Benefit Guide

Health Insurance Benefits Guide

February 1, 2017 - January 30, 2018

An electronic version of this Benefits Guide, an interactive medical cost
calculator and important plan documents and forms can be found at

bit.ly/netcraftsmenbenefits

What’s Inside:

Resources ......................................................................................... 2
Eligibility ........................................................................................... 3
Medical and Prescription Plan Highlights ........................................... 4
Health Savings Account Overview ...................................................... 5
Dental Plan Highlights ....................................................................... 6
Vision Plan Highlights ........................................................................ 7
Company-paid Life and Disability Insurance ....................................... 8
Employee-paid Life Insurance ............................................................ 8
Required Federal Notices................................................................... 9

Resources Contact Phone Number Website or Email
1-877-716-6618 [email protected]
Plan UnitedHealthcare 1-866-873-3903
Benefits Hotline Humana 1-877-877-1051 www.myuhc.com
PSA Insurance & Financial Services Humana 1-877-877-1051 www.Humana.com
Medical & Prescription 1-800-877-5176 www.Humana.com
Dental Mutual of Omaha 1-800-316-2796 www.mutualofomaha.com
Vision Mutual of Omaha www.mutualofomaha.com/eap
Life and Disability Insurance

Employee Assistance Program

2

Eligibility The NetCraftsmen benefits
plan year runs February 1 to
Employees January 31. You will not be
able to make changes to
All full-time employees who work a minimum of 30 hours per week are eligible for your elections during the
benefits. Benefits are effective on the first day of the month following date of hire. plan year unless you
experience a change-in-
Eligible Dependents status event. If you do not
experience a change-in-
In addition to enrolling yourself, you may also enroll any eligible dependents. status event, the elections
you make will remain in
Eligible dependents include: effect through January
 Spouse: a person to whom you are legally married. 31, 2018.
 Dependent children up to the age of 26, regardless of marital status, student

status or financial dependency. Coverage for a dependent child will terminate at
the end of the month in which they turn age 26.

Making Changes

Please keep in mind that benefit elections and their related payroll deductions
cannot be changed until the next Open Enrollment period unless you, your spouse,
or your dependent child(ren) experience an IRS defined change-in-status event.

Change-in-Status events are changes in:
 Legal marital status, including marriage, death of a spouse, and divorce
 Number of covered dependents due to birth, death, adoption, granting of legal

custodianship, reaching maximum age for coverage.
 Employment for you, your spouse or your dependent, including commencement

of or return from leave of absence, or change in employment status.
 Eligibility for other coverage, or loss thereof, due to spouse’s open enrollment

period, loss or gain of benefit eligibility.

You must notify the HR Department within 30 days of the
change-in-status event in order to make a change to your benefit
elections. Documentation supporting the change will be required.

3

Medical and Prescription Plan Highlights

NetCraftsmen offers medical coverage through UnitedHealthcare. Both options utilize the UHC Choice National Network. You do
not need to chose a Primary Care Physician (PCP), and you do not need a referral to visit a specialist.

Option 1: Gold HSA (AK36) Option 2: Platinum Traditional (AACX)
In-Network Only
Plan Features In-Network Only $250 Individual

Plan Year Deductible $1,500 Individual $500 Family (separate)
$3,000 Family (combined)
Amount you must pay before the plan begins to pay for $2,000 Individual
covered services, unless otherwise noted. $2,800 Individual $4,000 Family (separate)
$5,600 Family (combined)
Plan Year Out-of-Pocket Maximum $0

Maximum amount you could pay during the year for your $15 Copay
share of the cost for covered services. $30 Copay

· Coinsurance and deductibles apply toward the out-of- $0
pocket maximum
Deductible, then $0
Wellness/Preventive Care Services Deductible, then $0

Eligible Preventive Care Services $0 Deductible, then $0
Deductible, then $250
Office Visits, Labs & Testing
$0
Physician Office Visit Deductible, then $0 $10
$40
Specialist Visit Deductible, then $0 $75

Diagnostic Lab and X-ray Deductible, then $0

Emergency / Urgent Care

Urgent Care Center Deductible, then $0

Hospital Emergency Room Deductible, then $250

Hospitalization precertification required

Inpatient Hospital Stay Deductible, then $0

Outpatient Facility Surgery Deductible, then $0

Prescription Drugs

Rx Deductible Integrated with Medical

Tier 1 Deductible, then $10

Tier 2 Deductible, then $40

Tier 3 Deductible, then $75

If there are any differences between this summary and the official plan documents, the
plan documents will govern.

