2015 BENEFIT PLAN OPEN ENROLLMENT

Open Enrollment Period November 10 – December 3

Table of Contents 2015 Open Enrollment Checklist 3

• Benefit Fair: November 7, 2014 • Online Open Enrollment Process • Resources and Information

Benefit Information Session Schedule 4

2015 Open Enrollment: Overview of Benefit Plans 6

Open Enrollment Questions 10

Appendices (UltiPro Logon Instructions, 2015 Rates, Summary of Medical Plan Coverage) 12-15

Online Open Enrollment

Open Enrollment for 2015 will be online through the UltiPro HR Payroll System. From SaraNet, click on Employee Center

and then UltiPro HR Payroll. Now, you also can access UltiPro from the Saratoga Hospital website on the “For

Employee” tab at www.saratogahospital.org

2015 OPEN ENROLLMENT CHECKLIST

It All Starts with the Benefit Fair on Friday, November 7th: Hospital Cafeteria 7 a.m. – 4 p.m.

Representatives from many of the benefit plans will be on site to discuss the plans and answer your questions.

• CDPHP • Delta Dental • Davis Vision • Unum Insurance Co. (supplemental term life, voluntary short and long term disability) • Morgan Stanley (Service Provider Retirement Plan of Saratoga Hospital) • AFLAC (cancer and critical care indemnity plan, accident indemnity plan) • New York Life (whole life insurance) • Liberty Mutual • LifeTime Benefit Solutions (flex spending account administrator previously called EBS)* • EnvisionRxOptions* • MetLaw (Hyatt Legal)*

* No representative in attendance. Informational packets available.

What’s New For 2015 Open Enrollment?

• Open enrollment will be done online through UltiPro. With few exceptions, the open enrollment process will be paperless.

Help and Information are Available in Human Resources, on SaraNet and on the Saratoga Hospital Website (www.saratogahospital.org)

• Information on all benefit Plans • Domestic Partner application paperwork (required if you are adding a domestic partner) • COBRA information - If you are enrolling for the first time you will need to sign and acknowledge

receipt of this information. • Unum Voluntary Long Term Disability, Short Term Disability and Supplemental Term Life Evidence of

Insurability Forms • Help with access to UltiPro for completing the on-line open enrollment process

2015 Open Enrollment Benefit Information Session Schedule

A number of benefit information sessions have been scheduled to provide opportunities for you to ask questions or receive assistance in completing

the online enrollment.

Date Time Location

Monday, November 10 8 a.m. – 12 p.m. Hospital Computer Training Room

Tuesday, November 11 4 – 8 p.m. HR Conference Room

Friday, November 14 3 – 4 p.m. Hospital Computer Training Room

Saturday, November 15th 9 a.m. – 1 p.m. HR Conference Room

Monday, November 17th 4 – 8 p.m. HR Conference Room

Thursday, November 20 12 – 4 p.m. 4 – 8 p.m.

Hospital Computer Training Room HR Conference Room

Friday, November 21 3 – 4 p.m. Hospital Computer Training Room

Saturday, November 22 9 a.m. – 1 p.m. HR Conference Room

Monday, November 24 3 p.m. – 4 p.m. 4 – 8 p.m.

Hospital Computer Training Room HR Conference Room

Tuesday, November 25 9 a.m. – 12 p.m. 4 – 8 p.m.

Hospital Computer Training Room HR Conference Room

Friday, November 28 7 – 9 a.m. Hospital Computer Training Room

Monday, December 1 4 – 8 p.m. HR Conference Room

Tuesday, December 2 4 – 8 p.m. HR Conference Room

Saratoga Hospital 2015 Open Enrollment: The Year Ahead

Saratoga Hospital is committed to providing you with benefits that promote health and well-being as part of a total compensation and benefit package. Our goal is to offer a wide range of benefits to meet the needs of you and your family.

