Your HSBP Benefits-At-A-Glance: Los Angeles County Harbor-UCLA Medical Center

WHEN YOU GET BENEFITS AND WHO YOU CAN COVERTo enroll for coverage, complete an enrollment form and

return it to your CIR organizer within 30 days after your

first day of work. You and your enrolled family members’

vision coverage starts on your first day of work. You will

receive a Davis Vision card in the mail from the insurance

carrier.

Outside of Orientation and Open E rollment, you have 30

days from the date of a qualifying event to add a spouse,

domestic partn r, and/or child during the year.

Qualifying Events Are:

• Marriage

• Birth of a child

• Loss of employment/insurance coverage

• Dependent(s) arriving in the United States during the year

When you enroll, you’ll need to add your dependents at

this time. You will need to submit a copy of your marriage

certificate. If you don't have a birth certificate, you ca

submit discharge papers from the hospital.

If you’re enrolling a domestic partn r, you’ll need to

submit the Domestic Partnership Application found on th

CIR website at cirseiu.org/benefits and select your

hospital’s name.

LA GAP INSURANCEAs you start your residency program with LAC Harbor-UCLA Medical Center, please be aware that there is a 90-day window from the beginning of your employment before your employer-sponsored healthcare coverage begins.

Your employer-sponsored healthcare coverage will start on or around September 1, as long as you enroll during your June/July orientation

You Can Purchase Healthcare Coverage for The Gap Period

• If you purchase COBRA coverage from your former insurance carrier or a form of GAP coverage to cover yourself and/or your family during this 90-day window, the CIR/SEIU Benefits Plan will reimburse you up to $500 for the 90-day window that you did not have LAC Harbor-UCLA employer-sponsored healthcare coverage.

• In order to receive the reimbursement, you will need to fill out the GAP Insurance Reimbursement Claim Form and provide:

1. A copy of the COBRA notice and p oof of COBRA coverage payment, or

2. The GAP policy statement, and a copy of the GAP policy payment receipt.

The HSBP Trustees understand how important it is for you to have additional healthcare coverage.

Once you enroll, you are eligible for GAP insurance, Vision Benefits, Supplemental Dental and Major Medical Benefits, Professional Educational Benefits (PEB) and Short-Term & Long-Term Disability. We hope this gives you peace of mind as you focus on caring for your patients.

We believe you’ll find this Benefits-At-A-Glance useful.You can also learn more by:

• Visiting our website (cirseiu.org/benefits and click on your hospital’s name)

• Emailing the Benefits Plan office at benefits@cirseiu.org

• Calling the Benefits Plan Office (212) 356-8180

With best wishes for a successful and fulfilling medical career,Your HSBP Trustees

Welcome to the House Staff Benefits Plan (HSBP)!

1

WHEN YOU GET BENEFITS AND WHO YOU CAN COVERTo enroll for coverage, complete an enrollment form and

return it to your CIR organizer within 30 days after your

first day of work. You and your enrolled family members’

vision coverage starts on your first day of work. You will

receive a Davis Vision card in the mail from the insurance

carrier.

Outside of Orientation and Open E rollment, you have 30

days from the date of a qualifying event to add a spouse,

domestic partn r, and/or child during the year.

Qualifying Events Are:

• Marriage

• Birth of a child

• Loss of employment/insurance coverage

• Dependent(s) arriving in the United States during the year

When you enroll, you’ll need to add your dependents at

this time. You will need to submit a copy of your marriage

certificate. If you don't have a birth certificate, you ca

submit discharge papers from the hospital.

If you’re enrolling a domestic partn r, you’ll need to

submit the Domestic Partnership Application found on th

CIR website at cirseiu.org/benefits and select your

hospital’s name.

LA GAP INSURANCEAs you start your residency program with LAC Harbor-UCLA Medical Center, please be aware that there is a 90-day waiting period from the beginning of your employment before your employer-sponsored healthcare coverage begins.

Your employer-sponsored healthcare coverage will start on or around September 1, as long as you enroll during your June/July orientation.

