Benefits Brochure 2017 PDF

2017 Summary of Employee Benefits24 1

For questions regarding benefits, please contact: Katie Harris Benefits Administrator at 629-3465 or [email protected] 23

Table of Contents Insurance Carrier Information…………………..………………….……………4 Medical Plan………………………………………………...……………….……….6-7 Health Reimbursement Account……………..…………………….………….8 Dental Plan…………………………………………………………………….………...9 Vision Plan…………………………………………..……………...…………….10-11 Basic Life Insurance and AD&D Benefits………………...……………….12 Voluntary Life Insurance and AD&D Benefits…………..……………..13 New York State Statutory Disability…………………………….………....14 Long Term Disability…………………………………………………….………...15 Flexible Spending & Dependent Care Account…………………..16-17 401(k) Plan……………………………………………………………………………..18 Employee Assistance Program………………………………………………..1922 3

Independent Health 21www.independenthealth.comGroup # 32823Customer Service: 716-631-8701Health Reimbursement AccountGroup # BCII55www.mywealthcareonline.com/myhnasCustomer Service—(800)518-8332Flexible Spending/Dependent Care AccountGroup # BCII55www.mywealthcareonline.com/myhnasCustomer Service—(800)518-8332401(k) - Vanguardwww.vanguard.com/retirementplansPlan # 097545Customer Service—(800)523-1188 4

Pet Insurance MetLife Dental Group # 5941621Pet insurance reimburses you for vet bills when your pet is sick orinjured, to help take the financial worry out of vet visits. MetLife VisionEmployees receive up to a 10% discount for pet insurance. Rates Group # 5941621are based on breed and age.Get an instant quote at: www.petsbest.com/summitpet or MetLife Basic & Voluntary Life www.guardiananytime.com call 888-984-8700 and reference code SUMMITPET Group # 494128 Customer Service—(800)525-4542 Group Long Term Disability www.guardiananytime.com Group # 494128 Customer Service—(800)538-458320 5

Medical InsuranceCoverage Cost per paycheck Annual Cost Employee Assistance ProgramSingleFamily $5.00 $120.00 Phone—1-800-511-3920 $241.69 $5800.56 Website—www.members.mhn.com Company Code: metlifeeap1 Passport Plan Select– 32823 The Employee Assistance program is a free benefit providing guidance In-Network Benefits for personal issues that you might be facing and information about other concerns that affect your life, whether it’s a life event or on a day-to-dayDeductible $1,000/$2,000 basis.Out-of-pocket Max $3,000/$6,000Primary Office Visit $25 copay/visit EAP offers help with:Specialist Office Visit $25 copay/visitTelemedicine Program $10 copay/consultation Education: Dependent Care & Care Giving:Laboratory Testing $0 copay/visitEmergency Room Deductible then 20% coinsurance  Admissions testing & procedures  Adoption AssistanceAmbulance Deductible then 20% coinsuranceUrgent Care Center $75 copay/visit  Adult re-entry programs  Before/after school programsInpatient Hospital Deductible then 20% coinsuranceOutpatient Surgical Procedures 20% coinsurance  College planning  Day Care/Elder CareRoutine Radiology 20% coinsurancePhysician prenatal and postnatal care $0 copay/visit  Financial aid resources  In-home servicesInpatient Maternity Delivery: Deductible then 20% coinsur-PT/OT/Speech 20% coinsurance Lifestyle & Fitness Management: Legal and Financial:Prescription Drug Tiers $10/$30/$50Additional Benefits $250 Wellness card  Anxiety & depression  Basic tax planning 6  Divorce & separation  Credit & collections  Drugs & alcohol  Debt counseling  Home buying  Immigration Working Smarter:  Career development  Effective Managing  Relocation 19

Medical Insurance 401(k) Coverage Cost per paycheck Annual Cost SingleEligibility 21+ years old Family $2.00 $48.00Deferral Amounts Completion of 6 months of service $150.00 $3600.00Annual Maximum 1—60% of salaryEmployer Match iDirect 1 Series C– 32823Vesting Schedule $18,000 In-Network Benefits Dollar for dollar up to 4% Deductible $1,500/$3,000 Out-of-pocket Max $5,000/$10,000 Employer Match—immediately Primary Office Visit Deductible then $20 copay/visit Profit Sharing—3 years of service Specialist Office Visit Deductible then $20 copay/visit Telemedicine Program $10 copay/consultationAt the discretion of the agency, a profit sharing contribution is made to Laboratory Testing Deductible then $0 copay/visityour 401(k) retirement account on an annual basis. To be eligible you Emergency Room Deductible then $125 copay/visit Ambulance Deductible then $25 copay/trip must be 21, complete 6 months and 1000 hours of service. Urgent Care Center Deductible $75 copay/visit Inpatient Hospital Deductible then $750 copay/admission Outpatient Surgical Procedures Deductible then $150 copay/visit Routine Radiology Deductible then $20 copay/visit Physician prenatal and postnatal care $0 copay/visit Inpatient Maternity Delivery: Deductible then $750 copay PT/OT/Speech Deductible then $15 copay/visit Prescription Drug Tiers $10/$30/$75 Additional Benefits $250 Wellness card 18 7