Open enrollment is the once-a-year opportunity for you to review your current benefit coverage, make changes, add or drop dependents and re-elect a flex spending account. The only other time that you can make these changes during the year is when you experience a qualifying event (birth of a child, marriage, divorce or change of employment status for you or your spouse).

It all Starts with the Benefit Fair: November 7th 7:00 a.m. - 4:00 p.m. Open enrollment begins with the Benefit Fair on November 7th in the Hospital Cafeteria. Representatives from CDPHP, AFLAC, Unum, Delta Dental, Davis Vision, Morgan Stanley and New York Life will be on hand to review their benefit programs and answer any questions you might have. Information will also be available on Metlaw, LifeTime Benefit Solutions Flex Spending and the hospital’s prescription drug plan through Envision RxOptions.

What to Expect in 2015 We will continue to offer a wide range of benefit programs this year. The biggest change this year will be with the open enrollment process itself. With just a few exceptions, all open enrollment will be completed online through the UltiPro HR Payroll system.

Online Open Enrollment through the UltiPro HR System You can now access UltiPro three different ways:

1. From Inside the Hospital… Go to SaraNet. Go to the Employee Center. Find UltiPro on the drop down menu and click. This will bring you to the UltiPro home page.

2. A New Option! Go to the Saratoga Hospital web page at www.saratogahospital.org. Find the “For Employees” button at the top of the home page. Click. This will bring you to a new page that provides a link to UltiPro, a link to Healthstream and a place where all benefit information will be posted for Open Enrollment. This will work on a computer either inside or outside of the hospital.

3. Enter Web address directly. You can enter the web address for UltiPro https://e22.ultipro.com into a web browser. This will work on a computer either inside or outside of the hospital.

To get ready for open enrollment, make sure you have successfully logged into UltiPro, created your unique password and reviewed your current benefit elections. If you haven’t done this already, instructions for logging into UltiPro can be found in Appendix A of this guide.

Your current benefit elections are summarized In the Current Benefits section of your UltiPro account. From your personal UltiPro home page, click on the Current Benefits box. Take a few minutes to review your current coverage and election of benefits. If you do not plan on making any changes to your current benefits, you don’t have to take any action. You will be automatically enrolled in the same benefits at the same coverage in 2015 with the applicable rates for 2015.Exceptions: If you want to continue a Flex Spending Account; Dependent Care or Medical Reimbursement, you must elect a new amount. Your current election will not roll over to 2015. In addition, if you are a full time employee and do not participate in the hospital’s medical insurance, you can elect to receive the 2015 waiver credit through open enrollment.

2015 Benefit Plans Overview

NEW!

Medical Plan (CDPHP) The medical plan will continue to be administered by CDPHP. The plan design remains the same with a few changes. The changes include the following:

• For patients of Saratoga Family Physicians (SFP), there will no longer be a copayment for office visits. • The copayment for Emergency Room Visits at Saratoga Hospital will increase to $100.00.

The plan will continue to waive office visit copayments for Saratoga Hospital employed physicians (Saratoga Regional Medical Group; also referred to as the Domestic Network in the plan). The Domestic Network of Saratoga Hospital employed physicians has continued to grow, adding cardiologists, an additional pulmonologist, additional primary care physicians and general surgeons, and a neurologist in 2014. Additional physician recruitment is expected in 2015 as well. Prescription Plan (EnvisionRxOptions) The hospital will continue to provide prescription coverage through EnvisionRxOptions. The copays for generic, brand and non-preferred brand remain the same at $5.00/$35.00/$50.00 respectively. The deductible for specialty drugs remains at 25% with the out of pocket maximum the same as last year, $150.00. Dental Plan The hospital will continue to offer two dental options; preventive and comprehensive. The annual yearly maximum benefit remains at $1,500 per individual. You may change your plan (comprehensive to preventive or vice versa) during this open enrollment only if you have been enrolled in your current plan for two years. The 2015 rates for Medical, Prescription, Dental and Vision can be found in Appendix B of this Guide. Retirement Plan of Saratoga Hospital In 2015, the hospital will make a non-elective (core) contribution of 2.75% to all eligible employees who are enrolled in the plan and have worked 975 hours in 2014. In addition, a matching percent based on years of service will also be made. The match is described in the chart below:

