2016 Big Ahs Final

CONTENTS
EMPLOYEE BENEFITS
INFORMATION GUIDE
AHS
2016
CONTENTS
Topic Page
Introducing Your 2016 Benefits 3
Eligibility & Enrollment 5
Medical Coverage 8
Pharmacy Provider 15
Health Savings Account (HSA) 19
Dental Coverage 23
Vision Coverage 25
Flexible Spending Account (FSA) 26
Disability Coverage 29
Life and AD&D Coverage 30
Voluntary Coverage 31
LegalShield 32
Employee Assistance Program (EAP) 34
The Cost of Coverage 35
Plan Guidelines / Evidence of Coverage 36
Legal Information Regarding Your Plans 38

The Childrens Health Insurance Program
42
(CHIP) Premium Assistance Subsidy Notice
Directory & Resources 43
Notes 44
Medicare Part D Notice 37
All rights reserved. No part of this document may be reproduced or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission
of Barney & Barney.
The rates quoted for these benefits may be subject to change based on final enrollment and/or final underwriting requirements . This material is for informational purposes only and is neither an offer of
coverage nor medical advice. It contains only a partial, general description of the plan or program benefits and does not constitute a contract. Consult your plan documents (Schedule of Benefits,
Certificate of Coverage, Group Agreement, Group Insurance Certificate, Booklet, Booklet-certificate, Group Policy) to determine governing contractual provisions, including procedures, exclusions and
limitations relating to your plan. All the terms and conditions of your plan or program are subject to applicable laws, regul ations and policies. In case of a conflict between your plan document and this
information, the plan documents will always govern.
INTRODUCING YOUR 2016 BENEFITS
Dear Colleague:
Open Enrollment for the 2016 benefits year is now upon us. This is your annual opportunity to make changes to
your benefit elections. We have very EXCITING AND IMPORTANT information to share about your 2016 benefits.
You will have the opportunity to enroll in one of two Alameda Health System Plans. Both plans are PPO plans and
offer great coverage for you and your dependents. These plans are designed to give you the greatest flexibility in
choosing where you receive care!! In 2016, the AHS plans will continue to be offered at no monthly cost to you!
Yes, there is no employee contribution for the AHS Freedom of Choice Plan or the HSA-Independence Plan! We
will also continue to offer three Kaiser plans and Share the Savings.
The Open Enrollment period is October 19 November 25, 2015!
PLEASE NOTE: to have benefits coverage in 2016, every benefit eligible employee will need to go on-line to
enroll in one of the five Medical benefit plans offered; selecting the one that best meets the medical needs
of yourself and/or your family.
NEW THIS YEAR!!
AHS is offering for the first time a new voluntary legal protection plan through LegalShield as well as IDShieldSM
identity protection. This plan is available for employee or family coverage. See the information included in the
Benefit Guide and attached flyer for more details.
During this Open Enrollment Period, AHS is offering all employees the opportunity to participate in a Health Risk
Assessment (HRA) survey. In addition to gaining valuable insight about your health, you will also be offered free
wellness coaching through our third party vendor. Please see the information included in the Benefit Guide and
attached flyer for more details. We strongly encourage all employees to participate.
Voluntary Benefits:
Voluntary Life and AD&D: continues to be available to ALL benefit eligible employees.
Vision Coverage: Vision coverage is available as a voluntary program through VSP. There were no changes to the
VSP plan. You will be able to elect this program during open enrollment for you and your dependents at group
rates.
Met Life: Critical Illness Plan, Home & Auto Insurance and Pet Insurance remain available at significant discounts.
Please find enclosed the 2016 Open Enrollment material. Please carefully read this material so you will be able to
make informed choices that best balance your financial and healthcare needs for yourself and your family.
We wish you and your family a healthy and happy 2016.
Jeanette Louden-Corbett
Chief Human Resources Officer
Benefits Information Guide 3

INTRODUCING YOUR 2016 BENEFITS
If you intend to have insurance benefits for you and/or your eligible
dependents in 2016 you must actively enroll in the plans for which you want
coverage!
Open Enrollment runs from October 19th through November 25th. During Open Enrollment you can:
Enroll in medical coverage for 2016. If you do not enroll in a medical plan you will not have medical
coverage in 2016
Enroll or change benefit elections for Dental, Vision, Voluntary Life, Long Term Disability Buy-Up,
and Voluntary Benefits (Critical Illness & Auto, Pet, Home Insurance) If you do not enroll in these
plans you will not have coverage in 2016
Make your annual election for Health Care Flexible Spending Account (FSA), Dependent Care
Assistance Program (DCAP), Commuter Benefits, and Health Care Savings Account (HSA)
Add a new dependent. If you add a dependent, you must present original, current documentation to the
Human Resources Benefits department no later than December 31, 2015. Your new dependent will be
dropped if such information is not received by the deadline. NOTE: This year you must provide a valid Social
Security Number for each covered dependent
Share the Savings If you participate in Share the Savings YOU MUST RE-ENROLL every year. If you
waive medical coverage, you are eligible to receive $250.00 per month added to your paycheck. If you
waive dental coverage, you are eligible to receive $20.00 per month added to your paycheck. Additional
information about the Share the Savings program can be found in this enrollment guide
Please take the time to review this Enrollment Guide carefully and complete your enrollment for 2016
through My Passport between October 19th and midnight, November 25th.
Health Fairs & Enrollment Guidance

The Human Resources Benefits department will offer Health Fairs and Enrollment Guidance to AHS employees.
The Health Fairs will provide an opportunity to get more information about the benefit plans offered and will also
have staff available to help with your enrollment.
October 19, 2015 7:30 am 3 pm San Leandro Hospital, Education Center

October 20, 2015 11 am 1 pm Hayward Wellness Center, Conference Rooms 2 & 3
October 21, 2015 11 am 1 pm Waters Edge, Conference Room
October 22, 2015 11 am 1 pm Eastmont Wellness Center, Sobrante Room
October 23, 2015 7:30 am 4 pm Fairmont Hospital, Special & Guest Dining Room
October 26, 2015 7:30 am 4 pm Alameda Hospital, Conference Room A
October 27, 2015 11am 1 pm Newark Health Center, Clinic Conference Room
October 28, 2015 2 pm 5 pm John George Pavilion, Courtyard Classroom 117
October 29, 2015 7:30 am 4 pm Highland Hospital, Atrium
All rights reserved. No part of this document may be reproduced or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission
of Barney & Barney.
The rates quoted for these benefits may be subject to change based on final enrollment and/or final underwriting requirements . This material is for informational purposes only and is neither an offer of
coverage nor medical advice. It contains only a partial, general description of the plan or program benefits and does not constitute a contract. Consult your plan documents (Schedule of Benefits,
Certificate of Coverage, Group Agreement, Group Insurance Certificate, Booklet, Booklet-certificate, Group Policy) to determine governing contractual provisions, including procedures, exclusions and
limitations relating to your plan. All the terms and conditions of your plan or program are subject to applicable laws, regul ations and policies. In case of a conflict between your plan document and this
information, the plan documents will always govern.
ELIGIBILITY & ENROLLMENT
If you are a new employee or you are re-evaluating your choices as a continuing
participant, the benefits program offers a variety of coverage options that are available to
you.
Who Can Enroll

All regular, U.S. based employees of AHS who have a calculated full-time equivalent (1) of half time or greater are
eligible for benefits. (2)
Eligible employees may also enroll their eligible dependents in the medical, dental, vision, voluntary life, accidental
death and dismemberment (AD&D,) critical illness and flexible spending account plans. Your eligible dependents
include:
Your legal spouse or state registered domestic partner
Your unmarried, dependent children / step-children or children of your state registered domestic partner up
to age 26
Your unmarried, dependent children / step-children or children of your state registered domestic partner of
any age, if they became incapable of self-support due to a physical or mental disability prior to age 19
When Coverage Begins

Your enrollment choices remain in effect for the benefits plan year, January 1, 2016 December 31, 2016. Benefits
for eligible new hires will commence as outlined below:
Eligibility Date Benefit Plan

Newly Hired or Newly Eligible Employees 1st day of the month following date of hire or eligibility
date
Employees of CIR Date of hire or date of eligibility
Please note: If you miss the enrollment deadline, you may not enroll in the benefits program unless you have a qualified
change in status during the plan year. See next page for details.
Active employees have an active open enrollment period, meaning you are required to take action and re-enroll in your
benefits in order to continue coverage. Additionally, you must re-elect your contribution amounts each year to the Flexible
Spending Account (FSA) and Health Savings Account (HSA). If you miss the enrollment deadline, you may not enroll in
the benefits program unless you have a qualified change in status during the plan year. See page 7 for details.
(1)
Calculated FTE is based on actual hours worked during a look back period, rather than the employees' position FTE. For 2016 benefits, the calculated FTE look
back period is September 1, 2014, through August 31, 2015. Benefit eligible employees (non-SAN) must have worked 50% or more of a full-time schedule during
the look back period to have a calculated FTE of .50 or higher to qualify for benefit coverage. Employees who worked less than 50% of a full-time schedule during
the look back period will not be eligible for benefits, regardless of their position FTE.
(2)
CIR members and Temporary Employees are only eligible for Medical, Dental and Vision coverage

Paying for Coverage

AHS pays a significant portion of the premium cost for many of your benefits to cover yourself and your eligible
dependents.
The portion that you pay for medical, dental, vision, employee supplemental life, employee AD&D and the flexible
spending accounts is deducted from your paycheck on a pre-tax basis. This means that the income you use to pay
for these benefits is not taxed, putting dollars back into your pocket. AHS pays 100% of the premium for the
following benefits:
HSA Independence Plan
Freedom of Choice Plan
Kaiser Low Option High Deductible Health Plan / HSA (for employees who work at least 40 hours per
week)
Delta Dental PPO Base Plan
Delta Care USA
Basic Life Insurance
Long-Term Disability (LTD) Base Plan
Employee Assistance Program (EAP)
Employees who choose to enroll in a medical plan other than the Freedom of Choice Plan, the HSA Independence
Plan or the Kaiser Low Option High Deductible Health Plan / HSA will contribute a portion of the monthly premium.
The voluntary life for spouse and child, voluntary AD&D for family, LTD buy-up, and critical illness plans require you
to pay 100% of the premium using after tax dollars.
Share the Savings Stipend

If you waive Medical coverage offered by AHS you may be eligible to receive a monthly stipend of $250 through the
Share the Savings Program.
If you waive Dental coverage offered by AHS you may be eligible to receive a monthly stipend of $20 through the
Share the Savings Program.
If you wish to enroll in the Share the Savings Plan you must decline medical and/or dental coverage in My Passport.
You must demonstrate that you have coverage under another Medical Plan, such as your spouses or domestic
partners employers Medical Plan. Acceptable proof of Medical coverage includes:
A letter from your spouse / state registered domestic partners employer.
A letter from your alternate insurance carrier demonstrating current coverage.
Medical cards which show coverage effective as of the 2016 benefit plan year. (Kaiser cards are not
acceptable, as they do not show an effective date.)
Documentation must include coverage effective dates and the employees name as either the subscriber or as a
covered dependent. You must also submit a Share the Savings form (available in Benefits Department or on the
Intranet) along with your documentation.
If you sign up for Share the Savings and do not provide documentation by January 6, 2016, Share the Savings will
be stopped. If you cannot obtain the documentation by January 6, contact the Human Resources Benefits
department at 510.346.7557.
You must re-enroll in Share the Savings each year to continue participation in the plan.
6 Alameda Health System

Duplicate Coverage Rule

Married AHS employees and employees in domestic Enrollment Made Easy
partnerships where both are employed by AHS, shall be
To enroll in your benefits please log into My Passport, the
entitled to one choice from the plans offered through
gateway to your personal HR/Benefits/Payroll information.
AHS. To access My Passport via the AHS intranet:
Changes during the Year

You are permitted to make changes to your benefits
outside of the Open Enrollment period if you have a
qualified change in status as defined by the IRS.
http://ahs-rwc-webapp1/wordpress/
Generally, you may add or remove dependents from
your benefits, as well as add, drop or change coverage From the AHS Intranet home page, click on the
if you submit your request for change within 30 days of MyPassport box on the left side of the page.
the event. Examples include:
Marriage, divorce or legal separation To access My Passport from home:
Birth or adoption of a child https://lawpa.c101.netaspx.com/lawson/portal/i

ndex.htm
Death of a dependent
Note: when logging in from home the Lawson
You or your spouses / state registered screen will appear.
domestic partner s loss or gain of coverage
My Passport can only be accessed from home
through our organization or another employer
using the browser, Internet Explorer.
Change in residence affecting eligibility or
access
If your change during the year is a result of the loss of Please disable pop up blockers before you begin!
eligibility or enrollment in Medicaid, Medicare or state Click on the To Access My Passport Link
health insurance programs, you must submit the
request for change within 60 days. Enter your Username (6-digit Employee ID number) same
as Kronos (ex. 099999). Your Employee ID can also be
For a complete explanation of qualified status changes, found on your payroll check.
please refer to the Legal Information Regarding Your
Enter your Password. If this is the first time you have
Plan section of this guide.
ever logged in to MyPassport, your default password is AC
and your birth date in the following format: MMDDYY (ex.
AC030175). You will be prompted to create a new
password. If you have accessed MyPassport before, use
the password you already created. To change your
password, please contact the Help Desk at x44503 or
510.437.4503.
Click on Open Enrollment to begin.

