Humira® ) are used to treat complex conditions such as rheumatoid arthritis. These drugs require special handling, administration or monitoring. Option Care will handle mail order prescriptions only for specialty drugs while many retail pharmacies will continue to dispense specialty drugs (check with your local pharmacy for availability). Other mail order prescription medications can continue to be sent to Medco. (Medco is an independent company providing pharmacy benefit services for Blue members.) A list of specialty drugs is available on our Web site at bcbsm.com. Log in under “I am a Member.” If you have any questions, please call Option Care customer service at 866-515-1355. What’s covered • “Rx only” drugs • State-controlled drugs • Disposable needles and syringes – when dispensed with insulin or other covered injectable legend drugs

Note: Needles and syringes have no copay. • Prescription contraceptive medications Copays • $5 for each generic drug • $25 for each brand name drug Note: If your prescription is filled by any type of network pharmacy, and you request the brand-name drug when a generic equivalent is available on the BCBSM MAC list and the prescriber has not indicated “Dispensed as Written” (DAW) on the prescription, you must pay the difference in cost between the brand-name drug dispensed and the maximum allowable cost for the generic plus the applicable copay. Payment of benefits • Network pharmacy – Paid at 100% of approved amount less applicable copay • Non-network pharmacy – Paid at 75% of approved amount less applicable copay Note: A network pharmacy is a Preferred Rx pharmacy in Michigan or a MedImpact pharmacy outside Michigan. MedImpact is an independent company providing pharmacy benefit services for Blue members. A non-network pharmacy is a pharmacy NOT in the Preferred Rx or MedImpact networks. Mail-order (home delivery) prescription drugs Covers up to a 90-day supply of medication by mail from Medco (BCBSM network mail order provider), subject to the following copays (no coverage out-of-network)

Copay for up to a 34 day supply: • $5 for mail order generic drugs • $25 for each brand name drugs

Copay for a 35 to 90 day supply: • $10 for mail order generic drugs • $50 for mail order brand name drugs This is intended as an easy-to-read summary. It is not a contract. Additional limitations and exclusions may apply to covered services. For a complete description of benefits, please see the applicable Blue Cross Blue Shield of Michigan certificates and riders. Payment amounts are based on the Blue Cross Blue Shield of Michigan approved amount, less any applicable deductible and/or copay amounts required by your plan. This coverage is provided pursuant to a contract entered into in the state of Michigan and will be construed under the jurisdiction of and according to the laws of the state of Michigan. 68579-013, 68579-064/RE MAR08

25

Blue Cross Blue Shield of Michigan - Value Added Programs

Blue Healthline Blue HealthLine is a free, confidential service that's available 24 hours a day, every day of the year, including holi-days. Just call 1-800-811-1764, and choose to either speak with a registered nurse, or listen to one of more than 1,600 recorded health topics under the following indexes:

♦ General Advice Index ♦ Parent’s Advice Index ♦ Women’s Advice Index

Our nurses can also help you make decisions about your personal health care, work with you to help you quit smoking, or recommend measures to prevent illness.

Blue HealthLine has helped more than 500,000 Blue Cross Blue Shield of Michigan and Blue Care Network mem-bers since July 1997. Currently, more than three million Blues members are eligible to use Blue HealthLine.

BlueHealthConnection Blue Cross Blue Shield and Blue Care Network of Michigan are strongly committed to the health and wellness of our members.

BlueHealthConnection, our collection of health management programs, is designed to provide information, assistance and resources to help you take charge of your health.

BlueHealthConnection is all about empowering you to make informed decisions about your health care and provides several options to help you make smart choices based on your individual needs.

At BlueHealthConnection you will find a wealth of health-related topics, issues and information - all custom tai-lored to meet your individual health needs.

• A Health Risk Appraisal you can take to show your health risks • A personalized home page called a Health Dashboard • The latest health news • Detailed health and medical information • Drug information and interaction alerts

The result is a highly personal, 100-percent secure online health experience, available to you 24 hours a day, seven days a week.

Visit BlueHealthConnection at one of the following web sites: www.bcbsm.com or www.mibcn.com.