Years of Plan

Service

Matching Contribution Total

Contribution 0-5 Years 40% of the first 2% of Pay [0.8%] 3.55% 6-9 Years 80% of the first 2% of Pay [1.6%] 4.35% 10-20 Years 120% of the first 2% of Pay [2.4%] 5.15% Over 20 Years 150% of the first 2% of Pay

[3.0%] 5.75%

The employer contribution is made once per year, usually in February to reflect the contribution earned from the prior calendar year.

The maximum amount you can defer in 2015 has been increased to $18,000 for those under age 50 and $24,000 for those over 50.

Any changes you wish to make to the allocation of your funds or how much you contribute bi-weekly to your retirement account must be done online at www.saratogahospital.trsretire.com or by calling 1-800-755-5801. Deferral changes cannot be made in UltiPro.

Group Term Life Insurance The hospital will continue to provide group term life insurance to all full time employees at no cost. This coverage will be offered through Unum in 2015. The coverage remains the same; one times your annual salary up to a maximum of $200,000. This coverage is automatic and requires no action on your part other than to identify a beneficiary. You can designate your beneficiary through the online enrollment.

Health Insurance Waiver Credit The waiver credit of $360 is available to those full time employees who have completed one year of service and who have medical insurance coverage with another carrier. Employees must indicate their eligibility for the waiver credit during open enrollment through the online open enrollment process. Employees who do not elect the waiver credit during the open enrollment time period, or who change status during the year, will not be eligible to receive the waiver credit in 2015.

If you indicated that you were eligible for the waiver credit during open enrollment last year, the credit will be paid to you in the last pay period of 2014. Employees eligible to receive the waiver credit will receive a letter in mid-November requesting evidence of insurance coverage for the 2014 plan year to receive the waiver credit. Acceptable forms of evidence of insurance coverage include a letter from the employer’s human resource department or from the insurance company.

Flex Spending Accounts Flexible Spending Accounts (FSA) allow employees to pay for medical/dental or child care with pretax dollars. You must elect a new flex spending amount during open enrollment. Previous election amounts do not roll over from one year to the next. This can be done online through UltiPro.

There are two types of Flex spending accounts:

Medical Reimbursement Account: You can defer up to $2,550 in 2015 on a pre-tax basis to be used for the reimbursement of eligible, non-reimbursed medical expenses (for example: copays, deductibles, coinsurance).

Dependent Care Account: A Dependent Care Account allows you to defer up to $5,000 per calendar year on a pre-tax basis to be used for reimbursement of eligible dependent care expenses.

You will be reimbursed out of your account for qualifying medical/dental or child care expenses incurred during the plan year. Our plan provides participants with Flex spending debit cards. The cards are good for three years. You will not get a new one when you re-enroll if your current card has not as yet expired.

Flex Spending for Dependents: You may make contributions to your flexible spending account on a pre-tax basis to pay for covered health expenses for your children through the end of the calendar year in which your child reaches age 26, even if your child is not your tax dependent. You will be reimbursed through your account for all medical expenses incurred through the end of the year that your child turns age 26.

YMCA Contribution The hospital will provide $200 towards a full or part time benefit eligible employee’s membership to one YMCA in the Saratoga Region, Glens Falls, and Greater Glenville branch of Capital District YMCA or Southern Saratoga. The employee must be one of the members listed on the membership. Please note that this amount is considered a taxable fringe benefit under IRS regulations and will be added to your W2 at the end of the year.

New York State Short Term Disability The hospital provides state mandated short term disability that covers 50% of your weekly salary up to a maximum of $170 per week in the event that you are out of work due to a non-work related illness or injury for more than 7 calendar days. No action is needed on your part to be enrolled in this benefit.