To add dependents, click the ADD button, then enter the
dependents personal information.
Click on the Close button to review and select your benefit
options.
Once you have completed your enrollment, a summary of
your benefits will display showing your elections, covered
dependents (if specified), and cost per pay period. Please
print and retain for your records.

MEDICAL COVERAGE
Whether you have a common cold or will be undergoing surgery, medical benefits cover a
range of services and can provide peace of mind to help you offset health care costs.
Your Medical Plan Option(s)

Alameda Health System offers two PPO plans: Freedom of Choice Plan and HSA Independence Plan. Both plans
utilize AHS facilities and physicians and also offer benefits using the Anthem Blue Cross network. These plans are
administered by HealthComp Administrators.
In addition, Alameda Health System offers three HMO plans administered by Kaiser: a traditional $15 copay plan, a
low deductible plan and a high deductible plan (HSA) option.
To help guide your plan selection, the following pages include details concerning how the plan(s) will operate, as
well as plan highlights and features. For your reference, an illustration of rates is listed in The Cost of Coverage
section of this guide.
Using a PPO Plan

With a Preferred Provider Organization (PPO) plan you have greater flexibility and choice to use both in-network
and out-of-network physicians. However, you are encouraged to receive services from the in-network doctors,
specialists or facilities. By doing so, you obtain a higher level of benefit than if services were rendered from an out-
of-network provider. Additional important information regarding the use of a PPO plan includes:
You and any enrolled dependent(s) are permitted to visit any doctor or facility without a referral from a
Primary Care Physician (PCP)
Certain services, such as doctors visits, may require a fixed-dollar payment up front, referred to as a
copayment
Before the insurance company will pay certain medical expenses, you may be required to pay a plan specific
amount, referred to as the deductible
Once the deductible has been fulfilled, the insurance company will pay a large percentage of the cost of your
care, known as coinsurance. You are then financially responsible for the remaining cost up to the out-of-
pocket maximum
Claim forms are submitted to the insurance company on your behalf when services are received from within
the network
MEDICAL COVERAGE
Administered by HealthComp, a summary chart of covered services for the PPO plans are listed on the following
pages. Please refer to your Summary Plan Description (SPD) for a complete listing of covered services under each
plan.
Using the HSA Plan

While a High Deductible Health Plan (HDHP) enforces a relatively larger deductible than traditional health plans,
they generally have lower payroll deductions. These medical plans encourage members to closely analyze their
health care decisions and the type of care utilized. A HDHP operates as follows:
You are financially responsible for all eligible expenses, such as doctors or specialist visits, prescriptions
and lab charges, until the deductible has been met
Regardless of if you have satisfied the deductible, several types of screenings, immunizations and other
forms of in-network preventive care will be covered at 100%
Once the deductible is met, the plan pays a large percentage of eligible expenses until the out-of-pocket
maximum is reached
Similar to a traditional Preferred Provider Organization (PPO) plan, you may use the provider of your choice,
but the plan will pay more if you see in-network physicians or facilities
After reaching the out-of-pocket maximum, covered expenses are paid at 100% for the remainder of the plan
/ calendar year
HDHPs can be paired with a Health Savings Account (HSA) to help pay for qualified health care expenses
HealthComp manages the HDHP and Custom Benefit Administrators (CBA) administers the HSA. The following
pages contain a summary of covered services under the plan(s), as well as detailed information regarding the use of
a Health Savings Account (HSA). The Summary Plan Description (SPD) contains a complete list of services covered
under the HDHP.
Using an HMO Plan

A Health Maintenance Organization (HMO) plan requires you and enrolled dependents to select a Primary Care
Physician (PCP) who will direct the majority of your health care needs. Generally, an HMO operates as follows:
With the exception of an OB/GYN specialist who is affiliated with your selected medical group, you must
receive a referral from your PCP before receiving services from a specialist
You and any enrolled dependent(s) are not required to see the same PCP, and you may change your PCP
at any time
Services may require a fixed-dollar payment up front, referred to as a copayment
You do not have to submit claim forms to your insurance company
Any services rendered out-of-network without the proper referral from your PCP will not be covered
Kaiser administers the HMO plan(s) and a summary of covered services is listed on the following pages. For a
complete listing of covered services for each plan, please refer to your Summary Plan Description (SPD).

MEDICAL COVERAGE
Your Medical Plan Option (Continued)
Kaiser High Option Traditional HMO Plan Kaiser Mid Option Low Deductible HMO
Members of Kaiser are encouraged to select a Plan
primary care physician but it is not a requirement. If you require the services of a specialist (any
There are no claims forms, no deductibles and no physician other than General Practice, Family
pre-authorization responsibilities for members. You Practice, Internal Medicine or Pediatrics), you must
and your eligible family members may each select the secure a referral from your PCP.
PCP of his/her choice and PCP changes can be
made by contacting Kaiser Member Services. Under this plan there is a calendar year deductible of
$1,000 / individual and $2,000 / family (2 or more
If you require the services of a specialist (any members). After the deductible is satisfied, most
physician other than General Practice, Family services are covered at 80%.
Practice, Internal Medicine or Pediatrics), you must
secure a referral from your PCP. Your office visit copayment under this plan is $30 for
a PCP and $30 for a specialist. Your outpatient
Your office visit copayment is $15 for a PCP and $25 laboratory and radiology services are $10 per
for a specialist. Your outpatient laboratory and encounter when authorized by your medical group.
radiology services are covered at 100% when Your hospitalization and inpatient services are also
authorized by your medical group. Your covered at 80% after satisfying the deductible.
hospitalization and inpatient services are also covered
at 100%. You will have a $10 copayment for generic drugs, a
$30 copayment for brand name drugs after a $250
There are no deductibles with the HMO and no claim drug deductible. You will be given up to a 100-day
forms for you to submit. supply for each prescription
You will have a $15 copayment for generic drugs, a
$15 copayment for brand name drugs on the Kaiser Low Option High Deductible Health
formulary. Non-formulary drugs must be authorized by Plan / HSA
a Kaiser physician. You will be given up to a 100 day
supply for each prescription. The calendar year deductible is $1,300 / individual
and $2,600 / family (2 or more members). For family
coverage, the full family deductible must be met
before the subscriber or dependents can receive
benefits. All medical and prescription expenses are
applied towards the deductible, except copayments
for specific services (refer to plan document).
Your office visit copayment under this plan is $20 for
a PCP and $20 for a specialist. Your outpatient
laboratory and radiology services are $10 per
encounter when authorized by your medical group.
Your hospitalization and inpatient services are $250
per admission after satisfying the deductible.
You will have a $10 copayment for generic drugs and
a $30 copayment for brand name drugs after the
deductible. You will be given up to a 30 day supply for
each prescription.

MEDICAL COVERAGE
Informing You of Health Care Reform
As of January 1, 2014, most U.S. citizens and legal residents are responsible for paying a penalty if they do
not have qualifying health insurance coverage. In 2016, the penalty increases to be the greater of 2.5% of
Modified Adjusted Gross Income (MAGI) or $695 per adult per year (50% of the adult penalty for children under 18
years of age), per household.
To avoid paying the penalty this year and in future years, you can obtain health insurance through our benefits
program or purchase coverage elsewhere, such as a State Health Insurance Exchange.
For more information regarding Health Care Reform, please contact Human Resources or visit www.cciio.cms.gov.
You can also visit www.coveredca.com to review information specific to the Covered California State Health
Insurance Exchange.
Selecting a Plan thats Right for You

As you evaluate your health plan options and insurance needs,
consider the following factors:
Free Preventive Health Care
Choice: If you prefer to have services rendered by The Federal Health Care Reform law now requires
specific physicians, specialists or facilities, check to insurance companies to cover preventive care
see if the medical plan option will cover services from services in full, saving you money and helping you
those providers. While some health plans restrict your maintain your health. Such preventive services
provider selection, others provide greater flexibility include:
and choice Routine doctors visits
Coverage: Whether routine, surgical, prescription or Annual checkups
another type of coverage, determine if the plan covers
the services and medical treatments you value most. Well-baby and child visits
Plan exclusions, restrictions and limitations may also Several types of immunizations and
guide your selection process, which are detailed in the screenings
Summary Plan Descriptions
To confirm that your preventive care services are
Cost: Cost may be a large determining factor in your covered, refer to your plan documentation.
selection and each plan may contain a variety of cost
components. Consider the amount of your payroll
deduction, as well as other plan expenses such as deductibles, co-payments or coinsurance
You are encouraged to review The Cost of Coverage section of this guide, along with the complete Summary Plan
Descriptions (SPD) of each plan.
Do you have questions regarding a plan? To correspond with a plan representative refer to the Directory &
Resources section for important contact information.

AHS FREEDOM OF CHOICE
Tier 1 Tier 2 Tier 3
Plan Highlights AHS Physicians &
Anthem Network Out of Network
Facilities
Annual Deductible
Individual None None $2,500
Family None None $5,000
(1)
Annual Out-of-Pocket Maximum Medical
Individual None $1,500 $10,000
Family None $4,500 $20,000
Annual Out-of-Pocket Maximum Rx
Individual None $5,100 None
Family None $8,700 None
Professional Services
Primary Care Physician (PCP) Paid in Full $15 Copay 30% Coinsurance
Specialist Paid in Full $15 Copay 30% Coinsurance
Preventive Care Exam Paid in Full Paid in Full 30% Coinsurance
Well-baby Care Paid in Full Paid in Full 30% Coinsurance
Diagnostic X-ray and Lab Paid in Full Paid in Full 30% Coinsurance
Therapy, including Physical, Paid in Full (24 visit max) $15 Copay (24 visit max) 30% Coinsurance
Occupational and Speech (24 visit max)
Hospital Services
Inpatient Paid in Full Paid in Full 30% Coinsurance
Outpatient Surgery Paid in Full Paid in Full 30% Coinsurance
Emergency Room Paid in Full $75 Copay (waived if $75 Copay (waived if
admitted) admitted)
Urgent Care Paid in Full $25 Copay 30% Coinsurance
Maternity Care
Physician Services Paid in Full Paid in Full 30% Coinsurance
(prenatal or postnatal)
Hospital Services Paid in Full Paid in Full 30% Coinsurance
Mental Health & Substance Abuse
Inpatient Paid in Full Paid in Full 30% Coinsurance
Outpatient Paid in Full $15 Copay 30% Coinsurance
Retail Prescription Drugs
(30-day supply)
Generic $10 Copay $10 Copay 50% Coinsurance after $10
Copay
Brand $25 Copay $25 Copay 50% Coinsurance after $25
Copay
Non-formulary $35 Copay $35 Copay 50% Coinsurance after $35
Copay
Mail Order Prescription Drugs
(90-day supply)
Generic $20 Copay $20 Copay
Brand $50 Copay $50 Copay Not available
Non-formulary $70 Copay $70 Copay
(1)
Out-of-pocket maximum is based on the maximum allowable charge the carrier allows. This does not include any balance billing that may occur when using
an out-of-network provider
The above information is a summary only. Please refer to your Evidence of Coverage for complete details of Plan benefits, limitations and exclusions.

AHS FREEDOM OF CHOICE
LiveHealth Online
LiveHealth Online services are available to employees and their dependents who are enrolled in the Freedom of Choice
Plan.
LiveHealth Online gives you access to U.S. board-certified doctors 24/7/365 who can treat many of your medical issues
by phone or video. It is not insurance but an added medical benefit that gives you an affordable alternative to costly urgent
care or ER visits and becomes a part of your permanent medical record.
When can I use LiveHealth Online?

LiveHealth Online does not replace your primary care physician. It is a convenient and affordable option for quality care.
When you need care now

If youre considering the ER or urgent care center for a non-emergency issue
On vacation, on a business trip, or away from home
For basic prescription
Get the care you need Start a conversation now!

