2

Every reasonable effort has been made for the information provided in this booklet to be accurate. It is intended to provide the employees with Southern College of Optometry an

overview of the coverages offered. It is in no way a guarantee or offer of coverage. Each carrier has the ability to underwrite based on its contract with Southern College of Optometry

or its employees. Each carrier’s contract, underwriting, and policies will supersede this document. Please be aware that each carrier may have exclusions or limitations and you must

consult your summary plan description and/or policies for details.

TABLE OF CONTENTS

2016-2017 Benefits at a Glance .......................................... 3 MySCOBenefits.com ............................................................ 4 Medical Plan ......................................................................... 5 Dental Plan ............................................................................ 6 Flexible Spending Accounts ............................................... 7 Critical Illness Plan ............................................................. 8 Accident Plan........................................................................ 9 Term Life, Voluntary Life, Dependent Life Plans ............... 10

UNITED HEALTHCARE Customer Service …………… 800-345-1520

UNITED HEALTHCARE DENTAL Customer Service ...... 800-335-8266

MUTUAL OF OMAHA (to file a life claim) ........................ 800-775-8805

MUTUAL OF OMAHA (to file a disability claim) ............... 800-877-5176

CORPORATE PLANNING NETWORK ............................ 800-737-0125

ALLSTATE BENEFITS Customer Service ....................... 800-521-3535

ENROLLMENT ASSISTANCE (BenefitHelp) ................... 888-663-1285, Option 2

WHO TO CONTACT

3

2016-2017 BENEFITS AT A GLANCE

Medical Insurance

Coverage is provided through United Healthcare. Eligible employees may choose from 3 plan options.

• The BRONZE plan has an annual, individual deductible of $2,000 with 80% coverage when using network providers.

• The GOLD plan deductible is $500 for an individual and coverage is 80% when network providers are used.

• The PLATINUM plan does not have an annual deductible and coverage is 100% after plan copayments.

Dental Insurance

Eligible employees are offered dental coverage also provided through United Healthcare. Eligible employees my choose from

two options.

• When using the BASE plan, coverage is only provided when using a dentist within the UHC network.

• The BUY-UP plan allows you to see the provider of your choice, however, benefits are greater when you remain in the UHC

network.

Flexible Spending Accounts

Flexible Spending Accounts enable you to put aside money for important expenses, while helping to reduce your taxable income

at the same time. Southern College of Optometry offers you both a HealthCare FSA and a Dependent Care FSA.

• The HealthCare FSA can be used for eligible expenses that your insurance does not cover. For example, copayments,

deductibles and coinsurance, as well as unreimbursed dental and vision expenses.

• A Dependent Care FSA can be used for childcare or eldercare services.

Be sure to calculate your expenses wisely, monies deposited into these accounts do not rollover from year to year.

Supplemental Plans

Supplemental Plans are designed to help protect your health and savings by paying a cash benefit directly to you to use as you

need it. Some things to consider when deciding if you need supplemental coverage are your health risk factors, your savings,

and how much you can afford.

The Critical Illness and Accident are offered through Allstate Benefits. Premiums are calculated based

upon your age and the coverage level you select and are deducted from your paycheck.

Life and AD&D Insurance

Southern College of Optometry provides eligible faculty and staff with basic life and AD&D insurance coverage. Coverage is

equal to 2.5 times your annual income, not to exceed $300,000 in coverage and is offered through Mutual of Omaha.

Employees may also purchase additional life insurance for themselves and their dependents through Mutual of Omaha. During

Open Enrollment you are given the opportunity to increase your Voluntary Term Life election by $10,000 without providing

evidence of insurability, as long as your total election amount does not exceed the Guaranteed Issue limit. If you choose to

increase coverage by more than $10,000 or you exceed the Guaranteed Issue amount you will be required to complete a

medical questionnaire.

4

Have you ever had trouble locating information about your benefits?

What about trying to remember how to find a participating doctor or dentist?

Not to worry, with MySCOBenefits.com you are just an

internet connection away from . . .

MYSCOBENEFITS.COM

• Important Phone Numbers • Employee Benefit News

• Carrier Information • Important Plan Documents

• Provider & Facility Searches

Where online can I get more information about my benefits?

Plan documents can be accessed without having to log in.