Voluntary Benefit Programs Additional voluntary benefit programs are also available. These programs are offered through Saratoga Hospital at group rate discounts.

The voluntary benefit programs include:

• Vision: The vision plan is through Davis Vision . There is no increase in the premium for the Vision

Plan.

• Voluntary Short Term Disability: This program is administered by Unum and allows benefit eligible employees to purchase additional coverage to supplement the New York State short term disability in the event that you are out of work due to a non-work related illness or injury for more than seven calendar days. Short term disability provides coverage for up to 26 weeks at 50% of your weekly wages up to a maximum of $2,000 per week.

• Voluntary Long Term Disability: Full time benefit eligible, hourly employees can purchase long term disability coverage through Unum Insurance. Rates are based on age and the amount of coverage elected. Long term disability provides coverage if you have been out of work for 6 months. The benefit is 50% of your monthly pay up to a maximum of $10,000 per month.

• Voluntary Supplemental Term Life Insurance: This product is administered by Unum. You can

purchase life insurance for you, your spouse and dependents. New enrollees (or current enrollees who are increasing coverage above the guaranteed issue amount of $100,000 for themselves or $30,000 for their spouse) must complete an Evidence of Insurability form and submit to Unum for review and approval. Forms can be obtained through Human Resources, SaraNet/Employee Center/2015 Open Enrollment or through the employee portal on the hospital website at www.saratogahospital.org. The completed form can be mailed or faxed to Unum. You must also elect this plan through the online open enrollment in UltiPro. Your deductions will not start until you are approved by Unum.

• NY Life Voluntary Whole Life Insurance: Voluntary whole life insurance is offered through New York

Life to full time employees with six months or more of service. New York Life Guaranteed Issue Whole Life insurance is available for you, your spouse, children, and grandchildren. You can get coverage for yourself up to $100,000 and up to $25,000 on your spouse, children or grandchildren. The New York Life representative will visit every department between Monday November 3-Friday, November 14th. You can email Benefits@saratogacare.org if you would like to set up an appointment. You must also elect this plan through the online open enrollment in UltiPro. Your deductions will not start until you are approved by NY Life.

• Liberty Mutual: Discounted auto and homeowners insurance is available through Liberty Mutual.

Employees interested in discussing coverage and cost, can contact the representative directly at 518- 782-2541. If you are interested in this plan you must indicate your interest by electing the option through the online open enrollment.

• AFLAC Cancer Care and Critical Illness: This voluntary cancer and critical care protection plan is provided through AFLAC Insurance and offers financial assistance to cover costs such as transportation, travel, lodging, household costs and other living expenses when an the insured individual is diagnosed with cancer or other critical illness. Visit or call the AFLAC plan representative at 321-1168. For more information, contactBenefits@saratogacare.org if you would like to schedule an appointment. You must also elect this plan through the online open enrollment in UltiPro. Your deductions will not start until you are approved by AFLAC.

• AFLAC Accident Only Indemnity Plan: This plan provides coverage to an employee, spouse and/or dependent under age 26. The plan covers costs related to an accident. It pays for accident emergency treatment, x-rays due to accident, accident follow up treatment, hospitalization, intensive care inpatient due to accident, physical therapy and appliance needs (wheelchair, crutches, leg brace, walker) due to accident. It also covers transportation costs, prosthesis, family lodging and accidental death and dismemberment. There are no deductibles, no copayments, no lifetime limit, no network restrictions and no coordination of benefits. Visit or call the AFLAC plan representative at 321-1168 for more information or contact Benefits@saratogacare.org if you would like to schedule an appointment. You must also elect this plan through the online open enrollment in UltiPro. Your deductions will not start until you are approved by AFLAC.

• Legal Plan: This benefit is available through MetLaw and Hyatt Legal Plans and offers eligible employees an opportunity to access affordable legal assistance for a wide range of needs.