The Healthcare Advisor powered by Subimo This online decision-making support resource provides information that empowers you to manage your health and make better health care decisions. For example, when you need care, you want to choose a doctor and hospital that’s right for you so you can get better faster with fewer problems during and after your treatment. If your doctor thinks medication will help or recommends surgery, you want to understand possible side effects, complications and risks and how quickly you will be back on your feet again. Included in the Healthcare Advisor is:

• PharmaAdvisor - Allows you to research and compare drug treatment options • Physician Selection Advisor - Allows you to select a physician using the criteria most important to you • Hospital Advisor - Allows you to find and compare hospitals using the factors most important to you • Treatment Cost Advisor - Allows you to research the cost of common health care service

To access the Healthcare Advisor, you will need to register and log into Member Secure Services at www.bcbsm.com or www.mibcn.com.

26

BlueSafe BlueSafe is an injury prevention program for Blue Cross Blue Shield and Blue Care Network of Michigan members. Show your Blues identification card to save 20 percent at Michigan Dunham’s Sports for safety items such as helmets and padding for bicycles, in-line skates and scooters, athletic braces and supports, and life jackets.

Our members also save 20 percent at Michigan Wright & Filippis stores on all home medical equipment not covered by their health coverage, including bathroom safety seats, grab bars and first aid kits.

BlueSafe also entitles our members to a 10 percent discount at Michigan Dunham’s Sports on all regularly priced merchandise, excluding firearms, golf balls, tennis balls, licenses, Minn Kota motors, Coleman appliances and fuel, Scout merchandise, Pro Line golf sets and drivers, select Nike products and gift certificates. This offer cannot be combined with any other offer or used on the Dunham’s web site.

To learn more or request a free injury prevention brochure, call our BlueSafe hotline at 1-877-258-3723

Naturally Blue If you are exploring alternatives to traditional medicine, we want to help you identify qualified practitioners and save you money. That’s why we created Naturally Blue, a value-added program for Blue Cross Blue Shield and Blue Care Network of Michigan members that provides discounts on select alternative medical services and natural health care related products, such as vitamins and herbs.

With Naturally Blue, Blues members get up to 30 percent off the cost of the following services when they visit a network practitioner:

• Acupuncture • Massage Therapy • Nutrition Counseling

Receive a Discount To receive a discount, show your Blue identification card to the network practitioner when you arrive for treat-ment. There is no limit to the number of times you can receive the discount.

Naturally Blue is made possible by a special arrangement with Healthways Wholehealth Network, Inc., a leader in alternative health care.

Naturally Blue is a value-added program for BCBSM and BCN members. The services and products made available under this program are not covered benefits under any BCBSM or BCN policy, certificate or rider. For more information visit www.bcbsm.com or www.mibcn.com.

Weight Watchers Discount Program We have formed a partnership with Weight Watchers to help you lose pounds. Even a moderate weight loss can help reduce your risk of chronic health conditions, including diabetes, high blood pressure, heart disease and cer-tain types of cancer.

Depending on where you live in Michigan, you’ll save money off the regularly priced package(s):

• More than 25 percent off registration and initial 12-week plan. (Area A) • More than 25 percent off registration and initial 13-week plan and 17 percent off additional 12-

week meeting packages. (Area B) • At work program: 10 percent off 12-week package; five percent off 10-week package. (Area A)

Show your Blues identification card at your first Weight Watchers meeting to receive your special discount.

Call Weight Watchers at 1-800-651-6000 or visit www.weightwatchers.com to find the Weight Watchers location nearest you.

Blue Cross Blue Shield of Michigan - Value Added Programs

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BCBSM Member Secured Services

What can you do with Member Secured Services?

•Find a provider •Verify eligibility and coverage for everyone on your contract •Request additional identification cards •Review the status of your claims •Review & print Explanation of Benefit statements (EOB’s) •See how much you have paid YTD in copayments and Deductibles •Update Coordination of Benefits information •Take a Health Risk Appraisal and use other online health care management tools •Access to health tips, articles and preventive information •Research a condition

Visit www.bcbsm.com to Register today!