You Can Purchase Healthcare Coverage f or The Gap Period

• If you purchase COBRA coverage from your former insurance carrier or a

form of GAP coverage to cover yourself and/or your family during this90-day wating period, the CIR/SEIU House Staff Benefits Plan willreimburse you up to $500 for the 90-day waiting period that you did nothave LAC Harbor-UCLA employer-sponsored healthcare coverage.

• In order to receive the reimbursement, you will need to fill out the GAPInsurance Reimbursement Claim Form and provide:

1. A copy of the COBRA notice and proof of COBRA coverage payment,or

2. The GAP policy statement, and a copy of the GAP policy paymentreceipt.

The HSBP Trustees understand how important it is for you to have additionalhealthcare coverage.

Once you enroll, you are eligible for GAP insurance, Vision Benefits, Supplemental Dental and Major Medical Benefits, Professional Educational Bene ts (PEB) and Short-Term & Long-Term Disability. We hope this gives you peace of mind as you focus on caring for your patients

We believe you’ll find this Benefits-At-A-Glance useful. You can also learn more about your benefits at our website, cirseiu.org/benefits and click on your hospital’s name, or by emailing the Benefits Plan Office at benefits@cirseiu.org,or by calling (212) 356-8180. For a complete description of yo r benefits and your rights, please read the Summary Plan Description (SPD) -- also ocated on the CIR website under “Benefits”-- which also serves as the Plan Document.

With best wishes for a successful and fulfilling medical career,

Your HSBP Trustees

Welcome to the House Staff Benefits Plan (HSBP)!

2

When You Get Benefits & Who You Can Cover

sign up for coverage, complete an enrollment form at Toorientation and return it to your CIR organizer or the CIR Office, Attention: Operations Department within 31 days after you start work. Please be sure to name at least one beneficiary in your Life Insurance benefit form.Coverage for you and your enrolled family member starts

n your foon your first day of work or the first of the monthe month you start working. The date depends on the

ospital at which you work and the calendar day on hwhich you start working. Contact the Benefits Plan Office for more details.Outside of Orientation and Open Enrollment, you have 30 days from the date of a Qualifying Life Event to add dependents.

ifQual ying Events Are:

• Marriage• Loss of employment/insurance coverage• Birth of a child• Dependent(s) arriving in the United States during the year

• You need to provide a Social Security Number (SSN) for you or your covered dependents, a copy of a marriage license, birth certificate(s) for children, or discharge papers from the hospital.

• If you are you are enrolling a domestic partner, you’ll need to submit the Domestic Partnership application found on the CIR web at cirseiu.org/benefits and select your hospital’s name.

During Open Enrollment in July or January, please note that:

Vision Benefits Below is a sample of the Davis

Vision ID card, which includes

your CIR Member ID number.

You will receive this ID card in

the mail from the insurer. Only

the primary card holder's name

will appear on this ID card.

It’s easy to take good vision for granted. However, getting our vision

checked each year is just as important as your annual physical or annual

dental check-up. That’s why the Plan offers vision benefits through

Davis Vision, which includes eye exams, eyeglass lenses and frames, and

contact lenses.

Vision Benefits-At-A-Glance(Amounts are what YOU pay, unless noted otherwise)

VISION BENEFIT – DAVIS VISION PROVIDER

In-Network Benefit

Out-of-Network Benefit

FREE EYE EXAM(One exam every year beginning July 1) $0

CLEAR PLASTIC LENSES(One pair every year beginning July 1)

$0

FRAMES(Every two plan years: Every other July 1) Davis Vision Collection

$0 co-pay forFashion Frames

(valued up to $125)

$15 co-pay forDesigner Frames

15% discount off lens-fitting exam

$100 allowance toward anyprovider-supplied contact lenses,

plus 15% off balance

$40 co-pay forPremier Frames

CONTACT LENSES(In lieu of eyeglasses)

You will receive a maximum of $40 per year toward an eye exam and $60 toward eyeglasses or contact lenses. You must file a claim with Davis Vision to be reimbursed.

3

Disability Benefits

“Disabled” means you can no longer perform the duties of our occupation due o accidental bodily injury, sickness, or a related medical condition, including p egnancy or childbirth. You must also be under the care of a licensed provider as defined by the State in which you work.