Step 1: Enroll for free at livehealthonline.com or
Doctors are available 24 hours a day and can treat many medical
conditions, including: on the app, and youre ready to see a doctor.
You can download the LiveHealth Online mobile
app for free on your mobile device by visiting the
Cold & flu symptoms
App Store or Google Play.
Allergies
Bronchitis
Urinary tract infection Step 2: Select the state you are located in and
Respiratory infection answer a few questions.
Sinus problems
And more! Questions?
Email customersupport@livehealthonline.com or
call toll free at 1.855.603.7985
Cost
Pay only $15 of the $49 copay

HSA INDEPENDENCE PLAN
High Deductible Plan (HSA)
Plan Highlights In-network
AHS Physicians / Facilities & Out-of-network
Anthem Network
Annual Calendar Year / Plan Year Deductible
Individual $2,000 $4,000
Family $4,000 $8,000
Maximum Calendar Year / Plan Year
(1)
Out-of-pocket
Individual $3,000 $8,000
Family $6,000 $16,000
Lifetime Maximum
Individual Unlimited Unlimited
Primary Care Physician (PCP) 100% after Deductible 80% after Deductible
Specialist 100% after Deductible 80% after Deductible
Preventive Care Exam 100% Not available
Well-baby Care 100% Not available
Diagnostic X-ray and Lab 100% after Deductible 80% after Deductible
Complex Diagnostics (MRI / CT Scan) 100% after Deductible 80% after Deductible
Therapy, including Physical, Occupational and
100% after Deductible 80% after Deductible
Speech
Hospital Services
Inpatient 100% after Deductible 80% after Deductible
Outpatient Surgery 100% after Deductible 80% after Deductible
Emergency Room 100% after Deductible 80% after Deductible
Urgent Care 100% after Deductible 80% after Deductible
Maternity Care
Physician Services(prenatal or postnatal) 100% after Deductible 80% after Deductible
Hospital Services 100% after Deductible 80% after Deductible
Inpatient 100% after Deductible 80% after Deductible
Outpatient 100% after Deductible 80% after Deductible
Retail Prescription Drugs (30-day supply)
Generic $10 copay after Deductible $10 copay after Deductible
Brand $30 copay after Deductible $30 copay after Deductible
Non-formulary $50 copay after Deductible $50 copay after Deductible
Mail Order Prescription Drugs (90-day supply)
Generic $25 copay after Deductible Not available
Brand $75 copay after Deductible Not available
Non-formulary $125 copay after Deductible Not available
(1)

AHS MEDICAL PLANS PHARMACY PROVIDER
Effective January 1, 2016, WellDyneRx will be the new prescription vendor for the AHS
Freedom of Choice Plan and the AHS Independence Plan.
All enrolled members will receive new medical ID cards with the pharmacy information included.
Questions?
Contact WellDyne at 888.479.2000 or www.myWDRX.com

KAISER HIGH OPTION TRADITIONAL HMO
Kaiser High Option Traditional HMO
Plan Highlights
In-network Only
Annual Deductible
Individual None
Family None
(1)
Annual Out-of-Pocket Maximum
Individual $1,500
Family $3,000
Lifetime Maximum
Individual None
Primary Care Physician (PCP) $15 Copay
Specialist $25 Copay
Preventive Care Exam No Charge
Well-baby Care No Charge
Diagnostic X-ray and Lab No Charge
Therapy, including Physical, Occupational and Speech $15 Copay
Hospital Services
Inpatient No Charge
Outpatient Surgery $15 Copay
Emergency Room $125 Copay
Urgent Care $15 Copay
Maternity Care
Physician Services (prenatal or postnatal) No Charge
Hospital Services No Charge
Inpatient No Charge
Outpatient $15 Copay
Retail Prescription Drugs (up to 100-day supply)
Generic $15 Copay
Brand $15 Copay
Non-formulary Must be Authorized by Kaiser Physician
Generic $15 Copay
Brand $15 Copay
(1)

KAISER MID OPTION LOW DEDUCTIBLE PLAN
Kaiser Mid Option-Low Deductible Plan
Plan Highlights
In-network Only
Annual Deductible
Individual $1,000
Family $2,000
(1)
Individual $3,000
Family $6,000
Lifetime Maximum
Individual None
Primary Care Physician (PCP) $30 Copay
Specialist $30 Copay
Diagnostic X-ray and Lab $10 Copay
Complex Diagnostics $50 per Procedure
(MRI / CT Scan)
Therapy, including Physical, Occupational and Speech $30 Copay
Hospital Services
Inpatient 20% Coinsurance after Deductible
Outpatient Surgery 20% Coinsurance after Deductible
Emergency Room 20% Coinsurance after Deductible
Urgent Care $30 Copay
Maternity Care
Hospital Services 20% Coinsurance after Deductible
Inpatient 20% Coinsurance after Deductible
Outpatient $30 Copay
Retail Prescription Drugs (up to 100-day supply)
Generic $10 Copay
Brand $30 Copay after $250 Deductible
Generic $10 Copay
Brand $30 Copay after $250 Deductible
(1)

KAISER LOW OPTION HIGH DEDUCTIBLE PLAN
Kaiser Low Option-High Deductible Plan
Plan Highlights
In-network Only
Annual Deductible
Individual $1,300
Family $2,600
(1)
Individual $3,000
Family $6,000
Lifetime Maximum
Individual None
Primary Care Physician (PCP) $20 Copay after Deductible
Specialist $20 Copay after Deductible
Diagnostic X-ray and Lab $10 Copay after Deductible
Complex Diagnostics $50 per Procedure after Deductible
(MRI / CT Scan)
Therapy, including Physical, Occupational and Speech $20 Copay after Deductible
Hospital Services
Inpatient $250 per Admission after Deductible
Outpatient Surgery $150 Copay after Deductible
Emergency Room $100 Copay after Deductible
Urgent Care $20 Copay after Deductible
Maternity Care
Hospital Services $250 per Admission after Deductible
Inpatient $250 per Admission after Deductible
Outpatient $20 Copay after Deductible
Retail Prescription Drugs (30-day supply)
Generic $10 Copay after Deductible
Brand $30 Copay after Deductible
Generic $20 Copay after Deductible
Brand $60 Copay after Deductible
(1)

HEALTH SAVINGS ACCOUNT (HSA)
By enrolling in the High Deductible Health Plan, you will have access to a Health Savings
Account, which provides tax advantages and can be used to pay for qualified health care
expenses.
HSA Overview
Administered by an authorized financial institution, a Health Savings Account (HSA) accumulates funds that can be
used to pay current and future health care costs. An HSA works in conjunction with qualified High Deductible Health
Plans (HDHP) and your additional HSA contributions can reduce your federal income taxes while enabling you to
pay certain health-related expenses on a tax-deductible basis.
When you incur costs while enrolled in a HDHP, you can
utilize HSA dollars to help pay the deductible as well as
copayments and other qualified medical, dental and vision
out-of-pocket expenses, subject to funds availability. After
satisfying the deductible, the plan may provide coverage for
covered medical expenses.
The funds you contribute to your HSA are tax-
deductible on your tax return if contributed post-tax
Distributions are tax-free for qualified expenses
The amount in an HSA rolls over from year-to-year
Because you own the HSA, the monies in the account
will remain with you if you leave the company or the
work force
HSA funds accumulate tax-free interest, subject to
change by State law
Advantages of an HSA
HSAs encourage consumers to purchase health care wisely,
simply for the reason that you are utilizing personal funds to
pay health-related expenses. Although an HSA comes with this responsibility, HDHP with an HSA may also lend
several advantages including:
Lower costs than traditional PPO medical plans
Reduced taxable income and tax-free withdrawals when paying for qualified expenses
A vehicle to save for future health needs, such as long term care premiums or health care after retirement
Qualifying for an HSA

The IRS has set guidelines regarding who qualifies for an HSA. An individual is considered eligible if:
You are covered under a qualified HDHP
You do not have qualified health insurance outside of your HDHP
You are not enrolled in Medicare
You are not claimed as a dependent on someone elses tax return
You are not enrolled a in a general Health Care FSA

Activating an HAS
By participating in the Kaiser Low Plan or the AHS HSA -
Independence Plan, you are eligible to set up a Health
Savings Account (HSA), administered through CBA
Administrators, or any other HSA administrator or bank
you choose.
If you choose CBA Administrators, your contributions will
be pre-tax, made through payroll deduction. If you choose
a different bank or administrator, you will need to make
arrangements to make your contributions directly with the
bank or administrator of your choice.
You may enroll in the Health Savings Account (HSA)
though the CBA website - www.cbadministrators.com. In
addition, enrollment instructions and informational
materials can be found in the Benefits Documents
section of My Passport.
Contributing to the HSA

Eligible employees, individuals family members, any other person and AHS can make financial contributions
towards an individuals HSA. The chart below outlines the maximum allowed amounts and other taxation
information.
Contribution Amounts Important Contribution Information

Employee contributions for 2016 cannot exceed: Aggregate funds include those made by any contributing
$3,350 for employee only source
$6,750 for an employee covering dependents The maximum aggregate contribution is adjusted each
$1,000 catch-up contribution only for individuals 55+ year to align with inflation
years of age A catch-up contribution is an amount in addition to the
HSA maximum aggregate contribution
When activating the HSA, you can elect pre-tax
contributions to be made through payroll deductions
Post-tax deductions are also acceptable and you will
receive a tax deduction on federal and state income tax,
excluding AL, CA and NJ up to the applicable maximum
contribution
To claim contributions on your tax return, contributions
must be made prior to December 31.
Please note: Consult your tax advisor for additional taxation information or advice.

Using HSA Funds

Keep in mind, the IRS only allows HSA funds to pay for qualified medical, dental and vision costs incurred by the
plan member or dependent(s) and will not allow for reimbursement for claim dates prior to the HSA account being
open. Such examples include:
Out-of-pocket expenses such as the high deductible and copayments
Qualified health care expenses for services not covered under the high deductible health plan including
chiropractic or acupuncture
Some dental expenses, including braces, mouth guards and more
Some vision expenses, including LASIK eye surgery, glasses, contacts and more
Lab fees, X-rays and more
Explicit guidelines for determining eligible expenses have not been provided by the Internal Revenue Service (IRS);
for a list of potential eligible expenses that may be covered by a Health Savings Account (HSA) visit Internal
Revenue Code (IRC) section 213 (d). Also, IRS Publication 502 (Medical and Dental Expenses) may be used as a
guide for what expenses may be considered by the IRS to be for medical care; however, these guidelines should be
used with caution when trying to determine what expenses are reimbursable under an HSA.
Please note: This is informational only and not intended to serve as legal, tax, or financial advice. Participants in an
HSA should consult their tax advisor before making any changes to their plan.

Using HSA Funds (continued)

HSA Year-to-Year Illustration
Because HSAs are employee-owned and there are no use it or lose it provisions, any unused funds remain in your
account for future use. In the example below youll learn just how your HSA can benefit you year after year.
Year 1: Amanda started with $2,500 in her HSA. Year 1

Service Type
As shown in the chart to the right, she used $580 $2,500 in HSA Fund
from her HSA to pay her Year 1 medical Preventive Care Exam $0
expenses.
Physicians Services $400
Amanda was not required to take any money out Prescriptions $180
of her own pocket. And, because she only used Total Medical Expenses $580
$580 in Year 1, she will carry over $1,920 to
Paid by HSA Funds $580
Year 2.
Paid by Amanda $0
Remaining HSA Funds $1,920
Year 2
Year 2: Amanda had $1,920 remaining in her Service Type $2,500 in HSA Fund +
HSA from Year 1 and an additional $2,500 was Remaining from Year 1
contributed in Year 2 for a total of $4,420.
Preventive Care Exam $0
Amanda used $85 from her HSA to pay for her Office Visit for Cold $77
Year 2 expenses. Again, she was not required to
pay any money out of pocket. Now, a total of
Generic Prescription $8
$4,335 will carry over to Year 3, which allows her Total Medical Expenses $85
to continue using funds for future eligible Paid by HSA Funds $85
expenses.
Paid by Amanda $0
Remaining HSA Funds $4,335
Please Note: This example does not reflect your plans coverage and does not take into consideration any possible payroll deduction for the HDHP. It simply
provides you an illustration of how HSA funds rollover from year-to-year to be used towards future health care expenses.
Additional HSA Information

The Directory & Resources section of this guide provides information for CBA if you are seeking answers or help.
Additionally, the U.S. Department of Treasury and IRS can inform individuals on what is new regarding HSAs,
qualified medical expenses, qualifying for HSAs, contributions, distributions, balances, death of an account holder,
forms required and more. They have also provided a comprehensive listing of Frequently Asked Questions
regarding HSAs.
Call 800.829.1040 or visit www.treasury.gov/resource-center/faqs/Taxes/Pages/Health-Savings-Accounts.aspx for
more information.

DENTAL COVERAGE
Dental benefits are another important element of your overall health. With proper care, your
teeth can and should last a lifetime.
Your Dental Plan Options

This year, you and your eligible dependents will have the opportunity to enroll in the DHMO plan (administered
through DeltaCare), the Base PPO plan or the PPO Buy-Up plan, both administered through Delta Dental. We
encourage you to review the coverage details and select the option that best suits your needs.
Using the Plan

In order to receive benefits while enrolled in the Dental HMO plan, you and your enrolled eligible dependents must
obtain services from a primary care dentist who participates in the Delta Care network. If you receive services from
a provider outside of the approved network, you would be responsible for paying the entire dental bill
yourself.
The Dental PPO plan is designed to give you the freedom to receive dental care from any licensed
dentist of your choice. Keep in mind, youll receive the highest level of benefit from the plan if you
select an in-network PPO dentist versus an out-of-network dentist who has not agreed to provide
services at the negotiated rate. Delta Dental PPO dentists are in-network and are reimbursed at
the lesser of the submitted charge or the PPO providers contracted fee. Delta Dental Premier
dentists are out-of-network and are reimbursed at the lesser of the submitted charge or the
Premier providers contracted fee. Basically, if a member utilizes services from a PPO
dentist, they could experience less out of pocket costs. Additionally, no claim forms are
required when using in-network PPO dentists.
Helpful Dental Hints

Dont forget about your semi-annual Dental
Cleanings! Review your plan information to
learn more about what is covered under the
plan
For the Dental HMO, refer to your Evidence

of Coverage booklet for a detailed list of
procedure codes and corresponding
copayment amounts
To find an in-network dentist, go to

www.deltadentalins.com and search the
Provider Network or call 800.422.4234
Plan highlights for both the Dental HMO and Dental PPO (Base & Buy-Up) are included on
the next page for your review and consideration.