5

MEDICAL PLANS

SOUTHERN COLLEGE OF OPTOMETRY MEDICAL PLANS (in network benefits)

BRONZE GOLD PLATINUM

Deductible

Individual/Family $2,000 / $4,000 $500 / $1,000 $0 / $0

Out of Pocket Maximum $6,000 / $12,000 $2,500/$5,000 $6,250/$12,500

Office Visit Copay $25 Primary Care

$50 Specialist

$20 Primary Care

$40 Specialist

$20 Primary Care

$40 Specialist

Preventive Care 100%, no deductible 100%, no deductible 100%, no deductible

Outpatient Services 80% coverage, after

deductible

80% coverage, after

deductible 100%

Urgent Care Services $75 copay $75 copay $50 copay

Emergency Room Visit $250 copay $250 copay $250 copay

Inpatient Services 80% coverage, after

deductible

80% coverage, after

deductible

$250 copay per

admission

Virtual Office Visits Unlimited visits, $15

copay applies

Unlimited visits, $15

copay applies

Unlimited visits, $15

copay applies

Retail Pharmacy

31 day supply $10/$35/$60 copay $10/$30/$50 copay $10/$25/$50 copay

Mail Order Pharmacy

90 day supply

$25/$87.50/

$150 copay $25/$75/$125 copay

$25/$62.50/

$125 copay

Medical Plan - Semi-Monthly Payroll Deduction

Who to Cover? BRONZE GOLD PLATINUM

Employee $26.50 $42.50 $65.00

Employee + 1 Dependent $109.00 $184.00 $221.00

Family $166.50 $285.00 $340.50

You are eligible for

Medical coverage on the

first day of the month

following your date of hire.

6

Southern College of Optometry offers 2 Dental plan options through United Healthcare for all eligible faculty and staff. • With the BASE dental plan you must use a provider in the UHC network to receive

coverage. If you use a provider that is not in the network, your dental work will not be covered..

• The BUY-UP Dental plan gives you the ability to obtain dental care services from the dentist of your choice (contracted or not). The BUY-UP dental plan also provides a higher level of benefit if you choose to use an in-network provider.

Please note: It is recommended that when a course of treatment is expected to cost $300 or more, and is of a non-emergency nature, your dentist should submit a treatment plan before work begins. This enables you to see what your out-of-pocket expenses will be so you are not surprised and can budget accordingly. There is also a possibility that suggested procedures may be denied, and alternative procedures approved based upon X-rays and supporting documentation.

DENTAL PLANS

BASE DENTAL

PLAN BUY-UP DENTAL PLAN

In-network Benefits

ONLY In-network Benefits

Out-of-network

Benefits

Annual Deductible

Individual/Family $50/$150 $50/$150 $50/$150

Annual Maximum

Benefit $1,500 $1,000 $1,000

Preventive Care

Services 100% 100% 100%

Basic Services 50% 90% 80%

Major Services 50% 60% 50%

Dental Plan - Semi-Monthly Payroll Deduction

Who to Cover? BASE Plan BUY-UP Plan

Employee $ 8.82 $ 18.84

Employee + Spouse $ 17.72 $ 37.69

Employee + Child(ren) $ 16.90 $ 36.71

Family $ 26.82 $ 57.81

You are eligible for

Dental coverage on the first

day of the month

following your date of hire.

7

Southern College of Optometry provides you the opportunity to pay for out-of-pocket medical, dental, vision, and dependent care expenses with pre-tax dollars through the Flexible Spending Accounts. • A health care FSA is used to reimburse out-of-pocket medical expenses incurred by you and your

dependents. The maximum allowable contribution for a health care (medical) FSA is $2,550. • A dependent care FSA is used to reimburse expenses related to care of eligible

dependents while you and your spouse work. The maximum allowable contribution amount for a dependent care FSA is $5,000.

Contributions to your FSA come out of your paycheck before any taxes are taken out. This means that you do not pay federal income tax, Social Security taxes, and state and local income taxes on the portion of your paycheck that you contribute to your FSA. You should contribute the amount of money you expect to pay out of pocket for eligible expenses* for the plan period. If you do not use the money you contributed it will not be refunded to you nor carried forward to a future plan year. This is known as the use-it-or-lose-it rule.

If your elected annual contribution amount is not evenly divisible by the number of pay periods (24) ,

your contribution amount may be reduced to allow for even installments.