4

Benefit Cost - Medical Please visit bit.ly/netcraftsmenbenefits for an interactive cost calculator

Tier Employee Cost Per Month
Costs based on Option 1: Gold HSA (AK36)
Employee Only
$51.96

Employee + Child(ren) $200.05

Employee + Spouse $207.84

Family $355.93

Health Savings Account (HSA)

When you enroll in the UnitedHealthcare Gold HSA (AK36) Qualified High Deductible Health Plan (QHDHP), you may be eligible to
open a Health Savings Account (HSA). An HSA can help you save money by allowing you to pay for health care expenses with tax-
free dollars. You can use the funds to pay for qualified health care expenses, such as medical and prescription drug expenses until
you meet your deductible, coinsurance, copays, and other out-of-pocket expenses including dental and vision expenses, for you
and your dependents—even if they are not covered under your medical plan! To be eligible to make contributions to an HSA, you
may not have any other health insurance coverage for services that are subject to the deductible (includes coverage through your
spouse’s plan, under a Healthcare FSA and Medicare coverage).

Reasons to Love a Health Savings Account (HSA) Still confused about HSAs?
Scan the QR code to WATCH
 Triple Tax Savings
 You can contribute to your HSA using tax-free dollars. the “HSA 101”
 You can use the money in your HSA to pay for health care expenses with tax- presentation or visit
free money. bit.ly/HSAinformation
 Whatever you don’t use in a year rolls over to the next year, and earns inter-
est that is tax-free!

 You decide how and when to use the funds in your account—you can use the
funds to pay for your health care expenses or save them for future health care
costs.

 The account may be used to build funds for retirement. Once you reach age 65,
you can withdraw the money for non-medical reasons without a penalty.

How to Set up your HSA

NetCraftsmen has partnered with OptumBank to offer the HSA to employees. Each account
is employee-owned and funded. Please see Human Resources for more information.

Funding your HSA

To fund your HSA, you can make deposits using one of the following:
1. pre-tax payroll deductions from your PSA paycheck tax deductible contributions
rollover funds from another HSA
2. one-time trustee-to-trustee transfer from your Individual Retirement Account (IRA)

5

Dental

NetCraftsmen offers dental coverage for you and your family through Humana. You have the freedom to select the dentist of your
choice; however when you visit a participating in-network dentist, you will have lower out-of-pocket costs, no balance billing, and
claims will be submitted by your dentist on your behalf.

Plan Features In-Network Out-of-Network1

Annual Deductible (Calendar Year) $50 Individual $50 Individual

Applies to Class II and III services only $150 Family $150 Family

Annual Maximum (Calendar Year) Unlimited!

Preventive & Diagnostic Care (Class I) No Charge 0% of Allowed Benefit
Oral exams, cleanings, bitewing x-rays

Basic Restorative Care (Class II) Deductible, then 10% Deductible, then 20%
Fillings, oral surgery, root canal therapy of Allowed Benefit of Allowed Benefit

Major Restorative Care (Class III) Deductible, then 40% Deductible, then 50%
Crowns, inlays/onlays, bridges, dentures, implants of Allowed Benefit of Allowed Benefit

Orthodontia Services Plan pays 50%, no deductible
Dependent children through age 18 Lifetime maximum - $1,000 per child

Limitations and exclusions may apply. If there are any differences between this summary and the official plan documents, the plan documents will govern.
1Balance Billing May Apply

Benefit Cost - Dental Employee Cost per Pay
(Based on 12 pays per Year)
Tier
Employee Only $15.91
Employee + Child(ren)
Employee + Spouse $43.69
Family
$31.82

$60.23

6

Vision

Your vision coverage provides a full range of vision care services
provided through Humana. You may receive care from any provider
you choose, but your benefits are greater when you see a participating,
in-network provider.