Health Reimbursement AccountCoverage Amount Flexible Spending AccountSingle iDirect $750Single Passport $375 Employees can choose to make pre-tax deductions out of their paycheck to payFamily iDirect $1500 for unreimbursed medical expensesFamily Passport $750 What your Benefits Cover: FSAEmployees who enroll in Summit’s Independent Health medical plan will Amount Maximum $2600 plan yearautomatically receive a Health Reimbursement Account (HRA) adminis- Rollovertered by HealthNow Administrative Services Up to $500 of funds can rollover in to the next Contributions plan year. Anything above that amount will be Employees will receive a debit card that can be used for out of pocket forfeited medical expenses—prescriptions, copays, etc. Employee makes contributions each paycheck Unused funds rollover into next year but total dollar amount is received up front Save your receipts—you may need to verify your purchases as per IRS regulations 8 17

Dental Insurance Dependent Care Spending Account Coverage Cost per paycheck Annual Cost SingleEmployees can choose to make pre-tax deductions out of their paycheck to pay for Family FREE FREE daycare expenses $19.25 $462.00 What your Benefits Cover: Dependent CareAmount Annual maximum $5000Rollover Unused funds do not rollover Services In-network Out-of-networkContributions coverage coverage Must contribute to the plan before requesting Preventive Services (Cleanings, reimbursement fluoride under age 14, sealants, x- 100% 100% *Daycare provider must have a tax ID number Basic care (Fillings, periodontal 90% 80% maintenance, root canal) Major Care (bridges, dentures, sin- 60% 50% gle crowns) 50% Orthodontia (lifetime max $2,000) 50% $50—single $150—family Deductible None $1,250 26 Annual Maximum Benefit Dependent Age Limit 16 9

Vision Insurance—High Option Long-Term DisabilityCoverage Cost per paycheck Annual Cost Employer provided benefit for all full time employees—no cost to employees.SingleFamily $5.30 $127.20 What your Benefits Cover: Long-Term Disability $12.45 $298.80Services In-network Benefits Coverage Amount 66.7% of salary to maximum $4000/month Benefits BeginExams Copay $10 copay Pre-existing conditions After day 181 of being disabledSingle Vision, bifocal, trifo- Covered in full after $10 eyewear copay A pre-existing condition includes any condition/cal and lenticular lenses symptom for which you, in the specified time period prior to coverage in this plan, consultedFrames $130 Allowance after $10 eyewear copay with a physician, received treatment, or took prescribed drugs. *You will receive an additional 20% savings on 3 Months look back; 12 months after limitation the amount you pay over your allowanceContact Lenses $130 Allowance *You will receive benefit payments while you are unable to work in your job(instead of eye glasses) Covered in full with max copay of $60 Typically employees are on Short-term disability prior to receiving LTD benefitsContact lens fittingService Frequencies Every calendar year 10 15

Short-Term Disability Vision Insurance—Low OptionEmployer provided benefit for all employees—no cost to employees. Coverage Cost per paycheck Annual Cost SingleWhat your Benefits Cover: Short-term Disability Family $3.38 $81.12 $7.94 $190.56Coverage Amount 50% of earnings up to $170/week for 26 weeksBenefits Begin After day 7 of being disabled Services In-network Benefits Exams Copay $20 copay*You will receive benefit payments while you are unable to work in your job Single Vision, bifocal, trifo- Covered in full after $20 eyewear copay cal and lenticular lenses Frames $100 Allowance after $20 eyewear copay *You will receive an additional 20% savings on the amount you pay over your allowance Contact Lenses $100 Allowance (instead of eye glasses) Covered in full with max copay of $60 Contact lens fitting Service Frequencies Every calendar year 14 11

Basic Life and AD&D Voluntary Term LifeEmployer provided benefit for all full time employees—no cost to employees. Cost is based on employee’s age and volume of life insuranceWhat your Benefits Cover: Basic Life What your Benefits Cover: Voluntary Term LifeEmployee Benefit 150% of your annual salary, to a max of Employee Benefit $10,000 increments to a maximum of $500,000 $200,000 Accidental Death and Dis- Enhanced employee, spouse, and child(ren)Accidental Death and Dis- Basic life coverage includes Accidental Death memberment coverage. Maximum 1 times life amountmemberment and Dismemberment coverage equal to one times to employee’s life benefits. Spouse/Domestic Partner $5,000 increments to a maximum of $100,000Guarantee Issue You are not required to answer health ques- Benefit tions to qualify for coverage. Child Benefit Your dependent children age 14 days to 20 years (26 if full time student) $1,000 incre- ments to a maximum of $10,000. 12 13