DENTAL COVERAGE
Delta Care Delta Dental
Dental Dental PPO
Plan Highlights HMO
In-network Base Plan Buy Up Plan
Only
Calendar Year / Plan Year Deductible
Delta Dental PPO Dentist $35 Delta Dental PPO Dentist $35
Per Person $0
Non Delta Dental PPO Dentist $70 Non Delta Dental PPO Dentist $70
No Annual
Calendar Year Maximum $1,200 $2,000
Max
Preventive Services
Office Visit 100% 100% 100%
X-rays 100% 100% 100%
Cleanings 100% 100% 100%
Sealants (per tooth) 100% 100% 100%
Basic Services
Endodontic Services/Root Canal 100% 80% 80%
Fillings (amalgam, silicate, acrylic) 100% 80% 80%
Oral Surgery (uncomplicated
100% 80% 80%
extractions)
Periodontal Scaling & Root Planning 100% 80% 80%
Periodontal Services 100% 80% 80%
Anesthetics 100% 80% 80%
Major Services
Crowns 100% 80% 80%
Dentures 100% 80% 80%
Bridges 100% 80% 80%
Orthodontia Services
Lifetime Maximum See below Not Covered $2,000
Delta Dental PPO Dentist 60%
Adults $1,100 Not Covered
Non Delta Dental PPO Dentist 50%
Delta Dental PPO Dentist 60%
Child(ren) up to Age 26 $900 Not Covered
Non Delta Dental PPO Dentist 50%

VISION COVERAGE
By practicing healthy eye habits, you and your family members can work towards preserving
your vision for the long haul.
Your Vision Plan Option

Vision coverage is offered by VSP as a Preferred Provider Can You See It?
Organization (PPO) plan.
Common daily symptoms that may suggest a
Using the Plan problem with your vision:
As with a traditional PPO, you may take advantage of the Blurriness, blind spots or halos
around lights
highest level of benefit by receiving services from in-network
vision providers and doctors. You would be responsible for a Frequent headaches
copayment at the time of your service. However, if you receive Loss of sharpness
services from an out-of-network doctor, you pay all expenses
at the time of service and submit a claim for reimbursement up Sitting too close to the television
to the allowed amount. Squinting
Any questions pertaining to your vision coverage can be
directed to VSP by calling 800.877.7195 or visiting their
website, www.vsp.com.
VSP Vision PPO

Plan Highlights
In-network Out-of-network
Exam $15
Every 12 months
Lenses
Every 12 months
Single Paid in Full Up to $26
Bifocal Paid in Full Up to $43
Trifocal Paid in Full Up to $60
Frames Up to $200, 20% off the amount over Up to $40
Every 12 months Allowance
Contacts
Every 12 months, in lieu of lenses & frames
Contact lenses Up to $200 Up to $100
Other Benefits
Progressive Lenses Covered in full after $50 Copay
Anti-reflective coating Covered in full after $40 Copay

FLEXIBLE SPENDING ACCOUNT (FSA)
Stretch your health care spending by using pre-tax dollars for qualified medical and/or
dependent care costs by participating in the Flexible Spending Account program.
FSA Overview
You may have the option to enroll in and contribute towards one of the following types of Flexible Spending
Accounts (FSA), helping to reduce your taxable income and pay for eligible expenses for yourself, spouse and
eligible dependents on a tax-free basis. The FSA plan operates on a calendar year basis from January 1 through
December 31. You may participate in one or all of the following accounts:
A Health Care FSA can reimburse for health care expenses that are not covered, or are only partially
covered, by your medical, dental and vision insurance plans including other eligible expenses. You will have
immediate access to the entire annual contribution amount from the first day of the benefit year, before all
scheduled contributions have been made
The Dependent Care FSA can be used to pay for qualified child care and/or caregivers for a disabled family
member living in the household who is unable to care for themselves. Unlike the Health Care FSA, you can
only access the money that is currently in the account
With regards to the FSA types available,
The plan administrator is Custom Benefit Administrators (CBA)
Contributions are deducted from your paycheck in equal amounts during the year before federal, state and
social security taxes are taken out
Since you are not paying federal, state or social security taxes on the contributions, your taxable income is
reduced and your spendable income actually increases
Additionally, Commuter Benefit plans such as a Mass Transit benefit can reimburse for eligible commuting
expenses also on a pre-tax basis.
Enrolling in an FSA
To participate in the FSA program, enrollment must be completed each year during the Open Enrollment period for
both new and active employees up to the maximum amounts allowed. An annual contribution amount must be
determined at the time of enrollment.
Once enrolled, you will have online access to view your FSA balance(s), check on a reimbursement status and
more. If youre a first time enrollee, register as a new user. Visit www.cbadministrators.com to access CBAs online
portal or call 916.303.7090 or 800.574.5448.
The following sections provide additional information on contributing towards the FSA and using funds, as well as
how reimbursements are completed.

Using Your Funds

The types of expenses reimbursable by your spending accounts are determined by the IRS. Examples of eligible
expenses and additional information are below.
Account Type Eligible Expenses

Health Care FSA Deductibles, copays and coinsurance, as well as out-of-pocket costs for
medical, dental and vision services, including chiropractic and acupuncture
services
Prescription drugs and over-the-counter medications with a prescription are
considered eligible
Explicit guidelines for determining eligible expenses have yet to be provided
by the Internal Revenue Service (IRS); for a list of potential eligible expenses
that may be covered by a Flexible Spending Account (FSA), review Internal
Revenue Code (IRC) section 213 (d). IRS Publication 502 (Medical and
Dental Expenses) may be used as a guide for what expenses may be
considered by the IRS to be for medical care; however, the guidelines should
be used with caution when trying to determine what expenses are
(1)
reimbursable under an FSA
Dependent Care FSA Eligible child care, nanny services or residential disabled adult daycare for
your dependents
Dependents claimed on your federal income tax return, including those under
age 13 and those of any age who are unable to care for themselves, who live
with you for more than half of the taxable year and do not provide more than
half of his/her own support would be considered eligible dependents for this
FSA
To determine potential eligible employment-related expenses view IRC
sections 129 and 21. IRS Publication 502 (Child and Dependent Care
Expenses) may also be used as a guide for what expenses that may be
considered employment-related; however, Publication 502 should be used
with caution when trying to determine what expenses are reimbursable under
(1)
a Dependent Care FSA
Commuter Spending Accounts Expenses such as transit passes, payments for transportation in a commuter
highway vehicle and certain qualified parking costs are allowed according to
Section 132 of the Internal Revenue Code
(1)
Please note: This is informational only and not intended to serve as legal, tax, or financial advice. Participants in a Health Care FSA or Dependent
Care FSA should consult their tax advisor before making any changes to their plan.
If you are at a participating FSA merchant when you incur eligible expenses, use your FSA debit card to complete
your transaction. Each FSA enrolled employee receives one debit card, which is mailed to the address on file with
CBA.
Keep itemized receipts in a safe place. The IRS or CBA may requests a copy to substantiate a claim. If you are
required to submit a receipt or some form of claim documentation and fail to comply, reimbursement may be denied.
Note: If you have an HSA with the HSA-Independence Plan or the Kaiser Low Option High Deductible Health
Plan, you can only use your FSA for dental and vision expenses.

Contributing to Your Accounts

Each account allows participants to contribute a set annual amount, as outlined in the chart below.
Account Type Contribution Limit

Health Care FSA You can contribute up to $2,550 pre-tax in 2016
Dependent Care FSA If you are single, you can contribute up to $5,000 pre-tax in 2016
If you are married and filing a joint tax return, you can contribute up to $5,000
pre-tax in 2016
If you are married and file separately, you can contribute up to $2,500 pre-tax
in 2016
Commuter Spending Accounts For a Mass Transit Spending Account, the monthly maximum contribution for
2016 is $130 (subject to change)
The monthly maximum contribution for a Parking Spending Account is $250
in 2016 (subject to change)
Please note: Consult your tax advisor for additional taxation information or advice.
Not sure how much to contribute? By estimating the eligible expenses you and your family might incur during the
plan year, you will have a better sense of how much your annual contribution towards the FSA should be. The
Planning Worksheets may help you determine an amount to contribute to the Health Care FSA and/or Dependent
Care FSA.
Receiving Reimbursements Use It Dont Lose It

You will have until March 31, 2017 to submit a reimbursement With this FSA, funds do not rollover.
request for claims incurred between January 1 and December
So long as you incurred expenses
31, 2016. If you do not receive automatic reimbursement by between January 1 and December 31,
using your debit card, you can submit a manual reimbursement 2016, and you were benefits eligible
request by: during that time, any qualified expenses
Email: customerservices@cbadministrators.com incurred within that time period can be
submitted for reimbursement as late as
Fax: 916.303.7083 March 31, 2017.
Mail: PO Box 2170, Rocklin, CA 95677 If you have additional funds in your
You may receive your manual reimbursement by check in the account that you need to spend, you
have the option to shop at
mail or by means of direct deposit into your personal Checking
www.fsastore.com to purchase FSA
or Savings Account.
eligible products. FSA Store offers 24/7
customer service and free shipping for
orders over $50.
Any leftover amounts after March 31,
2017 will be forfeited.
The FSA Health Plan and Termination

If you are a participant in your Health FSA plan and you are terminated, your funds may be preserved and you may
have other options available to you at the time of termination, if applicable. It is important that you check your
Summary Plan Description or contact Human Resources if you have any further questions regarding your FSA
health plan funds at the time of termination. Your failure to act in conjunction with your Health FSA plan may cause
your funds to be permanently forfeited after your termination.

DISABILITY COVERAGE
Should you experience a non-work related illness
or injury that prevents you from working, disability
coverage acts as income replacement to protect Defining Disability Coverage
important assets and help you continue with some
Benefit Period: Maximum amount of
level of earnings. Benefits eligibility may be based
time you may receive proceeds for a
on disability for your occupation or any continuous disability
occupation.
Commencement Date: The first day
your disability is covered, which
State Disability Insurance immediately follows the completion of
the waiting period
The state you reside in may provide a partial wage-
replacement disability insurance plan. For more information Elimination or Waiting Period:
regarding statutory disability programs, contact Human The time you must wait before you are
eligible to receive benefit payments
Resources.
Long Term Disability (LTD)

Disability insurance allows you to plan for unexpected life events. If you are unable to work for an extended period of
time because of a prolonged illness or injury, disability coverage would provide a steady income for you and your
family. AHS provides base Long-Term Disability (LTD) coverage at no cost to you and also provides you the
opportunity to buy-up your coverage.
The Base plan is 100% paid by AHS. This plan would pay 50% of your pre-disability earnings to a maximum
monthly benefit of $2,500. Benefits would begin after you have been disabled for 180 days.
ALL Benefit Eligible Employees (1) can choose to purchase additional LTD benefits under the Buy-Up LTD plan.
This plan offers employees the option to buy-up their benefit to 66 2/3% of their salary to a maximum monthly
benefit of $12,500 per month. The cost is $0.73 per $100 of covered payroll.
All applications and requests for coverage increases will be subject to medical underwriting approval.
(1)
CIR members and Temporary Employees are only eligible for Medical, Dental and Vision coverage

LIFE AND AD&D COVERAGE
In the event of your death, Life Insurance
will provide your family members or other
Select Your Beneficiary
beneficiaries with financial protection and
security. Additionally, if your death is a Beneficiaries are individuals or entities that you
result of an accident or if you become select to receive benefits from your policy.
dismembered, your Accidental Death & You can change your beneficiary
Dismemberment (AD&D) coverage may designation at any time
apply. You may designate a sole beneficiary or

multiple beneficiaries to receive
Employer Paid Basic Life payment in the amount you specify
To select or change your beneficiary you

AHS provides benefit eligible employees with Group can do so online.
Life coverage of $9,000 or $25,000 depending on
your union membership. Coverage is automatic you
are not required to enroll.
Note: CIR members and Temporary Employees are Note: If you did not elect optional life insurance when
only eligible for Medical, Dental and Vision coverage. you were first eligible or you wish to increase
coverage for yourself or your spouse / domestic
Voluntary Employee Paid Life and partner, you will be required to submit a health
AD&D questionnaire to Reliance Standard, also known as
Evidence of Insurability (EOI).
If you would like to supplement your employer paid Please note: Benefits coverage may reduce when you reach age 65.
insurance, additional Life and AD&D coverage for you
and/or your dependents is available for purchase Cost of Voluntary Life Coverage
through Insurance Point.
Age of Insured Monthly Rate per $1,000
Life Insurance: Less than 25 $0.048
For employees: Increments of $10,000 up to 2529 $0.048
a $1,000,000 or 5x Annual Salary maximum,
whichever is less 3034 $0.056
For your spouse / state registered 3539 $0.078

domestic partner: Increments of $10,000 up 4044 $0.110
to a $150,000 maximum (cannot exceed
100% of employees covered amount) 4549 $0.184
5054 $0.292
For your child(ren): Increments of $2,500 up
to $10,000 5559 $0.464
Accidental Death & Dismemberment: 6064 $0.626
Employee Level of Coverage: Increments of 6569 $0.960
$25,000 up to $500,000 or 10x Annual Salary 70 + $1.67
maximum, whichever is less.
Dependent Child(ren) $0.160
Dependent Level of Coverage: Spouse only:
60%; Spouse / Children: 50%, Children only:
15% Cost of Voluntary AD&D Coverage
No requirements for a medical questionnaire
Coverage Level Monthly Rate per $1,000
AD&D Employee $0.016
AD&D Family $0.031

