Benefits Brochure 2017 PDF2

2017Summary of Employee Benefits 1

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Table of ContentsInsurance Carrier Informa on…………………..………………….……………4Medical Plan………………………………………………...……………….……….6-7Health Reimbursement Account……………..…………………….………….8Dental Plan…………………………………………………………………….………...9Vision Plan…………………………………………..……………...…………….10-11Basic Life Insurance and AD&D Benefits………………...……………….12Voluntary Life Insurance and AD&D Benefits…………..……………..13New York State Statutory Disability…………………………….………....14Long Term Disability…………………………………………………….………...15Flexible Spending & Dependent Care Account…………………..16-17401(k) Plan……………………………………………………………………………..18Employee Assistance Program………………………………………………..19 3

Independent Healthwww.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/re rementplansPlan # 097545Customer Service—(800)523-1188 4

MetLife DentalGroup # 5941621MetLife VisionGroup # 5941621MetLife Basic & Voluntary Lifewww.guardianany me.comGroup # 494128Customer Service—(800)525-4542Group Long Term Disabilitywww.guardianany me.comGroup # 494128Customer Service—(800)538-4583 5

Medical InsuranceCoverage Cost per paycheck Annual CostSingleFamily $5.00 $120.00 $241.69 $5800.56 Passport Plan Select– 32823 In-Network BenefitsDeduc ble $1,000/$2,000Out-of-pocket Max $3,000/$6,000Primary Office Visit $25 copay/visitSpecialist Office Visit $25 copay/visitTelemedicine Program $10 copay/consulta onLaboratory Tes ng $0 copay/visitEmergency Room Deduc ble then 20% coinsuranceAmbulance Deduc ble then 20% coinsuranceUrgent Care Center $75 copay/visitInpa ent Hospital Deduc ble then 20% coinsuranceOutpa ent Surgical Procedures 20% coinsuranceRou ne Radiology 20% coinsurancePhysician prenatal and postnatal care $0 copay/visitInpa ent Maternity Delivery: Deduc ble then 20% coinsur-PT/OT/Speech 20% coinsurancePrescrip on Drug Tiers $10/$30/$50Addi onal Benefits $250 Wellness card 6

Medical InsuranceCoverage Cost per paycheck Annual CostSingleFamily $2.00 $48.00 $150.00 $3600.00 iDirect 1 Series C– 32823 In-Network BenefitsDeduc ble $1,500/$3,000Out-of-pocket Max $5,000/$10,000Primary Office Visit Deduc ble then $20 copay/visitSpecialist Office Visit Deduc ble then $20 copay/visitTelemedicine Program $10 copay/consulta onLaboratory Tes ng Deduc ble then $0 copay/visitEmergency Room Deduc ble then $125 copay/visitAmbulance Deduc ble then $25 copay/tripUrgent Care Center Deduc ble $75 copay/visitInpa ent Hospital Deduc ble then $750 copay/admissionOutpa ent Surgical Procedures Deduc ble then $150 copay/visitRou ne Radiology Deduc ble then $20 copay/visitPhysician prenatal and postnatal care $0 copay/visitInpa ent Maternity Delivery: Deduc ble then $750 copayPT/OT/Speech Deduc ble then $15 copay/visitPrescrip on Drug Tiers $10/$30/$75Addi onal Benefits $250 Wellness card 7

Health Reimbursement AccountCoverage AmountSingle iDirect $750Single Passport $375Family iDirect $1500Family Passport $750Employees who enroll in Summit’s Independent Health medical plan willautoma cally receive a Health Reimbursement Account (HRA) adminis-tered by HealthNow Administra ve Services Employees will receive a debit card that can be used for out of pocket medical expenses—prescrip ons, copays, etc. Unused funds rollover into next year Save your receipts—you may need to verify your purchases as per IRS regula ons 8

Dental InsuranceCoverage Cost per paycheck Annual CostSingleFamily FREE FREE $19.25 $462.00Services In-network Out-of-network coverage coveragePreven ve Services (Cleanings,fluoride under age 14, sealants, x- 100% 100%Basic care (Fillings, periodontal 90% 80%maintenance, root canal)Major Care (bridges, dentures, sin- 60% 50%gle crowns) 50%Orthodon a (life me max $2,000) 50% $50—single $150—familyDeduc ble None $1,250 26Annual Maximum BenefitDependent Age Limit 9

Vision Insurance—High Op onCoverage Cost per paycheck Annual CostSingleFamily $5.30 $127.20 $12.45 $298.80Services In-network BenefitsExams Copay $10 copaySingle Vision, bifocal, trifo- Covered in full a er $10 eyewear copaycal and len cular lensesFrames $130 Allowance a er $10 eyewear copay *You will receive an addi onal 20% savings on the amount you pay over your allowanceContact Lenses $130 Allowance(instead of eye glasses) Covered in full with max copay of $60Contact lens fi ngService Frequencies Every calendar year 10