Supplemental Short-Term Disability Leave (STD)• Coverage begins on the eighth (8th) day of a non-occupational

disability, the maximum benefit payable is 70% of your weekly salary, up to $875 per week, for up to 26 weeks.

• If you are going out on a disability leave, contact your employer as soon as possible.

Long-Term Disability Leave (LTD)• The LTD Benefit pays you 70% of your monthly salary, up to a

maximum of $3,500 per month.

• LTD Benefits typically start if you are still disabled fter 26 continuous eeks.

• When you terminate employment, you will have the option o convert this benefit into an individual policy, subject to certain conditions.

SUPPLEMENTAL MEDICAL ANDDENTAL BENEFITS

These benefits will reimburse you for out-of-pocket expenses you incur from your primary major medical and dental insurance carriers.

Supplemental Dental Reimbursement Benefit $1,000 Reimbursement

Whatever you pay out-of-pocket for your dental services the plan will pay 20% of what your dental insurance carrier pays the provider, up to $1,000 per person per plan year (July 1 – June 30). Submit your Explanation of Benefits (EOB) with areimbursement form found on CIR website, cirseiu.org/benefits and click on your hospital's name.

Supplemental Major Medical Reimbursement Benefit $1,000 Reimbursement

This benefit supplements your medical coverage with your primary major medical carrier. You must submit the Explanationon of Benefits (EOB) you will receive from your insurance carrier with a reimbursement form found on CIR website, cirseiu.org/benefits and click on your hospital's name.

Medical Services That Have Co-paysAre Paid at 100%You will be reimbursed for co-pay amounts for office visits, outpatient diagnostic tests (x- y, lab tests, etc.), emergency room care and hospital admissions up to 100%.

Supplemental Medical & Dental Benefit

These benefits will reimburse you for out-of-pocket expenses you incur from your primary major medical and dental insurance carriers.

$1,000 Supplemental Dental Reimbursement BenefitThis benefit supplements your dental coverage. The plan pays 50% of what your dental carrier pays the provider, up to a maximum of $1,000 per person, per plan year (July 1-June 30). Submit yourExplanation of Benefits (EOB) with a reimbursement form found on the CIR website (cirseiu.org/benefits) and click on your hospital's name.

$1,000 Supplemental Major Medical Reimbursement BenefitThis benefit supplements your medical coverage. The plan pays 50% of what your medical carrier pays the provider, up to a maximum of $1,000 per person, per plan year (July 1-June 30). Submit your Explanation of Benefits (EOB) with a reimbursementform found on the CIR website (cirseiu.org/ benefits) and click onyour hospital's name.

Medical Services That Have Co-pays Are Paid at 100%ou will be reimbursed for co-pay amounts fY or office visit

Outpatient diagnostic tests (x-ray, lab tests, etc.), emergency room care, and hospital admissions up to 100%.

Disability Benefit

“Disabled” means you can no longer perform the duties of your occupation due to accidental bodily injury, sickness, or a relatedmedical condition, including pregnancy or childbirth. You must also be under the care of a licensed provider as defined by the state in which you work.

Supplemental Short-Term Disability Leave (STD)• Coverage begins on the eighth (8th) day of a non-occupational

disability. The maximum benefit payable is 70% of your weekly salary, up to $875 per week, for up to 26 weeks.

• If you are going out on a disability leave, contact youremployer as soon as possible.

Long-Term Disability Leave (LTD)• The LTD Benefit pays you 70% of your monthly salary, up to

a maximum of $3,500 per month.

• LTD Benefits typi ally start if you are still disabled fter 26continuous weeks.

• When you terminate employment, you will have the optionto convert this benefit i to an individual policy, subject to certain conditions.

ac

n

4

Employee Assistance Program (EAP)

5

We are here to support you in managing life's challenges. WorkLifeMatters is a free confidential employee assistance program provided through Guardian and Integrated Behavioral Health (IBH). Counselors are available 24/7 and are just a phone call away. WorkLifeMatters offers help to assist you with family and personal issues you might be facing or questions you might have.