The following example shows how you can save money with a flexible spending account:

FLEXIBLE SPENDING ACCOUNTS

You must

re-enroll

each year

Without FSAs With FSAs

Gross Income $30,000 $30,000

FSA Contributions $0 - $5,300

Gross Income $30,000 $24,700

Estimated taxes

Federal - $2,550** - $1,755**

State - $900*** - $741***

FICA - $2,295 - $1,890

After-tax earnings:

Eligible out-of-pocket

Medical and dependent care expenses - $5,300 $0

Remaining spendable income $18,955 $20,314

Spendable income increase $1,359

*A full list of FSA eligible expenses is available at www.irs.gov/pul/irs-pdf/p502.pdf.

**Assumes standard deductions and four exemptions

***Varies, assume 3%

The example above is for illustrative purposes only. Every situation varies and it is recommended that you consult a tax advisor for all tax advice.

8

CRITICAL ILLNESS PLANS

Critical Illness benefits help families pay off debts and other expenses not covered by

medical insurance such as a loss of income, childcare services, and travel to treatment

centers. These benefits are paid directly to you.

Eligibility All active faculty and staff working .75 FTE.

Benefit Amount Select a lump sum benefit of either $10,000 or $20,000

Guaranteed Issue

Policies are Guaranteed Issue for New Hires; Current

employees who did not elect when first eligible may apply for

coverage by answering a few questions.

Covered Conditions

Heart Attack, Stroke, Coronary Artery Disease, End Stage

Renal Failure, Paralysis, Major Organ Transplant, Cancer

(this list is not all inclusive, refer to the plan documents for additional

covered conditions and any limitations)

Who to cover? Coverage is available for employee, spouse and children

Portability Yes, coverage is portable.

Critical Illness Plan SAMPLE Rates Semi-Monthly Payroll Deduction

Sample Rates are based on a $10,000 policy - non-tobacco user

Age Named Insured Family 18-35 $ 2.10 $ 3.38

36-49 $ 4.60 $ 7.08

50-59 $ 9.40 $ 14.18

60-64 $ 14.90 $ 22.33

65-69 $ 19.15 $ 28.68

70+ $ 23.10 $ 34.43

9

ACCIDENT PLAN

Accidents can happen anytime, anywhere and can often lead to medical care. Accident

coverage provides cash benefits to help cover out-of-pocket medical costs and other

incidental expenses. Accident plan benefits pay directly to you and can serve as a

compliment to your major medical and disability coverage.

Eligibility All active faculty and staff working .75 FTE.

Benefit Amount Select from the Basic or Enhanced plan. A full description of

covered services is available at www.MySCOBenefits.com.

Guaranteed Issue Policies are Guaranteed Issue

Covered Services and

Conditions

Emergency Room, Ambulance, Hospitalization, Radiology,

Broken Bones, Burns, Concussions, Lacerations,

and Paralysis

(this list is not all inclusive, refer to the plan documents for additional

covered treatments and any limitations)

Who to cover? Coverage is available for employee, spouse and children

Portability Yes, coverage is portable.

Accident Plan Rates—Semi-Monthly Payroll Deduction

Who to Cover? Basic Plan Enhanced Plan

Employee $ 5.95 $ 9.26

Employee + Spouse $ 8.82 $ 13.47

Employee + Child(ren) $ 11.96 $ 18.74

Family $ 14.95 $ 23.43

10

LIFE INSURANCE

Basic Term Life Insurance and AD&D

All active, full-time faculty and staff employees receive Life and Accidental Death &

Dismemberment coverage equal to 2.5 times their salary, to a maximum benefit of $300,000.

Coverage is provided for you by Southern College of Optometry after one year of employment

and is through Mutual of Omaha.

Eligibility All active faculty and staff working .75 FTE.

Benefit Amount 2.5 Salary to maximum of $300,000

Guaranteed Issue Up to $300,000 for New Hires

Additional Benefits 75% Accelerated Death Benefit, Waiver of Premium

Benefit Reduction 65% at 70

50% at 75

Termination At retirement or other end of employment.

Voluntary Term Life Insurance and AD&D

Employees who want to supplement their group life insurance benefits may purchase

additional coverage. When you enroll yourself and/or your dependents in this benefit, you

pay the full cost through payroll deductions.

You can purchase coverage on yourself in $10,000 increments. Minimum coverage is

$10,000 and maximum coverage is $250,000 ($100,000 Guaranteed Issue). Spouse

amounts may be purchased in $5,000 increments up to $50,000, not to exceed the

employees’ benefit amount. $35,000 in coverage is Guaranteed Issue for the spouse of a

new hire. You may purchase $10,000 in coverage on your dependent child(ren).