BCBSM Member Secured Services gives you instant access to personal health and account information. With member services, you can:

With just a few clicks of the mouse, BCBSM members can now view their claims status online. The Blues recently launched an Online Claims Status Summary application that allows members to view the status of their claims at any time. Members can now check their claims status 24 hours a days 7 days a week, regardless of whether they are signed up to receive explanation of benefits online. Members are able to view their claims and those of their dependents. Here is the information you will find: • Claim Number • Service Date • Member name and birth year • Provider name • Claim Charge • Member balance • Claim status While subscribers will be able to view all members claims, dependents are limited to view only their own claims. The Online Claims status Summary tool currently does not include dental, vision, hearing and prescription drug claims, but those are planned for a later release.

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Good News for Grosse Pointe Public School System Your Dental Plan Just Got Even Better

No matter how comprehensive the coverage, dentists’ bills can still hurt. To help minimize out-of-pocket dentalexpenses, you have advantages to your ADN Dental plan: more choice and opportunity to save!

How it WorksYour employer has now added the ADN, MDP, and DenteMax dental provider networks to your plan allowingyou to receive dental services at greatly reduced costs. While your plan does not require you to use a Participating Provider from any of the above networks, you will be able to experience these savings if you choose to see a network Provider at any time. Some of you may already be a patient at one of the participatingproviders!

The following illustration is an example of the savings you could receive by utilizing network providers. This list is not meant to be all inclusive and shows only examples of the range of discounts that are provided through use of the networks.

Non-network NetworkService Provider Charge Provider Charge

Oral Examination $ 71 $ 45 Prophylaxis – Adult $ 84 $ 52 Prophylaxis – Child $ 72 $ 38 Bitewing X-Rays $ 53 $ 40 Amalgam Filling $ 91 $ 57 Tooth Extraction $ 103 $ 72 Periodontal Cleaning $ 195 $ 138 Root Canal $ 908 $ 615 Crown $1,015 $ 685

Below is an example of how this applies to you & reduces your out-of-pocket costs.

Benefits for a Root CanalNon-Network Care Network Care

Typical non-network dentist fee: $908

If service is covered at an 80% co-insurance level:Plan pays: $726.40 You Pay: $181.60 Amount Applied to Annual Maximum: $726.40 Annual Maximum Remaining: $273.60

Typical network dentist fee: $615

If service is covered at an 80% co-insurance level Plan pays: $492 You Pay: $123 Amount Applied to Annual Maximum: $492 Annual Maximum Remaining: $508

Your Out-of-Pocket Savings: $58.60

*Savings may be greater or less depending on your dentist’s location.

29

FLEXIBLE SPENDING ACCOUNT REIMBURSABLE ITEMS

Prescription Drugs

Allowable expenses:- Prescription drugs or insulin - Birth control drugs (prescribed)- Vitamins (as prescribed by a physician

and not available over the counter) - Over the counter drugs

Expenses specifically disallowed:- Illegal or non-prescribed drugs

Medical Equipment Allowable expenses:- Wheelchair or autoette (cost of

operating/maintaining)- Crutches (purchased or rented) - Special mattress & plywood boards

prescribed to alleviate arthritis - Oxygen equipment and oxygen used to

relieve breathing problems that result from a medical condition

- Artificial limbs - Support hose (if prescribed by physician) - Wigs (where necessary to mental health

of individual who loses hair because of disease)

- Excess cost of orthopedic shoes over cost of ordinary shoes

Expenses specifically disallowed:- Wigs, when not medically necessary for

mental health - Vacuum cleaner purchased by an

individual with dust allergy - Mechanical exercise device not

specifically prescribed by physician

Fees and Services

Allowable expenses:- Physicians, anesthesiologist’s,

dermatologist’s, gynecologist’s and Christian Science practitioner fees

- Obstetrical expenses - Hospital services - Nursing services for care of a specific

medical ailment - Cost of a nurse’s room & board if paid

by the taxpayer where nurse’s services qualify

- Surgical or diagnostic services - Services of chiropractors and

osteopaths

Expenses specifically disallowed:- Payments to domestic help, companion,

babysitter, chauffeur, etc. who primarily render services of a non-medical nature