Courtesy Discount The courtesy discount will continue to be offered to all benefit eligible part time and full time employees, their spouse, dependents, domestic partner * and hospital retirees. The courtesy discount is available at all Saratoga Hospital employed physician practices** including:

• Family Health Centers (Galway, Schuylerville, Saratoga Family Health at Wesley), • Saratoga Family Physicians, • Endocrinology, • Pain Management, • Pulmonology, • Nephrology, • Podiatry, • Medical Oncology, • General and Bariatric Surgery, • Urology, and • Neurology.

The courtesy discount also applies to outpatient, ambulatory and inpatient services provided at Saratoga Hospital and its outpatient facilities. For employees who have insurance through Saratoga Hospital, all copays, deductibles and coinsurance are discounted at 100% with the exception of the exclusions noted below.

For employees who are covered under another insurance plan, the courtesy discount covers a maximum of $150 per outpatient visit and $1,000 per inpatient visit. For ED visits, the courtesy discount only applies to those plans that have copayments or deductibles over $100. For example, if your plan has an ED copayment of $50.00, you will be responsible for the full copayment. If your plan has an ED copayment or deductible of $200.00, you will be responsible for $100.00 and the courtesy discount will be applied to the remaining $100.00.

Exclusions to Courtesy Discount: The following exclusions apply:

• Saratoga Hospital Emergency Department ($100.00 copay in 2015 for employees with insurance with Saratoga Hospital. Maximum discount of $150.00 for employees with other insurance)

• Community Health Center (copayments apply with the exception of annual well visits) • Malta Medical Emergent Care ($75.00 copay with a $25.00 credit applied through Patient accounts) * Domestic partners must be covered under the hospital insurance plan to receive the courtesy discount.

**For a current list of Saratoga Hospital providers included in the Domestic Network and included under the Courtesy Discount, please refer to the Courtesy Discount policy on SaraNet.

Important Contact Information

Benefit Program Vendor Website Telephone Health Insurance CDPHP www.cdphp.com

1-800 -777 -227 3

Prescription Plan EnvisonRXOptions www.envisionrx.com 1-800 -361 -454 2

Retirement Plan of Saratoga Hospital

Transamerica www.trsretire.com 1-800 -755 -580 1

Dental Insurance Delta Dental www.deltadentalins.com 1-800 -932 -078 3

Vision Insurance Davis Vision www.davisvision.com 1-800 -999 -543 1

Online Open Enrollment Questions What if I don’t want to make any changes? Do I still have to complete the open enrollment process? The only benefits that require you to take action are the Flex Spending Account: either the Medical Reimbursement or Dependent Care and the Medical Insurance Waiver Credit. For the Flex Spending accounts, you must elect a new amount each year. If you are a full time employee and do not take the medical insurance through the hospital, you are eligible for the $360 waiver credit and must elect the credit each year and show proof of coverage from the prior year. For all other benefits, you don’t need to take any action. All your current benefit elections will continue in 2015 at the 2015 rates.

Is there any paperwork that needs to be completed? If you are enrolling in supplemental term life for the first time or increasing your term life benefit coverage amount above guaranteed issue limits, you will have to complete an Evidence of Insurability Form and send it to Unum for review and approval. These forms are available in Human Resources, on SaraNet/Employee Center/2015 Open Enrollment or on the Saratoga Hospital website (www.saratogahospital.org) in the For Employees tab under the Benefits button.

Are the rates increasing for the plans? There are rate increases for some of the plans this year. The rates for Vision, Short Term and Long Term disability and Supplemental Life are all staying the same as last year. The premiums for Medical are increasing slightly (3.5%), the premiums for the Prescription Plan increased 7.0% due to the continued expense of specialty drugs and the premiums for Dental also increased slightly.

Were any changes made to the medical plan for 2015? There are a few changes planned for 2015. Here is a summary of those changes:

1. Additional physicians have been added to our domestic network of providers. For a complete list, refer to the updated list of Domestic Providers on SaraNet or the Courtesy Discount policy.