Vision Insurance—Low Op onCoverage Cost per paycheck Annual CostSingleFamily $3.38 $81.12 $7.94 $190.56Services In-network BenefitsExams Copay $20 copaySingle Vision, bifocal, trifo- Covered in full a er $20 eyewear copaycal and len cular lensesFrames $100 Allowance a er $20 eyewear copay *You will receive an addi onal 20% savings on the amount you pay over your allowanceContact Lenses $100 Allowance(instead of eye glasses) Covered in full with max copay of $60Contact lens fi ngService Frequencies Every calendar year 11

Basic Life and AD&DEmployer provided benefit for all full me employees—no cost to employees.What your Benefits Cover: Basic LifeEmployee Benefit 150% of your annual salary, to a max of $200,000Accidental Death and Dis- Basic life coverage includes Accidental Deathmemberment and Dismemberment coverage equal to one mes to employee’s life benefits.Guarantee Issue You are not required to answer health ques- ons to qualify for coverage. 12

Voluntary Term LifeCost is based on employee’s age and volume of life insuranceWhat your Benefits Cover: Voluntary Term LifeEmployee Benefit $10,000 increments to a maximum of $500,000Accidental Death and Dis- Enhanced employee, spouse, and child(ren)memberment coverage. Maximum 1 mes life amountSpouse/Domes c Partner $5,000 increments to a maximum of $100,000BenefitChild Benefit Your dependent children age 14 days to 20 years (26 if full me student) $1,000 incre- ments to a maximum of $10,000. 13

Short-Term DisabilityEmployer provided benefit for all employees—no cost to employees.What your Benefits Cover: Short-term DisabilityCoverage Amount 50% of earnings up to $170/week for 26 weeksBenefits Begin A er day 7 of being disabled*You will receive benefit payments while you are unable to work in your job 14

Long-Term DisabilityEmployer provided benefit for all full me employees—no cost to employees.What your Benefits Cover: Long-Term DisabilityCoverage Amount 66.7% of salary to maximum $4000/monthBenefits BeginPre-exis ng condi ons A er day 181 of being disabled A pre-exis ng condi on includes any condi on/ symptom for which you, in the specified me period prior to coverage in this plan, consulted with a physician, received treatment, or took prescribed drugs. 3 Months look back; 12 months a er limita on *You will receive benefit payments while you are unable to work in your jobTypically employees are on Short-term disability prior to receiving LTD benefits 15

Dependent Care Spending AccountEmployees can choose to make pre-tax deduc ons out of their paycheck to pay for daycare expenses What your Benefits Cover: Dependent CareAmount Annual maximum $5000Rollover Unused funds do not rolloverContribu ons Must contribute to the plan before reques ng reimbursement *Daycare provider must have a tax ID number 16

Flexible Spending AccountEmployees can choose to make pre-tax deduc ons out of their paycheck to pay for unreimbursed medical expenses What your Benefits Cover: FSAAmount Maximum $2600 plan yearRollover Up to $500 of funds can rollover in to the nextContribu ons plan year. Anything above that amount will be forfeited Employee makes contribu ons each paycheck but total dollar amount is received up front 17

401(k)Eligibility 21+ years oldDeferral Amounts Comple on of 6 months of serviceAnnual Maximum 1—60% of salaryEmployer MatchVes ng Schedule $18,000 Dollar for dollar up to 4% Employer Match—immediately Profit Sharing—3 years of serviceAt the discre on of the agency, a profit sharing contribu on is made toyour 401(k) re rement account on an annual basis. To be eligible you must be 21, complete 6 months and 1000 hours of service. 18

Employee Assistance Program Phone—1-800-511-3920 Website—www.members.mhn.com Company Code: metlifeeap1The Employee Assistance program is a free benefit providing guidancefor personal issues that you might be facing and informa on about otherconcerns that affect your life, whether it’s a life event or on a day-to-daybasis. EAP offers help with:Educa on: Dependent Care & Care Giving: Admissions tes ng & procedures  Adop on Assistance Adult re-entry programs  Before/a er school programs College planning  Day Care/Elder Care Financial aid resources  In-home servicesLifestyle & Fitness Management: Legal and Financial: Anxiety & depression  Basic tax planning Divorce & separa on  Credit & collec ons Drugs & alcohol  Debt counseling  Home buying  Immigra on Working Smarter:  Career development  Effec ve Managing  Reloca on 19

Pet InsurancePet insurance reimburses you for vet bills when your pet is sick orinjured, to help take the financial worry out of vet visits.Employees receive up to a 10% discount for pet insurance. Ratesare based on breed and age.Get an instant quote at: www.petsbest.com/summitpet or call 888-984-8700 and reference code SUMMITPET 20

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For ques ons regarding benefits, please contact: Ka e Harris Benefits Administrator at 629-3465 or [email protected] 23

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