- Nursemaids or practical nurses who render general care for healthy infants

- Marriage counseling provided by clergyman

- Payments related to elective cosmetic surgery

Hearing Expenses

Allowable expenses:- Hearing aids - Batteries for operation of hearing aids

30

Dental & Orthodontic Care

Allowable expenses:- Dental care - Artificial teeth/dentures - Cost of fluoridation of home water supply

advised by dentist - Braces/orthodontic devices

Expenses specifically disallowed:- Cosmetic dental procedures including

bonding, whitening, or teeth bleaching

Therapy Treatments

Allowable expenses:- X-rays - Alcoholism or drug dependency treatment - Sterilization - Vaccinations - Hair transplant, if medically necessary - Electrolysis, if medically necessary - Physical/Occupational/Speech therapy as

a medical treatment - Smoking Cessation Program (except

over-the-counter expenses)

Expenses specifically disallowed:- Tattoos and body piercing - Religious cult de-programming - Physical treatments unrelated to a specific

health problem (e.g. massage for general well-being)

- Any illegal treatment

Physicals

Allowable expenses:- Routine & preventive physicals - School & work physicals

Allowable expenses:- Optometrist’s or ophthalmologist’s fees - Eyeglasses/contact lenses - Contact lens solutions

Expenses specifically disallowed:- Sunglass clips - Nonprescription eyeglasses/lenses

Assistance for the Handicapped

Allowable expenses:- Cost of guide for a blind person - Cost of note-taker for a deaf child in

school- Cost of Braille books and magazines in

excess of cost of regular editions - Cost of buying, training, and

maintaining a seeing-eye dog - Cost of buying, training and maintaining

a hearing-trained animal to assist a deaf person

- Household visual alert system for deaf person

- Excess costs of specifically equipping automobile for handicapped person over cost of ordinary automobile device for lifting handicapped person into automobile

- Special devices such as tape recorder or typewriter, for a blind person

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Mental Health Care

Allowable expenses:- Services of psychiatrists, psychologists,

and clinical social workers - Psychiatric therapy for sexual problems - Legal fees directly related to mental

commitment of mentally ill person

Expenses specifically disallowed:- Psychoanalysis undertaken to satisfy

curriculum requirements of a student

Miscellaneous

Allowable expenses:- Expenses of services connected with

donating an organ - Cost of special diet, only if medically

necessary and only to the extent that costs exceed that of a normal diet

Miscellaneous

Expenses specifically disallowed:- Expenses of divorce - Cost of toiletries, cosmetics, soap, and

toothbrushes - Cost of special foods taken as a

substitute for regular diet when the special diet is not medically necessary or cost is not in excess of a normal diet

- Maternity clothes - Diaper service - Distilled water purchased to avoid

drinking fluoridated city water supply - Installation of power steering in

automobile- Pajamas purchased to wear in hospital - Mobile telephone used for personal

calls as well as calls to physician - Insurance against loss of income, life,

limb, or sight - Any portion of a premium charge which

represents a tax - Union dues for sick benefits for

members - Contributions to state disability funds - The cost of weight loss programs for

general well-being - Cosmetic expenses

The expenses listed above are examples of reimbursable items. This list is not all-inclusive. The final determination of whether an expense is reimbursable is subject to Internal Revenue Code guidelines and your Flexible Spending Account plan document.

32

Health Care Reimbursement Account

WorksheetPlanning Your Expenses

As you know, Federal tax laws require that any unused amounts remaining in your Health Care Reimbursement Account at plan year end must be forfeited. Therefore, it is a good idea to carefully estimate your eligible expenses before you make an annual contribution election.

When considering your Health Care Reimbursement Account contribution, you may want to review your out-of-pocket costs for medical, dental and vision care services from last plan year. Also, ask yourself these questions:

� Do you expect your family's overall health to be the same next year as it has been this year?

� Are you expecting any large "one-time" bills next year, such as for surgery or pregnancy?

� Do you routinely incur non-covered expenses for preventive health care, vision or hearing services as well as deductibles and co-payments for medical and dental care?