2. There will no longer be an office visit copayment for patients of a Saratoga Family Physician (SFP). 3. Copayment for a visit to the Emergency Department visit at Saratoga Hospital has been increased to $100.

How does the deductible work in the medical plan? The plan has a $500 deductible per individual with a maximum deductible of $1,500 for a family. The deductible applies to care and services provided outside the Domestic Network of Saratoga Hospital and it’s employed providers. Once you meet the $500 deductible, you are then responsible for any applicable coinsurance. Office visits to a provider do not count towards the deductible.

How do I meet my annual deductible? Whenever you receive services at a hospital, health care facility or have diagnostic testing done somewhere other than Saratoga Hospital, the deductible will apply. This includes inpatient care, ambulatory surgery, laboratory work and diagnostic testing. For employees with an individual plan, once you have reached $500, you will have met your deductible for the plan year. For those with a two-person plan, the deductible is $500 per person. For those with family coverage, the deductible is $500 per person with a maximum deductible of $1,500 for the family.

What is coinsurance and how does it work? Coinsurance is the amount that an employee pays after the annual deductible is met. It is a percentage that is applied to the contracted rate that CDPHP has agreed to pay a provider. The coinsurance is 20%. Here is an example of how both the deductible and coinsurance work:

Example: An employee with individual coverage ($500 deductible) has an ambulatory surgery procedure at St. Peter’s Hospital in Albany. CDPHP approved the procedure at $2,000. The employee would first pay $500. This would meet their annual deductible. They would also have a 20% coinsurance in the amount of $300 (the coinsurance of 20% is applied to the total procedure rate ($2000) less the deductible of $500). For any additional services provided at a hospital other than Saratoga, the employee no longer has a deductible, but would continue to be responsible for any coinsurance.

Deductibles and coinsurance can really add up. Is there any cap on my out of pocket expenses? Yes. There is an out of pocket maximum of $3,000 per individual with a total cap of $9,000 for family coverage. The annual out of pocket maximums include copayments, deductibles and coinsurance.

What do I pay if I receive care at Saratoga Hospital? Care provided at Saratoga Hospital facilities and by Saratoga Hospital employed physicians is considered the Domestic Network under our medical plan. For employees who have health insurance through Saratoga Hospital, there are no copays, deductibles or coinsurance applied for services provided at Saratoga Hospital inpatient and outpatient services, Wilton Urgent Care/Medical Arts or any Saratoga Hospital physician practices. The exceptions to this include the $100.00 copayment for the Saratoga Hospital Emergency Department and care and services provided on the first floor of Malta Medical Emergent Care. For emergent care services at Malta Med there is a $75.00 copay. For diagnostic services (lab and x-ray) provided on the first floor, these services are subject to the deductible and coinsurance.

Employees who have insurance coverage through a spouse are also eligible for a courtesy discount. The discount is up to $150.00 for each outpatient visit and $1,000 for an inpatient stay on the remaining balance after payment by their insurance company.

Appendix A

Accessing UltiPro

You can access UltiPro three ways:

1. To access UltiPro from a hospital computer. Go to SaraNet/Employee Center and click on the UltiPro link at the bottom of the drop down menu. Click on the “Click Here to Enter UltiPro”.

2. To access UltiPro from a computer outside of the hospital. Go to the Saratoga Hospital website at www.saratogahospital.org and click on the For Employees button at the top of the page. This will bring you to a landing page that has a button for UltiPro. Click on this button and it will bring you to the UltiPro log in page.

3. To access UltiPro from a computer outside of the hospital. You can enter the UltiPro web address directly into a web browser. The address is https://e22.ultipro.com.

The Online Open Enrollment will be active on Monday November 10, 2014.

Once you have reviewed your current benefit coverage in your UltiPro account, you can go start the open enrollment process by clicking on the Open Enrollment tab at the top of the page. All employees who are benefit eligible will have the access to the 2015 Open Enrollment session.