VOLUNTARY COVERAGE
In addition to employer paid coverage, a variety of optional benefits are available for
purchase if you are seeking additional insurance.
Critical Illness Coverage Auto / Home Insurance &

MetLife Critical Illness Insurance provides you with a
Pet Insurance (Continued)
lump sum benefit payment in the event that you or MetLife Auto & Home is a brand of Metropolitan
your covered dependent experience one of the Property and Casualty Insurance Company and its
covered conditions in three distinct categories: affiliates: Economy Fire and Casualty Company,
Category 1 incorporates certain cancer-related Economy Preferred Insurance Company, Metropolitan
conditions: Full Benefit Cancer, Partial Benefit Cancer General Insurance Company, Metropolitan Casualty
and Bone Marrow Transplant. Insurance Company, Metropolitan Direct Property and
Casualty Insurance Company, Metropolitan Group
Category 2 incorporates certain heart-related Property and Casualty Insurance Company, and
conditions: Heart Attack, Heart Transplant, Stroke and Metropolitan Lloyds Insurance Company of Texas, all
Coronary Artery Bypass Graft. with administrative home offices in Warwick, RI.
Category 3 incorporates certain other covered Coverage, rates, and discounts are available in most
conditions: Major Organ Transplant (other than bone states to those who qualify.
marrow and heart) and Kidney Failure. Veterinary pet insurance policies are provided by
During this enrollment period, you and your Veterinary Pet Insurance Company (in California),
spouse can enroll for a category benefit amount Brea, CA, or National Casualty Company (in all other
of $15,000 of Critical Illness Insurance, $10,000 for states), Madison, WI, an A+15 rated company. These
dependent child(ren). companies are not affiliated with Metropolitan Life
Insurance Company, nor its affiliates.
Auto / Home Insurance & Copyright 2009, MetLife, Inc. MetLife, MetLaw,
Pet Insurance MetLife Auto & Home are registered trademarks of
Metropolitan Life Insurance Company, 1095 Avenue
As you know, AHS is committed to providing a
of the Americas, New York, NY 10166.
comprehensive employee benefits plan, and as part L03090256`28[exp0212][All States]
of an ongoing effort to better meet your needs, it has
arranged with MetLife and its affiliates to add some
new employee benefits and discounts to its current
program.
Veterinary Pet Insurance: With veterinary pet For a quote or to enroll in any
insurance, you can stop worrying about the ever-
of the programs:
increasing costs of caring for your pets, because your
pets will be covered for thousands of medical Call 1.800.GET.MET8
problems and conditions. (1.800.438.6388), or
Auto and Home Insurance: Special employee rates Visit MetLife online at www.metlife.com
and discounts could help you save on average up to
15% (1) on your auto insurance alone. Plus, you can
count on convenient payment options, including
payroll or bank account deduction, outstanding
customer service, and valuable coverage for all of
your personal auto and home insurance needs.
All AHS employees are eligible to apply for auto,
home, and pet insurance.

VOLUNTARY COVERAGE
Long Term Care Insurance

Alameda Health Systems offers a long-term care (LTC)
insurance plan through Unum to all full-time and part-
time benefit-eligible employees with discounted group
rates. Although we conduct an LTC open enrollment
3
each year with guaranteed issue for newly hired and
newly eligible employees, other eligible employees and
family members may still apply at any time for the plan
with medical underwriting.
What is Long-Term Care Insurance?

LTC insurance provides coverage for expenses related
to long-term care services whether received at home, in
the community, or in a nursing facility. Importantly:
Seven in ten of us will likely need some kind of
1
long term care as we get older
Neither health nor disability insurance will cover
this kind of care
Relying on government programs may not be a
viable solution
The costs for LTC services generally range from

2
$40,000 to $84,000 annually . Without LTC insurance,
the money to pay for these expenses may have to come
from your savings, family or other assets. All are options
most people would rather not rely upon.
For more information, please contact our long-term care
insurance consultant, LTC Solutions, at (877) 286-2852
or visit our online benefit guide at
www.myltcguide.com/ahs

LEGAL SHIELD
To enroll, please visit: www. legalshield.com/info/alamedahealth

Pay Period Amounts LegalShield IDShield Combined
INDIVIDUAL $6.90 $3.90 $10.80
FAMILY $7.37 $7.37 $13.34

HEALTH RISK ASSESSMENT (HRA)

PERSONALIZED WELLNESS COACHING

EMPLOYEE ASSISTANCE PROGRAM (EAP)
Alameda Health System understands that you and your family members might experience a
variety of personal or work related challenges. Through the EAP, you have access to
resources, information and counseling in order to address situations affecting your work-life
balance.
Your EAP Option

Provided by MHN, the Employee Assistance Program (EAP) is Access Support Today!
available to all employees and your dependents, as well as any
EAP Phone Access 24 hours a day /
member of your household. The purpose of the program is to
7 days a week
provide confidential assistance at no-cost for a wide range of
personal topics. By Phone: 800.227.1060
3 face-to-face sessions per year per member per incident are TDD callers: 866.726.1785
available Consultations are available for subjects such as: Online: www.mhn.com
Child and eldercare assistance Access code: acmc
Identity theft
Marital, relationship, parenting and family problems
Depression, stress and anxiety
Bereavement or grief counseling
Substance abuse and recovery
Premium Legal Services

With this service you are entitled to 60 minutes of office or telephone consultation per separate legal matter, with
either a network attorney or mediator. In addition, if you choose to retain an attorney or a mediator after your initial
consultation, you will receive 25 percent off of the normal hourly rate.
You can use this program for:
Civil and Consumer Issues
Personal Family Legal Services
Financial / IRS Matters
Business Legal Services
Real Estate
Criminal Matters
Organizing Lifes Affairs / Online Estate Planning
Premium Financial Services

With Premium Financial Services, MHN can help you overcome financial distress and meet your financial goals with
telephone assistance and referrals to professional services. For each separate financial issue, you are eligible for 60
minutes of consultations, at no cost to you. In addition, you are entitled to a 25 percent discount on additional
services. Issues covered include:
Tax Planning
Credit Counseling
Retirement Planning
Financial Planning for College
Debt and Budgeting Assistance

THE COST OF COVERAGE
The rates below are effective January 1, 2016.
The employee costs shown below are an example for a full time employee. To see your employee costs, log on to
the benefits enrollment system during the open enrollment period.
Alameda Health
Total Employee Biweekly
Coverage Level Monthly Cost
System
Payroll Deduction
Monthly Contribution
AHS Freedom of Choice Plan
Employee Only $876.48 $876.48 $0
Employee +1 $1,753.06 $1,753.06 $0
Employee + 2 or more $2,480.56 $2,480.56 $0
HSA Independence Plan
Employee Only $655.92 $655.92 $0
Employee +1 $1,331.99 $1,331.99 $0
Employee + 2 or more $1,884.69 $1,884.69 $0
Kaiser High Option Traditional HMO Plan
Employee Only $685.79 $617.21 $31.65
Employee + 1 $1,371.58 $1,234.42 $63.30
Employee +2 or more $1,940.79 $1,746.71 $89.57
Kaiser Mid Option Low Deductible Plan
Employee Only $599.31 $569.34 $13.83
Employee +1 $1,198.62 $1,138.69 $27.66
Employee + 2 or more $1,696.05 $1,611.25 $39.14
Kaiser Low Option High Deductible Health Plan / HSA
Employee Only $526.72 $526.72 $0
Employee +1 $1,053.44 $1,053.44 $0
Employee + 2 or more $1,490.62 $1,490.62 $0
Delta Dental Base PPO Plan
Employee Only $53.53 $53.53 $0
Employee +1 $101.53 $101.53 $0
Employee + 2 or more $155.09 $155.09 $0
Delta Dental Buy-Up PPO Plan
Employee Only $84.94 $53.53 $14.50
Employee +1 $161.09 $101.53 $27.49
Employee + 2 or more $246.07 $155.09 $41.99
DeltaCare DHMO Plan
Employee Only $28.88 $28.88 $0
Employee +1 $48.83 $48.83 $0
Employee + 2 or more $74.85 $74.85 $0
VSP Vision Plan
Employee Only $9.56 $0 $4.41
Employee +1 $19.13 $0 $8.83
Employee + 2 or more $30.80 $0 $14.22

PLAN GUIDELINES AND EVIDENCE OF COVERAGE
The benefit summaries listed on the previous pages are brief summaries only. They do not fully describe the
benefits coverage for your health and welfare plans. For details on the benefits coverage, please refer to the plans
Evidence of Coverage. The Evidence of Coverage or Summary Plan Description is the binding document between
the elected health plan and the member.
A health plan physician must determine that the services and supplies are medically necessary to prevent,
diagnose, or treat the members medical condition. These services and supplies must be provided, prescribed,
authorized, or directed by the health plans network physician unless the member enrolls in the PPO plan where the
member can use a non-network physician.
The HMO member must receive the services and supplies at a health plan facility or skilled nursing facility inside the
service area except where specifically noted to the contrary in the Evidence of Coverage.
For details on the benefit and claims review and adjudication procedures for each plan, please refer to the plans
Evidence of Coverage. If there are any discrepancies between benefits included in this summary and the Evidence
of Coverage or Summary Plan Description, the Evidence of Coverage or Summary Plan Description will prevail.

MEDICARE PART D NOTICE
Important Notice about Your Prescription Drug Coverage and Medicare
Model Individual CREDITABLE Coverage Disclosure (for use on or after 04/01/2011)

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage and about
your options under Medicares prescription drug coverage. This information can help you decide whether or not you want to join a Medicare prescription
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 Medicares 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. Your employer has determined that the prescription drug coverage offered is expected to pay, on average, as much as standard Medicare
prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you
can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.
When Can You Join A Medicare Drug Plan?
You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15 to December 7. 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 prescription drug plan.
What Happens to Your Current Coverage if You Decide to Join a Medicare Prescription Drug Plan?
Individuals who are eligible for Medicare should compare their current coverage, including which drugs are covered, with the coverage and cost of the
plans offering Medicare prescription drug coverage in their area.
If you are eligible for Medicare and do decide to enroll in a Medicare prescription drug plan and drop your employers group health plan prescription drug
coverage, be aware that you and your dependents may not be able to get this coverage back.
Please contact Human Resources for more information about what happens to your coverage if you enroll in a Medicare prescription drug
plan.
Your medical benefits brochure contains a description of your current prescription drug benefits.
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 your employer and dont join a Medicare prescription drug plan within 63
continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later. If you go 63 continuous
days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium
per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may
consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you
have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.
For More Information about This Notice or Your Current Prescription Drug Coverage
Contact your Human Resources Department for further information NOTE: You will receive this notice annually, before the next period you can join a
Medicare prescription drug plan, and if this coverage through your employer 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. Youll 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 the Social Security Administration (SSA) online at www.socialsecurity.gov, or call SSA 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 prescription 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).