Use the worksheet below to help you estimate what your eligible health care expenses will be for the coming year:

EXPENSE ESTIMATED OUT-OF-POCKET COSTS Medical Plan Deductibles $______________________

Medical Co-Payments $______________________

Prescription Drug Co-Payments $______________________

Not Covered Medical Expenses (physicals, well-child care, etc.) $______________________

Vision Care Expenses (exams, lenses, frames, contacts) $______________________

Hearing Care Expenses $______________________

Dental Plan Deductibles $______________________

33

Health Care Reimbursement Account Worksheet (Continued)

Dental Plan Co-Payments $______________________

Not Covered Dental Expenses (orthodontia) $______________________

Other Eligible Expenses (birth control pills, immunizations, home modifications for medical reasons, $______________________etc.)

TOTAL ESTIMATED HEALTH CARE EXPENSES $______________________

Remember, only amounts not paid by any benefit plan are eligible expenses under the Health Care Reimbursement Account.

Estimating Your Savings

This worksheet will help you figure your tax savings when you pay eligible expenses with before-tax dollars through the Health Care Reimbursement Account.

The example shown here illustrates the kind of tax savings that are available. To figure out how much you will save, enter your own information in the spaces provided.

You Example

1. Enter your annual base pay $_____________ $15,000 (from 7/1-6/30)

2. Enter the amount you'll contribute to the Health Care Spending Account $_____________ $500

3. Enter your federal income _____________% 15% tax rate based on your annual pay (or your combined income if you are married), your filing status and the number of exemptions you claim

34

Health Care Reimbursement Account Worksheet (Continued) You Example

4. Social Security tax 7.65% 7.65%

5. State tax rate 4.4% 4.4%

6. Enter your total tax rate _____________% 27.05%

7. Multiply your total tax rate (line 6) by your annual Health Care Account contribution (line 2) ______________ $135.25

The amount shown on line 7 is your total estimated tax savings. The sample employee shown here will save an estimated $135.25 in combined Federal, state and social security taxes by paying $500 in medical expenses with before-tax dollars through the Health Care Reimbursement Account.

35

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

THIS NOTICE IS EFFECTIVE ON APRIL 14, 2003

The Health Insurance Portability and Accountability Act of 1996, as amended (HIPAA), and the regulations issued to carry out this law (Privacy Rules), require health plans to notify participants and beneficiaries about the policies and practices the plan has adopted to protect the confidentiality of their health information, including health care payment information.

This Notice describes the privacy policies of the Grosse Pointe Public School System’s health care benefit programs (Plan), sponsored by the Grosse Pointe Public School System (System) which offers information for the medical, prescription drug, dental, vision and/or health care flexible spending account (FSA) benefits (Protected Health Information or PHI). These policies protect information, including any and all information relating to your past, present or future medical conditions, health care treatment and payment for that treatment.

The law requires the Plan to maintain the privacy of your PHI, to provide you with this

Notice of its legal duties, and to abide by the terms of this Notice. In general, the Plan may only use and/or disclose your PHI in those circumstances where it is required to do so, it is permitted by law to do so, or you have expressly authorized it to do so.

WHEN IS THE PLAN REQUIRED TO DISCLOSE YOUR PHI?

The Plan must disclose your PHI:

• To you;

• To the Secretary of DHHS to determine whether the Plan is in compliance with the HIPAA; and

• Where required by law. This means the Plan will make the disclosure only when

the law requires it do so, but not if the law would just allow it to do so.

WHEN IS THE PLAN PERMITTED TO USE AND DISCLOSE YOUR PHI WITHOUT YOUR AUTHORIZATION?

The Plan is permitted to use and/or disclose your PHI in the following circumstances:

36

DET_B\368853.2 HMSC.040303

For Treatment. The Plan does not provide medical treatment directly, but it may disclose your PHI to a health care provider who is giving treatment. For example, the Plan may disclose the types of prescription drugs you currently take to an emergency room physician, if you are unable to provide your medical history due to an accident.

For Payment. The Plan may disclose your PHI, as needed, to pay for your medical

benefits. For example, the Plan may tell a doctor whether you are eligible for coverage or what percentage of the bill might be paid by the Plan. The Plan may also use or disclose your PHI in other ways to administer benefits, for example, to process and review claims, to coordinate benefits with other health plans, to exercise its subrogation rights, and to do utilization review and pre-authorizations.