You can go back into the Open Enrollment session and review your elections and make changes throughout the open enrollment period. If you are making any changes, they must be completed by the close of the last day of open enrollment, December 3rd. If you do not take any action, your will be automatically enrolled in the same benefits at the applicable rates for 2015.

All plans that you are eligible to enroll in will be available to you through the online open enrollment. A step- by-step guide on the enrollment process is available on SaraNet at 2015 Open Enrollment and on the For Employee page on the external Saratoga Hospital website (www.saratogahospital.org). Hard copies will also be available outside Human Resources.

In addition, a short video is available on SaraNet and on the For Employee link at www.saratogahospital.org. This narrated video will walk you through the open enrollment process and show you how to access additional information.

FULL TIME HOSPITAL

CONTRIBUTION

FULL TIME EMPLOYEE

CONTRIBUTION

PART TIME HOSPITAL

CONTRIBUTION

PART TIME EMPLOYEE

CONTRIBUTION EPO * INDIVIDUAL $185.81 $31.95 $172.23 $45.53

2 PERSON $315.18 $120.35 $274.93 $160.60 FAMILY $398.94 $167.25 $304.52 $261.66

FULL TIME HOSPITAL

CONTRIBUTION

FULL TIME EMPLOYEE

CONTRIBUTION

PART TIME HOSPITAL

CONTRIBUTION

PART TIME EMPLOYEE

CONTRIBUTION EnvisionRxOptions INDIVIDUAL $42.66 $7.61 $36.63 $13.64

2 PERSON $73.81 $25.94 $54.85 $44.90 FAMILY $95.26 $37.08 $66.15 $66.19

FULL TIME HOSPITAL

CONTRIBUTION

FULL TIME EMPLOYEE

CONTRIBUTION

PART TIME HOSPITAL

CONTRIBUTION

PART TIME EMPLOYEE

CONTRIBUTION Preventive INDIVIDUAL $5.17 $0.91 $3.86 $1.90

2 PERSON $7.19 $3.23 $5.68 $4.22 FAMILY $8.12 $6.64 $6.64 $7.38

FULL AND PART TIME EMPLOYEE CONTRIBUTION

$2.87 $5.16 $8.03

Appendix B 2015 Saratoga Hospital Bi-Weekly Benefit Deductions

January 1-December 31, 2015

SARATOGA HOSPITAL HEALTH INSURANCE PLAN RATES

*Exclusive Provider Organization Administered through Capital District Physician Healthcare Network (CDPHN)

Employees who elect the health plan are also required to participate in the prescription plan.

PRESCRIPTION INSURANCE RATES

DENTAL INSURANCE RATES

Comprehensive INDIVIDUAL $14.11 $4.76 $10.40 $8.40 2 PERSON $20.98 $11.42 $14.64 $17.42 FAMILY $29.96 $16.29 $20.90 $24.59

Please note once the dental plan choice has been made, the employee must remain in that plan for two years.

VISION INSURANCE RATES

Definitions:

INDIVIDUAL 2 PERSON FAMILY

Full Time is defined as regularly scheduled to work 75 hours or more per pay period (72 hours for 12 hour shift employees). Part Time is defined as regularly scheduled to work 37.5 hours or more per pay period (36 hours for 12 hour shift employees).

Employees are automatically enrolled in a pre-tax benefit. If you would like a post-tax benefit, you must complete a Post Tax Deduction form available on SaraNet or in Human Resources. Forms must be turned in to Human Resources no later than November 26, 2014.