LEGAL INFORMATION REGARDING YOUR PLANS
Required Notices HIPAA Privacy Notice
Womens Health & Cancer Rights Act Notice of Health Information Privacy Practices
The Womens Health and Cancer Rights Act (WHCRA) requires group health plans to make certain This notice describes how medical information about you may be used and disclosed, and how you can
benefits available to participants who have undergone or who are going to have a mastectomy. In obtain access to this information. Please review it carefully.
particular, a plan must offer mastectomy patients benefits for: This notice is required by law under the federal Health Insurance Portability and Accountability Act of
All stages of reconstruction of the breast on which the mastectomy was performed; 1996 (HIPAA). One of its primary purposes is to make certain that information about your health is
handled with special respect for your privacy. HIPAA includes numerous provisions designed to maintain
Surgery and reconstruction of the other breast to produce a symmetrical appearance; the privacy and confidentiality of your protected health information (PHI). PHI is health information that
Prostheses; and contains identifiers, such as your name, address, social security number, or other information that
Treatment of physical complications of the mastectomy, including lymphedema. identifies you.
These benefits will be provided subject to the same deductibles and coinsurance applicable to other Our Pledge regarding Health Information
medical and surgical benefits provided under this plan.
We understand that health information about you and your health is personal.
Your plans comply with these requirements.
We are committed to protecting health information about you.
Health Insurance Portability & Accountability Act Non-discrimination This notice will tell you the ways in which we may use and disclose health information about you.
Requirements We also describe your rights and certain obligations we have regarding the use and disclosure of
Health Insurance Portability & Accountability Act (HIPAA) prohibits group health plans and health health information.
insurance issuers from discriminating against individuals in eligibility and continued eligibility for benefits
and in individual premium or contribution rates based on health factors.
We are required by Law to
These health factors include: health status, medical condition (including both physical and mental Make sure that health information that identifies you is kept private;
illnesses), claims experience, receipt of health care, medical history, genetic information, evidence of Give you this notice of our legal duties and privacy practices with respect to health information about
insurability (including conditions arising out of acts of domestic violence and participation in activities such you;
as motorcycling, snowmobiling, all-terrain vehicle riding, horseback riding, skiing, and other similar
Follow the terms of the notice that are currently in effect.
activities), and disability.
Special Enrollment Rights The Plan will use Your Health Information for
Treatment: The plan may use your health information to assist your health care providers (doctors,
If you are declining enrollment for yourself or your dependents (including your spouse) because of other
pharmacies, hospitals and others) to assist in your treatment. For example, the plan may provide a
health insurance or group health plan coverage, HIPAA Special Enrollment Rights require your plan to
treating physician with the name of another treating provider to obtain records or information needed for
allow you and/or your dependents to enroll in your employers plans (except dental and vision plans
your treatment.
elected separately from your medical plans) if you or your dependents lose eligibility for that other
coverage (or if the employer stopped contributing towards your or your dependents' other coverage). Regular Operations: We may use information in health records to review our claims experience and to
However, you must request enrollment within 30 days (60 days if the lost coverage was Medicaid or make determinations with respect to the benefit options that we offer to employees.
Healthy Families) after your or your dependents' other coverage ends (or after the employer stops Business Associates: There are some services provided in our organization through contracts with
contributing toward the other coverage). business associates. Business associate agreements are maintained with insurance carriers. Business
In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for associates with access to your information must adhere to a contract requiring compliance with HIPAA
adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment privacy and security rules.
within 30 days after the marriage, birth, adoption, or placement for adoption. As Required by Law: We will disclose health information about you when required to do so by federal,
Other midyear election changes may be permitted under your plan (refer to Change in Status section). state or local law.
To request special enrollment or obtain more information, contact your Human Resources Workers Compensation: We may release health information about you for Workers Compensation or
Representative. similar programs. These programs provide benefits for work-related injuries or illness.
HIPAA Special Enrollment Opportunities include: Law Enforcement: We may disclose your health information for law enforcement purposes, or in
COBRA (or state continuation coverage) exhaustion response to a valid subpoena or other judicial or administrative request.
Loss of other coverage (1) Public Health: We may also use and disclose your health information to assist with public health
Acquisition of a new spouse or dependent through marriage (1)
, adoption (1)
, placement for adoption (1) activities (for example, reporting to a federal agency) or health oversight activities (for example, in a
or birth (1) government investigation).
Loss of state Childrens Health Insurance Program coverage (e.g., Healthy Families) Your Rights Regarding Your Health Information
(60-day notice) (1)
Although your health record is the physical property of the entity that compiled it, the information belongs
Employee or dependents become eligible for state Premium Assistance Subsidy Program (60-day to you. You have the right to:
notice)
Request a restriction on certain uses and disclosures of your information, where concerning a service
Change in Status Permitted Midyear Election Changes already paid for;
Due to the Internal Revenue Service (IRS) regulations, in order to be eligible to take your premium Obtain a paper copy of the Notice of Health Information Practices by requesting it from the plan
contribution using pre-tax dollars, your election must be irrevocable for the entire plan year. As a privacy officer;
result, your enrollment in the medical, dental, and vision plans or declination of coverage when you Inspect and obtain a copy of your health information;
are first eligible, will remain in place until the next Open Enrollment period, unless you have an Request an amendment to your health information;
approved change in status as defined by the IRS.
Obtain an accounting of disclosures of your health information;
Examples of permitted change in status events include:
(2) Request communications of your health information be sent in a different way or to a different place
Change in legal marital status (e.g., marriage , divorce or legal separation) than usual (for example, you could request that the envelope be marked "Confidential" or that we send
(2)
Change in number of dependents (e.g., birth , adoption (2) or death) it to your work address rather than your home address);
Change in eligibility of a child Revoke in writing your authorization to use or disclose health information except to the extent that
Change in your / your spouses / your state registered domestic partners employment status (e.g., action has already been taken, in reliance on that authorization.
reduction in hours affecting eligibility or change in employment)
The Plans Responsibilities
A substantial change in your / your spouses / your state registered domestic partners benefits
coverage The plan is required to:
A relocation that impacts network access Maintain the privacy of your health information;
Enrollment in state-based insurance Exchange Provide you with a notice as to our legal duties and privacy practices with respect to information we
Medicare Part A or B enrollment collect and maintain about you;
Qualified Medical Child Support Order or other judicial decree Abide by the terms of this notice;
A dependents eligibility ceases resulting in a loss of coverage (3) Notify you if we are unable to agree to a requested restriction, amendment or other request;
Loss of other coverage (2) Notify you of any breaches of your personal health information within 60 days or 5 days if conducting
business in California;
Change in employment status where you have a reduction in hours to an average below 30 hours of
service per week, but continue to be eligible for benefits, and you intend to enroll in another plan that Accommodate any reasonable request you may have to communicate health information by
provides Minimum Essential Coverage that is effective no later than the first day of the second month alternative means or at alternative locations.
following the date of revocation of your employer sponsored coverage The plan will not use or disclose your health information without your consent or authorization, except as
provided by law or described in this notice.
You enroll, or intend to enroll, in a Qualified health Plan (QHP) through the State Marketplace (i.e.
Exchange) and it is effective no later than the day immediately following the revocation of your The plan reserves the right to change our health privacy practices. Should we change our privacy
employer sponsored coverage. practices in a material way, we will make a new version of our notice available to you.
You must notify Human Resources within 30 days of the above change in status, with the exception of the
following which requires notice within 60 days: (1)
Indicates that this event is also a qualified Change in Status
(2)
Loss of eligibility or enrollment in Medicaid or state health insurance programs (e.g., Healthy Families) Indicates this event is also a HIPAA Special Enrollment Right
(3)
Indicates that this event is also a COBRA Qualifying Event

For More Information or to Report a Problem Why am I getting this notice? (Continued)
If you have questions or would like additional information, or if you would like to make a request to Divorce or legal separation (36 months of COBRA for the ex-spouse)
inspect, copy, or amend health information, or for an accounting of disclosures, contact the plan Entitlement to Medicare (36 months of COBRA for the spouse and dependents)
privacy officer. All requests must be submitted in writing. Loss of dependent child status (36 months of COBRA for the dependent)
If you believe your privacy rights have been violated, you can file a formal complaint with the plan Federal law requires that most group health plans (including this plan) give employees and their families
privacy officer; or with the U.S. Department of Health and Human Services. You will not be penalized the opportunity to continue their health care coverage through COBRA continuation coverage when
for filing a complaint. theres a qualifying event that would result in a loss of coverage under an employers plan.
Other Uses of Health Information Whats COBRA continuation coverage?

Other uses and disclosures of health information not covered by this notice or the laws that apply to us COBRA continuation coverage is the same coverage that the plan gives to other participants or
will be made only with your written authorization. If you authorize us to use or disclose health information beneficiaries who arent getting continuation coverage. Each qualified beneficiary (described below)
about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization we who elects COBRA continuation coverage will have the same rights under the plan as other participants
will no longer use or disclose health information about you for the reasons covered by your written or beneficiaries covered under the plan.
authorization. You understand that we are unable to take back any disclosures we have already made
with your authorization, and that we are required to retain our records of the payment activities that we Who are the qualified beneficiaries?
provided to you.
Each person (qualified beneficiary) from the list below may qualify to elect COBRA continuation
coverage:
Important Information on how Health Care Employee or former employee
Spouse or former spouse
Reform Affects Your Plan Dependent child(ren) covered under the plan on the day before the event that caused the loss of
coverage
Child who is losing coverage under the plan because he or she is no longer a dependent under the
Primary Care Provider Designations plan
For plans and issuers that require or allow for the designation of primary care providers by participants or Contact your Human Resources Representative to determine eligibility for spouse and dependents.
beneficiaries:
Your HMO generally requires the designation of a primary care provider. You have the right to
Are there other coverage options besides COBRA Continuation
designate any primary care provider who participates in our network and who is available to accept Coverage?
you or your family members. For information on how to select a primary care provider, and for a list of
Yes. Instead of enrolling in COBRA continuation coverage, there may be other more affordable coverage
the participating primary care providers, contact your Human Resources office
options for you and your family through the Health Insurance Marketplace, Medicaid, or other group
For plans and issuers that require or allow for the designation of a primary care provider for a child: health plan coverage options (such as a spouses plan) through what is called a special enrollment
For children, you may designate a pediatrician as the primary care provider period. Some of these options may cost less than COBRA continuation coverage.
For plans and issuers that provide coverage for obstetric or gynecological care and require the You should compare your other coverage options with COBRA continuation coverage and choose the
designation by a participant or beneficiary of a primary care provider: coverage that is best for you. For example, if you move to other coverage you may pay more out of
pocket than you would under COBRA because the new coverage may impose a new deductible.
You do not need prior authorization from your insurance provider or from any other person (including a
primary care provider) in order to obtain access to obstetrical or gynecological care from a health care When you lose job-based health coverage, its important that you choose carefully between COBRA
professional in our network who specializes in obstetrics or gynecology. The health care professional, continuation coverage and other coverage options, because once youve made your choice, it can be
however, may be required to comply with certain procedures, including obtaining prior authorization difficult or impossible to switch to another coverage option.
for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a
list of participating health care professionals who specialize in obstetrics or gynecology, contact your If I elect COBRA continuation coverage, when will my coverage begin and
Human Resources office. how long will the coverage last?
Grandfathered Plans In the case of a loss of coverage due to end of employment or reduction in hours of employment,
coverage generally may be continued for up to a total of 18 months. In the case of losses of coverage due
If your group health plan is grandfathered then the following will apply. As permitted by the Affordable to an employees death, divorce or legal separation, the employees becoming entitled to Medicare
Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in benefits or a dependent child ceasing to be a dependent under the terms of the plan, coverage may be
effect when that law was enacted. Being a grandfathered health plan means that your plan may not continued for up to a total of 36 months. When the qualifying event is the end of employment or reduction
include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the of the employee's hours of employment, and the employee became entitled to Medicare benefits less
requirement for the provision of preventive health services without any cost sharing. However, than 18 months before the qualifying event, COBRA continuation coverage for qualified beneficiaries
grandfathered health plans must comply with certain other consumer protections in the Affordable Care other than the employee lasts until 36 months after the date of Medicare entitlement. This notice shows
Act, for example, the elimination of lifetime limits on benefits. the maximum period of continuation coverage available to the qualified beneficiaries. Contact your
Questions regarding which protections apply and which protections do not apply to a grandfathered Human Resources Representative for specific start and end dates for COBRA coverage.
health plan and what might cause a plan to change from grandfathered health plan status can be directed
Continuation coverage may end before the date noted above in certain circumstances, like failure to pay
to the plan administrator.
premiums, fraud, or the individual becomes covered under another group health plan.
Prohibition on Excess waiting Periods Can I extend the length of COBRA continuation coverage?
Group health plans may not apply a waiting period that exceeds 90 days. A waiting period is defined as
If you elect continuation coverage, you may be able to extend the length of continuation coverage if a
the period that must pass before coverage for an eligible employee or his or her dependent becomes
qualified beneficiary is disabled, or if a second qualifying event occurs. You must notify Human
effective under the Plan. State law may require shorter waiting periods for insured group health plans.
Resources of a disability or a second qualifying event within a certain time period to extend the period of
California law requires fully-insured plans to comply with the more restrictive waiting period limitation of no
continuation coverage. If you dont provide notice of a disability or second qualifying event within the
more than 60-days.
required time period, it will affect your right to extend the period of continuation coverage.
Preexisting Condition Exclusion For more information about extending the length of COBRA continuation coverage visit
Effective for Plan Years on or after January 1, 2014, Group health plans are prohibited from denying http://www.dol.gov/ebsa/publications/cobraemployee.html.
coverage or excluding specific benefits from coverage due to an individuals preexisting condition,
regardless of the individuals age. A PCE includes any health condition or illness that is present before How much does COBRA continuation coverage cost?
the coverage effective date, regardless of whether medical advice or treatment was actually received or Generally, each qualified beneficiary may be required to pay the entire cost of continuation coverage. The
recommended amount a qualified beneficiary may be required to pay may not exceed 102 percent (or, in the case of an
extension of continuation coverage due to a disability, 150 percent) of the cost to the group health plan
Important Information about COBRA (including both employer and employee contributions) for coverage of a similarly situated plan participant
or beneficiary who is not receiving continuation coverage. The required payment for each continuation
Continuation Coverage and other Health coverage period for each option is described in this notice.
Other coverage options may cost less. If you choose to elect continuation coverage, additional
Coverage Alternatives information about payment will be provided to you after your election is received by the plan. Important
information about paying your premium can be found at the end of this notice.
Note: For use by single employer group health plans. You may be able to get coverage through the Health Insurance Marketplace that costs less than
COBRA continuation coverage. You can learn more about the Marketplace below.
This notice has important information about your right to continue your health care coverage in
your companys plan, as well as other health coverage options that may be available to you, What is the Health Insurance Marketplace?
including coverage through the Health Insurance Marketplace at www.healthcare.gov or call
800.318.2596. You may be able to get coverage through the Health Insurance Marketplace that The Marketplace offers one-stop shopping to find and compare private health insurance options. In the
costs less than COBRA continuation coverage. Please read the information in this notice very Marketplace, you could be eligible for a new kind of tax credit that lowers your monthly premiums and
carefully before you make your decision. cost-sharing reductions (amounts that lower your out-of-pocket costs for deductibles, coinsurance, and
copayments) right away, and you can see what your premium, deductibles, and out-of-pocket costs will
Why am I getting this notice? be before you make a decision to enroll. Through the Marketplace youll also learn if you qualify for free
or low-cost coverage from Medicaid or the Childrens Health Insurance Program (CHIP). You can
Youre getting this notice because your coverage under the plan will end on the last day of the month in
access the Marketplace for your state at www.healthcare.gov.
which the following qualifying events occur:
Termination of employment (18 months of COBRA)
Coverage through the Health Insurance Marketplace may cost less than COBRA continuation coverage.
Reduction in hours of employment (18 months of COBRA) Being offered COBRA continuation coverage wont limit your eligibility for coverage or for a tax credit
Death of employee (36 months of COBRA for the spouse and dependents) through the Marketplace.