For Health Care Operations. The Plan may use and/or disclose your PHI to make sure

that the Plan is well run, is administered properly and does not waste money. For example, the Plan may use information about your claims to project future benefit costs or audit the accuracy of its claims processing functions. The Plan may also disclose your PHI for a claim under a stop-loss or re-insurance policy. Among other things, the Plan may also use your PHI to undertake underwriting, premium rating and other insurance activities relating to changing health insurance contracts or health benefits.

For Special Information. In addition to the Privacy Rule, special protections under state

or other federal law may apply. The Plan will comply with these state or federal laws where they are more protective of your privacy rights than are the Privacy Rules.

To the System. In certain cases, the Plan may disclose your PHI to the System. • Some of the people who administer the Plan work for the System. Before your PHI

can be used by, or disclosed to, these people, the System must certify that it has: (1) amended the Plan documents to explain how your PHI will be protected; (2) identified which individuals who work for the System are entitled to know your PHI to carry out their duties to administer the Plan; and (3) separated the work of these individuals from the rest of the workforce so that your PHI cannot be used for employment-related purposes or to administer other benefit plans. For example, these individuals will be able to contact an insurer or third party administrator to find out about the status of your claim without your specific authorization.

• The Plan may disclose information to the System that summarizes the claims

experience of Plan participants as a group, but without identifying specific individuals, in order to get new benefit insurance or to change or terminate the Plan. For example, if the System wants to consider adding or changing organ transplant benefits, it may receive this summary health information to assess the costs of those changes.

• The Plan may also disclose limited health information to the System in connection

with the enrollment or disenrollment of individuals into or out of the Plan.

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To Business Associates. The Plan may hire third parties that may need PHI to perform certain services on behalf of the Plan. These third parties are “Business Associates” of the Plan. Business Associates must protect any PHI they receive from, or create and maintain on behalf of, the Plan. For example, the Plan may hire a third party administrator to process claims, an auditor to review how an insurer is processing claims, or an insurance agent to assess coverages and help with claim problems.

To Individuals Involved with Your Care or Payment for Your Care. The Plan may disclose your PHI to adult members of your family or another person identified by you, who is involved with your care or payment for your care if: (1) you authorize the Plan to do so; (2) the Plan informs you that it intends to do so, and you do not object; or (3) the Plan infers from the circumstances, based upon professional judgment, that you do not object to the disclosure. The Plan will, whenever possible, try to get your written objection to these disclosures (if you wish to object), but in certain circumstances it may rely on your oral agreement or disagreement to disclosures to family members.

To Personal Representatives. The Plan may disclose your PHI to someone who is your personal representative. Before the Plan will give that person access to your PHI or allow that person to take any action on your behalf, it will require him/her give proof that he/she may act on your behalf, like a court order or power of attorney. Generally, the parent of a minor child will be the child’s personal representative. In some cases, however, state law allows minors to obtain treatment (e.g., sometimes for pregnancy or substance abuse) without parental consent, and in those cases the Plan may not disclose certain information to the parents. The Plan may also deny a personal representative access to PHI to protect people, including minors, who may be subject to abuse or neglect.

For Treatment Alternatives or Health-Related Benefits and Services. The Plan may contact you to provide information about treatment alternatives or other health-related benefits or services that may be of interest to you. ADDITIONAL CIRCUMSTANCES WHEN THE PLAN IS PERMITTED TO USE AND

DISCLOSE PHI WITHOUT YOUR AUTHORIZATION

The Plan may use or disclosure your PHI without your authorization under the following additional circumstances:

• Public Health Purposes. The Plan may: (1) report specific disease or birth/death

information to a public health authority authorized to collect that information, (2) report reactions to medication or problems with medical products to the Food and Drug Administration (FDA) to help ensure the quality, safety, or effectiveness of those medications or medical products, or (3) if authorized by law, disclose PHI to a person who may have been exposed to a communicable disease or who may otherwise be at risk of contracting or spreading a disease or condition.

• Report Violence and Abuse. The Plan may report information about victims of abuse, neglect or domestic violence to the proper authorities.