NOTE: If you do not elect voluntary life insurance when you first become eligible, you will

need to complete an Evidence of Insurability form to obtain approval for coverage.

If you are currently enrolled in voluntary life insurance, you have the ability to increase your

coverage during you each open enrollment by $10,000 without providing medical evidence of

insurability. If your open enrollment increase is more than $10,000 or exceeds the Guaran-

teed Issue amount, you will be required to complete an Evidence of Insurability (EOI) form.

11

LEGAL NOTICES

New

and Your

Form Approved

OMB No.

PART A: General

When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance: the Health Insurance

Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic information about

the new Marketplace and employment-based health coverage offered by your employer.

The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace

offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible for a new kind of

tax credit that lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace

begins in October 2013 for coverage starting as early as January 1, 2014.

You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers

coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on your household

income.

Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax

credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be eligible for a tax

credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does not offer coverage to you at

all or does not offer coverage that meets certain standards. If the cost of a plan from your employer that would cover you (and not

any other members of your family) is more than 9.5% of your household income for the year, or if the coverage your employer

provides does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax credit.1

Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your

employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer contribution

-as well as your employee contribution to employer-offered coverage- is often excluded from income for Federal and State

income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis.

For more information about your coverage offered by your employer, please check your summary plan description or

contact Human Resource Dept, Ann Fields 901-722-3229 .

The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace

and its cost. Please visit HealthCare.gov for more information, including an online application for health insurance coverage

and contact information for a Health Insurance Marketplace in your area.

1 An if the share of by is no

less of

12

Legal Notices

PART B: Information About Health Coverage Offered by Your Employer

This section contains information about any health coverage offered by your employer. If you decide to complete an application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the Marketplace application.

Here is some basic information about health coverage offered by this employer:

As your employer, we offer a health plan to: All employees. Eligible employees are:

Some employees. Eligible employees are:

With respect to dependents: We do offer coverage. Eligible dependents are:

We do not offer coverage.

If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended to be affordable, based on employee wages.

** Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount through the Marketplace. The Marketplace will use your household income, along with other factors, to deter-mine whether you may be eligible for a premium discount. If, for example, your wages vary from week to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly employed mid-year, or if you have other income losses, you may still qualify for a premium discount.

If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here's the employer information

you'll enter when you visit HealthCare.gov

Full time Faculty employees working 30 hours per week,

Full time Staff employees working 26.25 hours per week

Full time students, actively enrolled in College courses

Spouse

Dependent Children to age 26

X X

X

X

X

13

Legal Notices

The information below corresponds to the Marketplace Employer Coverage Tool. Completing this section is optional for

employers, but will help ensure employees understand their coverage choices.

13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in

the next 3 months?

Yes (Continue)

13a. If the employee is not eligible today, including as a result of waiting or probationary period, when is the

employee eligible for coverage? 90 Days fro date of hire

No (STOP and return this form to employee)

14. Does the employer offer a health plan that meets the minimum value standard*?

Yes (Go to question 15) No (STOP and return form to employee)

15. For the lowest-cost plan (BRONZE PLAN) that meets that minimum value standard* offered only to the employee

(don’t include family plans): If the employer has wellness programs, provide the premium that the employee would

pay if he/she received the maximum discount for any tobacco cessation programs, and didn’t receive any other

discounts based on wellness programs.

a. How much would the employee have to pay in premiums for this plan? $ 53

b. How often? Weekly Every 2 weeks Twice a month Monthly Quarterly Yearly

If the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don’t know,

STOP and return form to employee.

16. What change will the employer make for the new plan year?______________

Employer won’t offer health coverage

Employer will start offering health coverage to employees or change the premium for the lowest-cost plan

available only to the employee that meets the minimum value standard.* (Premium should reflect the

discount for wellness programs. See question 15.)

a. How much would the employee have to pay in premiums for this plan? $ _______

b. How often? Weekly Every 2 weeks Twice a month Monthly Quarterly Yearly

X

X

14

Legal Notices

Important Legal Notices & Annual Disclosures

Medicare Part D

This notice applies to employees and covered dependents who are eligible for Medicare Part D.

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage

with United Healthcare and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or

not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage 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 prescrip-

tion drug coverage is at the end of this notice.