When can I enroll in the Marketplace coverage? Important Information about Payment (Continued)
You always have 60 days from the time you lose your job-based coverage to enroll in the Marketplace. Periodic payments for continuation coverage. After you make your first payment for continuation
That is because losing your job-based health coverage is a special enrollment event. After 60 days your coverage, youll have to make periodic payments for each coverage period that follows. The amount due
special enrollment period will end and you may not be able to enroll, so you should take action right away. for each coverage period for each qualified beneficiary may be obtained by contacting Human Resources.
In addition, during what is called an open enrollment period, anyone can enroll in Marketplace coverage. The periodic payments can be made on a monthly basis. Under the plan, each of these periodic
payments for continuation coverage is due on a specified date for that coverage period. If you make a
To find out more about enrolling in the Marketplace, such as when the next open enrollment period will be
periodic payment on or before the first day of the coverage period to which it applies, your coverage
and what you need to know about qualifying events and special enrollment periods, visit
under the plan will continue for that coverage period without any break. The plan will not send periodic
www.healthcare.gov.
notices of payments due for these coverage periods.
If I sign up for COBRA continuation coverage, can I switch to coverage in Grace periods for periodic payments. Although periodic payments are due on specified dates (contact
the Marketplace? What about if I choose Marketplace coverage and want Human Resources for this information), youll be given a grace period of 30 days after the first day of the
to switch back to COBRA continuation coverage? coverage period to make each periodic payment. Youll get continuation coverage for each coverage
period as long as payment for that coverage period is made before the end of the grace period.
If you sign up for COBRA continuation coverage, you can switch to a Marketplace plan during a
If you pay a periodic payment later than the first day of the coverage period to which it applies, but before
Marketplace open enrollment period. You can also end your COBRA continuation coverage early and
the end of the grace period for the coverage period, your coverage will be suspended as of the first day of
switch to a Marketplace plan if you have another qualifying event such as marriage or birth of a child
the coverage period and then retroactively reinstated (going back to the first day of the coverage period)
through something called a special enrollment period. But be careful though - if you terminate your
when the periodic payment is received. This means that any claim you submit for benefits while your
COBRA continuation coverage early without another qualifying event, youll have to wait to enroll in
coverage is suspended may be denied and may have to be resubmitted once your coverage is reinstated.
Marketplace coverage until the next open enrollment period, and could end up without any health
coverage in the interim. If you dont make a periodic payment before the end of the grace period for that coverage period, youll
lose all rights to continuation coverage under the plan.
Once youve exhausted your COBRA continuation coverage and the coverage expires, youll be eligible
to enroll in Marketplace coverage through a special enrollment period, even if Marketplace open Contact your Plan Administrator for information for where your first payment and all periodic payments for
enrollment has ended. continuation coverage should be sent.
If you sign up for Marketplace coverage instead of COBRA continuation coverage, you cannot switch to Separate USERRA Rights for Military Service: The COBRA health care coverage continuation rights
COBRA continuation coverage under any circumstances. discussed above are separate from USERRA health care coverage continuation rights for qualifying
military service.
Can I enroll in another group health plan?
If you leave employment to enter military service, you should contact Human Resources to determine
You may be eligible to enroll in coverage under another group health plan (like a spouses plan), if you whether you also have USERRA health care coverage continuation rights.
request enrollment within 30 days of the loss of coverage.
OMB Control Number 1210-0123 (expires 10/31/2016)
If you or your dependent chooses to elect COBRA continuation coverage instead of enrolling in another
group health plan for which youre eligible, youll have another opportunity to enroll in the other group
health plan within 30 days of losing your COBRA continuation coverage. Employee Rights & Responsibilities under the
What factors should I consider when choosing coverage options? Family Medical Leave Act
When considering your options for health coverage, you may want to think about:
Premiums: Your previous plan can charge up to 102% of total plan premiums for COBRA coverage.
Basic Leave Entitlement
Other options, like coverage on a spouses plan or through the Marketplace, may be less expensive. Family Medical Leave Act (FMLA) requires covered employers to provide up to 12 weeks of unpaid, job
protected leave to eligible employees for the following reasons:
Provider Networks: If youre currently getting care or treatment for a condition, a change in your health
coverage may affect your access to a particular health care provider. You may want to check to see if For incapacity due to pregnancy, prenatal medical care or child birth;
your current health care providers participate in a network as you consider options for health coverage. To care for the employee's child after birth, or placement for adoption or foster care;
Drug Formularies: If youre currently taking medication, a change in your health coverage may affect To care for the employee's spouse, son or daughter, child or parent, who has a serious health
your costs for medication and in some cases, your medication may not be covered by another plan. condition; or
You may want to check to see if your current medications are listed in drug formularies for other health
For a serious health condition that makes the employee unable to perform the employee's job.
coverage.
Severance payments: If you lost your job and got a severance package from your former employer, Military Family Leave Entitlements
your former employer may have offered to pay some or all of your COBRA payments for a period of time. Eligible employees whose spouse, son, daughter or parent is on covered active duty or call to covered
In this scenario, you may want to contact the Department of Labor at 1-866-444-3272 to discuss your active duty status may use their 12-week leave entitlement to address certain qualifying exigencies.
options. Qualifying exigencies may include attending certain military events, arranging for alternative childcare,
Service Areas: Some plans limit their benefits to specific service or coverage areas so if you move to addressing certain financial and legal arrangements, attending certain counseling sessions, and attending
another area of the country, you may not be able to use your benefits. You may want to see if your plan post-deployment reintegration briefings.
has a service or coverage area, or other similar limitations. FMLA also includes a special leave entitlement that permits eligible employees to take up to 26 weeks of
Other Cost-Sharing: In addition to premiums or contributions for health coverage, you probably pay leave to care for a covered servicemember during a single 12-month period. A covered servicemember is:
copayments, deductibles, coinsurance, or other amounts as you use your benefits. You may want to (1) a current member of the Armed Forces, including a member of the National Guard or Reserves, who
check to see what the cost-sharing requirements are for other health coverage options. For example, one is undergoing medical treatment, recuperation or therapy, is otherwise in outpatient status, or is otherwise
option may have much lower monthly premiums, but a much higher deductible and higher copayments. on the temporary disability retired list, for a serious injury or illness (1); or (2) a veteran who was
discharged or released under conditions other than dishonorable at any time during the five-year period
For More Information prior to the first date the eligible employee takes FMLA leave to care for the covered veteran, and who is
undergoing medical treatment, recuperation, or therapy for a serious injury or illness. (1)
This notice doesnt fully describe continuation coverage or other rights under the plan. More information
about continuation coverage and your rights under the plan is available in your summary plan description Benefits & Protections
or from the Plan Administrator.
During FMLA leave, the employer must maintain the employee's health coverage under any "group health
If you have questions about the information in this notice, your rights to coverage, or if you want a copy of plan" on the same terms as if the employee had continued to work. Upon return from FMLA leave, most
your summary plan description, contact your Human Resources Representative. employees must be restored to their original or equivalent positions with equivalent pay, benefits, and
other employment terms.
For more information about your rights under the Employee Retirement Income Security Act (ERISA),
including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health Use of FMLA leave cannot result in the loss of any employment benefit that accrued prior to the start of
plans, visit the U.S. Department of Labors Employee Benefits Security Administration (EBSA) website at an employee's leave.
www.dol.gov/ebsa or call their toll-free number at 1-866-444-3272. For more information about health
insurance options available through the Health Insurance Marketplace, and to locate an assister in your Eligibility Requirements
area who you can talk to about the different options, visit www.healthcare.gov. Employees are eligible if they have worked for a covered employer for at least 12 months, have 1,250
Keep Your Plan Informed of Address Changes hours of service in the previous 12 months (2), and if at least 50 employees are employed by the employer
within 75 miles.
To protect your and your familys rights, keep the Plan Administrator informed of any changes in your
address and the addresses of family members. You should also keep a copy of any notices you send to Definition of Serious Health Condition
the Plan Administrator. A serious health condition is an illness, injury, impairment, or physical or mental condition that involves
Important Information about Payment either an overnight stay in a medical care facility, or continuing treatment by a health care provider for a
condition that either prevents the employee from performing the functions of the employee's job, or
First payment for continuation coverage. You must make your first payment for continuation coverage prevents the qualified family member from participating in school or other daily activities.
no later than 45 days after the date of your election (this is the date the Election Notice is postmarked). If Subject to certain conditions, the continuing treatment requirement may be met by a period of incapacity
you dont make your first payment in full no later than 45 days after the date of your election, youll lose all of more than 3 consecutive calendar days combined with at least two visits to a health care provider or
continuation coverage rights under the plan. Youre responsible for making sure that the amount of your one visit and a regimen of continuing treatment, or incapacity due to pregnancy, or incapacity due to a
first payment is correct. You may contact Human Resources to confirm the correct amount of your first chronic condition. Other conditions may meet the definition of continuing treatment.
payment.
(1)
The FMLA definitions of serious injury or illness for current servicemembers and veterans are distinct from the FMLA
definition of serious health condition
(2)
Special hours of service eligibility requirements apply to airline flight crew employees

Use of Leave What Happens if You do not Elect to Continue Coverage?
If you fail to submit a timely, completed Election Form as instructed or do not make a premium payment
An employee does not need to use this leave entitlement in one block. Leave can be taken intermittently
within the required time, you will lose your continuation rights under the Plan, unless compliance with
or on a reduced leave schedule when medically necessary. Employees must make reasonable efforts to
these requirements is precluded by military necessity or is otherwise impossible or unreasonable under
schedule leave for planned medical treatment so as not to unduly disrupt the employer's operations.
the circumstances.
Leave due to qualifying exigencies may also be taken on an intermittent basis.
If you do not elect continuation coverage, your coverage (and the coverage of your covered dependents,
Substitution of Paid Leave for Unpaid Leave if any) under the Plan ends effective the end of the month in which you stop working due to your leave for
uniformed service.
Employees may choose or employers may require use of accrued paid leave while taking FMLA leave. In
order to use paid leave for FMLA leave, employees must comply with the employer's normal paid leave Premium for Continuing Your Coverage
policies.
The premium that you must pay to continue your coverage depends on your period of service in the
Employee Responsibilities uniformed services. Contact Human Resources for more details.
Employees must provide 30 days advance notice of the need to take FMLA leave when the need is Length of Time Coverage Can Be Continued
foreseeable. When 30 days notice is not possible, the employee must provide notice as soon as
practicable and generally must comply with an employer's normal call-in procedures. If elected, continuation coverage can last 24 months from the date on which employee's leave for
uniformed service began. However, coverage will automatically terminate earlier if one of the following
Employees must provide sufficient information for the employer to determine if the leave may qualify for
events takes place:
FMLA protection and the anticipated timing and duration of the leave. Sufficient information may include
that the employee is unable to perform job functions; the family member is unable to perform daily A premium is not paid in full within the required time;
activities, the need for hospitalization or continuing treatment by a health care provider; or circumstances You fail to return to work or apply for reemployment within the time required under USERRA (see
supporting the need for military family leave. Employees also must inform the employer if the requested below) following the completion of your service in the uniformed services; or
leave is for a reason for which FMLA leave was previously taken or certified. Employees also may be
required to provide a certification and periodic recertification supporting the need for leave. You lose your rights under USERRA as a result of a dishonorable discharge or other conduct
specified in USERRA.
Employer Responsibilities We will not provide advance notice to you when your continuation coverage terminates.
Covered employers must inform employees requesting leave whether they are eligible under FMLA. If Reporting to Work / Applying for Reemployment
they are, the notice must specify any additional information required as well as the employees' rights and
responsibilities. If they are not eligible, the employer must provide a reason for the ineligibility. Your right to continue coverage under USERRA will end if you do not notify Human Resources of your
Covered employers must inform employees if leave will be designated as FMLA-protected and the intent to return to work within the timeframe required under USERRA following the completion of your
amount of leave counted against the employee's leave entitlement. If the employer determines that the service in the uniformed services by either reporting to work (if your uniformed service was for less than
leave is not FMLA protected, the employer must notify the employee. 31 days) or applying for reemployment (if your uniformed service was for more than 30 days). The time
for returning to work depends on the period of uniformed service, as follows:
Unlawful Acts by Employers
FMLA makes it unlawful for any employer to:
Period of Uniformed
Report to Work Requirement
Service
Interfere with, restrain, or deny the exercise of any right provided under FMLA;
Discharge or discriminate against any person for opposing any practice made unlawful by FMLA or for Less than 31 days The beginning of the first regularly scheduled work period
involvement in any proceeding under or relating to FMLA. on the day following the completion of your service, after
allowing for safe travel home and an eight-hour rest period,
Enforcement or if that is unreasonable or impossible through no fault of
An employee may file a complaint with the U.S. Department of Labor or may bring a private lawsuit your own, then as soon as is possible
against an employer. 31180 days Submit an application for reemployment within 14 days after
FMLA does not affect any Federal or State law prohibiting discrimination, or supersede any State or local completion of your service or, if that is unreasonable or
law or collective bargaining agreement which provides greater family or medical leave rights. impossible through no fault of your own, then as soon as is
possible
FMLA section 109 (29 U.S.C. 2619) requires FMLA covered employers to post the text of this notice.
Regulations 29 C.F.R. 825.300(a) may require additional disclosures. 181 days or more Submit an application for reemployment within 90 days after
For additional information: (866) 4US-WAGE ((866) 487-9243) TYY: (877) 889-5627 completion of your service
www.wagehour.dol.gov Any period if for purposes of an Report by the beginning of the first regularly scheduled work
examination for fitness to perform period on the day following the completion of your service,
Uniformed Services Employment & uniformed service after allowing for safe travel home and an eight-hour rest
period, or if that is unreasonable or impossible through no
Reemployment Rights Act Notice of 1994, fault of your own, as soon as is possible
Any period if you were hospitalized for Report or submit an application for reemployment as above
Notice of Right to Continued Coverage under or are convalescing from an injury or (depending on length of service period) except that time
illness incurred or aggravated as a periods begin when you have recovered from your injuries
USERRA result of your service or illness rather than upon completion of your service.
Maximum period for recovering is limited to two years from
completion of service but may be extended if circumstances
Right to Continue Coverage beyond your control make it impossible or unreasonable for
Under the Uniformed Services Employment & Reemployment Rights Act of 1994 (USERRA), you (the you to report to work within the above time periods
employee) have the right to continue the coverage that you (and your covered dependents, if any) had
under the Company Medical Plan if the following conditions are met: Definitions
You are absent from work due to service in the uniformed services (defined below); For you to be entitled to continued coverage under USERRA, your absence from work must be due to
You were covered under the Plan at the time your absence from work began; and service in the uniformed services.
You (or an appropriate officer of the uniformed services) provided your employer with advance notice Uniformed services means the Armed Forces, the Army National Guard, and the Air National Guard
of your absence from work (you are excused from meeting this condition if compliance is precluded by when an individual is engaged in active duty for training, inactive duty training, or full-time National
military necessity or is otherwise impossible or unreasonable under the circumstances). Guard duty (i.e., pursuant to orders issued under federal law), the commissioned corps of the Public
Health Service, and any other category of persons designated by the President in time of war or
How to Continue Coverage national emergency
If the conditions are met, you (or your authorized representative) may elect to continue your coverage Service in the uniformed services or service means the performance of duty on a voluntary or
(and the coverage of your covered dependents, if any) under the Plan by completing and returning an involuntary basis in the uniformed services under competent authority, including active duty, active
Election Form 60 days after date that USERRA election notice is mailed, and by paying the applicable and inactive duty for training, National Guard duty under federal statute, a period for which a person is
premium for your coverage as described below. absent from employment for an examination to determine his or her fitness to perform any of these
duties, and a period for which a person is absent from employment to perform certain funeral honors
duty. It also includes certain service by intermittent disaster response appointees of the National
Disaster Medical System (NDMS)