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• Health Oversight Activities. The Plan may disclose PHI for civil, administrative or criminal investigations, oversight inspections, licensure or disciplinary actions (e.g., to investigate complaints against medical providers); and other activities for the oversight of the health care system or to monitor government benefit programs.

• Lawsuits and Disputes. The Plan may disclose PHI in response to an order of a court or administrative agency, but only the PHI expressly authorized in the order. The Plan may also disclose PHI in response to a subpoena, discovery request, or other lawful process, but only if the Plan has received adequate assurances that the information will be protected.

• Law Enforcement. The Plan may disclose PHI to law enforcement officials for law enforcement purposes, and to correctional institutions regarding inmates.

• Coroners, Funeral Directors and Medical Examiners. The Plan may disclose PHI to a coroner or medical examiner, for example, to identify a person or determine the cause of death. The Plan may also release PHI to a funeral director that needs it to perform his or her duties.

• Organ Donations. The Plan may disclose PHI to organ procurement organizations to facilitate organ, eye or tissue donations.

• Limited Data Sets. The Plan may disclose PHI for use in a limited data set for purposes of research, public health or health care operations, if a data use agreement has been signed.

• To Avert Serous Threats to Health or Safety. The Plan may disclose PHI to avert a serious threat to your health or safety or that of members of the public.

• Special Governmental Functions. The Plan may disclose PHI to authorized federal officials in certain circumstances. For example, for national security, or for members of the armed forces and veterans if required by military command authorities.

• Workers’ Compensation. The Plan may disclose PHI for workers’ compensation if necessary to comply with these laws.

• Research. The Plan may disclose PHI for research studies, subject to special procedures intended to protect the privacy of your PHI.

• Emergencies and Disaster Relief. The Plan may disclose PHI to organizations engaged in emergency and disaster relief efforts.

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WRITTEN AUTHORIZATION

In all other situations the Plan will not use or disclose your PHI without your written

authorization. The authorization must meet the requirements of HIPAA and the Privacy Rules. If you give the Plan a written authorization, you can cancel that authorization, except for uses or disclosures that the Plan already made, based on the authorization. You may not, however, cancel the authorization, if it was obtained as a condition for obtaining insurance coverage, and other law provides the insurer with the right to contest a claim under the policy. The Plan may condition your enrollment or eligibility for benefits on your signing an authorization, but only if the authorization is limited to disclosing information necessary for underwriting or risk rating determinations needed for the Plan to obtain insurance coverage.

YOUR INDIVIDUAL RIGHTS

You have certain rights under HIPAA and the Privacy Rules relating to your PHI maintained by the Plan. All requests about those rights must be made in writing to the Privacy Officer. Your rights are: Right to Request Restrictions on Uses and Disclosures of Your PHI

You may request that the Plan restrict any of the permitted uses and disclosures of your PHI listed above. The Plan, however, does not have to agree to your requested restriction. A restriction cannot prevent uses or disclosures that are required by the Secretary of DHHS to determine the Plan’s compliance with the Privacy Rules, or that are otherwise required by law. You must make your request to restrict the uses and disclosures of your PHI in writing to the Privacy Officer

Right to Access or Copy Your PHI

You generally have a right to access your PHI that is kept in the Plan’s records, except

for: (1) psychotherapy notes (as defined in the Privacy Rules), or (2) information compiled in reasonable anticipation of, or for use in, a civil, criminal or administrative action or proceeding.

In some cases, the Plan can deny your request. You may, under some circumstance, request a review of that denial. The Plan may charge a reasonable fee for copying the information you request and the cost of any mailing, but cannot charge you for time-spent finding and pulling together the information you are seeking.

The Plan’s insurers and HMOs keep their own records. You should make requests for access to your PHI that is in the insurer’s or HMO’s records directly to the insurer or HMO. Right to an Accounting of Disclosures

The Plan must provide you with a list of any disclosures of your PHI made within the six-

year period just before the date of your request, except disclosures made:

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• For purposes of treatment, payment or health care operations. • Directly to you or close family members involved in your care. • For purposes of national security. • Incidental to otherwise permitted disclosures. • As part of a limited data set. • To correctional institutions or law enforcement officials. • With your express authorization. • Before April 14, 2003.