Appendix C Saratoga Hospital Health Insurance Plan

Summary of Benefit Coverage 2015 2015

Saratoga Hospital Health Insurance Plan (EPO)

Domestic (D) Saratoga Hospital Providers

and Facilities

Non Domestic (ND) All Other Providers and

Facilities

Single/Family

Single/Family

Deductible (Single/Family)

Not Applicable

$500/$1,500

Coinsurance

Not Applicable

20%

Out of Pocket/Coinsurance Maximum

Not Applicable

$3,000/$9,000

Annual Benefit Max

Unlimited

Unlimited

Physician Services Office visits for illness, injury or second opinion

(PCP/OBGYN)

Covered in Full

$30 Copayment

Office visits for illness, injury or second opinion (Specialist)

Covered in Full

$40 Copayment

Physician visits during inpatient stay

Covered in Full

$30(PCP/OBGYN)/$40 Specialist

Well Baby and Child Care including immunizations and inoculations

Covered in Full

Covered in Full

Annual Adult Physical Covered in Full Covered in Full

Annual Gynecological Exam Covered in Full Covered in Full

Hospital Services Inpatient Hospital (semi-private room, anesthesia, x-ray,

lab tests, etc)

Covered in Full

Deductible then 20% Coinsurance

Outpatient Surgery Covered in Full Deductible then 20% Coinsurance

Diagnostic Testing Outpatient Hospital Laboratory Services Covered in Full Deductible then 20% Coinsurance

Outpatient Hospital Radiology Services Covered in Full Deductible then 20% Coinsurance

Office Based Laboratory Services Covered in Full Deductible then 20% Coinsurance

Office Based Radiology Services: Covered in Full Deductible then 20% Coinsurance

Mammogram

Covered in Full Covered in Full

*If billed as non-routine, deductible then 20% Coinsurance

Cytology Screening

Covered in Full

Covered in Full *If billed as non-routine, deductible then

20% Coinsurance

Maternity

Inpatient Physician Services

Covered in Full

Deductible then 20% Coinsurance

Inpatient Hospital Services

Covered in Full

Deductible then 20% Coinsurance

Newborn Nursery

Covered in Full

Deductible then 20% Coinsurance

2015 2015

Saratoga Hospital Health Insurance Plan (EPO)

Domestic (D) Saratoga Hospital Providers

and Facilities

Non Domestic (ND) All Other Providers and

Facilities

Single/Family

Single/Family

Emergency Care

Worldwide Emergency Care

$100 Copayment

$150 Copayment

Ambulance

Not available In-Domestic

$100 Copayment

Urgent Care

Covered in Full

$75 Copayment

Other Services Physical Therapy Covered in Full $40 Copayment

Speech Therapy Covered in Full $40 Copayment

Occupational Therapy Covered in Full $40 Copayment

Chiropractic Benefits Not available In-Domestic $40 Copayment

Home Health Care (if deductible, maximum is $50)

Covered in Full

$40 copay/visit

Skilled Nursing Facility

Covered in Full

Deductible then 20% Coinsurance

Prosthetic Devices and Durable Medical Equipment

Not available In-Domestic

Deductible then 20% Coinsurance

Mental Health

Outpatient Mental Health Services

Not available In-Domestic

$30 Copayment

Inpatient Mental Health services

Covered in Full

Deductible then 20% Coinsurance

Chemical Abuse and Dependency

Outpatient Services Not available In-Domestic $30 Copayment

Inpatient Detoxification Services

Not available In-Domestic

Deductible then 20% Coinsurance

Inpatient Rehabilitation Services

Not available In-Domestic

Deductible then 20% Coinsurance

Dependent Coverage

Description

Dependent to 26

Dependent to 26

Primary Care Physician Not required Not required

PCP Referral No Referrals Required No Referrals Required

National Network N/A Yes- National Network Applies

Prior Authorization

Some Services require Prior Authorization Some Services require Prior Authorization

* Domestic (D)- All Saratoga Hospital owned facilities and physicians/professionals. * Non Domestic (ND)- All other CDPHP(including National Network) facilities & physicians/professionals that participate in the carrier's EPO network.

This document has been provided to you for informational purposes only. Coverage is always subject to the member's eligibility, specific contract benefits and CDPHP medical policy. For a full Summary of Benefit Coverage (SBC) document, go to SaraNet, select 2015 Open Enrollment link from the home page and select Summary of Benefit Coverage .