THE CHILDRENS HEALTH INSURANCE PROGRAM
(CHIP) PREMIUM ASSISTANCE SUBSIDY NOTICE
Premium Assistance under Medicaid and the Childrens Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and youre 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 arent eligible for Medicaid or CHIP, you wont 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, you can contact your State Medicaid or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, you can contact your State Medicaid
or CHIP office or dial (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
arent already enrolled. This is called a special enrollment opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions
about enrolling in your employer plan, you can contact the Department of Labor at www.askebsa.dol.gov or call (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 January 31, 2015.
Contact your State for more information on eligibility.
ALABAMA Medicaid MINNESOTA Medicaid PENNSYLVANIA Medicaid

Website: www.dhs.state.mn.us/
Website: www.myalhipp.com Website: www.dpw.state.pa.us/hipp
Click on Healthcare, then Medical Assistance
Phone: (855) 692-5447 Phone: (800) 692-7462
Phone: (800) 657-3629
ALASKA Medicaid MISSOURI Medicaid RHODE ISLAND Medicaid
Website: health.hss.state.ak.us/dpa/programs/medicaid/ Website: Website: www.ohhs.ri.gov
Phone (outside of Anchorage): (888) 318-8890 www.dss.mo.gov/mhd/participants/pages/hipp.htm Phone: (401) 462-5300
Phone (Anchorage): (907) 269-6529 Phone: (573) 751-2005
COLORADO Medicaid MONTANA Medicaid SOUTH CAROLINA Medicaid
Website: www.colorado.gov/hcpf Website: Medicaid.mt.gov/member Website: www.scdhhs.gov
Phone (in-state): (800) 866-3513 Phone: (800) 694-3084 Phone: (888) 549-0820
Phone (out-of-state): (800) 221-3943
FLORIDA Medicaid NEBRASKA Medicaid SOUTH DAKOTA Medicaid
Website: https://www.flmedicaidtplrecovery.com/ Website: www.accessnebraska.ne.gov Website: dss.sd.gov
Phone: (877) 357-3268 Phone: (855) 632-7633 Phone: (888) 828-0059
GEORGIA Medicaid NEVADA Medicaid TEXAS Medicaid
Website: dch.georgia.gov/ Medicaid Website: dwss.nv.gov/ Website: https://www.gethipptexas.com/
Click on Programs, then Medicaid, then Health Insurance Medicaid Phone: (800) 992-0900 Phone: (800) 440-0493
Premium Payment (HIPP)
Phone: (800) 869-1150
INDIANA Medicaid NEW HAMPSHIRE Medicaid UTAH Medicaid and CHIP
Website: www.in.gov/fssa Website: www.dhhs.nh.gov/oii/documens/hippapp.pdf Medicaid Website: health.utah.gov/upp
Phone: (800) 889-9949 Phone: (603) 271-5218 CHIP Website: health.utah.gov/chip
Phone: (866) 435-7414
IOWA Medicaid NEW JERSEY Medicaid and CHIP VERMONT Medicaid
Website: www.dhs.state.ia.us/hipp/ Medicaid Website: Website: www.greenmountaincare.org/
Phone: (888) 346-9562 www.state.nj.us/humanservices/dmahs/clients/medicaid/ Phone: (800) 250-8427
Medicaid Phone: (609) 631-2392
CHIP Website: www.njfamilycare.org/index.html
CHIP Phone: (800) 701-0710
KANSAS Medicaid NEW YORK Medicaid VIRGINIA Medicaid and CHIP
Website: www.kdheks.gov/hcf/ Website: www.nyhealth.gov/health_care/medicaid/ Medicaid Website: www.dmas.virginia.gov/rcp-
Phone: (800) 792-4884 Phone: (800) 541-2831 hipp.htm
Medicaid Phone: (800) 432-5924
CHIP Website: http://www.covera.org/programs_
premium_assistance.cfm
CHIP Phone: (855) 242-8282
KENTUCKY Medicaid NORTH CAROLINA Medicaid WASHINGTON Medicaid
Website: www.hca.wa.gov/medicaid/premiumpymt/
Website: chfs.ky.gov/dms/default.htm Website: www.ncdhhs.gov/dma
pages/index.aspx
Phone: (800) 635-2570 Phone: (919) 855-4100
Phone: (800) 562-3022 ext. 15473
LOUISIANA Medicaid NORTH DAKOTA Medicaid WEST VIRGINIA Medicaid
Website: www.lahipp.dhh.louisiana.gov Website: www.nd.gov/dhs/services/medicalserv/medicaid/ Website: www.dhhr.wv.gov/bms/
Phone: (888) 695-2447 Phone: (800) 755-2604 Phone: (877) 598-5820, HMS Third Party Liability
MAINE Medicaid OKLAHOMA Medicaid and CHIP WISCONSIN Medicaid
Website:
www.maine.gov/dhhs/ofi/public-assistance/index.html Website: www.insureoklahoma.org Website: www.badgercareplus.org/pubs/p-10095.htm
Phone: (800) 977-6740 Phone: (888) 365-3742 Phone: (800) 362-3002
TTY: (800) 977-6741
MASSACHUSETTS Medicaid and CHIP OREGON Medicaid WYOMING Medicaid
Website: www.oregonhealthykids.gov
Website: www.mass.gov/masshealth Website: health.wyo.gov/healthcarefin/equalitycare
www.hijossaludablesoregon.gov
Phone: (800) 462-1120 Phone: (307) 777-7531
Phone: (800) 699-9075
To see if any other States have added a premium assistance program since January 31, 2015, or for more information on special enrollment rights, contact either:
U.S. Department of Labor U.S. Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare & Medicaid Services
www.dol.gov/ebsa www.cms.hhs.gov
(866) 444-EBSA (3272) (877) 267-2323, Menu Option 4, ext. 61565
OMB Control Number 1210-0137 (expires 10/31/2016

DIRECTORY & RESOURCES
Below, please find important contact information and resources for AHS.
Information Regarding Group / Policy # Contact Information

Enrollment & Eligibility
Enroll or view health plan 510.346.7557 Human Resources - Benefits
selections 15400 Foothill Blvd., Bldg. C
Add / delete dependents, etc. San Leandro, CA 94578
http://ahs-rwc-webapp1/wordpress/
Medical Coverage
Kaiser Permanente Kaiser Permanente #603140 800.464.4000 www.kp.org
HealthComp Administrators
AHS Freedom of Choice Plan & Group #G60
HSA-Independence Plan Anthem Group Numbers: 800.442.7247 www.healthcomp.com
Customer Service / Claims CA Freedom Plan
PPO Network Information #278149MOO1 800.688.3828 www.anthem.com/ca
Non CA Freedom Plan
#278149M002
CA Independence Plan Single
EE #278149M003
Non CA Independence Plan
Single EE
#278149M004
CA Independence Plan Family
#248149M005
Non CA Independence Plan
Family
#278149M006
Pharmacy Coverage for AHS
Plans
WellDyneRx PPO: G60PPO
HSA Single: G60HDS
888.479.2000 www.myWDRX.com
HSA Family: G60HDF
Dental Coverage
How do I find a provider Delta PPO #5732 800.765.6003 www.deltadentalins.com
Verify coverage for procedure
Check status of claim DeltaCare USA #6364 800.422.4234 www.deltadentalins.com
Vision Coverage
How do I use the plan VSP #30015775 800.877.7195 www.vsp.com
What is covered
Life, AD&D and Disability
Basic Life/AD&D Insurance Point 800.583.1571 www.insurancepoint.com
Voluntary Life Life #GL668942
LTD AD&D #VAR672921
LTD #LTD669905

DIRECTORY & RESOURCES
HSA & Flexible Spending Account
What is eligible for reimbursement CBA 800.574.5448 customerservice@cbadministrators.com
Claim Status / Account Balance PO Box 2170 916.303.7090 www.cbadministrators.com
Flex System Claim Card Rocklin, CA 95677
Employee Assistance Plan
24-hour Crisis Hotline MHN #8561 800.227.1060 http://mhn.advantageengagement.com
Get referrals for face-to-face
counseling sessions
Voluntary Benefits
Critical Illness MetLife #142986 800.438.6388 www.metlife.com
Pet Insurance
Auto / Home Insurance
Long Term Care Insurance
How to enroll in the plan Unum #205740 001 877.286.2852 www.myltcguide.com/ahs
What is covered Unum #205740 002
Claim status
LegalShield
Customer Service Inquiries Member Services 800.654.7757 www.legalshield.com/info/alamedahealth
24-Hour Emergency Access

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2016 Big Ahs Final

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2016 Big Ahs Final

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CONTENTS

Eligibility & Enrollment 5

Health Savings Account (HSA) 19

Flexible Spending Account (FSA) 26

Life and AD&D Coverage 30

Employee Assistance Program (EAP) 34

The Cost of Coverage 35

Plan Guidelines / Evidence of Coverage 36

Legal Information Regarding Your Plans 38

Medicare Part D Notice 37

The Open Enrollment period is October 19 November 25, 2015!

NEW THIS YEAR!!

We wish you and your family a healthy and happy 2016.

Benefits Information Guide 3

Health Fairs & Enrollment Guidance

October 19, 2015 7:30 am 3 pm San Leandro Hospital, Education Center

Who Can Enroll

When Coverage Begins

Eligibility Date Benefit Plan

Benefits Information Guide 5

Paying for Coverage

Share the Savings Stipend

6 Alameda Health System

Duplicate Coverage Rule

Changes during the Year

Birth or adoption of a child https://lawpa.c101.netaspx.com/lawson/portal/i

Click on Open Enrollment to begin.

Benefits Information Guide 7

Your Medical Plan Option(s)

Using a PPO Plan

Using the HSA Plan

Using an HMO Plan

Benefits Information Guide 9

10 Alameda Health System

Selecting a Plan thats Right for You

Benefits Information Guide 11

12 Alameda Health System

When can I use LiveHealth Online?

When you need care now

Get the care you need Start a conversation now!

Benefits Information Guide 13

14 Alameda Health System

Benefits Information Guide 15

16 Alameda Health System

Benefits Information Guide 17

18 Alameda Health System

Qualifying for an HSA

Benefits Information Guide 19

Contributing to the HSA

Contribution Amounts Important Contribution Information

20 Alameda Health System

Using HSA Funds

Benefits Information Guide 21

Using HSA Funds (continued)

Year 1: Amanda started with $2,500 in her HSA. Year 1

Additional HSA Information

22 Alameda Health System

Your Dental Plan Options

Using the Plan

Helpful Dental Hints

For the Dental HMO, refer to your Evidence

To find an in-network dentist, go to

Benefits Information Guide 23

24 Alameda Health System