• Anxiety

• Dependent Care & Caregiving

• Depression

• Drug & Alcohol Dependency

• Education

• Grief Assistance

• Legal & Financial

• Lifestyle & Fitness Management

• Parenting

• Pet Care

• Work Issues

• And More

Professional Education Benefit (PEB)Amount You Can Receive Back:• Up to $1,000

Audio & Videotapes DVDs, CDs, MP3s

Board Exam Fees Books & eBooks 1 Conference or online courses

Dues & Journals

License Application& Exam Fees Medical Recorders

Mobile Electronic Medical Devices (MEMD) - iPads, Smartphones, Laptop*

Software or Electronic Medical

Apps

Equipment Examples:• Blood Pressure Monitors• Pen Light• Pulse Oximeter• Scrubs• Stethoscope• Surgical Shoes (clogs)

YOUR FELLOW HOUSE STAFF OFFICERS FOUGHT FOR AN LA COUNTY PROFESSIONAL EDUCATION BENEFIT ALLOWANCE WITH YOUR EMPLOYER, AND WON!

Types of Reimbursements You Can Submit For:

COVID-19 Medical Equipment

6

If you do not use your entire eligible reimbursement

amount in a given Plan Year, then the unused amount can

be carried over to the next Plan Year, as long as you remain

on your employer’s payroll.

Mobile Electronic Medical Devices (MEMD)The maximum reimbursement for a MEMD per Plan Yearis limited to 75% of the total device cost up to the maximum amount.

Carry Over Balance to the Next Plan Year

.

7

Benefit Administrator Contact InformationPhone: (212) 356-8180ProfessionalEducational HSBPFundOffice

Benefit(PEB) Days/Hours: Monday–Friday,9:00am–5:00pmEST

Email:Website:

benefits@cirseiu.org www.cirseiu.org/benefit

Short-TermDisability Phone: (323) 890-8383(1stpointofcontact)

LosAngelesCountyPayrollOffice

Short-TermDisability HSBPFundOffice Phone: (212) 356-8180(2ndpointofcontact) Days/Hours: Monday–Friday,9:00am–5:00pmEST

Email:Website:

benefits@cirseiu.org www.cirseiu.org/benefit

Long-TermDisabilityGroup # G-348692

HSBPFundOffice Phone: (212) 356-8180Days/Hours: Monday–Friday,9:00am–5:00pm EST

Email:Website:

benefits@cirseiu.org www.cirseiu.org/benefit

Vision DavisVision Phone: (800) 999-5431Clientcode:3614 Days/Hours: Monday–Friday,8:00am–11:00pmEST;

Saturday,9:00am–4:00pmEST; Sunday,12:00pm–4:00pmEST;automatedassistanceavailable24/7

Website: www.davisvision.comandenterclientcode(3614)

SupplementalDental HSBPFundOffice Phone: (212) 356-8180&MajorMedical Days/Hours: Monday–Friday,9:00am–5:00pmEST

Email:Website:

benefits@cirseiu.org www.cirseiu.org/benefit

TheBenefits-At-A-GlancedescribesyourbenefitsprovidedthroughtheHouseStaffBenefitsPlan(HSBP)foryouandyourcovereddependentsasof July1,2020.TheonlyauthorizedinformationconcerningyourbenefitsisinwritingfromtheHSBPTrusteesactingintheirofficialcapacityand

whose soledecisionregardingbenefitsisfinal.TheTrusteesreservetherighttochangeordiscontinuetheeligibilityrulesandthetypeandamountsof benefitsunderthisPlanatanytime.PleasereadtheSummaryPlanDescription(SPD)/PlanDocument.

For questions on benefit coverage, please see information below:

Contact Information

8

The House Staff Benefits Plan staff can help with all areas of benefits, including questions about appeals, reimbursements, ID cards, and more.

For questions contact the HSBP Benefits Office

10-27 46th Avenue, Suite 300-2Long Island City, NY 11101

Phone: (212) 356-8180 Monday - Friday 9:00 am - 5:00 pm EST

6 a.m. - 2 p.m. PST Fax: (212) 356-8181

Email: benefits@cirseiu.org