Plan Features In-Network Out-of-Network

Vision Exam $10 Copay $35 Allowance
Once every 12 months

Retail Frame Allowance $50 Wholesale Allowance $40 Retail Allowance
Once every 12 months

Eyeglass Lenses $15 Copay $25 Allowance
Once every 12 months $15 Copay $40 Allowance
$15 Copay $60 Allowance
Single
Bifocal $150 Allowance $150 Allowance
Trifocal Covered in full with Prior Approval $210 Allowance

Contact Lenses
Once every 12 months in lieu of lenses and
frames

Elective
Medically Necessary

If there are any differences between this summary and the official plan documents, the plan documents will govern.

Benefit Cost - Vision Employee Cost per Pay
(Based on 12 pays per Year)
Tier
Employee Only $2.37
Employee + Child(ren) $4.49
Employee + Spouse $4.73
Family $7.06

7

Company-paid Life and Disability Insurance

Mutual of Omaha

Basic Life and AD&D Insurance* Don’t forget to
designate a beneficiary!
Life insurance helps protect your family from financial risk and sudden loss of income in the event
of your death. Accidental Death & Dismemberment (AD&D) insurance provides an additional
benefit if you lose your life, sight, hearing, speech or use of your limbs in an accident.

NetCraftsmen provides you with Basic Life insurance in the amount of $50,000—at no cost to you. Choosing who will receive your
If you die as a result of an accident, your beneficiary will receive an additional benefit. For other life insurance benefits is an
covered losses, the amount of the benefit is a percentage of the AD&D insurance coverage amount. important decision. Please
Evidence of good health is not required. make sure your beneficiary
information is up to date by
*Please refer to the full plan summaries for age reduction information contacting the HR Department.

Disability Insurance

To protect your income in case you are unable to work due to a non-work related illness or injury,
NetCraftsmen provides both short and long term disability coverage.

Short Term Disability (STD)
 Benefit is 60% of your salary, up to a maximum benefit of $2,200 per week.
 Benefits begin on the 15th day following an accident or illness and may continue as long as you meet the definition of disability for up
to 11 weeks

Long Term Disability (LTD)
 Benefit is 60% of your salary, up to a maximum benefit of $10,000 per month.
 Benefits begin after you have been disabled for 90 days and may continue for as long as you meet the definition of disability until you
reach Age 65 or Social Security Normal Retirement Age

Employee-paid Supplemental Life and AD&D Insurance*

Mutual of Omaha

You may purchase additional Life and AD&D insurance for yourself, your spouse, or your children through Mutual of Omaha.

Participation is voluntary, and premiums are 100% paid by the Employee.

Yourself: a maximum of 5x your annual salary, up to $300,000, in $10,000 increments
Evidence of Insurability is needed for coverage amounts over $80,000,
or if you enroll in or change your coverage after the initial eligibility period

Spouse: a maximum of 100% of the employee’s benefit, up to 100% of Employee’s Election, up to $150,000, in $5,000 increments
Evidence of Insurability is needed for over $40,000 of coverage,
or if you enroll in or change your coverage after the initial eligibility period

Children: a minimum of $2,000 and a maximum of $10,000, in $1,000 increments
Evidence of Insurability is needed for if you enroll in or change your coverage after the initial eligibility period

*Please refer to the full plan summaries for age reduction information

Supplemental Life Cost Breakdown

Employee’s Age** Employee & Spouse Rate **Employee and spouse rates are calculated
based on the employee’s current age as of the
0-29 (Cost Per Month, per $1,000 effective date of the plan. Rates are adjusted
30-34 once each year on the plan anniversary date
35-39 $0.11 for employees advancing to the next age band.
40-44 $0.13
45-49 $0.17 Spouse coverage terminates when the employ-
50-54 $0.19 ee attains age 70 (regardless of the spouse’s
55-59 $0.27 actual age).
60-64 $0.43
65-69 $0.74
70+ $1.03
$1.87
$3.24

Child’s Cost per Month per $1,000 $0.20

8

Important Notice: Prescription Drug & Medicare

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage
with Chesapeake Netcraftsmen 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, including
which drugs are covered at what cost, with the 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 prescription 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
Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All
Medicare 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. Chesapeake Netcraftsmen has determined that the prescription drug coverage offered by the UnitedHealthcare plans are, on average
for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage 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 drug plan.