You may request one accounting, which the Plan must provide at no charge, within a

single 12-month period. If you request more than one accounting within the same 12-month period, the Plan may charge you a reasonable fee. You must request an accounting of disclosures by an insurer or HMO from the insurer or HMO. Right to Amend

You may request that the Plan change your PHI that is maintained in the Plan’s records,

but the Plan does not have to agree to your request. The Plan may deny your request if the information in its records: (1) was not created by the Plan, (2) is not part of the Plan’s records, (3) would not be information to which you would have a right of access, or (4) is deemed by the Plan to be complete and accurate as it then exists.

Right to Request Restrictions and Confidential Communications

You have the right to request that the Plan communicate with you in a confidential manner, for example, by sending information to an alternative address. The Plan will accommodate any reasonable request, though it will require that any alternative used must still allow for payment information to be effectively communicated and for payments to be made. Requests for confidential communications made to the Plan will not apply to any insurers or HMOs providing your benefits. If you prefer that the insurers or HMOs make these confidential communications, you must make your request directly to the appropriate insurer or HMO.

Right to File a Complaint

If you believe your rights have been violated, you have a right to file a written complaint

with the Plan’s Privacy Officer or with the Secretary of DHHS. The Plan will not retaliate against you for filing a complaint, and cannot condition your enrollment or your entitlement to benefits on your waiving these rights. If your complaint is with an insurer or HMO, you may file a complaint with the individual named in their Notice of Privacy Practices to receive complaints. If your complaint is with the Plan, you may submit your complaint to the Privacy Officer at the address at the end of this Notice.

To file a complaint with the Secretary of DHHS, you must submit your complaint in

writing, either on paper or electronically, within 180 days of the date you knew or should have known that the violation occurred. You must state who you are complaining about and the acts or omissions you believe are violations of the Privacy Rules. Complaints sent to the Secretary

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must be addressed to the regional office of the DHHS’ Office of Civil Rights for the state in which the alleged violation occurred. For information on which regional office you should file with, and the address of that regional office, go to the OCR website at www.hhs.gov/ocr/hipaa/.

Right to Receive a Paper Copy of This Notice Upon Request

You have a right to obtain a paper copy of this Notice upon request. To request a paper

copy of the Notice, contact the Privacy Officer. KINDS OF HEALTH INFORMATION THAT ARE NOT COVERED BY THIS NOTICE This Notice does not cover:

• Health information that does not identify you and with respect to which there is no reasonable basis to believe that the information could be used to identify you.

• Health information that the System can have under applicable law (e.g., the Family

and Medical Leave Act, the Americans with Disabilities Act, workers’ compensation, federal and state occupational health and safety laws, and other state and federal laws), or that the System properly can get for employment-related purposes through sources other than the Plan and keeps as part of your employment records (e.g., pre-employment physicals, drug testing, fitness for duty examinations, etc).

CHANGES TO THE NOTICE

The Plan reserves the right to change the terms of this Notice and to make the new

revised notice provisions effective for all PHI that it maintains, including any PHI created, received or maintained by the Plan before the date of the revised notice.

If you agree, the Plan may provide you with a revised Notice electronically. Otherwise, the Plan will provide you with a paper copy of the revised Notice. In addition, the Plan will post the revised Notice on its web site used to provide information about the Plan’s benefits.

CONTACT THE PRIVACY OFFICER FOR MORE INFORMATION If you have any questions regarding this Notice or if you wish to exercise any of your rights described in this Notice, you may contact the Privacy Officer at: Fringe Benefit Coordinator Grosse Pointe Public School System Dept. of Business & Finance, Fringe Benefits 389 St. Clair Grosse Pointe, MI 48230 1.313.432.3072 (phone) 1.313.432.3011 (fax)

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800-637-2227 www.bcbsm.com

888-236-1100 www.adndental.com

800-421-0344 www.unum.com

800-789-9058 www.nis-sif.com

313-432-3072 https://private.gpschools.org/fringebenefits/default.htm

586-977-6300 www.bbdetroit.com

800-521-1555 www.ngsamerican.com

GROSSE POINTE PUBLIC SCHOOL SYSTEM

2009 CARRIER CONTACTS

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