There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:

1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you join a Medi-

care Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare

prescription 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. United Healthcare has determined that the prescription drug coverage offered by the Health and Welfare Plan for employees of Southern

College of Optometry is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug cover-

age 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 prescription drug plan.

Individuals can enroll in a Medicare prescription drug plan when they first become eligible for Medicare and each year from October 15th to De-

cember 7th. However, if you lose your current creditable prescription drug coverage, through no fault of you own, you will also be eligible for a

two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.

If you do decide to join a Medicare drug plan, your current United Healthcare drug coverage will not be affected. You can keep this coverage

if you elect Part D and the United Healthcare plan will coordinate with Part D coverage.

If you decide to join a Medicare drug plan and drop your current United Healthcare coverage, be aware that you and your dependents will be

able to get this coverage back with a qualifying event.

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 our office for further information (see contact information below). NOTE: You will receive this notice annually and before the next peri-

od you can join a Medicare drug plan, and if this coverage through United Healthcare changes. You may also request a copy of this notice at

any time.

15

Legal Notices

For more information about your options under Medicare prescription drug coverage…

More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of

the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.

For more information about Medicare prescription drug coverage:

> Visit www.medicare.gov

> Call your State Health Insurance Assistance Program (see 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 on the web at www.socialsecurity.gov or you call them 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 drug plans, you may be required to pro-

vide 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).

Name of Entity/Sender: Human Resources, Southern College of Optometry, Ann Fields, 901-722-3229

The Newborns’ and Mothers’ Health Protection Act of 1996

The Newborns’ and Mothers’ Health Protection Act of 1996 prohibits group and individual health insurance policies from restricting benefits for

any hospital length of stay for the mother or newborn child in connection with childbirth; (1) following a normal vaginal delivery, to less than 48

hours, and (2) following a cesarean section, to less than 96 hours. Health insurance policies may not require that a provider obtain authoriza-

tion from the health insurance plan or the issuer for prescribing any such length of stay. Regardless of these standards an attending health

care provider may, in consultation with the mother, discharge the mother or newborn child prior to the expiration of such minimum length of

stay.

Further, a health insurer or health maintenance organization may not:

1. Deny to the mother or newborn child eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the plan, solely to

avoid providing such length of stay coverage;

2. Provide monetary payments or rebates to mothers to encourage such mothers to accept less than the minimum coverage;

3. Provide monetary incentives to an attending medical provider to induce such provider to provide care inconsistent with such length of stay

coverage;

4. Require a mother to give birth in a hospital; or

Restrict benefits for any portion of a period within a hospital length of stay described in this notice.

These benefits are subject to the plan’s regular deductible and co-pay. For further details, refer to your Summary Plan Description. Keep this

notice for your records and call Human Resources for more information.

16

Legal Notices

HIPAA Privacy Policy for Fully-Insured Plans with no Access to PHI

The group health plan is a fully-insured group health plan sponsored by the “Plan Sponsor”. The group health plan and the plan sponsor in-

tend to comply with the requirements of 45 C.F.R. §164.530 (k) so that the group health plan is not subject to most of HIPAA’s privacy require-

ments

I. No access to protected health information (PHI) except for summary health information for limited purpose and enrollment / dis-

enrollment information.

Neither the group health plan nor the plan sponsor (or any member of the plan sponsor’s workforce) shall create or receive protected

health information (PHI) as defined in 45 C.F.R. §160.103 except for (1) summary health information for purpose of (a) obtaining pre-

mium bids or (b) modifying, amending, or terminating the group health plan, and (2) enrollment and dis-enrollment information.

II. Insurer for group health plan will provide privacy notice

The insurer for the group health plan will provide the group health plan’s notice of privacy practices and will satisfy the other require-

ments under HIPAA related to the group health plan’s PHI. The notice of privacy practices will notify participants of the potential dis-

closure of summary health information and enrollment / dis-enrollment information to the group health plan and the plan sponsor.

III. No intimidating or retaliatory acts

The group health plan shall not intimidate, threaten, coerce, discriminate against, or take other retaliatory action against individuals for

exercising their rights , filing a complaint, participating in an investigation, or opposing any improper practice under HIPAA.

IV. No Waiver

The group health plan shall not require an individual to waive his or her privacy rights under HIPAA as a condition of treatment, pay-

ment, enrollment or eligibility. If such an action should occur by one of the plan sponsor’s employees, the action shall not be attribut-

ed to the group health plan.