__________________________________________________________________________________________________________

When Can You Join A Medicare Drug Plan?
You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th through December 7th.
However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2)
month Special Enrollment Period (SEP) to join a Medicare drug plan.

What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?
If you decide to join a Medicare drug plan, your current Chesapeake Netcraftsmen coverage will not be affected.

If you do decide to join a Medicare drug plan and drop your current Chesapeake Netcraftsmen coverage, be aware that you and your dependents
will not be able to get this coverage back until the next open enrollment period.

When Will You Pay A Higher Premium (Penalty) To Join A Medicare Drug Plan?
You should also know that if you drop or lose your current coverage with Chesapeake Netcraftsmen and don’t join a Medicare drug plan within 63
continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.

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 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 the inside back cover of 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 Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).

Remember: Keep this notice. If you decide to join one of the Medicare drug plans, you may be required to provide 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).

9

Required Federal Notices Newborns’ and Mothers’ Health Protection Act

Women’s Health and Cancer Rights Act of 1998 Group health plans and health insurance issuers generally
may not, under federal law, restrict benefits for any hospital
If you have had or are going to have a mastectomy, you may length of stay in connection with childbirth for the mother or
be entitled to certain benefits under the Women’s Health and newborn child to less than 48 hours following a vaginal
Cancer Rights Act of 1998 (WHCRA). WHCRA requires group delivery, or less than 96 hours following a cesarean section.
health plans and their insurance companies and HMOs to However, federal law generally does not prohibit the
provide certain benefits for mastectomy patients who elect mother’s or newborn’s attending provider, after consulting
breast reconstruction. For individuals receiving mastectomy- with the mother, from discharging the mother or her
related benefits, coverage will be provided in a manner newborn earlier than 48 hours (or 96 hours as applicable). In
determined in consultation with the attending physician and any case, plans and issuers may not, under federal law,
the patient, for: require that a provider obtain authorization from the plan or
 All stages of reconstruction of the breast on which the issuer for prescribing a length of stay not in excess of 48 hours
(or 96 hours if applicable).
mastectomy was performed;
 Surgery and reconstruction of the other breast to Special Enrollment Rights

produce a symmetrical appearance; If you are declining enrollment for yourself, or your
 Prostheses; and dependents (including your spouse) in the medical plan
 Treatment of physical complications of the mastectomy, because of other medical coverage, you may be able to enroll
yourself and/or your dependents in this plan if you or your
including lymphedema. dependents lose eligibility for that other coverage (or if the
employer stops contributing toward your or your dependents’
Breast reconstruction benefits are subject to deductibles and coverage). However, you must request enrollment within 30
co-insurance limitations that are consistent with those days after your previous coverage ends (or after the employer
established for other benefits under the plan. stops contributing toward the other coverage). In addition, if
you have a new dependent as a result of marriage, birth,
Health Insurance Portability and Accountability Act (HIPAA) adoption or placement for adoption, you may be able to
enroll yourself and your dependents in the medical plan,
This group health plan complies with the privacy requirement provided that you request enrollment within 30 days of the
for Protected Health Information (PHI) under HIPAA. A copy marriage, birth, adoption, or placement for adoption.
of the Privacy Practices is available from the insurance
carriers for medical, dental and vision insurance. If you or your dependent lose eligibility for coverage under
Medicaid or a State child health plan or if you or your
Certificate of Creditable Coverage dependent become eligible for State-sponsored premium
You should be provided with a certificate of creditable assistance for the medical plan, you may be able to enroll
coverage, free of charge, from your group health plan or yourself and/or your dependents in this plan if you request
health insurance issuer when you lose coverage under the enrollment within 60 days of the date of termination of
plan, when you become entitled to COBRA, when COBRA Medicaid or State child health plan coverage or your eligibility
coverage ceases, if you request it before you lose coverage, or for premium assistance.
if you request it up to 24 months after losing coverage.
Without evidence of creditable coverage from the plan, you
may be subject to a pre-existing condition exclusion for 12
months (18 months for late enrollees) after your enrollment
date in other coverage if you are age 19 or older.