Children’s Health Insurance Program Reauthorization Act (CHIPRA) of 2009

Effective April 1, 2009, a special enrollment period provision is added to comply with the requirements of the Children’s Health Insurance Pro-

gram Reauthorization Act (CHIPRA) of 2009. If you or a dependent is covered under a Medicaid or CHIP plan and coverage is terminated as

a result of the loss of eligibility for Medicaid or CHIP coverage, you may be able to enroll yourself and/or your dependent(s). However, you

must enroll within 60 days after the date eligibility is lost. If you or a dependent becomes eligible for premium assistance under an applicable

State Medicaid or CHIP plan to purchase coverage under the group health plan, you may be able to enroll yourself and/or your dependent(s).

However, you must enroll within 60 days after you or your dependent is determined to be eligible for State premium assistance. Please note

that premium assistance is not available in all states.

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 1-877-KIDS NOW or www.insurekidsnow.gov to find out

how to apply. If you qualify, you can ask the State if it has a program that might help you pay the premiums for an employer-sponsored plan.

Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, your employer’s health plan is

required to permit you and your dependents to enroll in the plan – as long as you and your dependents are eligible, but not already enrolled in

the employer’s plan. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined

eligible for premium assistance.

To see if your state has assistance, or for more information on special enrollment rights, you can contact either:

17

Legal Notices

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

1-866-444-EBSA (3272) 1-877-267-2323, Ext. 61565

Notice of Special Enrollment Rights

If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan

coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage

(or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 30

days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).

In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself

and your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.

Further, if you decline enrollment for yourself or eligible dependents (including your spouse) while Medicaid coverage or coverage under a

State CHIP program is in effect, you may be able to enroll yourself and your dependents in this plan if:

• coverage is lost under Medicaid or a State CHIP program; or

• you or your dependents become eligible for a premium assistance subsidy from the State.

In either case, you must request enrollment within 60 days from the loss of coverage or the date you become eligible for premium

assistance.

To request special enrollment or obtain more information, contact the person listed at the end of this summary:

Name of Entity/Sender: Attn: Southern College of Optometry, Ann Fields - Human Resources, 901-722-3229

Statement of ERISA Rights

As a participant in the Plan you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974

(“ERISA”). ERISA provides that all participants shall be entitled to:

Receive Information about Your Plan and Benefits

• Examine, without charge, at the Plan Administrator’s office and at other specified locations, the Plan and Plan documents, including the

insurance contract and copies of all documents filed by the Plan with the U.S. Department of Labor, if any, such as annual reports and

Plan descriptions.

• Obtain copies of the Plan documents and other Plan information upon written request to the Plan Administrator. The Plan Administrator

may make a reasonable charge for the copies.

• Receive a summary of the Plan’s annual financial report, if required to be furnished under ERISA. The Plan Administrator is

required by law to furnish each participant with a copy of this summary annual report, if any.

18

Legal Notices

Continue Group Health Plan Coverage

If applicable, you may continue health care coverage for yourself, spouse or dependents if there is a loss of coverage under the plan as a result

of a qualifying event. You and your dependents may have to pay for such coverage. Review the summary plan description and the documents

governing the Plan for the rules on COBRA continuation of coverage rights.

If you have creditable coverage from another plan, you may be entitled to a reduction or elimination of exclusionary periods (if applicable) of

coverage for preexisting conditions under your group health plan. You should be provided a certificate of creditable coverage, free of charge,

from your group health plan or health insurance issuer when you lose coverage under the plan, when you become entitled to COBRA continua-

tion of coverage, when COBRA continuation of coverage ceases, if you request before losing coverage or if you request it up to 24 months

after losing coverage. Without evidence of prior creditable coverage, you may be subject to a preexisting condition exclusion for 12 months (18

months for late enrollees) after your enrollment date in your coverage.

Prudent Actions by Plan Fiduciaries

In addition to creating rights for participants, ERISA imposes duties upon the people who are responsible for operation of the Plan. These peo-

ple, called “fiduciaries” of the Plan, have a duty to operate the Plan prudently and in the interest of you and other Plan participants.

No one, including the Company or any other person, may fire you or discriminate against you in any way to prevent you from obtaining welfare

benefits or exercising your rights under ERISA.

Enforce your Rights

If your claim for a welfare benefit is denied in whole or in part, you must receive a written explanation of the reason for the denial. You have a

right to have the Plan review and reconsider your claim.

Under ERISA, there are steps you can take to enforce these rights. For instance, if you request materials from the Plan Administrator and do

not receive them within 30 days, you may file suit in federal court. In such a case, the court may require the Plan Administrator to provide the

materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent due to reasons beyond the control of

the Plan Administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, and you have exhausted the available

claims procedures under the Plan, you may file suit in a state or federal court. If it should happen that Plan fiduciaries misuse the Plan’s money,

or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in

a federal court. The court will decide who should pay court costs and legal fees. If you are successful, the court may order the person you have

sued to pay these costs and fees. If you lose (for example, if the court finds your claim is frivolous) the court may order you to pay these costs

and fees.

Assistance with your Questions

If you have any questions about your Plan, this statement, or your rights under ERISA, you should contact the nearest office of the Employee

Benefits and Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and

Inquiries, Employee Benefits and Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210.

Name of Entity/Sender: Attn: Human Resources, Southern College of Optometry, Ann Fields 901-722-3229

19

Legal Notices

Health Care Reform and You

The Patient Protection and Affordable Care Act & The Health Care and Education Affordability Reconciliation Act of 2010, together, create the most comprehen-

sive health insurance reform ever under taken in recent history by our Country.

Many of the new law’s required changes have already been incorporated into company health plans across the country since the effective date in September of

2010. However, there will be many more changes taking place in the months to come, as more guidance is issued by the government to employers, insurance

carriers and individuals. One of the key requirements of the new law beginning in 2014, is the mandate that all U.S. citizens & legal residents either carry health

insurance or pay an income tax penalty. While the tax penalty is not too severe in the first year, it becomes progressively more costly each year thereafter.

Penalties for failing to buy coverage

Tax penalties for failing to buy coverage are phased in according to the following schedule:

In 2014, the greater of $95 or 1% of taxable income;

In 2015, the greater of $325 or 2% of taxable income;

In 2016, the greater of $695 or 2.5% of taxable income; and

After 2016, the penalty is indexed for inflation.

However, there are two ways to avoid the tax penalty:

You can buy coverage for you and your family through your place of employment, if your employer offers such coverage. That coverage must meet certain

standards set by the law in order for you and the employer to escape respective tax penalties. The coverage must meet certain minimum coverage standards

(Generally pays at least 60% of your covered medical expenses) and must be considered “affordable” (Employer cannot charge you a premium for single or

employee only coverage greater than 9.5% of your W-2 earnings for the year). The 9.5% would apply to annual salaries of up to about $45,000.

Or, you can provide coverage for you and your family through a Federally run Insurance Exchange that is supposed to be up and running by 1/1/2014. Essential-

ly, an Exchange is an interactive site where an individual can go to research, evaluate and buy health plans. The State of Florida chose not to set up a state run

exchange, so the Federal government will take over that responsibility.

If you obtain coverage through an Exchange:

The Exchange will eventually sell insurance policies at certain levels of coverage:

- Bronze level – a medical plan designed to pay 60% of covered medical benefits;

- Silver level – a medical plan designed to pay 70% of covered medical benefits;

- Gold level – a medical plan designed to pay 80% of covered medical benefits;

- Platinum level – a medical plan designed to pay 90% of covered medical benefits;

- Catastrophic – available to young adults up to age 30 or those exempt from the individual mandate (additional requirements may apply)

You may only obtain coverage through an Exchange if you are not participating in your employer’s plan.

If you satisfy certain low income thresholds and do not have medical coverage through an employer, or have employer-provided coverage that is considered

“unaffordable” or pays benefits that are below the “Bronze” plan

discussed above, there are tax credits available to help you pay the premiums for coverage purchased through the Exchange. The credits also help pay for

expenses like deductibles and copays. More information on these credits will be provided to you later.

If you and your family are below 133% of the Federal Poverty Level in 2014, you may qualify for Medicaid.

Other changes that took effect in 2014:

- The health plan may no longer exclude coverage of a pre-existing condition;

- The health plan may not impose more than a 90-day waiting period for coverage;

- Your plan may no longer place an annual limit on key benefits in the plan;

- Your health plan must allow dependent children up to age 26 to enroll in coverage, regardless of the availability of employer-sponsored

coverage where they work.

© BenefitHelp Southern College of Optometry, 2016 v5